Tạp Chí Nha Khoa Vol 19 No 4 năm 2012

dental news volume xix number iv 2012

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The EMA First Step Appliance

Hidrotic Ectodermal Dysplasia

A Case Study

The Effect of Curing Light

Type and Intensity on the

Depth of Cure of Dental Resin

Composites

Minimal Invasive Dentistry:

Mock-Up and Tooth Tissue

Preservation Techniques

By Dr Derek Mahony & Dr Terry Whitty

By Dr Adel Jragh & Dr Hassan Mousawi &

Dr Manar Al-Nouri

By Dr Hashem M Ridha & Dr Hadi A

Al-Bahrani & Dr Abdulaziz H Aljazzaf

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12.

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Dental News, Volume XIX, Number IV, 2012

ITI Congress Middle East Beach Rotana Hotel, Abu Dhabi, UAE

Dubai Implantarium

The 17th Kuwait Dental Association Conference

13th International Convention (LUSD) Lebanese University

The Oman International Dental Conference

8th CAD/CAM & Digital Dentistry International Conference

The 2nd Arabian Academy of Esthetic Dentistry meeting (ARAED)

January 28 - 30, 2013

at the Riyadh International Exhibition Center.

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March 22 - 24, 2013

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February 5 - 7, 2013

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May 2 - 3, 2013

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May 3 - 4, 2013

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Alfred Naaman, Nada Naaman,

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Antoine Saadé, Lina Chamseddine,

Tarek Kotob, Mohammed Rifai,

Mock-up and Tooth Tissue Preservation Techniques

Minimal Invasive Dentistry

Constant improvements in terms of bonding

to dental tissue, together with technical improvements in ceramic materials, have made it possible to develop aesthetic dentistry with less risk of fracture

This adhesive revolution has quickly become part

of the concept of tissue conservation by providing new types of preparations, mixtures of traditional techniques and new ideas related to bonding

Especially, one crucial clinical factor has become apparent: the difference in bonding quality between dentine and enamel In fact, due to the nature of these two substrates, enamel bonding

practitioner must always systematically find the best compromise between sufficient thickness,

to ensure strength and aesthetics (table 1), and maximum conservation of the enamel on the prepared surface However, when taking into consideration the variations in ceramic translucency and the original shade of the substructure, a more

“aggressive” approach may be necessary in order

to better conceal a discolouration2 Similarly,

pressed-ceramic veneers require more overall thickness than feldspathic ones

Whenever clinically possible, it is recommended

to favour a minimally-invasive enamel preparation that will enhance the longevity of the restoration3,4and prevent post-operative sensitivity When preparing for this, the varying degree of enamel thickness must be taken into account first (fig 1)

Pressed Veneers

(leucite, lithium disilicate)

Table 1: Minimum thickness recommended for different ceramic

types on a non-discoloured substructure

Fig 1: Labial view and medium sagittal cut of four central maxillary incisors of different ages (from left to right: patients of 19, 32, 42 and 68 years respectively) Enamel thickness is variable between teeth and also in each tooth depending on the height.

Minimal Invasive Dentistry:

Mock-up and Tooth Tissue

Preservation Techniques

This thickness depends on the patient’s age, dental history and, most of all, on possible wear of the enamel This loss of thickness can be aggravated, either by abrasive compounds (toothpaste with high concentrations of bicarbonate) or acids (acidic drinks, citrus fruits, etc.) In order to optimise the aesthetic result and to get a better preview via the wax-up, detailed clinical observations of the initial wear should be undertaken right from the start Normally the natural thickness of the labial enamel of anterior teeth will measure on average between:

Mock-up and Tooth Tissue Preservation Techniques

Esthetic Dentistry

Evolution of preparation concepts

Taking these basic requirements into account, several clinical propositions have been suggested

to minimise the preparation of dental tissue

Mainly, these propositions are based on the idea

of progressive reduction or the idea of controlled penetration5

I Progressive Reduction Methods

In progressive reduction methods, a reference point such as an adjacent tooth, the dimension

of the cutting tool or a pre-op silicone index are used in order to visually enhance and mechanically control the amount of tooth structure that is to be removed

The Depth Cut Technique

During preparation of the teeth, the simplest method is to estimate the volume removed by comparison with neighbouring teeth This three-dimensional visualisation has great operator variability and makes the results not very efficient

in terms of tissue conservation

In order to improve this procedure, vertical grooves can be cut in the tooth at the beginning

of the preparation while visually making sure not

to penetrate more than the diameter of the bur.6,7

As in the previous method, it relies on the contour

of the tooth to be restored and therefore has the great advantage of controlling the preparation

If the shape of the tooth can be reproduced in the same proportions then this is the method of choice (fig 2)

The Index Technique

Development of this approach involves using the final morphology of the reconstruction as a reference This is performed before preparation with an aesthetic wax-up built on the initial plaster cast Using this model as a guide, it is possible

to prepare either a thermoformed transparent matrix (ensuring both control of the preparation and, later, fabrication of the temporary veneers

by using it as a mould) or to make one or more silicone indexes to check the preparation (fig 3)8

consists of preparing two silicone indexes cut into strips (one for the vertical and one for the horizontal axis); making it possible to assess the reduction of tissue during preparation This method completely supports the principle of maximum tissue conservation and ensures a predictably consistent outcome However, this is a complex and time-consuming procedure because

Fig 2: It is possible to achieve a uniform preparation

by using vertical grooves with a thickness that is ally controlled and does not exceed the diameter of the bur Monitoring with a pre-operative silicone index makes it possible to confirm this uniform reduction.

visu-Fig 3: When using the technique with silicone indexes

it is necessary to work out an aesthetic plan hand This is fabricated on a situation model, a dupli- cate of the study model with the help of a wax-up Several indexes can be prepared from this model and will be sectioned in their horizontal or vertical axes To make it easy to reposition these indexes they should cover the gingiva and the surrounding teeth.

Mock-up and Tooth Tissue Preservation Techniques

Esthetic Dentistry

frequent use of the control indexes is necessary

II Controlled Penetration Methods

Contrary to the methods described above, the idea of controlled penetration makes it possible to perform a predictable reduction of dental tissue (table 3) thanks to the use of specially designed burs Using their shape will physically limit the potential for possible errors

The Direct Technique

The first clinical suggestions for this technique recommend the use of specific burs that limit the depth of penetration due to their shape (fig 4)

While with this technique the depth of penetration

is controlled and known, the initial thickness of the enamel cannot be assessed Also, with time and through varying aetiological wear and tear there

is a natural variation (table 4) between teeth.12,13,14

Consequently there is no guarantee with respect

to enamel preparation

The Indirect Technique

The logical evolution of all these concepts was put forward by G Gürel in 200316 : it combines the idea of minimum reduction while considering the volume of the final restorative shape, and also the use of specific burs that make a controlled penetration possible This technique is based

on a simple, but rigorous procedure ensuring

a high level of reproducibility irrespective of the clinician.17,18

Clinical Procedure Phase I: Aesthetic analysis and wax-up

Smile analysis is an indispensable prerequisite for any planned aesthetic restoration It is based on several well defined criteria19/20 The changes envisaged are illustrated by modelling with composite resin, applying it directly to the dry tooth without the use of an adhesive (fig 5)

Teeth

Average enamel thickness according to the dental surface concerned

pen-to the initial shape.

Table 4

Average thickness at the

centre of each dental surface

according to Naveau et al.15

(max: maxilla ; mdb: mandible)

Fig 5: The aesthetic analysis and the patient’s wishes indicate the need for bonded ceramic veneers With the help of composite resin placed freehand on the labial surfaces an initial chairside impression can be taken To simulate the shortening of the canines the teeth that are too long are marked with a black felt-tip pen (arrows) The superimposition of the images il- lustrates the aesthetic advantages of the elimination of the diastema and the realignment of the incisors.

Mock-up and Tooth Tissue Preservation Techniques

Esthetic Dentistry

Once the desired modifications have been agreed upon (form of teeth, diastema closure, etc.) an impression will enable the dental technician to make a more detailed wax-up (fig 6)

Based on this model, a rigid matrix can now be made either by using thermoforming or with a silicone impression

Phase II : Making the mock-up

The mould is filled with a composite resin and inserted over the patient’s teeth until polymerization is completed (fig 7)

Fig 6: The diagnostic model is modified according to the instructions given by the practitioner (impressions, photos etc) The wax-up makes it possible to lengthen and re-size the teeth At this point, it becomes evident that the tissue reduction will not be uniform: the white zones (wax) will be spared more than the zones

in ochre (plaster) The new appearance is recorded using a double mix silicone impression made in order

to optimise precision This impression will serve as a mould when making the intraoral mock-up.

Fig 7: Details of the wax-up are reproduced by the double mix impression The resin (Luxatemp Star, DMG) is dispensed into it before repositioning it in the mouth After polymerization, the aesthetic appearance can be immediately assessed Because of its variable thickness, the resin layer should not be removed at this point.

Fig 11: The resin mock-up in place over the prepared teeth The depth of the grooves do not depend only

on the diameter of the bur, but also on the thetic template (mock-up) used Once the mock-up is removed the depth of the guide grooves varies It is now possible to finalise the preparation by joining the bottom of the grooves The enamel layer is preserved better and the thickness of the ceramic veneer is standardised.

aes-To avoid clogging up the instruments, it is recommended to use a bis-acryl resin for this mock-up and not a conventional powder/liquid system

Once in place the matrix will indicate the final restoration and should be left on the teeth as a guide during preparation

Phase III : A minimally invasive preparation through the mock-up

Depending on the material chosen, the thickness

of the restorative material should determine the diameter of the bur and thus the depth of penetration (table 3) Once determined, the horizontal grooves are cut into the labial surface ensuring a penetration parallel to the surface, until there is contact with the smooth part of the chuck

on the resin of the mock-up (fig 11)

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Once these labial grooves have been made, the occlusal reduction should be undertaken before removing the mock-up To visualise the depth limit for the preparation better, the bottom of each groove can be highlighted with a pencil or felt tip marker (fig 8).

The mock-up is removed leaving only the coloured grooves (fig 9)

These are then joined together and the final preparation design is completed At the end of the appointment, an impression is taken Then the mock-up impression can be used to make the

Fig 8: With the mock-up in place, the bur is moved over the labial surface, in parallel lines, until contact with the shank is achieved Three to four grooves are sufficient to mark the final depth of the preparation

After establishing the occlusal reference points, the grooves are accentuated with a pencil.

Fig 9: The remaining parts of the mock-up are removed and allow the practitioner to get a clear view

of the guiding grooves Preparation will continue until the coloured grooves are completely removed, and completed within the proximal zones in accordance with the aesthetic needs The impression can be used again, when filled with bis-acrylic resin (Luxatemp Star, DMG), in order to make the provisional restora- tions.

provisional restoration

A preparation based on this principle of tissue conservation ensures that only necessary enamel surfaces need to be adjusted for aesthetic and functional results (fig 10)

Limitations of the technique

In certain specific cases, when one or more teeth are malaligned from the desired archform, it will be necessary to prepare and reduce these teeth first This prevents any risk of incorrect positioning of the thermoformed index or the impression when doing the mock-up To ensure a perfect placement

of the mock-up impression over the teeth, one should check first that the initial reduction is enough with the help of a silicone index

The labial surfaces are fully involved in this technique However, when it comes to the palatal area, it is difficult to extend this technique for partial crowns With the help of the silicone indexes, it is possible to visually control the situation in static and dynamic occlusion and to ensure a proper thickness of material

Conclusion

Saving tooth structure should be the foremost concern because it ensures both a better longevity and, more importantly, makes future interventions more feasible Each decision and clinical intervention should be made taking a therapeutic gradient into consideration When it comes to tissue conservation it is fundamental to recognise that bonding to enamel is far superior to that to dentine when indications call for adhesive bonding In other words, all techniques that make

it possible to preserve enamel should be favoured when the thickness of the restoration allows this

Fig 10: Clinical case after one week The final thetic appearance is determined by the volume of the relevant anterior teeth Preparation through the mock-up has made it possible to create the desired final result

aes-Mock-up and Tooth Tissue Preservation Techniques

Esthetic Dentistry

Mock-up and Tooth Tissue Preservation TechniquesEsthetic Dentistry

The most successful development in this respect is based on the management of the final mock-ups, used as a template for the preparation, associated with drills of optimal shape for a controlled penetration

REFERENCES

1 STANGEL I, E LLIS TH, S ACHER E A DHESION TO TOOTH STRUCTURE MEDIATED BY CONTEM PORARY BONDING SYSTEMS D ENT C LIN N ORTH A M 2007 J UL ;51(3):677-94.

-2 SPEAR F, H OLLOWAY J W HICH ALL - CERAMIC SYSTEM IS OPTIMAL FOR ANTERIOR ESTHETICS

? J A M D ENT A SSOC 2008 S EP ;139 S UPPL :19S-24S.

3 CHRISTENSEN GJ W HAT IS A VENEER ? R ESOLVING THE CONFUSION J A M D ENT A SSOC

2004 N OV ;135(11):1574-6.

4 PEUMANS M, V AN M EERBEEK B, L AMBRECHTS P, V ANHERLE G P ORCELAIN VENEERS : A REVIEW OF THE LITERATURE J D ENT 2000 M AR ;28(3):163-77.

5 KOIS JC N EW PARADIGMS FOR ANTERIOR TOOTH PREPARATION : RATIONAL AND TECHNIQUE

C ONTEMPORARY E STHETICS AND R ESTORATIVE P RACTICE 1996;2(1)1-8

6 SEYMOUR KG, S AMARAWICKRAMA DY, L YNCH EJ M ETAL CERAMIC CROWNS A REVIEW

OF TOOTH PREPARATION E UR J P ROSTHODONT R ESTOR D ENT 1999 J UN -S EP ;7(2):79-84.

7 AHMAD I P ROTOCOLS FOR PREDICTABLE AESTHETIC DENTAL RESTORATIONS B LACKWELL

S CIENCE 1 ST EDITION 2006

8 PARIS JC., O RTET S ET AL S MILE E STHETICS : A M ETHODOLOGY FOR S UCCESS IN A

C OMPLEX C ASE E UR J E STHETIC D ENTISTRY 2011 ;6(1) :50-74

9 MAGNE P, M AGNE M U SE OF ADDITIVE WAX - UP AND DIRECT INTRAORAL MOCK - UP FOR ENAMEL CONSERVATION WITH PORCELAIN LAMINATE VENEERS E UR J E STHET D ENT 2006

A PR ;1(1):10-9.

10 MAGNE P, B ELSER UC N OVEL PORCELAIN LAMINATE PREPARATION APPROACH DRIVEN BY

A DIAGNOSTIC MOCKUP J E STHET R ESTOR D ENT 2004;16(1):7-16; DISCUSSION 7-8.

11 MAGNE P, B ELSER U B ONDED P ORCELAIN R ESTORATIONS IN THE A NTERIOR D ENTITION : A

B IOMIMETIC A PPROACH Q UINTESSENCE P UBLISHING ; 2002

12 ATSU SS, A KA PS, K UCUKESMEN HC, K ILICARSLAN MA, A TAKAN C A GE - RELATED CHANGES IN TOOTH ENAMEL AS MEASURED BY ELECTRON MICROSCOPY : IMPLICATIONS FOR PORCELAIN LAMINATE VENEERS J P ROSTHET D ENT 2005 O CT ;94(4):336-41.

13 LAMBRECHTS P, B RAEM M, V UYLSTEKE -W AUTERS M, V ANHERLE G Q UANTITATIVE IN VIVO WEAR OF HUMAN ENAMEL J D ENT R ES 1989 D EC ;68(12):1752-4.

14 GRINE FE E NAMEL THICKNESS OF DECIDUOUS AND PERMANENT MOLARS IN MODERN

H OMO S APIENS A M J P HYS A NTHROPOL 2005 J AN ;126(1):14-31.

15 NAVEAU A, R ENAULT P, P IERRISNARD L P ULPE ET PROTHÈSE FIXÉE À ANCRAGE PÉRIPHÉRI QUE C AH P ROTH 2007;138:55-64

-16 GUREL G P REDICTABLE , PRECISE , AND REPEATABLE TOOTH PREPARATION FOR PORCELAIN LAMINATE VENEERS P RACT P ROCED A ESTHET D ENT 2003 J AN -F EB ;15(1):17-24.

17 GÜREL G T HE S CIENCE AND A RT OF P ORCELAIN L AMINATE V ENEERS Q UINTESSENCE

P UBLISHING , C AROL S TREAM , IL: 2003

18 GUREL G P ORCELAIN LAMINATE VENEERS : MINIMAL TOOTH PREPARATION BY DESIGN D ENT

Sleep apnea, in its simplest definition, occurs when a patient stops breathing during sleep This can be as a result of Central Sleep Aponea (CSA) i.e a neurological condition, in which the brain temporarily stops sending signals to the muscles that control breathing More commonly, the sleep Aponea occurs from

Obstructive Sleep Aponea (OSA)

OSA is caused by a narrowing, or complete sure, of the upper Airway, while we sleep This obstruction to our breathing rapidly depletes the supply of oxygen to our body This, in turn, forcesour body to “wake up” - termed an arousal -

clo-in order to recommence breathclo-ing

The number of times, per hour, that our breathing ceases (aponeas) or becomes diminished

(hyponeas), is used to categorise the level of OSA

as either mild, moderate or high This is based on what we term the apnea-hypopnea index (AHI) The higher the score, the greater the number of times, per hour, that sleep has been interrupted, and the greater the risk of compromising our over-all systemic health

The symptoms of OSA can include daytime ness, fatigue, frequent napping, headaches, poor memory, inattention, irritability, and insomnia The long term effects can be very serious

sleepi-Snoring is also often a symptom of OSA, but it is also possible to have OSA and not snore; and vice versa

Obstructive Sleep Aponea may be a risk factor for the development of other medical conditions, including high blood pressure (hypertension), heart failure, heart rhythm disturbances, athero

The EMA First Step kit

includes all materials and

parts to construct the

appliance including

complete instructions.

Figure 3

Position the upper lugs

between the canine and first

bicuspid Use the blue sticky

wax included.

Figure 4

Using the included jig mark

the position for the

lower lugs.

Figure 1

Figure 2

Figure 4 Figure 3

The EMA First Step appliance

The EMA First Step appliance

Prosthetic Dentistry

sclerotic heart disease, pulmonary hypertension and insulin resistance In other words, sleep ap-noea is a serious medical condition that requires proper diagnosis by a medical practitioner, typi-cally through a sleep study (using a polysomno-gram) This PSG is used to determine the type, and severity, of the problem, before a treatment strategy is developed

Treatments for OSA include weight loss, surgery, mechanical maintenance of the airway, using con-tinuous positive airway pressure (CPAP), or the use

of oral appliances Acceptance of the efficacy of oral appliances, in the treatment of OSA, has in-creased significantly, in the last 5 years This hasbeen as a result of research conducted by the sleep medicine community, showing that whilst

an oral appliance may not be as effective as CPAP, (considered to be the gold standard of treatment), patient compliance is significantly higher This means that patients are more likely to wear an oral appliance, during sleep, than a CPAP mask, con-nected to a mechanical pumping device

The number, and variety, of oral appliances, to treat snoring and sleep aponea, has seemingly ex-ploded in the past few years A type termed man-dibular advancement splints (MAS) or mandibularrepositioning appliances (MRA), are the most common oral appliances, prescribed for OSA.This type of appliance moves the lower jaw for-ward, which tightens the soft tissue, and muscles,

of the upper airway to prevent obstruction of the airway during sleep The tightening created, by the device, also prevents the tissues of the upper air-way from vibrating as air passes over them - the most common cause of snoring

The price for an MAS/MRA varies from $25 to

$2500 You can imagine that they also vary in quality and effectiveness All oral appliances have their advantages, and disadvantages, and it seems every other week someone is patenting something new

EMA First Step appliance

The EMA First Step appliance is a new and unique appliance that is not only a mandibular advance-ment splint, but also acts as a clinical diagnostic

Position the lower lugs

using the blue sticky

wax included.

Figure 6

Upper and lower models

with lugs in place.

Figure 7

Use a vacuum- or

pressure-forming machine to form

the material over the model

and lugs The material will

form well over the lugs due

to the nature of the

The EMA First Step appliance

Prosthetic Dentistry

aid It’s a simple device, incorporating two flexible splints, connected by flexible straps, that hold the mandible forward, in the desired position

The advantages of the EMA first Step appliance include:

1 A low profile which is comfortable to wear;

2 Fits the upper and lower jaw snugly;

3 Easily able to be adjusted, in 1mm increments

by the patient

4 Vertical and lateral excursions are possible; and

5 It is inexpensive and easy to construct

The EMA First Step appliance has some unique clinical and diagnostic advantages, including the ability to:

1 Test a patient’s tolerance to an MAS;

2 To measure the correct mandible repositioning (This is very useful especially if another MAS is to

It comes in kit form, with all parts needed for struction Construction time is approximately 15 minutes and can easily be completed in the dental laboratory, or in a dental chair

con-A vacuum - or pressure - forming machine is all that is required to assist in the EMA construction Figures 1-13 are a step-by-step guide to the con-struction of the EMA First Step appliance

Changing the length of the

elastic strap changes the

Ectodermal dysplasia is a multiple disorder disease, which affect two or more ectodermal structures such as the development or function of teeth, hair, nails and sweat glands It occurs in two forms: Hy-pohidrotic form, or Hidrotic form A case ectoder-mal dysplasia in hidrotic form was reported Early dental treatment with implants supported pros-thesis improve patient’s, both functionally and esthetically

Introduction

Ectodermal Dysplasia is not a single disorder, but

a group of closely related disorders known as the Ectodermal Dysplasias The condition was first de-scribed by Thurnman in 1848 1 and was coined

by Weech in 1929 2 Ectodermal dysplasias are heritable conditions in which there are abnormali-ties of two or more ectodermal structures such as the development or function of teeth, hair, nails and sweat glands 3 Freire-Maia and Pinheiro described numerous varieties of ectodermal dys-plasia involving all possible Mendalian modes of inheritance 4 More than 192 different syndromes have been identified till date 5; depending on the particular syndrome, ectodermal dysplasia can af-fect the skin, eye lens or retina, parts of the inner ear, development of fingers and toes, nerves and other parts of the body 6 Despite some of the syndromes having different genetic causes, the symptoms are sometimes very similar Ectodermal dysplasia can be classified by its mode of inheri-tance or by which structures are involved

Diagnosis is usually conducted by clinical tion often accompanied by family medical histories

observa-so that it can be determined whether transmission

is autosomal, dominant or recessive Ectodermal dysplasia can occur in any race but is much more prevalent in caucasians than any other group

From the clinical point of view, two main forms have been distinguished 7:

It exhibits the classic triad-hypohirdosis, chosis, and hypodontia Usually X-linked recessive inheritance is seen with this syndrome Males are affected severely while females show only minor defects 9,10,11 In the hidrotic form of ectoder-mal dysplasia teeth, hair, and nails are affected, while the sweat glands are usually spared 12 It

hypotri-is commonly inherited as an autosomal dominant trait GJB6, encoding gap junction protein 6 (con-nexin-30), is the only gene currently known to be associated with hidrotic ectodermal dysplasia 13,14.Most individuals with hidrotic ectodermal dyspla-sia syndrome have an affected parent Offspring

of affected individuals have a 50% chance of heriting the mutation and being affected Other inheritance modalities like autosomal recessive have also been reported 15 Table 1

in-The characteristic facial features associated with ectodermal dysplasias are: frontal bossing, de-pressed nasal bridge, prominent supra orbital ridg-

es and obliquely set ears, midface is depressed, the lower third of the face appears small due to lack of alveolar bone development, lips are protru-berant 16 A cephalometric study by Vierucci and collegues has shown significant differences in the craniofacial features of unaffected and affected children 17 In the oral cavity the most striking fea-ture is oligodontia; the condition of missing over 6 teeth or more, excluding 3rd molar Teeth in the anterior region of the maxilla and the mandible are conical or pointed in shape 18 The enamel may also be defective There is a wide midline dia-stema and hypoplastic labial frenum

HIDROTIC ECTODERMAL

DYSPLASIA - A CASE STUDY

Fig 1 Table 1: differences between the hidrotic and the hypohidrotic forms of ectodermal dysplasia

HIDROTIC ECTODERMAL DYSPLASIA - A CASE STUDY

Oral Pathology

Commonly, there is only one molar tooth in the second molar region, which usually exhibits a bud crown form Cosmetic dental treatment is almost always necessary and children may need dentures

as early as two years of age 19 Multiple ture replacements are often needed as the child grows, and dental implants may be an option in adolescence, once the jaw is fully grown Nowa-days this option of extracting the teeth and sub-stituting them with dental implants is quite com-mon In other instances, teeth can be crowned in conjunction with orthodontic treatment Due to the complexity of the dental treatment, a multi-disciplinary approach is best This case report de-scribes the implant oral rehabilitation of a patient with ectodermal dysplasia with severe atrophy

den-of the residual alveolar crest, and maxillary sinus pneumatization

Case presentation:

A 21-year-old female diagnosed with genetic todermal dysplasia present to Amiri Dental Center Dep of Prosthodontics for implant rehabilitation

ec-of her partially edentulous maxilla and mandible Her family history revealed that her grandmother, father, uncle, and her brother had the same condi-tion (Figure 1) Her chief complaints were unaes-thetic appearance and difficulty in chewing food Her medical history revealed anemia, with no oth-

er current pathologic conditions or allergies to any medications She did report taking folic acid under the supervision of her physician She assured a clinical history of normal sweating from birth with normal tolerance to heat (Figure 2)

The clinical examination revealed very fine and soft hair on the scalp, slow growing nails, multiple

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Figure 7 Provisionals with maxillary wax rims

missing teeth (excluding third molars): #2, 3, 4,

5, 12, 13, 14, 15, 18, 23, 24, 25, 26, 28, 29 and

31 Enamel Hypoplasia was found on teeth #13, and 23 The panoramic radiograph assessment showed abnormal morphology of teeth: #7, 8, 9,

10, and 21 Also, horizontal bone loss in posterior mandibular area, super eruption of teeth #19, and 30, loss of occlusal vertical dimension, underdeveloped alveolar ridges, and bilateral infe-rior expansion of the maxillary sinus were noticed (Figure 3, and 4)

Diagnosis:

s (Hidrotic form/Clouston syndrome)

ss

s and verbal dysfunctions

sThe treatment plan of the maxillary arch involved extraction of all teeth A bilateral sinus lifting procedure, and alveolar ridge augmentation

Followed by immediate complete denture, implant placement, and maxillary cemented fixed partial dental prosthesis on dental implant In the man-dibular arch, crowns retained by natural teeth and cemented fixed partials dental prosthesis, along with cemented dental crowns retained by dental implants # 28, and 29 Initially, preliminary impres-sions were made, along with a centric relation

occlusal record, and a face bow transfer Study models were mounted, and a diagnostic wax-up with the new vertical dimension of occlusion was fabricated A CT scan was ordered to evaluate the presence of sufficient cancellous and cortical bone volume at each potential implant position site, and for site-specific selection of the implants accord-ing to the surgical and prosthetic treatment plan (Figure 5, and 6) Finally, the case and the treat-ment plan were presented to the patient Follow-ing patient consent, all the mandibular teeth were prepared and provisional restorations were placed

based on the wax-up A new bite registration with the maxillary wax rim was made to fabricate the maxillary immediate denture (Figure 7)

The second visit involved, extraction of all lary teeth and alveoloplasty procedure were per-formed under local anaesthesia A bilateral sinus lifting procedure and a simultaneous alveolar ridge augmentation of the maxilla using autogenous corticocancellous particulate bone grafts from the maxillary crest were performed to reconstitute the lacking bone This was followed by delivering of immediate maxillary complete denture After 4 months of socket healing implant surgery was

of this condition suggested an autosomal domi

performed under local anesthesia The reopening

of the mucoperiostal flaps revealed that the mented bone had been resorbed to a significant extends within four months Using the prefab-ricated templates from the maxillary denture, 8 standard self-tapping implants (Dentium, IMPLAN-TIUM® Implant, Korea) were inserted in the maxil-

aug-la, and 2 implants in the mandible in site of teeth #

28, and 29 (figure 8) Bone augmentation around the dental implants was performed using a mix-ture (ratio 1:0.5) of Cadaver Freezed Dried Bone and Demineralized Freezed Dried Bone (Grafton® DBM Putty in a Jar and MinerOss® mixture of al-lograft mineralized cortical and cancellous chips, BioHorizons IPH, USA) Postoperative healing was uneventful Following 4 months of healing, the im-plants were uncovered and healing abutment sur-gery was performed All implants were completely osseointegrated in the new bone Two weeks after replacing the healing abutments, final impressions for both arches were made with a light body-vinyl polysiloxane and heavy putty impression material

in a custom impression trays The working casts were then mounted on a semi-adjustable, non-ar-con type articulator using facebow records (Hanau 95H2, WhipMix, USA) Maxillary and mandibular metal frameworks were fabricated and returned from the laboratory for a try in The frameworks were verified and new centric relation records were obtained The new vertical dimension of occlusion was evaluated and verified The final prostheses were cemented with glass ionomer luting cement (GC Fuji I® - GC America, Inc., USA) Oral hygiene instructions were given and reinforced to the pa-tient (figure 9, 10, and 11)