Dr. Ara Nazarian describes how full mouth restorations can be achieved within budget and time constraints.
Dr. Ara Nazarian offers options to fit a patient’s lifestyle and budget
In today’s economy, we have seen dramatic changes in lifestyle, health, and income. Because of this, we have seen patients delay dental treatment until it ultimately becomes very painful. Although patients may want full mouth dental implant reconstructions with fixed restorations, this may not always be something that fits into their budget. As dental providers, we need to offer our patients a variety of different treatment options in order to restore their dentition to proper form and function. This article focuses on the steps involved in providing denture and overdenture treatment in addition to extractions, grafting, and dental implant placement.
A patient presented to my practice for a consultation wanting to restore his smile. He complained of generalized discomfort in his teeth due to the caries and periodontal disease that was readily apparent (Figures 1-4). Previously, the patient had teeth removed, one at a time, when there was severe pain or infection. However, this time he wanted to have a “game plan” and be proactive in any suggested treatment that would fit into his budget. He had already been informed by a few dental providers that he would probably need all his remaining teeth removed due to his advanced periodontal disease so he was aware that this might be the case.
At the consultation appointment, the patient was informed that we would require a CBCT to assist us in accurately diagnosing his dental conditions (Figure 5). Using the CS 8100 3D (Carestream Dental), a CBCT was taken so that we would be able to identify not only the areas of infection and decay, but also the areas of remaining bone for dental implant placement. Since the patient had expressed his concern about cost, our goal was to not only find a treatment modality that would restore esthetics and function cost economically, but also provide a treatment that could potentially be upgraded in the future.
Preliminary impressions for immediate dentures were obtained using Silginat® (Kettenbach), a cost-effective elastomeric polyvinyl siloxane (PVS) impression material. Orthodontic retractors were utilized in order to observe the patient was accurately biting in centric occlusion (CO) when capturing the bite registration with fast-setting Futar® (Kettenbach) bite material. Photographs of the patient’s smile and midline were acquired in order to properly inform the dental laboratory of any changes that were desired, including tooth position, tooth size, and arch form for the immediate dentures.
All risks, benefits, and alternatives were fully described to the patient, and any questions were fully answered. Upon listening to the various treatment options, the patient decided to have all his remaining teeth extracted and those sites grafted. The patient would be getting a complete denture in the upper arch whereas in the lower arch, he would be getting an overdenture retained by four dental implants.
In order to assist the patient with this investment, financing options using a third-party payment option (Alphaeon Credit) was discussed. This consideration was a very important part of facilitating acceptance of his care since it made the cost of treatment more economical.
Once anesthesia was acquired (Figure 6), we started removing the teeth in the maxillary arch using the Physics Forceps® (Goldendent) (Figure 7). Since the Physics Forceps act like a Class I lever, the only force applied with the beak is on the lingual aspect of the tooth.
With the beak positioned at the lingual cervical portion, the soft bumper is placed on the buccal alveolar ridge at the approximate location of the mucogingival junction. While the beak grasps the tooth, the bumper acts as the fulcrum providing leverage and stability for the beak. Extraction is accomplished with slight wrist movement rotation in the buccal direction for about 30 to 60 seconds depending on the length and curvature of the roots.
Once the teeth in the maxillary arch were removed, any granulation tissue remaining within the sockets was removed using a curette (Goldendent), and any sharp areas of the alveolar crest were smoothed with a bone bur (Goldendent). OsteoGen® plugs (Goldendent) were placed in each socket to facilitate bone growth within the sockets over a 4- to 5-month period for future implant placement if the patient desired. Using resorbable sutures, the OsteoGen plugs were further stabilized and the tissue sutured (Figure 8).
The immediate maxillary denture was tried in to confirm a passive placement as well as a visual inspection of the patient’s midline (Figure 9). Once this was confirmed, and the immediate denture was fully seated, a self-cured, silicone-based soft reline material (Sofreliner Tough® Medium, Tokuyama Dental) was used to line the inner aspects. According to the manufacturer, Sofreliner Tough is designed to provide long-lasting consistent relief with outstanding durability for up to 2 years, superb stain and odor resistance, and excellent adhesion to the denture.
The GoldenForce Forceps (Goldendent) in the lower arch (Figure 10) were used to remove any remaining teeth in the lower arch (Figure 11). The remaining sockets were curetted to further remove any debris or granulation tissue.
Once the sockets were curetted and irrigated with surgical saline, the necessary drilling steps were followed for the preparation of osteotomies in the placement of Touareg® OS (Adin) dental implants (Figure 12). This implant was utilized because it is uniquely designed for immediate function for all bone types, with optimal implant-abutment seating, minimal horizontal bone stress and retention-screw loading stress.
Since the patient was interested in upgrading to a lower FPD restoration in the future, additional implants were placed in key position areas as compared to traditional placement of just two or four dental implants for an overdenture. Two 3.50 mm x 13.0 mm Touareg OS (Adin) dental implants and four Touareg-OS (Adin) 4.20 mm x 10 mm (Figures 13 and 14) were torqued down to the desired depth at approximately 50Ncm.
The Touareg OS Spiral Implant (Adin) is a tapered implant with a spiral tap that condenses the bone during placement for immediate stability. It has two large variable threads and a tapered design for accurate implant placement, self-drilling, and better load distribution.
Once fully torqued down, four 5 mm height Zest Locators® were inserted within the implants using the Zest tool. Using a torque wrench with the appropriate adapter, the Zest Locators were tightened to 30Ncm. Now that the internal aspect of the dental implants was sealed, bone-grafting putty material (Goldendent) was injected and packed in any remaining voids in the bone (Figure 15). Using resorbable sutures, primary closure was accomplished around the locations of the implants (Figure 16). In order to avoid tearing the sutures during the pickup procedure of the Zest housings, small strips of C-fold towel were used to cover any exposed areas of the sutures.
Since the bone had been leveled with the guide, there were no interferences detected between the denture base and attachments in the anterior portion of the immediate denture. Using Tokuyama® Rebase II Chairside Hard Denture Reline (Tokuyama Dental), the female components of the Zest Locators would be picked up. Since this material is methyl methacrylate-free, it doesn’t have a strong odor or taste in addition to very minimal heat generation.
The first step in the pickup process was to brush a thin coat of Rebase II adhesive included in the Rebase II kit (Tokuyama Dental) into the area of the overdenture attachments. This would enhance the chemical retention between the denture base and the hard reline/pickup material. KY® lubricant was applied to the surrounding surfaces of the denture to prevent unwanted adherence of excess material. Once the powder and liquid of Rebase II material was mixed, it was then placed into a plastic dispensing syringe and injected into the internal anterior portion of the lower immediate denture as well as on to the receptor attachments.
The prosthesis was held in position by the patient biting together in centric occlusion bite captured previously with Futar (Kettenbach) bite material (Figure 17). After approximately 3 minutes, the overdenture with the incorporated retention caps was removed, and any excess material was removed with a trimming bur. The bite of the upper immediate denture with soft reline opposing the lower overdenture was verified and any interference eliminated. The patient was instructed to return in a week for a follow up. In 3 to 4 months following his surgery, we would do an indirect reline of both upper denture and lower overdenture to compensate for any settling of bone and tissue. The patient was very pleased with the final outcome of his treatment (Figures 18-20) and actually referred several patients to the practice.
As we see more patients presenting with dental issues requiring full mouth edentulation, we need to offer a variety of different treatment modalities to accommodate their esthetic and functional needs in addition to fitting their budget. Overdentures, which can later be upgraded to fixed restorations with additional dental implant therapy, are a great treatment option for these patients.
Besides full mouth restoration, Dr. Nazarian has written on immediate loading implants. Read about how to care for the contemporary implant patient here: https://implantpracticeus.com/immediate-loading-dental-implants-todays-patient/