Treatment of the Severe Full Arch Maxillary Deficiency Part 4

568 Rating(s).


Posted on By Maurice Salama In Full Arch & Dentures

Patient recently lost her maxillary teeth due to severe periodontal disease. Poor bone quality and quantity present throughout. Plan for 3D reconstruction of the ridge simultaneously with implant placement. Will use mid-palatal mini screws to assist with denture stability during healing phase. Other options and considerations welcome? 6 Weeks Healing, maintained closure of LARGE GBR and placed Palatal Transitional Implants to Assist with Denture Stability during the healing phase. Thoughts on management? Anything else? Challenges? Thoughts on Treatment? Uncovering results and Final Prosthesis shown. The need for additional grafting was expected. Big Question, All on Four or All on 6 or 8? Zygomatic Implants/Pterygoid Angled implants or standard prosthetics? Thanks Dr. Salama

Full arch with abutments
Mandible with abutments

Cadcam Ti framework PA
Finals Maxilla Lab


Add to Favorites
Add a comment to the discussion on Treatment of the Severe Full Arch Maxillary Deficiency Part 4


Upload photos
1.  Photo Title:

2.  Photo Title:

Would you like to follow this post?
Case has been added to your favorites.
Case has been removed from your favorites.
Thank you for your input. Your comment has been posted.
You are now following this member. You will get notified on any new topics posted by this member.
You are no longer following this member. You will not get notified on any new topics posted by this member.
Edit Comment
1.  Photo Title:
Current Image:   Delete Image
2.  Photo Title:
Current Image:   Delete Image
Comment has been updated.

32 Comments

Completed Case Series Parts 1-4. I learned a great deal from this case. Great job by my Team Prosthodontist Wendy AuClair!!


Reply

Mo. Is this the case you used the Curve barrier? Chuck.


Reply

Yes Sir...take a look at the other parts of this case. Quite proud of the result. Very challenging in so many ways. I have never shown this case in a lecture. Only here on XP. regards Maurice


Reply

Mo. Congratulations! I remember this was a tough one! Amazing outcome with a relatively non invasive approach considering the circumstances. A lot of nice looking KT. Did you graft CT or is this a product of the curve and particulate remodeling? Thank you for sharing. Best regards. Chuck


Reply

Chuck; thanks. All 4 Parts are on top Right in RELATED POSTS. You can see the entire case all the way through. No additional CTG, only Flap Management and avoided tissue compression during healing. thanks Mo


Reply

Thanks for sharing dr Salama I am not familiar with the
Curve membranes you used can you tell us what kind of material they are made from? They look rigid enough are they as rigid as the sonicweld membranes? Are they resorbable?
Why did you chose to do the bonegrafting and implant placement in one procedure? Wouldn't it be safer to stage the procedures and place six implants after bone healing?
Great result though can't argue with that.
Thanks for sharing amazing result!
Regards Melvin Maningky


Reply

Melvin; Yes, the CurV is from Zimmer and it is Resorbable Collagen Type 2 and somewhat Rigid. I chose to do the implants at Stage 1 simultaneously as it would LIMIT the already long treatment time in an interim transitional denture prosthesis and provide me a 2nd stage to observe and regraft as needed....check the Parts 2-3 of this case series. regards Dr. Salama


Reply

This was a difficult case with an interesting management approach and a great result. How did you utilize the mini-implants to stabilize the maxillary denture they appear to project below the alveolar ridges. Was there no palatal vault concavity? I would really appreciate seeing a pre and post CBCT of the case. Can you post the images?


Reply

Jerome; No post-op CBCT to share. The mini-implants placed into the Vomer process provided interim stability of the transitional denture during the healing phase. Dr. Salama


Reply

The maximum result for this approach Maurice. Grafting is perfect and I love the way you expected some dehiscences at the second stage. Do you recommend CTscan to check regeneration before 2nd stage surgery?
Do you think that even performing perfect surgery and primary closure, right graft material and PRGF protocol the profile of the patient (generalized & severe chronic periodontitis) added to the biological limitations has been a key factor for those dehiscences?
Thanks for sharing this cases. Is a privilege to enjoy your work.
Nicolas


Reply

Yes, I do recommend a 2nd CBCT to evaluate success of first regeneration. With an interim denture prosthesis I do expect additional grafting to be required at 2nd stage. Yes, despite ALL the surgical technique and skill the patient profile and healing is a key factor. More importantly, I believe LOADING of the surgical site with a REMOVEABLE transitional prosthesis is a BIG ISSUE!!!
regards Dr. Salama


Reply

Impressive Case, and challenging. Great teaching case. One thing I am seeing is excess tissue around the multi-abutments in my cases, having the Surgeon remove and contour excess, prior to final impression.


Reply

Mo. I forgot to ask how and why you elected not to actively engage the most facial placed fixture in the anterior region? This was a guided placement correct? So much to learn from this case! Thank you again. Chuck


Reply

Chuck; Great Question. We decided to remove this implant as it did not retain enough bone after loading of the temporary prosthesis and it appeared to labial for the framework design. Always a tough decision to remove an osseointegrated fixture but we felt we had enough and that's why we always prefer to over engineer the cases with this level of difficulty. We elected to remove it and not include it in the framework and Final prosthesis as it posed a risk for future complications. Just like Payton Manning....an audible or call at the line of scrimmage. Mo


Reply

Mo we´re familiar with your expectacular cases but this one is the most challenging ! Great topic for discussion. I certainly would have choiced this option instead of Zigomatic implants!
And the results are beautiful.
Congratulations once again.
And thanks for sharing.
Jorge.


Reply

Mo,
This is a real difficult case and it is a great thing that was a patient of yours!
The bone vitality seem diminished and stimulus applied did not completely turn into bone (there fibrous tissue too).
Question I'm asking is whether the patalal and soft tissue architecture may reveal this lowered ability of bone regrowth?
Was patient a smoker in the past?
These are the challenging cases that needs to be shown for everyone professional growth.
Thanks to you Mo.


Reply

Jorge and Armando; I agree.Thanks. Very challenging case. Yes, Armando I believe this patient presents with POOR Bone Quality, she was a past smoker 2 packs a day and significant history of periodontal disease. This case must be over engineered (2X bone Augmentation and more implants). Not sure if one day she may still require Zygomatic and Pterygoid Implants as a solution. regards Maurice


Reply

Thank you for the case! I usually try to avoid placing implants between canines, it limits my prosthetic options. Gregory


Reply

Thanks for posting this case Dr. Salama. I saw that you used mid-palatal mini screws to stabilize her denture during the healing. Can you please explain what kind of screws are those and how did you attach them to her denture?
Thanks, Anurag.


Reply

Excellent ! Needless to say anything else. Miguel


Reply

2 years post op check. Full Zirconium Case. Removed and cleaned and checked occlusion.

Maxilla
Mandible


Reply

Additional images....happy patient.

Full mouth
Lateral image


Reply

Happy and well maintained patient is the BEST gift of all.

Full face
emotional dentistry


Reply

Mo. Beautiful Dentistry at many levels of appreciation. Congratulations to both you and your extremely fortunate patient. Best regards. Chuck


Reply

Thanks Chuck. I appreciate the comments from you my friend. I tried to display the many many challenging facets of this case through Parts 1 thru 4 and to see this case ALL the way through 2 years post loading was really great. The big question here should be would "she have been better off with All of Four" or "Zygomatic approach"?? thanks Mo


Reply

How long did you wait after the re-graft at second stage before you loaded the fixtures with function? How did you modify your temporary denture during this phase?


Reply

Jerome; We loaded immediately after the second surgery as you can see on the image we placed healing abutments and left the implants exposed for the prostheitc work to begin. regards Dr. Salama


Reply

Mo we've been following this marveĺous case.
Looks spectacular, my compliments.
What is your protocol on screwed total prosthesis?
How often do you check unscrewing the denture?
How regularly do you profijet them?
Patient looks and is fully satisfied with the miracle.
Jorge


Reply

Thanks Jorge.


Reply

Thank you for sharing this case! What do you think if you used BMP2 would be result of your bone grafting be better? I am going to do similar case soon. Gregory


Reply

Gregory; BMP-2 would be very useful in cases like this one but I would add some autogenous bone to the mix and a rigid Ti-mesh. regards Dr. S


Reply

Jorge, we check the prosthesis once every 2 years. Remove and evaluate. This is very critical to long term success. regards Mo


Reply

Related Posts


NovaBone
Versah