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Treatment with implants and fixed prostheses: Guided Surgery Making the uncontrollable predictable. A case report.

Guided surgery · Implants ·

Dr. Paco Acedo

With a degree in odontology from the Alfonso X El Sabio University, a Master’s in Oral Surgery and Implantology from the UCSC, University Expert certification in Surgery from the University of Seville, University Expert certification in Implantology and Advanced Surgery from the University of Havana (UH).
He is currently the director of his own dental clinic in Seville, Clínica Dr. Acedo, and he is a speaker for Avinent surgery courses.

Introduction

Treatment with implants and fixed prostheses is currently the first choice for restorations in fully edentulate patients, as it is linked to a high long-term success rate.

The use of new digital technology in odontology has made it possible to make better diagnoses and apply better treatment plans, such as fitting the fixed prosthesis on implants in the same surgical session with an immediate-load protocol. Treatment with implants and fixed prostheses.

These immediate-load clinical protocols reduce the total treatment time and notably improve the edentulate patient's quality of life in terms of function, aesthetics and psychological wellbeing. But to do this, a multidisciplinary focus is required, perfectly integrating and synchronizing the diagnostic, surgical and prosthodontic techniques.Treatment with implants and fixed prostheses.

Patient history

Male 72-year-old patient with Parkinson's disease.
Smoker of a couple of packets of cigarettes a day for more than 18 years.
He has not visited the dentist for years as he experiences extreme fear in the consulting room, to the extent that he requested that any treatment be carried out under general anesthesia.

Reason for consultation

He came to the clinic wishing to improve his oral health and appearance.
His request, if possible, was to never see himself with no teeth from the moment he enters the operating room until he wakes up.

Treatment plan

After the radiodiagnostics examination conducted using CBCT, it was verified that the severe periodontitis that the patient suffered had caused infection and bone loss in certain areas of both arches that made it unfeasible to preserve the teeth, which is always the principal objective of any treatment.

We opted for a treatment plan based on a multidisciplinary focus between the odontological team, the dental laboratory and the technology partner, planning dental implants with guided surgery immediately post-extraction in the maxilla and mandible, to be able to secure a provisional prosthetic restoration on transepithelial abutments in each arch in the same surgical intervention.

This was a patient with odontophobia, so it was decided to perform the surgery in a hospital environment due to the duration of the treatment.

Description of the case

After the patient had approved the treatment, the virtual planning of the implant placement surgery and the digital design of provisionals based on virtual models could begin.

The data obtained by diagnostic imaging was transferred to the digital planning software Implant Studio (3Shape). This three-dimensional view enabled the controlled insertion of the implants to be planned in terms of length, diameter and spatial angle according to the characteristics of the alveolar ridge of the edentulate maxillae and taking into account the patient's final prosthetic restoration.

Surgical guides were manufactured so that the placement of the planned implants would be minimally invasive, without the need to make a flap, which simplified the treatment and improved the post-operative period for the patient.

We planned for a total of 14 Avinent Ocean IC Biomimetic implants in the following positions:
Implants in the maxilla: 10x3.5 (12), 11x3.5 (14), 13x3.5 (22), 7x4.0 (26), 8.5x4.0 (16, 17, 24, 27)
Implants in the mandible: 10x3.5 (44), 11.5x3.5 (34), 13x3.5 (31, 41), 10x4.0 (37), 11.5x4.0 (47).

It was also planned to place of Avinent straight transepithelial abutments during the surgery with different heights on all implants to standardize the level for the connection of the provisional prosthesis.

The two provisional prostheses were designed by the laboratory and manufactured in temporary resin in advance by the Avinent CadCam center, so they could be positioned on the same day of the surgery, as the patient had requested.

Although surgery under general anesthesia prevents patient collaboration and usually limits the surgery, we were able to complete it as planned. The implants were placed transmucosally full-guided in the anterior sector (from 15 to 25 and 34 to 44) and pilot-drill guided in the posterior sector. Four more unplanned implants were placed freehand. Given the survival expectations of some of them due to poor care by the patient, these implants were not included in the immediate load.

After evaluating the primary stability of the implants placed it was decided to screw-mount the resin provisional prostheses immediately to 5 implants in the maxilla and 4 in the mandible. As we were working with general anesthesia, the occlusion could not be checked when the prostheses were loaded, but a visit was scheduled within 24 hours to do so.

X-ray image of the implants placed with the screw-mounted provisional prostheses

During the osseointegration period of the implants, the provisional prostheses were replaced three times to work on the tissue shaping.

Finally, after 4 months, impressions were taken with a Trios (3Shape) intraoral scanner. The final structures were designed and then milled at the Avinent CadCam center. The aesthetic part of the ceramic load was finished at the Laboratorio Dentico (Seville).

The soft tissue management during the four-month healing period was essential to manufacture a definitive prosthesis that fitted the tissues perfectly and that facilitated good hygiene, necessary due to the patient's motor skills.

Definitive prosthesis in the mouth
Clinical result

During the treatment process, the surgeon and the prosthodontist attempt to control all the variables that could arise for the sake of a optimum result. 

In the planning phase prior to starting a case, seeking the greatest predictability possible along with reducing surgical and post-surgical trauma are reason enough to view guided surgery as the best alternative in highly complex cases.

The surgical and prosthetic references that the latest-generation digital software provides give us a simple yet precise overview of the treatment. It is very straightforward for the operator to put the plan into practice and makes it easier to explain to the patient the process they are about to undergo and even show them the final result.

Treatment with post-extraction implants using guided surgery and an immediate-load protocol is a successful alternative in the treatment of complex edentulate situations. In this case it has been possible to create a prior overall focus that was expressed perfectly in the surgery, satisfying the patient's initial expectations.