Successful immediate implant placement associated with immediate loading remains one of the biggest clinical challenges. In addition to the placement of multiple implants into sockets, an immediate screw-retained provisional restoration is critical for an optimal aesthetic outcome. When using a conventional approach, the procedures require surgeon experience and ability to optimize the position of the implants in relation to an analogue designed outcome. Fortunately, nowadays digital workflows can be implemented in our practice and with this, our treatments could be considerably shortened and be more predictable. In the following case report, a digital workflow allowed us to have an efficient and predictable treatment protocol for the immediate implant placement and the prosthetic restoration design, including the individual emergence profiles prior to the surgery. This also led to an excellent patient experience and satisfaction. The goal of this clinical report is therefore, to introduce the Smile in a Box (Straumann, Basel, Switzerland) concept by using the latest technological improvements in prosthetic and surgical planning software and seamlessly integrating the dental technician into the development of the digital treatment planning and new prosthetics options.

Initial situation

Description of the patient:

A 65-year-old female patient, non-smoker, with a good general health condition; presented in the clinic with missing teeth, mobile teeth, unesthetic smile, traumatized occlusion and gum inflammation. The anterior zone showed different levels of recession, crowding, bone resorption and deep periodontal pockets; periodontal disease was prevalent throughout. (Fig. 01)

Treatment planning

Following the clinical and radiographic assessments as well as a CT examination, the patient was presented with her diagnostic parameters which indicated a failing dentition in both jaws. The patient was keen on a Fp1/Fp2 design to avoid any pink in her restorations.

After a number of visits to understand expectations, it was decided that an approach which involved a definitive outcome was desired.

The treatment option consisted of extractions of all the remining teeth of maxilla and mandible, restoration of the full arches with the Smile in a Box Pro Arch concept. The starting point was to carry out a digital wax up utilizing smile design and facial aesthetics (Fig. 02). This consisted in the placement of eleven Straumann® BLX implants immediately after extractions with a fully digitalized approach, using guided surgery. Preoperative prosthetic screw retained restorations were in function and aesthetic right after surgery with a planned final restoration placed after healing

The treatment was to be carried out over 2 visits, and then planned healing for 6 months. Note: the current Covid19 situation forced us to delay the final treatment for a further 6 months.

Surgical procedure

The STL file was taken to record the patient’s current oral situation and DSD file, the future prosthetic design was created with a dedicated lab software. (Fig. 3). The three-dimensional radiographic DICOM data and the prosthetic design project STL file were matched in coDiagnostiX™ (Fig. 4, 5, 6). The pin fixation guide, bone reduction guide, surgical guide and bite registration guide was designed with coDiagnostiX™ and produced using three-dimensional printing technology. (Fig. 7, 8, 9)

Prosthetic procedure

Loading protocol (time), description of workflow (e.g. chairside, conventional), impression taking, prosthesis and abutment type, occlusion, materials used, follow-up.

Prosthetic design planning

To design the prosthetic digitally firstly we selected the screw retained abutment (SRA) angle and gingival height. The digital planning using coDiagnostiX (Version 9.14) allowed the dental technician to identify all the necessary parameters related to implant position. Emergence profiles were set-up, and a CAD/CAM temporary restoration was designed and milled (PMMA-based restoration material) This restoration was finessed by composite addition. (Fig. 10, 11)

Guided surgery

On the day of surgery, we prepared the surgical protocol provided by the implant planning software, which guided us on the drilling sequence and the use of the appropriate instruments for the implant bed preparation. After the fixation pins were fully engaged, the teeth were atraumatically extracted at mandible and maxilla (Fig. 12, 13) and a controlled alveolectomy (Fig. 14) conducted, using a bone reduction guide. The lower arch had six straight implants (Straumann® BLX SLActiveRoxolid®) placed (Fig. 15), All implants were stabilized with a torque of 50-60 N/cm and the straight 1.5mm height SRAs were placed on top.

The restoration guide was fixed with pins and we checked the temporary CAD/CAM bridge, which was designed before surgery and finally, protective caps were placed on the SRAs followed by bone grafting in the extraction sockets and sutured. (Fig. 16, 17)

Impression taking for final upper Zirconia bridge and lower hybrid bridge.

Due to covid circumstances patient was not able to visit the clinic periodically and delayed finals for 1 year.

For the impressions, we used open tray impression copings and together with the bite registration were transferred to the lab. Fit check jigs, screw retained try ins were required to confirm passivity and tooth position. (Fig. 18, 19, 20)

Lab procedures for Anthogyr Simeda® Zirconia bridge and hybrid bridge titanium

After creating the master cast, we were able to scan and design the upper Zirconia prosthesis. The design of the Zirconia frame was done by obtaining the information form the bite registration, the image of the temporary prosthetic design and the mock copied by DSD with temporary PMMA bridge; at this moment we could apply a few modifications to the zirconia frame. The design of the zirconia bridge (Fig. 21) was sent to the milling unit and produced on a full contour zirconia disc (Fig. 22). The zirconia frame uses an innovative new direct to abutment solution, meaning no titanium interface (Ti Base) unit is needed coping as an interface to be screwed on SRA abutment. In addition, it’s also possible to apply Angulated Access solution on the zirconia frame, still without intermediate Ti-base (Fig. 23).

The lower arch had a very similar process but instead of zirconia, a titanium framework with composite was utilized (Fig. 24, 25). The manufacturing of this framework can be conducted either fully by milled technology or a by a new combination of additive and milling technology (Simeda Additive, Anthogyr, Sallanches, France). Using the additive solution for the preparation allows for the ideal supports without the limitations of using several milling bur diameters and “approximating” the materials shapes at their interface by generally oversizing the milled metal to reach the perfect fit at the end of the process.. Therefore, Angulated Access correction was applied in the framework. All channels have axis corrections to optimise aesthetic and function as we can see on the CAD design. (Fig. 26, 27)

Fit stage

Patient returned to the clinic, the fixed PMMA temporary bridge was removed (Fig. 28), and the final zirconia bridge and final hybrid bridge (Fig. 29). were placed allowing a passive fit on the abutments, with an initial hand tightening of each SRA screw up to 5 N.cm. After the seating was checked, the bridge was screwed in at a torque of 15 N.cm. Occlusion was checked, and contacts were inspected. Screw holes were sealed with PTFE and a composite filling material. A panoramic X-ray was recorded, and SRA screw positions were evaluated to confirm the perfect bridge fit. Oral hygiene and diet instructions were given to the patient, and a one-week follow-up appointment was scheduled. (Fig. 30, 31, 32)

Treatment outcomes

Immediate implant placement associated with immediate loading is a predictable protocol. The digital tooth extraction, digital smile design was integrated with the production of a screw-retained CAD/CAM provisional restoration. Utilizing Smile in a Box procedure, the entire treatment workflow was done fully digitally. Only a single surgical step for each jaw was required to provide an entire individualized prosthetic rehabilitation.