CHIEF COMPLAINT:
Patient showed dissatisfaction with the instability of the inferior prosthesis and also expressed the desire to perform an inexpensive treatment.
DIAGNOSIS:
52-year-old female patient, non-smoker. Presented only teeth 3.3.3.4 and 4.3. Teeth with endodontic treatment and extensive restorations with composite resin. Had two removable acrylic dentures. The upper one had already been subjected to a relining and presented capable retention. The lower one was poorly adjusted and showed little retention. Patient had good oral hygiene.
TREATMENT PLAN:
Due to financial constraints, the patient was offered the most economical solution to stabilize the inferior prosthesis, making one over acrylic denture retained by two implants. The treatment plan consisted of extracting the remaining teeth and immediately placing 2 implants in the area of the lower canines. The extracted teeth would be added to the pre-existing prosthesis, to be relined with tissue conditioner over the healing screws. After osseointegration, the 3 hypotheses for retention of the prosthesis were available for consideration. Thus, the three hypotheses would be pursued, and the patient would choose the one that pleased her the most. The 3 solutions presented would be 2 individual retention mechanisms, the Locator Implant ZEST®, and the Novaloc® with an Akerman bar.
TEAM PLAY “DENTIST – DENTAL TECHNICIAN” NOTES:
After imaging and prosthodontic study for implant placement, the surgery was performed. Before extraction of the teeth and placement of the implants, we made an alginate pre-impression at the laboratory, to add to the 3 teeth to be extracted. The two implants were placed at the site of the lower canines, taking care to be parallel and placed at the same level in the horizontal and anteroposterior plane. After placement of the healing screws and suturing, the prosthesis was rebased with tissue conditioner. After two months, and osseointegration of the implants was verified, the first impression was made. This impression was done with the open tray technique, using standard tray with soft and regular consistency putty silicones. This impression gave rise to the first working model where bite wax screws were fixed to the implants with acrylic stabilized base. An open individual tray with set tops was also made for a definitive functional impression. In the mouth, the articulation waxes were screwed to the implants and a correct Vertical Dimension Occlusion was collected, as well as the inter maxillary relation recorded. The open individual tray allowed a functional impression of the soft tissues with fluid consistency silicon. At the laboratory, the teeth of the prosthesis were assembled, and after proof in mouth, they could be screwed onto the implants. After the aesthetic, occlusal and functional approval of this test, a silicone wall was prepared at the laboratory, which guided the definitive preparation of the three rehabilitation hypotheses. The first one to be made was Akerman's bar. The section of the bar must be round or oval to allow a slight forward rotation movement of the prosthetic base. The rotation of the clips, embedded in the overlying denture with bar, compensates for the elasticity of the mucosa in the posterior sectors, so the bar must be straight and parallel to the occlusal plane to allow an axis of rotation parallel to the axis that passes through the center of rotation of the mandibular condyles. In this case, in order to increase the retention and to make the prosthesis more implant-supported, the bar had two extensions, distal to the implants, and the clips were placed in this zone. The bar was tested in the mouth by checking its passive seating and the imaging control validated this procedure. At the laboratory, the work was finished, acrilinzing the removable prosthesis and inserting the clips. The second hypothesis to be followed was the Locators. The Locator Implant ZEST® is a supra-gingival resilient fitting, for over dentures on implants. The implant locator system consists of two elements: a metal Locator Abutment, screwed directly onto the implant, and a metal cap, placed on the prosthesis, containing Nylon retention. In this case, the work did not require any type of proof. After acrylization of the prosthesis and inclusion of the metal capsule at the laboratory, the work was sent for final placement in the mouth. Placing it in the mouth involves screwing Locator Abutment® to implants with a torque of 35 N using a special wrench. The last hypothesis was the Novalocs®. The Novaloc® denture retainer system features a carbon-based (amorphous diamond-like carbon) coating for abutments, with good wear resistance, filling up to 60 ° implant divergence. Straight and angled posts are available at 15 ° for various gingiva heights, covering various clinical situations. This hypothesis, like the previous one, does not require any type of proof. After acrylization of the prosthesis and inclusion of the metallic capsule at the laboratory, the work is sent for definitive placement in the mouth. Its placement in the mouth involves the bolting of Novaloc® to implants with a torque of 35 N, using the SCS switch. All hypotheses were tried by the patient. The Novaloc® retentive system was elected for definitive treatment.