A clinical case report by Dr. Luis Henrique Kohler Chaves, Brazil
Introduction
This case report outlines the successful smile transformation of a patient who had been completely edentulous in the maxilla for over 20 years. The patient had stopped wearing his maxillary removable denture due to inadequate retention and compromised masticatory function, leading to significant functional and esthetic challenges.
Our treatment plan involved the guided placement of six Straumann® BLX implants in the maxilla, employing coDiagnostiX® for precise surgical planning. The integration of Straumann Digital Tools and Workflow, particularly the RevEX™ scanbody, played a crucial role in enhancing accuracy and streamlining the prosthetic workflow. This ultimately facilitated the development of a fixed hybrid prosthesis for the upper arch.
On the day of surgery, we performed the guided placement of the implants, followed by the immediate loading of the new prosthesis. A similar approach was used for the mandibular arch prior to the maxillary procedure, in which four Straumann® BLX implants were placed and immediately loaded. For conciseness, this report presents only the step-by-step procedure for the maxillary arch. The use of the Straumann® Pro Arch concept, combined with advanced digital tools and the high primary stability provided by the BLX Implants, enabled us to achieve exceptional accuracy and quality in our results. This comprehensive approach not only addressed the patient’s functional needs but also exceeded his esthetic expectations, leading to a remarkable improvement in both his confidence and quality of life.
Initial situation
A 53-year-old male patient with well-controlled diabetes presented to our clinic experiencing significant difficulties when chewing and speaking. He reported that the poor quality and instability of his upper dentures severely impacted his daily function and overall confidence (Figs. 1,2).
To address his concerns, we initiated the initial prosthetic phase: creation of new dentures for jaw relationship determination. During this phase, we meticulously evaluated key factors such as vertical dimension of occlusion (VDO), maxillomandibular relationship, midline, incisal edge position, buccal corridor dimensions, high smile line, plane of occlusion, esthetics, phonetics, and function. Photographic documentation was also conducted to capture these assessments. After thorough adjustments and evaluations, we provided the patient with a new upper removable denture and a lower partial denture. This intervention substantially improved his ability to eat comfortably and speak confidently.
This intervention not only improved his quality of life, but it also established a solid foundation for future rehabilitation with fixed prostheses. An intraoral examination revealed a satisfactory amount of keratinized gingiva and good general oral hygiene, indicating favorable conditions for the next stages of the treatment.
To assess the complexity and potential risks associated with this case, we utilized the ITI SAC classification system, categorizing it as complex from both surgical and prosthodontic perspectives (Fig. 3).
Treatment planning
After a thorough clinical evaluation, along with radiological (CBCT), digital (intraoral) scanning and extraoral/intraoral pictures, we proposed the following treatment plan: placement of six Straumann® BLX implants using guided surgery techniques, followed by the conversion and immediate loading of the denture. Once adequate soft tissue healing was achieved, a fixed hybrid full-arch prosthesis would be fabricated and fitted from an intraoral scan of the maxilla and the temporary denture. This transformation would result in a fully stable and durable prosthesis, thereby significantly improving the patient’s quality of life.
In order to plan a digitally guided surgery we performed CBCT with the removable denture.
We used light-cured radiopaque composite as markers to match the STL and DICOM files.
We planned to place the implants in areas with sufficient bone volume to ensure a good primary stability. Adequate alveolar bone width and height were present in the regions of both central incisors, canines, and second premolars, allowing for ideal load distribution and optimal A/P spread. To avoid intervention in the sinus area and minimize invasiveness, we decided to place the two posterior implants tilted at 17o degrees.
All planning was carried out in the coDiagnostiX® software (Fig. 4).
Accordingly, the overall treatment workflow included:
Preliminary data acquisition: intraoral and extraoral photos, digital impressions (DWOS Virtuo Vivo™) and CBCT scan.
Esthetic analysis of the clinical case, pre-visualization of the final result using a digital mock-up.
Processing of DICOM (CBCT scan) and STL (optical impression and digital wax-up) data in coDiagnostiX® planning software to carefully plan the implant placement and design the surgical guide/template.
Production of printed surgical guide.
Guided implant placement with a flapless technique and Immediate loading of the converted denture (through a chairside pick-up approach) and confirmation of passive fit of provisional prostheses.
Wait for healing and soft tissue conditioning to occur, and for the patient to adjust to the new smile and occlusion.
RevEX™ protocol
Intraoral scanning of the converted prostheses and occlusion.
Intraoral scanning of the maxillary and mandibular soft tissues.
Extraoral scanning using RevEX™ with the reverse scanning technique.
Milled prototype and verification jig try-in.
Final rehabilitation with the fixed zirconia arch.
Follow-up and maintenance program.
Surgical procedure
The patient received bilateral local anesthesia for comfort during the procedure. Infiltrative vestibular anesthesia was administered using articaine 4% with epinephrine 1:100,000, and palatal anesthesia was provided with 2% lidocaine with epinephrine 1:100,000.
In addition, appropriate intraoral and extraoral antisepsis was performed with chlorhexidine before anesthesia.
We utilized a tongue depressor to accurately determine and record the Vertical Dimension of Occlusion (VDO) and the Vertical Dimension at Rest (VDR) (Figs. 5-7).
This method facilitated the precise pickup of the denture following implant placement, ensuring optimal fit and function. The surgical guide was then meticulously positioned and secured with the fixation pins, ensuring precise fitting for the guided surgery (Figs. 8,9).
Next, we used the Straumann® Soft Tissue Punch, to remove the soft tissue on each implant site (Fig. 10). We then initiated our osteotomy with Straumann® VeloDrillsTM ensuring a faster and more precise osteotomy without overheating the bone, following our coDiagnostiX® surgical protocol (drill length, handle, and height position) for each implant planned (Figs. 11,12).
After completing the osteotomy in all sites, we placed the planned implants according to each site (Figs. 13-17):
Implant #16: Straumann® BLX Roxolid® SLA 3.5 x 12 mm
Primary Stability: 50 N.cm.
Straumann® Screw-retained Abutment RB 17o, 4.6 mm GH, 3.5 mm.
Implant #14: Straumann® BLX Roxolid® SLA 3.5 x 12 mm
Primary Stability: 50 N.cm.
Straumann® Screw-retained Abutment RB Straight 0o, 4.6 mm GH, 2.5 mm.
Implant #12: Straumann® BLX Roxolid® SLA 3.5 x 10 mm
Primary Stability: 60 N.cm.
Straumann® Screw-retained Abutment RB Straight 0o, 4.6 mm GH, 2.5 mm.
Implant #22: Straumann® BLX Roxolid® SLA 3.5 x 10 mm
Primary Stability: 60 N.cm.
Straumann® Screw-retained Abutment RB Straight 0o, 4.6 mm GH, 2.5 mm.
Implant #24: Straumann® BLX Roxolid® SLA 3.5 x 12 mm
Primary Stability: 45 N.cm.
Straumann® Screw-retained Abutment RB Straight 0o, 4.6 mm GH, 2.5 mm.
Implant #26: Straumann® BLX Roxolid® SLA 3.5 x 12 mm
Primary Stability: 50 N.cm.
Straumann® Screw-retained Abutment RB 17°, 4.6 mm GH, 3.5 mm.
Once the implants were placed, we removed the guide (Fig. 18), and a bone profiler was used on #16 and #26 to remove any bone interference to engage the angled screw-retained abutments (Figs. 18-20).
Screw-Retained Abutments (SRAs) were properly positioned and torqued to 35 Ncm (Figs. 21-23), five protection caps were secured over the abutments (Fig. 24), and light-body PVS was applied to the intaglio of the prostheses, which was positioned in the patient’s mouth and secured in placed with the aid of the bite registration device to determine where to create openings for connecting the temporary copings to the screw-retained abutments (Figs. 25-28).
After creating the openings (Figs. 29,30), we seated the denture over the protective caps to ensure a secure fit on the soft tissue without any interference from the protective caps.
Concluding that step, we removed all the protective caps, and screw-retained five temporary copings over the SRAs (Fig. 31), we seated the denture one more time to understand the clearance of the denture holes and occlusion according with the copings (Fig. 32), and we then positioned a rubber dam to protect the soft tissue and avoid any acrylic resin infiltration on the surgical wound. We also protected the screw channel of the temporary copings with Teflon tape to prevent any acrylic resin from reaching into their chimneys (Fig. 33).
Then we positioned the denture, following the bite registration and locked it at this point (Fig. 34) to start applying acrylic resin, using a brush, monomer and polymer through the salt & pepper technique, to lute the temporary copings to the denture (pick-up) (Figs. 35,36).
After the resin was cured, we removed the denture with the captured temporary copings by unscrewing the temp coping screws (Fig. 37). Then we sent it to the laboratory for polishing, contour refinement, and final adjustments of the now converted, temporary fixed prosthesis. Meanwhile, protective caps were positioned over the abutments (Fig. 38).
Upon the lab’s completion of their work on the temporary fixed prosthesis, we removed the protective caps (Fig. 39), and screw-retained the conversion prosthesis over the SRAs and torqued to 15 Ncm (Figs. 40,41).
After delivering the temporary fixed prosthesis, aspects such as occlusion, esthetics, and phonetics were carefully checked, ensuring a passive fit and optimal functional and esthetic outcome during the healing phase. (Figs. 42-47)
Finally, a CBCT scan and panoramic x-ray were taken to verify the final positioning of the implants (Figs. 48,49).
Prosthetic procedure
Three months post-implant placement, following successful osseointegration and soft tissue healing, we initiated the first phase of our scanning protocol. We obtained comprehensive views of the conversion prostheses, including all perspectives (occlusal, palatal, and buccal).
Additionally, we took a bite registration scan to accurately establish the tooth position, maxillomandibular relationship, and vertical dimension, which was adequate on the conversion prosthesis.
Once the conversion prostheses were removed, we proceeded with a second set of scans, concentrating on the maxillary soft tissues of the edentulous arch, with the screw-retained abutments (SRA), allowing us to capture the soft tissue contours, which would allow hygienic and intimate intaglio contact for the prototype design and subsequent definitive prostheses.
Lastly, we conducted a third set of scans utilizing an extraoral approach with the reverse scanning technique. Straumann® RevEX™ scanbodies were tightened to the conversion prostheses, and these, along with the intaglio of the prosthesis, were digitally scanned extraorally, optimizing accuracy for the milling of the final prosthetic rehabilitation. A confirmation jig (GIG) was created using open-tray impression posts for the screw-retained abutments (SRAs). This was sent to the lab to confirm accuracy of the scans (Figs. 50-54).
The scans were imported to a CAD software and superimposed to digitally articulate and cross-mount the STL files (Figs. 55,56).
After the PMMA try-in prototype was approved and passive fitting was achieved, the final prosthesis was milled using a block of high-translucency zirconia (HT ZrO2), based on the initial PMMA try-in reference. The zirconia framework then underwent a 12-hour sintering process at a final temperature of 1530 °C. After sintering, it was covered with a micro-layer of feldspathic ceramic (e.max). Following finishing, texturing, and glazing, the Variobase® for Bridge/Bar Cylindrical Copings were cemented into the zirconia arch using self-adhesive resin cement (Fig. 57).
We then rechecked all aspects, including occlusion, function, and esthetics, to ensure everything aligned with the treatment plan. The occlusal screws were torqued to 15 Ncm, and the occlusion was adjusted to achieve uniform contacts in centric relation, and balanced touch points during excursive movements. Finally, the access holes for the screws were filled (Figs. 58-60).
The patient was provided with a night guard and given detailed instructions on how to maintain proper oral hygiene. Additionally, a comprehensive care plan was established, which included scheduling follow-up appointments for regular monitoring and any necessary adjustments.
Treatment outcomes
The patient expressed immense satisfaction with the overall treatment, which successfully restored esthetics and function immediately following the implant placement surgery. We established a comprehensive maintenance care program that extended over a one-year follow-up period (Figs. 61–64). Clinical evaluations and x-ray assessments indicated stable peri-implant conditions, with consistent bone levels maintained throughout the period. This positive outcome emphasizes the effectiveness of the treatment and the importance of ongoing care in supporting long-term success.
Author’s testimonial (optional)
The combination of Straumann® Pro Arch concept, and the Straumann® guided surgery and digital workflow, highlighting the RevEX™ Scanbody, ensured a highly precise, efficient, and minimally invasive procedure. This approach not only reduced the total treatment time but also expedited the restoration of esthetics and function, significantly enhancing the patient's quality of life and streamlining the process for the dentist.