Australasian Dentist Magazine Sept-Oct 2021

Category Australasian Dentist 63 This clinical outcome was achieved in a single day and with no complications. The patient was highly satisfied with the positive impact the treatment had on her quality of life due to significantly improved aesthetics and recovery of masticatory function. Initial situation A systematically healthy 58-year-old female patient presented to our office with the chief complaint of aesthetic dissatisfaction and impaired masticatory function due to an unstable removable partial denture (Fig. 1). The initial comprehensive clinical evaluations revealed partial edentulism, a deep overbite with the lower incisors impinging upon the palatal gingiva and increased overjet. The upper incisors were buccally tilted and presented tooth wear and mobility. Moreover, there was interference between the lower lip and the anterior teeth in the smile position (Figs. 2-5). Intraoral periapical X-rays showed approximately 50–75% alveolar bone loss. In addition, the patient had an uneven smile line (Fig. 6,7). Treatment planning The benefits, risks, and alternative treatment options were discussed with the patient and a decision was then reached in partnership with the patient. This is a fundamental stage in treatment planning to ensure that the patient’s needs and wishes are met and to achieve a successful outcome. The treatment workflow included the immediate placement of implants into the extraction sockets and immediate loading using computer-guided surgery and a flapless approach. A suitable new removable partial denture was planned as a starting point. Following the clinical documentation, a digital smile design (DSD) preview was created. The dental technician then made a wax-up of the frontal teeth and a model of the posterior area, thereby creating a new dental arrangement. This new model increased the vertical dimension to define an optimal vertical position for the front teeth (Figs. 8,9). The next step was to transfer this data to the patient’s mouth to verify its accuracy. Using a silicone mask created based on the wax-up and filled with flowable composite, a mock-up of the front teeth was made (Fig. 10). A set-up of the posterior teeth was added to the mock- up to complete the previsualization of the proposed new smile (Fig. 11). A digital smile design was created and included the initial clinical situation, the proposed shape and position of the teeth, and the lower lip line position (Fig. 12). In addition, the deep bite and the overjet were corrected, and the smile was improved. This prosthetic plan was discussed with the patient and then approved (Figs. 13-15). The cast model was scanned and an STL file was generated. Moreover, a CBCT exam was requested for the radiographic assessment. This data, including the DICOM files, were imported in coDiagnostiX ® software for the analysis and treatment planning (Fig. 16). The prosthetic plan is just as important as the surgical plan. For this, the STL file of the initial situation was compared with the DICOM files (Fig. 17,18). Furthermore, the STL file related to the proposed prosthetic plan was aligned with the rest of the files (Fig. 19). Finally, the last pairing was performed by superimposing the STL file with the virtual extraction of the lateral incisors, which were potential sites for implant placement (Fig. 20). After this preliminary phase, all the data related to the initial situation, bone availability, gingival profiles, and prosthetic strategy were ready to start the planning of implant positioning. On this basis, four Straumann ® Bone Level Tapered implants (22: diameter 4.1 length 12; 15: diameter 4.1 length 12; 25: diameter 4.1 length 12; 12: diameter 3.3 length 12) were strategically distributed among the maxilla and fixation pins were considered for the stabilization of the surgical guide (Fig. 21). Furthermore, suitable screw-retained abutments (XXXX) were chosen and the corresponding sleeves for the implant and pin placement were selected (Figs. 22,23). The implants at sites #16, #12, #22, and #26 were planned according to bone volume, soft tissue position, and prosthetic strategy (Figs. 24-27). The surgical guide for implant clinical Figure 10 Figure 13 Figure 16 Figure 11 Figure 14 Figure 17 Figure 12 Figure 15 Figure 18