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Dental Tribune Middle East & Africa Edition | 2/2017 ◊Page 8 persons, as the surgical and prostho- dontic procedures are accomplished on the same day. Patients can leave the dental office with a stable, esthet- ic and retentive prosthesis. The flapless technique, first pro- posed by Tramonte3, can be per- formed when the bony crest is wide and an adequate amount of attached gingiva is present. The technique al- lows for uneventful healing, a reduc- tion of postsurgical inflammation and only moderate inconvenience for the patient, who can eat efficient- ly the same day. Provisional prosthesis and tooth arrangement During the surgical session a tem- porary resin prosthesis is inserted. Occlusal plane height must be cor- rect. A lingualized (lingual contact) scheme of occlusion is recommend- ed. The upper anterior teeth are best arranged without any vertical overlap. The amount of horizontal overlap is determined by the jaw re- lationship. A vertical overlap for ap- pearance can be used, provided that an adequate horizontal overlap is in- cluded to guard against interference within the functional range.4 Lingualized (lingual contact) occlusion Lingualized (lingual contact) occlu- sion maintains the esthetic and food penetration advantages of anatomic teeth while maintaining the me- chanical freedom of nonanatomic teeth. Among the advantages of a lingualized occlusion are occlusal forces centered over the ridge crest in centric occlusion, masticatory force is effectively transferred more “lingual” to the ridges during work- ing side excursions, the “mortar and pestle” type of occlusion minimizes the occlusal contact area provid- ing for more efficient food bolus penetration and elimination of the precise intercuspation that can com- plicate the arrangement of anatomic denture teeth. Lingualized occlusion also prevents cheek biting by holding the buc- cal mucosa off the food table by eliminating occlusal contacts on the maxillary buccal cusps, minimizes occlusal disharmonies created from errors in jaw relationships, denture processing changes and settling of the denture base, and simplifies set- ting of denture teeth, balancing the occlusion and any subsequent oc- clusal adjustment procedures.5 mCME 9 Clinical report A healthy 50-year-old caucasian woman presented for treatment at the office of one of the co-authors (LDC) with a mobile, painful, 12-tooth semiprecious alloy-ceramic fixed prosthesis (Fig. 2). The prosthesis was removed and all of the remain- ing abutment teeth were found to be nonrestorable with extraction in- dicated (Fig. 3). After removal of the retained teeth, eight titanium one- piece implants were inserted in one session (Fig. 4). Immediate stabilization of the eight implants and 2 additional implants that were previously inserted in the posterior regions was achieved by welding (Acerboni Intraoral Weld- ing Unit, Casargo, Italy) each implant to a 1.5 mm supporting titanium bar (Acerboni, Casargo, Italy), which previously had been bent to fit pas- sively on the palatal mucosa (Fig. 5). A provisional resin prosthesis was inserted, which provided an accept- able vertical dimension and lingual contact occlusion. Oral hygiene pro- cedures were demonstrated to the patient and reviewed at all future ap- pointments. After 90 days, a panoramic radio- graph suggested complete integra- tion (Fig. 6) and a healthy mucosa was observed. (Fig. 7). The definitive full-arch gold-ceramic maxillary prosthesis was inserted, which great- ly pleased the patient and her family. In the lower arch, the right first and second bicuspids were extracted and implants placed in the first bicuspid and first molar regions. The implants were welded together intraorally (Fig. 8), followed by the fabrication and cementation of a three-tooth fixed prosthesis (Fig. 9). A 7-year follow-up radiograph (Fig. 10) shows satisfactory preserva- tion of bone surrounding all of the implants. An intraoral photograph of the definitive prosthesis shows healthy gingival tissue (Fig. 11). References 1. Mondani PL, Mondani PM. The Pierliugi Mondani intraoral electric solder. Principles of development and explanation of the solder using syncrystallization. Riv Odontostom- atol Implantoprotesi. 1982;4:28-32. 2. Rossi F, Pasqualini ME, Dal Carlo L, Shulman M, Nardone M, Winkler S. Immediate loading of maxillary one-piece screw implants utilizing intraoral welding: a case report. J implants with Oral Implantol (in press). 3. Tramonte, S. A further report on intraosseous im- proved drive screws. J Oral Implant Transplant Surg. 1965;11:35-37. 4. Winkler S, ed. Essentials of Com- plete Denture Prosthodontics. 3rd ed. Delhi, India: AITBS Publish- ers; 2015. 5. Lang BR, Lauciello FR, McGivney GP, Winkler S. Contemporary Com- plete Denture Occlusion, revision 4. Amherst, NY: Ivoclar Vivadent, 2012. Dr. Luca Dal Carlo is in private practice in Venice, Italy. Dr. Franco Rossi is in private practice in Varese, Italy. Dr. Marco E. Pas- qualini is in private practice in Milan, Italy. Dr. Mike Shulman is in private practice in Clifton, N.J., and adjunct associate profes- sor at the School of Oral Health Sciences, Kingston, Jamaica. Dr. Michele Nardone is with the Ministry of Public Health, Rome, Italy. Dr. Sheldon Winkler is adjunct pro- fessor at Midwestern University College of Dental Medicine, Glendale, Ariz., and School of Oral Health Sciences, Kingston, Jamaica. Dr. Tomasz Grotowski is in pri- vate practice and professor at the School of Minimally Invasive Implantology, Szc- zecin, Poland. ◊Page 7 Discussion The number of implants placed for an edentulous patient should be based upon whether the design is to be implant-assisted or implant- supported. If the goal is a minimal- ist design utilizing the soft tissue for support, two implants using Lo- cator attachments are appropriate to retain a mandibular denture and will provide a predictable outcome. However, when more than two im- plants using resilient overdenture retainers are employed, there is not a corresponding linear increase in retention of the denture and the re- sult may suffer. Therefore, when at least four implants are planned, the restoration should be designed as implant-supported to maximize the value of the patient’s greater invest- ment. This article discusses just such a situation where a patient had experi- enced repeatedly low value from her investment of five implants. By re- designing her treatment to become implant-supported through the use of the ATLANTIS Conus concept, a successful result was achieved with- out the greater expense of a fixed hybrid. The final result was function- ally comparable to a fixed restora- tion while providing lip and cheek support of a removable prosthesis without complicating or obstructing oral hygiene. The telescopic design of the ATLAN- TIS Conus concept provides out- standing retention of the prosthesis during function as edentulous pa- tients chew in a relatively flat ellipti- cal pattern and the bridge can only be removed vertically. The abut- ments themselves are patient-spe- cific and can be made for all major implant systems, allowing rescue of many frustrating results with over- dentures. As long as there is sufficient inter- arch space (at least 12 mm), existing finished dentures can be retro-fit with ATLANTIS Conus abutments, reducing patient cost while pro- viding a stable result. Cast chrome frame reinforcement is advised for all new ATLANTIS Conus prosthe- ses as the tremendous increase in strength of the bridge by the frame more than offsets the slight increase in cost and may actually reduce re- quired inter-arch space. The clinical procedure is relatively simple and comparable to implant overdentures; however, because the abutments are patient-specific, tooth position must be established before the design of the abutments is begun. Conclusion A patient with an 11-year history of frustration with her dental implant investment was treated successfully with the ATLANTIS Conus concept using patient-specific abutments and SynCone caps, providing an im- plant-supported, removable bridge with all the benefits of a fixed design and none of the limitations. Figure 15. Completed bridge with SynCone caps processed in po- sition. Because they have been processed intra-orally, there is no error in fit, these caps are extremely retentive allowing only verti- cal displacement of the prosthesis Figure 16. Completed restoration. Note the absence of screw ac- cess holes for a prosthesis that looks like a denture yet fits like a bridge Figure 17. ATLANTIS Conus abutments torqued to specified level, obturated with Teflon tape and composite resin Figure 18. Laboratory processed, clear duplicate prosthesis with siliconized reline material to improve retention; to be used as a nighttime appliance to protect the tongue from the sharper edges of the abutments Figure 19. Panoramic radiograph of the abutments seated on the four selected implants. Because the restoration is fully implant- supported, gradual diminution of the residual ridge will present no consequence to the patient Figure 20. Completed bridge in place showing flange length suit- able to prevent food Acknowledgements The author would like to thank Fred Senne, John Bergstresser and Sean Ferguson (DENTSPLY Implants) for their expertise and information. The author would also like to thank Tom Wiand and the talented team at Wiand Dental Laboratory for the laboratory procedures and products described in this article. References 1. Zarb G A. The edentulous milieu. J Prosthet Dent 1983; 49: 825-831. 2. Fish E W. Using the muscles to sta- bilize the full lower denture. JADA, Dec 1933: 2163-69. 3. The Glossary of Prosthodontic Terms. Eigth edition. J Prosthet Dent, 2005. 94; 1: 10-92. Editorial note: The full list of refer- ences is available from the publisher. Dr. Marc Montana Dr. Montana graduat- ed from the University of Southern California School of Dentistry in 1987 and completed his certificate in Ad- vanced Prosthodontics at USC in 1989. He has maintains a full-time private practice in Tempe, Arizona since 1989, emphasiz- ing fixed, removable and implant pros- thodontics. He has been a clinical instruc- tor while attending USC and currently is a clinical instructor and lecturer in the Advanced Education of General Dentistry program at the Arizona School of Dentist- ry and Oral Health. He is a member of the Dentsply Implants’ PEERS North America study club, the American College of Pros- thodontists, the American Academy of Fixed Prosthodontics, the Pacific Coast Society for Prosthodontics, the Academy of Osseointegration and the American and Arizona Dental Associations. He has lectured extensively throughout North America on the topics of implant, fixed and removable prosthodontics. He can be reached at 480-820-2901 or office@ markmontanadds.com