On reviewing the case report presented by Dr. Udatta Kher, a visual essay of a full mouth implant supported restoration for a 62-year-old healthy non smoker male patient, editorial board member Dr. Ali Tunkiwala had some interesting queries.
2. The following is a visual essay of a full mouth
implant supported restoration for a 62- year- old
healthy non smoker male patient
3. FIG 1: Baseline situation
FIG 3: Extraction of teeth
and flapless implant
placement
FIG 2: Pre- operative radiograph showing satisfactory
bone condition in mandible and highly compromised
bone in the maxilla
FIG 4: Flapless implant
placement. Bio- horizon,
FIG 5: Sinus graft for maxillary first
left molar region with Novabone
(Calcium PhosphoSilicate)
putty with simultaneous implant
placement
4. FIG 6: Implant positions
for maxillary anterior
region
FIG 8: Bio- horizon
tapered internal implants
placed in
sockets of teeth
FIG 7: Ridge expansion
using bone expansion
screws
5.
6.
7. FIG 20: Jaw relation
FIG 21: Verification jig in resin for
fit of the framework
8.
9.
10.
11. Q. Why was a flapless approach chosen for
implants in the mandible?
The CBCT showed good volume of bone in
the mandible at the sites where implants were
planned. The flapless implant placement is
minimally invasive and the postoperative
recovery after the procedure is very rapid. The
patient’s existing denture served as a stent and
the 2 extraction sockets of teeth # 33 and 43
provided a guideline for accurate implant
locations.
12. Q. What were the challenges faced in the surgery for maxillary
implant placement?
The bone volume in the maxilla in the sites of previous
extraction was very deficient. Hence bone manipulation and
augmentation procedures were used simultaneously to place
implants in the maxilla. The left maxillary sinus was grafted to
increase vertical height of bone. The anterior maxilla had
reduced width of bone. Hence, bone expansion
and GBR procedure using Calcium phosphosilicate putty and
collagen
membrane was performed at the location of teeth #12 and 22.
Since the
extraction sockets of teeth # 13, 14, 15 and 23 were found
suitable, implants were placed in those sockets and the gaps
were grafted with CPS putty.
13. Q. What prosthesis was the patient wearing
during the healing phase?
An immediate denture relined with a soft
denture reliner was used as an interim
prosthesis.
14. Q. Why were the mandibular and maxillary
maxillary prosthesis made at different times?
The mandibular implants were placed in
good non grafted sites. Hence, they were
ready for loading after 2 months. Since the
maxillary sites were compromised
and needed extensive grafting, the maxillary
implants were loaded after 6 months.
15. Q. Why were different impression procedures
chosen for the two arches?
The mandibular implants were almost parallel to each
other. A closed or an open tray technique is suitable in such
cases. In this case we chose an open tray impression in a
stock tray without splinting the impression posts. Due to
the configuration of the maxillary bone,
the implant angulations have a few degrees of divergence.
Hence an open tray impression procedure with a custom
tray and splinted impression posts was used to minimize
errors in transfer of the implant prosthetic platform.
16. Q. How was the jaw relation recorded?
A screw-retained base with a wax rim was
made to record the jaw relation. The firm base
rested on the implants and not the soft tissue.
This helped in reducing errors while recording
the relation of the maxilla against the
mandibular fixed prosthesis.
17. Q. Why were screw retained restorations
chosen?
The screw-retained restorations are easier to
maintain since they can be retrieved. That is a
big advantage while making multi implant
prosthesis.
18. Q. Why were different materials chosen for the
mandibular and maxillary prosthesis?
Porcelain fused to metal screw-retained bridge without
any flanges was chosen in the mandible for better
maintenance. A hybrid denture was chosen the maxilla to
compensate for the loss of the hand and soft tissue. The
labial contour needed to be optimum for adequate lip
support. A screw retained hybrid denture with acrylic
teeth served this purpose. Also, since the maxillary bone
was of poorer quality and had grafted sites, a softer
material like acrylic was chosen to reduce occlusal stresses
transmitted to the bone.
19. Q. Why was the mandibular prosthesis made in 2
pieces?
The terminal implants in the mandible were
placed bilaterally in the region of the first molar.
Flexure of the mandible while opening and closing
would have created stress in the prosthesis which
would eventually lead to bone loss around the
implants. The prosthesis was split between right
canine and first premolar region to minimize this
effect.
20. Q. How will the patient maintain the prosthesis?
The patient has been advised to use an oral
irrigation device for cleaning the prosthesis and
interdental brushes to clean the underside of the
bridge. The mandibular prosthesis being a
flangeless PFM prosthesis will be easier to maintain
compared to the one in the maxilla. During a 6
monthly recall, both the prosthesis will be removed
for cleaning and better maintenance.
