Straumann Pro Arch

The rehabilitation of edentulous maxillae

A 42-year old male patient in good physical health required a dental treatment. He reported
that he was a former smoker and did not take any medication. He complained that his upper
teeth were getting loose and he was unhappy with his aesthetics. Following his clinical (Fig-
ure 1) and radiological examination (Figure 2), it was decided that his remaining upper teeth
prognosis was hopeless. At the lower jaw, 23 through 26, 28 and 31 prognosis were hopeless
too. The remaining lower teeth prognosis was fair. Plaque, and gingival index were 90% and
2.5, respectively. In radiological exam, we observed more than 70% of horizontal bone loss
in the maxilla and 23% through 26% in the mandible (Figure 2). Furthermore, CBCT analysis
Memhet Akif Eskan, DDS, PhD
showed that there was a rounded and dome-like lesion in the left maxillary sinus (Figure 3).
Diplomate, American Board of Periodontology-
Clinic Eska, Private Practice, Istanbul, Turkey
1 2

Cemil Kavrayis CDT Fig. 1 Initial clinical view of the remaining maxillary Fig. 2 Showing preoperative orthopantomograph
teeth from frontal and occlusal view
Kavrayis Dental Lab, Istanbul, Turkey
3 4

Murat Cil CDT Fig. 3 CBCT analysis showing resorbed maxillary alveo- Fig. 4 Showing a BLT implant macroscopic design
lar bone and a retention cyst in the left maxillary sinus
Kavrayis Dental Lab, Istanbul, Turkey
5 6

Fig. 5 Alveolar ridge after extraction (left) and ridge Fig. 6 Surgical guide. At least an 8 mm space was
reduction needed from the neck of the tooth to the alveolar crest
Following a consultation with an ENT, it was diagnosed as a retention One of the most critical steps is to manage interocclusal space.
cyst of the maxillary sinus, which may show 17% to 38% spontaneous Inadequate bone removal may result in esthetic issues during pros-
regression and disappearance. thetic procedures. A surgical guide was made of clear acrylic, which
helped us to determine if there was enough interocclusal space, at
Due to the hopeless prognosis of the maxillary remaining teeth, all least 8 mm (Figure 6). A small window was opened to the sinus with
upper teeth were planned for extraction. The patient will not tolerate a round bur to locate the medial sinus wall (Figure 7). Countersinking,
a removable prosthesis in the maxilla at any time during treatment. when needed, was done to secure both buccal and lingual cortical
The patient requested a fixed restoration throughout the treatment bone contact at the implant collar in the thin bone crest. Care was
time. In order to meet the patients request and shorten the treat- taken in the selection of the axial implant length to avoid a conflict
ment time, a screw-retained provisional prosthesis was planned fol- with the posterior implants. Usually, the axial anterior implant length
lowing extractions and implant placement at the same time in the is shorter than the tilted implants. The posterior implants were placed
maxilla. Four implants, of which the two posterior implants were with about 45- 30 of inclination and 30 angulated screw-retained
tilted, were planned to be placed in the maxilla. Since our goal was to abutments were placed on the posterior implant correcting the
load implants immediately, the implants primary stability had to be angulation for the immediate prosthetic rehabilitation. For the
established for immediate function. However, primary stability may anterior axial implants, 0 SRA were placed and the wound was
become an issue especially in the soft bone, which may be handled sutured using an absorbable suture (Figure 8). Then, the inserted
by macroscopic implant design, such as a tapered implant tip (Figure implant position was roughly transferred on the temporary prosthesis
4). This modification may result in enhanced mechanical anchorage of using a bite registration material (Imprint Bite 3M ESPE) (Figure 9).
the implant at the placement, allowing for immediate loading. The opened holes were checked (Figure 10) before attachment of the
temporary abutment on the provisional prosthesis. A provisional full
The surgical procedures were carried out under local anesthesia with acrylic complete-arch prosthesis using temporary titanium copings
articain hydrochloride (40 mg/ml in 1.7 ml). The patient was pre- was delivered on the day of surgery. The provisional prosthesis was
scribed an antibiotic (amoxicillin + clavunic acid) one day before the screwed into the patients mouth, the patients smile was checked
surgery and continued for one week. NSAID (ibuprofen, 800 mg) was (Figure 11) and an OPG was taken (Figure 12). In terms of oral hygiene,
given on the day of surgery and daily for five days postoperatively. the patient was instructed to use cholorhexine for the first week then
Following reflection of a full thickness flap, the remaining upper teeth recommended to use a water pick. The patient also was instructed to
were extracted and all granulation tissues were removed (Figure 5). eat a soft diet for 6 weeks post-operatively.

7 8 9

Fig. 7 Determining the medial wall of the maxillary sinus Fig. 8 Suturing using an absorbable material Fig. 9 Transferring the inserted implant positions

10 11 12

Fig. 10 Checking the holes in the mouth Fig. 11 Views of the temporary fixed prosthesis, frontal Fig. 12 An orthopantomograph was taken after the
(right) and lateral (left) view surgery
After four months healing time, the provisional prosthesis was removed (Figure 13). All
implants fulfilled: 1) stable when tested manually and 2) no sign of peri-implantitis at the
clinical and radiological exam. Before the impression, all implants were splinted to each other
using pattern resin (GC, America Inc) (Figure 14) to avoid any unpredictable distortion. Then,
an open tray impression was taken using polyether siloxane (3M ESPE) (Figure 15).Using the
plaster model, the provisional was seated on the model to see if the impression was taken
correctly. Since the patient was happy with the esthetic provisional prosthesis, it was scanned
(Figure 16) for a CAD/CAM framework. Following all try-ins, including metal and porcelain, the
prosthesis was delivered (Figure 17). The patient was appointed for the first 3-month re-call.
The final prosthesis clinically was functional and radiologically showed no bone loss (Figure 18).

The overall functional and esthetic outcome of the treatment was judged excellent by the
patient. Seven months after the initial loading, no crestal bone loss was observed around the
implants. This case report showed that a resorbed endentulous maxilla with various types
of bone quality could be restored with good function and esthetic using immediately loaded
implants featuring a narrow apex. Favorable marginal bone level/s were maintained by the
inserted BLT implants.

13 14 15

Fig. 13 Healed implants after 4 months Fig. 14 Splinting the impression copings using pattern Fig. 15 Taken impression using an open tray technique
resin

16 17 18

Fig. 16 Showing CAD/CAM pictures Fig. 17 A final ceramic fixed prosthesis (left) and its OPG Fig. 18 Clinical (left) and radiological (right) findings.
(right). 3-months post-op after the final prosthesis.