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ePaper created 2016-01-07, 12:59:38 | version 1.38.0
industry I GmbH; Frankfurt/Main, Germany) would have been the ideal restorations given the need for long-term durability in this case, the product was not yet avail- able at the time of treatment. Thus, PFM prostheses were chosen in order to avoid acrylic and its suscepti- bilitytostaining,wearandfracture.TheproposedPFM restorations included layered pink porcelain to recre- atethepatient’snaturalgingivalcontours.Allaspects of treatment were explained to and accepted by the patient. The first phase of treatment began by atrau- matically extracting the patient’s entire dentition us- ingPhysicsForceps(GoldenDentalSolutionsInc.;De- troit, USA), which allowed for removal of the teeth withoutcausinganydamagetothesurroundingbone. Theextractionsocketswerefilledwithgraftingmate- rialinordertopreservethesocketsandrebuildthemax- illary and mandibular ridges for ideal implant place- ment. The patient was provided with immediate den- tures, which were prefabricated based on impressions thatweretakenatapreviousappointment(Fig.3). Afterapproximatelyfivemonthsofhealing,thepa- tientwascalledinsocone-beamcomputedtomogra- phy(CBCT)scanningcouldbeperformed.Thesofttis- sue of the patient’s now-edentulous arches exhibited excellent health (Figs. 4a & b). CBCT scanning con- firmed that the grafting procedure was successful in increasingthebonevolumeavailabletoaccommodate the planned implants. The CBCT scanning data was used to devise a virtual treatment plan that would place the eight implants for each edentulous ridge in the maximum amount of bone while adhering to the keyimplantpositionsastaughtbyDr.CarlMisch.6 Sur- gical guides were fabricated to ensure placement of the implants in the precise positions called for by the treatmentplan(Figs.5a&b). Atthenextappointment,thetissue-supportedsur- gicalguidesweretriedinandfoundtobewell-fitting. Thefixationpinsofeachsurgicalguideweretightened with a surgical index in place to ensure complete, se- cure seating of the appliances (Fig. 6). A tissue punch was used to provide access to the implant sites, facili- tating a flapless surgical procedure that would min- imise gingival trauma. The osteotomies were created through metal inserts placed in the surgical guides, which precisely controlled drilling depth and orienta- tionaccordingtothedigitaltreatmentplan(Fig.7). Eight BioHorizons® Laser-Lok® dental implants (BioHorizons; Birmingham, USA) were placed in each ridge, including 5.7 mm implants in the two distal- most locations of each arch, and 4.5 mm implants in the remaining sites. After placing healing abutments intheimplants,asoftrelinewasperformedonthepa- tient’s temporary dentures so they could continue to serveasinterimprosthesesforthedurationofhealing and osseointegration. Four months after surgery, the patient returned to the office so impressions could be taken.Removalofthehealingabutmentsrevealedop- timaltissuehealthsurroundingtheimplantsites(Figs. 8a & b). Transfer posts were seated to capture the po- sitionoftheimplants(Fig.9).Closed-trayimpressions were taken of the upper and lower arches using Take 1® Advanced™ vinyl polysiloxane material (Kerr Corp.; Orange, USA, Figs. 10a & b). At the same ap- pointment, thermoformed suck-down impressions were made and a bite registration taken with the Figs. 14a & b_The lab digitally produced the custom abutments and verified the design on the soft-tissue models. Fig. 15_A diagnostic wax-up was created to assist in the development of the full-arch reconstructions. Fig. 16_The BioTemps prostheses were fabricated, and the interocclusal relationship was verified on the articulator prior to patient try-in. Fig. 17_Acrylic positioning jigs were used to seat the custom abutments in the patient’s mouth. I 35implants4_2015 Fig. 15 Fig. 17Fig. 16 Fig. 14a Fig. 14b