case study-removable bridge :Full arch reconstruction of the edentulous maxilla

Full arch reconstruction
of the edentulous maxilla
Using the CAMLOG Guide System Prosthetics

Claudio Cacaci, DMD
Photos/Provided by Dr. Claudio Cacaci

Information on patient and treatment
The male patient, aged 59, was looking for a new
fixed restoration for his maxilla. His case history
showed no general disease. The patient had been fitted
with telescopic model casting prostheses in the
maxilla and mandible.
Due to the periodontally insufficient anterior
residual teeth in the maxilla (teeth 11, 12, 21, 22),
the prosthesis could no longer be supported. After
loosing the residual teeth, the patient wanted a fixed
implant-based restoration of the maxilla.
The residual teeth of the mandible showed the
following findings: tooth 48 was impacted and displaced,
tooth 45 showed mobility grade 3 and was
periodontally insufficient. The anterior residual teeth
33–43 presented with increased probing depths on
the canine teeth and increased mobility (grade 2).
The treatment strategy for the maxilla included
as a first step a conservative periodontal therapy of
the anterior residual teeth for strategic preservation
and fixation of the existing prosthesis until implant
insertion.
Afterwards, the residual teeth were removed and
a bilateral sinus floor augmentation was performed
in a two-stage procedure. Following a 3-D planning,
eight endosseous implants were inserted with the
CAMLOG® Guide System in a flapless procedure, and
the prosthetic restoration was realized using a telescopic
bridge. In the mandible, tooth 45 was removed
while the other teeth were treated with conservative
periodontal therapy. The mandibular posterior teeth
were replaced and realigned. Teeth 43–33 received
reveneering of the removable denture.

Conclusions
The original goal of the prosthetic reconstruction
was a fixed bridge restoration. Due to the hygienic
and functional training phase with the long-term
temporary appliance, the patient decided for a removable
bridge.
The accuracy and simplicity with which the
implants can be inserted in prosthetically correct
or anatomically difficult situations is increased
significantly by virtual 3-D implant planning in the
cone-beam CT or CT in combination with the guided
implant bed preparation and implant insertion. Implant
therapy is thus facilitated.
The drilling sequence in the CAMLOG® Guide
System is different from other systems. While in
a conventional drilling sequence the pilot drill is
advanced to the final implant length, the drilling
sequence guided by the CAMLOG Guide first starts
with the shorter pilot drill (length 6 mm). So that all
drills are guided by the sleeve geometry from the
start, the drilling sequence I performed in succession
from the 9 mm drill to the 11 mm drill and finally
to the 13 mm drill (maximum implant length). The
CAMLOG Guide offers a sleeve system. As opposed to
multi-sleeve systems, a single sleeve inserted into the
surgical template is adequate for guidance during all
drilling sequences and implantation procedures. The
implants can be inserted through the sleeves

Initial presentation













Fig. 1_Panoramic radiograph. The
maxillary posterior regions on both
sides show significantly reduced
vertical bone height (residual height
less than 2 mm).














Fig. 2_Clinical situation with
removable telescopic prosthesis
inserted

Sinus floor augmentation










 


Fig. 3_The facial maxillary sinus
wall is moved inwards and becomes
the neurocranial floor of the maxillary
sinus. On the left side, a vertical bone
septum (visible on Fig. 1) requires
two separate lateral approaches


 Insertion of interim implantsInsertion of interim implants
The planned minimally invasive flapless procedure for implant insertion requires a unique fixation for the preparation of radiological materials. The fixation is facilitated by temporary implants in a suitable position.
In order to ensure accurate transferability, the fixation must be performed under radiological control in the identical position as the one of the implantation...













Fig. 4_Filling of the right sinus
cavity with blood and xenogenic
bone substitute material. Coverage
of the lateral window with a
resorbable collagen membrane
to avoid displacement of the bone
substitute material.













Fig. 5_Postoperative panoramic
radiograph shows filling of both
maxillary sinus cavities.














Fig. 6_Panoramic radiograph with
scan prosthesis for determining
the fixation positions using the four
interim implants.



Implant placement














Fig. 7_Two-part temporary
implants fitted with ball abutments
in positions 11 and 21. Posterior
anchorages in positions 15 and 25.

















Fig. 8_The system-specific
matrices are placed and secured in
the scan template with plastic.


















Fig. 9_Fixed ball abutment
matrices in scan template. The DVT
image is taken immediately with the
radiology template mounted.


 

  Cone-beam diagnostics
The scan template is fabricated based on prosthetic requirements (functional, esthetic).
A bone-anchored and prosthetic-oriented scan can be taken under radiological control due
to the unique fixation of the scan template using the interim implants.
The thickness of the mucous membrane can be measured by fitting the radio-opaque tooth on the plaster surface. The distance from holding sleeve to bone surface must not exceed 3.5 mm.



Fig. 10_Transversal view at region 26. The central axial borehole is clearly visible.
Good ossification in the sinus


















Fig. 11_All views at implant region 27. From left to right: Lateral view with projection
of the temporary implant in region 25, transversal view, panoramic anatomic view,
occlusal view.



















Fig. 12_Transversal view at 24.











.






Fig. 13_Transversal view at 23.





















Fig. 14_Transversal view at 17.



















Fig.15_All views at implant region 16. From left to right: Lateral view with projection
of the temporary implant in region 15, transversal view, panoramic anatomic view,
occlusal view.





















Fig. 16_Transversal view at 14.

















Fig. 17_Transversal view at 13.























Fig. 18_Transversal view at 12.







CAMLOG Guide Surgery














 Fig. 19_Surgical template with ball retention elements at positions 21, 15, 25 for
stable positioning of the template during drilling procedures. Before placement,
careful cleaning and disinfection(please see previous page for image).

















Fig. 20_Ball retentions on temporary implants for stabilization of the temporary
prosthesis, fixation of the scan template during cone-beam scan and positioning of the
surgical template during the drill procedure.

















 Fig. 21_The gingival punch is guided through the sleeves onto the mucous
membrane. The punch has no depth stop.


















Fig. 22_A scalpel is used to cut out and remove the punched gingival islands after
removing the template.




 














Fig. 23_Resected implant locations 26 and 27.





















 Fig. 24_The template is mounted again. Start of the Camlog Guide drilling sequence
with pilot drill followed by drills of the appropriate lengths depending on the implant
length (region 23).

























 Fig. 25_Guided insertion through the sleeves utilising special Camlog Guide inserting
tool.






















Fig. 26_The sleeve dimension allows bone condensing and bone spreading
procedures through the sleeve (here, osteotome for vertical bone condensation).



















Fig. 27_Implants in first quadrant in situ. Depth stops on the surface of the sleeves.























Fig. 28_Postoperative panoramic radiograph.





















Fig. 29_Healing after one week postoperatively. The patient had neither complaints
nor postoperative swelling (please see previous page for image).





Preparation for provisional




















Fig. 30_The surgical template is set back on its fabrication model. The analog plaster
reamers are used to create the cavity for the lab analog through the sleeve
.



















Fig. 31_Implant positions on the plaster cast



















Fig. 32_Mounted lab analogs together with the inserting posts are secured to the
sleeves with wax. The lab analogs are fixed into in the plaster cast




















Fig. 33_Cast with lab analogs in place. The transfer of the analog into the correct
position through the sleeve of the surgical stent




















Fig. 34_A 0.5 mm thick thermoformed splint is drawn over the abutments. The
thermoformed copings perform the space-making task for passivation when
cementing the interim restoration


















Fig. 35_Long-term temporary appliance in the articulator




















Fig. 36_PEEK abutments in situ


















Fig. 37_Long-term temporary appliance cemented in situ in terms of early treatment
eight weeks postoperatively



Final prosthetic
CAD/CAM was used to fabricate the bridge framework
out of a fiber composite (KaVo C-Temp) and veneered
with an acrylic material. For passivation of the
design, proven electroplating was used. Custom CAD/
CAM-fabricated zirconia abutments were selected.



















Fig. 38_Impression with closed impression posts




















Fig. 39_CAD/CAM-fabricated zirconia abutments bonded to
CAMLOG Esthomic inset abutments.



















Fig. 40_CAD/CAM fabricated zirconia abutments after one year.


















Fig. 41_Veneering work.




















Fig. 42_Occlusal view before treatment.




















Fig. 43_Radiological situation before treatment.





Final restoration




















Fig. 44_Occlusal view two years after final prosthetic
restoration.





















Fig. 45_Radiological situation two years after loading.














Table I: Implants used
Implants used are noted in the table. There were no implants used
for teeth #41–48 and #31–38.
Implant type as noted in the table include,
ROOT LINE (RL)/SCREW-LINE (SL) Implant Surface:
Promote® (P)/Promote® Plus (PP)





_References
• Ewers R, Seemann R, Krennmair G, Schicho K,
Kurdi A.O, Kirsch A, Reichwein A. Planning implants
crown down — A systematic quality control for proof
of concept. J Oral Maxillofac Surg 68:2868–2878,
2010.
• Neugebauer J, Stachulla G, Ritter L, Dreiseidler
T, Mischkowski A.R, Keeve, E, Zöller, J.E. Computeraided
manufactoring technologies for guided implant
placement. Expert Rev. Med. Devices 7(1),
113–129 (2010).
• Eggers G, Evan Gelos P, Mühlin G J. Accuracy of
template-based dental implant placement. Int J Oral
Maxillofac Implants 2009;24:447–454.
• Kirsch A, Nagel R, Neuendor Ff G, Fiderschek J,
Ackermann K L. Implant placement and immediate
final rehabilitation. EDI Journal 2009;3(5):53–71.
• Dreiseidler, Neugebauer, Zöller et al. Accuracy
of a newly developed integrated system for implant
planning. Clin Oral Implants Res Nov 2009.
• Ackermann KL, Kirsch A, Nagel R, Neuendorff
G. Mit Backward Planning zielsicher therapieren.
Teamwork 2008;4:466–484.
• Kirsch A, Nagel R, Neuendorff G, Fidersche K J,
Ackermann Kl. Backward Planning und dreidimensionale
Diagnostik. Teamwork 2008;9:734ç754.
Editorial note: The case was first published in: Mairoana
C., Beretta M. Manual of Oral Implantology.
Italia Press 2010. (Reprinted with kind permission of
the publisher).

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