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Case Example 1:
Bone-supported guide
This patient is a 61-year-old female with
a longstanding history of full edentulism.
The initial clinical and panoramic radio-
graphic evaluation (Figs. 1-2) revealed
severe alveolar ridge atrophy in themaxilla
and mandible, resulting in ill-fitting and
non-retentive maxillary and mandibular
full dentures. The patient had stopped
wearing her mandibular denture regularly
due to the associated discomfort. Aprelim-
inary treatment plan was devised to place
four maxillary and two mandibular dental
implants in two separate surgical proce-
dures to supportmaxillary andmandibular
overdentures. This treatment plan was to
be confirmed or modified as needed after
cone beam computerized tomographic
evaluation. This case example will high-
light the procedure in themandible.
The first step of the treatment was to
fabricate a new set of transitional dentures
based on a functionally, phonetically and
esthetically verified tooth set-up. These
dentures were then duplicated in radio-
opaque acrylic and were used as radio-
graphic templates. A cone beam CT radio-
graphic evaluation was then performed
Fig. 1: Preoperative clinical situation
of the fully edentulous mandible
Fig. 2: Preoperative panoramic radiograph
Fig. 3: Simplant plan for implant in site #22
Fig. 4: Simplant plan for implant in site #27
Fig. 5: Stereolithogrphic bone-supported
guide and partial bone model
Fig. 6: Bucco-lingual, full-thickness flap
reflection
Fig. 7: Bone-supported guide seated and
secured with two anchor pins
Fig. 8: Guided implant placement
Fig. 9: Osteoplasty performed after
implant placement and removal of
surgical guide
Fig. 10: Bone grafting with mineralized
bone allograft putty
Fig. 11: Suturing to allow for non-sub-
merged healing
with the Sirona Orthophos XG3D CBCT.
The DICOM files were exported into the
Simplant implant treatment planning
software, and two Straumann Bone Level
implantswereplanned insites#22and#27
(Figs. 3-4). A bone-supported SurgiGuide
was ordered through the software andwas
produced byMaterialise Dental in Leuven,
Belgium, using stereolithographic tech-
nology. The bone-supported SurgiGuide
was delivered with a partial stereolitho-
graphic bonemodel (Fig. 5).
The dental implant surgical proce-
dure was performed under intravenous
conscious sedation and local anesthesia.
A crestal incision and a midline buccal
vertical incision were performed to allow
the reflection of a bucco-lingual full thick-
ness flap (Fig. 6). The flap was carefully
extended distally, with judicious attention
andconsideration to the locationof inferior
alveolar neurovascular bundle, to allow for
complete seating of the bone-supported
SurgiGuide. The SurgiGuide was immobi-
lizedby insertionof twoNobel anchorpins,
which had been previously preplanned
(Fig. 7). The Straumann Guided Surgery
kit was utilized to prepare the guided
implant osteotomies in sites #22 and #27,
and two Straumann Bone Level RC 4.1 X
12 mm SLActive implants were placed in a
fully guided approach (Fig. 8). The guided
implant mounts and surgical guide were
removed, and an osteoplasty performed to
achieveasmooth,flat alveolar ridge(Fig. 9).
With bone-supported guides, it is impor-
tant to perform this osseous re-contouring
after the implants have been placed to
ensure an accurate fit of the surgical guide.
Healing caps were placed and a bone graft
putty (DynaBlast mineralized bone graft
putty, Keystone) was applied around the
implants as a protective layer and to cover
the minute dehiscence defects (Fig. 10).
The flaps were sutured with resorbable
(5.0 Chromic Gut) and non-resorbable (4.0
Cytoplast, Osteogenics) sutures toallowfor
a non-submerged healing of the implants
(Fig. 11).
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