Indication 3, Case 1

Distal extension situation maxilla

Surgeon:
Dr. Tom Wilson
Restorative Dentists:
Dr. Frank Higginbottom

A 63-year-old female patient of record lost a fixed partial denture replacing tooth #14. The prosthesis failed due to long term periodontal problems and root caries. Due to prolonged retention of the periodontally compromised teeth, and early resective surgical techniques there was not adequate residual alveolar bone to allow for placement of dental implants. Since any form of fixed prosthesis would be desirable over a removable option the patient accepted the prospect of sinus and ridge augmentation and the time it would require for bone to be regenerated. Subsequent to six months of bone regeneration three ITI solid screw implants were placed in a non-submerged manor. After twelve weeks of healing the implants were ready for restoration.

	1 Implants with healing abutments in place at twelve weeks.

	2 Radiographic picture of three ITI solid screw SLA implants.

	3 Occlusal view of the well positioned implants.

	4 Healing abutments removed and the internal synocta configuration exposed. The restorative options were going to be determined in the laboratory therefore an implant level impression was planned.

	5 Non-repositionable synocta transfer copings were seated on the individually on the implants.

	6 An open tray impression was taken using a custom tray and a two-phase polyvinyl impression material.

	7 Laboratory analogs were carefully positioned in the impression.

	8 The impression was poured in a low expansion die stone, and allowances made for a soft tissue model. The working model was recovered from the impression to start the laboratory procedure.

9
Abutment selection begins after the working models are articulated to duplicate intra-oral relationships. The Straumann abutment selection kit is helpful in determining what abutments might serve the patient the most advantageously. In most instances the dentist would prefer single cemented restorations on individual solid components. However, the quality of the bone, the length and diameter of the implants, and their angulation dictated splinting of the implants and some means therefore of axis correction between the implants and the opposing arch.

	10 Through the use of the abutment selection kit it was determined that angled abutments would correct the axis and arch discrepancies and still allow for splinting and for the restoration to be cemented. Buccal view of the try-in components.

	11 Again a buccal view showing the arch and axis corrections solved with two 15A degree abutments and one 20A degree abutments.

	12 Occlusal view of the selected try-in components. This allows the technician to order the proper components for the fabrication of the prosthesis. Note the parallelism achieved with the angled components.

	13 The angled components seated on the working cast.

	14 The angled components as well as correcting the axis problems between the implants allow for a controlled amount of crossbite in the second molar position.

	15 Occlusal view of the provisional restoration. 4mm solid abutments were used for provisionalization purposes only.

	16 Buccal view of the fixed auto-polymerizing resin provisional restoration.

	17 Final metal ceramic restoration. In all instances prior to porcelain application a metal try-in in the mouth is performed.

	18 Final metal ceramic restoration. In all instances prior to porcelain application a metal try-in in the mouth is performed.

	19 Definitive restoration on working model prior to returning for insertion.

20
Prior to placing the framework or the final restoration the angled abutments need to be removed from the laboratory model and accurately transferred to the implants in the mouth. This can be greatly facilitated by fabrication of a transfer jig prior to removing the abutments from the laboratory model. In this case a large gauge orthodontic wire was attached to the abutments with a fast setting auto-polymerizing resin.

	21 Transfer jig used to easily position the angled abutments in the mouth.

	22 Radiograph of the framework try-in showing complete seating of the framework.

	23 Temporary prosthesis and abutments removed. The implant abutment interface is cleaned and dried.

	24 The angled abutments are seated and the fixation screws are tightened to 35 Ncm using the Straumann torque device and the SCS screwdriver.

	25 The buccal view of the seated angled abutments.

	26 Buccal view of the final metal ceramic three unit fixed partial denture. Due to the definitive fit of the prosthesis and the parallelism created, a provisional cement may be used allowing for possible retrieval of the prosthesis.

	27 Occlusal view of the final prosthesis.

	28 Final Radiograph.

Conclusions
Implants offer our patients many treatment options. The best option is that when patients lose a complete posterior arch of their dentition they can have replacement teeth similar to their own natural dentition. The Straumann Dental Implant System offers the clinician outstanding treatment options. The system can be treated with standard components or with newly designed components for the "Synocta System". The implant level impression will allow the technician to select abutments appropriate for the individual patient.