"Sticky Bone" Use in Implant Dentistry: Zirconia Full Arch Implant Restoration
"Sticky Bone" Use in Implant Dentistry: Zirconia Full Arch Implant Restoration
10 December 2015
"Sticky Bone"
Use in Implant Dentistry
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Table of Contents
11 Utilization of Autologous
Concentrated Growth Factors
(CGF) Enriched Bone Graft
Matrix (Sticky Bone) and
CGF-Enriched Fibrin Membrane
in Implant Dentistry
Dong-Seok Sohn, Bingzhen Huang,
Jin Kim, W. Eric Park, Charles C. Park
Case courtesy of Dr. Mariano Polack and Dr. Joseph Arzadon, Gainesville, VA
The Journal of Implant & Advanced Clinical Dentistry
Volume 7, No. 10 • D ecember 2015
Table of Contents
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The Journal of Implant & Advanced Clinical Dentistry
Volume 7, No . 10 • D ecember 2015
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The Journal of Implant & Advanced Clinical Dentistry
Founder, Co-Editor in Chief Co-Editor in Chief
Dan Holtzclaw, DDS, MS Leon Chen, DMD, MS, DICOI, DADIA
Editorial Advisory Board
Tara Aghaloo, DDS, MD Michael Herndon, DDS
Faizan Alawi, DDS Robert Horowitz, DDS Michele Ravenel, DMD, MS
Michael Apa, DDS Michael Huber, DDS Terry Rees, DDS
Alan M. Atlas, DMD Richard Hughes, DDS Laurence Rifkin, DDS
Charles Babbush, DMD, MS Miguel Angel Iglesia, DDS Georgios E. Romanos, DDS, PhD
Thomas Balshi, DDS Mian Iqbal, DMD, MS Paul Rosen, DMD, MS
Barry Bartee, DDS, MD James Jacobs, DMD Joel Rosenlicht, DMD
Lorin Berland, DDS Ziad N. Jalbout, DDS Larry Rosenthal, DDS
Peter Bertrand, DDS John Johnson, DDS, MS Steven Roser, DMD, MD
Michael Block, DMD Sascha Jovanovic, DDS, MS Salvatore Ruggiero, DMD, MD
Chris Bonacci, DDS, MD John Kois, DMD, MSD Henry Salama, DMD
Hugo Bonilla, DDS, MS Jack T Krauser, DMD Maurice Salama, DMD
Gary F. Bouloux, MD, DDS Gregori Kurtzman, DDS Anthony Sclar, DMD
Ronald Brown, DDS, MS Burton Langer, DMD Frank Setzer, DDS
Bobby Butler, DDS Aldo Leopardi, DDS, MS Maurizio Silvestri, DDS, MD
Nicholas Caplanis, DMD, MS Edward Lowe, DMD Dennis Smiler, DDS, MScD
Daniele Cardaropoli, DDS Miles Madison, DDS Dong-Seok Sohn, DDS, PhD
Giuseppe Cardaropoli DDS, PhD Lanka Mahesh, BDS Muna Soltan, DDS
John Cavallaro, DDS Carlo Maiorana, MD, DDS Michael Sonick, DMD
Jennifer Cha, DMD, MS Jay Malmquist, DMD Ahmad Soolari, DMD
Leon Chen, DMD, MS Louis Mandel, DDS Neil L. Starr, DDS
Stepehn Chu, DMD, MSD Michael Martin, DDS, PhD Eric Stoopler, DMD
David Clark, DDS Ziv Mazor, DMD Scott Synnott, DMD
Charles Cobb, DDS, PhD Dale Miles, DDS, MS Haim Tal, DMD, PhD
Spyridon Condos, DDS Robert Miller, DDS Gregory Tarantola, DDS
Sally Cram, DDS John Minichetti, DMD Dennis Tarnow, DDS
Tomell DeBose, DDS Uwe Mohr, MDT Geza Terezhalmy, DDS, MA
Massimo Del Fabbro, PhD Dwight Moss, DMD, MS Tiziano Testori, MD, DDS
Douglas Deporter, DDS, PhD Peter K. Moy, DMD Michael Tischler, DDS
Alex Ehrlich, DDS, MS Mel Mupparapu, DMD Tolga Tozum, DDS, PhD
Nicolas Elian, DDS Ross Nash, DDS Leonardo Trombelli, DDS, PhD
Paul Fugazzotto, DDS Gregory Naylor, DDS Ilser Turkyilmaz, DDS, PhD
David Garber, DMD Marcel Noujeim, DDS, MS Dean Vafiadis, DDS
Arun K. Garg, DMD Sammy Noumbissi, DDS, MS Emil Verban, DDS
Ronald Goldstein, DDS Charles Orth, DDS Hom-Lay Wang, DDS, PhD
David Guichet, DDS Adriano Piattelli, MD, DDS Benjamin O. Watkins, III, DDS
Kenneth Hamlett, DDS Michael Pikos, DDS Alan Winter, DDS
Istvan Hargitai, DDS, MS George Priest, DMD Glenn Wolfinger, DDS
Giulio Rasperini, DDS Richard K. Yoon, DDS
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Sohn et al
Utilization of Autologous Concentrated Growth Factors
(CGF) Enriched Bone Graft Matrix (Sticky Bone) and
CGF-Enriched Fibrin Membrane in Implant Dentistry
Dong-Seok Sohn, DDS, PhD1 • Bingzhen Huang, MD, PhD2 • Jin Kim, DDS, MS3
W. Eric Park, DDS4 • Charles C. Park DDS5
Abstract
P
latelets are known to release several tion. PRF and CGF can be used as alternative
growth factors which stimulate tissue to traditional barrier membrane over bone graft,
regeneration. Several techniques for plate- therefore acceleration of tissue regeneration is
let concentrates have been introduced in surgi- acquired. Unlike PRF using constant centrifuga-
cal field for the prevention of hemorrhage and tion speed, CGF utilizes altered centrifugation
acceleration of tissue regeneration. Platelet rich speed to produce much larger, denser and richer
plasma (PRP) and plasma rich in growth factors fibrin matrix containing growth factors. A new con-
(PRGF) belong to the first generation of platelet cept of fabricating growth factors-enriched bone
concentrates. PRP and PRGF require chemical graft matrix (also known as “sticky bone”) using
additives such as anticoagulants and thrombin autologous fibrin glue has been demonstrated
or calcium chloride to induce fibrin polymeriza- since 2010. Sticky bone provides stabilization
tion before applying to the surgical site. Platelet of bone graft in the defect, and therefore, accel-
rich fibrin (PRF) and concentrated growth fac- erates tissue healing and minimizes bone loss
tors (CGF), as second generation of platelet con- during healing period. This report presents the
centrate, utilizes patient’s venous blood alone to method of preparing and utilizing CGF and sticky
trigger platelet activation and fibrin polymeriza- bone, and clinical cases that support its use.
KEY WORDS: Concentrated growth factors, platelet rich fibrin, ridge augmentation,
growth factors-enriched bone graft, sticky bone. guided bone regeneration
1. Professor, Department of Dentistry and Oral and Maxillofacial Surgery, Catholic University of Daegu, Republic of Korea
3. Lecturer, UCLA School of Dentistry; Private practice, Diamond Bar, California, USA
5. Lecturer, UCLA School of Dentistry; Private practice, Orange County, California, USA
Figure 1: Patient’s venous blood taken from patients’ healing of bone graft over the bony defect, numer-
vein in patient’s forearm is divided into two types of ous techniques utilizing platelet and fibrinogen
vacutainers without anticoagulant. Non-coated test concentrations have been introduced in the litera-
tubes (yellow cap) are used to obtain AFG, which will
ture. Platelet is known to contain high quantities
make sticky bone and glass coated test tubes (red cap),
is used to obtain CGF layer.
of growth factors, such as transforming growth
factors ß-1 (TGFß-1), platelet-derived growth
factor (PDGF), epithelial growth factor (EGF),
INTRODUCTION insulin growth factor-I (IFG-I) and vascular endo-
Implant supported dental restorations have thelial growth factors (VEGF), which stimulates
become a major option in the treatment of eden- cell proliferation and up regulates angiogenesis.2-4
tulous alveolar ridge for the past several decades. Platelet rich plasma (PRP) is the first form of
Extensive loss of alveolar bone presents a com- autologous platelet concentrate to replace com-
plex challenge for reconstruction. Numerous mercial fibrin glue.5,6 Small amount of PRP is pre-
augmentation techniques are currently in use to pared in dental office for use in clinical implant
create sufficient bone volume for reliable place- dentistry. Numerous PRP kits, such as the Plate-
ment of endosseous implants in severely resorbed let Concentrated Collection System (PCCS; 3i/
edentulous alveolar ridges.1 In order to accelerate Implant Innovations, Palm Beach Gardens, FL),
SmartPReP (Harvest Autologius Hemobiolog- is drawn via venipuncture, and the blood is col-
ics, Norwell, Massachusetts), Curasan PRP lected in collection tube that contains a chemi-
kit (Curasan, Pharma Gmbh AG, Lindigstrab, cal anticoagulant. Red cell layer is discarded
Germany) and Placon (Oscotec Co, Chunan, after first centrifugation, and the buffy coat layer
Korea), are available in the current dental market. and platelet-poor plasma is collected in a new
Preparation methods for all commercially avail- test tube for second centrifugation. Concentrated
able systems are somewhat similar. Relatively platelet with fibrinogen is obtained as a result of
small amount of patient’s venous blood (8-10cc) the second spin. PRP is mixed with particulate
Figure 9: Note horizontal bone deficiency after implant Figure 10: Mineral allograft (BioTis, Bone Bank, BioTis Co,
placement. Left site shows more larger deficiency than Seoul) saturated with exudate taken from compressed CGF
right edentulous area. was grafted on the bony defect.
Case report 1: Comparison of CGF free primary suture was placed. Bone graft site
Membrane and Collagen Membrane was surgically re-entered after a 6-month heal-
A 39 year old female patient presented with ing period, and favorable ridge augmentation
missing teeth #7, #8, #9, #10. She wanted was seen at the both augmented site. To com-
implant supported fixed restoration. Prophylac- pare both augmented sites using collagen mem-
tic oral antibiotics, Cefditoren pivoxil (Meiact®; brane and CGF membrane, bone biopsy using
Boryung Parm.,Seoul, Korea) 300mg t.i.d. were 2mm wide trephine bur was taken at the buccal
used routinely, beginning one day prior to the wall of both sites (Fig 12). The specimens was
procedure and continuing for five days. Implant fixed with 4% paraformaldehyde for 24 hours,
site was exposed under local anesthesia with no and washed with 0.1M phosphoric buffered
intravenous sedation. Implants (Biocer implant, solution and decalcified with 10% formic acid
OMT GmbH, Lübeck, Germany) were placed for five days. The specimen was embedded in
at the site of tooth numbers #7, #9 and #11, paraffin (Paraplast®, Oxford, USA), and sliced
and horizontal bone deficiency was seen. Min- coronally into serial sections about 5㎛ thick. The
eral allograft (BioTis, Bobe Bank, BioTis Co, specimens were stained with Hematoxylin-Eosin
Seoul) was mixed with exudate taken from com- (H-E) stains, and examined under light micros-
pressed CGF and grafted on horizontal bony copy to verify newly-formed bone. Both speci-
defect and a collagen membrane (Pericardium, mens reveals favorable new bone formation
Zimmer Dental, CA) was covered on the right along mineral allograft without sign of inflamma-
side and two CGF membrane was covered tion (Fig 13, 14). Esthetic final results have been
on the left augmented site (Figs 9-11). Tension maintained after 2 years follow up (Figs 15-17).
Figure 11: A collagen was covered on the right augmented Figure 12: Reentry was done after a 6-month healing
site and two CGF membrane was covered on the left period. Favorable ridge augmentation was seen at the both
augmented site. augmented site. To compare both augmented sites using
collagen membrane and CGF membrane histologically,
bone biopsy core using 2mm wide trephine bur was taken
at the buccal wall of both sites.
Figure 13: Biopsy in left augmented site shows newly Figure 14: Biopsy in right augmented site shows favorable
formed bone along mineral allograft. Hematoxylin-Eosin new bone formation along mineral allograft without sign
(H-E) stains (X100). of inflammation.. Hematoxylin-Eosin (H-E) stains ( X100).
Figure 15: Esthetic final result in 2 years follow up. Figure 16: A postoperative periapical radiograph.
Figure 18: A plain radiograph reveals sever vertical bony Figure 19: Prepared sticky bone using bovine and mineral
deficiency on the right posterior mandible. allograft.
Case 2: Three Dimensional Ridge sticky bone using bovine bone (Biocera, Oscotec
Augmentation using Sticky bone with/ Co, Chunan, Korea) and mineral allograft (Puros
without Titanium Mesh allograft, Zimmer Dental, CA) was grafted over
A 45-year-old male patient with a complaint the exposed implant surface and boney defect for
of masticatory difficulty was referred from pri- 3-dimentional ridge augmentation, and resorbable
vate dental clinic for the ridge augmentation and collagen membrane (Pericardium, Zimmer Dental,
implant placement. Radiographic and clinical CA) alone was covered over the bone graft (Figs
examination revealed severe vertical and horizon- 19-22). The left edentulous ridge revealed sever
tal ridge resorption on the right mandibular eden- horizontal deficiency. Three implants were placed
tulous ridge and severe horizontal ridge deficiency at the sites corresponding to tooth numbers #18,
on the left the mandibular edentulous ridge (Fig #19, and 20 with good stability, and severe expo-
18). Sticky bone was prepared as described sure of implants was shown. Particulate bone
above before surgery (Fig 19). The surgery was graft was placed on the defect and titanium
performed under the local anesthesia through mesh (Neo implant Co, Seoul, Kora) was covered
maxillary block anesthesia by using 2% lidocaine to stabilize particulate bone graft. Three CGF
that includes 1:100,000 epinephrine. Full thick- membrane was covered over the bone graft and
ness mucoperiosteal flap was elevated to expose mesh (Figs 23-25). Implants were exposed after
the both implant sites. Right edentulous poste- 4months healing. Favorable 3-dimentional ridge
rior area showed severe vertical defect and nar- augmentation was observed on the right area
row (2-3mm wide) alveolar ridge. Three implants even titanium mesh was not used because sticky
(Dentis implant Co, Daegu, Korea) were placed bone didn’t migrate during healing period. Favor-
at the sites of tooth numbers #29, #30, and 31 able horizontal ridge augmentation was observed
with good stability. Exposure of implant surface on the left site. The patient came back to her
was shown at the site of #30 and #31. Prepared dentist for prosthetic restoration (Figs 27-29).
Figure 20: Note severe exposure of implant surface after Figure 21: Sticky bone was grafted on the exposed
implant placement and vertical bone defect. implant surface and bony defect for 3-dimentional ridge
augmentation.
Figure 22: A resorbable collagen membrane alone was Figure 23: Note sever exposure of implant surface on the
covered over the bone graft without additional bone edentulous left posterior mandible.
stabilization procedure.
Figure 24: Sticky bone was not prepared, so particulate Figure 25: Three CGF membrane was covered over the
bone graft was placed on the defect and customized bone graft and mesh to accelerate tissue regeneration.
titanium mesh (Neo implant Co, Seoul, Kora) was utilized to
stabilize particulate bone graft.
Case 3: Minimally Invasive Horizontal Ridge mentation and simultaneous implant placement.
Augmentation using Sticky Bone and Tunnel Osteoinductive replaceable bone window was
Technique prepared with a thin bladed saw insert (S-Saw,
A 49 year old female patient visited at our Bukboo Dental Co., Daegu, Korea), connected
department with complaint of masticatory dif- to piezoelectric devices (Surgybone®, Sil-
ficulty and esthetic problem. She has suffered fradent srl, Sofia, Italy) to access sinus cavity.
from chronic periodontitis in whole dentition The bony window was detached from sinus
and showed the missing of upper two central membrane and sinus membrane elevation was
incisors (Figs 30, 31). The hopeless upper performed carefully. Four pieces of CGF was
right and left lateral incisor and left canine inserted in the new compartment under the
were extracted under local anesthesia. Three elevated sinus mucosa and three implants were
implants (MIS Implant, Israel) were placed placed immediately at the sites correspond-
immediately. Labial fenestration defect was veri- ing to tooth numbers #13, #14 and #15. The
fied in the all implant sites through the vertical detached bony window was repositioned and
releasing incision which was made in buccal particulate bovine bone was grafted in the
mucosa adjacent to implant site. Sticky bone extract defect and collagen membrane was
prepared with bovine bone (Biocera, Oscotec covered over the bone graft to prevent soft tis-
Co, Chunan, Korea) and mineral allograft (Puros sue invasion and stabilize particulate bone graft
allograft, Zimmer Dental, CA) was grafted over (Figs 36-41). Immediate temporary restora-
the exposed implant surface through the verti- tion on anterior implant was delivered on
cal incision. Collagen membrane or titanium the next day. Final ceramic restoration was
mesh was not used to stabilize bone graft (Figs cemented in all implant sites after 6 months
32-35). After closing of incision area in eden- healing. The cross sectional image of cone
tulous anterior maxilla, hopeless upper right beam computed tomogram shows stable
second premolar and first and second molar bone augmentation over the exposed implant
were extracted in order to perform sinus aug- surface after 1 year loading (Figs 42-46).
Figure 30: Preoperative intraoral view reveals the missing Figure 31: Preoperative intraoral image reveals chronic
of upper two central incisors and chronic periodontitis in periodontitis with severe bone resorption in entire
whole dentition. dentition.
Figure 32: A pain radiograph reveals severe alveolar bone Figure 33: Implants were placed immediately after
resorption in entire dentition. extraction of upper right and left lateral incisor and left
canine. Dehiscence defect was detected on implant site
corresponding to right lateral incisor.
Figure 34: Labial fenestration defect was verified in Figure 35: Prepared sticky bone was grafted over the
implants corresponding to tooth number #10 and #11. exposed implant surface by tunnel technique. Any barrier
membrane was not utilized.
Figure 36: After extraction of hopeless upper right second Figure 37: Sinus membrane was elevated carefully after
premolar and first and second molar, laterally approached detachment of the bony window.
sinus augmentation was performed. Osteoinductive
replaceable bone window was prepared with a thin bladed
saw insert to access sinus cavity.
Figure 38: Four pieces of CGF was inserted in the sinus Figure 39: Particulate bovine bone was grafted in the
and implants were placed simultaneously at the site of extraction defect and collagen membrane was covered
tooth numbers of #13, #14 and #15. The detached bony over the bone graft.
window was repositioned.
Figure 42: Postoperative radiograph. Figure 43: Final ceramic restoration was cemented after 6
months healing.
Figure 44: The cross sectional image of CBCT reveals stable bone augmentation over the exposed implant surface after 1 year
loading.
ADVERTISE
nected each other by fibrin network. Sticky bone
has numerous advantages: 1) it is moldable, so
ADVERTISE WITH well adapted over various shape of bony defect;
2) Micro and macro movement of grafted bone
is prevented. So the volume of augmentation
is maintained during healing period, therefore
the need of block bone and titanium mesh is
Correspondence:
Professor Dong-Seok Sohn
Department of Oral & Maxillofacial Surgery,
Catholic University Hospital of Daegu,
3056-6 Daemyung-4 Dong,
Namgu, Daegu,
Republic of Korea
e-mail: [email protected]
WWW.JIACD.COM
Disclosure 13. Dohan Ehrenfest DM, Rasmusson L, Albrektsson 22. Gassling V, Purcz N, Braesen JH, Will M, Gierloff
The authors report no conflicts of interest with T.Classification of platelet concentrates: M, Behrens E, Acil Y, Wiltfang J. Comparison
anything mentioned in this article. from pure platelet-rich plasma (P-PRP) to of two different absorbable membranes for the
leucocyte- and platelet-rich fibrin (L-PRF).Trends coverage of lateral osteotomy sites in maxillary
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Oralife is a single donor grafting product processed in accordance with AATB standards as well as
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allografts are processed by LifeLink Tissue Bank and distributed by Exactech Inc. www.exac.com/dental
1. Data on file at Exactech.
1-866-284-9690
2. McAllister BS, Hagnignat K. Bone augmentation techniques. J Periodontal. 2007 Mar; 78(3):377-96.
3. Blum B, Moseley J, Miller L, Richelsoph K, Haggard W. Measurement of bone morphogenetic proteins and
other growth factors in demineralized bone matrix. Orthopedics. 2004 Jan;27(1 Suppl):s161-5.
Binon et al
A New Paradigm for
Fixed Complete Dentures
Abstract
T
he ever expanding role of Zirconia is applied overall natural appearance and refined esthetic is
to one piece full arch implant supported limited only by the mastery of the dentist / tech-
restorations that mirror their metal counter- nician team that applies this new technology. The
part in strength and versatility and exceeds them clinical and laboratory sequence of the prosthe-
in complete passivity at the implant interface. Their sis creation is presented from start to completion.
1. Prosthodontist, Private practice, Roseville, CA; Adjunct Professor of Prosthodontics, Graduate Prosthodontics,
Indiana University
Figure 1: Pretreatment bridge. Figure 2: Master cast. New implants placed in sites 2, 3,
5, 8, 9, and 11. Both the new implants and the original
implants in sites 4, 12, 13 and 14 had universal conical type
of abutments placed.
Figure 3: Full contour diagnostic wax up on articulated Figure 4: Duplicated epoxy teeth are set up on the master
cast. Note the amount of pink wax representing soft tissue. cast with the cast to cylinders attached to the implant
This indicates clearly that this should be a profile type of abutments. The soft tissue space is replicated in pink wax.
fixed prosthesis.
Figure 5a: Duplicated wax up poured in PolyDie material Figure 5b: Duplicated wax up poured in PolyDie material
with cast to cylinders in place. 5 A Shows the occlusal with cast to cylinders in place. 5 B Shows the intaglio
surface with the screw access holes visible. surface of the model with the cylinder / abutment mating
surfaces.
technology has been explored and applied to erties of zirconium oxide, its strength, reliability,
milled bars and complete all Zirconia one piece inhibition of plaque formation and its ideal optical
fixed complete dentures.7,8 Studies have dem- appearance.9,10 Milled Zirconia offers an unlimited
onstrated the excellent chemical/physical prop- plethora of prosthetic applications and an ideal
Figure 6: Model is modified with veneer and/or full Figure 7a: The outline of the model is the marked and
coverage preparations in the anterior segment before it is cut out of the polyurethane disc, leaving multiple support
copy milled in the Zirkograph. elements. 7A shows the resultant mounted casts occlusal
surface.
alternative to metal ceramic and metal resin res- optical standpoint, it does not have the dark grey
torations. In its green state it is easily milled and or grey brown color of metal ceramics. This new
then sintered to clinically acceptable character- generation of metal free Zirconia restorations has
istics that mirror the strength of metal. From an generated extensive interest and use in Europe.
Figure 9: Occlusal surface of the copy milled green Figure 10: Intaglio surface of the copy milled green
Zirconia. The screw access holes are checked for clearance, Zirconia. The internal bridging support elements and the
screw seat configuration and screw seating. foot piece are left in place until the first sintering to insure
absolute stability.
CLINICAL EXAMPLE
A 59 year old male patient of record presented
with a maxillary implant supported porcelain
fused to metal restoration dating back to the
1990’s that was failing (Fig. 1). The original
treatment involved bilateral sinus augmenta-
tions, the placement of ten Frialit-2 implants
(Dentsply-Frialit, Mannheim Ger.) and a three
segment, precision attachment interconnected
Figure 11: Prior to sintering, the tissue areas of the frame PFM full arch restoration. In 2009 the T block
are infiltrated with pale pink tissue color and the teeth with joint between the right cuspid and first bicus-
tooth colored liquids. The frame has just been removed pid failed and the right posterior and anterior
from the furnace. It illustrates the ideal light purple color
segment was mobile. Several efforts to remove
attained after the first bake.
the fractured retaining screw and to re-tap the
T block screw recess proved unsuccess-
ful. For an extended period of time the patient
was unable to pursue additional treatment
Zirconia is an excellent alternative for patients with due to significant systemic issues. By the
metal allergy and sensitivity.11 Currently, there time active treatment was resumed, consider-
are very few laboratories in the United States that able bone loss had occurred around numer-
have the capability to produce these restorations. ous implants in the right quadrant. The failing
Figure 12a: Illustrates the excellent passive fit that is Figure 12b: Illustrates the excellent passive fit that is
obtained with the sintered Zirconia frame. Regardless of obtained with the sintered Zirconia frame. Regardless of
it size, there is not distortion during repeated firing for it size, there is not distortion during repeated firing for
porcelain and stain application with Zirconia. porcelain and stain application with Zirconia.
Figure 14a: Veneers and crowns pressed in Authentic Figure 14b: Veneers and crowns pressed in Authentic
porcelain are in place on the Zirconia frame. Facial and porcelain are in place on the Zirconia frame. Facial and
occlusal aspects of the completed restoration with veneers occlusal aspects of the completed restoration with veneers
in place confirm the natural appearance and excellent in place confirm the natural appearance and excellent
esthetics obtainable with this technique. esthetics obtainable with this technique.
Figure 16a: The completed fixed Zirconia denture bridge Figure 16b: Post insertion smile.
in place. Space is provided between the prosthesis and
the mucosa for adequate hygiene access both facially and
lingually.
of the master model are manually copy milled sary to obtain the depth and vibrancy necessary
into the block of green Zirconia in the replicat- to replicate living tissue and natural shades.
ing frame with a variety of cutting instruments Once the frame was completed, the anterior
(Fig. 9). Rotating the disc 180 degrees allows veneers and crowns were pressed in Authen-
the intaglio surface and the details of the abut- tic porcelain (Jensen Dental, North Haven
ment/prosthesis interface to be replicated CT) and fitted onto the Zirconia frame work
(Fig. 10). The Green Zirconia frame can be (Figs. 14A, 14B). Because of the facial angula-
further refined with a dental handpiece if nec- tion of implants 11 and 12, the screw access
essary. The frame is then painted with base holes exited on the facial aspect of the clini-
colors and fired in a vacuum furnace. The heat- cal crown (Fig. 15). Cementing porcelain
ing and cooling cycles of the frame are rigidly veneers over the preparations after the frame
controlled for optimal physical properties. Fresh was inserted in the mouth resulted in optimal
out of the oven, the ideal light purple color of esthetics of the anterior segment and the com-
the frame becomes evident (Fig. 11). The frame plete masking of the anterior screw access
work is then tested on the master model for a holes (Fig. 16). On seating, the occlusal
perfect passive fit (Figs. 12A, 12B). Once the parameters were again checked carefully and
Zirconia has been sintered, repeated firings the patient was given thorough oral hygiene
will not alter its dimensional stability. A vari- instructions. Typical regiment includes the use
ety of colors are readily available to achieve of an oral irrigation devise with an antimicro-
an esthetic result (Fig. 13). Typically, multiple bial rinse, an end tufted brush and Superfloss.
additional layers of colors and stains are neces-
SUMMARY Disclosure
The all Zirconia restoration offers a very strong The authors report no conflicts of interest with anything mentioned in this article.
documentation in the literature, this technique 2. Strowe L. Technical problems in the preparation of a milled bar. QDT 1(11-
12):49-54, 1976.
and material has been used very successfully in
3. Bueno-Samper A, Hernandez-Aliaga M, Cavalo-Guirade JL. The implants
Europe since its introduction in 2005. It can be supported milled bar overdenture: A literature review. Med Oral Patol Oral Cir
Bucal 15(2):e375-8,2010.
used for fixed bridgework applications as well
4. Strietzel R, Lahl C. Introduction to CAD / CAM systems Part 1- CAD / CAM
as any application where there is a deficiency of procedure: principles and history. Spectrum Dialogue 9(4):12-25, 2010.
soft tissue. If it can be created in wax or resin, 5. Poticny D, Klim J. CAD / CAM in office technology- Innovations: After 25 years
it can be replicated in Zirconia. What distin- for predictable esthetic outcomes. JADA 141(6 Suppl):5s-9s, 2010.
guishes this technique is the simplicity of direct 6. Touchstone A, Nieting T, Ulmer N. Digital transitions – the collaboration
between dentist and laboratory technician on CAD / CAM restorations. JADA
copy milling with the Zirkograph. Zirkon Zahn’s 141(6 Suppl):15s-19s, 2010.
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Clinically Value
Manageable Packs
Bone
Predictable Volume
Maintenance
NEW
PACKAGING
NEW
OsseoGuard Flex™
Membrane
OsseoGuard® Membranes And Endobon® Xenograft Granules Provide Clinicians One Solution At A Time
Abstract
T
he existence and preservation of attached gain clinical attachment and keratinized tissue
keratinized gingiva around natural teeth levels in addition to possible root coverage.
and dental implants plays an important A combination of traditional periodontal plas-
role in periodontal and peri-implant health. tic procedures is utilized with sound evidence
This paper describes a novel surgical tech- based techniques. To date, over 100 surgical
nique that addresses multiple adjacent Miller cases have been completed. Surgical steps and
class II and III recession defects in a predict- rationale for this new technique are detailed
able one staged surgical procedure. The goal and representative cases will be shown.
of treatment is to improve esthetic outcomes,
KEY WORDS: Gingival grafting, keratinized tissue, Periodontics, root coverage, recession
Figure 1: Case I lower left sextant presurgical photo. Figure 2: Case I lower left periapical xray.
PROCEDURE
Figure 3: Case I lower left postop clinical follow up. Patients chosen exhibit posterior sextants of
recession with interproximal bone loss (Miller II
or III) and encroachment of gingival recession on
with a corrective surgical procedure able to stabi- the MGJ, commonly with frenal pulls and muscle
lize progressive recession with the added benefit attachments which may or may not have played
of some root coverage in Miller III recessions.11 a role in the etiology of attachment loss but will
play a role on the success and stability of surgi-
INCLUSION CRITERIA FOR cal treatment to resolve progressive recession.15,49
SINGLE STAGE CPF/FGG A modified one staged FGG + CPF12,14 sur-
Patients eligible for the one stage CPF/FGG gical approach is suggested: implementing Sum-
procedure included those with: 1) no health ner’s full thickness envelope16 and Sorrentino and
issues as a contraindication for periodontal sur- Tarnow’s17 semilunar procedure augmented with
Figure 4: Case II upper right presurgical photo. Figure 5: Case II upper right surgical flap photo.
Figure 6: Case II upper right surgical flap repositioned Figure 7: Case II upper right postop photo 1.
photo.
a traditional FGG18 apical to the coronally posi- some root coverage in addition to an ample gain
tioned semilunar flap is suggested. This combi- in keratinized(KT) and attached tissues (AT).11,12
nation procedure proposes to inhibit the coronal The first incision was performed by the
reattachment of the musculature and freni which Er,Cr:YSGG laser (with appropriate soft tissue
can play havoc with graft stability in the long settings due to its known properties of hemo-
term,49 in addition to increasing the zone of kera- stasis). The T4 laser tip incises precisely at the
tinized and attached tissues. Results showed MGJ in a contact/non-contact manner depend-
that most class III recessed cases even showed ing on the extent of fibrous and ligamentous fre-
Figure 8: Case III upper left pre surgical photo. Figure 9: Case III upper left post surgical photo.
nal attachment to make a split thickness incision manner20 with microsurgical blades, without the
release of all musculature/fibers prior to reach- use of vertical incisions on the facial aspect and
ing the periosteum. All elastomeric fibers are split thickness in the papillary regions. The flap is
thus incised and denatured at the MGJ. This coronally positioned with vertical mattress inter-
allows the mucosa to apically relax, laying pas- rupted sutures using 6-0 non resorbable mono-
sively extending the vestibular region without filament microsurgical sutures. Once the coronally
causing any tension on the future graft’s recipi- placed flap is secure, then the soft tissue laser
ent surgical site. Rarely was vestibular suturing setting of the Er,Cr:YSGG allows gingivoplasty/
needed for hemostasis in the region unlike with gingivectomy by microplasty of the marginal tissue
a traditional blade incision. Resorbable 4-0 gut outline and adaptation of the marginal papillary
sutures are used in the vestibule for this purpose. regions of the gingival margins. An ideal scallop-
Root preparation is done in a conserva- ing in the manner of a “paintbrush” stroke of the
tive manner if the anatomy is deemed to be laser tip allows the coronal architecture of the
inhibitory to coronal flap positioning and sta- free gingival margin (FGM) adjacent to the teeth
bility (ie. in root abrasion, horizontal groov- to adapt the marginal tissues precisely. This gin-
ing, caries cases, etc). The root surfaces are givoplasty allows the whole site to have a more
traditionally modified with root planing to remove finessed marginal gingival adaptation and con-
calculus, plaque, debris and to create a flat/con- toured appearance against the dentition. The
vex architecture and etched with the hard tissue whole coronally positioned tissue is still attached
setting with the Er,Cr:YSGG at the coronal gin- with its mesial and distal blood supplies intact
gival margins prior to suturing of the coronal flap. and is now fixed with interproximal sutures gain-
The second incision is the release of the cor- ing blood supply from the split thickness papillae
onally attached keratinized tissues incised as an and the alveolar bone beneath it. The coronally
envelope flap19 from the sulcus in a full thickness positioned tissue is immobile and well adapted
Figure 10: Case IV upper left presurgical photo 1. Figure 11: Case IV upper left presurgical photo 2.
Figure 13: Case V upper right presurgical photo. Figure 14: Case V upper right postsurgical photo.
follow-up as with traditional periodontal plas- the initial incision. The author has done this
tic procedures. Patients were asked to refrain procedure in over 100 cases with no untow-
from any mechanical hygiene techniques in ard results and with great patient satisfaction.
the treated area for the 3 weeks following sur-
gery and were prescribed 0.12% chlorhexi- DISCUSSION
dine mouthwash to be used 3-4 times per In recession studies available to review, Miller
day during the 3 weeks after the procedure. I and II recessions are the majority found in
the literature. In one such study21 coronally
RESULTS advanced flaps were used for multiple teeth in
All patients demonstrated surgical results that the esthetic zone for root coverage and were
had an improved and stable zone of attached noted to be stable after 1 year’s time with a
and keratinized tissues with no evidence of statistically significant increase in the amounts
muscle or frenal reattachment compromis- of KT. Yet in another study by Gurgan,49 after
ing the zone of KT. Most often there was evi- 5 years 50% of these cases receded to the
dence of partial root coverage in class III Miller presurgical levels when alveolar connective
recessions. The typical white “scar” line evi- tissue was used as donor as opposed to gin-
denced at the MGJ discussed in Sorrentino & gival tissue. Baldi22 concluded that coronally
Tarnow’s17 original paper can rarely be seen in advancing tissues in the treatment of multiple
this one staged procedure. Patients also found gingival recessions irrespective of the number
the procedure no more arduous than any other of recessions or the minimal amount of keratin-
periodontal plastic procedure and more often ized tissue apical to the defects, is a success-
than not, the treatment was more comfortable ful method in which to achieve root coverage;
than expected using the Er,Cr:YSGG laser for but that a CPF thickness of >0.8mm was asso-
ciated with 100% root coverage and that there taining the full buccal lingual thickness of KT
is a direct relationship between flap thick- remains a huge asset.20 Also the elevation of
ness and recession reduction. Animal & human a full or partial thickness flap did not appear
papers demonstrate that altered gingival cir- to influence the amount of KT or the percent-
culation and vitality as determined by fluores- age of root coverage achieved postsurgically.20
cein angiography show that more vascularity is Literature comparing the CPF vs semilunar
associated with greater graft survival.23 Hwang flaps showed that both designs were effec-
and Wang24 also indicated that a positive asso- tive in obtaining and maintaining a coronal dis-
ciation exists between weighted flap thick- placement of the gingival margin. The CPF
nesses and mean and complete root coverage. resulted in clinical improvements significantly
Langer & Langer’s25 technique utilized partial better than semilunar flaps for percentage of
thickness flap elevation to enhance revascular- root coverage, frequency of complete root cov-
ization of the graft, which was then stabilized erage and gain in clinical attachment level.27
on the recipient site using periosteal sutures. A recent review50 points out that aber-
Raetszke19 however advocated the use of the rant frenal pulls are a contraindication to
split thickness envelope in isolated areas only, the traditional CPF/SCTG as aberrant fre-
reporting difficulty in obtaining sufficient tissue num cannot be corrected at the time of sur-
for use in more extensive areas of recession. gery because incisions would compromise
However surgically, the elevation of a par- the blood supply available to the graft. When
tial thickness flap can be arduous to perform, indicated, a frenectomy is scheduled 4 to 6
particularly in patients with a thin gingival bio- weeks prior to grafting.15,50 The beauty of the
type. A partial thickness flap also reduces the single stage laser CPF/FGG is that all aber-
KT tissue thickness, and mucosal flaps less rant frenal attachments are dealt with imme-
than 1 mm thick have been correlated with a diately in order not to compromise graft
reduction in the percentage of root coverage stability, or the microvasculature from the recipi-
in defects treated using coronally advanced ent bed and subsequent graft longevity and
flaps.22,27 Since bilaminar vascularity is required thus future recession of the new donor tissue.
ONLY to provide blood supply to a SCTG, a In another paper, Harris10 treated 266
full thickness CPF was used in this procedure. defects with connective tissue grafts associated
Any chance of fenestration or dehiscence with a coronally advanced or a double papilla
over the roots remaining after a full thickness flap and reported that the average results of
CPF is compensated for by the FGG placed deep recessions ( ≥ 5 mm) were less favorable
over these denuded sites and has proven to (87% vs 95%), when connective tissue grafts
be historically not an issue28,29 when grafts were associated with a coronally advanced
were placed straight onto the alveolar bone. flap. Although these results were for Miller I and
No issues were observed due to coronally II recessions and showed better results than
positioning a full thickness flap vs a partial seen in the Miller III laser CPF/FGG procedure,
thickness flap26,29 and yet the benefit of main- they confirm limitations when recessions reach
5 mm.30 In the traditional SCTG + CPF with- 66% for an average attachment level of 3.81
out vertical releasing incisions results in Miller mm, in comparison to 50% and 33.3% for mean
III root coverage, ranged from 1 to 3 mm (mean attachment levels of 5.23 and 5.5 mm, respec-
1.0 ± 1.5); and Miller IV recessions ranged tively.33,34 Glise and Monnet-Corti also reported
from 2 to 10 mm (mean 1.86 ± 0.14) the num- that percentage of root coverage was inversely
ber of Class III and IV recessions were fewer proportional to the width and height of the initial
than class I and II recessions. Nevertheless the recession dimensions.35 Thus, even though the
authors noted that these type III/IV clinical situ- literature indicates that Miller III and IV reces-
ations can be improved with this procedure.12 sions have little probability of 100% root cover-
It has also been shown that when CPF plus age, increasing the KT and AT can increase the
CTG versus CPF procedures for root cover- health and longevity of a patient’s dentition.54
age are compared, the two surgical procedures Even if only some slight root coverage (based
resulted in similar degree of root coverage but on individual anatomy and physiology) is pos-
the CPF’s alone reverted to presurgical lev- sible, this may be a significant improvement for
els of the MGJ.31 In addition, other long term the patient esthetically, and also increases the
papers evaluating CPF with CTG all show that chances of additional root coverage as a result
an apical rebound of the MGJ occurs resulting of “creeping reattachment” for the patient.36
in unstable root coverage and increased reces- The Er,Cr:YSGG laser is used here for the
sion.31,45,52 These findings may be explained first time in surgical grafting procedures as it
by Ainamo et al.51 who reported that the MGJ allows a precision not possible with a surgical
will regain its original apical position over time blade. Erbium lasers have the unique ability to
resulting in unstable root coverage while the vaporize water containing tissue because of its
current paper has reestablished a brand new wavelength but also has a hemostatic effect to
MGJ by adding keratinized FGG apically. cauterize blood vessels without the requirement
A study comparing CPF techniques with to pick up another laser machine at a differ-
and without the use of vertical releasing inci- ent wavelength - translating to more practical-
sions both showed to be effective in reduc- ity and efficiency in a private practice setting.
ing recession depth, but the envelope type of What is clearly observed is that the
CAF was associated with an increased prob- Er:YSGG laser allows the operator a “micro-
ability of achieving complete root coverage surgical approach” to finesse the marginal tis-
and with a better postoperative course. Keloid sue adaptation at the coronal edges along
formation along the vertical releasing inci- with “laser welding” the FGG donor portion to
sions was responsible for a poor esthetic out- the CPF portion of the surgical site and con-
come along with a longer healing period and a trol the hemostasis without additional suturing.
more uncomfortable postoperative course.32 Pini Prato37 showed that the gingival marginal
Complete root coverage has been shown to position at the end of plastic surgery allowed
be more likely in Miller I and II type recessions, for complete root coverage in Class I and
when marginal tissue recessions are shallower: Class II gingival recession defects, and apply-
ing this philosophy of treatment to the laser ise of this technique is for root coverage (40-80%
CPF/FGG will only enhance any probability of after 5-33 months) while minimal KT (<1.5mm)
root coverage in Miller III/IV recession defects. was gained and in most cases lost (+/- 1.9mm).
The elevation of a full thickness versus par- Only 2.8 teeth were treated per patient versus
tial thickness flap does not appear to influ- 4-5 in the current paper, nor was frenal relief
ence either the amount of keratinized tissue discussed or mentioned for long term stability.
or the percentage of root coverage achieved
post-surgically. In fact, the thicker coronal tis- CONCLUSIONS
sue, allows an increase in blood supply, sur- Clinicians have all too often are faced with the
gical anchorage and less tissue trauma with request “can you not do something to cover
better potential root coverage.38 Pedicle and these teeth?” Many times the concern is not
envelope flaps are successful if the grafted tis- related to sensitivity but rather that of esthet-
sues remain vital on the exposed dental avas- ics due to recession increasing over a period of
cular root surface and soft tissue healing is time for a patient on a stable maintenance sched-
critically controlled by this vascularity.28,29 Most ule. Once the periodontal health was assessed
reaffirming was Romanos et al.43 showing that to be stable, the remaining compromised zone
the lateral bridging flap technique designed of KT/AT and the location of the muscle/frenal
similar to this paper’s CPF, exhibited the most attachment often appeared to play a role in pro-
stable location of the repositioned MGJ which gressive recession. Thus the single staged laser
was 2-3mm coronally over 5-8 years with CPF/FGG was developed and completed in over
stable root coverage and gingival margins. 100 patients and was reported to be a comfort-
Of further interest is that treatment success is able procedure with an esthetic improvement.
more predictable with limited interproximal bone There are even documented areas of root cov-
loss and undamaged interproximal soft tissue.5,39 erage in Miller III and IV situations and over the
Gurgan commented that tooth location, ves- years some “creeping reattachment” has been
tibular depth, muscular and frenal insertions may documented.36 More investigation in a prospec-
affect wound stability once a flap is advanced.50 tive clinical study, with volumetric methodology44
Fombellida analyzed the significance of the “vas- needs to be done in order to assess the statisti-
cular supply” as a critical factor on the predic- cal significance of increases in KT and root cov-
tion of root coverage success; a positive balance erage results of this new procedure or with the
between the vascularized and nonvascularized adjunct of tissue engineering and biological
areas of the surgical field yields better results in adjuncts such as enamel matrix derivative, PRP
terms of root coverage, even in those less favor- (platelet rich plasma) or PRF (platelet rich fibrin).41
able cases, such as Miller Class III recessions.40 The CAF procedure is effective in the treat-
A recent paper53 presents a novel approach ment of gingival recessions. However, reces-
to root coverage with pinhole versus flap access sion relapse and reduction of KT occurred
and use of allograft donor tissue in anterior teeth during follow up periods without any FGG
only for Miller I, II and fewer III defects. The prem- adjunct.42 The baseline width of KT is a pre-
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Disclosure 14. Bernimoulin JP, Luscher B, Muhlemann HR, 28. Dordick B, Coslet JG, Seibert JS. Clinical
The authors report no conflict of interest with Coronally repositioned periodontal flap. Clinical Evaluation of Free Autogenous Gingival Grafts
anything mentioned in this article. evaluation after one year. J Clin Periodontol Placed on Alveolar Bone. Part I. Clinical
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iller PD Jr. A classification of marginal tissue M, Montebugnoli L, De Sanctis M. Coronally
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ortellini, Tonetti, Baldi et al. Multi center 21. Zuchelli G & de Santis M. Treatment of Multiple
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placement of the CTG improve Coronally Demands J Periodontol 2000;(71)9:1506-1514. R. Cortellini P. Coronally advanced flap versus
Advanced Flaps for single Tooth Recessions connective tissue graft in the treatment of
22. Baldi C et al. Coronally Advanced Flap
of maxillary upper anterior Teeth? J Clinical multiple gingival recessions: a split-mouth study
Procedure for Root Coverage. Is Flap
Periodontol 2009; (36)1:68-79. with a 5 year follow-up. J Clinical Periodontology
thickness a relevant predictor to Achieve Root
2010;(37)7:644-50
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of the gingival margin: semilunar versus
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Periodoncia y Osteointegración 2002;(12):121–132.
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Muñoz H, Goiriena de Gandarias FJ. Estudio com- parativo de la eficacia
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marginal clase III de Miller. Av Periodoncia 1996;(8):147–152
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resorption following partial-thickness connective tissue graft placement: Using recolutionary online technology,
a case report. J Periodontol 2002; (73)3:334-339
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with subepithelial connective tissue graft for root coverage: experience that is simply not available
clinical and histological report of a case. Int Journ Perio Rest Dent
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with traditional hard copy paper journals.
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5 years after Coronally Repositioned Flap Surgery. J Periodontol
2004;(75)6:893-901.
50. Richardson CR, Allen EP et al. Periodontal Soft Tissue Root Coverage
Procedures: Practical Applications From the AAP Regeneration
Workshop. Clinical Advances in Periodontics February 2015;(5)1: 2-10.
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Technique. Int Journal Perio Rest Dent2012;(32)5: 521-531.
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keratinized gingiva and gingival health. Journal of Periodontology
1972;(43)1:623-627.
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Abstract
KEY WORDS: Dental implants, bar attachment, implant supported overdenture, case report
1. PhD Student, Prosthodontics Department, Faculty of Oral and Dental Medicine, Cairo University ,Egypt and
Assistant Lecturer, Prosthodontics Department, Faculty of Dentistry, IBB University, IBB, Yemen
2. Lecturer of Prosthodontics, Faculty of Oral and Dental Medicine, Cairo University
Figure 1: Intra-oral radiograph show distal tilting of left Figure 2: Transmucosal abutment connected to implant
implant. fixtures.
Figure 3: Abutment level final impression. Figure 4: Abutment analogue was tightened to impression
post.
(Figure 3). Abutment analogue was tightened mouth check for the passive fit (Figure 5). Cast-
to impression post ensuring immobility of the able abutment (plastic abutment, DENTIS implant
impression post during this process. Then a soft system, KOREA) was used in this case over the
tissue mimic material was applied around gin- transmucosal abutment. The dental surveyor
gival part of analogue and the whole impression and silicon index, made previously after try in of
was poured with improved stone (Figure 4). The new complete denture, were used to ensure pre-
verification jig was constricted and tried in patient cise bar attachment plastic pattern placement
Figure 5: The verification jig tried in patient mouth check Figure 6: Silicon index used to ensure precise bar
for the passive fit. attachment plastic pattern placement.
Figure 7: Surveyor used to ensure precise bar placement. Figure 8: Final plastic pattern on the cast.
(Figures 6-8). The wax pattern was cast in a bar attachment assembly was connected to
Ni-Cr alloy using standard technique. Casting was transmucosal abutment and tightened prop-
than retrieved, finished and highly polished to erly by screw driver and torque wrench up to
avoid any plaque accumulation along the bar. 25Ncm. The remaining steps of the conven-
Then, the metal bars assembly was tried intra- tional denture construction were carried out
orally to check for the passive fit. In this case as usual. The plastic clips were placed, the fin-
the metal bar was cut and then re-soldered as ished denture prepared for chairside pickup,
result of misfit (Figure 9). After this step, the using putty silicone to close the undercut
Figure 9: Metal bars assembly tried intra-orally. Figure 10: Blockout under the bar with putty silicon.
Figure 11: Picked up retentive clips on the fitted surface of Figure 12: Patient happy with new prosthesis.
the denture.
dicular to the occlusal plane as possible so that 2. Block MS, Almerico B, Crawford C, Gardiner D, Chang A. Bone response
to functioning implants in dog mandibular alveolar ridges augmented with
they are loaded axially without producing a bend- distraction osteogenesis. Int J Oral Maxillofac Implants 1998;13(3):342-51.
ing moment.7 It has been also suggested that 3.
Skalak R. Biomechanical considerations in osseointegrated prostheses. J
angled implants was associated with more pros- Prosthet Dent 1983;49(6):843-8.
thetic repairs if inclined by more than 6 degrees8. 4. Van Kampen F, Cune M, van der Bilt A, Bosman F. Retention and postinsertion
maintenance of bar-clip, ball and magnet attachments in mandibular implant
In an attempt to correct these misalignments, bar overdenture treatment: an in vivo comparison after 3 months of function. Clin
Oral Implants Res 2003;14(6):720-6.
attachments were used to splint these implants. It
5. Jiménez-Lopez V. Oral rehabilitation with implant-supported prostheses : implant
was even claimed that bar attachments placed on supported mandibular overdenture Chicago,Berlin,London,Paris: Quintessence
publishing Co.; 1999.
distally inclined implants offered better mechani-
6.
Banton B, Henry M. Overdenture retention and stabilization with ball-and-
cal advantages than those placed on vertical socket attachments: principles and technique. Journal of dental technology: the
implants with distal cantilevers.9 The patient peer-reviewed publication of the National Association of Dental Laboratories
1997;14(7):14-20.
instructed to devote more interest for cleaning 7. Mericske-Stern R. Forces on implants supporting overdentures: a preliminary
around the bar attachment. Proper oral hygiene study of morphologic and cephalometric considerations. The International
journal of oral & maxillofacial implants 1992;8(3):254-63.
around the bar is more difficult than for individ-
8.
Walton JN, Huizinga SC, Peck CC. Implant angulation: a measurement
ual attachments. After one year follow up, the technique, implant overdenture maintenance, and the influence of surgical
experience. The International journal of prosthodontics 2000;14(6):523-30.
patient was very satisfied with new overdenture,
9.
Zampelis A, Rangert B, Heijl L. Tilting of splinted implants for improved
with no maintenance required during the first year. prosthodontic support: a two-dimensional finite element analysis. The Journal of
prosthetic dentistry 2007;97(6):S35-S43.
CONCLUSION
The present case report describes the prob-
lem of frequent retention loss of ball retained
implant mandibular overdenture, and solution
of this problem by changes the ball attach-
ments with bar attachment this approach
solve the problem of mis-angulated implant. ●
Correspondence:
Dr. Ahmed Yaseen Alqutaibi
Email: [email protected]
Tel: 00201144772955
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