PMC10258398_01
Clinical findings of the Papillon-Lefevre patient. a) pre-operative frontal extra-oral view, b) pre-operative extra-oral view of the profile, c) hyperkeratosis of the palms, d) hyperkeratosis of the feet, e) pre-operative intra-oral view of the maxilla, f) pre-operative intra-oral view of the mandible
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F1
III jaw relationship, and hyperkeratosis of the palms and feet. Intraoral findings consisted of a completely edentulous maxilla and partially edentulous mandibular arch with all teeth missing except #17 and #32 (Fig 1).
Pre-operative orthopantomogram showing maxillary augmentation with graft stabilizing pins and right and left mandibular third molars in an atrophic arch
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F2
The maxillary arch had sufficient width after the augmentation procedure while the mandibular arch was atrophic with insufficient bone height in the posterior mandible (Fig 2).
Surgical procedure and implant placement. a) maxillary implants connected to healing abutments, b) primary closure with sutures in the maxilla, c) thin alveolar crest in the mandibular anterior region, d) implants placed in mandibular anterior region after crestal osteotomy
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F3
After implant placement, healing abutments were connected and sutured (Fig 3a, b). A full-thickness flap was elevated in the mandibular anterior region (Fig 3c) and crestal osteotomy of 3-4 mm was performed to attain sufficient width (Fig 3d). ADIN Dental implant system Ltd, Israel) were placed between the two mental foramina regions (Fig 3d). All implants were placed axially (non-tilted) and no surgical guides were used.
Follow-up orthopantomograms taken six months after implant placement
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F4
OPG taken during the review showed a radiolucency around the apex of the implant in tooth #10 region (Fig 4) suggesting implant failure.
Laboratory procedures for prosthetic rehabilitation. a) temporary denture base with occlusal rims attached, b) casts mounted on semi-adjustable articulator with trial dentures, c) try-in of dentures in the patient, d) evaluation of space for the bar using trial dentures, e) maxillary and mandibular Co-Cr frameworks, f) framework trial, g) occlusal view of the prosthesis, h) tissue surfaces of the prosthesis
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F5
Briefly, light cure denture bases were fabricated on the casts and occlusal rims were attached to the denture bases (Fig 5a). A tentative jaw relation record was obtained and the casts were mounted on a semi-adjustable articulator (Fig 5b). Trial dentures were fabricated and tried in the patient (Fig 5c). The space and position of the bar was evaluated using these trial dentures (Fig 5d).  Bego, Germany) were then fabricated and tried in the patient (Fig 5 e, f). Bite rims were attached to the frameworks and the optimal vertical dimension was re-established. Ltd., New Delhi, India) were arranged and extended only till the first molar region in both maxilla and mandible to limit the cantilever length (Fig 5 c, d).
Post-operative intra-oral view of the hybrid prosthesis a) frontal view, b) right lateral view, c) left lateral view
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F6
After acrylization, finishing and polishing, the final prosthesis was inserted with a tightening torque of 15Ncm using a torque wrench (Fig 6 a- c).
Follow-up orthopantomograms taken four years after prosthetic rehabilitation
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F7
No implants were mobile or lost and the follow-up OPG also showed only minimal bone loss around the implants (Fig 7).