Full Digital Rehabilitation of a Complex Partially Edentulous Patient via Toronto Prosthesis: A Case Report

Öz

This case report describes the oral rehabilitation of a complex partially edentulous patient with malpositioned teeth and implants using a full digital workflow and hybrid prosthesis design. A 55-year-old male patient presented with pain, oral hygiene, aesthetic, and functional complaints. Following extraction of teeth 26, 27, and 47, five endosseous dental implants were placed in regions 24, 26, 36, 46, and 47. Due to advanced hard and soft tissue loss and the patient's refusal of additional augmentation, implants in the 24–27 region were placed in a buccal-apical malposition despite guided tissue regeneration. After osseointegration, full-arch fixed partial dentures (FPDs) were planned for both jaws. Intraoral scanning, CBCT data, and pre/postoperative photographic records were integrated into the digital design workflow. Tooth-supported FPDs were designed as monolithic restorations; mandibular implant-supported FPDs (ISFPDs) as screw-retained monolithic; and maxillary ISFPDs as a hybrid Toronto Bridge design comprising a screw-retained zirconia substructure with a cement-retained monolithic superstructure. All restorations were fabricated from hybrid-composition multilayer monolithic zirconia blocks (3–5Y-PSZ) via CAD/CAM subtractive manufacturing. Try-in temporary restorations were evaluated for marginal fit, occlusion, and esthetics prior to final delivery. Digital workflow applications integrating intraoral scanning and photographic guidance are effective for achieving predictable aesthetic and functional outcomes in complex rehabilitations with malpositioned implants. The Toronto Bridge hybrid design successfully compensates for implant malposition, and hybrid-composition multilayer monolithic zirconia provides clinically reliable esthetic and mechanical results.

Anahtar Kelimeler

• Digital workflow
• Hybrid retained restoration
• Partial edentulism
• Toronto bridge.

Malpoze Dişler ve İmplantlar İçeren Kompleks Parsiyel Dişsiz Bir Vakanın Toronto Tasarımlı Protez ve Tam Dijital İş Akışı ile Oral Rehabilitasyonu: Bir Vaka Sunumu

Öz

Bu vaka sunumu, malpoze dişlere ve implantlara sahip kompleks parsiyel dişsiz bir hastanın tam dijital iş akışı ve hibrit protez tasarımı kullanılarak oral rehabilitasyonunu tanımlamaktadır. Elli beş yaşında erkek hasta ağrı, ağız hijyeni, estetik ve fonksiyonel şikayetlerle kliniğimize başvurdu. 26, 27 ve 47 numaralı dişlerin çekiminin ardından 24, 27, 36, 46 ve 47 numaralı bölgelere dört adet endoosseöz dental implant yerleştirildi. İleri düzey sert ve yumuşak doku kaybı ile hastanın ek ogmentasyon prosedürlerini reddetmesi nedeniyle, ileri cerrahi rejenaratif cerrahi uygulamalarına karşın 24–27 bölgesindeki implantlar bukkal-apikal yönde malpoze olarak yerleştirildi. Osseointegrasyon sonrasında her iki çene için tam ark sabit parsiyel protez (SPP) planlandı. Ağız içi tarama, KIBT verileri ile ameliyat öncesi ve sonrası fotoğrafik kayıtlar dijital tasarım iş akışına entegre edildi. Diş destekli SPP'ler monolitik restorasyon olarak; alt çene implant destekli sabit parsiyel protezler (İDSPP) vida tutuculu monolitik olarak; üst çene İDSPP'ler ise vida tutuculu zirkonya altyapı ile siman tutuculu monolitik üst yapıdan oluşan hibrit Toronto Köprü tasarımı olarak planlandı. Tüm restorasyonlar, CAD/CAM eksiltmeli üretim yöntemiyle hibrit kompozisyonlu çok katmanlı monolitik zirkonya bloklardan (3–5Y-PSZ) üretildi. Geçici try-in restorasyonlar, nihai teslimat öncesinde marjinal uyum, oklüzyon ve estetik açısından değerlendirildi. Ağız içi tarama ve fotoğrafik rehberliği entegre eden dijital iş akışı uygulamaları, malpoze implantlar içeren kompleks rehabilitasyonlarda öngörülebilir estetik ve fonksiyonel sonuçların elde edilmesinde etkilidir. Toronto Köprü hibrit tasarımı implant malpoze durumunu başarıyla telafi etmekte; hibrit kompozisyonlu çok katmanlı monolitik zirkonya ise klinik açıdan güvenilir estetik ve mekanik sonuçlar sunmaktadır.

Anahtar Kelimeler

• Dijital iş akışı
• Hibrit destekli restorasyon
• Parsiyel dişsizlik
• Toronto köprü.

Kaynakça

1. Al-Thobity, A. M. (2022). Titanium base abutments in implant prosthodontics: A literature review. European Journal of Dentistry, 16(1), 49–55.
2. Alghamdi, A., Al-motari, K., Sundar, C., & Jansen, J. A. (2020). Dental implants treatment: Clinical indications. In H. Alghamdi & J. Jansen (Eds.), Dental implants and bone grafts (1st ed., pp. 23–42). Elsevier Ltd.
3. Carpentieri, J., Greenstein, G., & Cavallaro, J. (2019). Hierarchy of restorative space required for different types of dental implant prostheses. Journal of the American Dental Association, 150, 695–706.
4. Deniz, D., & Aktaş, G. (2023). Zirkonya güncel jenerasyonları: Klinik ipuçları. Acta Odontologica Turcica, 40(3), 95–102.
5. Egilmez, F., Ergun, G., Cekic-Nagas, I., & Bozkaya, S. (2015). Implant-supported hybrid prosthesis: Conventional treatment method for borderline cases. European Journal of Dentistry, 9, 442–448.
6. Gönder, A., Polat, S., Demirdağ, E. D., & Babayev, N. (2021). Clinical applications used for detecting residual cement in implant-supported restorations. ADO Clinical Sciences Journal, 3, 222–228.
7. Gönüldaş, F., & Yılık, B. (2021). Hybrid prostheses in complete edentulism. In D. D. Öztaş (Ed.), Implant supported prosthesis fabrication techniques (1st ed., pp. 34–42). Türkiye Klinikleri.
8. Görgülü, G. M., & Egilmez, F. (2024). Optical and mechanical properties of highly translucent monolithic zirconia materials. Selcuk Dental Journal, 11(1), 96–102.

9. Javaid, A., Ritu, M., Manjit, B., Ajay, K., & Himani, B. (2019). Prosthodontic rehabilitation of edentulous patient with implant supported hybrid prosthesis: A case report. Dental Journal of Advanced Studies, 122–125.
10. Joda, T., & Brägger, U. (2015). Complete-arch restoration with implant-supported monolithic zirconia fixed dental prostheses: A fully digital workflow. The Journal of Prosthetic Dentistry, 114(1), 1–8.
11. Kaur, H., Bhatia, V., & Singh, M. B. A. (2020). Full-mouth rehabilitation of screw-retained maxillary and mandibular hybrid denture. National Journal of Maxillofacial Surgery, 11, 146–149.
12. Misch, C. E. (2008). Contemporary implant dentistry (3rd ed.). Mosby Elsevier.
13. Misch, C. E., & Resnik, R. R. (2021). Rationale for dental implants. In R. R. Resnik (Ed.), Misch's contemporary implant dentistry (4th ed., pp. 2–17). Elsevier Inc.
14. Misch, C. E., & Resnik, R. R. (2020). Available bone and dental implant treatment plans. In Misch's contemporary implant dentistry (4th ed., pp. 415–434). Elsevier.
15. Mohamed, S., & Emarah, A. (2020). Three-dimensional marginal bone loss around implants supporting metal ceramic and metal acrylic screw retained hybrid prosthesis for rehabilitation of atrophied mandible: A cone beam radiographic study. Egyptian Dental Journal, 66, 1687–1697.
16. Montero, J., de Paula, C. M., & Albaladejo, A. (2012). The "Toronto prosthesis", an appealing method for restoring patients candidates for hybrid overdentures: A case report. Journal of Clinical and Experimental Dentistry, 4, e309–312.
17. Nematollahi, F., Alikhasi, M., & Beyabanaki, E. (2018). Restoring a post-traumatic partial edentulous mandible with the Toronto prosthesis: A clinical report. Journal of Dental Research, Dental Clinics, Dental Prospects, 12, 135–139.
18. Patil, V. V., ve diğerleri. (2024). Evaluating the impact of prosthetic material choices on the clinical outcomes of implant-supported restorations. Journal of Pharmacy and Bioallied Sciences, 16(Suppl 2), S1624–S1627.
19. Qamheya, A. H., Yeniyol, S., & Arısan, V. (2015). Full mouth oral rehabilitation by maxillary implant-supported hybrid denture employing a fiber reinforced material instead of conventional PMMA. Case Reports in Dentistry, 2015, 841745.
20. Stawarczyk, B., Keul, C., Eichberger, M., Figener, D., Edelhoff, D., & Lümkemann, N. (2017). Zirconia as a dental implant abutment material: A systematic review. Biomedical Engineering Online, 16(1), Article 32.
21. Sulaiman, T. A. (2020). Materials in digital dentistry: A review. Journal of Esthetic and Restorative Dentistry, 32(2), 171–181.
22. Şakar, O. (2024). The effects of partial edentulism on the stomatognathic system and general health. In O. Şakar (Ed.), Removable partial dentures (pp. 9–17). Springer.
23. Vazouras, K., ve diğerleri. (2021). Digital workflow for complete-arch implant rehabilitation with a combined tooth-and-implant-supported monolithic zirconia prosthesis. The Journal of Prosthetic Dentistry, 126(1), 10–15.
24. Wittneben, J. G., Joda, T., Weber, H. P., & Brägger, U. (2017). Screw retained vs. cement retained implant-supported fixed dental prosthesis. Periodontology 2000, 73(1), 141–151.
25. Yıldırım, Z. S., Bakır, E. P., & Bakır, Ş. (2019). Aesthetic adjustments on maxillary anterior teeth with shape and positional abnormalities using direct composite resin: Four case reports. Selcuk Dental Journal, 6, 182–189.