Full mouth rehabilitation utilizing traditional fixed and removable prostheses

Treatment plan

The accepted treatment plan is extraction of teeth #6, 11, 24, 25, and 26 (non-restorable), followed by initial maxillary and mandibular scaling and root planning. Root canal therapy is needed for tooth #22, coupled with a prefabricated post and core build-up material and a surveyed metal ceramic restoration. Crowns will be fabricated for teeth #21, 22, 27 and 28 as well as #8, 9, and 10 (#21 and 28 will have semi-precision attachments). The maxillary dentition will receive a maxillary Kennedy Class III, Modification I removable partial denture following the fabrication of fixed partial dentures for teeth #8, 9, and 10. Teeth #2 and 3 will have a lab-processed restoration (gold onlays with rest seat) following caries excavation and sedation. After caries excavation, the patient will have an endodontic referral for a prognosis of the teeth. Teeth #15 and 16 require a Class I posterior composite restoration (3M ESPE Z100, St. Paul, MN, U.S.A.). The final restoration for the mandibular dentition will be a fixed partial denture from tooth #21 through tooth 28 in combination with a semi-precision Kennedy Class I removable partial denture.

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Treatment sequence

It is important to remind the patient before starting any treatment plan that the rehabilitation process will be long and arduous, requiring both patient patience and a strong commitment. During the first treatment session, the extraction of teeth #24, 25, 26 and root tips #6 and 11 under local anesthesia (Lidocaine HCl with epinephrine 1:100,000, Graham Chemical Co., Barrington, IL, U.S.A.) is performed and 4-0 chromic gut sutures are placed. The patient is then given time to recuperate. At the second visit, non-surgical periodontal therapy is administered on the maxillary posterior teeth, which included scaling and root planning. Oral hygiene instructions are presented at this time. On the third visit, the remaining dentitions receive periodontal therapy. On the fourth visit, root canal therapy is initiated and completed for tooth #22 in same visit. During the fifth visit, tooth #22 is prepared for a prefabricated Para-Post metal post size 4 (Coltene Whaledent, Cuyahoga Falls, OH, U.S.A.) and Ti-Core white core build-up material (Essential Dental Systems, Hackensack, NJ, U.S.A.). On this visit, teeth #21 and 22 are prepared for metal ceramic restorations using diamond burs (Brasseler, Savannah, GA, U.S.A.). The restored abutment teeth are protected with full coverage provisional restorations fabricated using

8. Lab putty index of wax-up of fixed partial denture #21-28 was used to fabricate provisional bridge with autopolymerizing acrylic.

Trim II autopolymerizing acrylic (HJB Bosworth, Skokie, IL, U.S.A.) and cemented with non-eugenol TempBond, (Kerr Corp., Orange, CA, U.S.A.). At the sixth visit, teeth #27 and 28 are prepared for metal ceramic restorations using diamond burs. A lab putty index of the wax-up of fixed partial denture #21-28 is used to fabricate a provisional bridge using Trim II autopolymerizing acrylic (HJB Bosworth, Skokie, IL, U.S.A.), which is cemented using non-eugenol TempBond (Kerr Corp., Orange, CA, U.S.A.) (Figure 8). On the seventh visit, teeth #8, 9, and 10 are prepared for core build-up material and then prepared with 45-degree bevels. The abutments then are provisionalized using Biotemps (Glidewell Laboratories, Newport Beach, CA, U.S.A.) for aesthetic reasons and cemented with non-eugenol TempBond (Kerr Corp., Orange, CA, U.S.A.). This provisional restoration will serve as a guide for the fabrication of the final prostheses by evaluating the patients’ smile line, tooth form, and labial support. On the eighth visit, a secondary impression of teeth #8, 9, and 10 is made with a stock tray (Benco Dental, Wilkes-Barre, PA, U.S.A.), and a retraction cord 2 (Ultradent, Jordan, UT, U.S.A.) soaked in a hemostatic agent Hemodent (Premier Dental, Plymouth Meetings, PA, U.S.A.) is placed around the sulcus of each abutment tooth. Permadyne light-body polyether impression material (3M ESPE, St. Paul, MN, U.S.A.) and Impregum Penta heavy body polyether (3M ESPE, St. Paul, MN, U.S.A.) impression material are used to capture the optimal tooth surface and finish-line details. The impression along with work authorization is then sent to the dental verifilaboratory to begin fabrication of the final restorations. The secondary impression including the mould and shade of teeth are made and sent to the dental laboratory with a work authorization. On the ninth visit, the wax-up transitional maxillary and mandibular removable partial denture with acrylic teeth is tried in and adjustments made based on aesthetics, phonetics, and patient’s wishes. The patient returned on the tenth visit for delivery of the maxillary and mandibular transitional removable partial dentures6. On the eleventh visit, small occlusal and lingual carious lesions on teeth #14 and 15 are restored using posterior composite (3M ESPE Z100, St. Paul, MN, U.S.A.). On the twelfth visit, an impression of crowns #21 through 28 is made using a stock tray (Benco Dental, Wilkes-Barre, PA, U.S.A.). Retraction cord #2 (Ultradent, Jordan, UT, U.S.A.) soaked in Hemodent hemostatic agent (Premier Dental, Plymouth Meeting, PA, U.S.A.) is packed around teeth #21, 22, 27, and 28. Permadyne light-body polyether (3M ESPE, St. Paul, MN, U.S.A.) and Impregum Penta heavy-body polyether (3M ESPE, St. Paul, MN, U.S.A.) impression materials are used to make the final impressions. The case is then sent to the dental laboratory to begin fabrication of the final restorations. The thirteenth visit marks the start of the fabrication of semi-precision attachments. On this visit, the patient has the castings of fixed partial denture #21 through 28 to confirm seating using a GC fit checker (GC America, Alsip, IL, U.S.A.). The castings are returned as two separate units. The distal abutment teeth housing the matrix attachments for the Thompson dowel semi-precision attachment are inspected. A solder connection index is obtained with GC acrylic resin (GC America, Alsip, IL, U.S.A.). A pickup impression of the castings and edentulous areas is obtained for the lower denture fabrication using a custom tray border molded with green compound (Kerr Corp., Orange, CA, U.S.A.) and filled with Impregum impression material (3M ESPE, St. Paul, MN, U.S.A.). On the fourteenth visit, the laboratory returned the lower removable partial denture cast chromium cobalt framework with distal abutment #21 and 28 Thompson dowel semi-precision attachments. The patrix and matrix attachments of the Thompson dowel assembly and removable partial dentures are constructed of Jensen gold alloy (Jensen Dental, North Haven, CT, U.S.A.) soldered onto the prostheses. The abutments and framework are evaluated for fit of the major connector over the edentulous ridges. The removable partial denture design for the intaglio surface included a metal base over the retro-molar pads and mesh-work over the edentulous ridges7. The lingual plate is evaluated over the lingual surface of the castings, as well as the fit of the matrix into the patrix of the semi-precision attachments. A centric related jaw record is captured using Sil-Tech bite registration polyvinylsiloxane impression material (Ivoclar Vivadent, Amherst, NY, U.S.A.) and the case is returned to the dental laboratory. During the fourteenth visit, castings for copings #8, 9, and 10 are tried in. The distal of #8 and 10 have deep lingual rest seats for the minor connectors of the maxillary removable partial denture. A palatal strap was chosen for the major connector. Circumferential clasps are placed on teeth #2, 3, 14, and 15. After verifying the fit of the removable partial denture, the case is sent back to the dental laboratory with work authorization to add denture teeth in wax of the removable partial denture frame. The metal ceramic shade was chosen. At the fifteenth visit, the try-in of maxillary and mandibular removable prostheses at the wax-up stage is completed (Figure 9).

9. Try-in of maxillary and mandibular removable prostheses at the wax-up stage. 

The fixed partial dentures are also evaluated at this time at the bisquebake porcelain stage. Vertical dimension of occlusion, labial drape, and aesthetics are all evaluated. Lastly, the patient’s speech was tested, especially with words using the “s” and “f” sounds. The work authorization for final glaze of the metal ceramic restorations and final processing of the RPDs is processed. The processed final prostheses are articulated in a Hanau articulator (Whip Mix, Louisville, KY, U.S.A.) and the centric relation is verified using three new bite registrations using green wax (Aluwax Dental Products Co., Allendale, MI, U.S.A.). Minor occlusal adjustments are necessary. On the sixteenth visit, provisional and transitional restorations are removed, and the maxillary and the mandibular fixed partial dentures are cemented with Optow Trial Cement (Waterpik, Fort Collings, CO, U.S.A.). The maxillary conventional RPD and mandibular semi-precision RPD are delivered (Figure 10). Evaluation of the patients’ occlusal relationships, denture base impingement, and aesthetics are done, followed by oral hygiene reinforcement. The patient is given postinsertion instruction and a follow up visit. In the follow up visit, the patient’s complaints are addressed. On the last visit, when all of the patients’ complaints have been addressed, all fixed partial dentures are removed. The abutment core structures are cleaned and final cement is used (Rely X, 3M ESPE, St. Paul, MN. U.S.A.). Excess cement is cleaned off the margins. The post-op instructions are again given to patient and patient is put on a six-month recall for follow up.

Full mouth rehabilitation utilizing traditional fixed and removable prostheses - Ultima modifica: 2013-04-13T15:51:31+00:00 da Redazione

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