All-Records-in-One® for immediate loading – a novel technique for manufacturing a full-arch, fixed, implant-supported provisional restoration in the surgical office
A clinical case report by Angel Moreno Lucendo, Spain
This case report presents an immediate-loading procedure as an innovative application for the newly described “All-Records-in-One®” impression technique*. This method allows us to fabricate a temporary implant-supported restoration for an edentulous patient in a quick, accurate and comfortable manner for both patients and clinicians. As the procedure is entirely prosthodontically driven, it is highly accurate and has a low incidence of occlusal corrections, thereby substantially reducing the average patient´s chair time.
An edentulous healthy 58-year-old non-smoking male, wearing maxillary and mandibular complete dentures presented at our dental office. He complained about their instability and unsatisfactory appearance (Fig. 1). He also reported pain and frequent pressure ulcers caused by the instability of the mandibular denture (Fig. 2) and also by the lack of keratinized tissue. We assessed viable bone from a panoramic radiograph and CBCT scan (Fig. 3), and the patient was offered several treatment options, including fixed, full arch implant-supported restorations in both maxilla and mandible, and also a free gingival procedure to increase the quality of the tissue, which was refused by the patient. For financial reasons, the patient chose a conventional complete denture in the upper jaw and a full-arch, screw-retained hybrid prosthesis in the lower jaw.
An immediate-loading option was discussed and fully explained to the patient. Once the patient agreed to have the treatment, we made two diagnostic wax-ups for the upper and lower jaws and tried them in the patient´s mouth to check esthetics, vertical dimension and centric relation records. After clinically assessing the esthetics and functional records, we fabricated a definitive complete denture in the upper jaw and a temporary acrylic complete denture in the lower jaw.
The patient received a prophylactic dose of 2g amoxicillin plus clavulanic acid one hour before the surgery. Also, an anti-inflammatory drug (ibuprofen) was prescribed for the day of the surgery and, only if necessary, after the procedure. The surgery was carried out under local anesthesia. A full-thickness flap was raised, and the residual bone was reduced in order to obtain a proper prosthetic space for the restoration and an adequate implant bed (Fig. 4). Five Straumann® Bone Level Tapered (BLT) implants were placed between the mental foramina (Fig. 5) according to the manufacturer´s instructions. All implants displayed a high degree of primary stability, requiring a ≥ 30Ncm torque as tested with a torque-control device.
Five Straumann® RC screw-retained abutments were tightened to 35 Ncm over each implant. The height of the abutments was clinically chosen according to the peri-implant mucosa and the 3D position of the implants (Fig. 6). Next, protective RC caps were tightened to the RC screw-retained abutments with 10 Ncm. At this point, the temporary prosthesis, now used as a prosthetic template, was placed in the patient´s mouth (Fig. 7). We then mixed and placed some silicone putty in the prosthetic stent window, and made an impression of the cap shapes at the same time as a centric occlusal record was taken against the upper definitive denture (Figs. 8-9). The silicone putty was removed, and an incision of about 1-2 mm was made (Fig. 10). Separating agent was applied over the silicone putty and was again placed in the prosthetic stent (Fig. 11). Polyvinyl siloxane material was poured (Fig. 12), and an impression was taken while asking the patient to close his mouth, taking care to keep the interocclusal centric record we just performed in the wax-up try-in. Once the impression material had set, we removed the impression (Fig. 13) and cut the entire thickness of the polyvinyl siloxane material corresponding to the mark of each protective cap (Fig. 14). Since we had already applied separating agent before, we were able to again remove the silicone putty material without breaking the impression (Fig. 15). We removed the RC protective caps, and titanium copings were placed over the RC screw-retained abutments and tightened to 15 Ncm. Finally, the prosthetic stent was again placed in the patient´s mouth over each titanium coping (Fig. 16) and autopolymerizing acrylic resin with a medium consistency was poured into the space (Fig. 17). Before this material set completely, we had to check that the occlusal centric relation record was maintained at all times. We waited for about 7 or 8 minutes until the acrylic material had set completely and, finally, we removed it from the patient´s mouth (Fig. 18).
Once we had removed the unfinished temporary hybrid prosthesis from the patient´s mouth, about 30-35 minutes from the beginning, we had two options: finish it in the surgical office or send it to the lab. In both situations the patient can stay in the waiting room or go for a walk during the process, since his presence is not required. In most cases, and taking account of profitability and our own and the patient´s convenience, the prosthesis is finished by the lab. In his lab the technician pours autopolymerizing acrylic resin to fill any gaps (Fig. 19), trims the prosthesis cantilevers and polishes it in order to obtain the final temporary hybrid prosthesis (Figs. 20-21). Finally, the full-arch, fixed, implant-supported provisional restoration is placed in the patient´s mouth. Fig. 22 shows the clinical situation immediately after placement of the temporary prosthesis as we received it from the lab, about one hour later. Only minor occlusal corrections were needed. Postoperative x-ray control confirmed the correct positioning and fit between the implants and the temporary implant-supported hybrid prosthesis.