Implants

Comprehensive implant restoration and the shortened dental arch

Roger A. Solow, DDS

The restoration of edentulous space or hopeless teeth with with multiple nonsplinted implant-supported crowns extending implant-supported restorations can involve extensive time, to the premolars. The results showed an immediate and dramatic effort, and financial commitment. This article presents a case of improvement in comfort, function, and esthetics while allowing the a debilitated dentition that was restored by using the shortened patient to practice normal oral hygiene. dental arch (SDA) concept in a comprehensive implant restoration. Received: April 13, 2010 An SDA design was used to replace removable partial dentures Accepted: June 7, 2010

hen the loss of posterior final restoration should be decided yielded a history of partial denture teeth results in bilateral for each patient on an individual repairs, which the patient said did Wedentulous spaces, dentists basis after considering all esthetic, not bother her. Her medical his- have several treatment options. phonetic, functional, emotional, tory was noncontributory. She was To recommend the best option, and economic factors.5,6 Using an able to, but would not, expose her the dentist needs to determine if SDA in an existing dentition may teeth when asked to smile broadly the patient will remain healthy avoid the need for restoration with (Fig. 1). and stable without a restoration, if fixed or removable prostheses. In Clinical examination revealed removable prostheses will improve addition, an SDA may preclude buccal palpation tenderness apical the status of the entire mouth or the need to place implants in soft to tooth No. 8; all other soft tis- be a detriment to the remaining posterior bone sites adjacent to sues were normal, as were muscle dentition and periodontium, and sinus and neurovascular anatomy palpation, range of motion, and how many implant-supported res- or to perform bone grafting for joint palpation. Her Doppler ultra- torations should be placed. site development, allowing dentists sound classification was a bilateral A shortened dental arch (SDA) is to avoid the cost of additional Piper Class 3B, indicating lateral defined as a dentition that is missing implants and crowns. Conversely, most of the posterior teeth. This an SDA offers less chewing surface is a common condition, as molars area and may increase force due are often lost earlier than other to function or parafunction on teeth due to caries and periodontal the remaining teeth and tem- disease.1 Although the minimum poromandibular joints (TMJs). number of teeth needed to satisfy This article illustrates how the functional demands has not been SDA concept was used in a com- absolutely determined, the mastica- prehensive implant restoration tory system is adaptable and various to treatment plan and restore a authors have proposed that an arch debilitated dentition. consisting of anterior teeth and pre- molars is functional and durable.2,3 Diagnosis Molar replacement may not A 72-year-old woman presented be necessary in terms of dietary with a chief concern of “a recently demands, but it may be indicated replaced large composite restora- for arch stability and esthetic tion on a front tooth” and wanted and psychological reasons.4 The to know what to do “if it was lost Fig. 1. A portrait view of the patient at her number of teeth included in the again.” A preclinical interview initial visit.

390 September/October 2010 General Dentistry www.agd.org pole disc displacement without reduction.7 Firm condylar load testing with bimanual guidance produced no discomfort. The remaining dentition consisted of teeth No. 8–10 and 24–27, with no caries, mobility, or periodontal probes greater than 3 mm. The gingival levels were asymmetrical on teeth No. 8–10. The maxillary and mandibular partial dentures had multiple repairs, no posterior occlusal contact, no retention, and Fig. 2. A retracted intraoral view of the patient taken at her initial visit. no occlusal rests (Fig. 2). The lower major connector had abraded the root dentin and lingual gingiva of teeth No. 24–26 and lacerated the mucosa apical to these teeth. The maxillary edentulous ridges had good vertical and horizontal dimen- sion (Class I, Division A), and the mandibular edentulous ridges were compromised vertically and hori- zontally (Class I, Division B).8 Fig. 3. Orthodontic wax was placed on the major Fig. 4. The wax spacer was removed, creating After the examination, orthodon- connector and the HydroCast soft liner was placed relief between the major connector and the tic wax (Henry Schein, Inc.) was in the intaglio of the mandibular partial denture. lacerated mucosa. applied to the major connector of the mandibular partial denture as a spacer, prior to adding a soft liner (HydroCast, Sultan Healthcare). Once the HydroCast was set, the wax spacer was removed and the major connector was elevated off the mucosa (Fig. 3 and 4). Pain relief was immediate. Full-mouth radiographs revealed a small apical radiolucency on tooth No. 8 and no other pathology (Fig. 5). The vertical height of the edentu- lous ridges was favorable, as the max- Fig. 5. Full-mouth periapical radiographs taken during the examination reveal a small radiolucency illary sinus and mandibular canals apical to tooth No. 8. showed no proximity to possible implant sites in the premolar regions. Diagnostic casts were mounted in centric relation using a marked anterior acrylic platform and of closure in centric relation is iden- incisal plane was present, with bimanual guidance. The lower tical to the patient’s.9 The residual significant wear facets and exposed central incisor of the diagnostic cast ridge relationship was recorded with incisal dentin on all teeth due to must contact the intraoral ink mark a polyvinylsiloxane bite registration attrition. The interoccclusal space of the acrylic platform placed on the material (Blu-Mousse, Parkell Inc.) on the casts indicated a minimal loss maxillary cast to verify that the arc (Fig. 6 and 7). A moderately uneven of vertical dimension.

www.agd.org General Dentistry Special Implants Section 391 Implants Comprehensive implant restoration and the shortened dental arch

The restorative dentist could now review the information (compiled from the preclinical history, clinical examination, full-mouth radio- graphs, and diagnostic wax-up) with the periodontist who would place the implants. A detailed surgical plan was made so that the implant spacing, angulation, and z-axis rela- tive to the gingival margin would Fig. 7. Diagnostic casts show the amount of coordinate with the restorative plan. Fig. 6. Diagnostic casts were mounted in tooth wear, the horizontal and vertical ridge Surgical guides were fabricated centric relation with an anterior acrylic resin relationships, and the maxillary and mandibular using the fixed position of the pilot platform and bimanual guidance. incisal planes. drill for maxillary flapless surgery and the variable position of the pilot drill for mandibular flap surgery, since the mandibular residual ridge required crestal reduction to accom- modate 4.3 mm implant platforms (Fig. 10–12).10 These guides were designed to ensure parallel implant alignment to permit the use of Fig. 8. The first stage of the diagnostic wax-up straight, stock titanium abutments, did not alter or augment the natural tooth thus avoiding the need for angled or sites. This cast was duplicated and used to Fig. 9. The completed maxillary and mandibular custom abutments. fabricate the surgical guides so that the guides wax-up, showing the planned prosthetic result. The patient was sent for tomo- would fit the teeth exactly for stability during grams to verify the mandibular implant surgery. ridge width (Fig. 13–15); this information was reviewed during the second consultation between the restorative dentist and the perio- dontist to confirm the treatment Treatment planning 11–13, 20–22, 28, and 29; and plan. The composite resin channels To visualize the final result, an cantilever pontics on the sites of of the surgical guide are markers additive diagnostic wax-up of both teeth No. 7 and 23. The SDA for the central axis of the planned arches was performed. The stone meant that the patient could avoid implant locations when used as a teeth were not altered and these replacing molars; in this case, she radiographic template. casts were duplicated to fabricate showed no esthetic deficit from At the restorative consult, diagnos- surgical guides that would fit accu- missing teeth. The patient had the tic casts, wax-ups, radiographs, and rately when placed on the existing option to restore these areas at a tomograms allowed for a thorough teeth. The stone teeth were then later time if desired. This was the discussion of all problems, solu- reduced and the diagnostic wax-up most conservative treatment plan tions, and goals with the patient. was completed to visualize final that would restore the patient to She received a one-page written tooth-to-tooth and tooth-to-ridge the most natural state while avoid- summary of problems, solutions, relationships (Fig. 8 and 9). ing the time and cost required for fees, and future concerns. Surgi- The restorative plan was to place eight implant-supported molar cal correction of the asymmetric incisal composite restorations on crowns and site development using gingival levels of teeth No. 8–10 was teeth No. 24–27; all-porcelain sinus or lateral ridge augmentation. not recommended, since these areas crowns on teeth No. 8–10; single Immediate implant placement and were not visible during an exagger- implanted-supported all-porcelain provisional restoration into occlu- ated smile. She was referred to the crowns at the sites of teeth No. 4–6, sion were planned. periodontist for the implant consult.

392 September/October 2010 General Dentistry www.agd.org Fig. 10. Occlusal view of the maxillary surgical Fig. 11. Side view of the maxillary surgical Fig. 12. An occlusal view of the mandibular guide. The bur mandrels orient the pilot drill guide. The parallel bur mandrels created surgical guide. in the central axis of the planned implant site, parallel pilot drill channels during implant parallel to the adjacent root or implant. placement.

Fig. 13. A panoramic view of the mandibular tomogram. The red line traces the mandibular canal. Fig. 14. The left mandibular Fig. 15. The left mandibular ridge at the site of the ridge at the site of the first second premolar. premolar.

matrix was seated completely on this lightly prepared cast (Fig. 16). The composite resin was polymer- ized (Optilux 501, Kerr Dental) Fig. 16. A duplicated stone cast of the for one minute through the clear diagnostic wax-up, recorded with clear Fig. 17. A lightly prepared cast with composite matrix. The composite resin shells vinylpolysiloxane bite registration material. resin provisional shells. then could be relined with an auto- polymerizing acrylic resin during surgery to create the provisional restorations (Fig. 17).11

The diagnostic wax-ups were Heraeus Kulzer Inc.), to create a Treatment lubricated (Separator, Great Lakes matrix for the provisional restora- Prior to implant surgery, endodontic Orthodontics Ltd.) and a duplicate tions. The stone teeth then were treatment of tooth No. 8 was stone model was fabricated so that reduced 1 mm on all surfaces to completed by the endodontist. the wax-up was preserved. An create space for the provisional Endodontics should be scheduled impression was taken of the stone material. Composite resin (Epic- prior to surgery to prevent any duplicate model, using a clear TMPT, Parkell Inc.) was placed in possible apical peri-implantitis. The vinylpolysiloxane (Memosil 2, the intaglio of the matrix and the periodontist placed regular and wide

www.agd.org General Dentistry Special Implants Section 393 Implants Comprehensive implant restoration and the shortened dental arch

Fig. 18. A maxillary arch surgical guide is placed on the existing Fig. 19. A radiograph of the maxil- Fig. 20. A radiograph of the maxillary left teeth. lary right implants with straight, implants with straight, stock abutments stock abutments torqued in place. torqued in place.

Fig. 21. The mandibular left residual ridge after surgical reduction for proper crest width. Fig. 22. The mandibular left implants and straight, stock Fig. 23. The maxillary composite-acrylic abutments show good spacing and provisional restorations on the day of parallelism. surgery.

Fig. 24. A retracted intraoral view on the day of surgery. Note the symmetry of maxillary and mandibular incisal and occlusal Fig. 25. A preoperative view reveals an Fig. 26. A postoperative view planes. Using electrosurgery, the facial gingiva at tooth No. 11 uneven incisal plane, wear into dentin, with regular incisal plane and was reduced by 1 mm for ideal sulcus depth. and excellent gingival tissue health. microhybrid composite restorations.

platform implants (Replace Select, torqued to 35 ncm (Fig. 18–20). Inc.) and cemented (IRM, Dent- Nobel Biocare USA), using flapless The mandibular surgical guide repli- sply International). The provisional surgery in the sites of teeth No. 4–6 cated the prosthetic outline without restorations were organized into and 11–13 and flap surgery in the the restriction of the pilot drill on two or three tooth segments. The sites of teeth No. 20–22, 28, and the maxillary guide. After crestal maxillary incisal plane was refined 29. All implants had good primary bone reduction (Fig. 21), pilot drill to optimize esthetics and “f” and stability and were torqued past 35 indents were placed in bone and “v” phonetics and adjusted to ncm. The surgical guide ensured proper spacing and parallelism were accommodate smooth lateral, pro- parallelism and spacing derived from maintained (Fig. 22). trusive, and crossover excursions the diagnostic wax-up, so the restor- The composite resin shells were (Fig. 23 and 24). The maxillary ative dentist used stock, straight relined with an autopolymer- palatal surfaces were shaped in titanium abutments (Replace Select) izing acrylic resin (Snap, Parkell coordination with the composite

394 September/October 2010 General Dentistry www.agd.org Fig. 28. A mandibular occlusal view of the Fig. 29. A maxillary occlusal view of the final Fig. 27. A maxillary occlusal view of the provisional restorations on the day after surgery. impressions 4.5 months after implant place- provisional restorations. The continuous lines on Note point contacts on all posterior teeth. ment. Note the tissue response to properly the central incisors and canines indicate smooth contoured and sealed provisional restorations anterior guidance in all mandibular excursions. with brushing only.

Fig. 30. A mandibular occlusal view of the final Fig. 31. The provisional models are mounted impressions. Note parallelism and spacing of on a semiadjustable articulator with magnetic Fig. 32. The maxillary master die solid cast the implant abutments. plates. used to control interproximal contacts.

bonding of the mandibular anterior provisional restoration was solicited teeth to provide smooth anterior until all details were refined. Her guidance. Channels were placed response was extremely positive. in the sclerotic dentin (without Due to the ceramist’s illness, final anesthesia) to provide mechanical impressions were not taken until retention, and the enamel was 4.5 months after implant placement Fig. 33. The mandibular master die solid cast. bevelled prior to adhesive bonding (Fig. 29 and 30). Gingival response with microhybrid composite resin and occlusal stability were con- (Renamel, Cosmedent, Inc.) (Fig. firmed at that time, judging by the 25 and 26). lack of inflammation, patient com- Smooth anterior guidance was fort, and retention by provisional be cross-mounted with a centric shown by continuous marked cement. The patient chose a lighter relation record on the same model lines from a 20 µ inked ribbon shade for the porcelain compared of articulator. Both solid and remov- (Accufilm, Parkell Inc.) on the with the provisional restorations. able die casts were used to ensure central incisors and canines in Casts of the provisional restora- predictable interproximal contacts excursive movements. Simultaneous tions were mounted with a facebow (Fig. 32 and 33). point contacts on the provisional on a semi-adjustable articulator Final porcelain restorations were premolars in closure and all excur- (Protar 5, KaVo Dental) (Fig. 31). guided by the contours of the pro- sions created mandibular stability Since the provisional restorations visional restoration casts (Fig. 34 without the adverse lateral torque were equilibrated to centric rela- and 35). The porcelain was refined that stresses crestal bone (Fig. 27 tion, these casts were mounted intraorally to match the occlusal and 28). Patient feedback concern- cast-to-cast and sent to the ceramist scheme of the provisional restora- ing the form and comfort of the so that the master die casts could tions (Fig. 36 and 37). The gingival

www.agd.org General Dentistry Special Implants Section 395 Implants Comprehensive implant restoration and the shortened dental arch

Fig. 36. A maxillary view of the final porcelain occlusal scheme. Blue silk marks indicate that the Fig. 34. A right side view of the porcelain Fig. 35. A left side view of the porcelain central incisors and canines contact in mandibular restorations. restorations. excursions. Red silk marks on the posterior teeth are point contacts during mandibular closure and excursions to avoid lateral torque.

Fig. 37. A mandibular view of the final porcelain occlusal scheme. Fig. 38. A right side view of the porcelain restoration.

Fig. 39. A left side view of the porcelain restoration.

Discussion Restoring a patient with fixed prosthetics and a full-arch design (including molars) in optimal occlu- sion represents the ideal treatment Fig. 40. A portrait view of the patient after Fig. 41. A maxillary occlusal bite splint with for many patients. Fulfilling each the porcelain restoration was placed. Note the the same detailed occlusal scheme as the patient’s goals for function, esthet- similarity to the provisional restorations. provisional and final restorations. ics, phonetics, and occlusal stability may not require this ideal treatment and the significant complexities involved.12 The SDA is a practical way to simplify comprehensive response and the esthetic and fracture during possible nocturnal implant-supported restorations. phonetic results were predictable, bruxing (Fig. 41). Masticatory performance is an since they were programmed by the Postoperative occlusal refinement objective measurement of chewing provisional restorations that had was checked after several weeks to efficiency and decreases as arch been tested over time (Fig. 38–40). refine any details and address any length is reduced.13-16 Although the A maxillary occlusal bite splint was concerns. The patient decribed SDA compromises chewing ability, fabricated with this same detailed the result as “life-changing.” The this compromise may not be appar- occlusion to comfortably protect implants and restoration have been ent to patients or affect their diet.17-20 the porcelain surfaces from wear or completely stable for two years. Patients with limited ability to

396 September/October 2010 General Dentistry www.agd.org tolerate extensive dental procedures Absence of molar contact has the TMJ.45 Cadaver studies showed and those who are comfortable with been shown to decrease electromyo- a correlation between missing teeth an existing SDA may not want to graphic (EMG) activity of the eleva- and the amount of bony remodel- increase their arch length. Financial tor muscles during clenching on an ing and articular disc alteration limitations may also dictate the anterior tooth bite splint compared while also showing that the risk of extent of restorative dentistry. to a full-arch bite splint.27,28 Canine osteoarthritic changes is increased in Removable prostheses may be a guidance during lateral excursion patients who have lost several teeth less expensive option than implant- contact on a bite splint was shown to or are edentulous.46-48 supported crowns for increasing reduce elevator muscle EMG activity Multiple patient studies show that arch length, although they may compared to group function, where the concern over increased force to not provide patients with the same more posterior teeth make con- the dentition and TMJs of an SDA chewing ability or level of satisfac- tact.29-31 Equilibration of the natural may not be a clinical problem, as tion.21-24 Removable partial dentures dentition to avoid posterior teeth neither decreased patient comfort can be detrimental to the support- contact during lateral excursions was nor increased tooth wear and mobil- ing teeth when plaque retained on shown to reduce abnormal elevator ity were reported.49 Hattori et al the prosthesis also accumulates muscle EMG activity.32-34 If molars recorded the pressures generated on the teeth, increasing the risk have excursive contact interferences, from clenching on two bite splints of decay and bone loss. Compres- one might expect a decrease in eleva- of different designs, one full-arch sion of the prosthesis against the tor muscle EMG activity if these and one SDA.50 The authors used residual ridge during chewing may teeth are lost. This decreased muscle finite element analysis with these cause bone loss that can change the activity would be less detrimental to clinical data to determine the fit of the prosthesis on the residual the remaining teeth. resulting forces at the TMJ. During ridge and increase stress at the Histopathology of the TMJs was maximum voluntary clenching, clasp-tooth interface.25 The bulk of demonstrated in rats whose molars SDAs produced smaller TMJ loads the prosthesis and its attachment had been extracted.35-37 Granados compared to a complete dentition to adjacent teeth prevent it from studied human skull specimens design. The SDA never caused over- being the most natural method for and attributed flattened articular loading in the TMJ, as the clench- restoring lost tooth structure. A eminences to increased forces from ing strength was limited by the 1999 study by Kuboki et al found edentulism and attrition.38 Human neuromuscular regulatory system via that some patients do not use their skull studies have correlated the the periodontal receptors.50 removable prosthesis and are more number of teeth lost with the sever- In a 1967 study, Franks evaluated comfortable with an SDA.26 ity of change in condylar form.39-41 the effect of missing teeth on man- The absence of molars is a clinical Conversely, Hodges found that TMJ dibular dysfunction and found that concern, since it could place more osteoarthritis was not correlated patients with three to five missing force on the remaining dentition with loss of molar support when age teeth formed the largest symptomatic and TMJs during tooth contact. was considered as a variable, since group; as the number of missing The level of potential increased force the frequency of both tooth loss and teeth increased, the incidence of dys- may be an individual response, osteoarthritis increases with age.42 function decreased.51 More recently, depending on the duration and Radiographic remodeling of the Holmlund and Axelsson evaluated intensity of tooth contact from condyle has been described as a 60 patients with chronic, painful oral habits and noctural or diurnal functional adaptation to mechani- locking of the TMJ and found no bruxing. Severe bruxers may display cal stress.43 Kopp and Rockler difference between the fully dentate significant tooth wear, fracture, reported an association between and reduced molar occlusion groups mobility, or migration not seen radiographs indicating reduced joint in terms of signs, symptoms, and in non-bruxers. If teeth have little space and subcortical sclerosis and arthroscopic diagnoses. The authors’ contact, no deleterious effect from a loss of molar support.44 Hansson results did not support the concept excessive force would be expected. et al found a correlation between of molar replacement to prevent Some of the effects of lost molar radiographic structural bone change TMJ osteoarthrosis.52 However, support on the teeth and TMJs, and same-side loss of molar support; Kopp reported significantly greater as reported in the literature, are they attributed these changes to loss of molar support among patients described below. increased biomechanical loading of with osteoarthrosis compared to

www.agd.org General Dentistry Special Implants Section 397 Implants Comprehensive implant restoration and the shortened dental arch

those with mandibular dysfunction, their proprioceptive capability Acknowledgements concluding that long-term loss of (which is approximately 10 times The author would like to express molar support was a factor in crepita- greater than that of implants).58-60 his appreciation to Michael Seda, tion, osteoarthrosis, and an increased This proprioception is compromised DMD, MS, for planning and severity of mandibular dysfunction.53 by replacing all teeth with complete placing the implants and to Mindy These skull, cadaver, and patient dentures, implant-retained overden- Buoncristiani, DDS, for the endo- studies do not show whether a tures, or a hybrid implant-supported dontic treatment. patient with an SDA risks structural fixed restoration. When tooth-to- breakdown of the dentition or TMJs tooth and tooth-to-implant contact Author information due to tooth loss alone or from were compared, Mericske-Stern et al Dr. Solow is in private practice in parafunction that may have contrib- reported a decrease in maximal chew- Mill Valley, California and is a visit- uted to that tooth loss. ing force and pressure sensitivity.61 ing faculty member at the Pankey Unrestored SDAs generally are Patients may perceive that Institute, Key Biscayne, Florida. stable, although they can display decreased proprioception prevents some tooth migration and interden- the restoration from feeling as natural References tal spacing without the mesial vector as original teeth. Implant-supported 1. Kayser AF. Shortened dental arches and oral function. J Oral Rehabil 1981;8(5):457-462. of force that results from molar restorations provide superior func- 2. Kayser AF. 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