Treatment planning in the prosthodontic patient involves consideration of many variables to achieve the ideal outcome. Prosthodontic procedures are often prescribed to restore damaged dentition or to replace lost function secondary to missing dentition. However, the social and psychological aspects of the treatment (such as esthetics and phonetics), cost-effectiveness, and treatment time are all important factors affecting patient satisfaction.
Several designs can be used to restore the edentulous maxilla with an implant-supported prosthesis. Some authors1-3 recommended not finalizing the fixed vs. removable prosthesis until the patient accepts the final wax try-in. However, this can lead to changes in the treatment plan after implant placement, sometimes affecting at the initial evaluation will help to indicate whether a fixed or removable implant-supported prosthesis is indicated.
This case report presents the restoration of an edentulous patient with the combination of a maxillary implant-supported removable bar overdenture and a mandibular implant-supported fixed porcelain-fused-metal prostheses. Through careful treatment planning and the patient’s participation and motivation, the ideal treatment outcomes and prognosis were achieved.
A 58 year old male patient visited the Advanced Education of General Dentistry clinic at Temple University Kornberg School of Dentistry with defective and carious definitive and provisional prostheses. The remaining dentition was diagnosed with a poor prognosis. The patient had high demands for esthetics and retention of the prostheses.
Following the guidelines by Zitzmann et al4, several clinical parameters were assessed including: phonetics, gag reflex, oral hygiene, lip support and esthetic display. The patient expressed a strong desire for a fixed restoration and lip support.
During the extraoral examination, we evaluated facial support, esthetic profile, maxillomandibular relationship, smile line, tooth display at smile and the length of the upper lip from subnasal to philtrum. In this case, the buccal flange of a removable restoration and the position of denture teeth were essential for the proper soft tissue support to improve the retrognanthic appearance of the maxilla, the flat facial profile, the maxillomandibular relationship, and the short and thin upper lip.
During the intraoral examination, it is essential to assess the following parameters: quality and quantity of the soft tissue, quantity and contour of the bone, interarch space, and tooth position relative to the bone. A thick mucosa is preferred to hide abutment margins and facilitate correct emergence profile. Due to bone loss from the history of the periodontal disease, the length of the clinical crowns were long. A slight tooth to arch size discrepancy and speech disruption were noted. It is significantly noted that patient had troublemaking “D”, “S”, and “T” sounds. It is essential to form a proper lingual anatomy in order that the tooth-tongue contact sounds, such as “D” and “T”, can be adequately produced by the patient. The excessive air escaping from the patient’s provisional crowns at the initial examination was creating “S” sound deficiencies. Tanaka5 demonstrated a curve in the anterior palatal region starting from 11 to 13 mm posterior to the incisors and 6 mm coronal the cervical margin in the sagittal plane. In this case, it is important to correct this S-ridge, which indicates the need for a removable prosthesis. The majority of maxilla was Type III bone quality.
After reviewing the diagnostic finding with the patient, the following treatment plan was finalized:
• Extractions of all remaining teeth
• Maxillary implant-supported screw-retained interim CD and mandibular interim RPD
• Bilateral sinus grafting
• Implant placements on #3, 5, 6, 11, 13, 14, 19, 21, 22, and 27
• Maxillary implant-supported porcelain-fused-metal bar removable overdenture with swiss lock attachments
• Mandibular implant-supported porcelain-fused-metal screw-retained FPDs on #19-x-21 and #22-x-x-x-x-27 and 28-x-30
Maxillary implant-supported porcelain-fused-metal bar overdenture and mandibular implant-supported porcelain-fused-metal screw-retained FPDs were fabricated and subsequently delivered. Soft-tissue support with flange is shown in profile.
During the interim phase with a fixed maxillary provision with flange removed, as expected during the treatment planning process. With the definitive prostheses, the patient demonstrated improved facial support support and phonetics. With theporcelain-fused-metal maxillary bar overdenture with Swiss-lock attachments, both retention and esthetic demands were satisfied. Demonstration of a customized hygiene protocol was given to the patient for both maxillary and mandibular prostheses.
1. Lewis S, Sharma A, Nisibura R. Treatment of edentulous maxillae with osseointegrated implants. J Prosthet Dent 1992; 68: 503-8.
2. Wicks RA. A systematic approach to definitive planning for osseointegrated implant prostheses. J Posthodont 1994;3: 237-42.
3. Taylor TD. Fixed implant rehabilitation for the edentulous maxilla. Int J Oral Maxillofac Implants 1991; 6: 329-37.
4. Zitzmann NU, Marinello CP. Treatment plan for restoring the edentulous maxilla with implant-supported restorations: removable overdenture versus fixed partial denture design. J Prosthet Dent 1999; 82:188-96.
5. Tanaka H. Speech patterns of edentulous patients and morphology of the palate in relation to phonetics. J Prosthet Dent 1973; 29: 16-28.