Four-year follow-up of the rehabilitation of a mandibular arch with a cementable zirconia-reinforced fixed dental prosthesis: A clinical report

Abdulmohsin Alhashim, BDS, MSD,a Mohamed Kamel, BDS, MSc, MSD,b and William W. Brackett, DDS, MSDc College of Dental Medicine, Georgia Health Sciences University, Augusta, Ga; New Jersey Dental School, University of Medicine and Dentistry of New Jersey, Newark, NJ
Implant-supported prostheses have been used extensively to rehabilitate completely edentulous arches. Although combinations of different restorative materials have reportedly been used to fabricate such prostheses, a metal framework is usually chosen for acrylic resin reinforcement. However, cost and the frequent need to section and solder to attain a passive framework fit are disadvantages for using metal. Zirconia has been used widely in restorative dentistry as an alternative to metal. This clinical report describes the fabrication of a zirconia-reinforced cementable fixed dental prosthesis with a 4-year follow-up. (J Prosthet Dent 2012;108:138-142) The restoration of completely edentulous arches with implant-supported prostheses is a predictable treatment modality.1-3 The choice of restorative materials and the occlusal scheme for implant-supported prostheses is generally determined by the opposing arch. In treatments where the opposing arch is restored with a complete denture, a bilateral balanced occlusal scheme and a reinforced acrylic resin prosthesis are recommended.4-7 Usually, metal is used to reinforce such prostheses. Distortion from heating and cooling during the lost wax casting technique may make it necessary to section and solder the framework to obtain a passive fit. Affordable base metal alloys cannot be soldered reliably,8 while the cost of noble metals, which can be soldered adequately, is prohibitive. The development of computeraided design/computer-assisted manufacturing (CAD/CAM) introduced milled frameworks with significantly better fit than conventional castings.9 Zirconia has been used extensively for milled cementable frameworks that have a lower fabrication cost
a

than cast frameworks. The use of a device to verify the accuracy of implant positions on the definitive cast is recommended because sectioning and soldering of milled zirconia frameworks is not possible. Acrylic resin is attached to cast metal with mechanical retention, produced by the addition of beads and strips to the wax pattern to obtain undercuts. Undercuts are not easily milled into zirconia frameworks, and cutting undercuts into the framework after milling reduces their strength; the framework, therefore, must be designed to allow encirclement by the acrylic resin. When a metal framework is used to reinforce a prosthesis, an opaque layer is required to mask the metal color; however, the opaque layer is not needed for a zirconia framework. This clinical report demonstrates the fabrication of a cementable fixed dental prosthesis by using a zirconia framework and acrylic resin.

CLINICAL REPORT
A 55-year-old white male presented for treatment complaining that he could not wear a mandibular denture.

He expressed a desire for a fixed mandibular restoration and also needed a new maxillary denture. A review of the patients medical history revealed no significant findings. Although unable to wear a mandibular complete denture because of lack of retention and stability, the patient had successfully worn a maxillary complete denture for approximately 10 years. The maxillary soft tissues appeared firm posteriorly and slightly displaceable anteriorly, with evidence of mild inflammation due to an ill-fitting denture. The patient had a well-developed mandibular ridge (Figs. 1, 2). The mandibular ridge and tongue size provided limited space for denture flanges, which compromised retention and stability. The patient was instructed to stop wearing the maxillary complete denture for 48 hours and finger massage the tissue frequently with gauze moistened with water. Tissue conditioner (Visco-gel; Dentsply Intl, York, Pa) was applied to the intaglio surface of the maxillary complete denture. Maxillary and mandibular preliminary impressions were made with irreversible hydrocolloid impression material

Assistant Professor, Department of Oral Rehabilitation, College of Dental Medicine, Georgia Health Sciences University. Assistant Professor, Department of Restorative Dentistry, New Jersey Dental School, University of Medicine and Dentistry of New Jersey. c Professor, Department of Oral Rehabilitation, College of Dental Medicine, Georgia Health Sciences University.
b

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(Jeltrate; Dentsply Intl) in stock metal trays (CEO; GC America, Alsip, Ill). The impressions were poured with Type III dental stone (Microstone; Whip Mix, Louisville, Ky). Record bases were fabricated with acrylic resin (Triad Tru Tray; Dentsply Intl) and occlusion rims were added by using baseplate wax. A tentative occlusal vertical dimension was established. A centric relation record was made with impression wax (Aluwax; Benco Dental, Pittston, Pa), and a facebow transfer (Hanau SpringBow; Whip Mix Corp) was made. The maxillary diagnostic cast was mounted on an articulator (Hanau Wide Vue; Whip Mix Corp) with Type III mounting stone (Mounting Stone; Whip Mix Corp). The mandibular diagnostic cast was mounted by using the centric relation record. Esthetics and phonetics were used to establish the position of the anterior teeth. Centric relation was verified with an additional centric relation record. A protrusive record was made to program the articulator settings for the horizontal and lateral condylar indications. Denture teeth (SR Ortholingual DCL; Ivoclar, Amherst, NY) were selected to develop a balanced, lingualized occlusal scheme since the maxillary dentition was provided by a complete denture. The occlusion and esthetics were verified at the trial insertion appointment. The mandibular diagnostic wax trial denture was duplicated in orthodontic acrylic resin (Dentsply Caulk, Milford, Del) to fabricate a surgical guide for implant placement. Six implants (4.7 13 mm; Zimmer Dental, Carlsbad, Calif ) were surgically placed in the mandible and allowed to heal for 4 months. The implants were uncovered and an open tray implant-level impression was made in medium-body polyether impression material (Impregum; 3M ESPE AG, Seefeld, Germany). Two temporary abutments (Zimmer Dental) were screwed into the 2 implants in the mandibular canine locations. The surgical guide was hollowed

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1 Pretreatment radiograph.

2 Pretreatment mandibular arch. out to create room for acrylic resin around the temporary abutments. The maxillary diagnostic wax trial denture and the mandibular surgical guide were placed into occlusion to verify complete seating of the surgical guide. Autopolymerized acrylic resin (Pattern Resin; GC Corp, Tokyo, Japan) was injected around the 2 temporary abutments to attach them to the surgical guide. The patient again was guided into centric occlusion to confirm complete seating. A centric relation record was made with modeling plastic impression compound (Impression Compound; Kerr Corp, Orange, Calif ). The surgical guide with the 2 temporary abutments was unscrewed and removed from the patients mouth in 1 piece. Implant analogs were connected to the impression copings and gingival moulage (Gi-Mask; Coltene/Whaledent, Inc, Cuyahoga Falls, Ohio) was injected around the junction of the impression copings and the analogs. The impression was poured with Type IV dental stone (Microstone; Whip Mix Corp). A verification index made of autopolymerized acrylic resin (Pattern Resin; GC Corp) and 6 nonengaging temporary abutments were evaluated intraorally to verify the accuracy of the mandibular definitive cast. The flanges were removed from the mandibular surgical guide. The surgical guide was screwed onto the mandibular definitive cast by using the 2 temporary abutments. Then the mandibular definitive cast was mounted to the maxillary diagnostic cast by using the centric relation record. The articulator, the maxillary diagnostic wax trial denture, and the mandibular surgical guide screwed onto the mandibular definitive cast were sent to a processing center (Atlantis Incorporation, Cambridge, Mass) to fabricate titanium custom abutments. The abutments were evaluated intraorally

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3 Milled titanium abutments placed intraorally.

4 Zirconia framework evaluation.

5 Completed prosthesis. to verify the margins of the abutments relative to the soft tissue (Fig. 3). The margins were maintained no more than 1 mm below the tissue margin to facilitate complete removal of any excess cement. The abutments were scanned by using a CAD/CAM touch-probe scanner (Forte; Nobel Biocare, Mahwah, NJ) to fabricate a cementable zirconia framework. The fit of the zirconia framework was confirmed with disclosing material (Fit Checker; GC Corp) (Fig. 4). The mandibular teeth were attached to the zirconia framework by using a labial index made from the surgical guide, which was a duplicate of the original diagnostic treatment. The wax was wrapped around the zirconia framework. The wax trial prostheses were evaluated intraorally and evaluated for esthetics, phonetics, the vertical dimension occlusal, and centric

6 Completed prosthesis, intaglio surface. relation. The patient approved the appearance of the prostheses and signed the patient record to confirm his acceptance. A centric relation record was made intraorally with modeling plastic impression compound to form an occlusal stage. A maxillary definitive impression was made with a tissue conditioning material (Visco-gel; Dentsply Intl) by closing gently into the occlusal stage. The maxillary definitive impression was poured with Type IV dental stone (Microstone; Whip Mix Corp). The new maxillary definitive cast (within the relined maxillary denture impression) was mounted against the mandibular definitive cast by using the centric relation record. A facebow preservation index was fabricated.10 The maxillary wax trial denture was flasked and processed conventionally with denture resin (Lucitone 199; Dentsply Intl). The inner surfaces of the zirconia framework were lubricated with petroleum jelly and filled with autopolymerized acrylic resin and dowel pins and poured in stone to make a new mandibular cast (mandibular processing cast). The mandibular processing cast was flasked and processed with denture resin (Lucitone 199; Dentsply Intl). The processed mandibular prosthesis was deflasked, removed from the processing cast, and placed on the definitive cast. A laboratory remount was performed to correct any processing error. The prostheses were removed from the casts, finished, and polished (Figs. 5, 6). The maxillary denture was inserted and pressure indicating paste (PIP; Mizzy Inc; Myerstown, Pa) was used to verify complete seating. The borders were evaluated with disclosing

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wax (Kerr Corp) and adjusted accordingly. The abutments were torqued to 30 Ncm. The relationship of the intaglio surface of the mandibular prosthesis to the soft tissue was evaluated with the pressure indicating paste (PIP; Mizzy) and adjusted accordingly. Disclosing material, explorers, and radiographs were used to confirm complete seating of the mandibular prosthesis. A centric relation record was made with modeling plastic impression compound on the mandibular prosthesis, and the mandibular remount cast was mounted against the maxillary denture. A new centric relation record was made to verify the remounted prostheses. Selective grinding was performed to refine the balanced lingualized occlusal scheme. The mandibular prosthesis was cemented with provisional implant cement (Premier Implant Cement; Plymouth Meeting, Pa). The occlusion again was verified intraorally (Fig. 7). Instructions on how to use and maintain the prostheses were given to the patient. The use of super floss (Oral-B, Inc, Iowa City, Iowa) and a water jet (Water Pik, Inc, Fort Collins, Colo) to clean underneath the mandibular prosthesis was demonstrated to the patient. The patient was seen after 24 hours and minor adjustments were made. It was explained to the patient that the maxillary complete denture would need to be relined or remade in the future and should be done when required to maintain healthy, physiologic tissue and minimize bone resorption. Recall was scheduled every 6 months, and a maxillary reline was performed after 3 years. The 4-year evaluation is seen in Figures 8 and 9. The positive attitude of the patient and his satisfaction with the treatment that addressed his chief complaints and desires contributed to a good prognosis (Fig. 10).

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7 Completed prosthesis in occlusion.

8 Prosthesis in occlusion, 4-year follow-up.

9 Occlusal view of prosthesis, 4-year follow-up.

SUMMARY
The combination of a zirconia framework with acrylic resin to fabricate an implant-supported fixed den-

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10 Posttreatment radiograph. tal prosthesis appears to be a satisfactory treatment option. A cementable implant-supported prosthesis has advantages that include the preservation of intact occlusal surfaces and the buffer effect of a cement layer that helps with passive fit.
3. Adell R, Eriksson B, Lekholm U, Brnemark PI, Jemt T. Long-term follow-up study of osseointegrated implants in the treatment of totally edentulous jaws. Int J Oral Maxillofac Implants 1990;5:347-59. 4. Reitz JV. Lingualized occlusion in implant dentistry. Quintessence Int 1994;25:177-80. 5. Lang BR, Razzoog ME. Lingualized integration: tooth molds and an occlusal scheme for edentulous implant patients. Implant Dent 1992;1:204-11. 6. Sadowsky SJ. The implant-supported prosthesis for the edentulous arch: design considerations. J Prosthet Dent 1997;78:28-33. 7. Nikolopoulou F, Ktena-Agapitou P. Rationale for choices of occlusal schemes for complete dentures supported by implants. J Oral Implantol 2006;32:200-3. 8. Anusavice KJ, Okabe T, Galloway SE, Hoyt DJ, Morse PK. Flexure test evaluation of presoldered base metal alloys. J Prosthet Dent 1985;54:507-17. 9. Drago C, Saldarriaga RL, Domagala D, Almasri R. Volumetric determination of the amount of misfit in CAD/CAM and cast implant frameworks: a multicenter laboratory study. Int J Oral Maxillofac Implants 2010; 25:920-9. 10.Rahn AO, Ivanhoe JR, Plummer KD. Textbook of complete dentures. 6th ed. Shelton: Peoples Medical Publishing House; 2009. p.238. Corresponding author: Dr Abdulmohsin Alhashim Department of Oral Rehabilitation College of Dental Medicine Georgia Health Sciences University 1430 John Wesley Gilbert Ave Augusta, GA30912 Fax: 706-721-8349 E-mail: aalhashim@georgiahealth.edu Acknowledgments The authors thank Dr Robert Flinton and Ms Eva Bober for guidance in the clinical and technical aspects throughout the treatment. Copyright 2012 by the Editorial Council for The Journal of Prosthetic Dentistry.

REFERENCES
1. Adell R, Lekholm U, Rockler B, Brnemark PI. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg 1981;10:387-416. 2. Brnemark PI, Hansson BO, Adell R, Breine U, Lindstrm J, Halln O, et al. Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10-year period. Scand J Plast Reconstr Surg Suppl 1977;16:1-132.

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