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Full Mouth Rehabilitation of Completely Edentulous Patient with Full Arch

Screw-Retained Prosthesis: A Case Report with 4 Year Follow Up

Article · February 2017

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Radwan Algabri Ahmed Yaseen Alqutaibi

Cairo University Cairo University
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Algabri et al
Full Mouth Rehabilitation of Completely
Edentulous Patient with Full Arch Screw-Retained
Prosthesis: A Case Report with 4 Year Follow Up

Algabri RS, PhD1 • Alqutaibi AY, PhD2 • Keshk AM, PhD3

Elkhadem AH, PhD4 • Fahmmy A, PhD5 • Aboalrejal HO, Ms6

Abstract

I
n completely edentulous patient’s rehabilita- complications is expected. In this case report,
tion with screw retained full arch fixed implant full mouth rehabilitation of patient with all on-4
supported prosthesis, the achievement pas- implant prosthesis was described. The treat-
sive fit of superstructure to the implants is con- ment performed includes full arch fixed implant
sidered as major challenge to prosthodontist. supported prosthesis for maxilla and mandi-
This passive fit is supposed to be one of the ble. To verify passive fit, a secondary splinting
most vital requirements for the maintenance impressions technique was used. The patient
of the osseointegration, otherwise unfavorable followed for four years with promising result.

KEY WORDS: Dental implants, Full arch, Maxilla, Mandible, Prosthetics

1. PhD Student, Department of Prosthodontics, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt
2. Lecturer, Department of Prosthodontics, Faculty of Oral and Dental Medicine. Ibb University, Ibb, Yemen.
3. PhD Student, Department of Prosthodontics, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt.
4. Associate professor, Department of Prosthodontics - Faculty of Oral and Dental Medicine. Cairo University, Cairo, Egypt.
5. Associate professor, Department of Prosthodontics - Faculty of Oral and Dental Medicine. Cairo University, Cairo, Egypt.
6. Ms student, Department of oral and maxillofacial radiology, Faculty of Oral and Dental Medicine, Cairo University,
Cairo, Egypt.

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 Algabri et al

Figure 1a: Intraoral photo of maxilla. Figure 1b: Intraoral photo of mandible.

INTRODUCTION which can compensate for superstructure dis-

Treatment of edentulous patients with implant- tortions and provide more passive fit.3 The accu-
retained prostheses provides predictable and racy of pouring technique affects the accuracy of
successful outcomes that overcome the func- the master casts which affect prosthesis fit. The
tional deficiencies which are associated with implant impression techniques can be divided into
conventional dentures. Patients prefer fixed over splinted or non-splinted techniques.4 The splinted
removable prostheses because they feel that a impression techniques can be performed either
fixed prosthesis is an integral part of their body.1 by splinting the impression transfer copings intra-
The implant-supported fixed prostheses comprise orally before impression making (primary splinted
screw and cement-retained superstructures. One technique) or splinting the implant analogues prior
of the considerable challenges for screw-retained to pouring of the impression (secondary splinted
multi-unit implant prosthesis is achieving passive technique).4 In this case report, full mouth rehabili-
fit of superstructure to the implants. This pas- tation of patient with all on-4 implant prosthesis
sive fit is supposed to be one of the most vital was described. The treatment performed includes
requirements for the maintenance of the osseo- full arch fixed implant supported prosthesis for
integration. Moreover, the misfit of the implant maxilla and mandible. The secondary splinting
supported superstructure may lead to unfavor- technique was used to decrease the discrepan-
able complications.2 The manifestations of these cies that result during pouring of the master casts.
complications may range from fracture of various
components in the implant system, and even loss CLINICAL REPORT
of osseointegration. On the other hand, cement- A 58-year-old, completely edentulous, medi-
retained implant prostheses have the potential cally fit male patient presented to Prosth-
for being passive because of the cement space odontics Department, Faculty of Dentistry

The Journal of Implant & Advanced Clinical Dentistry • 39

Algabri et al

Figure 2a: Maxillary surgical stent stabilized with fixation Figure 2b: Mandibular surgical stent stabilized with
screws. fixation screws.

Figure 3a: Prepared osteotomy sites in maxilla. Figure 3b: Prepared osteotomy sites in mandible.

– Cairo University with history of un-reten- Preoperative Planning

tive conventional complete dentures that ini- After primary impressions taken, diagnostic max-
tiate sever gag reflex in January 2012. The illary and mandibular casts were mounted on an
patient asked for fixed prosthesis for the upper articulator. A diagnostic wax up and set up was
and lower arches. Clinical and radiographic made to represent the anatomy and ideal posi-
examination revealed well developed maxil- tion of the planned implants. A duplicate of the
lary and mandibular arches (Figs.1a, 1b). wax up was then converted to a radiographic

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 Algabri et al

Figure 4a: Maxillary impression with acrylic resin splint. Figure 4b: Mandibular impression with acrylic resin splint.

Figure 5a: Maxillary master cast. Figure 5b: Mandibular master cast.

guide. The patient wore the radiographic guide ally placed at 12, 15, 22, 25 site for each arch
during CBCT scan. The CBCT data was then to support all on 4 maxillary and mandibular
imported into the planning software. Virtual fixed prosthesis. The virtual planning was sent
planning of dental implants according to the for construction of CAD /CAM surgical stents.
patient’s anatomy was then performed. Eight
implants are planned to place, 4 for maxilla Surgical Procedure
and 4 for mandible. The implants were virtu- Two hours before the surgery the patient received

The Journal of Implant & Advanced Clinical Dentistry • 41

Algabri et al

Figure 6a: Final restoration (maxillary view). Figure 6b: Final restoration (mandibular view).

Figure 6c: Final restoration (maximum intercuspation). Figure 7: Panoramic radiograph at 4 years post-op.

2gm Amoxicillin; an additional dose of 1g twice according to the manufacture instruction. Irri-
a day for 1 week after surgery, was prescribed. gation was very strictly ensured during drilling
Surgery was performed under local anesthesia. in all proposed sites. All the implants (DENTIS,
CAD /CAM surgical stent placed in the maxil- Korea) were installed in the proposed pre-
lary arch and fixed with anchoring pins. Flapless operative planned sites and covering screws
implant site preparation was followed. The stent were placed to all implants (Figs. 3a, 3b).
was stabilized using fixation anchor screws as Postoperative instructions were given as
planned pre-operatively. Similar procedures patients were instructed to apply ice packs
were followed for the lower arch (Figs. 2a, for the first 24 hours and follow the antibi-
2b). The sequence of drilling was carried out otic regimen for five days. 0.2% Chlorhexi-

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 Algabri et al

dine mouth wash solution was prescribed struction, metal framework fabrication and
for the patients at least two times daily for definite prosthesis delivery were followed. The
3 days. The patient upper and lower den- final fit, stability and occlusion were evaluated.
tures were relieved and a soft liner (Acros- The patient was instructed on maintenance
tone, Acrostone Relining Materials) was of the health of the oral tissues. The patient
applied to help in seating of the denture after returned for a 1-week, 1-month 6-months,
implant installation. After implant installation, 12 months, 2 years and 4 years post inser-
a post-operative panoramic x-ray was made. tion appointments stating that he was satisfied
with the esthetics and function of the maxillary
Prosthetic Procedure and mandibular prosthesis (Figs. 6a-c and 7).
After 6 months of implant placement the sec-
ondary splinted impression was performed. DISCUSSION
acrylic custom trays for the patient were man- The All-on-4 concept is a highly successful
ufactured for upper and lower jaws both treatment option for the edentulous patient with
utilizing open tray non-splinted impression excellent clinical outcomes. This is achieved
technique. Master casts generated from non- without major grafting and its associated costs
splinted coping impression technique, and and surgical morbidity.5 To ensure ideal place-
the lab analogues were splinted before pour- ment of the implants providing favorable force
ing the impression through joining them with direction on the implants and the prosthetic
low shrinkage cold cure acrylic resin (Bredent. components, the patient denture was dupli-
Multisil-mask. cold cure gingival mask resin. cated to act as a radiographic templates.6
Germany). The resin was injected to surround Accurate assessment of the peri-implant site is
each implant analogue using cartridge dis- essential for the establishment of a success-
penser until it was reaching a reasonable thick- ful dental implant treatment plane. The success
ness covering a part of the implants analogues key of any surgical implant procedure is the
(Figs. 4a, 4b). After one hour the imperssion, proper pre-operative treatment planning. In this
secondary splinted, was poured with extra- case, the implants were inserted through the
hard type IV dental stone(Kimberlit, Type IV surgical guide with a flapless technique. Accu-
Dental Stone, Protechno- Spain) that was rate surgical guides were fabricated, precise
manipulated with a vacuum machine(Vacuum surgical instrumentation and 3D virtual plan-
mixer. BEGO Motova sl.U.S.A), with a powder/ ning technique aid in placing implants without
water ratio of 100g/20ml mixed for 30 sec- raising a flap and improving their clinical out-
onds. The pouring was under constant vibration comes.7, 8 The surgical procedures were done
(Lab vibrator. BEGO Motova sl.U.S.A) into the under complete aseptic conditions to control
impression. After set, 25 minutes, the impres- infection during and after implant installation.
sions were separated from the casts (Figs. 5a, Pre-surgical antibiotics and chlorhexidine were
5b). After that a classical steps of prosthesis prescribed to the patients to reduce the bac-
construction that include verification jig con- terial load and prevent infection during the ini-

The Journal of Implant & Advanced Clinical Dentistry • 43

Algabri et al

tial healing period from the surgical wound,9 and impression procedure using rigid material is
so significant decrease in implant failure occurs to stabilize and prevent the rotational, hori-
with the use of postoperative antibiotics.10 zontal and vertical movements of implant cop-
For secondary impression, direct opened tray ings during removal of the impression and
impression technique was performed as recom- due to shrinkage of the impression material as
mended by Filho et al.11 The open tray technique reported by Hussaini and Wong.23 Also splint-
allows for the impression coping to stay in the ing of implant analogues during pouring proce-
impression. This reduces the effect of implant dure is to stabilize and prevent the movements
angulation, the deformation of the impression of them due to expansion of the stone.24, 25
material upon recovery from mouth, and removes In this case, a promising result appeared, the
the concern for replacing the coping back framework generated from secondary splinting
into its respective space in the impression.12 impression pouring technique was passively fit in
Addition silicon impression material was patient mouth as indicated by single screw test
used in this study as it produce highly accu- and radiograph. This result suggests the impor-
rate impressions because they reproduce fine tant role of splinting the implant analogues prior
surface detail, and have excellent elastic recov- to pouring in preventing displacement of the
ery, adequate tear strengths, and exceptional analogues. Deformation of impression copings
dimensional stability. Also they are compat- during removal of non-splinted impressions is
ible with all common die materials, can be dis- usually reversible due to the high elastic recov-
infected or sterilized, and can be repoured ery of the addition silicone. Without this tech-
after delayed periods. Also they are dispensed nique, a distortion of non-splinted analogues
in convenient auto-mixing dual cartridges or may result due to expansion of gypsum prod-
single tubes and are available in several vis- uct during setting that is irreversible because
cosities.13 The application of auto-polymerizing of the fact that analogues in the set model will
acrylic resin as a splinting material had been be permanently fixed in the distorted position.
reported in several studies.4,14-20 Jørgensen and
Kono21 showed that vacuum mixing increased CONCLUSION
the compressive strength of dental stone Secondary splinting of implant analogues
by 20% owing to reduced gypsum porosity. prior to pouring was easy and reliable
The accuracy of the master cast can be method to obtain accurate master casts.
verified before the metal framework is cast. Non-splinted impression pouring technique
A verification jig is commonly used to record should always be verified to assess accu-
the accurate 3-dimentional relationship of racy before construct the framework. l
the implants, serve as a guide for a corrected
cast procedure, transfer occlusal relations Correspondence:
and gnathologic recordings to the articula- Dr. Ahmed Yaseen Alqutaibi
tor and verify the fit of the metal framework.22 Email: [email protected]
The splinting of implant copings during

44 • Vol. 9, No. 2 • February 2017

 Algabri et al

Disclosure [9] A
 bu-Ta’a M, Quirynen M, Teughels W, van [18] Vigolo P, Fonzi F, Majzoub Z, Cordioli G. An
The authors report no conflicts of interest with Steenberghe D. Asepsis during periodontal evaluation of impression techniques for multiple
anything mentioned in this case report. surgery involving oral implants and the internal connection implant prostheses. The
usefulness of peri-operative antibiotics: a Journal of prosthetic dentistry. 2004;92:470-6.
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