Alfonso Rao, Clinical Director at Queen Square Dental and Implant Clinic presents a clinical case report using Straumann® Pro Arch.
A 65-year-old female patient in good physical health required fixed rehabilitation in her upper jaw to replace an existing unsuitable full acrylic denture.
Due to bone resorption, the support of her upper lip was inadequate. It was discussed with the patient that the needs of support to her upper lip could either be with a prosthesis or with bone augmentation.
The patient was satisfied with a removable prosthesis in the mandible.
The aim was to perform implant placement and loading with screw-retained provisional prostheses and GBR to improve the support of the upper lip on the same day.
After a complete history and clinical examination were completed, diagnostic alginate impressions and photographs were obtained (Fig 1, Fig 2, Fig 3).
A second opinion from a specialist periodontist was requested to confirm that the periodontal disease on the lower jaw was stable and under control.
Her diagnostic study casts were mounted on a SAM-3 articulator with a facebow transfer and evaluated for skeletal relationship, basal alveolar bone, and potential ideal tooth position.
A temporary acrylic full denture was made to evaluate teeth position, lip support, phonetic and desired aesthetic outcome (Fig 4).
A cone beam CT scan was obtained to evaluate bone quantity and quality and for identification of available bone volume for implant placement to maximise implant distribution and avoid vital structures including maxillary sinuses and nasal floor. Her temporary denture was used with radiopaque resin as a radiographic stent (Fig 5, Fig 6, Fig 7).
The scan was sent to a radiologist for a report and a residual cyst in the area of the upper left central incisor was noticed.
The patient made clear during her initial visit and throughout the treatment planning process that she would not have an external sinus lift.
Informed consent was obtained for placement of five implants and simultaneous bone augmentation with mix of autogenous and xenograft bone under local anaesthetic with conscious sedation. In addition, the goal of treatment that day included fabrication of an immediate load fixed provisional bridge.
The patient’s nephew escorted her to our office on the day of the surgery. The patient’s vital signs were monitored throughout the procedure. After reflection of a muco-periosteal flap, a residual cyst was removed.
Implant osteotomy sites were initiated. These distal implant sites were tilted to avoid the anterior wall of the maxillary sinuses and to maximise the amount of anterior-posterior implant distribution.
Implant site preparation and final placement was confirmed with the assistance of a clear surgical template.
A total of five Straumann Bone Level RC SLA Roxolid® implants were placed in the maxilla with insertion torque between 35-50 Ncm.
In order to achieve the placement of screw access hole location in ideal prosthetic positions for the prosthesis, two 17° angled and three straight SRA (screw-retained abutments) were placed using 35 Ncm of torque on the abutment screws.
Autogenous bone was harvested from the maxillary tuberosity and nasal spine with bone scraper and mixed with Straumann Cerabone®. Straumann Jason® membrane was placed and stabilised with bone tacks.
The flap was closed with a 4.0 Vicryl horizontal mattress and interrupted sutures.
A maxillary complete denture was then inserted over the abutments and protective caps to transfer position of screw access hole locations to the prosthesis.
Titanium copings for the SRA abutments were attached at 15 Ncm to confirm proper modification of the denture. Teflon tape was placed into the titanium copings
A dual polymerising resin (Q-resin) was placed in the denture and injected around the copings to firmly index and attach the titanium copings within the denture. The maxillary prosthesis was disinfected and taken into the in-house laboratory for conversion into a fixed provisional bridge.
The converted maxillary hybrid was delivered on the abutments with prosthetic screws at 15 Ncm.
Post-operative written instructions were reviewed with the patient and her nephew. They were reminded that the patient must adhere to an extremely soft diet for the first 6 weeks following the procedure.
The patient was seen for a series of follow-up appointments to evaluate healing over the first two months.
After five months of uneventful healing, the patient was brought back to begin fabrication of the final prostheses.
The fabrication of the final hybrid restorations usually requires a series of 5 one-hour appointments, which usually do not require the administration of local anaesthetic. The screw-access hole fillings were removed and the provisional bridge was removed. All abutment screws were checked to confirm and tighten at 35 Ncm.
Open tray SRA impression copings were placed over the abutments and final full arch impressions were made with a Polyvinylsiloxane material. Master casts were poured using SRA analogues and Soft Tissue Moulage material. The casts were then mounted using the patient’s provisional hybrids during the second clinical appointment. A tooth set up on wax rims was tried in to verify aesthetics and phonetics at the third clinical appointment to confirm tooth position. The technician designed the CAD/CAM titanium bar to precisely fit the implant abutments and support the final denture teeth in the permanent prostheses. The Createch titanium bars were tried in to verify passive fit on the implant abutments prior to final processing. The bridge was then returned to the lab for opaquing of the bars, final flasking and processing with an injection moulded acrylic resin.
The final bridge was delivered to the patient and occlusion was again checked and adjusted. An orthopanoramic of the completed treatment verified ideal implant healing and fit of the final CAD/CAM titanium bars.
The patient’s post-operative clinical result revealed a patient who was extremely pleased with the process and the definitive outcome.
The Straumann® Pro Arch protocol using screw-retained abutments was particularly well-suited for this patient’s challenge.
The benefits include improved masticatory function and appearance immediately following surgery, no sinus bone augmentation, reduced treatment time, and reduced cost.
The patient was very happy with the final result and extremely pleased not to have to wear a removable prosthesis.
Correct patient selection and case planning are key factors for success.
I would like to thank Nick Tyler of Tyler Crown and Bridge for his exceptional work and support with this case www.tylercrownandbridge.com.
Dr Alfonso Rao GDC No 172344
DIP. DENT CHIETI, DIP IMPLANT DENTISTRY – GENERAL DENTISTRY, MASTERS IN ENDODONTIC DENTISTRY(ITALY)*
Born in Italy, Dr Alfonso Rao graduated with distinction from the University of Chieti. Until 2009, he worked at hospitals in Caserta, Napoli and Pescara as an oral surgeon before moving to England. Since then he has worked in numerous clinics between Bath, Bristol and Cheltenham.
As the owner of Queen Square Dental Clinic, Dr Rao believes strongly in 21st century dental technology. He is passionate about continuing his education and spent three years at the Eastman Dental Institute of London, where he completed a three year Diploma in Implant Dentistry. He also has a Masters from the Global Institute for Dental Education in Los Angeles, which he obtained in 2014.*
Dr Rao’s advanced training and vast knowledge provides him with the expertise to successfully provide a number of implant solutions to patients including replacing a single tooth, replacing multiple teeth, denture stabilisation using dental implants and the Straumann Pro Arch Teeth in a Day Solution.
He uses state-of-the-art X-ray technology and 3D treatment planning software to ensure precise placement of bone grafts and dental implants.
As well as being a member of the Association of Dental Implantology and ITI, he is an accredited Straumann mentor. This enables him to teach Implantology on several courses.
* ”Masters In Endodontic Dentistry” is the title of the course Dr Rao completed and does not imply that Dr Rao is on a specialist dentist list
Facebook: Straumann UK