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08 I I case report _ implant placement lowingforfabricationofanaccurateorientationjig on an articulator. The surgical guide was placed in the patient’s mouth, and the tissue was punched utilising a tissue punch (Figs. 6–8). Then, the surgical guide was again oriented in the patient’s mouth with the orientation jigcreatedonthearticulatorandstabilisedwiththree SurgiGuidefixationscrews(Fig.9).UtilisingtheZim- mer Guided Surgery Instrumentation and Guided Surgerydrills,alleightosteotomieswerecreatedand completed using minimally invasive flapless surgery (Figs.10&11).TheZimmerguideisaSAFEsystem,ac- curately providing for depth and size. The right and left molar (teeth #3 and 14) osteo- tomies were created short of the maxillary sinus. Then, using the new Sinus Crestal Approach Kit (Zimmer), I extended these two osteoto- mies into the left and rightmaxillarysinus- es. Alloplastic bone (Puros, Zimmer) was placed into the sinus cavity through the osteotomy and spread using the paddle- shapedspreadingbur. Then, all eight im- plants were placed. Eachhadinitialstabi- lityexceeding35Ncm. I decided to immediately load only the six im- plants that did not involve the sinus cavity. There- fore,healingheadswereplacedonimplants#3and 14, and non-engaging titanium temporary cylin- ders were placed on #5, 6, 8, 9, 11 and 12 (Fig. 12). The provisional, which the laboratory fabricated, was attached to the titanium cylinders using cold cure acrylic, thus creating a screw-retained provi- sional (Figs. 13 & 14). A post-operative CT scan showed how accurately the eight implants had been placed in the bone using a mucosa-supported SurgiGuide with orientation jig (made on the Immediate Smile model; Figs. 16a, b & 17). The ac- curacy and success of this case wereachievedthroughCTscanning, SimPlant planning with restorative model overlay, the Zimmer Guided Surgery Instrumentation and the Immediate Smile model. The surgical guide allowed for minimally invasive surgery and greatly reduced surgery time. TheImmediateSmilemodelalsoreducedchairtime by allowing for fabrication of the temporaries well in advance of surgery. The final restoration for this case is a milled zirconia, screw retained appliance. _Acknowledgement Laboratory procedures and photographs were provided by Dr Marcelo Silva._ CAD/CAM 3_2011 Dr Max J.Cohen 4700ChambleeDunwoodyRoad Dunwoody,GA 30338 USA MaxJCohen@hotmail.com www.DrMaxCohen.com CAD/CAM_contact Fig. 13_Provisional hollowed out to fit over the temporary abutments. Fig. 14_Provisional with bite registration for alignment in mouth. Fig. 15_Completed screw-retained provisional. Figs. 16a & b_Final restoration. Fig. 17_Post-op CT scan. Fig. 16a Fig. 16b Fig. 15 Fig. 17 Fig. 13 Fig. 14