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Fully Digital Workflows for Fixed Implant Restorations

Home Topics Fully Digital Workflows for Fixed Implant Restorations

Case report of an immediate maxillary conversion Sarah Jockin, DDS

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. 

The highly predictable and accurate workflow demonstrated here avoided the use of any analog impression material. During the initial visit, an intraoral scan using the Primescan® (DentsplySirona) was obtained, including the entire hard palate. These full arch upper and lower impressions as well as a dual buccal bite were captured in about 3 minutes. [3a-c] The patient was instructed to stay on a liquid diet until surgery and dismissed with pre-op instructions. The file was then imported to a CBCT image (Orthophos SL, Sirona) using Galaxis software and measurements were taken for the final prosthetic design. [4] Implant position was determined via a reverse engineering process and a soft tissue guide was designed using InLab 18 software and milled. [5]

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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] 

Once all pickup cylinders were fixed to abutments, the clear duplicate guided the location of the access holes on the temporary. This was now predictably seated in the proper position using the hard palatal stop. Intraoral pickup was achieved using Voco QuickUp [11] upon which the temporary was removed from mouth for extra-oral flange reduction and finishing to a highly polished convex intaglio surface. After re-insertion, occlusion was verified, esthetics approved by the patient, an ice pack applied and post-operative instructions given. Patient took 1000 mg of Acetaminophen PO and continued his regimen of Amoxicillin and Diflunisal. He was dismissed in stable condition. [12a-b]

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Twenty-four hours post-op he presented with absence of pain and swelling. He had not taken any additional pain medications. Tension free primary closure and hemostasis were verified. The patient remarked at this visit how pleasant the complete absence of goopy impressions was, how smooth the procedure and the restoration felt and how glad he was that he didn’t have to wear conventional dentures while the implants healed. Despite the diet restrictions he experiences having “real teeth” that he can chew with.