Canada (EN)
CLINICAL CASE
Full-arch immediate loading in the maxilla and single molar in the mandible
Prof. Alessandro Pozzi
Patient: 65-year-old male. Hyperglycemia; coronary angioplasty and stent; clopidogrel (Plavix). Smoker (fewer than 10 cigarettes per day).
Clinical situation: terminal dentition in the upper jaw. Tooth mobility and periodontal support of less than 30%. Periapical radiolucency of approximately 1 cm of first molar, lower left side. Patient refuses any invasive surgical periodontal bone regeneration procedures.
Surgical solution: immediate tooth extraction. Four NobelActive TiUltra implants placed with X-Guide dynamic navigation system. Immediate loading of full-arch temporary prosthesis, with Multi-unit Abutment Xeal. Restorative solution: immediate loading of screw-retained full-arch temporary prosthesis.
Final restoration: screw-retained porcelain fused to NobelProcera Zirconia full-arch implant bridge.
Surgery date: April 2019.
Total treatment time: 6 months.
Tooth position: upper full-arch and tooth 3.
Initial clinical situation
Terminal dentition in the upper jaw. Tooth mobility and periodontal support of less than 30%. Periapical radiolucency of approximately 1 cm of first molar, lower left side. Patient refuses any invasive surgical periodontal bone regeneration procedures.
Preoperative clinical frontal and lateral views in occlusion.
Treatment planing
DTX Studio Implant and DTX Studio Lab for streamlined 3D planning and execution. A screw-retained full-arch restoration supported by four implants was planned with an FP1-FP3 prosthetic design (direct emergence from the soft tissue with pink interface).
DTX Studio Implant 3D implant planning. In the cross section, the reduced periodontal support and the discrepancy between the original tooth contour and virtual wax-up design are visible (left).
DTX Studio Lab 3D prosthetic planning according to the digital assisted soft tissue sculpturing (DASS) technique (right).
Surgical procedure
X-Guide dynamic navigation with 360° control of implant drill angulation and position.
Minimally invasive tooth extraction, flapless surgical approach, periapical infection removal, careful debridement of the post-extraction socket, X-Guide immediate implant positioning, xenogeneic soft tissue matrix to enhance the gingival architecture healing and thickening.
NobelActive TiUltra RP 4.3 x 15 mm positioned in the post-extraction sockets in straight and angulated positions.
Intraoperative occlusal view of the bone and soft tissue grafting. The xenogeneic collagen matrix was packed and secured on the buccal side and interproximally (left).
A screw-retained full-arch temporary prosthesis was placed on the day of surgery (right).
Postoperative orthopantomogram.
Occlusal view: 1 month postoperative after the DASS technique (left). Occlusal view: 4 months post implant placement and DASS technique.
Excellent soft tissue healing and maturation around the Multi-unit Abutments Xeal (right).
Smiling scan technique: DTX Studio software 3D rendering of the preoperative patient smile (left).
Smiling scan technique: DTX Studio software preoperative 3D smile design (center).
Postoperative clinical outcome with the full-arch temporary prosthesis (right).
Screw-retained zirconia crown bonded on Universal Base on On1 Xeal. Preoperative periapical X-ray. Radiolucency-periapical infection of about 1 cm of the 1st molar lower left side (first image from the left).
Intra-operative periapical X-ray. After tooth extraction and removal of the cyst a NobelParallel TiUltra 5.5 mm x 13 mm was positioned in the fresh extraction socket and the defect was regenerated with xenogeneic bone particulate graft (second image from the left). Periapical X-ray after 3 months.
After ISQ assessment, an IOS impression was taken with a dedicated scan body (third image from the left).
Periapical X-ray after 5 months. A screw-retained zirconia crown bonded on a Universal Base on On1 Xeal was delivered (fourth image from the left).
Restorative procedure
Soft tissue healing around the On1 Xeal abutment 1 month after tooth extraction and cyst removal (left).
3D printed master cast with On1 Xeal analogue secured in the correct position (right).
Screw-retained zirconia crown to be rebonded on Universal Base on On1 Xeal (left).
Definitive screw-retained zirconia crown bonded on Universal Base seated on On1 Xeal (right).
Extraoral chairside bonding sequence of screw-retained zirconia crown on Universal Base seated on On1 Xeal.
DTX Studio Lab software prosthetic workflow for CAD/CAM manufacturing of a screw-retained NobelProcera zirconia full-arch prosthesis.
Extraoral view of the definitive screw-retained NobelProcera Implant Bridge and the screw-retained zirconia crown bonded on Universal Base secured on On1 Xeal.
Outcome
Digital assisted soft tissue sculpturing (DASS) technique. Scalloping of the soft tissue interface.
Postoperative view: Natural appearance of the perio-restorative interface to embrace the screw-retained full-arch porcelain fused to NobelProcera zirconia prosthesis (left).
Final view: Natural appearance of the perio-restorative interface to embrace the screw-retained full-arch porcelain fused to NobelProcera zirconia prosthesis (right).
Screw-retained NobelProcera porcelain fused to zirconia implant bridge.
Screw-retained NobelProcera porcelain fused to zirconia implant bridge.
Preoperative patient smile. Tooth wear, reduced tooth exposure. Failing anterior dentition. Posterior edentulism (left).
Postoperative patient smile. Pleasant smile with proper tooth exposure, incisal edge position, tooth length and occlusal plane (right).
Excellent marginal bone levels around Multi-unit Abutments Xeal and NobelActive TiUltra implants in the upper jaw and On1 Base Xeal and NobelParallel TiUltra in the 1st molar lower left side.
1-year follow-up. Orthopantomogram. Excellent bone level around Multi-unit Abutments Xeal and NobelActive TiUltra implants in the upper jaw and On1 Base Xeal and NobelParallel TiUltra in the 1st molar lower left side (left).
2-year follow-up. Orthopantomogram. The bone architecture is preserved with a scalloped design. The bone resorption pattern is within the criteria of success around the Multi-unit Abutments Xeal and NobelActive TiUltra implants in the upper jaw and On1 Base Xeal and NobelParallel TiUltra in the 1st molar lower left side (right).
Upper jaw 2-year follow-up. Periapical X-rays upper jaw. Excellent bone levels around Multi-unit Abutments Xeal and NobelActive TiUltra implants (left).
2-year follow-up. Periapical X-ray. On1 Xeal abutment and NobelParallel TiUltra in the 1st molar lower left side (right).
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