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CAD/CAM international magazine of digital dentistry No. 3, 2016

fixed and removable implant restorations ce article | 25 CAD/CAM 3 2016 such a restoration for both arches, he wanted a re- tentive appliance for his mandible, with the option of later upgrading to a fixed prosthesis. The patient accepted a treatment plan in which his maxilla would be restored with a BruxZir Full-Arch Implant Prosthesis and his mandible with an Inclu- sive Locator Implant Overdenture. Fabricating his maxillary restoration from monolithic zirconia would ensure maximum long-term durability. This was important provided the relatively young age of the patient, who would not have to worry about hisupperprosthesissuccumbingtofractures,chips or stains. His lower appliance would be held in place by connecting to the implants via Locator attach- ments (Zest Anchors), which are an economical means of improving prosthetic retention and sta- bility. The overdenture caps that connect to the Locator attachments would be incorporated in the prosthesischairside,thoughitshouldbenotedthat many clinicians elect to have the laboratory handle this step. The surgical phase of treatment called for the extractionofthepatient’sremainingteethfollowed by the immediate placement of eight dental im- plants. CBCT scans were taken to help determine the optimal placement of the implants within the availableboneandawayfromthepatient’svitaloral anatomy. Evaluation of the CBCT scan determined that there was sufficient height, width and quality of bone to place the implants in the appropriate locations and angulations via freehand surgery. Four 3.7 mm Inclusive Tapered Implants (Glidewell Direct) would be placed in each arch to support the fixed maxillary restoration and the removable mandibular prosthesis. At the surgical appointment, the patient’s remain- ing teeth were removed, and a flap was raised to visualise the socket sites and areas of implantation. Bonelevellingwasperformedonthepatient’smax- illary arch to elevate the patient’s smile transition line above the upper lip. The maxillary osteotomies were positioned to facil- itate an All-on-4 configuration, with the posterior implants tilted to maximise the anterior-posterior (A-P) spread, avoid the sinuses, and accommodate the patient’s bone limitations (Fig. 3). Osteotomies were created for the placement of four mandibular implants, as opposed to the minimum of two re- quired for a Locator overdenture. This would en- hance retention of the overdenture while affording the possibility of upgrading to a fixed restoration at a later time. Following the creation of the osteotomies, the implants were placed (Figs. 4a–c). Inclusive Multi-Unit Abutments (Glidewell Direct) were attached to the maxillary implants, correcting for the divergent angulation of the implants. This would both position the restorative platform in a manner that would situate the screw access Fig. 2: Preoperative panoramic radiograph exhibits periodontal disease, cervical caries, terminal state of the patient’s dentition, and the compromised state of the surrounding periodontium, which had rendered the teeth mobile. Fig. 3: Maxillary implants with parallel pins in place exhibit the axial placement of the anterior implants and the tilted angulation of the posterior implants. Figs 4a–c: The Inclusive Tapered Implants were threaded into place, achieving excellent initial stability. Fig. 2 Fig. 3 Fig. 4a Fig. 4b Fig. 4c 32016

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