Introduction

Full-arch fixed dental prostheses present high survival and success rates. In recent years, several clinical studies and systematic reviews have demonstrated that the early and immediate functional loading of dental implants can be as effective as those treated with conventional loading protocols^1,2. Immediate loading of dental implants offers various advantages, including time savings, enhanced esthetic and occlusal function, elimination of temporary removable prostheses, avoidance of secondary surgical procedures, and the preservation of residual alveolar ridges³.

The following case report demonstrates the successful management of a 67-year-old patient with a hopeless dentition and the desire for a long-term fixed solution. Through a periodontal and orthodontic treatment and an implant-supported rehabilitation with six Straumann® BLT implants in the mandible and four Straumann® Tissue Level implants in the maxilla, we fulfilled her expectations.

The interdisciplinary approach employed in this clinical scenario reflects the collaborative synergy between dental professionals, each contributing their expertise to create a customized treatment plan that renews not only the patient's smile but also their confidence and quality of life.

Initial situation

A 67-year-old female patient without any relevant medical history came to the clinic seeking a solution for her oral health concerns. She stated that, for as long as she could remember, she had been experiencing feelings of embarrassment about her mouth. Her ongoing struggles with bleeding gums and loose teeth had significantly hindered her ability to eat and smile confidently. She expressed her desire for a fixed rehabilitation of her failing dentition and reiterated her inability to tolerate traditional full removable dentures at any treatment step.

The intraoral examination revealed a hopeless dentition with inadequately treated teeth in terms of preservation and prosthetic restoration. In the upper jaw she had two metal ceramic bridges at #16-14 and #24-27, which presented mobility and caries on the cervical area. The mandible had deep periodontal pockets, an active infection, mobility, suppuration, and bleeding on probing, and tooth 42 was especially affected (Figs. 1,2). Likewise, there was a root remnant in region 36.

The radiographic assessment showed, in the upper jaw, moderate bone resorption on the anterior teeth and bone loss around pillar teeth. In the lower jaw, severe alveolar bone resorption was observed, particularly in the anterior mandible, around tooth 42. (Figs. 3,4).

According to the SAC classification, the patient was categorized as complex and advanced, respectively, in from the surgical and prosthodontic standpoints (Fig. 5).

Treatment planning

Following a comprehensive discussion of the available treatment options with the patient, it was determined that a comprehensive periodontal treatment would be carried out on the upper jaw, and all the lower jaw teeth would be extracted. Subsequently, immediate BLT (Bone Level Tapered) implants using the Straumann® Pro Arch system would be placed.

The treatment workflow included:

1. Full mouth scaling/root planing and oral hygiene instructions. 
2. Periodontal surgery/soft tissue grafting for the maxillary anterior teeth. 
3. Orthodontic treatment of the maxillary anterior teeth.
4. Posterior maxilla implant placement. 
5. Extraction of mandibular teeth. 
6. Prosthetic and esthetic analysis.
7. Preparation of immediate mandibular full-arch prosthesis.
8. Preparation of analog implant insertion guide. 
9. Immediate Straumann® BLT implant placement and bone augmentation. 
10. Immediate loading of Straumann® BLT SLActive implants. 
11. Final monolithic zirconia screw-retained restorations. 
12. Periodontal supportive therapy (every 3-4 months). 

Surgical procedure

Initially, the patient was scheduled to undergo a comprehensive periodontal treatment regimen that included oral hygiene instructions, scaling and root planing, and regular follow-up evaluations. Clinically, significant improvements were noted in oral hygiene, gingival health, and a reduction in periodontal pocket depths. Subsequently, periodontal therapy was performed in the upper maxilla, which included root planing, guided tissue regeneration (GTR), and soft tissue grafting (Fig. 6).

As the patient also expressed a desire to enhance esthetic outcomes, it was decided to improve the alignment of the upper teeth through orthodontic treatment before implant placement in the maxilla. In the maxillary arch, two Straumann® Tissue Level implants Ø4.1x12 mm and two Ø 4.8 x 10 mm were surgically positioned in the regions corresponding to teeth #16, # 14, #24, and #26.Next, under local anesthesia, a mucoperiosteal flap was elevated, and an atraumatic extraction technique was employed to remove all the lower jaw teeth, with the aim of preserving oral soft and hard tissues and minimizing any potential trauma. Furthermore, the crestal alveolar bone was removed, and bone reduction was carried out using a straight surgical handpiece, with copious sterile saline irrigation to address the significant bone deficiency, thereby augmenting the available bone volume to optimize the placement of dental implants (Fig. 7). On the same day, a thorough prosthetic and esthetic analysis was conducted for the fabrication of the immediate load, fixed mandibular full-arch prosthesis, along with the preparation of an analog implant insertion guide. The drilling sequences for BLT implants were performed in accordance with the manufacturer's instructions. Six Straumann® BLT implants were then strategically positioned with an anterior-posterior distribution, carefully planned to ensure the most effective distribution of forces (Fig. 8). Bone Level Tapered (BLT) SLActive® Roxolid®, Ø 3.3 mm x 12 mm, Ø 4.1 x 12 mm, Ø 4.1 x 10 mm implants were placed utilizing the Pro Arch guide. The insertion torque was measured within the range of 35-55 Ncm using a torque wrench. The decision was made to use Straumann® BLT implants due to their design, which facilitates primary stability, allows for immediate loading, and can be seamlessly integrated with Straumann® Pro Arch for the creation of implant-supported, fixed, full-arch restorations, ensuring predictable outcomes.

Bone augmentation was performed to establish a stable buccal bone thickness of at least 2 mm for the implant placement (Fig. 9). Straight screw-retained abutments (NC Ø 3.5 x 4.0 mm, RC Ø 4.6 x 4.0 mm and RC Ø 4.6 x 2.5 mm) were chosen based on soft tissue thickness. Next, healing caps were screwed in place. The soft tissue was closed without tension through periosteal releasing and apical mattress sutures (Fig. 10).

Impression copings were connected together (splinted) to guarantee an immediate, precise and passive fit of the prosthesis (Fig. 11). An impression was taken using polyvinyl siloxane material, and sent to the laboratory for the production of a complete-arch provisional prosthesis. The provisional prosthesis was delivered on the same day and was inserted with a torque of 15 Ncm. Occlusal contacts were carefully adjusted to align with centric relation to prevent excessive stress on the implants during the healing period (Fig. 12).

Prosthetic procedure

At the 3-month control after implant placement, osseointegration was achieved in all the implants. It was also noted that there was sufficient buccal keratinized tissue, which plays a crucial role in ensuring the long-term stability of the soft tissues and facilitating proper oral hygiene maintenance (Fig. 13). The definitive prostheses, monolithic zirconia screw-retained restorations, were then placed (Fig. 14).

The patient received oral hygiene instructions, and the occlusion was checked. The patient was scheduled for periodontal supportive therapy sessions at intervals of 3-4 months.

At the three-year follow-up, the periodontal and peri-implant bone remained stable (Figs. 15,16).

After fives years, a clinical and radiographic control of the rehabilitation on implants was carried out, demonstrating the long-term success of the initial treatment (Fig. 17).

Treatment outcomes

The utilization of BLT implants following the Pro Arch concept delivered exceptional results in a patient with a history of periodontal compromise, including healthy soft and hard tissues, functional improvement, and enhanced esthetics. This system allowed for immediate implant loading and successful osseointegration. The patient was satisfied with the achieved results.

Author’s testimonial

“Full-arch immediate implant restorations in patients with an advanced periodontal background can be challenging for any practice. The Straumann® Pro Arch workflow offers a more predictable and simplified approach with a proper anterior-posterior distribution that provides optimum force distribution, and also, for your patients, reliability, comfort, and compliance for an excellent long-term result”.