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| opinion 3-D technology 38 CAD/CAM 2 2016 their sites. Extensive boney destruction was the re- sult of periapical pathology in teeth #9 and #11, which were bone grafted to repair the damage (Fig. 30). Each implant was checked with insertion torque and Osstell Resonance Frequency values to ensure that these implants could handle the imme- diate load of the fixed prosthesis. All were ade- quately stabilised except the angled implant at the #14 site. Osstell readings measure implant stability quotient or ISQ and is related to bone to implant contactorthepercentageofimplantsurfaceincon- tact with bone as seen at the microscopic level. Readings taken in the 70–74 level is suitable for immediately loading an implant. Bone quality in the#14sitewasclassIII/IV,mostlytrabecularbone. This was second staged and buried to allow for osseointegration. The restorative phase during this visit began with the placement of multi-unit abutment which changed the angulation of the implant platforms and received the prosthetic screw that secured the prosthesis to the implants. The surgical field was closed with sutures around plastic caps placed over the multi-units that kept the gingival tissue from collapsing (Fig. 31). The prefabricated complete denture was tried in and then the intaglio surface wasfilledwithbluemoussebitematerialtoregister the positions of the implants. This provided the lab techwithastartingpointtoopenupthesiteswhere the temporary cylinders would exit through the crowns. As anticipated during the planning phase some access holes were posi- tioned labially and will be addressed tooptimisetheresultinthefinalcase. Once the denture was seated and enough room existed around each temporarycylinder,triadmaterialwas placed into the openings and posi- tioned while the assistants cured the resin completely 360 degrees. It is ex- tremely important to cover the pros- thetic screws with cotton or Teflon tape and temporary resin while the triad is curing otherwise you might not be able to remove the prosthesis when cured. This would be a disaster best avoided by being diligent with this step in the procedure. When the material was cured I was able to un- screw each prosthetic screw and remove the pros- thesis. The lab tech spent time reducing the flanges, palate any excess material, and polishing while — converting the final shaped horseshoe prosthesis which the patient would leave the office with (Fig. 32). A 3-D scan was taken to evaluate and it revealed each implant well situated in bone and the prosthesis being secured properly on the five Nobel Active implants. All of the fixtures were 4.3 mm x 13 mm or 15 mm except #14, which was 5 mm x 13 mm. I have worked with Nobel Active implants since their introduction with very high success.Iwouldhavelikedtheimplantinthe#7site to be straighter but the threads of the Nobel active implant may have created its own path of inser- tion. These implants have an aggressive thread design and are capable of changing direction when inserting into the osteotomy, especially in softer bone. Alexwasabletoleavetheofficewithanewcomple- ment of teeth, something he lacked for many years. The fixed prosthesis was developed with implant protectedocclusion,crossarchstabilisation,centric stops with freedom in lateral excursions. Four months will be required at a minimum to allow for integration, evaluating the new tooth positons, occlusal analysis and assess overall function prior to mov- ingforwardwithadefinitiveprosthe- sis. Alex was dismissed with post-op instructions given to continue with prescribed medications, to eat an es- pecially soft diet for the next two weeks and gradually increase addi- tional foods over time which would progressively load the implants. I ex- amined Alex 4 days later where he exclaimed ‘I can finally smile again!’ Fig. 29 Fig. 30 Fig. 31 Fig. 32 22016