Severe periodontal disease frequently results in terminal mandibular dentition, functional impairment, and progressive bone resorption, making implant-supported rehabilitation both biologically and mechanically challenging (1-2). Achieving sufficient primary stability in an atrophic mandible is a critical prerequisite for immediate loading and long-term clinical success (2-3).

Full-arch rehabilitation using four strategically positioned implants to support a fixed prosthesis, while reducing the need for extensive bone grafting procedures, is a widely accepted concept (3-4). When combined with digital planning and guided surgery, this approach allows prosthetically driven implant placement and improved control in anatomically compromised situations (4-5).

The Axiom® X3S implant system was selected in this case due to its capacity to achieve high primary stability in reduced bone volume and its compatibility with guided surgery and immediate loading protocols. Its macro-design and implant-abutment connection are intended to enhance anchorage in low-density or resorbed bone.

This clinical report presents a guided full-arch mandibular rehabilitation with four implants in a patient with advanced periodontal destruction and significant bone resorption. The objective of this report is to describe a reproducible digital workflow and to evaluate the clinical performance of Axiom® X3S implants in a challenging full-arch immediate loading indication.

A 45-year-old female patient presented with pain, impaired mastication, and mobility of the remaining mandibular teeth, associated with severe dental anxiety but no systemic contraindications. She had worn a provisional prosthesis for 20 years following multiple tooth loss, with progressive periodontal deterioration resulting in terminal mandibular dentition. After initially declining implant therapy at her 2025 consultation, she opted for treatment following further clinical progression.

A full-arch mandibular rehabilitation using a guided four-implant immediate loading protocol was planned based on digital diagnostics (intraoral scans, radiographs, and CBCT) and interdisciplinary prosthetic planning. The procedure involved atraumatic tooth extraction, guided implant placement of four Axiom® X3S implants in positions 32, 34, 42, and 44, and immediate loading. Localized posterior bone augmentation was performed where required, followed by placement of multi-unit abutments and preparation for provisional prosthetic restoration.

Clinical examination revealed terminal mandibular dentition associated with advanced periodontal disease. The remaining teeth (33 and 43–47) exhibited severe mobility, gingival inflammation with bleeding, marked periodontal attachment loss, and significant discomfort during mastication (Fig 1-3). The patient reported persistent pain and an inability to chew properly. In addition, the gingival tissues showed signs of active infection, and the teeth presented with discoloration and compromised aesthetics.

Radiographic and CBCT evaluation confirmed severe horizontal and vertical bone resorption with advanced periodontal destruction, indicating a poor prognosis (Fig 4). Based on these clinical and radiological findings, the remaining teeth were deemed non-restorable.

Under local anesthesia, all remaining mandibular teeth were atraumatically extracted, flap raised. Implant osteotomies were then performed using a digitally designed surgical guide to ensure accurate, prosthetically driven positioning (Fig 5-10).

Four Axiom® X3S implants were placed in regions 32, 34, 42, and 44. Adequate primary stability (33N.cm) was achieved in all sites, allowing implementation of an immediate loading protocol (Fig 11-12). Due to localized posterior bone deficiencies, additional bone augmentation was performed in regions 34 and 44 using a xenogenic bone substitute material (Xenogenic bone substitute material).

Following implant placement, multi-unit abutments were installed (Fig 13-14).

Following implant placement and verification of primary stability, multi-unit abutments were secured and temporary cylinders connected. A prefabricated provisional full-arch prosthesis, designed from the preoperative digital workflow, was then positioned intraorally, adjusted, and screw-retained (Fig 15-18).

This immediate restoration re-established function, aesthetics, and phonetics, allowing rapid return of masticatory ability and improved patient comfort.

Postoperative healing was uneventful, with stable implants and favourable soft tissue response. Follow-up evaluations confirmed satisfactory prosthetic integration and high patient satisfaction, with a notable improvement in overall function and quality of life (Fig 19-21).