This healthy 62 yo male patient presented for urgent care with complaints of a loose maxillary bridge that produces pain on mastication.[1] Oral cancer screening and head & neck examination resulted in no significant findings. Intraoral exam revealed few remaining maxillary teeth supporting a fixed PFM restoration with extensive decay on most distal abutment tooth #11, causing complete lack of support on left side and resulting in a large cantilever on abutment tooth #6. Note the slanted occlusal plane and anterior open bite due to malpositioned manidbular teeth. [2] Patient desires to treat upper arch first and really wants to avoid palatal coverage. After treatment options were discussed, he selected a screw-retained fixed prosthesis. He desired no changes in tooth position on upper but was open to correction of occlusal plane. 

Simultaneously, the provisional restoration was prepared using the same software. After digital removal of teeth, the case was mounted on virtual articulator. [6] The vertical dimension of occlusion and midline position were left unchanged while the slant of the occlusal plane and midline were corrected. [7] Note that the extensions of the temporary extend onto the hard palate for stability and easy post-operative conversion. The file was milled in a clear material for surgical and prosthetic guidance and in multilayer shade A1 PMMA material for temporization (Harvest Dental). [8a-b] Gingival contouring and coloring was achieved with pink composite addition (Gradia, GC) and finished with optiglaze coating. 

Surgery was executed 3 days later. The patient was premedicated with Amoxicillin 875 mg BID and Diflunisal 500 mg BID starting the previous morning. A chlorhexidine rinse was administered for 1 minute and aseptic surgical protocols were followed. After anesthesia was administered (7 ml of 2% Articaine 10^-5 epi via bilateral MSA, ASA, greater palatine and incisive blocks), teeth were removed in atraumatic fashion and sockets debrided before access was established via a mid-crestal incision with bilateral oblique releases. The ridge was levelled using the clear duplicate temporary as a guide to ensure adequate prosthetic space. [9a-b] Two Astra EV Straight and two Astra EV Profile implants were placed and multiunit abutments were seated assisted by the clear temporary. [10a-c]