Rehabilitation of an edentulous patient with moderate-to-severe ridge resorption
Frank J Tuminelli DMD FACP, Jay Neugarten DDS MD, Ralph Epstein DDS, Ben Brovnick CDT MDT, Steve Pigliacelli CDT MDT
“The ability to help the edentulous patient is paramount. Our team strives to help as many patients as possible with expedited predictable treatment protocols. Both Trefoil and Zygoma treatment options lend themselves to this. We are able to provide fixed solutions immediately and not have patients limited by removable prostheses.
Patient: male, 57 years old
Clinical situation: fully edentulous patient with conventional removable denture in the maxilla and absence of mandibular prosthesis awaiting stage 2 surgery on a previously placed unknown implant system.
Surgical solution: Trefoil™ system in mandible. All-on-4® treatment concept on 2 NobelActive® and 2 NobelZygoma™ implants in the maxilla.
Restorative solution: full-contour zirconia restorations for both jaws.
Surgery date: mandible August 2017, maxilla April 2018
Total treatment time: 12 months
Case courtesy of Dr. Frank J Tuminelli, Dr. Jay Neugarten, Dr. Ralph Epstein, Dr. Ben Brovnick, Dr. Steve Pigliacelli.
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Initial clinical situation
Orthopantomogram (OPG) before treatment shows moderate-to-severe ridge resorption in both jaws. Note the implants and healing abutments in the mandible.
Initial clinical situation
Intraoral view showing the locator abutments in the mandible (left).
Occlusal view of the maxilla showing unfavorable ridge form (right).
Cross-sectional CBCT of the mandible for evaluation of residual bone height and morphology (left).
The patient is highly suitable for Trefoil implant placement (right).
Following removal of the patient’s prior mandibular implants, the three Trefoil Implants were placed in a predetermined position (between the mental foramina) with the aid of different standardized guides and templates. The position of the Trefoil Implants corresponds to the pre-manufactured prosthetic bar of the Trefoil system.
The Trefoil Bar after adjustment of the fixation mechanism and applying opaquer and fixation material to the fixation mechanism components (left).
Trefoil acrylic prosthesis for the mandible and removable conventional denture for the maxilla (right).
OPG of provisional Trefoil prosthesis 3 months after surgery. Note the bone quality.
Trefoil acrylic prosthesis in the mandible and conventional removable denture in the maxilla. Note tissue stability at 6-month follow-up.
Following the successful restoration of the mandible with the Trefoil system, the patient sought a fixed prosthesis for the maxilla. The moderate-to-severe bone resorption and an unfavorable maxillary ridge form necessitated the use of NobelZygoma implants in the posterior. These were combined with NobelActive implants in the anterior for hybrid All-on-4® treatment concept (left).
Maxilla cast with Multi-unit Abutments in situ (right).
OPG showing maxillary arch with NobelZygoma implants in the posterior, NobelActive implants in the anterior and Trefoil system in the mandible.
Milling of the final mandibular prosthesis from full-contour zirconia. After delivery of the full-contour zirconia prosthesis in the maxilla, The patient elected for a full-contour zirconia prosthesis in both the maxilla and mandible.
Full-contour zirconia prosthesis attached to the Trefoil Bar (top left). Completed prosthesis with polished, rounded, intaglio surface to facilitate cleaning (bottom left).
Full-contour zirconia prostheses in both jaws (right).
Healed mandible after 6 months (top left). Final mandibular prosthesis in situ (bottom left).