Results:
The patient presented for the surgical phase of treatment, consent forms
were reviewed and signed by the patient. Local anesthetic was applied to
the maxillary arch using 4% Articaine + 1/200,000 epinephrine. The
surgical guide was inserted to verify seating on the arch. A 2 mm wide
screw was placed through the surgical guide at sites 5, 8 and 12 to
stabilize the guide and prevent motion during osteotomy preparation.
(Figure 16) Utilizing Guide Right 3 mm depth stop drills (Figure 15),
sites #4, 6, 10 and 13 osteotomies were prepared through the 3 mm guide
sleeves in the surgical guide. The implants were placed 4-5 mm below the
alveolar crest as was planned to provide adequate room for the Conus
abutments. The fixation screws were removed, and the surgical guide was
removed intraorally. An incision was made at the center of the ridge and
soft tissue flapped to expose the crestal bone with some buccal and
palatal ridge exposure. A surgical carbide was then utilized to reduce
the crestal bone across the arch to 1mm from the platform of the
implants at the four sites. Alveolar crestal reduction was performed
after implant placement to prevent loss of stability of the surgical
guide. Cover screws were placed and soft tissue reapproximated and
fixated with 4 0 nylon sutures in an interrupted pattern. The current
maxillary denture was relined with Karlin, Easy Soft Liner to
accommodate the reduction in crestal height performed with implant
placement. A panoramic radiograph was taken to document implant
placement. (Figure 17) The patient was dismissed.
The patient was allowed to heal for 4 months during which periodic
post-operative visits were performed. The implants were uncovered, and
healing abutments placed. Following a 2-week healing of the soft tissue,
the healing abutments were removed intraorally, and impression abutments
placed. (Figure 18) A full arch impression was taken with Permadyne (3M,
St Paul, MN) heavy & light bodied polyether impression material in a
custom tray to start the restorative phase of treatment.
A master cast was poured in ResinRock (Whip Mix, Louisville, KY) with
implant analogs and GI-Mask (Coltene/Whaledent, Cuyahoga Falls, OH) to
replicate the soft tissue architecture. Inter-fixture spacing was
verified with a verification jig fabricated from GC Pattern Resin (GC
America, Alsip, IL). An impression of the mandibular arch was taken
with alginate. The master cast was mounted with a Hanau facebow on a
modular, semi-adjustable articulator. A jaw relation record was made
with a custom Triad (Dentsply Sirona, York, PA) resin baseplate with a
wax rim and Blue-Mousse (Parkell, Brentwood, NY) VPS bite material.
The wax rim was marked to show the desired midline and tooth position,
then a protrusive check bite was made to set the occlusal parameters on
the articulator. The patient chose shade Vita B1.
A try-in of the full arch with denture teeth (Ivoclar Vivadent, Amherst,
NY) to confirm esthetics and function. The teeth were positioned to
optimize esthetics and phonetics, but were repositioned, per the
patient’s request until a satisfactory result was achieved and patient
approval was acknowledged. A buccal matrix was made on the master cast
with Express VPS putty (3M) to preserve the tooth position. The dental
laboratory fabricated 4 custom Atlantis Conus abutments (Dentsply
Sirona) and a cobalt-chrome denture framework/baseplate that
incorporated the SynCone caps (Dentsply Sirona) that would retain to the
Conus abutments. (Figure 18) The denture teeth were placed on the master
cast with the Conus abutments and denture framework present. Utilizing
the buccal matrix a new full arch wax try-in was fabricated with a
spacer over each Conus abutment.
The patient returned to the office and the Conus abutments were placed
intraorally using the insertion guide and verified clinically and
radiographically for fit and orientation. A new jaw relation was made
and verified. The wax try-in was inserted intraorally over the Conus
abutments to verify fit, occlusion and get patient approval on the
esthetics. The wax try-in was returned to the lab for processing.
The maxillary overdenture was processed without the incorporation of the
Syncone caps, which would be picked up clinically using Chairside resin
(Zest Dental Solutions, Calsbad, CA). The finished maxillary overdenture
was returned to the office for insertion.
The finished overdenture was tried in with the Syncone caps seated on
the Conus abutments and passive fit was confirmed as well as the
occlusion and esthetics. Chairside resin was placed into the sites in
the intaglio of the denture where the abutment spaces were present. The
overdenture was then seated intraorally, and the patient instructed to
occlude. Upon set of the resin the overdenture was removed with the
Syncone caps embedded within. Any resin flash was removed around the
Syncones and the areas polished. The overdenture was reinserted
intraorally and retention was confirmed as well as occlusion. (Figure
19) The patient was appointed for a follow up appointment the following
week to check fit and function.