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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5199_Библиотеки_им_академика_М_И_Перельмана.pdf
6. 31 C as e 31
Fig. 6.264 The intraoral renderings
219
Fig. 6.265 Digital design of integrated bracket
Fig. 6.266 STL data export
after bracket design
shape major connector is used to cover the
extension range of the base in advance.
After the design of human teeth and brackets,
the design of articial gingiva was carried out.
According to the shape of adjacent teeth, the
natural cervical line, gingival papilla, and root
protrusion are formed. Combine the STL data of
the bracket, articial teeth, and gingiva to obtain
the designed data (Fig.6.266).
(ii) Machining of integrated support
Use the CAD/CAM cutting machine to cut
the PEEK disk, remove the support rod, and polish and nish the production of the integrated
bracket (Fig. 6.267). The weight of maxillary
stent is 8.2g, while that of mandibular stent is
only 6.9g.
3. After restoration
Trying in of the denture shows that the stent is suit-
able, occluded well, and has good retention. The facial
view shows part of the clasp entering the esthetic area
(Fig. 6.268), but the patient indicates acceptance. The
patient feels that the quality of the stent is very light, the
self-report has no metal odor, and the comfort is better
than the traditional metal removable partial denture. The
patient was satised with the nal results.
220
Fig. 6.267 Bracket
fabrication completion
Fig. 6.268 Repair effect
6 Case Analysis ofEsthetic Clasp
6.32 Case 32
1. Before restoration
A 58-year-old woman with severe dentition defection
(Fig.6.269), whose oral opening was limited to approximately 40mm (width) and 25mm (height) as the result of
scleroderma. Oral examination showed a severely
absorbed alveolar bone with 16, 17, 25–27, and 36–46
teeth missing. Mobility of 11, 12, 21, and 25 was degree
III; mobility of 13–15 and 22–24 was degree
I.Nonrestorable teeth (11, 12, 21, 25) were extracted.
2. RPD analysis design and manufacturing
Record the maxillary and mandibular dentition size
from CBCT data for tray design.
Import digital les of another patient’s casts with similar dentition scale. Adjust models to the same size of target dentition, and remove tooth dental crowns to simulate
patient’s dentition defect. Design and separate trays into
two or three parts and 3D print them (Figs. 6.270 and
6.271). Insert CAD/CAM custom sectional trays into
patient’s mouth, and take each impression. Pour dental
stone to make casts and then scan them after setting.
Align sectional models to form nal maxillary and mandibular models (Fig.6.272).
Embrasure clasps were planned bilaterally of the maxillary dentition (in 14–15 and 23–24 spaces) to further disperse occlusal forces to the abutment teeth. Also, the
combined clasps can act as a periodontal splint to stabilize
6.32 Case 32
Fig. 6.269 Pretreatment
condition. (a) Facial frontal
view. (b) Oral condition. (c)
Oral ssure evaluation
221
222
6 Case Analysis ofEsthetic Clasp
Fig. 6.270 Design process of
custom trays. (a) Dentition
size simulation. (b) Dentition
defect simulation. (c) Models
relief. (d) Custom trays
design
a
b
c
d
6.32 Case 32
223
Fig. 6.271 CAD/CAM
custom sectional trays. (a)
Maxillary custom sectional
trays. (b) Mandibular custom
sectional trays. (c) 3D-printed
maxillary custom sectional
trays. (d) 3D-printed
mandibular custom sectional
trays
a
b
c
3D-printed maxillary custom sectional trays
d
224
6 Case Analysis ofEsthetic Clasp
a
c
b
Fig. 6.272 Alignment of models. (a) Alignment of maxillary models.
(b) Final maxillary model. (c) Alignment of mandibular models. (d)
Final mandibular model
d
Fig. 6.272 (continued)
the remaining teeth, which had been inuenced by severe
alveolar absorption. Since the RPD is in one piece and not
foldable, a shortened RPD design was adopted, which
referred to the restoration of dentition only to the rst
molars instead of the second molars. As for the mandibular RPD, ring clasps with mesial rests were placed bilaterally on the second molars to provide more retention and
stability. Due to the mesio-ligual inclination of the abutment teeth, the tips of clasps were placed at the lingual
undercut area, and the rests were placed at the mesiocclusion surfaces. The third molars were excluded from the
RPD design in order to reduce the RPD length (Fig.6.273).
6.32 Case 32
225
a
b
a
b
Fig. 6.273 Design of frameworks. (a) Design of maxillary framework.
(b) Design of mandibular framework
Fig. 6.274 Trying in of resin frameworks
The frameworks were 3D printed with Co-Cr alloy
and were tried intraorally (Fig.6.274); the maxillomandibular relationship in centric relation was recorded. The
articial teeth were arranged and were trimmed and polished (Fig.6.275).
c
Fig. 6.275 Fabrication of RPD. (a) Record occlusal relationship. (b)
Arrangement of maxillary dentition. (c) Arrangement of mandibular
dentition
3. After restoration
It’s the nal effect of patient with denture (Fig.6.276),
reporting satisfaction with the treatment results.
226
Fig. 6.276 Facial view with denture
6 Case Analysis ofEsthetic Clasp
6.33 Case 33
1. Before restoration
A 7-year-old kid diagnosed with ectodermal dysplasia
(EDA) was referred for restoration treatment (Fig.6.277).
EDA is a group of complex diseases with more than
200 different pathological damages, predominantly affecting the developmental defects of ectodermal tissues like
the sweat glands, hair, nail, teeth, and nervous system. Its
oral representation can be congenital missing tooth, tooth
dysplasia, and conical tooth, which affect severely the
chewing, pronunciation, and appearance of patients and
will harm the physical and mental health of the patients.
Fig. 6.277 Pretreatment
condition. (a) Facial frontal
view. (b) Oral condition.
(c) CBCT
a
b
c
6.33 Case 33
227
The patient’s oral cavity was characterized by congenital missing teeth, and the patient is too young with active
skeletal development to be repaired with implant denture.
Early complete denture not only can restore the shape of
teeth to reconstruct occlusion and the function of chewing
and pronunciation but also can accelerate the development of jaw and temporomandibular joint, which can prevent malocclusion, improve patient’s facial contour,
establish good relations between the face and the skeleton, promote his physical and mental health, and raise the
life quality.
2. Treatment plan
Considering the particularity of the patient, we made a
sequential treatment plan for him:
(a) Stage I: Removable denture restoration immediately.
Make the nal impression with a two-step impres-
sion; after that, make the complete denture on the
nal model (Fig.6.278). The treatment of the patient
will be throughout the whole life cycle, so we record
the change of the jaw position and jaw digitally, as
the approach to evaluate the repair effects and the
basis of the following repair at return visit.
Due to the considerable aging changes of hard and
soft tissues and anatomic structure of young edentulous patients’ oral system and the appearance of denture is basically a constant except occlusal surface
abrasion, we specially design a custom gothic arch
positioning plate with coordinate system and scale on
the denture (Fig.6.279), which can be used to determine the change of jaw position at return visit and
also can establish an intraoral coordinate system to
record the change of the jaw in different development
stages throughout the whole life. The following is the
approach we used:
Fig. 6.278 Trying on
Fig. 6.279 Maxillary and
mandibular custom gothic
arch positioning plate. (a)
Design data. (b) Print
a
b
228
6 Case Analysis ofEsthetic Clasp
After the rst treatment, we made four blocking
points on the maxillary positioning plate (Fig.6.280)
and then made CBCT images with the plate seated on
the complete denture to obtain the relative position
relationship between the jaw and positioning plate
(Fig.6.281). Next, we placed the maxillary guide on
the maxillary denture and mandibular guide with
tracing screw product on the mandibular ridges.
Relining with bite silicone rubber is necessary if the
tissue surface of the denture or the mandibular guide
was not t with alveolar ridge. Until the maxillary
and mandibular guides were seated stably, we can
describe the horizontal jaw position curve on the
maxillary guide; due to that, there were no articial
teeth. After adjusting the height of tracing screw, we
asked the patient to bite at CR position and do
protrusive and lateral movements and recorded the
coordinates of the CR position (Fig.6.282).
Record the horizontal jaw position in the same
way every 3 months in the rst year (7–8 years old).
When the coordinate deviation between two visits is
large, complete denture should be fabricated again.
The data recorded is two-dimensional.
a
b
Fig. 6.280 Blocking points
Fig. 6.281 Relative position
relationship between the jaw
and the positioning plate
Fig. 6.282 Obtaining the relationship between horizontal jaw position. (a) Placed the custom gothic arch positioning plate. (b) The
recorded relationship between horizontal jaw position