Zygomatic implant-retained fixed complete denture for an elderly patient

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1 Case rept Zygomatic implant-retained fixed complete denture f an elderly patient Mirza Rustum Baig 1,, Gunaseelan Rajan and Nsiah Yunus 1 1 Department of Prosthetic Dentistry, Faculty of Dentistry, University Malaya, Kuala Lumpur, Malaysia; Department of Prosthodontics, Ragas Dental College and Hospital, Chennai, India; Rajan Dental Institute, Chennai, India Gerodontology 0; doi:./j x Zygomatic implant-retained fixed complete denture f an elderly patient Dental rehabilitation of a completely edentulous geriatric patient has always been a challenge to the clinician, especially in treating those with higher expectations and demands. Treatment duration and the amount of residual alveolar bone available are often imptant considerations when planning f dental implant-based fixed treatment f these patients. With the introduction of zygomatic implants, a graftless alternative solution has emerged f deficient maxillary bone with provision f immediate loading. This article describes the treatment of a completely edentulous elderly patient using zygomatic implants in conjunction with conventional implants. The implants were immediately loaded using a definitive acrylic resin fixed denture reinfced with a cast metal framewk, to provide function and aesthetics. Keywds: geriatric dentistry, zygomatic implants, patient satisfaction. Accepted October 00 Introduction G E R B In recent years, implant-based fixed rehabilitation of completely edentulous arches has become one of the preferred modes of treatment f many elderly patients transitioning to complete edentulism 1. The limiting facts, however, f pursuing this treatment may be medical, financial, insufficient patient motivation, inadequate available alveolar bone and time constraints. However, some of these limitations have been overcome with the relatively successful introduction of zygomatic implants 1,, f the rehabilitation of completely edentulous atrophic maxillae, serving as an alternative to bone grafting and/ sinus flo lifts associated with conventional implant placements. The duration of the treatment time has also been significantly reduced by the immediate loading option available with these implants, with high clinical success rates being repted by various auths,. With metalreinfced acrylic resin dentures finding predictable usage, the process of fabrication of a complete arch fixed prosthesis on zygomatic implants, has become relatively simple. Several auths have repted the use of metal-reinfced implant dentures employing various techniques. This article Dispatch:.. Journal: GER CE: Balaji Prasad Journal Name Manuscript No. Auth Received: No. of pages: PE: Sathya Kala describes an alternative technique f fabricating a complete-arch, metal-acrylic resin implant-suppted fixed prosthesis. The primary advantage of this technique is the improvement of passive fit achieved through the intra-al cementation of the metal-acrylic resin dentures to the milled abutments. Undesirable stresses on the immediately loaded implants due to potential errs in prosthesis fabrication are minimised to an extent. With this technique, the definitive prosthesis could be fabricated and issued within 1 days post-implant placement, depending upon the co-dination between the clinician and labaty technician, patient s needs and efficiency of labaty suppt. A limitation of this technique is the application in cases with severe angulation of the implants. The alignment of abutments f the insertion of the cast framewk becomes difficult, but to an extent, castable and pre-fabricated angulated abutments can be used to alleviate the problem. In addition, resin veneer failure, occlusal wear and staining of the teeth are also concerns. The objective of this article is to elucidate the treatment of a completely edentulous geriatric patient using a zygomatic implant-retained fixed Ó 0 The Auths Journal compilation Ó 0 The Gerodontology Society and John Wiley & Sons A/S 1

M. R. Baig et al. 1 1 1 1 1 1 1 0 1 denture with the description of a technique to achieve simultaneous cement and screw-retention of the prostheses.

On clinical examination, a few mobile teeth were found with po periodontal prognosis. Radiographic examination revealed severe alveolar bone loss in the posteri maxillary and mandibular regions (Fig.

The patient was averse towards wearing any removable prosthesis and hence, he was planned f complete arch implant-fixed prostheses.

2 M. R. Baig et al denture with the description of a technique to achieve simultaneous cement and screw-retention of the prostheses. Clinical rept A -year-old male repted to the clinic requesting fixed replacement f all his lost teeth. The patient had no past histy of wearing dental prostheses. On clinical examination, a few mobile teeth were found with po periodontal prognosis. Radiographic examination revealed severe alveolar bone loss in the posteri maxillary and mandibular regions (Fig. 1). The patient was planned f complete extraction of the remaining dentition and was presented with the various treatment options f restation of his completely edentulous arches. The patient was averse towards wearing any removable prosthesis and hence, he was planned f complete arch implant-fixed prostheses. Due to time constraints and other facts, bone grafting and other adjunct procedures to aid in dental implant placement were considered inappropriate. Bilateral single zygomatic implants in conjunction with two conventional implants were planned f the maxillary arch and four root fm implants were planned f the mandibular arch, f restation of the edentulous arches. Technique 1. Use diagnostic dentures f the immediate placement of maxillary and mandibular implants (Replace Select Tapered TiU; Brånemark Zygoma TiUnite, Nobel Biocare AB, Sweden), under general anaesthesia.. Tque the abutments (multi-unit abutments; 1 zygoma multi-unit abutments, Nobel Biocare AB) to the implants post-placement (Fig. ), and take polyether (Impregum, M ESPE) open-tray Figure 1 Panamic view of the maxillae and mandible pre-treatment. Figure Maxillary occlusal view with tqued abutments. impressions with the impression copings coated with adhesive and splinted with bite registration polyether (Ramitec M ESPE AG).. Pour dental stone casts using implant replicas (NobRpl, Nobel Biocare AB) and fabricate recd bases with tempary cylinders (NobRpl, Nobel Figure Maxillary and mandibular trial dentures fitted on the wking casts. Ó 0 The Auths Journal compilation Ó 0 The Gerodontology Society and John Wiley & Sons A/S

1 1 1 1 1 1 0 1 Figure Milled abutments on the wking casts. Figure Resin pattern framewk fabricated on the abutments using silicone putty index guide.

intra-al try-in. After confirming the vertical dimension, aesthetics, speech and occlusion with the wax trial dentures, remove and refit them back on to the wking casts (Fig. ).

3 Figure Milled abutments on the wking casts. Figure Resin pattern framewk fabricated on the abutments using silicone putty index guide. Zygomatic implant-fixed complete denture Biocare AB) and pattern resin splints (GC pattern resin, GC Cp) on the wking casts, to reinfce and aid accurate positioning of the recd bases during the intra-al try-in. After confirming the vertical dimension, aesthetics, speech and occlusion with the wax trial dentures, remove and refit them back on to the wking casts (Fig. ).. Recd the teeth and soft tissue positions of the trial dentures on the definitive wking casts with silicone putty, to serve as an index guide in the fabrication of the framewk.. Disassemble the dentures and fit screw-retained titanium cylinders (Nobel Biocare AB) on to the implant analogues on the wking casts. Mill the abutments to a degree taper (F00 H ; Bredent BF 1) and align them (Fig. ) befe fabricating a resin pattern framewk on the abutments with spacer thickness of lm (Fig. ). Cast the pattern into a metal framewk (Co Cr alloy; d.sign, Ivoclar Vivadent AG) (Fig. ).. Test the framewk fit on the abutments and, if satisfacty, bond heat-cured acrylic resin and teeth to the cast framewk using silicone index guides by a compression moulding technique (Fig. ). Maintain the occlusal screw-access channels free, during the entire fabrication process.. Following this, transfer the milled abutments intra-ally with the same position as on the wking casts using acrylic resin indices. Finish and polish the metal-resin acrylic dentures and cement them intra-ally to the milled abutments in the maxillary and mandibular arch with composite cement (DTK adhesive, Bredent) (Fig. a,b) and rubber dam in position. Ó 0 The Auths Journal compilation Ó 0 The Gerodontology Society and John Wiley & Sons A/S

1 1 1 1 1 1 0 1 M. R. Baig et al. Figure Maxillary and mandibular arch metal framewks pri to bonding of acrylic resin and teeth.. Remove the prosthesis after setting of the cement and clear the excess.

. Post-issue instructions are given and patient is placed on a follow-up maintenance protocol (Fig. ).

4 M. R. Baig et al. Figure Maxillary and mandibular arch metal framewks pri to bonding of acrylic resin and teeth.. Remove the prosthesis after setting of the cement and clear the excess. Re-tque the prosthesis to the implants after checking f aesthetics, occlusion and function (Fig. ). The screw-access channels are sealed with gutta percha and light-cured composite.. Post-issue instructions are given and patient is placed on a follow-up maintenance protocol (Fig. ). Discussion Though zygomatic implants have been predictably employed in the last few years f the rehabilitation of completely edentulous atrophic maxillae 1,, there is an impending need f conducting randomised controlled clinical trials to test the efficacy of these implants in comparison with the me traditional bone augmentation procedures. Also, the placement of zygomatic implants requires an experienced surgeon, as the procedure is not entirely risk-free. In completely edentulous geriatric patients, these implants may overcome the need f bone augmentation in the posteri maxilla but there should be enough bone in the anteri maxillary region f placement of at least two root-fm implants to complement the bilateral zygomatic implants. In this patient, the zygomatic implants were placed mainly to avoid bone grafting procedures and provide function and aesthetics in a sht time frame. Cost was also a concern; hence a definitive splinted prosthesis was fabricated with a precise framewk and loaded immediately. With the technique used in this article, repair of the prosthesis, if required, was easy and economical. It could be disassembled by untquing the screws and repositioned after the repair. A base metal alloy was used in the fabrication of the cast framewk, making the treatment me affdable. The prosthesis could also be easily maintained and in addition, any soft tissue deficit was well-managed along with provision of satisfacty aesthetics. A minimum number of implants were used with reasonable antero-posteri spread in the mandibular arch, hence, avoiding long cantilevers and providing acceptable bio-mechanics f the fixed prosthesis. In the maxillary arch, the bone resption was severe and cantilevers were unavoidable. Figure Cast framewks fitted on the milled abutments f final waxup using index guides. Ó 0 The Auths Journal compilation Ó 0 The Gerodontology Society and John Wiley & Sons A/S

1 1 1 1 1 1 0 1 (a) (b) Figure (a) Metal-resin framewk luted intra-ally to the milled abutments in the maxillary arch.

The principle of all-on-four was applied in the restation of the arch, with long and angulated zygomatic implants.

Figure Panamic view of the maxillae and mandible post-treatment.

fixed prostheses. It provides an alternative approach to managing geriatric patients with complete denture needs.

5 (a) (b) Figure (a) Metal-resin framewk luted intra-ally to the milled abutments in the maxillary arch. (b) Metalresin framewk luted intra-ally to the milled abutments in the mandibular arch. Figure Anteri view of the definitive prosthesis after issue. The principle of all-on-four was applied in the restation of the arch, with long and angulated zygomatic implants. With this treatment, the patient needs to be infmed befehand of the steps involved, sequence and the issues associated with immediate loading with zygomatic implants. Figure Panamic view of the maxillae and mandible post-treatment. Conclusion This rept describes a graftless implant fixed option f completely edentulous elderly patients with use of zygomatic implants in combination with root fm implants f suppting complete arch fixed prostheses. It provides an alternative approach to managing geriatric patients with complete denture needs. The indications f such treatment are specific and to an extent driven by patient facts. Long-term clinical studies are required befe recommending routine use of zygomatic implants f patients. This treatment alternative is economical compared to the conventional metal-ceramic fixed option, it is strong and durable, with features to maximise the passive fit of the prosthesis. Fabrication is also relatively simple involving a shter time period and with provision f retrievability and al hygiene maintenance. Patient satisfaction was achieved with the care provided. References Zygomatic implant-fixed complete denture 1. Mozzati M, Monfrin SB, Pedretti G, et al. Immediate loading of maxillary fixed prostheses retained by zygomatic and conventional implants: -month preliminary data f a series of clinical case repts. Int J Oral Maxillofac Implants 00; :.. Balshi SF, Wolfinger GJ, Balshi TJ. A retrospective analysis of 1 zygomatic implants in a single-stage immediate loading protocol. Int J Oral Maxillofac Implants 00; :.. Aparicio C, Ouazzani W, Aparicio A, et al. Immediate/early loading of zygomatic implants: clinical experiences after years of follow-up. Clin Implant Dent Relat Res 00;????:????????. [Epub ahead of print]. 1. Bedrossian E, Rangert B, Stumpel L, et al. Immediate function with the zygomatic implant: a graftless solution f the patient with mild to advanced atrophy of the maxilla. Int J Oral Maxillofac Implants 00; 1:. Ó 0 The Auths Journal compilation Ó 0 The Gerodontology Society and John Wiley & Sons A/S

6 M. R. Baig et al.. Purcell BA, McGlumphy EA, Holloway JA, et al. Prosthetic complications in mandibular metal-resin implant-fixed complete dental prostheses: a - to - year analysis. Int J Oral Maxillofac Implants 00; :.. Testi T, Meltzer A, Del Fabbro M, et al. Immediate occlusal loading of osseotite implants in the lower edentulous jaw. A multi-center prospective study. Clin Oral Implant Res 00; 1:.. Jemt T, Johansson J. Implant treatment in the edentulous maxillae: a 1-year follow-up study on consecutive patients provided with fixed prostheses. Clin Implant Dent Relat Res 00; : 1.. Rodrigues A, Mgano SM, Guimaraes M, et al. Labaty processed acrylic resin provisional restation with cast metal substructure f immediately loaded implants. J Prosthet Dent 00; 0: Greven B, Leupke M, Von Dsche SH. Telescopic implant prostheses with intra-al luted galvano mesostructures to improve passive fit. J Prosthet Dent 00; :.. McCracken M, Simmons B, Simmons W. Cement retained Superstructure f a metal-resin fixed complete denture. J Prosthet Dent 00; : 0.. Esposito M, Wthington HV, Coulthard P. Interventions f replacing missing teeth: dental implants in zygomatic bone f the rehabilitation of the severely deficient edentulous maxilla (Review). Cochrane Database of Syst Rev 00; : Art No.CD00. Crespondence to: Mirza Rustum Baig, Assistant Profess, Department of Prosthetic Dentistry, Faculty of Dentistry, University Malaya, 0 Kuala Lumpur, Malaysia Tel.: Fax: +0 drmrbaig@yahoo.com; drmrbaig@gmail.com Ó 0 The Auths Journal compilation Ó 0 The Gerodontology Society and John Wiley & Sons A/S

7 Auth Query Fm Journal: GER Article: Dear Auth, During the copy-editing of your paper, the following queries arose. Please respond to these by marking up your proofs with the necessary changes/additions. Please write your answers on the query sheet if there is insufficient space on the page proofs. Please write clearly and follow the conventions shown on the attached crections sheet. If returning the proof by fax do not write too close to the paper s edge. Please remember that illegible mark-ups may delay publication. Many thanks f your assistance. Query reference Query Remarks 1 AUTHOR: Please provide volume and page number f Ref. [].

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Implant-based fixed rehabilitation of

Implant-based fixed rehabilitation of CLINICAL Treatment of a Maxillary Dento-Alveolar Defect Using an Immediately Loaded Definitive Zygoma Implant-Retained Prosthesis With 11-Month Follow-Up: A Clinical Report Mirza Rustum Baig, MDS, MRD