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INTRODUCTIONThe conventional Brånemark approach ofrestoring implants 4 to 6 months afterplacement achieves excellent results.1-7However, this approach requires increasedtreatment time for the patient and mayresult in dissatisfaction, as he or she maynot wish to be transitioned with removablerestorations or be without teeth for extend-ed periods of time.8-10 High success rates ofone-stage treatment and immediatelyloaded mandibular fixed interforaminalimplant restorations are supported by theliterature.1,9,11-17 For a patient with a hope-less dentition desiring prosthesis on theday of the surgery, the treatment sequenceincludes the following: (1) extraction of theremaining teeth, (2) performing bone re -duction or alveoloplasty (as needed), (3)placement of implants in the “general”vicinity of the fabricated immediate den-ture, and (4) converting the immediate den-ture into a fixed prosthesis.18,19 With thisprotocol, the restorative dentist has beenoften encumbered by an “osseous-driven”implant placement approach and has strug-gled to predictably and efficiently engageimplant components during immediateprovisionalization procedures. Discrep an -cies between the path of insertion and theimplant trajectory results in significantacrylic and tooth reduction around theanticipated implant locations of the provi-sional restoration. Such discrepancies com-promise prosthesis strength and aes -thetics.20 Also, the entire process is labori-ous and time consuming for both thepatient and practitioner and at times, yieldsless than ideal results.

Digital Treatment Planning for ImplantsSince last decade, implant placement andimmediate provisionalization techniqueshave undergone major changes.21-23 Thishas been due to the advancements andaccessibility to better imaging and comput-er technology.24,25 For any implant restora-tion to be successful, it is critical to planand place implants accurately.3,19

The restorative dentist should decidethe type and the design of the definitiveprosthesis before implant placement andplan the implants based on the design of

the final prosthesis. This can be most pre-dictably achieved through 3-D-guided plan-ning and 3-D-guided implant surgery.20-22Combining the CAD and CAM techniques,digital implant planning can be applied toclinical practice using 3-D surgical guides.These techniques help with visualization ofbone and the prosthesis at the same time.26This has helped change the osseous-drivenapproach to a combination osseous- andprosthetic-driven approach for implantplacement.26 This digital implant planningcan also be sent to the laboratory for pre-fabrication of fixed restorations. Sinceimplants are placed in a near to ideal posi-tion, the surgery and provisionalization isdone predictably and in a relatively shorttime.27,28

Nobel Biocare and Simplant (Materi -alise Dental) have been 2 of the largest con-tributors to this treatment modality. Whilethe NobelGuide Surgical Template (NobelBiocare) guides the 3-D placement of im -plants and the fabrication of accurate retro-engineered casts for the fabrication of im -mediate provisional restorations, it doesnot support the design and fabrication ofbone reduction guides. Most of the studiesdiscussing 3-D-guided surgeries for the

rehabilitation of the mandible on the sameday with implant-supported fixed restora-tions describe procedures done on edentu-lous ridges with acceptable contours,29-34since any modification of the ridge couldaffect the seating of the surgical template,placement of the implants, and the fit of therestoration. This article describes a novelapproach of integrating a guided bonereduction system (Simplant) to the Nobel 3-D-guided surgery protocol (NobelGuideSurgical Template) for im plant placementand provisionalization. Many patients withnonrestorable teeth may benefit fromimmediate extraction, bone reduction,immediate placement, and immediate load-ing of implants. In addition, combiningthese modalities can improve managementof the restorative space both surgically andprosthetically.35,36

This article outlines a case report inwhich a bone reduction guide was integrat-ed in the 3-D implant-planning software(NobelClinician [Nobel Biocare]) to accom-plish 3-D-guided alveoloplasty and 3-D-guided implant surgery to transition a pa -tient with nonrestorable mandibular teethto a transitional hybrid restoration on thesame day.

Swati Ahuja,BDS, MDS

NicholasEgbert, DDS,MDS

Russell Wicks,DMD, MS

RobertBrandt, DDS,MS

Immediate Implant ProsthesisVia Guided Bone Reduction

Figure 1. Preoperative panoramic radiograph of the patient.

IMPLANTS

dentalCEtoday.comGo online to earn credit for reading this CE article.

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For any implant restoration to be successful, it is critical to plan and place implants accurately.

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CASE REPORTDiagnosis and Treatment Planning

A 56-year-old female presented to the Pros -thodontic Graduate Residency Clinic at theUniversity of Tennessee Health Science Centerin Memphis with the complaint that she couldnot chew her food. She had no significant med-ical history. The patient knew that her mandibu-lar teeth were nonrestorable; however, she haddelayed treatment because she did not want towear a complete denture at any time. The pa -tient had many missing teeth (teeth Nos. 3, 4, 6,11, 13 to 16, 17 to 22, 27 to 30, and 32), all lostapproximately 7 to 9 years previously due tocaries and periodontal disease (Figure 1).

Upon examination, probing depths of theremaining maxillary teeth were between 2.0 to3.0 mm in all areas. Probing depths of themandibular teeth were between 5.0 to 7.0 mm.The mandibular teeth were affected by general-ized chronic perio dontitis. There was extremevertical and horizontal bone atrophy of the poste-rior mandible in the region of the molar teeth(Figure 2). Teeth Nos. 5 and 12 had been previous-ly repositioned with orthodontic treatment intothe cuspid position. Teeth Nos. 1 and 2, and theremaining mandibular teeth, all had a poor prog-nosis. Two implants placed in the position ofteeth Nos. 22 and 27 were not restorable due totheir extreme angle of divergence. An implant,previously placed in the position of No. 22, was indirect contact with tooth No. 23, causing painduring mastication. Removal of these 2 implantswas recommended to the patient.

Diagnostic impressions were made and diag-nostic casts were mounted on a semiadjustablearticulator (Whip Mix 2240 [Whip Mix]) to eval-uate the occlusion, occlusal plane, as well as theavailable restorative and aesthetic space. A diag-nostic 3-D CBCT scan was taken to verify theclinical findings and to plan treatment. The scandemonstrated that the mandibular ridge, fromteeth Nos. 21 to 28, had optimal quality andquantity of bone; however, it was knife-edged.So, alveoloplasty was indicated to optimize thecontours of the mandibular ridge.

After a thorough diagnostic work-up, thepatient was treatment planned as follows:

For the Mandible:l Removal of the 2 implantsl Extraction of the remaining mandibular

teeth l 3-D-guided alveoloplasty in the region of

teeth Nos. 21 to 28 l 3-D-guided implant surgery l Immediate provisionalization with an

implant-supported fixed restoration (hybrid)l Delivery of the definitive prosthesis after

healing of implants. For the Maxilla:l Extraction of teeth Nos. 1 and 2l 3-D-guided implant surgery l Rehabilitation with implant-supported

fixed partial dentures bilaterally after healing ofthe implants.

Treatment Protocol for the MandibleThe patient was scheduled for re moval of the 2mandibular implants and they were removed asatraumatically as possible.37,38 The site was graftedand augmented with Puros (Zimmer Dental) allo-graft, and a barrier membrane (CopiOs [ZimmerDental]) was draped over the bone graft prior to clo-sure. The site was then allowed to heal for 2 months.

The next step was to extract the teeth, reducethe mandibular anterior bone in a controlledand accurate fashion using a surgical guide, andthen to place the implants following the 3-D-guided surgery protocol (NobelGuide) andsecure a provisional implant-supported fixedrestoration at the same appointment.29-31 Theprocedure for the same is described as follows.

Phase I: Fabrication of RadiographicTemplate No. 1

The original protocol for planning a 3-D-guidedsurgery (NobelGuide; Nobel Clinician) requires 2scans.29,30,32,33 The first scan is taken of thepatient wearing the radiographic template, andthe second scan is taken of the radiographic tem-plate by itself. The scan of the radiographic tem-plate automatically translates the fit of the radio -graphic template to the fit of the surgical tem-plate. The 2 scans permit digitization of thepatient’s anatomy and the radiographic guide(template). The raw data obtained from the scansis then converted to Digital Imaging and Com -munications in Medicine (DICOM) data using theNobel Clinician 3-D implant-planning software.The DICOM files are imported to the treatmentplanning Nobel Clinician software that allows forimplants to be virtually placed in the bone. (Note:In order to be able to import files in the 3-Dimplant-planning software, they must be con-verted into DICOM format.) Both the bone andthe prosthesis are taken into consideration whenplanning the implant position, since the 3-Dimplant-planning software permits visualizationof the bone and the prosthesis individually andtogether. This allows collaboration among therestorative dentist, the surgeon, and the dentallaboratory team to ensure ideal implant place-ment with consideration of the anatomic struc-tures, aesthetics, and the design of the prosthesis.

The radiographic template was constructed asfollows: Primary maxillary and mandibular im -pressions were made and diagnostic casts werefabricated for the patient. Record bases and waxrims were fabricated on diagnostic casts. Jawrelation records were taken. The mandibularcast was blocked and duplicated. The maxillaryand mandibular casts were then mounted onthe articulator (2240 Q articulator [Whip Mix]).Denture teeth (SR orthotype DCL [IvoclarVivadent]) were set in the wax rims to replacethe missing teeth (to define the position of the

Figure 2. Severe resorption of the mandibular ridge notedin the region of the molar teeth.

Figure 3. Radiographic template No. 1 with an anteriorlabial window. The inferior border of the window of thetemplate denotes the proposed post-surgical bone level.

Figure 4. Scan with template No. 1. (Left) 3-D planningwith 5 implants and 4 anchor pins. (Right) Cross-section-al view of implant in the position of tooth No. 22. The redline defines the height of the proposed bone reduction.

Figure 5. Scan with template No. 2 with anterior acrylicto support the sleeves. (Left) 3-D planning imported fromthe previous scan (5 implants and 4 anchor pins).(Right) Cross-sectional view of implant in the position of tooth No. 26. The red line defines the height of theproposed bone reduction.

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prosthetic teeth in the definitiverestoration). The wax trial denture wastried in the patient’s mouth. The occlu-sion was verified, and the wax-up wastransferred to the duplicate cast.

The mandibular wax trial den-ture along with the duplicate castwas sent to the laboratory team forfabrication of radiographic templateaccording to the Nobel 3-D-guidedsurgery protocol.32 This radiographictemplate, designated as “Radio -graphic Template No. 1,” had 6 fiduci-ary markers (gutta-percha mark-ers)—4 buccal and 2 lingual (Figure3).32 These markers are used by theNobelClinician software to align thepatient scan with the scan of the radi-ographic template.32 RadiographicTemplate No. 1 was constructed witha window around the existing natu-ral teeth. The exact amount of bone tobe removed from the mandibularridge was calculated utilizing thediagnostic CBCT scan. Accordingly,the inferior border of the window ofthe template was constructed suchthat it could be used as a referencepoint to denote the proposed post-surgical bone level (Figure 3).

Phase II: CBCT Scan and Planning of Implants

A CBCT scan (CBCT CS 9300 [Care -stream Dental]) was made of thepatient with the Radiographic Tem -plate No. 1 completely seated in themouth. (The field of view was medi-um, slice thickness: 0.5 mm.)

As seen in the previous scan, themandibular anterior ridge was knife-edged, but it had optimal quality andquantity of bone. Three 3.5 x 10implants were virtually planned inthe region of teeth Nos. 23, 24, and 26.Two 3.5 x 11.5 implants were plannedin the Nos. 28 and 21 regions of themandible (Figure 4). Four anchor pins(used routinely with NobelGuide)were planned to stabilize the surgicalguide during implant surgery (Figure4). Anchor pins help fixate the surgi-cal guide to the ridge and prevent itsmovement during implant place-ment. Care was taken to avoid place-ment of the anchor pins in the area ofthe bone reduction to not lose thelocation of the pins after osteotomy.This is because they serve as refer-ence points and also help with stabi-lization of the surgical template.Once the plan was approved, it wassaved for future use.

The 3-D-guided surgery protocolguides the implant placement in x, y,and z axes. The implants were placedthrough the sleeves present in thesurgical guide. The NobelClinician

implant-planning software requirestemplate material (acrylic) to inte-grate the implant guide sleeves in thesurgical template. Since there was awindow in Radiographic TemplateNo. 1, sleeves could not be integratedin it; hence, it had to be modified. Toaccomplish it, a controlled modifica-

tion (removal of all the remainingmandibular anterior teeth) was per-formed on the diagnostic cast. Then,Radiographic Template No. 1 wasplaced on the modified cast and self-curing acrylic (Lang Dental) wasadded to it to bridge the gap betweenthe buccal and the lingual anterioraspect of the template. This modifiedtemplate was then designated as“Radiographic Template No. 2.”

Since Radiographic Template No.2 was a modified version of the origi-nal template, it maintained the origi-nal fiduciary marker positions.Another scan was made of Radio -graphic Template No. 2 by itself, rawdata was converted to DICOM data,and the DICOM files were importedinto the software.

Anchor pins and implants wereimported from the first plan to thenew DICOM files (Figure 5). A total of5 implants were planned to fabricatean implant-supported fixed restora-tion for the patient (Figure 5).

Next, the planning with bothRadiographic Templates Nos. 1 and 2was approved, and then the CAD fileswere sent to the production facility(NobelProcera [Nobel Biocare]) for thefabrication of 2 surgical guides. In theproduction facility, the stereolithicguides were constructed based on theinformation provided by the CADfiles. The CAD files would also beused to construct the stereolithic den-ture that would then be used by thedental laboratory team to constructthe provisional prosthesis. The firstsurgical guide, designated as “Sur -gical Guide No. 1,” was fabricatedfrom the scan (and CAD files) ofRadiographic Template No. 1 andwould be used to reduce the bone and

place the posterior implants. The sec-ond surgical guide (Figure 6), desig-nated as “Surgical Guide No. 2,” wasfabricated from the scan (and CADfiles) of Radiographic Template No. 2and would be used to place the ante-rior implants and retro-engineer acast from it.33,34,39

Phase III: Fabrication of theProvisional Restoration

Surgical Guide No. 1 was tried in thepatient’s mouth and adjusted as neces-sary to ensure an acceptable fit. Then avinyl polysiloxane (Regisil [DENT -SPLY Caulk]) interocclusal record wasmade with the Surgical Guide No. 1 inplace (Figure 7).

Surgical Guide No. 2 was used tofabricate a retro-engineered implantlevel cast following the manufactur-er’s protocol (Figure 8).33,34,39 Theinterocclusal record made with Sur -gical Guide No. 1 was used to mountthe retro-engineered cast with theSurgical Guide No. 2 seated on it,against the maxillary diagnostic cast.

Temporary abutments were fixat-ed to the implant analogs and the pro-visional implant-supported fixedrestoration was fabricated for thepatient.39-41 The provisional was fab-ricated with plastic temporary cylin-ders in all but No. 28 (titanium cylin-der), since it was theoretically themost predictable surgical implantposition. The plastic temporary cylin-ders were then removed with drillsfrom the intaglio surface; they wouldbe picked up at the chair on the day ofthe surgery.

Phase IV: Extraction,Alveoloplasty, 3-D-Guided Implant

Surgery, and Delivery of theProvisional Prosthesis

Local anesthetic was administered tothe patient, and then Surgical GuideNo. 1 was placed in the mouth. Oste -otomies were made for the anchorpins using the pilot drills. Then,anchor pins were screwed throughthe guide to the bone. Two posteriorimplants (Nos. 21 and 28) were placedthrough the Surgical Guide No. 1, fol-lowing the guided-surgery protocol(NobelGuide).

The mandibular anterior teethwere extracted atraumatically and themandibular ridge was reduced to thepredetermined level (Figure 9). SurgicalGuide No. 1 was removed following theremoval of implant mounts andanchor pins. Then, Surgical Guide No. 2was placed in the mouth (Figure 10)and was checked for fit and stability.Next, anchor pins were screwed intothe bone as discussed previously.

DENTALCETODAY.COM • JULY 2015

Figure 6. Surgical Guide No. 2.

Figure 7. Surgical Guide No. 1 and the interocclusal record that was made with template in the mouth to mount the retro-engineered cast.

Figure 8. Retro-engineered cast.

Figure 9. Alveoloplasty was performed withthe inferior border of the guide as the reference. The anchor pins maintained theposition of the guide during surgery.

Figure 10. Surgical Guide No. 2, in placeafter the alveoloplasty.

Figure 11. Panoramic radiograph depictingthe maxillary and mandibular implants.

Figure 12. Provisional restoration deliveredto the patient on the same day.

IMPLANTS

The remaining 3 implants wereplaced using Surgical Guide No. 2, fol-lowing the NobelGuide protocol.During the surgery, when the oste -otomies were created and the qualityand quantity of bone was verified andfound to be optimal, a radiographwas taken to assess the positions ofthe implants in the patient’s mouth(Figure 11). Bone graft (Puros allo-graft) was used to graft the voidsaround the implants, then a barriermembrane (CopiOs) was then drapedover the bone graft prior to closure.

Titanium temporary abutmentswere fixed to the implants in all thelocations except No. 28. Provisionalrestoration was lined with acrylic onthe intaglio surface and the abut-ments were picked up chairside. Theprovisional and the abutments wereadjusted as necessary, the occlusionwas adjusted and verified as neededand the restoration was finished andpolished. The provisional restorationwas connected to the implants withthe attachment screws. The screwaccess holes were firmly closed withcotton pellets and light cured com-posite resin (Filtek P60 [3M ESPE]).

The patient was very pleased withthe transitional restoration (Figure12). She was asked to return the nextday for recall and was given postoper-ative home care instructions eat onlysoft foods and to avoid putting exces-sive pressure on the prosthesis for 8 to12 weeks. She was asked to come backafter 4 months for the fabrication ofthe definitive restoration.

Implant Surgery and Restoration of the Maxilla

Simultaneously, the patient wasscheduled for extraction of teeth Nos.1 and 2 and site preservation. Four im -plants [NobelActive [Nobel Bio care])(Figure 11) were placed in the regionof Nos. 3, 5, 12, and 14 to replace themissing teeth. These were then re -stored following the traditional 2-stage protocol with implant-support-ed fixed partial dentures bilaterally.

CLOSING COMMENTSThe treatment plan and the tech-nique discussed in this article en -sured predictable bone removal andplacement of implants, allowing thepatient to receive the mandibularprovisional prosthesis on the sameday the osseous surgery (alveoloplas-

ty) and osteotomies were performed.As a result, the delivery of the pros-thesis was more efficient and pre-dictable. Also, patient satisfactionincreased as did the fit, aesthetics,cleansability, and strength of theprosthesis.�

AcknowledgmentThe authors acknowledge Dr.Nicholas Egbert for providing the sur-gical and restorative support.

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16.Schnitman PA, Wöhrle PS, Rubenstein JE, et al.Ten-year results for Brånemark implants imme-diately loaded with fixed prostheses at implantplacement. Int J Oral Maxillofac Implants.1997;12:495-503.

17.Schulte W, Heimke G. The Tübinger immediateimplant [in German]. Quintessenz. 1976;27:17-23.

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21.D’haese J, Van De Velde T, Komiyama A, et al.Accuracy and complications using computer-designed stereolithographic surgical guides fororal rehabilitation by means of dental implants:a review of the literature. Clin Implant Dent RelatRes. 2012;14:321-335.

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32.Nobel Guide—Digital Precision for AllIndications: Complete Treatment Concept forDiagnostics, Prosthetic-Driven TreatmentPlanning, and Guided Implant Surgery. nobelbio-care.com/us/en/home/products-and-solu-tions/treatment-concepts/guided-surgery.html.Accessed on April 8, 2015.

33.van Steenberghe D, Naert I, Andersson M, et al.A custom template and definitive prosthesisallowing immediate implant loading in the maxil-la: a clinical report. Int J Oral MaxillofacImplants. 2002;17:663-670.

34.Sanna AM, Molly L, van Steenberghe D.Immediately loaded CAD-CAM manufacturedfixed complete dentures using flapless implantplacement procedures: a cohort study of con-secutive patients. J Prosthet Dent.2007;97:331-339.

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38.Marini E, Cisterna V, Messina AM. The removal ofa malpositioned implant in the anterior mandibleusing piezosurgery. Oral Surg Oral Med Oral PatholOral Radiol. 2013;115:e1-e5.

39.van Steenberghe D, Glauser R, Blombäck U, etal. A computed tomographic scan-derived cus-tomized surgical template and fixed prosthesisfor flapless surgery and immediate loading ofimplants in fully edentulous maxillae: a prospec-tive multicenter study. Clin Implant Dent RelatRes. 2005;7(suppl 1):S111-S120.

40.Balshi TJ. The Biotes conversion prosthesis: aprovisional fixed prosthesis supported byosseointegrated titanium fixtures for restorationof the edentulous jaw. Quintessence Int.

1985;16:667-677.41.Balshi TJ, Wolfinger GJ. Conversion prosthesis: a

transitional fixed implant-supported prosthesisfor an edentulous arch—a technical note. Int JOral Maxillofac Implants. 1996;11:106-111.

Dr. Ahuja is an adjunct assistant professor inthe department of prosthodontics at the Uni -versity of Tennessee Health Science Center,Memphis. She is a prosthodontic consultantfor Lutheran Medical Center, NY, and lecturesinternationally on implant overdentures, hy -brid restorations, restorative space issues inimplant overdentures, and the implementa-tion of CBCT in the dental practice. She canbe reached at sahuja@uthsc.edu.

Disclosure: Dr. Ahuja reports no disclosures.

Dr. Egbert received his bachelor’s of sciencein medical biology at the University of Utahand his doctor of dental surgery at CreightonUniversity in Omaha. He then pursued a full-time 3-year residency in advanced surgicalprosthodontics at the University of TennesseeHealth Science Center. During his residency,he earned his master’s of dental science eval-uating the accuracy of CT-generated implantguides, and he also led clinical research pro -jects comparing the efficacy of modern bone-grafting techniques. He is certified by the ADAand Utah Dental Association to provide safeintravenous moderate sedation. One of 4board-certified prosthodontists in Utah, hecurrently serves as the president of the UtahProsthodontic Society. He is in private prac-tice in Salt Lake City. He can be reached atnicholasegbert@gmail.com.

Disclosure: Dr. Egbert reports no disclosures.

Dr. Wicks is professor and chair of the de -partment of prosthodontics at the Universityof Tennessee (UT) Health Science Center,College of Dentistry in Memphis. He receivedhis dental degree from UT in 1978 and amaster’s degree and certificate in the spe-cialty of prosthodontics from the University ofTexas at San Antonio in 1993, and was in pri-vate general practice from 1979 to 1990. Hehas conducted prosthodontic research anddirected the undergraduate curriculum inremovable prosthodontics and dental im -plants at the UT College of Dentistry. He alsoholds membership in a variety of profession-al honorary and service organizations, and in1995, the American College of Prostho -dontists recognized him as the “OutstandingYoung Prosthodontist” in America. He hasauthored more than 30 publications in theprosthodontic literature. He can be reachedat rwicks@uthsc.edu.

Disclosure: Dr. Wicks reports no disclosures.

Dr. Brandt is professor and director of the ad -vanced education in general dentistry and isin the department of prosthodontics at theUniversity of Tennessee (UT) Health ScienceCenter, College of Dentistry in Memphis. Hereceived a certificate in the specialty ofprosthodontics from the Wilford Hall MedicalCenter Lackland AFB Texas in 1975. Hejoined the faculty at the University of Floridaas an assistant professor of prosthodonticsin 1988, afterwards holding university ap -pointments in University of Queensland,Brisbane, Australia; Nova Southeastern Uni -ver sity; and University of Tennessee. He hasconducted prosthodontic research and direct-ed the undergraduate curriculum in implantdentistry and occlusion at the UT College ofDentistry. He has authored more than 25 pub-lications in the prosthodontic literature andholds memberships in a variety of profes-sional honorary and service organizations. Hecan be reached at rbrandt@uthsc.edu.

Disclosure: Dr. Brandt reports no disclosures.

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Patient satisfaction increased as did the fit, aesthetics, cleansability, and strength of the prosthesis.