Case #5 By Borja Diaz Oliver

Written on 08/04/2017
Masoud Abu Zant

Case by Dr. Borja Diaz, Madrid-Spain
Technician. Salvatore Fiorillo.

A 55-year-old patient comes to the office demanding implant treatment.

We performed previous periodontal study. She was treated several years ago with periodontal surgery.

At the exploration there is type II and III mobility in almost all the teeth with big pockets and furc lesions in the posterior sectors so it is decided to speak with the patient to communicate that we are inclined to the extraction of all the teeth and placement of upper and lower implants with immediate loading prosthesis.

Through conscious sedation we decided to perform all the treatment in a single session making extraction of all the teeth in the upper and lower arches with placement of 8 upper implants and 6 lower implants post-extraction, and ordered to the lab 2 prosthesis of immediate loading that will be placed on the same day of the surgery only 8 hours later.

First we made a resin prosthesis with loosen contact with the gingiva to leave room for the regeneration of tissues.

After 4 months we made a new provisional prosthesis where we will start to work on the creation of ovoid pontics in order to start the soft tissue management.

Once we have a good design of the gingival architecture we make the definitive prosthesis.

As a case of soft tissue and implant management we decided to perform our DSD during the upper prosthesis biscuit test to minimize errors.

We finish with a metal ceramic upper prosthesis and hybrid resin in lower jaw.

Given the achieved nature of the gingival architecture, we decided that it is a good case to make a check between metal-ceramic and zirconium structures and to test the behavior of the tissues and aesthetics differences with different materials.

We perform a scan of the metal-ceramic prosthesis that we sent to the laboratory for the making of a zirconium prosthesis as similar as possible.

Although we know that it will be a controversial issue, since we have two prostheses for the same patient, we decided to carry out the following study.

There are numerous problems today to combine ceramic materials on implants in both arches: fractures, chipping, overloads ... Many of us have finished large jobs and in a short time have a porcelain fracture in some of our prosthesis. This causes a great problem for the clinician and the patient, since in these cases there are only two possible solutions, in-office repair with resins with the consequent problems of adhesion to the ceramics, or send to the laboratory to remove all the porcelain and reload again.

What do we propose?. We make a groove of at least 1.5 or 2 mm along the occlusal faces where the loads undergo. In this case, said groove was milled after manufacture, but we propose, to prevent the suffering of zirconium structure, that it must be designed and milled directly from the CAD-CAM.

We ordered to the laboratory reconstructions of composite throughout the groove, which were adhered mainly by mechanical retention, given the convergence of the design, and we ended with an ultra polishing of them.

By means of light-curing resin we take some molds for the registration of the occlusal anatomy that we will keep in the clinic. This way, if there is wear of the composites in the long term, we can make the replacement of the same in a fast, efficient way and with little cost.

We believe, so we are studying it, that it can be a very effective way to absorb forces and avoid problems or turn them into less important problems with an easier, faster and cheaper solution.



We apologize for not having the initial photos, so here is the initial TAC of the patient. We decided to extract all the teeth because of a very serious periodontal disease, with type II and III mobility.

 


Placement of 8 post extraction upper implants with immediate loaded prosthesis. We never load the posterior implants to be more predictable.
Placement in the same surgery of 6 post-extraction lower implants with immediate loaded prosthesis.
The prosthesis were loaded 8 hours after surgery.



Immediate loaded prosthesis with loosen contact with the gingiva to leave room for the regeneration of tissues.

 


Four months later we take measurements for making another provisional.

 


In this case we have a thick biotype, so we can use implants with external conection, and don't need to use a multiunit or transepithilial abutment. Here you can see the aspect of the upper arch gingiva four months after surgery.



Aspect of the lower arch gingiva four months after surgery.



Making new provisionals. We decide to cement the two anterior implants for the provisional.




Provisional acrylic prosthesis to shape papilas. As you can see we beguin with the ovoid pontics to shape our emergency profiles and papilas.



Every 20 days we increase with composite the pontics to give a more natural look. It is mandatory that everything is perfectly polished because the gingiva shaping depends on it.





Progress.

 



Tylite structure test.

 



While making tests with the structure, we continue working with the provisionals, because we know that changes still needed are very small.




A first biscuit test is made at 920º. Noritake ceramic is much more stable along cooking, so we can make subtle changes before finishing.

 


In implant cases, predictability is very complicated, so we decide to make the DSD when we are confident enough with the result. This is what we call DSD Quality Control.







This is our own technique to obtain a greater lifelike look. With a little crest at zenit level, we can make a light pressure for a more natural aspect without preventing a good hygiene.

 


We use to make simulations for a better communication with the lab.

 


Here you can see the difference between normal technique and our technique.

 


Now we are ready for placement of final prosthesis.

 



As you can see the implant in 13 is lost. We fill the gap but we barely had modification in the gingival architecture, so we can continue with our work.

 


Here you can see some of the steps in the ceramic creation.

 


The prosthesis is ready for the patient.

 


METAL CERAMIC- Noritake EX3 polychromatic laminate with ceramic.

1- Opaque dentin blend OB-A1 60% + BA1 40%
2- Dentin cooking T-Cooking 910º
3- Dentin A2 Cervical, A1 Middle-Incisal
4- Application of TX (Transparent window) to mimic the amelodentinary junction.
5- Application of Aqua Blue 2 (Blue effect)
6- Mass of mamelones M-1
7- Mass ECT3 (more opaque white enamel for angled lines)
8- Green mass ECT1 50% + LT Natural 30% + Aqua Blue 2 20%, red mass for cervical translucency CCV2
9- Incisal Aura (halo effect)
10- Cooking at 900º and glazing at 840º



Final prosthesis placement in the patient's mouth. We played with some asymetry to obtain the most natural look possible and harmony.

 


Control radiography.

 



Five months after placement of the final prosthesis, we take out to make new measurements for zirconium prosthesis and we perform a scan of the metal ceramic prosthesis.



Five months after placement of final prosthesis.

 



Photographs taken with mirror. This is the evolution of the papilas along the treatment.

 


Another view of the evolution. To achieve a good result is very important a good design of the provisionals and time. This will drive to a more stable situation over time.

 


One year follow-up.

 




Zirconium structure.

 


Zirconium structure. This structures have been obtained from the scanner of the final metal ceramic prosthesis and a cut-back has been made.



Structure and biscuit test adjustment.

 


From the biscuit to the final zirconium prosthesis.

 


Comparison between metal ceramic and zirconium. Our conclusion is that in hands of a great technician, esthetic differences are practically unnoticeable.

 


Registration of the oclusal form.

 


Keys of rigid acrylic.

 



As explained in the title, this groove was made after the finishing of the prosthesis. It is a groove with a convergent towards the apex section, to have mechanical retention for the composites made to fill it.



Composites finished and in place in the oclusal faces to fight loads. Is very important a microscope finishing to get the perfect integration between zirconium and composite.