A 62-year-old male patient with a bilateral removable partial denture in the jaw supported by the lower canines presented with a wound in the right mandibular mucosa.
The patient reported having undergone surgery to remove a tooth in this region four months ago.
The operated region did not have good healing and this condition prevented the use of removable prosthesis.
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During the clinical examination, the presence of a wound in the alveolar mucosa of the right mandibular side is observed.
Panoramic radiography shows a well-defined radiopaque area associated with a remaining tooth root in the 46 region and a well-defined periapical area of the left lower canine.
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Treatment plan and implant installation
Depending on the conditions presented by the patient, extraction of the remaining tooth and resection of tumors, installation and implants and immediate loading prosthetic rehabilitation were proposed.
Although the reason for consultation of the patient was the presence of a wound in the mandibular mucosa that prevented its masticatory function with the removable prosthesis.
The proposed treatment to be rehabilitated with a fixed prosthesis over implants installed at 48 hours was accepted by the patient.
Surgery consisted of a supracrestal incision in the anterior region of the jaw with buccal and lingual flap.
Then teeth were identified and rotated osteotomy was performed to perform a bone flattening of the alveolar crest and achieve a plateau.
In relation to the conditions presented by the patient, it was planned the extraction of the remaining tooth and the resection of the tumors along with the implant installation and a prosthetic rehabilitation of immediate load.
Although the reason for consultation of the patient was the presence of a wound in the mandibular mucosa, which prevented its masticatory function with removable prosthesis, the patient accepted the proposed treatment with fixed prostheses installed 48 hours after implant placement or rehabilitation.
Surgery consisted of a supracrestal incision in the anterior region of the mandible vestibular and lingual detachment.
Then, teeth were extracted and an osteotomy with fissures cavity HA 701 and 702 was performed to remove a bone block along with cementoma, after filling the bovine bone with biomaterial.
In the implant installation area with the Speedy Master system, an osteotomy was performed for flattening the alveolar crest and forming a plateau.
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One hour before surgery, 2 g amoxicillin and 4 mg betamethasone were administered to the patient.
In the postoperative period the patient took amoxicillin 500 mg 4 times a day for seven days and tenoxicam 20 mg once a day for three days and for plaque control if indicated eyedrops with chlorhexidine solution 0.12%.
Histological examination revealed a well-circumscribed tumour showing a mosaic pattern, with irregular pigment epithelium and a cement-like tissue without interstitial tissue.
Presence of cementoid tissue with cementoblasts hyperchromia.
As the proposed treatment consisted of installing implants subjected to immediate loading, the Speedy Master system (Conexao Sistema de Protesis - São Paulo - Brazil) was used.
This system is composed of a prefabricated metallic template that should be fixed with a proposed micro-torn titanium mesh.20 In order to pierce the immediate implant placement protocols in the pre-established areas, Vasconcellos et al.
After instrumentation, four implants 3.75 mm in diameter and 13 mm in length were installed with a screw-type design, surface treated with acid and internal hexagon region torque 45 cm.
The conical abutments were connected to the implants with a torque of Ncm. The impression pillars were installed and the blandos tissues were sutured with monony 5-0.
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Post-operative registry and proband protocol
After suturing, the abutments were ferulized with acrylic resin (Pattern Resin, GCAmerica, Alsip, IL) and then these were joined to the multifunctional guide as auxiliary position (E).
Speedex condensation silicone (Vigodent, Rio de Janeiro, Brazil) was injected underneath the guide wire to establish a reference level of bl tissues.
Once the multifunctional guide was removed, the titanium components were installed on the pillars, under absolute isolation with dique gum, metallic, titanium Covia superstructure components were cemented under Panuraray Japanuraed (K suprastructure).
The metal structure with the united components was removed and sent to the laboratory for the manufacture of the final prosthesis.
Then the protective caps of the columns were installed.
Based on the records established by the multifunctional acrylic guide, a master cast model was made in type IV Velmix plaster (Kerr, Orange, CA).
The master model was mounted in a semi-adjustable articulator (Whip-Mix) to make the prosthesis.
A hybrid prosthesis was made with acrylic teeth pressed on the prefaced metallic suprastructure.
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A mandibular prosthesis fixed to the pillars was installed 48 hours after surgery.
During the first 6 months the prosthesis was not removed, controlling patients with clinical examinations monthly until completing 1 year.
When removing the prosthesis, the implants showed no signs of mobility or inflammation.
For the revision of each implant we used the criteria proposed by Albrektsson and Zarb1 in relation to bleeding index, radiographic control and counter-torque test (10 Ncm).
