Initial situation

Description of the patient:

A 58-year-old patient presented to our office with loss of posterior support in the upper and lower jaws. His chief complaint was the loss of masticatory function (Figs. 1,2). The patient was systemically healthy and smoked more than 20 cigarettes per day. At the periodontal evaluation he presented several teeth with probing depths up to 10 mm, with bleeding on probing and severe mobility. Full-mouth subgingival debridement was therefore carried out, and all hopeless teeth were extracted

Treatment planning

The treatment plan initially involved restoration of the posterior support and, at a later stage, the third quadrant. The CBCT scan showed a low bone height, with an average of 5.5 mm. The patient was presented with two treatment choices with vast supporting evidence. The first one required a sinus lifting procedure to enable a second surgical intervention for the implant placement. The second option allowed a direct tilted placement of a regular length implant in the maxillary tuberosity and two short implants. Due to the long healing time, the risks associated with the sinus procedure, and the additional cost of the intervention, the patient opted for the second treatment option.

A digital workflow was employed to plan the placement of the implants based on the intraoral optical scan and the CBCT. The prosthetic plan with a screw-retained restoration and the placement of the implants was dictated not only by the bone availability, but was also decided in close collaboration with the dental technician in order to obtain an optimal screw access.

A surgical guide was planned with 2.2 mm sleeves for pilot drilling to achieve optimal depth and axis. Straumann® BLX SLActive implants were planned for insertion with the dimensions Ø 3.75 x 8 mm, Ø 4.5 x 6 mm, and Ø 4.5 x 12 mm.

Also, screw-retained abutments (two straight and one angled at 30 degrees) were prepared for the placement during the surgical procedure following the one-abutment, one-time protocol to avoid removal and insertion of components afterwards at the bone level.

Surgical procedure

The surgery was performed under local anesthesia with 2% lidocaine with 1:100,000 epinephrine. A mid-crestal incision was made at the recipient site, and a minimal full thickness flap was raised to allow proper visualization and seating of the surgical template (Figs. 7,8). The osteotomies were done with the Ø 2.2 mm VeloDrill® through the guide to ensure precise depth and axis, followed by site probing to ensure integrity of the surrounding structures (Figs. 9,10). Since the bone in this area was soft, the last drill for the osteotomies was the Ø 2.8 mm VeloDrill® (Fig. 11). For tooth #24, the following Straumann® BLX Roxolid® SLActive® implants were inserted: Ø 3.75 mm RB 8 mm and Ø 4.5 x 6 mm for tooth #25 and Ø 4.5 x 12 mm for tooth #26 (Figs. 12,13).

Screw-retained abutments were inserted into the implants: straight ones with 2.5 mm GH and 3.5 mm GH for teeth #24 and #25, and a 30 degree angled abutment with 4.5 mm GH for tooth #26 (Fig. 14). Protective caps were placed over the abutments, and 5/0 interrupted PGA sutures were used to close the flap (Fig. 15). A panoramic radiograph was taken after the surgery to assess optimal implant positioning and correct abutment seating (Fig. 16).

Prosthetic procedure

Two months after surgery the patient returned to the dental office for assessment of his peri-implant condition (Fig. 17). The protective caps were removed, and a CARES® Mono Scanbody for Screw-retained abutment (Fig. 8) was selected and screwed onto the implants to obtain an intraoral digital impression, which was then sent to the dental laboratory for the fabrication of a screw-retained porcelain fused to metal bridge (Figs. 20-22). The bridge was seated, contact points and occlusion were properly checked, and the screw access points were protected and closed with light-curing composite (Figs. 23- 25). A final radiograph was taken to ensure a passive fit of the restoration (Fig. 26).

Treatment outcomes

The final outcome of treatment and the health of the hard and soft tissues, combined with the short healing period and the low-risk surgery, showed that the use of tilted and short implants to avoid the sinus grafting procedure can be considered a reliable option to treat the posterior maxilla, ensuring high-quality implant therapy while significantly reducing the potential morbidity and risks. The patient was very pleased with the outcome and has not reported any mechanical or biological complications.

Author’s testimonial

A digital workflow combined with very active and high-quality dental implants, e.g. Straumann® BLX, allows the posterior maxilla to be managed in a very predictable and efficient manner, providing an alternative to the need for additional costs, risks and treatment time associated with sinus grafting. I have particularly noticed the increased willingness to undergo dental therapy in my practice ever since I started to offer this alternative to my patients.