The Straumann® Pro Arch protocol enables personalized treatment protocols for implant-borne fixed full-arch restorations, leveraging the Straumann® Dental Implant System combined with the Prosthetics portfolio to treat different clinical situations with predictable outcomes. This protocol offers a variety of treatment options to address specific indications and patient needs, making it particularly beneficial for elderly patients with bone atrophy. The Roxolid® 3.3 mm implants provide superior strength and stability, making them a viable option for patients with compromised bone density and/or volume.^1,2

In this case report, we present the clinical application and benefits of using four BLT 3.3 mm Roxolid® implants to rehabilitate the maxilla of an edentulous elderly patient. The Straumann® Pro Arch protocol facilitated a personalized treatment plan, utilizing the narrow and short implants to preserve bone and avoid grafting. The use of guided surgery technology ensured precision and accuracy in implant placement, significantly enhancing the treatment's predictability and success. Additionally, the integration of digital workflows played an important role in optimizing treatment planning, improving patient outcomes, and reducing chair time. Through this approach, we achieved a full-arch rehabilitation, demonstrating the efficacy of contemporary digital dentistry techniques in complex clinical scenarios.

Initial situation

A healthy female patient, classified as ASA I, presented to our clinic. She was a non-smoker with no known medications or allergies. The patient had a partially edentulous maxilla and mandible and was using a removable acrylic denture. However, she was experiencing significant mobility issues with the denture, leading to inefficient masticatory function and considerable discomfort. Seeking to improve her situation, the patient aimed to enhance her masticatory functionality and overall quality of life. She expressed a desire for a fixed solution to rehabilitate her failing dentition in both the upper and lower jaws.

During the extraoral examination, we noted a medium smile line. The current prosthesis exhibited inadequate esthetics and an uneven occlusion, which contributed to the patient's dissatisfaction. (Figs. 1,2).

Upon removal of the upper acrylic denture, it was evident from the patient's profile that facial support from the prosthesis flanges was necessary (Figs. 3,4).

The intraoral examination showed partial edentulism in the upper jaw, with mobile, hopeless teeth #17 and #27. Palpation detected a sharp bone edge on the maxillary ridge. In addition, according to the patient, due to tooth decay, her teeth in the mandible had been restored with metal-ceramic bridges.

The radiographic evaluation revealed advanced bone resorption with bilateral pneumatization of the maxillary sinuses and alveolar ridge resorption. The bone showed limited but adequate availability for implant placement (Figs. 5-8).

Treatment planning

To address her primary concern, we decided to implement the Straumann® Pro Arch protocol for the upper jaw and perform implant rehabilitation in the lower jaw at sites #34, #36, and #37. Digital implant planning was enhanced by preparing a complete upper denture that met both the patient’s esthetic and functional requirements. Using the Straumann® coDiagnostiX® software, we guided the prosthetic implant plan, which included the selection of Straumann® Screw-retained abutments (SRA). We also custom-designed and manufactured a surgical template and an immediate-loading temporary restoration. Following implant placement, we proceeded with the rehabilitation of the overdenture in the upper jaw and a bridge in the lower jaw.

The treatment workflow included:

1. Removal of the bridge and extraction of the hopeless teeth #17, #27, #34, and #37, followed by endodontic treatment in the lower jaw (Fig. 9).

2. Production of a complete upper denture to fulfill both esthetic and functional criteria, featuring radiopaque composite denture teeth (Fig. 10).

3. Denture secured in patient's mouth with light-body impression material, followed by CT scanning; plaster model created and scanned with and without denture, scans aligned with CT data using radiopaque markers (Figs. 11-16).

4. Use of the Straumann® coDiagnostiX® software for prosthetically guided implant planning, selection of Straumann® Screw-retained abutments and design of a surgical template for an immediate-loading temporary restoration (Figs. 17-22).

5. Placement of four Straumann® BLT implants in the upper jaw and three in the lower jaw

• Position #14: Straumann® BLT implant ∅3.3 mm NC, SLA® 14 mm Roxolid®.
• Position #12: Straumann® BLT implant ∅3.3 mm NC, SLA® 10 mm Roxolid®.
• Position #22: Straumann® BLT implant ∅3.3 mm NC, SLA® 10 mm Roxolid®.
• Position #24: Straumann® BLT implant ∅3.3 mm NC, SLA® 12 mm Roxolid®.
• Position #34: Straumann® Standard ∅4.1 mm, SLA® 8 mm Roxolid®.
• Position #36: Straumann® Standard ∅4.1 mm, SLA® 10 mm Roxolid®.
• Position #37: Straumann® Standard Plus ∅4.8 mm, SLA® 10 mm Roxolid®. 

6. Installation of four angulated abutments for the provisional bridge in the upper jaw and healing abutments in the lower jaw.

• Position #14: Straumann® NC Screw-retained abutment angled 30°, type A, ∅ 4.6 mm, gingiva height 4.5 mm.
• Position #12: Straumann® NC Screw-retained abutment angled 17°, type A, ∅ 4.6 mm, gingiva height 3.5 mm.
• Position #22: Straumann® NC Screw-retained abutment 17°, type A, ∅ 4.6 mm, gingiva height 3.5 mm.
• Position #24: Straumann® NC Screw-retained abutment angled 30°, type A, ∅ 4.6 mm, gingiva height 4.5 mm. 

7. Final prosthetic rehabilitation with a screw-retained bridge over implants in the upper jaw and bridge in the lower jaw.

Surgical procedure

One hour before surgery, the patient was given two grams of amoxicillin and her mouth was rinsed with 0.12% chlorhexidine. The surgical guide template was positioned and checked for proper fit in the patient’s mouth. Infiltration anesthesia was administered via the sleeves of the lateral pins. Osteotomies were prepared, and the lateral pins were inserted one by one, beginning with the central pin. The template’s stability was subsequently confirmed (Figs. 23,24).

Additional anesthesia was administered on both the facial and palatal sides. A trapezoidal mucoperiosteal flap, which involved a horizontal incision with two vertical relieving incisions at the medial and distal aspects, was released, and the guide was then secured using lateral pins (Figs. 25-27).

Osteotomies were prepared according to the surgical protocol using a handpiece with saline irrigation. Osteotomies were performed, ensuring proper alignment, avoiding drill deviation, and maximizing the surface contact between the implant and bone. By creating a flat and even bone surface, the procedure enhanced the stability and integration of the implants. Initially, a 2.2 mm diameter drill was used to prepare the implant bed, and subsequent steps followed the manufacturer's recommended insertion protocol (Figs. 28,29).

In accordance with the pre-established prosthetic plan, Straumann® BLT implants (Roxolid®, SLA®) were carefully positioned using a guided implant driver, guaranteeing exact alignment as defined in the prosthetic plan. Each implant was secured with a torque of 35 Ncm (Figs. 30,31). The Loxim™ Transfer Piece was used as an alignment pin to indicate the implant position and angulation for correct parallel placement of the neighboring implants (Fig. 32). Once the position was confirmed, the transfers were released by hand. All implants achieved good initial stability, as confirmed by Ostell readings.

Next, the coronal bone was reduced using bone profilers, which gradually remove excess bone surrounding the coronal part of the implant, ensuring that the prosthetic components can be properly seated. Bone profilers were placed along with a guiding pin, which helped avoid contact between any prosthetic components and bone. Straumann® Screw-retained abutments (SRA) were tightened to 35Ncm on each of the four implants (Figs. 33,34). Radiographs were taken to confirm the correct position of the implants (Figs. 35-38).

The provisional restoration was secured using prefabricated lateral pins in the same location as the surgical guide to ensure exact positioning. The temporary copings were individually bonded to the provisional restoration to maintain the exact position (Figs. 39-41). Finally, the provisional was removed, any excess material was trimmed, and additional material was added where needed. The restoration was then sent to the lab for final adjustments.

On the lower jaw, Straumann® Tissue Level implants were placed in the areas of teeth #34, #36, and #37. Infiltration anesthesia was administered. After verifying the surgical guide, a mucoperiosteal flap was created with a crestal incision. The surgical guide (Template Fixation Pin, ∅ 1.3 mm) was then positioned, and the Straumann® Surgical Cassette was used to prepare the implant bed following the SP Tissue Level drilling protocol. The depth preparations were checked using depth gauges. The implants were inserted with a handpiece, rotating clockwise at a speed of 15 rpm, and torqued to 35 Ncm. Closing caps were placed, and the mucoperiosteal flap was carefully adapted and sutured (Figs. 42-47).

Two months after placing the implants in the lower jaw, a flap was created for tissue augmentation. A connective tissue graft extracted from the patient’s maxillary tuberosity was then adapted around the implants to enhance soft tissue volume. Subsequently, the implants were exposed, healing abutments were placed, and the mucoperiosteal flap was carefully adapted and sutured (Figs. 48-53).

After two weeks, healing progressed without complications, and a PMMA resin provisional crown and bridge were placed. These were designed to minimize contact during lateral and protrusive movements. (Figs. 54-56).

Prosthetic procedure

For the rehabilitation of the maxilla, the temporary fixture was relined, finished, and glazed in the dental lab (Fig. 57).

After placing the provisional prosthetic in the patient’s mouth, the neighboring soft tissues were stabilized with U-shaped small-caliber sutures to minimize scarring after healing. This method increased the width of the attached keratinized mucosa and eliminated the need for a connective tissue grafting procedure. As a result, this approach offered an effective alternative for soft tissue augmentation, eliminating the need for secondary surgical access to a donor site and thereby reducing postoperative discomfort (Figs. 58-61).

The patient was examined and remained symptom-free. The implants were osseointegrated, and the peri-implant soft tissues healed well with appropriate soft tissue shaping. Final impressions were then taken, and the second temporary restoration was fabricated (Figs. 62-65).

The second temporary restoration was delivered, and prosthetic screws were torqued to 15Ncm. (Figs. 66-68).

Radiographs confirmed the correct position and satisfactory bone healing around all implants (Figs. 69-71).

After six months, the temporary restoration was exchanged for the final milled titanium restoration with a titanium framework. The occlusion and esthetics of the prosthesis were evaluated, the screws were torqued to 15 Ncm, and the access holes were sealed using Teflon and composite resin. The patient was given general oral health guidelines and advised to schedule professional oral hygiene visits every six months. The patient was very satisfied with the results (Figs. 72-84).

Treatment outcomes

The successful treatment of this patient with fixed restorations using Straumann® Roxolid® 3.3 mm diameter implants not only resolved the issue of ongoing bone loss but also achieved outstanding health outcomes for both hard and soft tissues. As a result, the patient was able to regain near-perfect masticatory function, which greatly enhanced her quality of life.

Author’s testimonial

Proper CT and intraoral scanning protocols, as well as pre-designing the final restoration at an early stage, are crucial for obtaining the best results. Straumann® coDiagnostiX® software is recommended since it includes all the necessary functions for designing surgical guides and provisionals. The Pro Arch protocol offers a variety of treatment options to address specific indications and patient needs, making it particularly beneficial for elderly patients with bone atrophy.