Dr Nikolas Vourakis treats a patient with severely atrophied bone and mobile teeth with a digital workflow.
A female patient presented with severe deterioration of her dentition and the surrounding soft- and hard-tissue. She had mobile teeth, and a malocclusion in class II division I, which gave a false indication of the incisal level.
Digital records were captured to inform the entire clinical team as best as possible. A CBCT scan and a pre-operative OPG displayed severe bone atrophy due to chronic periodontal disease.
Considering treatment options
Treatment options included doing nothing at all, and using dentures to restore the dentition. The patient agreed upon a full arch rehabilitation using implant supported prosthetics.
Experienced clinicians will know that full arch surgery is a complex and demanding procedure, and efficient patient selection and communication is key to maximising success. You must understand their needs and desires, and recognise that many patients will suffer from chronic dental issues and dental anxiety: it is the clinician’s responsibility to create a predictable patient journey.
However, fixed implant prostheses routinely develop complications. Biological problems include early and late implant failures, whilst aesthetic complications are associated with miscommunication, poor planning, poor ceramic work, and misplacement of the transition zone.
The incidence of fracture of a provisional restoration in full arch cases ranges up to 30%[i] – time-consuming to repair, they may also shake a patient’s confidence.
These risks were communicated to the patient, who consented to the procedure and was given clear oral hygiene instructions. She was provided periodontic therapy to arrest the progression of present disease.
Perfect planning
We undertook an interdisciplinary strategy that incorporated sophisticated surgical procedures and prosthetically-driven digital treatment.
This workflow is fully digital, and keeps the final prosthesis in mind when devising the surgical steps, tailored to each patient. The surgeon and dental technician are involved in all aspects of planning, improving communication and collaboration for optimal delivery of the provisional prosthesis and final hybrid restoration.
Intraoral scans were merged with the DICOM data from the CBCT to allow for software-based planning. This ensured that all the tissue anatomy necessary for denture fabrication was captured.
Digital files and photographs were imported into EXOCAD smile design software. The desired tooth placement, shape, and length were determined, as was the ideal transition line between mucosa and prosthesis. Working closely with the dental technician informed me of any prosthetic challenges and limitations, enhancing my communication with the patient.
The implants’ positions were planned using a prosthetically-driven approach. The STL digital files of the existing dentition and the virtual plan were merged, and the DICOM data from our CBCT scans was implemented. Implant placement could then be planned for optimal recovery and success, and the teeth that would be extracted first were identified.
We created a tooth-supported surgical guide, the easiest and most accurate solution in my hands. This was designed alongside a provisional prosthesis and steps to follow during surgery, which could then commence.
Effectively managed surgery
The previously identified teeth were extracted, whilst the lateral incisors, premolars, and second molars were strategically left to secure the guide support. A full thickness buccal flap was raised, and thorough degranulation of the sockets was performed.
With the surgical guide in place, the implant beds were prepared. Six CONELOG PROGRESSIVE implants, from BioHorizons Camlog, were inserted through the template, allowing precise depth and angulation control. These feature an optimal thread design and tapered figure, helping achieve high primary stability. The guide was removed, and the remaining teeth extracted – except the last two molars.
Straight multi-unit abutments were fixed and tightened with a torque value of 25 n/cm. Titanium cylinders were adjusted and fixed onto these, ready for the provisional restoration.
We used a Gallucci Prosthetic Guide. Though this looks like a normal denture, it is a 3D printed composite bridge with palatal support. The palatal support sits below the fitting surface of the bridge, and is used to locate the bridge in centric occlusion using the hard palate of the patient. The provisional restoration is an exact copy of the digital wax up that helped to plan the positions of the implants, meaning minimum adjustments were necessary. It was established using a light cured composite resin-based material and reinforced with a bent titanium wire, of 2mm diameter.
The procedure progressed in the same manner, entirely as planned, in the mandible. Our guided approach and clear communication meant that the provisional restoration in situ was easily comparable to the prosthetic plan. Post-operative X-rays demonstrated accurate implant placement in accordance with our original designs.
Post-provisional placement
Routine post-surgery advice was given to the patient. She returned a week later, smiling confidently and experiencing no major complications.
Creating the final prosthesis was simple due to our extensive planning and refinement. The chosen workflow was the digital fabrication process through the Atlantis Bridge Base System. The Bridge Base is fabricated directly from the digital impression by milling the MUA connections on a Titanium Select Laser Melted support bar. This extremely accurate support structure also acts as a support structure for the zirconia overlay. This combined the strength and biocompatibility of titanium with the biocompatibility and aesthetics of the zirconium, in a minimal number of appointments.
The patient was delighted with the treatment and the final result. We managed to improve the function of the patient by reducing the original overjet and deep bite and we managed, with the right hard and soft tissue manipulation, to improve the cleanability and thus the predictability of the therapeutic outcome.
I am equally thrilled with the outcome. With an emphasis on effective communication, my team ensured that each stage was well considered, formulating approaches that could be taken with confidence. The result – a successful full arch rehabilitation that has restored aesthetics and function – speaks for itself.
Dr Nikolas Vourakis is a tutor at One to One Implant education, where he guides clinicians of all experiences through their implant dentistry journey.
To reserve your place or to find out more, please visit
https://121implanteducation.co.uk or call 020 7486 0000.
Author: Dr Nikolas Vourakis
Dr Nikolas Vourakis is a dental implant specialist at the One to One Dental Clinic in Harley Street, and is also a lecturer and tutor at One to One Implant Education. He supports clinicians of all experiences throughout their implant dentistry journeys on a range of informative, hands-on courses. Dr Vourakis has been a practicing dental surgeon since graduating in 2005 from the prestigious Military Academy Medical School at the University of Thessaloniki, Greece, and spending time as a military dental surgeon in Afghanistan, from 2006-07. He received his MSc degree in Oral Surgery and Implantology from Goethe University of Frankfurt Germany.
[i] Lemos-Gulinelli, J., Pavani, R., Nary-Filho, H., Alves-Pesqueira, A., Pessoa, J., & Santos, P. L. (2020). Incidence of surgical and prosthetic complications in total edentulous patients rehabilitated by the All-on-Four® technique: a retrospective study. International journal of interdisciplinary dentistry, 13(2), 76-79.
