IFCIA - Hadi Antoun Menu
  • The institute
    • Hadi Antoun
    • Study Group
    • Contributors
    • Testimonies
    • IFCIA Newsletter
  • Courses
    • The All-on-4® approach
    • La Régénération Osseuse Guidée
    • Les Greffes de Sinus
    • Bone grafting in Implantology
    • Soft Tissue Management
  • Publications
    • Clinical Cases
  • Mes ouvrages
  • News
  • Contact
    • Coming to the Institute
    • Inquire about our courses
  • Registrations
  • Covid-19
  • My account
  • Version française
All publications

Complete rehabilitation: from pre-implant surgery to immediate prosthesis 6 November 2014

Clinical case

Case history and general health

  • A 63 year-old woman, with no medical history and no general contraindications, consults for an overall treatment plan. She smokes 15 cigarettes per day and has the impression of having suffered from "40 years of dental care".
  • She has little respect for her teeth. She has never been informed of periodontal diseases and has never received any periodontal treatment nor any oral hygiene instructions. The functional and aesthetic demand is high.

 

We observe:

  • 2 removable prostheses with visible clasps and an adequate prosthetic space;
  • A large accumulation of tartar with colouring;
  • Anterior maxilla edentulism, old bridge on sector 2, important recessions and periodontal retractions;
  • More or less serious bleeding on probing, endodontic lesions and a terminal phase mobility around the maxilla;
  • Topographical survey of initial pockets with generalised 8 to 15mm pockets, affected furcations on tooth 16 and 48 in the mesial plan.
  • Migration of teeth, total loss of gingival attachment at the edentulous level, although keratinised and thick, mastication is difficult.

Fig. 1 : Examen clinique initial montrant le port de prothèses amovibles avec des crochets visibles, du tartre en grande quantité et des dénudations radiculaires. Une situation vécue douloureusement par la patiente. Noter l’espace prothétique convenable.

Fig. 1: Initial clinical examination showing the removable prostheses with visible clasps, a large accumulation of tartar and root denudations. A painful experience for the patient.

Fig. 2: The anterior edentulism has resulted in a ridge and a total loss of gingival attachment. Nonetheless, the periodontal biotype remains thick.

Fig. 3: Initial panoramic X-ray showing the depth of periodontal lesions, the affected furcations, the general osseous loss and deep caries in the maxillary.

  • The cone beam X-ray examination (Fig. 4a and 4b) shows roots outside the alveolar bones, thin ridges, molars surrounded by important osteolysis, near complete destruction of vestibular and palatal tables as well as a low height of sinus floor without effraction of the inferior wall.

Figs 4a and b: Cone beam X-ray shows residual dental roots outside of the alveolar bones, an important osteolysis which has led to a low height of the sinus floor and reduced bone thickness.


Fig. 4b

November 2011
Treatment decision

  • Initial periodontal treatment: root planning, commitment, education in oral hygiene and maintenance;
  • Extractions of superior maxilla teeth;
  • Provisional removable complete denture;
  • Anterior onlay graft and bilateral sinus augmentation;
  • 8 buried implants;
  • Immediate Aesthetics and Loading,
  • Final screw-retained complete zirconia-ceramic prosthesis.
  • The provisional removable complete denture (Fig. 5), pre-prepared with a spaced individual impression tray, will meet all the aesthetic, functional and occlusion criteria and will be our best ally for the rest of the treatment. Therefore, it should be prepared carefully, as if it were our only treatment plan. A reasonable period of periodontal maintenance (Fig. 6), healing and aesthetic and functional validation for this first step of the treatment is necessary.
  • A precise aesthetic analysis taking into account the anatomic variations, the lip support, the residual bone position, and teeth proportions and positions is essential in order to find out the available prosthetic space which will need or not a final prosthesis with a false gingiva.

 

Fig. 5: The provisional removable complete denture must be completely satisfying at the functional and aesthetic levels. This will be crucial for the rest of the treatment.

Fig. 6: The initial periodontal treatment must be accompanied by rigorous maintenance as well as unfailing commitment. This is a prerequisite prior to any implant prosthetic treatment.

March 2012
Pre-implant surgery (Fig. 7)

In the course of the same session, a bilateral sinus augmentation and an onlay graft in the anterior sectors are performed with allogeneic blocks of cadavers from the Tissue Bank of France (Phoenix®) and fixed with 2 osteosynthesis screws each

Fig. 7 : Une chirurgie pré-implantaire sera nécessaire. Un comblement sinusien bilatéral ainsi qu’une greffe d’apposition dans les secteurs antérieurs seront réalisés lors de la même séance. L’utilisation d’os de banque d’origine allogénique évitera à la patiente un important prélèvement autogène et permettra des suites post-opératoires plus simples.

Fig. 7: A bilateral sinus augmentation as well as an onlay graft in the anterior sectors will be performed during the same session. The use of allogeneic bone from a bank avoids considerable autogenous sampling and will allow for a simpler post-operative course.

October 2012
Placement of 8 implants (Fig. 8)

  • A 3D X-ray control of the bone healing is performed with a radiological and surgical guide (duplicate of the removable complete denture). 8 implants (Branemark System MK3 and Speedy Groovy, Nobel Biocare) are placed using the buried method in order to allow the patient to keep her removable prosthesis during the healing phase.

Fig. 8 : Après une période de cicatrisation de 6 mois, huit implants (Branemark System et Speedy, Nobel Biocare®), seront harmonieusement placés sur l’arcade en méthode enfouie grâce à un guide chirurgical réalisé à partir d’un duplicata de la prothèse complète amovible.

Fig. 8: After a 6-month healing period, 8 implants are harmoniously placed on the arch with the buried method.

February 2013
Functional loading (Fig. 9)

  • After an implant healing period (4 months), loading is performed within 24 hours thanks to the removable complete denture which will be transformed into a provisional bridge. A transitional period of several months is then necessary in order to check all functional, phonation and aesthetic parametersAfter an implant healing period (4 months), loading is performed within 24 hours thanks to the removable complete denture which will be transformed into a provisional bridge. A transitional period of several months is then necessary in order to check all functional, phonation and aesthetic parameters

Fig. 9 : Mise en fonction après 4 mois de cicatrisation. Mise en place de piliers MUA RP 1mm (Multi-unit Abutment, Nobel Biocare) vissées à 35N/cm. Des cylindres provisoires seront placés et serviront à une empreinte immédiate. La prothèse amovible complète sera dans les 24 heures transformée en bridge provisoire fixe.

Fig. 9: Functional loading after 4 months of healing. Placement of MUA RP 1mm abutments (Multi-unit Abutment®, Nobel Biocare) tightened at 35N/cm. Provisional cylinders are placed and will be used for an immediate impression.

September 2013
Screw-retained zirconia-ceramic final prosthesis (Figs. 10 to 12).

  • A plaster impression is made with the copings in place. Even if done with great precision, a plaster core will be tried in order to validate this step. An aesthetic teeth arrangement is produced and tried in the mouth. After validation, the fabrication of the zirconia framework using CAD/CAM can begin. This method guarantees a passive fit in comparison with cast frameworks. The zirconia framework shows excellent mechanical properties and of biocompatibility.
  • Then, the stratification of ceramics will start. A ceramic thickness of 1.5 to 2mm maximum will prevent any fracture of the ceramics.
  • The quality of work and experience of the prosthesist are crucial to the success of this step. Sufficient time (about a month) is needed for the production of the zirconia framework and for the stratification of ceramics.

Fig. 10 : La forme et le profil d’émergence et l’intrados du bridge provisoire permettront une meilleure intégration biologique et esthétique de la reconstruction définitive. Une période raisonnable de transition de plusieurs mois avant l’empreinte définitive est nécessaire afin de valider tous les paramètres fonctionnels et esthétiques.

Fig. 10: The shape, the emergence profile and the basal surface of the provisional bridge will enable better biological and aesthetic integration of the final rehabilitation.

Fig. 11 : L’empreinte sera réalisée grâce à un PEI et de préférence toujours au plâtre. C’est une condition essentielle pour l’obtention d’une armature passive.

Fig. 11: The impression will be made using an individual impression tray and, preferably, always in plaster so that a passive framework can be produced.

Fig. 12 : L’armature en zircone (Procera®, Nobel Biocare) est réalisée ainsi que la stratification de la céramique. Noter la présence de la fausse gencive en céramique rose afin de palier à la résorption osseuse dans le sens vertical (Prothésiste M. Jean-Pierre Casu, laboratoire Kosmeteeth, Nice).

Fig. 12: The zirconia framework (Procera®, Nobel Biocare) and the ceramics stratification are produced. Note the presence and the quality of the buccal flange in pink ceramic to overcome any osseous resorption in the vertical direction (Prosthetist Mr. Jean-Pierre Casu, Laboratory Kosmeteeth, Nice).

  • The denture (Fig. 13 to 15) is tried on over a long session to check the passive fit of the prosthesis as well as all the functional and aesthetic parameters determined during the transition period of the provisional bridge. If necessary, the occlusion is adjusted directly in the mouth.

Fig. 13 : Pose de la prothèse d’usage en bouche et réglage de l’occlusion.

Fig. 13: Try-on of the final prosthesis in the mouth and adjustments of the occlusion.

 

Fig. 14 : Vue clinique occlusale montrant la répartition harmonieuse des implants sur l’arcade maxillaire, malgré le positionnement plus palatin des implants antérieurs afin d’éviter la partie corticale des greffes d’apposition.

Fig. 14: Occlusal clinical view showing the harmonious distribution of the implants on the maxillary arch, despite the more palatal position of the anterior implants in order to avoid the cortical part of the onlay graft.

Fig. 15 : Ligne du sourire idéalisée et très bonne intégration esthétique de la prothèse d’usage permettant une satisfaction de la patiente tant au niveau fonctionnel qu’esthétique.

Fig. 15: Idealised smile line and excellent aesthetic integration of the final prosthesis ensuring the patient's satisfaction at the functional and aesthetic levels.

Conclusion

The main purpose of such a prosthetic rehabilitation, which lasted 2 years, is the patient's satisfaction at functional and aesthetic levels.

A preliminary pre-prosthetic project is essential and will be instrumental in the progress of the treatment plan; the prosthesis guides the surgery and not the opposite. The experience and understanding of the surgery and prosthetics team in partnership with those of the prosthetist will be key to the success of this type of treatment.

Periodontal maintenance and a permanent commitment are inseparable from the longevity of the treatment; the patient must be accompanied at all stages of the treatment.

Recommended reading

Attard N. J., Zarb G. Long-term treatment outcomes in edentulous patients with implant-fixed prostheses: the Toronto study. Int J Prosth 2004;17:417-424.

Antoun H. Les greffes de sinus en implantologie, éditions CdP, 2011

Mainjot AK, Schajer GS, Vanheusden AJ, Sadoun MJ. Influence of zirconia framework thickness on residual stress profile in veneering ceramic: measurement by hole-drilling. Dent Mater 2012:28:378-84.

Novell J, Novell-Costa F, Ivorra C, Fariñas O, Munilla A, Martinez C. Five-year results of implants inserted into freeze-dried block allografts. Implant Dent. 2012;21:129-135.

Authors:

Hadi Antoun

Private practice solely limited to Periodontology and Implantology, Paris
Founder of the IFCIA Institute

Joseph Eid

Private practice, Neuilly sur Seine
Postgraduate degree Surgery and Implant Prosthesis
Paris V

Posted on 06/11/2014 in « Clinical Cases »
Last update : 15/03/2018 11:26
Share this publication
IFCIA - Hadi Antoun
11 bis, avenue Mac Mahon
75017 Paris
Telephone : + 33 (0)1 85 09 22 89
Follow us Twitter Facebook Instagram Linkedin
IFCIA Website
  • The institute
  • Courses
  • Clinical Cases
  • Publications
  • News
  • Partner hotels
Contact
Next training sessions
  • 16 & 17 March 2023 - La Régénération Osseuse Guidée
  • 15 & 16 June 2023 - Traitement de l’Édenté Complet en Implantologie
  • 6 & 7 July 2023 - Aménagements Muqueux sur dents
Subscription to IFCIA Newsletter Archives
Our partners
Biotech DentalBiobank
Geistlich BiomaterialsIPP PharmaDental ForceHu-Friedy Group3MC ConceptEklerMeisingerPhilips

Statutory rights - Cookies - General terms and conditions of sale

IFCIA - Hadi Antoun - Paris © 2003 - 2023 - All rights reserved

This website is certified by Health On the Net Foundation.

This site complies with the HONcode standard for trustworthy health information.

Verify here.