Immediate Vacuum Formed Overdenture for a Pediatric Patient with Ectodermal Dysplasia

Restoring the dental and facial esthetics in a growing patient with ectodermal dysplasia (ED) is fundamental to improve psychosocial issues, esthetics, and function. The purpose of this clinical report was to present a simple, fast, and cost-effective technique to re-establish a pleasant smile of an eight-year-old male patient with hypohydrotic ED. A vacuum-formed overdenture prosthesis is described, which is recommended as an immediate interim restorative treatment in the maxillary arch with excellent stability and retention.

NON-REMOVABLE DENTURE PROTOTYPES, EFFECTIVE IN DENTAL IMPLANTATION

Temporary prosthesis transformed into a prosthetic prototypes and manufactured by CAD/CAM technologies (computer copy milling) are used to specify the final form of future permanent restoration and to correct occlusal relationships, vertical size of non-removable dentures, and their occlusal surfaces. A progressive loading on bone tissue in the implantation area and soft tissues formation, have been assessed. In this regard, the choice and placement of temporary mini-implants, as the supports for non-removable denture prototypes for the period of osseointegration of two-stage intraosseous dental implants, are the issues of great importance. Temporary dental implants are the object of complex loads of different magnitude, duration and direction. The action of the prosthesis is closely related to load delivery to the surface of dental implant between the components of the system - "implant-temporary prosthesis". According to the study results, minimization of the momentum acting on temporary implants in the mesiodistal direction allows reducing stress level in the areas of permanent implant placement.

Immediate vs conventional loading of variable-thread tapered implants supporting three- to four-unit fixed partial dentures in the posterior maxilla: 1-year interim results of a split-mouth randomised controlled trial

PURPOSE

To compare the outcome of immediately loaded and one-stage conventionally loaded variable-thread tapered implants in the posterior maxilla.

MATERIALS AND METHODS

This study was designed as a split-mouth randomised controlled trial. Twenty-six patients missing teeth bilaterally in the posterior maxilla received three to four implants in each of the posterior sextants. Bone quality was recorded based on Misch criteria (D1-D4) and insertion torque values were measured using a manual wrench. The implants on one side were immediately loaded with a temporary resin fixed partial denture on definitive multi-unit abutments. The implants in the contralateral side received definitive multi-unit abutments according to the one-stage unloaded protocol. Three to 3.5 months following implant placement, the implants were restored with metal-ceramic fixed prostheses. Outcome measures were implant and prosthesis failure rates, complications, and peri-implant bone level changes at 1 year following delivery of the definitive prostheses.

RESULTS

Two patients dropped out prior to the delivery of definitive prostheses. Four implants supporting a four-unit immediately loaded prosthesis failed in one patient, 3 months following delivery of the definitive prostheses. None of the conventionally loaded implants or prostheses failed. There were no significant differences in the proportions of implant and prosthesis failures (difference = 4.2%; 95% CI -4.2 to 12.6%; P = 0.999). In the immediately loaded group, four early prosthetic complications occurred during the provisionalization phase (three small resin chippings and one prosthetic screw loosening). No other complications were reported. The difference in the rate of complications between the two interventions was not statistically significant (difference = 16.7%; 95% CI -1.2% to 35.6%; P = 0.125). The 1-year peri-implant marginal bone level changes were evaluated in 23 patients (77 immediately loaded and 76 conventionally loaded implants). On average, patients lost 0.42 mm at the immediately loaded and 0.46 mm at the conventionally loaded implants, the difference being statistically not significant (difference = 0.044 mm; 95% CI -0.27 to 0.18 mm; P = 0.701).

CONCLUSIONS

Immediate loading of 3- to 4-unit fixed partial prostheses supported by variable-thread implants in the posterior maxilla can yield good and similar 1-year results to one-stage conventionally loaded implants.

Compromised Hard- and Soft-Tissue Architecture: Immediate Implant Placement and Provisionalization in the Esthetic Zone

Careful case selection is crucial for achieving short- and long-term success with immediate implant placement and provisionalization. Caution should be exercised for a tooth that presents with a compromised soft- and hard-tissue architecture. Nevertheless, a successful outcome can be achieved provided that the principles elucidated in the current literature are applied. The following report describes a case with a severely reduced but healthy periodontium around a tooth scheduled for extraction. Immediate implant placement and provisionalization utilizing the extracted tooth with simultaneous hard- and soft-tissue augmentation were performed in one surgical visit. This facilitated the restoration of a healthy peri-implant tissue complex and delivery of a functional and esthetic final implant-supported restoration.

Training Plates: A Solution for Patients Unable to Tolerate a Removable Prosthesis

Dealing with patients who are unable to tolerate dentures can present a challenge to the general dental practitioner (GDP). Careful assessment of patients and their dentures will identify any causes of the intolerance to dentures. Training plates are a useful technique that can be used to allow patients to become accustomed to removable prosthesis but will inevitably lengthen the treatment process. CPD/Clinical Relevance: Training plates offer a possible solution to general dental practitioners who treat patients who are struggling to tolerate dentures.

Site development interim removable dental prosthesis

Transitioning a patient with partial edentulism through hard and soft tissue grafting to an implant restoration with an interim removable dental prosthesis (IRDP) presents a challenge to the restorative dentist. The management of grafted sites requires care, and without the appropriate design, an IRDP may impede surgical outcomes and place the graft at risk for displacement or necrosis. A site development IRDP (SDIRDP) for a grafted site must fulfill restorative goals and promote the surgical objectives for site development. A technique is described for fabricating an SDIRDP that facilitates surgical procedures and maintains prosthetic goals.

Comparison of fracture loads of CAD/CAM and conventionally fabricated temporary fixed dental prostheses after different aging regimens

This study evaluated the fracture loads of different threeunit fixed dental prostheses (FDPs) for temporary restorations. In total, three CAD/CAM materials (VITA CADTemp [CT], Telio CAD [TC], and ZENO ProFix [ZP]) and two chairside materials (Protemp 4 [PT], and Dentalon Plus [DP]) were used for the fabrication of the FDPs. Sixteen FDPs were fabricated from each material in an anatomical shape and stored in 0.9% NaCl solution at 37°C for 14 days. Thereafter, one half of the specimens from each group (n = 8) were additionally mechanically and thermally loaded (240,000 chewing cycles, 50 N, 5°/55°C, 2,100 thermal cycles). Fracture loads were measured and data analyzed using two- and one-way ANOVA, followed by Scheffé's post hoc test. ZP showed the highest mean fracture loads, regardless of the aging regime. Significantly lowest values were identified for DP and TC within the non-thermal loaded group, and for PT and CT within the thermal loaded group. No negative impact of aging regimes could be observed.

Immediate occluding definitive partial fixed prosthesis versus non-occluding provisional restorations - 4-month post-loading results from a pragmatic multicenter randomised controlled trial

PURPOSE

To compare the clinical outcome of dental implants restored with definitive occluding partial fixed prostheses within 1 week, after implant placement with immediate non-occluding provisional restorations, which were to be replaced by definitive prostheses after 4 months.

MATERIALS AND METHODS

Fifty partially edentulous patients treated with one to three dental implants, at least 8.5 mm long and 4.0 mm wide inserted with a torque of at least 35 Ncm, were randomised in two groups of 25 patients each, to be immediately loaded with partial fixed prostheses. Patients of one group received one definitive screw-retained metal-ceramic prosthesis in occlusion within 1 week after placement. Patients of the other group received one non-occluding provisional acrylic reinforced prosthesis within 24 h after implant placement. Provisional prostheses were replaced after 4 months by definitive ones. The follow-up for all patients was 4-months post-loading. Outcome measures were prosthesis and implant failures, any complications, peri-implant marginal bone level changes, aesthetic evaluation by a clinician, patient satisfaction, chair time and number of visits at the dental office from implant placement to delivery of definitive restorations.

RESULTS

No patient dropped out. Two immediately occlusally loaded implants with their related definitive prostheses (8%) failed early (difference in proportions = 0.08; 95% CI: -0.03 to 0.19; P = 0.490). Four complications occurred in the occlusal group versus one in the non-occlusal group; (difference in proportions = 0.12; 95% CI: -0.04 to 0.28; P = 0.349). Four months after loading, patients subjected to non-occlusal loading lost an average of 0.72 mm of peri-implant bone versus 0.99 mm of patients restored with occluding definitive partial fixed prostheses. There were no statistically significant differences for marginal bone level changes between the two groups (mean difference = -0.27 mm; 95% CI: -0.84 to 0.30; P = 0.349). The differences for aesthetic scores showed no statistical significance (8.26 versus 7.58; P = 0.445); the same was seen for aesthetics evaluated by patients (Mann-Whitney U test: P = 0.618). Patients in the non-occlusal group were significantly more satisfied with the function of their implant-supported prostheses (Mann-Whitney U test: P = 0.039). Significantly less chair time (mean difference = -28.4 min; 95% CI: -48.82 to -7.99; P = 0.007) and the number of visits (mean difference = -1.88; 95% CI: -2.43 to -1.33; P < 0.001) were required for the immediate definitive prosthesis group.

CONCLUSION

This study did not provide a conclusive answer but may suggest that provisional prostheses non-occlusally immediately loaded may increase patient functional satisfaction, chair time and the number of visits, with respect to definitive prostheses immediately loaded in functional occlusion.

A 10-year report from a multicentre randomised controlled trial: Immediate non-occlusal versus early loading of dental implants in partially edentulous patients

PURPOSE

To compare peri-implant bone and soft-tissue levels of immediate non-occlusally loaded versus non-submerged early loaded implants in partially edentulous patients 10 years after loading.

MATERIALS AND METHODS

Fifty-two patients were randomised in five Italian private practices: 25 in the immediately loaded group and 27 in the early loaded group. To be immediately loaded, single implants had to be inserted with a torque of at least 30 Ncm, and splinted implants with a torque of at least 20 Ncm. Immediately loaded implants were provided with non-occluding temporary restorations within 48 h. After 2 months, the provisional restorations were put in full occlusion. Implants were early loaded after 2 months. Definitive restorations were provided 8 months after implant placement. Outcome measures were prosthesis failures, implant failures and complications, recorded by non-blinded assessors, and peri-implant bone and soft-tissue levels evaluated by blinded assessors.

RESULTS

Fifty-two implants were loaded immediately and 52 early. Three patients with 8 implants dropped out from the immediate group versus two patients with 3 implants from the early loaded group; all remaining patients were followed for at least 10 years after loading. One single immediately loaded implant failed 2 months after placement. Three patients with immediately loaded implants and two with early loaded implants were affected by complications. There were no statistically significant differences for implant/prosthesis failures (Fisher's exact test: P = 0.294; difference = 4%, 95% CI: -16% to 24%) and complications between groups (Fisher's exact test: P = 0.574; difference = 4.5%, 95% CI: -12% to 21%). Both groups gradually lost peri-implant bone in a highly statistically significant way at 2, 8 and 14 months, and at 4, 5 and 10 years. After 10 years, immediately loaded patients lost an average of 1.34 mm and early loaded patients lost 1.42 mm of peri-implant marginal bone. At 10 years, there was a statistically significant recession (P < 0.001) of the vestibular soft tissues from baseline (delivery of the final restorations 8 months after implant placement) at both immediate (0.38 mm) and early (0.25 mm) loaded implants. There were no statistically significant differences in terms of peri-implant bone (difference = 0.08 mm, 95% CI: -0.49 to 0.65; P = 0.49) and soft-tissue level changes (difference = 0.07 mm, 95% CI: -0.48 to 0.62; P = 0.469) between the two groups at 10 years after loading.

CONCLUSIONS

In well-maintained patients, complications are uncommon and healthy and stable peri-implant tissues can be maintained for 10 years around both immediate and early loaded implants. Conflict-of-interest statement: This trial was independently designed and initiated by the investigators. BIOMET 3i, the manufacturer of the implants used in this investigation, provided partial economic support at a later stage, and finally ZIMMER-BIOMET partially supported the present publication, however data belonged to the authors and by no means did the sponsor interfere with the conduct of the trial or the publication of its results.

Achieving Anterior Aesthetics in a Full-Arch Implant Case

The proper approach to achieving the best possible smile for any aesthetic case must start with a full-smile analysis. Only when the practitioner determines the ideal final position of the teeth can the restorative phase begin. In this case, using provisional restorations and a transferable wax-up resulted in a final restoration that yielded optimal aesthetics, excellent function, and a very satisfied patient.

[Transient removable dentures]

Removable dentures are always transient current. The epidemiology and causes of tooth gaps demonstrate the need to master the different prosthetic treatment. This made whether to propose treatment plans that take into account psychological, physiological and technical support for this patient. Different situations may arise. A gradual transition may be considered or immediate passage to the total edentulous according to general criteria, local and desiderata of patients. After tooth extraction, the transitional prosthesis can control bone lysis thereby it is part of a complete treatment before prosthesis. It also facilitates a good psychological and physiological integration before the prosthesis use.

Do repeated changes of abutments have any influence on the stability of peri-implant tissues? Four-month post-loading preliminary results from a multicentre randomised controlled trial

PURPOSE

To evaluate the influence of at least three abutment changes against the placement of a definitive abutment, which was no longer removed, on hard and soft tissue changes, and to compare the clinical outcomes of immediate non-occlusal loading versus conventional loading.

MATERIALS AND METHODS

Eighty patients requiring one single crown or one fixed partial prosthesis supported by a maximum of three implants were randomised, after implants were placed with more than 35 Ncm, according to a parallel group design to receive definitive abutments which were loaded immediately (definitive abutment or immediate loading group) or transmucosal abutments which experienced delayed loading after 3 months and were removed at least three times: 1) during the making of the impression (3 months after implant placement); 2) when checking the zirconium core of titanium abutments at single crowns or the fitting of the metal structure at prostheses supported by multiple implants; 3) at delivery of the definitive prostheses (repeated disconnection or conventional loading group). Patients were treated in four centres and each patient contributed to the study with only one prosthesis followed for 4 months after initial loading. Outcome measures were: prosthesis/implant failures, any complication, peri-implant marginal bone level changes, and patient satisfaction.

RESULTS

Forty patients were randomly allocated to each group according to a parallel group design. No patient dropped-out and no implants failed. However four provisional prostheses and one definitive prosthesis had to be remade because of misfitting (five single crowns) in the repeated disconnection group; and one provisional prosthesis had to be remade because of frequent debondings in the immediate loading group (difference=10%; 95% CI: -1%, 21%; P=0.109). Five complications (all debondings of the provisional prostheses) were reported in two patients of the immediate loading group, in comparison to three biological complications in three patients of the repeated disconnection group (difference=2%; 95% CI: -8%, 13%; P=1). All patients were very satisfied or satisfied with the function and aesthetics of the prostheses, and would undergo the same procedure again. Mean peri-implant marginal bone loss 4 months after loading was -0.08 (0.16) mm for the definitive abutment group and -0.09 (0.20) mm for the repeated abutment changes group (difference=0.01; 95% CI: -0.07, 0.09; P=0.97). There were no statistically significant differences for any of the outcome measures between the two procedures up to 4 months after initial loading.

CONCLUSIONS

Preliminary short-term data (4-month post-loading) showed that repeated abutment changes do not alter bone levels significantly. Immediate non-occlusal loading of dental implants are a viable alternative to conventional loading. Therefore clinicians can use the procedure they find more convenient for their specific patient.

Predictably replacing maxillary incisors with implants using 3-D planning and guided implant surgery

Replacement of multiple adjacent teeth in the esthetic zone with dental implants is a surgical and restorative challenge, especially when an esthetic outcome is essential. Sound diagnosis and treatment planning can be combined with use of cone-beam computed tomography (CBCT) and 3-dimensional (3-D) software to achieve desired results. Placement of implants using guided surgical templates is critical when there is limited space between adjacent teeth or limited bone volume. Slight deviations in implant positioning during placement can lead to implants being too close to adjacent teeth, resulting in bone loss, recession, and encroachment upon adjacent papillae. Placement of implants in anatomically deficient or compromised areas is difficult when using a freehand drill protocol, because attaining the necessary precision cannot be achieved routinely. Esthetically demanding patients require precise implant placement. Use of guided surgical planning and implant placement enables the surgeon to take maximum advantage of available bone in anatomically restricted areas. Restoratively, ideal implant placement facilitates rehabilitation; therefore, all parameters must be observed in order to achieve an esthetically pleasing final restoration.

A CAD/CAM designed, semi-fixed, high strength, all-ceramic prosthesis for maxillary rehabilitation--a case report

The clinical and laboratory steps involved in rehabilitating the maxillary arch following the loss of several teeth due to periodontal disease are outlined in this case report. This article illustrates the use of a laboratory based CAD/CAM system (Sirona In-Lab) and a copy milling technique in the fabrication of a fixed-movable bridge, high strength, all-ceramic, cross-arch bridge.

CLINICAL RELEVANCE

Adopting a semi-fixed approach in cross-arch rehabilitation has conventionally involved the use of porcelain fused to metal (PFM) components but the demands placed by patients and clinicians have led to the development of novel techniques in order to achieve highly aesthetic and functional results.

Cosci versus Summers technique for crestal sinus lift: 3-year results from a randomised controlled trial

PURPOSE

To compare the effectiveness of two different techniques to lift the maxillary sinus via a crestal approach: the Summers versus the Cosci technique.

MATERIALS AND METHODS

Fifteen partially edentulous patients missing bilaterally maxillary molars and/ or premolars, having 4 to 7 mm of residual crestal height and at least 5 mm thickness below the maxillary sinuses measured on CT scans, were randomised to have implants placed in sinuses crestally lifted according to the Cosci or the Summers techniques, with bone substitutes according to a split-mouth design. Implants were left to heal submerged for 6 months. Implants were loaded with acrylic provisional crowns/prostheses. Screw-retained definitive metal-ceramic prostheses were delivered 4 months after provisional loading. Outcome measures were: prosthesis and implant failures; any complications; operation time; operator preference; patient preference and peri-implant marginal bone level changes assessed by a blinded outcome assessor. All patients were followed to 3 years after implant loading.

RESULTS

Nineteen study implants were placed according to each technique. Three years after loading, 3 patients dropped out and no implant failed. No discomfort/complications occurred at sites treated with the Cosci technique, whereas 12 patients reported discomfort during the augmentation procedure at the side treated with the Summers technique; this was statistically significant (P = 0.0005). In one of these patients, a perforation of the sinus membrane occurred. Postoperatively, headache was reported by 9 patients and swelling occurred in 3 of these patients at the Summers treated sides. Statistically significant less time (9.7 mins, SD = 4.0, P < 0.001, 95% CI -11.9 to -7.5) was required to place implants according to the Cosci technique (33 versus 24 mins on average). The 2 operators and 14 out of 15 patients preferred the Cosci technique 1 month after surgery (P = 0.001), and 1 year after surgery (13 out of 15 patients, P = 0.007). The ceramic layer of one prosthesis of the Summers' group and one abutment screw of the Cosci's group loosened between 1 to 3 years post-loading. After 3 years, implants inserted according to the Cosci technique lost 1.39 mm of peri-implant bone versus 1.54 mm for the implants placed with the Summers technique. There were no statistically significant differences for marginal bone level changes between the two groups (difference 0.15 mm, 95% CI -0.11 to 0.41, P = 0.24).

CONCLUSIONS

Both crestal sinus lift techniques produced successful results over a 3-year follow-up period, but the Cosci technique required less surgical time, determined less intra- and postoperative morbidity and was preferred by patients. Conflict of interest statement: This was an investigator-initiated trial, however the trial was partially supported by Zimmer Dental Italy, Vittorio Veneto (TV), Italy. One of the authors (Dr Cosci), who treated 8 patients in this study, is the inventor of the Cosci technique and his partipation was a prerequisite of the sponsor to support the trial.

Treatment planning and dental rehabilitation of periodontally compromised partially edentulous patient: a case report - part II

When planning a prosthetic rehabilitation of a periodontally compromised case, the clinician is often confronted with difficulties and dilemmas related to selecting the appropriate treatment that would provide long-term successful outcomes in function and esthetics. In such cases, a correct diagnosis and prognosis of the intraoral situation supported by evidence-based dentistry is the basis for the establishment of a proper treatment strategy. In this second part of a two-part treatment planning series, a systematic approach of patient examination and prognosis of each tooth is presented. Furthermore, different removable and fixed treatment possibilities are described and the rationale governing the decision-making process is revealed. The execution of the final treatment plan as specified by the concept of comprehensive dental care is outlined, and the final outcome is discussed according to the literature.

A simple technique for replacing extracted anterior teeth using a vacuum formed retainer

This technique can be used as an immeciate short-term solution after extraction, implant placement or grafting procedures. Long-term use is not appropriate and it is not suitable where there is poor hygiene or a high smile line where the junction of the flange and soft tissue would be conspicuous. This device is easily removed to facilitate hygiene, it is available almost immediately, is inexpensive, comfortable to wear, conservative of abutment teeth and can be relieved of soft tissue contact. It is not appropriate in situations where occlusal units are required, where multiple teeth are to be extracted, where there are high aesthetic demands or when a long-term solution is required.

Effectiveness of desensitizing agents in relieving the pre- and postcementation sensitivity for full coverage restorations: a clinical evaluation

Patients frequently report sensitivity of prepared abutment teeth during the temporization period and after the fnal cementation of full coverage restoration. Purpose of this clinical investigation was to evaluate the effectiveness of desensitizing agents in reducing the pre- and postcementation sensitivity for full coverage restorations and to compare the relative effcacy of three in offce applied desensitizing agents in relieving the postcementation sensitivity with the use of glass ionomer luting cement.

MATERIALS AND METHODS

This study consisted of 30 patients requiring either full coverage restoration or 3 unit fxed partial denture. Total of 40 restorations (n = 40) were made and were randomly assigned into four groups comprising 10 restoration (n = 10) in each group. Group C control where no desensitizer application was done, group BB applied with BisBlock dentin desensitizer (Bisco Inc.), group ST applied with Systemp desensitizer (Ivoclar Vivadent), group GC applied with GC Tooth Mousse desensitizer (GC Asia). Desensitizer application was done immediately after the tooth preparation. Sensitivity of the tested abutment was determined by the patient response to cold, hot and bite stimuli and were recorded on visual analog scale (VAS). Sensitivity level scores was evaluated at 4 time intervals, i.e. 1 week after desensitizer application at baseline precementation appointment and others at 5 minutes, 1 day and 1 week postcementation appointment. VAS score data was statistically analyzed using one-way ANOVA followed by post hoc Tukey's test.

RESULTS

BisBlock and GC Tooth Mousse desensitizer resulted in statistically signifcant (p < 0.01) reduction in postcementation sensitivity of glass ionomer cement in comparison to Systemp desensitizer at 5 minutes, 1 week postcementation time interval with no statistical difference was seen between all desensitizer groups at 1 day postcementation. Application of BisBlock and GC Tooth Mousse desensitizer resulted in highly signifcant (p < 0.01) reduction in sensitivity level at the end of 1 week.

CLINICAL SIGNIFICANCE

Desensitizer's application on the prepared abutment teeth is considerably effective in relieving both pre- and postcementation sensitivity for full coverage restoration over the short duration of time. Immediate reduction in postoperative sensitivity relatively in a short time period may be benefcial in terms of patient's comfort. Nonetheless, multicenter long-term clinical trials should be conducted to confrm the results.

CONCLUSION

Efficacy of BisBlock and GC Tooth Mousse desensitizer was more in relieving the postcementation sensitivity of glass ionomer cement at various time intervals in comparison to Systemp desensitizer. In conclusion, application of desensitizers was beneficial to reduce the pre- and postcementation abutment sensitivity.

Fixed prosthodontics provisional materials: making the right selection

Clinicians have many choices when selecting an appropriate material for interim restorations for both single crowns and multi-units. Interim restorations serve as a diagnostic as well as biologic and biomechanical component of fixed prosthodontics treatment; in the anterior, they are also important in evaluating the esthetics for the definitive restoration. Factors to be considered when choosing provisional materials are physical properties, handling characteristics, patient response to the appearance of the interim restoration, durability of the restoration, and the cost of the material. Practitioners should, therefore, base their choice on the clinical needs for each situation.

[Optimization of implant and teeth retained restorations by two-step dental implantation]

Strength properties of provisional resin implant-retained restorations were assessed in vitro. The results were used to justify the use of combined temporary and two-step dental implantation.

CAD/CAM-based polymer provisionals as treatment adjuncts

The role and function of provisional restorations has changed significantly in recent years. The reasons include the improvement of material properties and the CAD/CAM production option using polymer blanks, which are offered by various manufacturers. Besides their classic indications in crown and bridge prosthodontics, provisional restorations are now used for soft-tissue management, preparation and adaptation in complex restorations that include changes in vertical relations, and as mock-ups in esthetic dentistry.

Provisional prostheses during ridge augmentation and implant dentistry

Recent advancements in ridge augmentation and bone regeneration have expanded the pool of patients that could benefit from dental implants. However, providing the patient with a temporary prosthesis during the wound healing phase without impairing the process is a challenging task. This article summarizes available information pertaining to provisional prostheses, both tooth-supported and soft tissue-supported, that may meet the patient needs. The advantages and disadvantages of each class of prosthesis, along with indications and contraindications, were taken into consideration to aid the restorative dentist in choosing the optimal provisional for their patients.

Evaluation of alternative approaches in designing CAD/CAM frameworks for fixed partial dentures

BACKGROUND

The need for proper framework support for the veneer porcelain in fixed partial dentures (FPDs) has been well documented. The aim of this study was to compare the variations of the support provided by frameworks designed directly on the computer, or indirectly through scanning a wax pattern.

MATERIALS AND METHODS

For each of the six upper anterior FPDs that were involved in the study, prior to milling one framework was designed conventionally in wax and scanned and another one was directly digitally designed. The restorations consisted of full coverage retainers and pontics on natural abutment teeth and implant abutments at random. The produced frameworks were evaluated regarding the incisal support they would provide to the veneer material, as this was revealed by a silicon key representing the outer labial contour of the provisional restoration. The distances between the distal and mesial incisaledges and the corresponding negative incisal contour of the key were measured with a digital caliper. Statistical analysis was performed by linear regression with the design method, abutment type and pontic type as independent parameters (a = 0.05).

RESULTS

The values recorded were: means ± SD: 3.3 ± (direct CAD), 2.6 ± mm (indirect CAD) 2.7 ± mm (for retainers on natural teeth) 2.7 (on implant abutments), and 3.3 mm (for pontics). Linear regression analysis showed that the indirect technique provided more intimate incisal support for the ceramic veneer on a statistically significant level and even more so in the pontic areas.

Posterior atrophic jaws rehabilitated with prostheses supported by 5 x 5 mm implants with a novel nanostructured calcium-incorporated titanium surface or by longer implants in augmented bone. One-year results from a randomised controlled trial

PURPOSE

To evaluate whether 5 × 5 mm dental implants with a novel nanostructured calciumincorporated titanium surface could be an alternative to implants at least 10 mm long placed in bone augmented with bone substitutes in posterior atrophic jaws.

MATERIALS AND METHODS

A total of 40 patients with atrophic posterior (premolar and molar areas) mandibles having 5 to 7 mm of bone height above the mandibular canal and 40 patients with atrophic maxillae having 4 to 6 mm below the maxillary sinus, were randomised according to a parallel group design to receive one to three 5 mm implants or one to three at least 10 mm-long implants in augmented bone at two centres. All implants had a diameter of 5 mm. Mandibles were vertically augmented with interpositional bovine bone blocks and resorbable barriers. Implants were placed after 4 months. Maxillary sinuses were augmented with particulated porcine bone via a lateral window covered with resorbable barriers and implants were placed simultaneously. All implants were submerged and loaded after 4 months with provisional prostheses. Four months later, definitive screw-retained or provisionally cemented metal-ceramic or zirconia prostheses were delivered. Patients were followed up to 1 year post-loading and the outcome measures were prosthesis and implant failures, any complications and peri-implant marginal bone level changes.

RESULTS

One maxillary grafted patient dropped out before the 1-year evaluation. In mandibles, 1 grafted patient did not want to go ahead with the treatment because of multiple complications and graft failure, and another grafted patient did not receive his prostheses due the loss of 2 implants. In maxillae, one 5 × 5 mm implant failed with its provisional crown 3 months post-loading. There were no statistically significant differences in prostheses and implant failures. Significantly more complications occurred at both mandibular and maxillary grafted sites: 17 augmented patients were affected by complications versus 8 patients treated with short implants in the mandible (P = 0.0079; difference in proportion = -0.45; 95% CI -0.67 to -0.15), and 5 sinus-lift patients versus none treated with maxillary short implants (P = 0.047; difference in proportion = -0.25; 95% CI -0.44 to -0.06). Patients with mandibular short implants lost on average 0.94 mm of peri-implant bone at 1 year and patients with 10 mm or longer mandibular implants lost 1.03 mm. Patients with maxillary short implants lost on average 0.87 mm of peri-implant bone at 1 year and patients with 10 mm or longer maxillary implants lost 1.15 mm. There were no statistically significant differences in bone level changes up to 1 year between short and longer implants in maxillae (mean difference -0.28 mm, 95% CI -0.56 to 0.01, P = 0.051) and in mandibles (mean difference -0.09 mm, 95% CI -0.26 to 0.08, P = 0.295).

CONCLUSIONS

One year after loading, 5 × 5 mm implants achieved similar results compared to longer implants placed in augmented bone. Short implants might be a preferable choice to bone augmentation especially in posterior mandibles since the treatment is faster, cheaper and associated with less morbidity, however 5 to 10 years of post-loading data are necessary before making reliable recommendations.

CONFLICT-OF-INTEREST STATEMENT

MegaGen partially supported this trial and donated implants and prosthetic components used in this study, whereas Tecnoss donated the biomaterials. The data belonged to the authors and by no means did the manufacturers interfere with the conduct of the trial or the publication of its results.

The connective tissue platform technique for soft tissue augmentation

The presence of a localized alveolar ridge defect, especially in the maxillary anterior dentition, may complicate an esthetic rehabilitation. The goal of this case report is to describe a novel subepithelial connective tissue graft technique for soft tissue augmentation in Class III ridge defects. Surgical intervention consisted of in situ maintenance of a connective tissue "platform" at the edentulous space, which facilitated the stabilization and suturing of the connective tissue grafts used for soft tissue augmentation. Adequate graft thickness to treat the deep horizontal soft tissue loss was obtained by doubling the width of a de-epithelialized free gingival graft that was subsequently folded on itself. The soft tissue conditioning at the level of the pontic began 9 months after surgery by shaping the soft tissue with a bur and filling the space with flowable composite resin applied above the pontic. The final prosthetic phase began 14 months after surgery. A reproduction of the anatomical cementoenamel junction in the provisional and definitive restorations was performed to improve the soft tissue emergence profile. Nine months after surgery, a soft tissue augmentation of 5 mm in the vertical and 4 mm in the horizontal dimension was accomplished. The suggested surgical technique was able to accomplish horizontal and vertical soft tissue augmentation in a single surgical step.

Sequential provisional implant prosthodontics therapy

The fabrication and long-term use of first- and second-stage provisional implant prostheses is critical to create a favorable prognosis for function and esthetics of a fixed-implant supported prosthesis. The fixed metal and acrylic resin cemented first-stage prosthesis, as reviewed in Part I, is needed for prevention of adjacent and opposing tooth movement, pressure on the implant site as well as protection to avoid micromovement of the freshly placed implant body. The second-stage prosthesis, reviewed in Part II, should be used following implant uncovering and abutment installation. The patient wears this provisional prosthesis until maturation of the bone and healing of soft tissues. The second-stage provisional prosthesis is also a fail-safe mechanism for possible early implant failures and also can be used with late failures and/or for the necessity to repair the definitive prosthesis. In addition, the screw-retained provisional prosthesis is used if and when an implant requires removal or other implants are to be placed as in a sequential approach. The creation and use of both first- and second-stage provisional prostheses involve a restorative dentist, dental technician, surgeon, and patient to work as a team. If the dentist alone cannot do diagnosis and treatment planning, surgery, and laboratory techniques, he or she needs help by employing the expertise of a surgeon and a laboratory technician. This team approach is essential for optimum results.

Removable partial denture assisted by implant-retained fixed prosthesis opposing implant-retained overdenture

Restoring an edentulous mouth is a challenge when the patient has both high esthetic expectations and financial limitations. This case report describes the prosthodontic management of an elderly edentulous patient with a maxillary anterior implant-supported fixed partial denture in conjunction with a distal extension-base removable partial denture opposing a mandibular implant-retained overdenture. The patient's clinical outcome after 30 months is presented.

Improving quality of life using removable and fixed implant prostheses

Removable and fixed implant-retained prostheses can greatly enhance patients' quality of life, improving their speech, appearance, and ability to eat and otherwise function normally. Yet patients may resist this type of treatment due to barriers, including cost, fear, and lengthy treatment times. It is, therefore, important that clinicians engage in discovering and understanding their patients' concerns and expectations in addition to making a thorough and complete diagnosis of their dental conditions. In the case presented, emphasis was placed on patient-clinician communication to correctly facilitate the desired clinical result. The final restoration consisted of a maxillary removable, implant-assisted denture and a mandibular screw-retained, fixed, implant-supported prosthesis.

Immediate loading of mandibular dental implants in partially edentulous patients: a prospective randomized comparative study

While immediate loading in the edentulous mandible is a well-documented procedure, there are limited scientific data on immediate loading in the partially edentulous mandible. Two-year success rates of immediate loading and conventional delayed loading of dental implants in partially dentate mandibles were compared. Patients were randomized into three groups: group A (n = 40), immediate provisionalization with nonocclusal loading; group B (n = 40), immediate provisionalization with occlusal loading; and group C (n = 37), delayed loading with single-stage surgery. Baseline and 2-year measurements included implant stability quotient, insertion torque, and peri-implant bone crest radiography. Two hundred nine implants were immediately loaded in 80 patients. The 2-year success rates were 93.3% for group B and 100% for groups A and C. Immediate provisionalization provided success rates similar to those for delayed loading only when not loaded in occlusion.

A multidisciplinary approach for the management of pathologic tooth migration in a patient with moderately advanced periodontal disease

The physiologic tooth position is determined by interactions between the periodontal tissue and occlusal, tongue, and lip forces. Bone destruction resulting from chronic periodontal disease disturbs the equilibrium of these interactive balances, leading to pathologic tooth migration, often requiring multidisciplinary treatment approaches. The present case demonstrates a systematic periodontal-orthodontic-prosthetic treatment for achieving the optimal structural, functional, and esthetic outcomes.

Effect of a procedural video CD and study guide on the practical fixed prosthodontic performance of Iranian dental students

Dental students in programs around the world typically pass preclinical courses before entering the clinic and working on actual patients. Since fixed prosthodontics is a preclinical course that requires a great deal of effort, students may experience a substantial amount of stress that may affect their self-confidence and/or clinical performance. In this study, an instructional video CD (VCD) and study guide depicting the step-by-step procedures involved in a metal-ceramic tooth preparation and provisional crown fabrication was prepared. Students at the Faculty of Dentistry, Tehran University of Medical Sciences, Tehran, Iran, were divided randomly into two groups. Group A students trained as usual with live patients, and Group B students were given a copy of the VCD and study guide following a lecture. The students in Group B were encouraged to read the study guide and watch the VCD after live demonstrations. Then, both groups practiced individually on mannequins. At the end of the course, the students completed a sixteen-item questionnaire about their stress level, self-confidence, and knowledge base. The results showed that the students exposed to the extra media performed significantly better on some practical phases, e.g., laboratory procedures. A moderate, insignificant correlation was detected between exposure to media and decreasing the students' stress and self-esteem. We concluded that supplementary teaching aids such as a VCD and study guide may improve the clinical performance of dental students to some extent, but the live demonstration is still preferred by students.

Soft tissue remodeling technique as a non-invasive alternative to second implant surgery

It is currently accepted that success in implant-supported restorations is based not only on osseointegration, but also on achieving the esthetic outcome of natural teeth and healthy soft tissues. The socalled "pink esthetic" has become the main challenge with implant-supported rehabilitations in the anterior area. This is especially difficult in the cases with two adjacent implants. Two components affect the final periimplant gingiva: a correct bone support, and a sufficient quantity and quality of soft tissues. Several papers have emphasized the need to regenerate and preserve the bone after extractions, or after the exposure of the implants to the oral environment. The classical implantation protocol entails entering the working area several times and always involves the surgical manipulation of peri-implant tissues. Careful surgical handling of the soft tissues when exposing the implants and placing the healing abutments (second surgery) helps the clinician to obtain the best possible results, but even so there is a loss of volume of the tissues as they become weaker and more rigid after each procedure. The present study proposes a new protocol that includes the connective tissue graft placement and the soft tissues remodeling technique, which is based on the use of the ovoid pontics. This technique may help to minimize the logical scar reaction after the second surgery and to improve the final emergence profile.

Considerations for a staged approach in implant dentistry

Full-arch and partial reconstruction is demanding for the clinician and a challenge for the patient. Traditionally, teeth are extracted, and implants are placed; the patient wears a provisional removable prosthesis during implant osseointegration. The patient is left to deal with a difficult transition from a fixed dentition to a removable one, albeit temporarily. This drastic alteration can generate functional, emotional, and esthetic changes for the patient, thereby making a difficult time even more challenging. Reconstructing the dentition through a staged approach has been documented and involves strategic extractions along with the placement of several implants, but leaves select abutment teeth for a fixed provisional prosthesis. This allows for the provisional prosthesis to be tooth-supported during implant integration and later converted to an implant-supported prosthesis. In this manner, the patient will benefit from a fixed provisional prosthesis throughout the treatment process. A staged approach is contingent upon a thorough periodontal and prosthetic evaluation and work-up. Success requires proper communication between the periodontist, surgeon, restorative dentist, laboratory, and patient. A team approach is necessary for success. The protocol, advantages, and disadvantages for a staged approach to a full-arch implant-supported reconstruction are discussed. The authors also present a case to show how the staged approach can be used for sextant or quadrant rehabilitation.

Partial rehabilitation of the posterior edentulous maxilla using axial and tilted implants in immediate function to avoid bone grafting

There is a need to create rehabilitation solutions for partial edentulism in the posterior maxilla, thereby reducing the need for grafting in these areas. The purpose of this study was to report the results of partial edentulism rehabilitation in the posterior maxilla with a three- to four-unit bridge supported by two implants: anterior implant placed in axial position and posterior implant tilted distally. A theoretical analysis of the concept including a biomechanical discussion is also provided.

MATERIALS AND METHODS

The clinical study included 35 patients (21 women, 14 men) with an age range of 37 to 80 years (mean = 55.5 years), rehabilitated with an implant-supported partial bridge, followed between 4 months and 8 years, with a mean follow-up time of 53 months. ASSESSMENT DATA:The success criteria included clinical parameters (ie, implant fulfilled its purported function as support for reconstruction; was stable when individually and manually tested; had absence of infection; demonstrated a good esthetic outcome of the rehabilitation; allowed fabrication of the implant-supported fixed prosthesis, which provided patient comfort and hygiene) and radiographic parameters (ie, implant probability of long-term stability, as judged by annual bone loss). The implant survival estimate was computed using the Kaplan-Meier product limit estimator. Data were analyzed with descriptive and inferential analyses.

RESULTS

The survival rates were 97.1% and 98.8% at 8 years (Kaplan-Meier), using the patient and implant as units of analysis, respectively. The overall average marginal bone resorption was 1.05 mm (SD = 0.65 mm) at 1-year follow-up, and 1.47 mm (SD = 0.37 mm) at 5-year follow-up, with no significant differences between axial and tilted implants in the 1-year (P = 0.107) and 5-year (P = 0.211) evaluations. DISCUSSION OF RESULTS:The results indicate that within the limitations of this preliminary study the present protocol is valid for the rehabilitation of partial edentulism in the posterior maxilla. The clinical results confirmed the theoretical analysis on biomechanics and load distribution, with high survival and success rates in the long-term, low implant marginal bone resorption, and low frequencies of complications.

Alveolar ridge augmentation: comparison of two socket graft materials in implant cases

With the variety of bone grafting materials available and their use around both natural teeth and dental implants, clinicians need to understand not only basic bone biology but also characteristics of different bone grafting materials to make a proper choice when selecting a material for alveolar bone augmentation and implant treatment. The grafting materials used in the maxillofacial region include autogenous bone, allografts, xenografts, alloplastic or synthetic products, and composite grafts (combination of different materials). This case report describes two frequenly used bone graft materials for socket preservation immediately after extraction: Puros® (Zimmer Dental Inc, www.zimmerdental.com) (allogeneic) and Bio-Oss®(Osteohealth Co, www.osteohealth.comwww.osteohealth.com) (xenogeneic). In the case presented, the authors perform biologic, clinical, radiologic, and histologic analysis of the two grafting materials by placing them side-by-side in the same patient during implant reconstruction. Implant-related phases of bone augmentation are proposed, and an overview of bone grafting materials, specifically Bio-Oss and Puros, is presented.

Chairside resin-based provisional restorative materials for fixed prosthodontics

Provisional restorations are vital to fixed prosthodontics treatment, providing an important diagnostic function while in place. In addition to protecting the prepared teeth, provisionalization enables clinicians to refine biologic and biomechanical issues before the final restoration is fabricated. Adjustments can be made in the provisional restoration to achieve both the clinician's and patient's desired results. The fabrication of temporary restorations requires that clinicians be proficient with a variety of materials and techniques that can be used to make well-adapted and functional provisionals. There are many material choices available to temporize a single crown as well as multi-unit fixed partial dentures, and the selection of provisional materials should be made based on a case-by-case evaluation. This article provides a review of polymeric resin provisional materials.

Implant repositioning by segmental osteotomy: a case series and review

Although every effort is made to place dental implants in a proper position, the restorative dentist does not always succeed. Historically, treatment options for poorly placed implants included removing the implant or leaving it "sleeping." Recent modifications of an existing technique, the segmental osteotomy, may offer hope in these situations by rendering many of these "hopeless" implants salvageable. This paper presents lessons learned from a series of cases in which segmental osteotomies were performed to improve the esthetic outcome of implant malpositioning. Two clinical cases (one successful, one failed) utilizing segmental osteotomy to surgically correct malposed implants are presented with a review of the literature associated with the technique. With adherence to proper case selection and detailed surgical protocol, segmental osteotomy is a viable treatment option to correct misaligned dental implants.

Alternative fabrication method for chairside fiber-reinforced composite resin provisional fixed partial dentures

A high level of clinical skill is required for fabricating a provisional fixed partial denture with fiber-reinforced composite resin (FRC) using either the direct or chairside technique. The freehand approach to restoring missing teeth represents a challenge to the clinician, particularly when shaping and finishing a hygienic pontic. This technical report describes a simplified method for chairside fabrication of a fixed dental prosthesis with FRC. It is based on using a translucent template to guide the buildup procedure and to ensure optimal anatomy and function.

IMRA: Immediate maxillary replacement appliance for anterior teeth

When faced with the need for emergency replacement of anterior teeth, the problem for dentists and their patients is how can lost teeth be replaced quickly? Laboratory-fabricated replacement appliances require significant time and expense, not to mention an extended period, during which the patient remains edentulous. This report describes a procedure to construct an immediate, low-cost replacement for one or more missing anterior teeth-one that requires no laboratory time. The resulting appliance is meant only as a stop gap and does not support chewing; but it does offer an esthetically pleasing, removable prosthesis that provides phonetic and lip support during the short time necessary to fabricate and place a permanent prosthesis.