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CASE PRESENTATION: Immediate Premade Provisional Bridge on Implants Placed With Guide

Categories: Implant Dentistry

Author(s): PERRY E. JONES, DDS, MAGD, IADFE

Date: 05-18-2020 06:36:11 am

The accuracy of implant placement has increased dramatically with the advent of guided surgical guides. The digital workflow offers the possibility of premade provisionals that can be delivered at the time of implant placement. Considering that precise data is the key to excellent outcomes, CBCT-based DICOM data can be file-merged with STL intraoral scan data to create a virtual planning platform. Planning software allows crown-down planning, with virtual representation of missing teeth and virtual placement of implants. This case will present the workflow used to plan and precisely place 3 implants to support an immediate placed 4-unit anterior provisional bridge. Following a bicycle accident in which he collided with a truck, this 28-year-old patient lost his 4 maxillary incisors. The patient presented with no contraindications to implant placement. After a discussion of alternatives, benefits, and complications, the patient consented to have 3 implants and a premade provisional placed.

Virtual Planning

Using implant planning software, CBCT-based DICOM data (PreXion) was file-merged with STL scan data (iTero Element scanner, Align Technology) to create a virtual planning platform. The 4 missing incisors were virtually created and placed in an optimal position to allow screw retention with the access hole lingual to the incisal edge. The implant locations were planned in relation both to available bone and the position of the wax-up maxillary incisors. As there was insufficient room for implant placement of tooth No. 10, three implants were planned with a cantilever 4-unit bridge resting on the implants. The access cylinders for the retention screws were precisely designed to be lingual to the incisal edges.

Using the planned bridge design, Glidewell Labs milled a PMMA Implant Provisional and cemented 3 titanium insert cylinders using Shofu luting cement. The planned surgical guide was created using an Objet30 3D printer (Stratysis) with FDA-approved MED610 translucent polymer.

Treatment

After administering 4% Septocaine (Septodont) local anesthesia, an anterior ridge incision with bilateral vertical releasing incisions was performed to allow observation of the implant to titanium insert fit for the premade provisional bridge. Using the 3D-printed surgical guide, sequential osteotomy drills implants were placed to shoulder stop depth. To ensure precision fit of the premade provisional, the Glidewell Direct Inclusive Tapered implants were placed with surgical guide in place and torqued to 35 Ncm. Close inspection of the PMMA provisional to the implant surface revealed a precise fit. No adjustment of implant depth or occlusal adjustment was necessary.

Outcome Summary

The patient was extremely happy with the immediate esthetic result, and the healing after 6 months was excellent. Superior outcomes can result from the use of accurate scan data for file merge and virtual planning. In this case, precise accuracy was achieved using a guided surgical guide sufficient to place 3 implants and immediately seat a premade provisional with no adjustment necessary.

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