Initial situation

This female patient has presented to the clinic with an upper denture (Fig. 1), presenting low stability and poor masticatory function. The esthetics was also a complaining, but the functional aspect was more crucial for her. After the clinical examination (Fig. 2-3) and CBCT analysis we planned six implants, all straight, in order to support a fixed full-arch bridge (Fig 4). The provisional bridge was produced prior to the implant placement. The surgical guide was printed to perform a static guided surgery.

Procedure

Treatment planning

Through Codiagnostix and we could see there was enough bone to place the implants (Fig. 5), apart off two regions that would need bone graft (Fig. 6). Six straight positioned implants were planned with an adequate cross-arch distribution to support the masticatory forces and avoid cantilevers (Fig. 7). The Straumann® BLX implants would be placed using a surgical guide (Fig. 8) and the provisional prosthesis would be screwed onto the implants just after the surgery, for an immediate loading protocol.

Surgical procedure

The surgical procedure was planned flapless for the implant placement and afterwards a small flap was performed just in the regions where we expected implant exposure. The surgical guide fitted perfectly to the mucosa (Fig. 9), that was scanned with a lab’s scan and it was fixed with fixation’s pins. The site preparation with the Velo Drill ran smoothly and the sites were under prepared in order to achieve an appropriate primary stability in soft bone conditions. (Fig 10-13). The six implants were placed with the rachet and the Straumann Surgical torque control® which primary stability could be measured above 35Ncm allowing the implants to be loaded immediately (Fig 14-17). After the implant placement, a small flap was elevated in the regions with pre planned implant exposure. The Screw-retained Abutments were screwed onto the implants (Fig 18). Over the exposed implant surface (Fig 19), we performed a Guided Bone Regeneration utilizing the Professor Buser concept with the first layer in contact with the implant to be with  autogenous bone chips (Fig 20). Over the autogenous bone we augmented the volume with a layer of biomaterial (cerabone®) and covered with a collagen membrane (Jason®) (Fig 21-24).  The provisional copings were screwed on the top of theabutments and after the suture we started to capture the provisional copings into the prosthesis.

Prosthetic procedure

The provisional prosthesis was produced prior to the surgery, based on the wax up (Fig 25-28) and implant planning made on the Codiagnostix. Six small holes were created in the printed models, based on the surgical guide (Fig 29-31) . Following the same orientation, six holes were opened in the provisional prosthesis (Fig 32-34). After the suture, we inserted the prosthesis in the patient’s mouth and over the implants to capture the final implant positions. With flowable composite, we connected the provisional prosthesis with the provisional titanium copings (Fig 35-36). The final adaptation was performed chairside and after some minutes the restoration was screwed onto the Screw-retained Abutments. After 3 months the temporary restoration was replaced by the final restoration. (Fig 37-44).

Treatment Outcome

The immediate loading in edentulous patients is a well-documented procedure with similar implant and restoration survival rates to conventional loading. The possibility to perform small adaptations in the provisional restoration that was produced before the surgery is a very good alternative in order to compensate small deviations that can occur following the guided surgery.