Advances in Prosthodontics – New Findings & Best Practices for Cosmetic & Restorative Dentistry

Advances in Prosthodontics – New Findings & Best Practices for Cosmetic & Restorative Dentistry

Advances in Prosthodontics

New Findings & Best Practices for Cosmetic & Restorative Dentistry

Do You have a Patient With Periodontal Disease?

Here’s the story of a patient who was referred from another dental professional…

If you have a patient with several missing, broken or severely worn teeth – or periodontal disease – they may be a candidate for oral rehabilitation with the assistance of an advanced Prosthodontist.

Do you want another opinion on a complex case? Or to meet and share ideas?

There are many ways we can help each other by working together on complex cases and by sharing knowledge and experience.

With your reputation for quality dental care, and my experience with restorative treatments, we can work together on advanced cases and both benefit!

If you’d like to meet to discuss a treatment, or talk on the phone about how we can help each other, please call or email my office with specific days and times when you’re available to talk or meet.


CASE SUMMARY: Full Mouth Reconstruction

by Dr. Esam Abou Nahlah, DDS, MS, Board Certified Prosthodontist

Patient “Mike” was referred to me by another dental professional in the area because Mike’s needs were more complex than they wanted to manage. Mike had several missing teeth, supra-erupted teeth, failing dentition, and advanced periodontitis. He had lost mastication functionality, which led to GI problems. He was also extremely self-conscious about his smile and appearance. Consequently, he felt unable to socialize with friends and family and wanted to regain his confidence.

As a prosthodontist, I have experience with complex cases, and can plan multi-stage treatments that coordinate with a patient’s general dentist and other dental specialists. For Mike, the treatment sequence included the following:

  • Phase 1 (Prep): Initial records were taken to establish the incisal edge position, as well as to correct the vertical dimension of occlusion (VDO) and centric relation (CR). I also prepared provisional teeth for Mike before surgery.
  • Phase 2 (Surgery): Remaining teeth were extracted, and alveoplasty was performed in conjunction with leveling the bone. 6 dental implants were placed in the maxillary arch and 5 dental implants in the mandible arch. An immediate load provisional full arch fixed detachable prosthesis was placed on the implants in both arches.
  • Phase 3 (Healing): Mike was back to his normal routine immediately with a soft diet for the first 4 months post surgery to allow for osseointegration of the implants, and to prevent any micromovements which can interrupt the osseointegration process. He was seen for follow up appointments at 2 weeks, 6 weeks and 4 months. During follow up appointments, occlusion was checked and adjusted thoroughly in centric and eccentric movements to eliminiate any immature contacts or interference contacts that can affect the osseointegration process. Healing was checked in each visit, and oral hygiene instructions were reviewed.
  • Phase 4 (Final Prosthesis): At 4 months, his provisional prostheses were removed, osseointegration of implants were verified and final impressions of both maxillary and mandible arch were taken. I chose to use a Ceramometal prosthesis in the maxilla and acrylic with titanium milled bar in the mandible. Ceramometal prostheses have a higher durability, are easier to clean, and have a better esthetic needed in the maxilla. I chose an Acrylic prosthesis with a milled bar in mandibular arch because esthetics were not as much of a concern, and it prevents clicking noises that happen when using ceramic against ceramic in both arches. In addition, using a Hybrid (Acrylic teeth with titanium bar) in one arch serves as a “shock absorber” when a patient has parafunctional habits, to prevent future fracture of the implants in the long run.

Do you have a patient in Mike’s situation?
Or another complex case?

If you have a question about a case and want another opinion, give my office a call. Or, if there’s a case that you want to work together on, please fill out and send in the enclosed referral form.

My office and I will take great care of your patient and keep you informed. Dental professionals refer to me as The Complex Case Specialist because I perform complex cases every day.

The case was challenging because Mike did not have a stable centric relation (CR) or a proper vertical dimension of occlusion (VDO), and was also missing all posterior contacts. This treatment had to be managed carefully to establish CR in repetitive position as well as establish the correct VDO to satisfy both esthetics and function. Failing to have the correct CR and/or VDO can lead to complications that include developing temporomandibular disorders (TMD), poor ability of mastication, and biting of the cheeks and lips.

7 suggestions to keep in mind for any full mouth reconstructions:

  1. There is a different requirement of restorative space for a Hybrid and a ceramic prosthesis. The minimum restorative space measured from platform of the implant to the occlusal surface for Hybrid prosthesis is 16 mm. The minimum restorative space for ceramic prosthesis is 10 mm. Failing to have the minimum thickness of prosthesis can lead to breakage and prosthetic failure.
  2. More restorative space requires more bone removal.
  3. The junction between the natural gingivae and a prosthesis needs to be hidden higher than the smile line to avoid esthetic failure.
  4. The intaglio surface of a prosthesis needs to be convex (not concave) to keep it hygienic.
  5. Treatment planning and exploring the patient’s esthetic demands are the most important parts of the process for a full mouth reconstruction. Inability to achieve the esthetic goals of a patient is the most common failure, and often it can be from their expectations that were not carefully managed.
  6. Unbalance traumatic occlusion in immediate loading prosthesis can be the main reasons of failure of osseointegration of some or all of the implants.
  7. Establishing the correct VDO and CR is very important to avoid TMD and studying the patient’s envelope of function early in the process can help in avoiding serious problems and irreversible damage to the temporomandibular joint (TMJ).

I gave Mike my full warranty and sent him backt to the referring doctor’s office for long-term care. I give all referred patients a warranty and refer them back to the general dentist for regular hygiene, unless advised otherwise by the referring office, depending on the patient and treatment. If you have questions about my prosthetic protocols, please call my office, or email me directly at:

How can a Board Certified Prosthodontist assist you and your dental team?

I specialize in the treatment of complex cases, usually involving several procedures over months of care. The next time you see a challenging case, please feel free to call me and we can discuss treatment planning or I can help you with any part of the treatment. My goal is to be a resource for your office by helping manage difficult and time-consuming procedures, restoring the function and esthetics that the patient desires, then referring them back to your office for their ongoing care.


Dr. Esam Abu Nahlah

DDS, MS, Prosthodontist • The Complex Case Specialist&trade

About Dr. Nahlah’s specialization:

As a Prosthodontist, Dr. Nahlah specializes in fixed and removable prosthodontics, dental implants, and all phases of esthetic dentistry. Dr. Nahlah is Board Certified by the American Board of Prosthodontics, and his training along with private practice experience make treatments of complex cases more successful, including:

  • Patients with ill-fitting dentures, severely worn or damaged teeth can receive a single dental implant or a full arch of natural-looking teeth.
  • Patients who have suffered from traumatic injury, congenitally missing teeth, or a chronic condition can receive oral prostheses, which may be a combination of dental implants, crowns, bridges, or veneers.
  • Patients with severe neglect of their oral health can receive a full mouth rehabilitation to restore function & esthetics.

Dr. Esam Abou Nahlah works with other dental professionals around Fairfax County to restore the smiles and confidence of patients facing a difficult diagnosis.

Personal Message To Fellow Dental Practitioners:

“As the referring dentist, you know your patient’s mouth and have key insight into your patient’s needs. I want to work with you to provide your patients with the best possible treatment outcomes. I will treat your patient in a manner that will reflect well on you and strengthen your relationship with your patient. I am here to make you look good! When your patient’s care is completed, they are referred back to your office for their ongoing dental care. I am grateful for your colleagueship and trust with your patients!”

Prostho Pledge

When your patient is referred:

  • I will only treat what’s been referred.
  • I will send you updates.
  • I will be part of your team, not take over your patients.

Why other dental professionals work with a Board Certified Prosthodontist

Board Certified Prosthodontists are specialists in implants, esthetic, and reconstructive dentistry.

  1. You have a patient requiring treatment outside your typical scope of practice.. Examples include patients with vertical dimension discrepancies, severly resorbed ridges, inadequate interarch space, severe bruxism, traumatic tooth loss, or congenital abnormalities.
  2. You have a patient with complex needs that may drain your time. If your patient may require treatment from several specialists, Board Certified Prosthodontists can help because they are trained to appropriately stage and manage complex treatment plans.
  3. You have a demanding patient who wants perfect esthetics. Examples include patients with a high smile line or needing a single tooth replacement in the esthetic zone. Board Certified Prosthodontists are trained in selecting the best solutions for high-demand patients.
  4. You have a question and want to discuss a case with a colleague to ease your mind. Board Certified Prosthodontists can be an excellent resource for you to ask questions because they are trained in many types of complicated treatments. For example, you may want to consult a Board Certified Prosthodontist for complex implant-supported restorations. They can work with you or complete the treatment for you to achieve the best in both function and esthetics.

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