Full rehabilitation with nobel clinician(®) and procera implant bridge(®): case report

Abstract

Implant surgery has been changing in different ways following improvements of computer technologies. Since its beginning, according to the original procedures of Branemårk system implants, guide-lines in implants-supported prosthetic rehabilitation have been founding on the placement of fixtures in a fairly upright position, after maxillary sinus floor elevation; while in the case of interforaminal rehabilitation, an upright distal implant may need to be placed anterior to the mental foramina without nerve damage (although the consequence would have been bilateral cantilevers to provide good chewing capacity). Some authors have proposed engaging the molar/tuberosity area: Bahat and Venturelli demonstrated these areas reliable and predictable alternative to distal cantilever prostheses or sinus elevation procedures. In recent years, the immediate loading of tilted implants with a provisional restoration has been proposed for the treatment of the atrophic maxilla. Tilted posterior implants in either arches could avoid (cantilever length) and provide to a better load distribution. Further studies have showed excellent outcomes for both tilted and axial implants; indeed this protocol allows to use longer implants, improve bone anchorage and avoid bone grafting procedures. Malò at al., in a retrospective clinical study, showed important results using two posterior tilted implants and two anterior non-tilted ones in the so-called All-on-four technique (Nobel Biocare, Göteborg, Sweden). Instead of the great loss of bone (amount and quality) in long-term edentuly the clinically documented computer-guided implantology software is able, through posterior tilted implants, to improve load distribution. Many authors have reported reduced surgical invasion (sinus grafting surgery is needless), shorter treatment time, lower cost, natural aesthetic profiles and functional bite.

Keywords: computer guided flapless implant placement; dental implants; immediate loading; prosthetic rehabilitation.

Figure 1

Axial image sections, transverse, frontal and 3D upper jaw.

Figure 2

3D image front upper jaw.

Figure 3

3D image occlusal upper jaw.

Figure 4

Left lateral 3D image upper jaw.

Figure 5

3D image right side upper jaw.

Figure 6

Image section front upper jaw.

Figure 7

Axial image sections, transverse, frontal and 3D lower jaw.

Figure 8

3D image front lower jaw.

Figure 9

3D image occlusal lower jaw.

Figure 10

Left lateral 3D image lower jaw.

Figure 11

Right lateral 3D image lower jaw.

Figure 12

Image section front lower jaw.

Figure 13

Vision intraoral.

Figure 14a

Preoperative intraoral view upper jaw.

Figure 14b

Preoperative intraoral view lower jaw.

Figure 15

The removable dentures of the patient, functionally and esthetically correct, with secure radiographic landmarks that make possible the right matching tc patient/tc dentures.

Figure 16

Surgical template with silicone index.

Figure 17

The master model of the provisional superior.

Figure 18

The master model of the provisional inferior.

Figure 19

Immediatly after the surgical stage we can proceed the application of the provisional prosthesis.

Figure 20

Surgical stage: preparation of the implant sites.

Figure 21

The manual installation of implants.

Figure 22

Implant inserted with reference mounter.

Figure 23

Stage surgery completed.

Figure 24

Intraoral post-operative maxillary vision.

Figure 25

Intraoral post-operative mandibular vision.

Figure 26

Final image after application of the immediate provisional prosthesis.

Figure 27

Immediate postoperative aesthetic.

Figure 28

Postoperative radiographic control.

Figure 29

Definitive rehabilitation: test of the framework.

Figure 30

Orthopanoramic control a six months.

Figure 31

Definitive rehabilitation: front view. Correct occlusal relations and aesthetic.

Figure 32

Final aesthetic.