Same-Day Smile With Full-Mouth Guided Surgery

INTRODUCTION
With the introduction of guided surgery to implant dentistry, multiple benefits to both the planning and surgical aspects of the workflow have been realized. Predictable placement, faster patient recovery, and less chair time are some of the main advantages to utilizing the new technology. Switching to a top-to-bottom planning approach where aesthetic results are given more priority has opened the door for clinicians to take more control of the prosthetic aspect of their implant cases and to have CAD/CAM provisional crowns designed and delivered at the time of surgery.

Whereas traditional implant procedures require waiting several days or, in some cases, weeks before a crown or bridge can be fabricated and placed, advances in CAD/CAM, coupled with guided surgery, allow for immediate-load implants with temporary crowns that are ready to be placed at the time of surgery. Today, solutions like Guided Full Mouth Restorations (3D Diagnostix [3DDX]) make it possible for full-mouth rehabilitation procedures that allow dentists to give their edentulous patients implants and teeth in a single visit. Utilizing such new solutions not only serves an aesthetic purpose, but also provides patients with much-needed functionality, all while simplifying an otherwise complex procedure.

CASE REPORT
A 44-year-old female patient presented to the dental office with a semi-edentulous mandible. All remaining lower teeth appeared to be suffering from severe attrition. The patient presented with a previously delivered All-on-4 denture in the maxilla.

Figure 1. Panoramic CBCT view (right) showing the previous All-on-4 maxillary rehabilitation and 9 remaining teeth in the mandible.	Figure 2. Patient information imported into 3D Diagnostix (3DDX) planning software with the mandible 3-D segmented (red) and the mandibular nerve mapped (purple).

Figure 3. All-on-6 implant plan by 3DDX.

Digital Workflow
A diagnostic CBCT scan (Figure 1) was acquired on the office’s Green CT (Vatech) imaging system and then uploaded to 3DDX to start the implant planning phase. After filling in the online form with case requirements for an All-on-6 procedure, DICOM data was uploaded through the 3DDX Connect HIPPA-compliant portal. The physical impressions and a bite registration were mailed to 3DDX, where they were digitized via laser scanning to aid in implant planning and for the creation of a digital wax-up for the patient.

Next, 3DDX dentists received the case and prepared it for planning by segmenting and cleaning up the CBCT scan and tracing the mandibular nerve in the 3DDX implant planning software (Figure 2). Then an All-on-6 Straumann Bone Level Tapered Implant plan was created according to the instructions they received (Figure 3).

Six implants were planned in position Nos. 19 (4.8 × 10 mm), 20 (4.1 × 10 mm), 24 and 25 (3.3 × 12 mm), and 29 and 30 (4.1 × 10 mm). All remaining teeth were planned for extraction, which was virtually simulated in the software to reflect the situation in the patient’s mouth at the time of implant surgery (Figures 4 and 5).

The next step was designing the different components of the Guided Full Mouth Restorations. This was carried out by the 3DDX Restorations team. First, the pin-positioning guide (Figure 6) was designed to rest on the remaining teeth to mark the pin positions and to make certain that the fixation pins on the base (Bone Reduction Guide) would be accurate during surgery. After that, the Snap-In Bone Reduction Guide (Figure 7) was designed. This guide has a double purpose, both as a bone leveling guide and as the base on which all the following steps are built. The 4 fixation pins would provide additional stability during surgery.

The Snap-In Implant Surgical Guide (Figure 8) is designed to fit securely on top of the Bone Reduction Guide and allows for sub-millimetric accuracy by providing full control over the osteotomy and implant placement procedures (Figure 9). The key-locking mechanisms on both sides provide extra stability during surgery and act as indicators that the guide is fitting on top of the base as digitally planned.

Figure 5. Panoramic view of the All-on-6 implant plan.

For this case, it was determined that angled abutments would be required. To ensure perfect alignment with the planned hybrid denture, an abutment guide (Figure 10) was necessary. This guide was also designed to fit on top of the Snap-In Bone Reduction Guide and had indented notches to help with accurately positioning the angled abutments (Figure 11).

Figure 6. Pin-positioning guide as designed in 3DDX software.

Figure 8. Implant surgical guide in place with 6 Straumann compatible sleeves.

Figure 9. Simulated Straumann implants after placement.	Figure 10. Abutment guide (red) helps with positioning angled abutments.
Figure 11. Angled abutments in their planned positions.	Figure 12. Hybrid denture (blue) as designed by the 3DDX prosthodontist.

Finally, a temporary hybrid screw-retained restoration (Figure 12) was designed by a 3DDX prosthodontist using the data available from the CBCT scan, the implant plan, and the digital wax-up.

Figure 14. Pin-positioning guide in place to mark the location of fixation pins as digitally planned.

Figure 15. Mandibular mucosa reflected after extraction.	Figure 16. Snap-In Bone Reduction Guide in place with all 4 fixation pins inserted.
Figure 17. Mandibular bone leveling completed.	Figure 18. Snap-In Implant Surgical Guide secured on top of the Bone Reduction Guide.

Figure 19. The osteotomy sites were drilled using the Straumann Guided Surgery kit.

Figure 22. A 3DDX-made silicone base was placed through Straumann temp-cylinders for hybrid denture pick-up. The cylinders were pre-trimmed by 3DDX.	Figure 23. Patient bit on the 3DDX-prepared bite (yellow) to confirm that the hybrid denture is in occlusion as digitally planned. Flowable relining material was then injected through the lingual/labial access holes for pickup.

Figure 26. Suturing completed with healing caps in place to preserve the gingival margin.	Figure 27. The screw-retained hybrid denture is shown in place. The patient was then sent home with a full set of teeth.

Updates were sent by 3DDX at every planning step, and, once the phase was completed, the plan was reviewed and confirmed to be following the instructions sent for this case. All parts were then sent into production and received at the office in the same week.

Surgery and Prosthetic Delivery
As seen in Figures 13 to 26, the patient was sedated, and the pin-positioning guide was placed to mark where fixation pins on the base guide should go. After that, all remaining teeth were extracted, and a flap was reflected. The Snap-In Bone Reduction Guide was then positioned firmly in place with 4 fixation pins for stability. After bone leveling was completed, the implant surgical guide was attached on top of the bone reduction guide. The osteotomy sites were drilled using the Straumann Guided Surgery kit, followed by the placement of the implants, which can be placed through the accompanying Surgical Guide Sleeves (Implant Placement Control) (3D Diagnostix) to ensure maximal accuracy according to the digital plan. Implant Placement Control is a prerequisite of using the Guided Full Mouth Restorations protocol for one-day teeth.

Once the pick-up procedure was completed, the Snap-In Bone Reduction Guide was removed, and healing caps were used to preserve the tissue margin after suturing. Now the temporary restoration was ready for placement and was perfectly in occlusion. The patient was sent home with a full set of teeth (Figure 27).

Dr. Engel is the founder of the Engel Institute and the Engel Dental Center in Charlotte, NC. In the past 15 years, he has been instrumental in teaching more than 8,500 alumni doctors who have produced more than 300,000 successful implant surgeries. Additionally, Dr. Engel has owned and operated 3 successful practices in his long tenure. He can be reached at drengel@engelinstitute.com.

Disclosure: Dr. Engel reports no disclosures.

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