Figure 2: Preoperative condition of the mandibular arch. The patient’s remaining lower teeth were painful and exhibited periodontal involvement and loss of attached tissue. The patient did not wish to spend money salvaging her remaining mandibular teeth, which had an unfavorable long-term prognosis.

Figure 3: While the patient’s existing upper denture provided sufficient retention, it did not function properly and the incisal edges in the anterior were subjected to excessive wear due to the lack of posterior occlusion. The patient’s maxillary arch exhibited the anatomical landmarks needed for a stable complete denture, including ridge thickness, a favorable U-shaped palate for a strong seal, and firm, keratinized soft tissue.

Figures 4a, 4b: Lateral views illustrate ridge resorption and thin soft tissue in the posterior areas of the mandible, which caused the patient pain, discomfort, and inadequate retention and function when she wore the existing partial appliance. A fixed implant solution was ideal for the mandible, as a removable, tissue-supported appliance could not achieve the stability and chewing capability the patient desired. Despite the bone loss in the posterior, the ridge width in the premolar areas was sufficient for a 3.5 mm implant on each side of the arch, which, in combination with four dental implants situated between the mental foramina, would provide the A-P spread needed for a fixed full-arch implant prosthesis.

Figures 4a, 4b: Lateral views illustrate ridge resorption and thin soft tissue in the posterior areas of the mandible, which caused the patient pain, discomfort, and inadequate retention and function when she wore the existing partial appliance. A fixed implant solution was ideal for the mandible, as a removable, tissue-supported appliance could not achieve the stability and chewing capability the patient desired. Despite the bone loss in the posterior, the ridge width in the premolar areas was sufficient for a 3.5 mm implant on each side of the arch, which, in combination with four dental implants situated between the mental foramina, would provide the A-P spread needed for a fixed full-arch implant prosthesis.

Figure 5: CBCT scanning confirmed sufficient bone volume for the placement of six implants in the mandible. The 3-D imaging also helped determine the proper diameters and lengths of implants to place while avoiding the inferior alveolar nerve and mental foramina. Treatment options were presented to the patient, using case examples and models to show the differences between a traditional denture, an implant overdenture and a fixed full-arch implant restoration.

Figure 6: The patient, who desired but could not afford implant therapy for both arches, agreed to a treatment plan in which her existing maxillary appliance would be replaced with a new complete denture, with implants placed in the mandible to support a fixed restoration. The patient opted for extraction with immediate implant placement — an approach with success ratios that compare favorably to extraction with delayed implant placement.^6,7 Many patients find this approach to implant therapy appealing due to the reduced number of surgical appointments, shortened treatment time, and opportunity for an immediate fixed restoration. To begin the procedure, a full-thickness flap was reflected and the anterior teeth of the mandible were extracted atraumatically using periotomes.

Figure 7: Lateral view of the mandible following completion of the bone-leveling procedure, which was performed in the anterior using a straight surgical handpiece with acrylic bur to create a uniform prosthetic platform for the implants. Note the location of the mental foramen, the visualization of which confirmed proper length of the 3.5 mm x 8 mm implants selected for the premolar areas.

Figure 8: Hahn™ Tapered Implants (Glidewell Direct; Irvine, Calif.) were selected for the surgical procedure because of this system’s ability to maximize primary stability and facilitate positioning within the limited bone volume of the residual ridge. After the osteotomies were created following a user-friendly drilling protocol, the implants were threaded into place, including 4.3 mm x 13 mm implants in the areas of teeth #22, #25 and #27, a 3.5 mm x 13 mm implant in the area of #23, and 3.5 mm x 8 mm implants in the areas of #20 and #29. The deep, sharp threads of the Hahn Tapered Implant eased positioning within the extraction sockets by engaging the lingual wall during insertion, helping maintain a safe distance from the facial plate.

Figure 9: Inclusive^® Multi-Unit Abutments (Glidewell Direct) were connected to the implants to establish a consistent, tissue-level prosthetic platform. Newport Biologics™ Mineralized Cortico/Cancellous Allograft Blend (Glidewell Direct) was placed in the gaps between the implants and the extraction sockets and was layered on top of the exposed cortical plate. By providing a scaffold for cell in-growth and consistent bone regeneration around the implants, the cortico/cancellous allograft material helped ensure a predictable outcome.

Figure 10: An immediate denture was fabricated in advance of the surgical appointment. The high primary stability established by the Hahn Tapered Implants allowed for conversion of the denture into a fixed screw-retained temporary appliance for immediate loading.

Figures 11a, 11b: The immediate denture was modified to serve as a fixed provisional prosthesis by adding and trimming temporary cylinders and removing the cantilevers in the molar areas of the prosthesis, which avoided the application of excess forces on the implants during healing.

Figures 11a, 11b: The immediate denture was modified to serve as a fixed provisional prosthesis by adding and trimming temporary cylinders and removing the cantilevers in the molar areas of the prosthesis, which avoided the application of excess forces on the implants during healing.

Figure 12: The converted denture was connected to the implants on the day of surgery, extending from premolar to premolar. The screw-retained provisional appliance immediately restored form and function and allowed the patient to leave the surgical appointment with a fixed prosthesis in place. The patient was extremely pleased to avoid wearing a removable appliance throughout the course of treatment.

Figure 13: The occlusion of the provisional implant prosthesis was verified against the patient’s existing upper denture, which was left in place until a new prosthetic design could be determined in concert with the lower full-arch implant restoration following integration of the implants.

Figures 14a, 14b: Postoperative CBCT scans illustrate the six axially placed Hahn Tapered Implants as well as the temporary cylinders of the immediate provisional implant prosthesis.

Figures 14a, 14b: Postoperative CBCT scans illustrate the six axially placed Hahn Tapered Implants as well as the temporary cylinders of the immediate provisional implant prosthesis.

Figures 15a, 15b: After five months of healing, the patient exhibited excellent soft-tissue health. The patient’s appliances were removed, integration of the implants was confirmed, and impressions were taken of both arches to begin the fabrication process for the mandibular full-arch implant restoration and the new maxillary complete denture. To meet the patient’s desire for a fixed restoration while ensuring the best possible long-term prognosis, the patient was prescribed a BruxZir Full-Arch Implant Prosthesis, which eliminates any concerns with wear and breakage at a cost that compares favorably with screw-retained hybrid dentures. Further, the opportunity to test-drive a PMMA provisional implant prosthesis addressed the patient’s concern with achieving an accurate fit for the final restoration.

Figures 15a, 15b: After five months of healing, the patient exhibited excellent soft-tissue health. The patient’s appliances were removed, integration of the implants was confirmed, and impressions were taken of both arches to begin the fabrication process for the mandibular full-arch implant restoration and the new maxillary complete denture. To meet the patient’s desire for a fixed restoration while ensuring the best possible long-term prognosis, the patient was prescribed a BruxZir Full-Arch Implant Prosthesis, which eliminates any concerns with wear and breakage at a cost that compares favorably with screw-retained hybrid dentures. Further, the opportunity to test-drive a PMMA provisional implant prosthesis addressed the patient’s concern with achieving an accurate fit for the final restoration.

Figure 16: After obtaining jaw relation records, wax setups were produced and tried in to evaluate function, lip support, smile line, esthetics and occlusion. The conversion denture delivered at the time of surgery served as the basis for the lower restoration, and a new design was determined for the maxillary denture. The final wax setup and verified master model were submitted to Glidewell Laboratories for copy-milling of the BruxZir Full-Arch Implant Prosthesis, significantly reducing the cost of the final restoration.

Figures 17a, 17b: After scanning the final wax setup and master model, Glidewell Laboratories created the digital design for the monolithic zirconia implant restoration using advanced CAD/CAM software. Because this case was submitted as a copy-mill restoration, the digital design represents a precise replica of the final wax setup; adjustments were made only to the openings through which titanium connections and screws are used to attach the prosthesis to the implants.

Figures 17a, 17b: After scanning the final wax setup and master model, Glidewell Laboratories created the digital design for the monolithic zirconia implant restoration using advanced CAD/CAM software. Because this case was submitted as a copy-mill restoration, the digital design represents a precise replica of the final wax setup; adjustments were made only to the openings through which titanium connections and screws are used to attach the prosthesis to the implants.

Figure 18: After fine-tuning the function, occlusion, and teeth shape and size of the upper denture with wax setups, a new maxillary denture was produced, significantly improving upon the esthetics of the patient’s existing appliance.

Figure 19: The lab fabricated a PMMA provisional implant prosthesis, which is recommended by the lab for copy-mill cases to ensure the design is completely accurate before the final restoration is milled from monolithic zirconia. The provisional implant prosthesis was attached to the master model to confirm a passive fit.

Figures 20a, 20b: Advanced staining techniques were used to achieve consistent, lifelike gingival and tooth shades for the denture and implant prosthesis.

Figures 20a, 20b: Advanced staining techniques were used to achieve consistent, lifelike gingival and tooth shades for the denture and implant prosthesis.

Figure 21: The provisional implant prosthesis was tried in and achieved an accurate fit due to the precision of the CAD/CAM copy-mill process. Screws were then threaded through the access openings to secure the prosthesis to the implants, and the screw access holes were filled with Camouflage^® NanoHybrid Composite.

Figure 22: The final upper denture was seated and the esthetics, function and occlusion were confirmed with both appliances in place. Minor occlusal adjustments were made to the denture and provisional appliance. After three weeks of wear, the patient was satisfied with the design of the implant prosthesis, so the provisional was returned to the lab with the master cast for fabrication of the final restoration.

Figure 23: The final mandibular restoration was milled from BruxZir Full-Strength Solid Zirconia. As an exact replica of the patient-confirmed PMMA provisional implant prosthesis (left), the final full-arch BruxZir restoration (right) aligned with the precise expectations of the patient.

Figure 24: The final BruxZir Full-Arch Implant Prosthesis was delivered with relative ease. As a result of verification with the PMMA provisional appliance, the final restoration fit perfectly and did not require any alterations.

Figure 25: Final CBCT scan illustrates the BruxZir Full-Arch Implant Prosthesis fully seated over the Hahn Tapered Implants.

Figures 26a, 26b: Before and after images illustrate the transformation provided by the new maxillary complete denture and the mandibular full-arch BruxZir restoration — a combination that met the functional and esthetic needs of the patient, who now enjoys substantially improved chewing capability, comfort, confidence and quality of life.

Figures 26a, 26b: Before and after images illustrate the transformation provided by the new maxillary complete denture and the mandibular full-arch BruxZir restoration — a combination that met the functional and esthetic needs of the patient, who now enjoys substantially improved chewing capability, comfort, confidence and quality of life.