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C r o s s - a r c h i m p l a n t - s u p p o r t e d f i x e d r e s t o r a t i o n Fig. 1 Fig. 2 Fig. 3 Fig. 1 Pretreatment photograph: frontal view. Fig. 2 Implants placed in the upper jaw after the second-stage surgery. Fig. 3 Implants placed in the lower jaw after the second-stage surgery. decreased to 90% at the 10-year follow- up.12, 13 The outcome would be dependent on the patient’s daily routine, home care and professional recall visits. The patient decided to proceed with reha- bilitation of the upper arch with a fixed complete denture, being aware of the associated cost, advantages and disadvantages. Comprehensive clinical, radiographic and study cast evaluation found that the previously placed implant in the maxilla (TiUnite machined collar Brånemark System MkIII, Nobel Biocare), inserted in the left central area to restore a tooth lost to an endodon- tic fracture complication in 1999, could be main- tained for planned rehabilitation. Three months after removal of the teeth and residual ridge healing, 7 Biocare replace implants (Nobel Biocare) were placed in additional sites across the maxillary arch. Simultaneously, extractions were performed of the mobile teeth in the right mandibular posterior site. Four months after extraction, 3 Biocare replace implants were placed to replace the extracted teeth. Bone grafting was not required for all procedures. All of the placed implants achieved stability at placement and were fully osseointe- grated, evidenced by radiography and clinical torque testing to 35 N cm, performed 3 months after insertion, during healing abutment con- nections (Figs. 2 & 3). Finally, the case was referred to a prosthodontist for full-arch upper fixed-removable and partial-arch fixed tooth form prostheses. All efforts were made to retain some access for a proxy brush under the pros- thesis to reduce the periimplantitis risk. The maxillary and mandibular prostheses were seated with custom titanium abutments using a temporary cement (Improv Temporary Implant Cement, Salvin Dental Specialities, Charlotte, N.C., U.S.). The patient had regular visits for periodontal control and maintenance in a well-organized scheme with appointments over the years. The maxillary prosthesis was remade once after 3 years of function, owing to porcelain breakage in the esthetic zone. However, after the remake, the patient improved compliance regarding use of the bruxism appliance and the prosthesis remained intact and functional for over 11 years. Nevertheless, there was progressive bone loss at a Class 3 furcation site of the mandibu- lar first molar (Fig. 4) that responded to root resection therapy in 2003 and remained stable thereafter (Fig. 5). The overall reduced peri- odontal disease activity may in part be due to the extraction of most of the involved teeth and in part to long-term therapy with a daily dose of 100 mg of minocycline for acne, begun by the patient in 2004, then switched in 2008 to 100 mg of doxycycline, cut into quarters and taken daily. Despite her progressive periodontal history, the bone loss at the implants showed the typical pattern of about 0.5 mm of bone loss beyond the machined collar and at most sites there was no sign of periimplantitis related to marginal bone loss. However, there were two sites in the left maxillary molar area where periimplant bone loss had developed. The implants placed at this position were both lost after 3 years of loading, primarily related to implant proximity between them, limiting proper oral hygiene access (Figs. 6 & 7). These implants were not replaced and the prosthesis was retained with a distal cantilever pontic at the first molar area off the most distal implant site at the second premolar area in the full-arch prosthesis. Acute suppuration and about 2 mm 50 Volume 3 | Issue 3/2017 Journal of Oral Science & Rehabilitation