Riabilitazione protesica ed implanto-protesica di pazienti in età evolutiva affetti da Displasia Ectodermica

Introduction. Ectodermal Dysplasias are a heterogeneous group of inherited disorders characterized by dysplasia of tissues of ectodermal origin (hair, nails, teeth, skins and glands). Clinically, it may be divided into two broad categories: the X-linked hypoidrotic form and the hidrotic form. Hypohidrotic Ectodermal Dysplasia (H.E.D) is characterized by the triad oligo-anodontia, hypotricosis, hypo-anhydrosis (Christ-Siemens-Tourane syndrome). The incidence of HED is about 1/100,000. Mutation in the actodysplasin-A (EDA) and ectodysplasin-A receptor (EDAR) genes are responsible for X-linked and autosomal HED. The clinical features include sparse, fine hair, missing or conical-shaped teeth, decreased sweat and mucous glands, hypoplastic skin, and heat intolerance with exercise or increased ambient temperature. Complete or partial anodontia and malformation of teeth are the most frequent dental findings. Incisors and canines are often conical-shaped while primarily second molars, if present, are mostly affected by taurodontism. Treatment is supportive and includes protection from heat exposure, early prosthetic rehabilitation, skin, hair ear, nose and nail care, and genetic counseling for family planning. The diagnosis of HED in the neonatal and early infancy period may be difficult since sparse hair and absent teeth are normal finding at this age. In childhood the diagnosis is more easily made on the basis of history and clinical examination. Dental abnormalities are the most common complaint. Prosthetic rehabilitation has been recommended as an essential part of the management of HED because is important from functional, esthetic, and psychological standpoint. A team approach that includes input from a pediatric dentist, an orthodontist, a prosthodontist, and an oral and maxillofacial surgeon is necessary for a successful outcome. Conventional prosthodontic rehabilitation in young patient is often difficult because of the anatomical abnormalities of existing teeth and alveolar ridges. The conical shaped teeth and “knife-edge” alveolar ridges result in poor retention and instability of dentures. Moreover, denture must permit jaws expansion and a correct pattern of growth. Materials and Methods. Complete removable dentures were provided to allow for normal physiological development and a corrected masticatory function. Initial maxillary and mandibular impressions were made with smallest stock trays and irreversible hydrocolloid and then final impressions ware made with light-bodied polysulfide rubber base impression material. A base of autopolymerizing resin was constructed and a wax rim was added to the base. The patient’s vertical dimension of occlusion was established by assessing phonetic and esthetic criteria. Preliminary occlusal relations were recorded, and the mandibular cast was mounted on the articulator. Acrylic resin teeth specific for children dentures were selected and mounted. The dentures were tried in and, after proper adjustments, were inserted. The patients were monitored clinically every month to fit prostheses. Cephalometric radiographs were taken every 6 month with the prostheses in place in order to evaluate correct pattern of growth. Cephalometric measurements were realized and used to evaluate the effect of rehabilitation on craniofacial growth. Cephalometric measurements of sound patients were compared with ED patients. After two month expander screws (three-way screw in the upper denture and two-way the lower one)were inserted in each denture in order to permit the expansion of the denture and the jaws growth. Where conical teeth were present, composite crown were realized and luted to improve the esthetic and phonesis. In order to improve retention the placement of endosseous implants was carried out. TC 3D Accuitomo was performed and a resin model of mandibular bone of the patient was realized. At the age of 11 years two implants were inserted into anterior mandible in a child with anodontia. Despite a remarkable multi-dimensional atrophy of the mandibular alveolar process, the insertion of two tapered screw implants (SAMO Smiler, diameter 3.8, length 10 mm). After a submerged healing period of two-three month, the implants were exposed. Implants were connected with an expansion guide that permits mandibular growth and prosthetic retention. The amount of mandibular growth was also evaluate dusing the expansion guide. Results. Early oral rehabilitation improve oral function, phonesis and esthetic, reducing social impairment. Treated patients showed normal cephalometric measurement. Early rehabilitation is able to prevent the prognatissm of the mandibula . The number of teeth was significantly related to several changes in craniofacial morphology. Discussion. In the present study the 5,3% of ED patients showed hypodontia, the l’89,4% di oligodontia, and the 5,3% di anodontia. The cephalometric analysis supports that ED patients showed midface hypoplasia. ED groups showed an increased pogonion to nasion measurement than sound patients, indicative of class III tendency. The present study demonstrated that number of teeth was significantly correlated with deviation of cephalometric measurements from normality. Oligoanodontia is responsible for changing of cephalometric measuraments also on sagittal plane with a class III tendency. Maxillary jaw showed a retrused position related to the presence of hypodontia.

Valutazione dello spostamento tridimensionale degli impianti in giovani pazienti affetti da EDs riabilitati con overdenture implanto-supportati

Ectodermal Dysplasias syndrome (EDs) are a heterogeneous group of inherited disorders characterized by dysplasia of tissues of ectodermal origin. Complete or partial anodontia are the most frequent dental findings. Prosthetic rehabilitation is recommended from functional, esthetic, and psychological points of view. Because of the anatomical abnormalities of existing teeth and alveolar ridges, conventional prosthetic rehabilitation in young patient is often difficult. Five growing patients (age 9 to 11 years) with oligo- or anodontia were prosthetically rehabilitated. Panoramic film and Cone Bean Computerized Tomography were performed and a resin model of mandibular bone was made. Despite a remarkable multi-dimensional atrophy of the alveolar bone, the insertion of two tapered implants was possible. After a submerged healing period of 2 month, the implants were exposed and abutment connection was performed. Implants were connected with an expansion bar that permits mandibular growth and prosthetic retention. A removable prosthesis was constructed with ball attachments. Mandibular growth was followed and evaluated using the expansion guide and cephalometric radiographs. Mandibular growth in sagittal and transverse direction had no adverse effects on implant position. The expansion bar permitted the undisturbed growth of the mandible. After 4.5 years of follow-up, this study showed that Implant-supported overdenture may improve oral function, phonesis and esthetics. The mandibular rotation accompanying growth had not caused a significant problem relative to the angulation and migration of the implants. Implants can be successfully placed, restored and loaded in growing EDs patients. The cephalometric analysis supported that EDs patients show midface hypoplasia with a class III tendency, which can be avoided by early rehabilitation. Thanks to the good stability and retention of the implant-supported overdenture, patients considered the prostheses as comparable to natural teeth.

Efficacia delle griglie in titanio con osso particolato nella ricostruzione dei difetti alveolari tridimensionali dei mascellari

Questa tesi valuta l’efficacia della tecnica delle griglie in titanio con osso particolato nella ricostruzione dei difetti alveolari tridimensionali ai fini della riabilitazione dentale implanto-protesica. Il primo studio ha considerato la metodica in termini di complicanze post-operatorie e di risultati implanto-protesici. Sono stati considerati 24 pazienti con difetti tridimensionali trattati con l’applicazione di 34 griglie di titanio e osso particolato e riabilitati protesicamente dopo circa 8-9 mesi. 4 su 34 griglie sono state rimosse prima dell’inserimento implantare (11.76% di fallimento totale); 20 su 34 griglie si sono esposte per deiscenza dei tessuti molli (58.82% di complicanze): 4 (11.77%) prima e 16 (47.05%) dopo le prime 4-6 settimane dall’intervento; in nessun caso il piano di trattamento implanto-protesico ha subito variazioni. Dopo un follow-up medio di 20 (3-48) mesi dal carico protesico, nessuno degli 88 impianti ha perso la propria osteo-integrazione (100% di sopravvivenza implantare), con un valore complessivo di successo implantare di 82.9%. Il secondo studio ha calcolato in termini volumetrici la ricostruzione ossea ottenuta con griglie e la sua corre-lazione con l’estensione dell’esposizione e la tempistica del suo verificarsi. Sono stati valutati 12 pazienti con 15 difetti alveolari. Per ciascun sito sono state studiate le immagini TC con un software dedicato per misurare i volumi in tre dimensioni: il volume di osso non formatosi rispetto a quanto pianificato, lacking bone volume (LBV), è stato calcolato sottraendo il volume di osso ricostruito, reconstructed bone volume (RBV) in fase di ri-entro chirurgico dal volume di osso pianificato pre-operativamente, planned bone volume (PBV). LBV è risultato direttamente proporzionale all’area di esposizione della griglia, con un valore del 16.3% di LBV per ogni cm2 di griglia esposta. Si sono evidenziate, inoltre, correlazioni positive tra LBV , la tempistica precoce di esposizione e il valore di PBV.

[Does the combination syndrome exist? A case report]

This case report documents the prosthetic rehabilitation of a patient showing the typical features of combination syndrome. This case documentation gives a general overview of the suspected development and the prevalence of this "syndrome". A treatment option should be shown by the example of a patient from the starting situation until the prosthetic therapy by means of a complete maxillary denture and an implant-supported mandibular overdenture rigidly retained with a milled bar.

Fibula free flap reconstruction of the mandible in cancer patients: Evaluation of a combined surgical and prosthodontic treatment concept

The final goal of mandibular reconstruction following ablative surgery for oral cancer is often considered to be dental implant-supported oral rehabilitation, for which bone grafts should ideally be placed in a suitable position taking subsequent prosthetic restoration into account. The aim of this study was to evaluate the efficacy of a standardized treatment strategy for mandibular reconstruction according to the size of the bony defect and planned subsequent dental prosthetic rehabilitation. Data of 56 patients, who had undergone such a systematic mandibular fibula free flap reconstruction, were retrospectively analyzed. Early complications were observed in 41.5% of the patients but only in those who had been irradiated. Late complications were found in 38.2%. Dental implant survival rate was 92%, and dental prosthetic treatment has been completed in all classes of bony defects with an overall success rate of 42.9%. The main reasons for failure of the complete dental reconstruction were patients' poor cooperation (30.4%) and tumour recurrence (14.3%) followed by surgery-related factors (10.8%) such as implant failure and an unfavourable intermaxillary relationship between the maxilla and the mandible. A comparison of our results with the literature findings revealed no marked differences in the complication rates and implant survival rates. However, a systematic concept for the reconstructive treatment like the method presented here, plays an important role in the successful completion of dental reconstruction. The success rate could still be improved by some technical progress in implant and bone graft positioning.

Patients with oral tumors. Part 2: Quality of life after treatment with resection prostheses. Resection prosthetics: evaluation of quality of life

In the present study, the oral health-related quality of life of 18 patients (13 men and 5 women) was evaluated using validated questionnaires as proposed by the European Organization of Research and Treatment of Cancer (EORTC). The patients belonged to a cohort of 48 patients, whose prosthetic treatment was performed during the years 2004-2007. In the course of tumor resection, 12 patients underwent graft surgery and 14 patients radiotherapy. One patient required a nasal epithesis since resection of the nose became necessary. Five patients underwent a full block resection of the mandible, and tumor resection in 3 patients resulted in a large oronasal communication. Prosthetic rehabilitation was performed in all patients, and the follow-up period with regular care covered a minimum of 3 years. Eleven patients received dental implants for better support and retention of the prostheses. In spite of compromised oral conditions, functional restrictions, and some difficulties with the prostheses, the answers to the questionnaire were quite positive. The majority judged their general health as good or even excellent. The subjective perception of the patients may contradict the objective view by the dentist. In fact, the individual patient's history and experience provide a better understanding of the impact of oral tumors on daily life. The overall assessment identified 4 items that were perceived as major problems by all patients: swallowing solid food, dry mouth, limited mouth opening, and appearance. Prosthetic rehabilitation has only a limited influence on such problems.

Zirconia-Based Screw-Retained Prostheses Supported by Implants: A Retrospective Study on Technical Complications and Failures

BACKGROUND Little information is yet available on zirconia-based prostheses supported by implants. PURPOSE To evaluate technical problems and failures of implant-supported zirconia-based prostheses with exclusive screw-retention. MATERIAL AND METHODS Consecutive patients received screw-retained zirconia-based prostheses supported by implants and were followed over a time period of 5 years. The implant placement and prosthetic rehabilitation were performed in one clinical setting, and all patients participated in the maintenance program. The treatment comprised single crowns (SCs) and fixed dental prostheses (FDPs) of three to 12 units. Screw-retention of the CAD/CAM-fabricated SCs and FDPs was performed with direct connection at the implant level. The primary outcome was the complete failure of zirconia-based prostheses; outcome measures were fracture of the framework or extensive chipping resulting in the need for refabrication. A life table analysis was performed, the cumulative survival rate (CSR) calculated, and a Kaplan-Meier curve drawn. RESULTS Two hundred and ninety-four implants supported 156 zirconia-based prostheses in 95 patients (52 men, 43 women, average age 59.1 ± 11.7 years). Sixty-five SCs and 91 FDPs were identified, comprising a total of 441 units. Fractures of the zirconia framework and extensive chipping resulted in refabrication of nine prostheses. Nearly all the prostheses (94.2%) remained in situ during the observation period. The 5-year CSR was 90.5%, and 41 prostheses (14 SCs, 27 FDPs) comprising 113 units survived for an observation time of more than 5 years. Six SCs exhibited screw loosening, and polishing of minor chipping was required for five prostheses. CONCLUSIONS This study shows that zirconia-based implant-supported fixed prostheses exhibit satisfactory treatment outcomes and that screw-retention directly at the implant level is feasible.

Reabilitação Oclusal com Prótese Parcial Removível Provisória Tipo “Overlay” – Relato de Caso

An appropriate design of a prosthetic rehabilitation should not impute the restoration of occlusal vertical dimension (OVD) to new prostheses, at the risk of the patient does not adapt to a new condition, since a certain amount of time is often necessary for adaptation to a new OVD. This article performed prosthetic rehabilitation with an overlay provisional removable partial denture prior to definitive treatment because the patient showed a considerable decrease in the OVD. Three techniques for OVD determination were used. It is possible to conclude that the use of interim removable partial dentures is of great importance at the beginning of the rehabilitation treatment in order to adapt the patient to a new occlusal condition.

Reabilitação Oclusal com Prótese Parcial Removível Provisória Tipo “Overlay” – Relato de Caso

An appropriate design of a prosthetic rehabilitation should not impute the restoration of occlusal vertical dimension (OVD) to new prostheses, at the risk of the patient does not adapt to a new condition, since a certain amount of time is often necessary for adaptation to a new OVD. This article performed prosthetic rehabilitation with an overlay provisional removable partial denture prior to definitive treatment because the patient showed a considerable decrease in the OVD. Three techniques for OVD determination were used. It is possible to conclude that the use of interim removable partial dentures is of great importance at the beginning of the rehabilitation treatment in order to adapt the patient to a new occlusal condition.

The use of a magnetic attachment in a removable partial denture of a patient with periodontal tissue loss

O uso dos magnetos em prótese parcial removível é uma alternativa viável para eliminar a estrutura metálica que pode interferir na estética sem perder retenção e estabilidade. Os magnetos podem ser recomendados para pacientes com perda de tecido periodontal, desde que eles diminuam a transmissão de forças ao dente remanescente. O objetivo deste relato de caso clínico foi apresentar uma alternativa de tratamento protético para dentes pilares comprometidos periodontalmente e descrever as vantagens e desvantagens do uso dos magnetos em prótese parcial removível sobre os pontos de vista funcionais, biológicos e estéticos.

Erros de comunicação entre Protésicos e Médicos Dentistas

Este trabalho consiste numa revisão de literatura sobre os erros de comunicação entre dois grupos de profissionais, cujos trabalhos na área da Medicina Dentária se complementam: o Médico Dentista (MD) e o Técnico de Prótese Dentária (TPD). A comunicação entre estes dois grupos é o um fator muito importante e deve existir uma boa sinergia para que o trabalho seja executado com o maior rigor e qualidade possível. Esta pressupõe aspetos funcionais, biomecânicos, estruturais e estéticos, da reabilitação a realizar, potenciando deste modo a máxima de qualquer tratamento médico: a satisfação do paciente. O objetivo que se propõe é expor os erros decorrentes de falhas de comunicação e alertar os MD e TPD para a mudança do nível de colaboração. É também objetivo desmistificar a postura dos MD em relação à Prótese Dentária. O culminar deste trabalho de equipa traduz-se na promoção da Saúde Oral e melhor qualidade de vida dos pacientes. As falhas na comunicação são o principal entrave ao sucesso da reabilitação protética, pois impedem a conjugação dos conhecimentos científicos e técnicos de ambos os profissionais perpetuando erros ao longo das etapas de fabrico. Com base numa pesquisa relacionada com a comunicação entre MD e TPD, utilizando-se as palavras-chave “dentist technician relationship”, “dentist technician communication”, “dentist technician survey”, “dental fixed architecture” e “dental technicians fabrication”, através dos motores de busca Pubmed, Scielo e Science Direct, foi realizada uma revisão de literatura com o intuito de avaliar a comunicação entre TPD e MD. Procurou-se caracterizar que tipos de erros que podem ser cometidos, bem como formas para melhorar a comunicação. Após a revisão, constatou-se que existe uma grande deficiência a nível de comunicação entre MD e TPD e que tal facto induz a que um trabalho perca em termos de qualidade. Também se verificou que os erros cometidos são a nível académico e profissional, proporcionando a que o trabalho final resulte na insatisfação do paciente, bem como dos profissionais envolvidos.

Avanço dos biomateriais e técnicas na correção dos defeitos ósseos maxilares

Introdução: Determinar as causas da perda óssea nos maxilares, compreender os mecanismos biológicos desencadeados após a perda dental e criar recursos técnicos no intúito de prevenir e/ou minimizar as sequélas decorrentes, tem sido ao longo dos anos uma das vertentes de maior pesquisa e desenvolvimento na medicina dental . Objetivo: Assim, o objetivo desta dissertação é realizar uma revisão da literatura sobre os avanços nos biomateriais e técnicas na correção dos defeitos ósseos maxilares, para que seja possível, futuramente, ampliar as suas aplicações em Medicina Dentária, ultrapassando as limitações das técnicas e materiais existentes atualmente. Metodologia: Para isso, foi realizada uma pesquisa de artigos na base de dados PubMed, Bireme, Lilacs, Medline, revistas e periódicos nos idiomas: português, inglês e espanhol; assim como livros consagrados na literatura médico-odontológica,com o recurso a limites e palavras-chave de forma a refinar essa pesquisa. Desenvolvimento: Os avanços nos biomateriais e técnicas na correção dos defeitos ósseos maxilares tem seguido, assim como os implantes dentais, dois principais eixos de pesquisa, primeiro no que diz respeito aos biomateriais empregados pós-exodontia, a prevenir a reabsorção osséa e aqueles utilizados à fim de corrigir defeitos já existentes; a aplicação destes materiais recai sobre fatores que são decisivos na escolha do cirurgião, tais como: disponibilidade, necessidade de procedimento cirúrgico adicional, compatibilidade, morbidade do enxerto, qualidade do osso resultante e tempo de neo-formação. Segundo, as técnicas e recursos desenvolvidos para garantir a eficáz correção do defeito, assim como proporcionar procedimentos menos traumaticos ao organismo e de maior simplicidade e previsibilidade na sua execução e reprodução pelos profissionais. Discussão: Os trabalhos desenvolvidos em volta dos biomateriais atualmente buscam não só o substituto ideal, mas sim a melhoria na interação entre o osso hospedeiro e o biomaterial enxertado perante os recursos já utilizados e consagrados pelas literaturas; assim como a utilização das técnicas já protocoladas de forma associada a estes novos materiais. Conclusão: As pesquisas sobre o aperfeiçoamento do processo de regeneração óssea nos defeitos maxilares avançam na questão de promover a rápida e eficaz interação entre organismo e biomaterial, a fim de trazer soluções para problemas como a anti-genicidade, previsibilidade dimensional, menor tempo entre a enxertia e a reabilitação protética e agrega-se a utilização de recursos técnicos práticos, uma vez que o planejamento da reabilitação inicia-se nas decisões pré-exodontias e pré-implantares.

Prótese obturadora palatina

Nos pacientes com defeitos ósseos palatinos congénitos ou adquiridos, quando a possibilidade de reconstrução cirúrgica não existe, poderá ter de se utilizar uma prótese obturadora palatina, com vista ao restabelecimento das funções do sistema estomatognático, tais como, a fonética, deglutição e mastigação. Contudo, esta necessidade não é só funcional mas também estética e psicológica, com vista a melhorar a qualidade de vida dos pacientes. As próteses obturadoras palatinas têm vindo a desenvolver há alguns séculos, com o aprimoramento das técnicas de confecção e materiais dentários que auxiliam na elaboração, cada vez mais eficientes, principalmente no que se refere a sua adaptação. Neste trabalho realizou-se uma revisão narrativa da literatura sobre próteses obturas palatinas utilizando as palavras-chave: maxillary birth bony defects; maxillary acquired bony defects; obturator prosthesis; prosthetic rehabilitation in maxillary defects; inflatable hollow obturator; prosthodontic rehabilitation of maxillary defects. Os objectivos deste trabalho foi o de conhecer os diferentes tipos de próteses obturadoras palatinas utilizadas na reabilitação de pacientes com defeitos ósseos palatinos, bem como, as suas indicações, contra-indicações, os cuidados de utilização e o protocolo clínico e laboratorial de confecção. As próteses obturadoras palatinas são assim uma solução possível na reabilitação funcional de um número grande de pacientes com defeitos ósseos palatinos, no entanto, o seu sucesso está dependente do correcto planeamento e da execução clínica e laboratorial cuidadosa.

A importância da impressão funcional - técnica modelo modificado em prótese parcial removível de extremo livre

A Prótese Parcial Removível esquelética na reabilitação de pacientes edêntulos parciais tem sido uma opção acessível, rápida e viável de restabelecer a função estética e fonética dos dentes perdidos, porém a grande problemática em torno deste tipo de reabilitação está nos casos de extremos livres uni e bilaterais que dependem do rebordo residual para sustentação, devido à falta de pilar posterior que pode comprometer a retenção e principalmente a estabilidade da prótese que estará sujeita a deslocamentos constantes durante a dinâmica dos movimentos funcionais. Na literatura é relatado que todos os conhecimentos devem ser observados a quando da confecção deste tipo de prótese, as explicações e orientações como se comporta este tipo de prótese e os cuidados que o paciente tem que ter, e principalmente as condições biológicas dos tecidos de suporte são da responsabilidade do Médico Dentista o qual ao ter em conta e transmitir estes conhecimentos no momento do planeamento consegue assim minimizar os riscos de fracasso. A impressão funcional é de extrema importância para o sucesso da reabilitação com este tipo de prótese, mais especificamente a técnica do modelo modificado, que o objeto deste trabalho é realçar a sua utilização. Sendo de especial interesse para a Medicina Dentária pela necessidade e demanda do tratamento clínico, quanto para o ensino nas universidades. Dessa forma este trabalho visa mostrar a importância da impressão funcional na Prótese Parcial Removível esquelética de extremo livre, em especial o modelo modificado, pois ela visa obter melhor estabilidade, suporte e retenção para conseguir um melhor conforto para o paciente, mantendo a integridade do periodonto e dos dentes de apoio, obtendo assim um bom prognóstico e sucesso no procedimento realizado, como forma de fazer com que este procedimento responda tanto a expectativa do paciente como da equipe que a confecciona.

T-Bar clasp-retained removable partial denture as an alternative to implant-based prosthetic treatment

This article reports the case of a 55-year-old female patient who presented with unsatisfactory temporary crowns in the right mandibular premolars and molars, and a premolar-to-molar fixed partial denture in the left side. The clinical and radiographic examinations revealed a fracture of the left first premolar that was a retainer of the fixed partial denture and required extraction. Initially, the acrylic resin crowns were replaced by new ones, and a provisional RPD was made using acrylic resin and orthodontic wire clasps to resolve the problem arising from the loss of the fixed partial denture. Considering the patient's high esthetic demands, the treatment options for the definitive prosthetic treatment were discussed with her and rehabilitation with implant-supported dentures was proposed because the clinical conditions of the residual alveolar ridge were suitable for implant installation, and the patient's general health was excellent. However, the patient did not agree because she knew of a failed case of implant-retained denture in a diabetic individual and was concerned. The patient was fully informed that implant installation was the best indication for her case, but the arguments were not sufficient to change her decision. The treatment possibilities were presented and the patient opted for a clasp-retained removable partial denture (RPD) associated with the placement of crowns in the pillar teeth. The temporary RPD was replaced by the definitive RPD constructed subsequently. Although RPD was not the first choice, satisfactory esthetic and functional outcomes were achieved, overcaming the patient's expectations. This case report illustrates that the dentist must be prepared to deal with situations where, for reasons that cannot be managed, the patient does not accept the treatment considered as the most indicated for his/her case. Alternatives must be proposed and the functional and esthetic requirements must be fulfilled in the best possible manner.