Presurgical occlusal view of mandible; assessment of tongue space.

NobelGuide seated and fixed in position to the underlying bone.

Multi-unit abutments connected.

Definitive CAD/CAM fabricated prostheses in occlusion.

0 Overview
1 Evaluation & Diagnosis
2 Treatment Planning
3 Progress & Completion
4 Follow-Up & Outcome

Patient cases:

Complete-arch treatments

(Maxilla / Mandible / Edentulous)

Immediate loading in the edentulous mandible for CAD/CAM prostheses

Lead:

Charles Goodacre

A 72-year-old female patient was affected by the poor fit of her existing mandibular complete denture, especially the constant movement while chewing. The final treatment included a new maxillary complete denture and a mandibular implant fixed complete denture. More precisely: an All-on-4® treatment concept was planned for the mandible that included the use of CAD/CAM computer-aided engineering for fabrication of the prostheses.

Overview

Final maxillary impression

Final mandibular impression

AvaDent AMD partial arch impressions connected together in centric relation at the desired occlusal vertical dimension. A tooth mold template is attached to the maxillary tray to show size of anterior teeth and their positioning.

Provisional CAD/CAM fabricated monolithic dentures (teeth and base as one unit) were fabricated using complete arch impression and connected partial arch impressions. They will be worn so patient can get accustomed to new denture form.

Evaluation & Diagnosis

Pretreatment view of maxilla.

Pretreatment view of mandible.

Mandibular CBCT scan with radiographic template present for implant planning.

Treatment Planning

CAD/CAM milled radiographic template that was a duplicate of the provisional mandibular denture provided to the patient.

Inferior view of mandible.

Frontal view of mandible, with computer-engineered template seated.

Implant placement planning; emphasis on mandibular nerve pathway.

Occlusal view of template.

Presurgical occlusal view of mandible; assessment of tongue space.

Progress & Completion

NobelGuide surgical template fabricated from computer planning using NobelClinician software.

NobelGuide seated and fixed in position to the underlying bone.

Drilling osteotomy using template.

Close up of osteotomy.

Implant above template.

Implant placement.

Implants placed & template removed.

Multi-unit abutments connected.

Temporary copings attached to multi-unit abutments.

Using the data from the provisional dentures, a CAD/CAM fabricated conversion denture was made with channels in the base positioned where the channels were located in the surgical template. There is also a slot around the perimeter of the denture.

The conversion denture is seated over the temporary copings and the occlusion with the maxillary provisional denture used to orient the conversion denture.

Acrylic resin is syringed around the copings to connect the conversion denture to the copings.

After resin polymerization, the conversion denture is removed.

The struts that connected the peripheral base to the central conversion denture were sectioned.

The final conversion denture after contouring and polishing.

Maxillary provisional complete denture in occlusion with mandibular conversion denture.

Impression tray that is duplicate of mandibular provisional denture was fabricated with recess to accomodate verification jig. It will be used to make impression for definitive prosthesis.

Verification jig that was CAD/CAM milled from prepolymerized resin to fit inside the milled impression tray.

Verification jig was attached to copings using incremental layers of flowable composite resin to minimize polymerization shrinkage. The one-screw test can be used to verify the connection accuracy.

The impression tray that is a duplicate of the mandibular provisional denture fits over the verification jig and is oriented using occlusion with the maxillary provisional denture.

Light-body impression material is syringed around the verification jig.

The impression tray, filled with heavier-body impression material, is seated over the verification jig and the occlusion used to orient the definitive impression relative to the implants.

The definitive mandibular impression and interocclusal record that shows relationship with maxillary provisional denture. These records will be used to fabricate definitive prostheses.

Titanium bar milled by Nobel Biocare oriented inside recess of AvaDent milled denture. The bar will be encased in resin.

Definitive maxillary complete denture that was CAD/CAM fabricated using data from provisional complete dentures.

Definitive CAD/CAM fabricated prostheses in occlusion.

Mandibular prosthesis.

Mandibular prosthesis - occlusal view.

Palatal view of final maxillary denture.

Mandibular multi-unit abutments.

Close-up of abutment connections.

Lateral movement to the left.

Protrusive movement of the right side.

Protrusive movement of the left side.

Right working side.

Left working side.

Definitive restoration

Follow-Up & Outcome

Facial view of mandibular prosthesis and mucosal health.

Some lingual plaque accumulation.

End-tuft brush where handle was heated in a Bunsen burner and bent so as to allow patient to brush lingual surface.

Questions

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Team members

Charles Goodacre

Prosthodontist

Jaime Lozada

Surgeon-Prosthodontist

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