Initial situation.

Identification of alveolar nerves, planning of 6 implants.

Placement of implant analogs on surgical template in order to create a master cast for the final restoration - note the 9 implants used here (3 reference implants included).

Frontal view of the definitive restoration.

0 Evaluation & Diagnosis
1 Treatment Planning
2 Progress & Completion

Patient cases:

Complete-arch treatments

(Mandible / Edentulous)

Fully edentulous mandible - a "different" treatment approach

Lead:

Lambert Stumpel

"Reference implants" have been used to treat this edentulous mandible in order to maintain the attached tissue. The aim was to re-position the old removable denture in its original position to be able to transfer it into a cement-retained provisional denture. This cement-retained provisional denture will be fixed onto CAD/CAM titanium abutments which have been fabricated prior to the surgery. 6 implants have been placed in the mandible, evenly distributed and loaded with a 6-unit bridge in the anterior zone and two 3-unit bridges in the posterior.

Evaluation & Diagnosis

Initial situation.

In a traditional approach this would have been the incision line to follow.

Treatment Planning

Evaluation of bone quantity in NobelClinician.

Prosthetically-driven planning of implant positions.

Identification of alveolar nerves, planning of 6 implants.

Creation of surgical template. For this treatment two guides have been ordered.

6 implants planned.

3 additional "reference implants".

Progress & Completion

The seating of the surgical guides is checked with thin PVS material.

Thin VPS layer indicating correctness of surgical index.

Placement of surgical template, check of seating with surgical index.

Reference implants, previously placed in order to maintain the attached tissue. Unmodified surgical guide was used.

Full flap, reflected away from surgical field.

Placement of modified surgical template, fixation with guided abutments on reference implants. Modification allows reflection of flap.

Guided implant placement, implant driver in place. Note duplication of timing as on initial cast.

Removal of surgical template, showing implants placed.

Immediate placement of individualized titanium abutments. Connective tissue grafting material added under flaps, to thicken gingival tissues.

The provisional prosthesis mounted onto the duplicate abutments and the impression bar.

Panoramic radiograph after surgery, reformatted from CBCT.

Placement of implant analogs on surgical template in order to create a master cast for the final restoration - note the 9 implants used here (3 reference implants included).

9 implants splinted with dental floss and blocked with triad gel, a composite material, to get a very stiff base with the implant analogs.

Casting of the implant analogs: for the alveolar part a regular polyvinyl siloxane (PVS) material is used.

Casting of the implant analogs: for the base a second, very stiff polyvinyl siloxane (VPS) material is used.

PVS cast, fabricated in the dental practice. Advantages: it is clean, no lab needed, the guide stays dry, it is fast.

Surgical guide on cast.

Mounting of duplicate dentures.

Surgical index.

The flats are marked on the surgical guide to duplicate the timing from the cast to the mouth so the CAD/CAM abutments will transfer identically.

A duplicate surgical guide is modified, allowing flap reflection. Note that 3 areas remain untouched at the reference implant sites.

Scanning of PVS cast to fabricate CAD/CAM abutments. The cast is scanned with the NobelProcera scanner.

Birdeye view of design of abutments.

The NobelProcera abutments are received and the seat is checked on the master cast.

Impression bar, will be segmented and reconnected to register actual implant positions.

Duplicate abutments which will be used to fabricate metal frameworks.

Acrylic pick-up copings with 0.5 mm thickness for the modification into the provisional denture.

The provisional complete denture has now landing areas for the healing caps on the reference implants and has been hollowed out around the CAD/CAM abutment sites.

The pick-up copings are bonded into the provisional prosthesis. The duplicate CAD/CAM abutments are repositioned, and the segmented impression bar has been luted together again.

The provisional prosthesis and impression bar are ready for casting.

Mach-2, a PVS casting material is used.

The provisional prosthesis on the definitive cast.

The CAD/CAM abutment on the planning cast.

The actual position of the CAD/CAM abutments on the definitive cast.

A soft vacuformed shim, indicating the prosthesis volume.

The shim is filled with a PVS material to create a duplicate of the provisional prosthesis.

The PVS prosthesis.

The definitive cast mounted with the PVS prosthesis.

Mounted casts with the PVS prosthesis removed.

The abutments are scanned again and copings in Cobalt Chromium are ordered.

Porcelain applied to metal frameworks.

CAD/CAM individual abutments at 6 weeks.

Right lateral view of the definitive restoration.

Left lateral view of the definitive restoration.

Frontal view of the definitive restoration.

Occlusal view of the definitive restoration.

Definitive restoration.

Questions

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Team members

Lambert Stumpel

Implantologist

Walter Haechler, MDT

Dental technician

JP Simon, MDT

Dental Technician

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