#Immediacy 16. Nov 2021

Immediate provisional restorations and loading of Straumann® Tissue Level implants using the Straumann® Guided Surgery solution

A clinical case report by Dr A Bortsov, Russia

Alexandr Bortsov

As dental implantation is steadily becoming a mainstream treatment option, most of the patients expect fast and successful results. Nowadays, many patients would like to leave the clinic with an esthetic and fully functional restoration. In this regard, immediate loading represents a time-efficient protocol and allows a patient to benefit from the restoration straightaway. For a surgeon, however, the main challenge is not immediate loading per se, but producing a precise and esthetically pleasing provisional restoration in an efficient, predictable and time-saving manner. Furthermore, bone atrophy poses additional risks and makes the procedure less predictable. In such situations, guided surgery based on fully digital workflows with pre-fabricated provisional restorations enables the surgeon to plan and place the immediate implants in deficient sites, as well as deliver esthetic provisional restorations efficiently in the same appointment. The following clinical case report describes a patient who had implants placed conventionally in the past, but who came into clinic asking for the new implants to be placed in such a way that “… I can smile and eat straightaway…”.

Initial situation

A non-smoker and systemically healthy 48-year-old female patient came to our clinic with partially edentulous areas in the upper and lower jaws (Fig. 1). Her dental history revealed implants that were conventionally placed and provisionally restored a year ago. She considered the experience to be rather prolonged, and this time she expressed a strong desire to have implants placed and restored immediately in the same appointment.

Treatment planning

The clinical examination and CBCT analysis revealed a significant deficit in the bone and soft tissue volume. Two years ago, eight implants had been placed in the upper jaw according to a conventional non-digital protocol. Since then, the patient has had a provisional restoration awaiting implantation in the lower jaw (Figs. 2-5). To meet the patient expectations, an immediate provisionalization and loading using a Straumann® Guided Surgery solution was planned. The color and shape of the provisionals were determined according to the patient’s requests and expectations. In cases with severe deficit of bone volume, the guided surgery approach can help achieve more precise positioning of the implants using a surgical guide. The surgical guide was planned based on the patient’s CBCT data using coDiagnostiX® software and then 3D printed. The same planning was used to plan provisionals, which were then pre-fabricated before the surgery so that the patient could leave the clinic with a fully functional temporary prosthesis (Figs. 7,8).

Surgical procedure

Under local anesthesia, the surgical intervention began with incisions along the alveolar ridge. The mucoperiosteal flap was raised, but not to the full extent in order to avoid interference with the fit of the guide template (Figs. 9,10). Next, the tooth-supported surgical template was additionally fixed with the template fixation pins (Figs. 11,12). Afterwards, the bone bed for implants was prepared in stages, starting from the distal sections. The template was additionally fixed with pins passing through the template sleeve and entering the bone bed formed for the implants (Figs. 13-15). The implants were planned and placed subcrestally (Figs. 16-18). After the implants were placed, the overhanging edges of the bone were removed using the Bone Profiler system (Figs. 19-21) to enable a subsequent passive fit of the prosthesis (Figs. 22,23), after which provisionals were inserted (Fig. 24).

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Prosthetic procedure

Three months after implantation, the provisional constructions were removed from the upper and lower jaws, the teeth were prepared, and an open-tray impression was taken to make permanent restorations for the full arches. Permanent monolithic zirconium dioxide crowns for teeth and implants were then modeled and fabricated in the dental laboratory (Figs. 28-30). The restorations on the implants were screw-fixed, and the crowns on the teeth were cemented (Fig. 31).

Treatment outcomes

In this case, the Straumann® TL Standard Plus SLActive® implants were placed in a patient with a pronounced bone volume deficit. Implantation was performed using a Straumann® Guided Surgery solution with coDiagnostiX® software. The solution allowed the implants to be placed in deficient sites without the need for bone grafting. The digital protocol (without the models) facilitated clinical efficiency and also made the procedure efficient and more convenient for the patient, as she was able to leave the office with an esthetic and fully functional temporary restoration straightaway after the surgery. The patient was satisfied with the functional and esthetic outcomes and returned for regular follow-ups. The follow-up at 8 months showed a stable marginal bone (Fig. 32) and favorable soft tissue outcomes. The patient was also pleased with the result achieved since the choice of shape and color was exclusively hers (Fig. 33).

Acknowledgements

The restorations were made by Albert Latypov, a dental technician at the Werk dental laboratory (Yekaterinburg, Russia).