Author: cglenn

Dentistry is the greatest profession in the world!!……there are very few careers where you can have such an immediate and life changing effect on the people you work on.  Last week I was in Puebla Mexico on a dental mission trip organized by Danny Domingue at the Wehrle Implant Immersion Institute.  Mike Wehrle has an incredible operation down there but has done his implants with a mostly analog approach.  He wanted to learn the fully digital workflow that Danny and myself teach at our full arch course so he found this wonderful patient for us to collab on. 

I did a facial analysis and a smile simulation to help design new teeth for the patient and I planned the ideal implant positions in Blue Sky Plan based on the waxup and simulation.  










Dr. Wehrle used the surgical guide to place 6 implants in the maxilla and then Danny performed intraoral scans and a Grammetry scan to accurately record the implant positions.  



Using this data, Danny’s lab (Louisiana Dental Implant Lab) designed her new teeth overnight and sent us the file.  The teeth were 3D printed in bleach shade OnX Tough resin on a Sprintray 95 printer and then I stained/glazed using GC Optiglaze.  This FP1 prosthetic was delivered the very next day and retained by the Vortex Screws designed by Danny.  This allowed the prosthetic to be attached directly to the multi-unit abutments.





This patient was so appreciative that she came back to the clinic 2 days later just to thank us in person and take a picture with us because she said “This has completely changed my life already” …….. and it absolutely shows when you look at her eyes and the way she’s smiling in the before/after photos.  This was a total team effort and took decades of combined experience to pull off but these are the moments that make it 100% worthwhile.

Two weeks ago, me and Danny Domingue went to help Ryan Gilreath, one of our past course attendees, with a couple full arch cases at his practice in Charleston SC so I got to document them real well. This was a patient who had a nice maxillary denture but she just had no ridge and it wouldn’t stay in. We treatment planned an upper AO6 and I designed some basic resin printed guides. I’ve posted lots of cases with elaborate full arch stackable metal guides and those are awesome and preferred in many circumstances like when there’s a lot of bone reduction to do. However, when there’s only 3-4 mm of bone reduction needed, this method is still my default as it’s quick to design and fabricate and I can print in house. Basically, all I do is design a bone reduction guide and then I repurpose that into a drill guide and an index for the immediate load prosthesis. The drill guide is just the reduction guide with the guide tubes added and the prosthesis just gets connected to the reduction guide to index it into position for the pickup. Since they are all the same guide essentially, they all fit the same and use the same pin fixation holes Total costs to fabricate this case were a $20 export from BSB, $3 in printed guides, and maybe $7 in printed prosthetics……then of course your implants, muas, and such. I created a video of the entire procedure too which I’ll post in the next reply as I can’t post it here.

Here’s her existing denture which was really good to start with. He performed a dual scan so I’d have all the data in blue sky plan. The only correction I thought was needed is to fix the slight cant sloping down to her left

This is just an overlay in powerpoint I use to help orient myself for doing the new waxup

Data was opened in Blue Sky Plan and bone segmentation performed. This is required any time you’ll make a guide directly on bone.

Here you see the purple is her current denture and the white is my redesign which fixes the cant and is made to sit 3mm off the bone.

With the teeth finalized, I planned 6 implants in the best positions I could.

Here’s the implant sizes

So this is the bone reduction guide. I just make a basic guide on the edentulous jaw and then cut the occlusal back where the bone needs to be reduced to. On these cases, I like to leave a little portion in the midline that hooks on the bone as a positive stop to aid in seating. This makes the positioning more precise and lets you drill the pin holes more accurately. Once that’s done, you can just buzz through it and reduced that small area too.

Here’s the drill guide………notice it’s the exact same as the reduction guide with exception of adding the guide tubes.

I printed all the jaws and mounted on my handy printed typodont so Ryan could go through and do a mock surgery.

Reduction guide

Drill guide

Printed prosthesis. This restoration is designed to sit 3mm off the bone so you need a way to preserve it’s relative position to the maxilla……..once again, just connect the reduction guide to the prosthesis. Here I did remove the lingual just to make seating easier. The pins will hold the position correctly.

And here’s how it looks on the model. I know it still looks like there’s a cant but there’s not. What you’re seeing is the slope to her lower arch which is for sure canted. The final pics will show that it’s aligned perfectly to her face.

Now for surgery……here’s Dr. Gilreath and his team working away. It was incredible how much more efficient they were in this surgery compared to case we did the day before. There’s just so many intangible things you can’t really describe but that you learn in actually doing such cases. The biggest factor in doing these cases efficiently is having multiple assistants that understand the steps and can have you the parts or tools you need in your hand without even asking but that only comes with experience.

Bone reduction guide seated and pinned into place and now he’s reducing bone

Once bone reduction is completed, take that guide out and toss it in the trash. Now pin in the drill guide and do the osteotomies. We’re using the Blue Sky Bio fully guided keyless kit here and BSB implants. Since we were working on soft maxillary bone and really wanted to immediate load, we decided to stop at the 2.5 mm drill. Rather than continuing to drill up to size, we’ll use rotary bone expanders to get to final diameter.

Here’s the osteotomies after removing the guide……..exactly where they were planned.

It’s in the video but I don’t have any pics of these in use………these are the rotary osteotomes. You just crank em slowly into the osteotomy in progressively bigger sizes until you’re expanded enough to place the implants. I think here we followed that 2.5 drill with the 3.0 bone expander, followed by the implant placement which does the final bit of expansion by itself. The kit we used comes from BSB but there are many on the market.

We also used the Plasmaloc to treat all the implants right before placement. If you’ve ever dipped an implant in water, you know they are hydrophobic. This applies a plasma field to the surface and destroys any hydrocarbons and makes the surface very hydrophilic. There are several studies that indicate this leads to faster/better integration.

The guide was put back on to place the implants with the guided carrier to the proper depth.

If you look back at the surgical guide, you’ll notice timing marks on the two distoangled implants………those are there to tell him where to align a flat so that the muas will line up correctly for the predesigned restoration.

Here’s the printed prosthesis pinned in place. The cylinders were placed through the holes onto the muas

Cylinder pickup with Taub Stellar DC resin. Be sure to plug the access holes so you don’t get blocked out.

Once the resin sets, you can remove it from the mouth and begin cleanup

Inevitably you’ll have some voids apically around your cylinders to fill in.

The reduction guide index has served it’s positioning purpose so now you can just cut it off leaving behind just the hybrid which is now indexed on the temp cylinders.

I’ll place analogs on the cylinders as I fill in any voids on the prosthesis just so that I don’t get composite in there that would interfere with seating.

Here’s the final prosthesis ready to deliver……..it’s smooth, ovate, polished, and has no concavities anywhere.

On the occlusal aspect, I just cut off any excess cylinder height and trimmed excess resin

This was her initial bite upon closing which was almost perfect. Just a couple minor adjustments to occlusion

Tissue gets sutured around the prosthesis

Here’s how she left after waking up from sedation. She was very happy as you’d expect.

Then we went out on Ryan’s boat on Charleston harbor to celebrate a job well done.

One of the best ways to preserve soft tissue architecture with an immediate implant is to place an immediate temp or custom tissue former. This will support the tissue avoiding collapse. There’s many ways to do this including just making one chairside but this is my preferred methods as they’re precise and can be done before surgery.

Here you see the surgical guide as well as my temp with a passive pickup hole indexed off the adjacent teeth. This option serves well when doing cases guided or free hand. I’ll show how to make it coming up.

Extraction- root tip was retrieved

Blue Sky Bio Fully Guided Keyless kit used to place a 6 x 11.5 mm Biomax Forte implant

6.0 x 11.5 BSB Forte implant placed fully guided with 50 ncm insertion torque. These implants are really nice for immediates and soft bone as you can get a lot of grab with them

Here’s a tibase placed on the implant after placement. As you can see the tibase emerges right through the center of the passive pickup hole. Now just pick it up and once set, you can remove and cut off the index and add a little flowable to the emergence profile. Unfortunately, I can’t find the pic of the finished product ; (

Ok here’s how I do it. Before planning the implant, I’ll do a virtual waxup in BSB

Now plan the implant backwards from the ideal prosthesis

Once you have it where you want it, you can put a virtual abutment on the implant- in this case a 1.8 mm emergence tibase

Go into the crown and bridge module and you can turn your tooth waxup into a screw retained crown

Emergence profile can be adjusted here. I’ll often segment the tooth root that is being extracted and then match my emergence to that tooth’s profile

Finished screw retained crown design.

If you don’t have adequate stability or just don’t want to immediate load, you can simply cut off the occlusal half of the restoration. Alternatively, you could just print it full contour and grind down the occlusion.

If you prefer the passive pickup hole like in the clinical shots above, just place a virtual custom abutment that’s really long and about 5 mm in diameter. Then you can just boolean subtract it from your crown to create the pick up hole

The implant guide I generated here can serve double purposes. Of course I printed it for surgery but you can also use it as an index for your temp to guarantee the positioning is correct. I’ll just cut out the center of the guide and import/combine the tooth I waxed up……..now just connect the two with some little tube extensions and you have an indexed temp. This gets printed in crown and bridge resin and serves as an awesome temp.

This is a really cool case I just wrapped up planning that I wanted to share. This is about as complex as guided/implant cases get so I’m going to walk through the thought process and how I execute these.

Here is the CT scan opened in Blue Sky Plan. Pt has numerous missing teeth and extensive decay throughout the mouth. The treating doctor planned to edentulate her and do 6 implants per arch and fixed immediate load prosthesis

The intraoral scans stitched to the CT

You might think that the way to start would be in planning implants but we really can’t adequately plan implants unless we know where the ideal teeth should be. So my starting point is always to begin by treatment planning the photos. This is my little powerpoint template I posted about a couple weeks ago. If you reach out through our website, I’m happy to send it to you. It’s really beneficial for smile analysis and smile simulations. You can see the extensive decay present. Midline good…….incisal edges too short……..reverse smile line……..empty buccal corridors. Definitely a lot we can improve upon. Also noticing pretty big masseters so we want to over-engineer this case as much as possible.

The lateral view helps me know if the teeth need to be brought out more facially and also helps in analyzing incisal length when referencing the wet dry line of the lip.

So the template has many smiles to choose from for smile simulations and I went with this one first because I thought it would be a good one for filling out her buccal corridor………..I was wrong! This one did not look good at all to me. In analyzing it, I think the buccal corridor is too toothy. So I went back and found another smile in the library that had more of a Ushaped arch form more similar to her current teeth.

Here I’m aligning everything and scaling it. I put the incisal edge just above the wet dry line of the lip; I scaled it to make the anterior 6 teeth be the same width as her nose; I also stretched the length of the teeth upwards because her original smile seemed gummy to me.

Here’s the second simulation which I thought fit her face much better. This is the one i chose to go with and I’ll use it to guide my 3d waxup

I ALWAYS save this picture as a reference for when I’m doing the waxup. This is the simulation I like turned down to 50% transparent so that I can correlate her existing teeth to the changes that need to be made.

So now, I’m ready to do a digital waxup. The maxillary arch is all I’m really focused on initially since it drives the esthetics. I do my waxups in the BSB Denture Module because it lets me pull in an arch of teeth all at once and quickly scale and align them

Again, the transparency function lets me reference back and forth between the 2d simulation to ideally position things. Once the max is set, we just set the mandibular dentition to it.

Completed Digital waxups

NOW, we’re ready to begin positioning implants. To get the 6 implants into the premaxilla was very challenging but we were able to do it by distoangulating the posterior implants along the sinus wall and using 30 degree abutments to determine where the screw access would emerge.

Prosthetic emergence is set to come through occlusal surfaces or just lingual to the incisal edges.

Mandibular planning was very similar except here we’re doing a couple shorties distal to the foramina to increase A-P spread.

At this stage, we send it back to the doctor for approval before going on to fabricate guides. Once they do, then the fun begins.

We knew this would be bone supported guides because of the depth the implants had to be at for prosthetic space. So if you are doing bone guides, you have to do bone segmentation to make STL’s of the jaws. I go a step further and cut the teeth off the bone segmentation model and combine back in the high quality teeth shapes from the stitched intraoral scans.

The reason this is important is because I’ve recently begun making the bone reduction guide such that it’s connected to a tooth guide for super accurate positioning. I’ll make the bone reduction guide and the tooth supporting section so that they both have the same path of draw and will have no interferences seating as a unit.

Printed models for testing all guide fits

So I take this bone/teeth model into the denture module just for purposes of generating a path of draw model. All undercuts get blocked out so it can seat as a unit.

Path of draw model to build guide on.

Now I’m ready to make the guide which I call the “pre-reduction guide”. What’s unique about this workflow is that I really only make a single guide in BSB. However, I’ll repurpose that same guide to function as the pin drilling guide, reduction guide, and the drill guide. It will even serve as the positioner for the temp prosthesis. It’s important to draw an overly generous guide boundary. It’s super easy to cut things back if they’re too over-extended but it’s a huge pain if they’re not extended enough to start with. Also the only tubes you should have turned on at this stage is the lateral pin tubes.

Completed “pre-reduction” guide made on that path of draw model. This is what I’ll turn into the reduction guide, drill guide, and everything else.

Showing upper/lower pre-reduction guides.

So what I’ll do next duplicate this guide…….on 1, cut away everything except where it sits on the teeth. This will serve as the positioning index for the initial pin placement and reduction guide. Then on the other duplicate, you can make the bone reduction cuts to generate a reduction guide. Finally, I’ll go into mesh mixer and just connect these 2 with some tubes. The idea is that you’d flap, seat this guide completely on the teeth which in turn perfectly positions the bone reduction guide. This allows it to be stable while you drill your pin osteotomies and pin it into place.

This picture is just showing the pre-reduction guides and the pin placement and reduction guides superimposed on one another. As you can see, they are one and the same…….it’s just that I’ve cut them into the shapes I want.

Flap, seat this, drill pin holes, and pin into place.

Once pinned in, you can just take your drill that you’ll do bone reduction with and zip through those little tubes which allows the tooth indexing section to fall away. I’d recommend doing extractions at this point before reduction. It adds a little support to the buccal bone having this guide in place and helps prevent blowing out a buccal plate during extractions. After extractions, use the drill to reduce bone down to the plane of the reduction guide. Note that it’s a buccal only guide.

Here’s the jaw shape after bone reduction.

Model work we include so you can test fit everything and do mock surgery if you want.

You don’t want to be drilling on printed plastic so I already have the implant sites subtracted out where the drill can penetrate into the space without dulling them.

Reduced Maxilla ready to seat the drill guide.

After reduction, just unpin and throw away the reduction guide. Now you’ll seat the drill guide. If you look closely, this is nothing more than the same reduction guide but with the guide tubes added in and connected with some tubes. Again, I’m just making 1 original guide and then repurposing it into these multiple forms. The fact that it’s the same reduction guide is advantageous because you know it will be able to seat and pin in the exact same way. When your pins go to place, you know you’re seated properly

This is just zoomed in on one of the angled implant showing the timing marks on the guide tube. Each of these lines corresponds to where the flats of the implants should line up. This is super important if you want the angled MUA to line up and emerge through the prosthetic in the planned position. This case is using the BSB fully guided kit so the guided driver has 6 notches that correspond to the flats on the BIomax implant. Drive the implant to seated position and then just make sure to align a driver notch to one of the timing marks.

Buccal only upper drill guide on the models

Note the tubes are floating with this design so hypothetically, you could not reduce the bone all the way and this would still seat without interference

Timing mark on the mandibular guide

Tubes floating off the ridge

Finally, we need to make the immediate load prosthesis. Since we’re doing things guided there’s no sense in doing a denture conversion. We can take the waxup done at the beginning of the case and just turn it into a fully contoured prosthesis. In this case due to spacing issues, it was necessary to make more of an FP1 design on the maxilla. They are designed such that the intaglio of the hybrid or pontics sits exactly 3mm off the level of the reduced jaw. To position it into the right VDO and A-P position, we’ve just repurposed the original bone reduction guide (again). This will pin into place just like the previous ones (because they’re all different versions of the same guide) and position the prosthesis into the planned position.

You can also see that there is a 2mm hole on the facial of each implant site so that for the pickup, you can just fill a syringe with acrylic, stick the tip into the hole and inject. This beats the heck out of doing a salt and pepper pickup. Salt and pepper is difficult anyways here because the size of the holes are so precise.

Notice that the intaglio is fully shaped so there should be no need to recontour anything. The only modification you’d do after the cylinder pickup is to cut those sacrificial supports connecting it to the positioner and trimming back any acrylic overflow from the pickup. These are 3d printed in Bego Varseocrown which is super strong and has been performing really well for me. From a surgical perspective, most people will suture the tissue before pickup but that’s got a lot of problems. The ridge will be convex so when you do it that way, your intaglio will always turn out concave and uncleansable. What me and Danny Domingue have figured out after doing a ton of these is that it’s far better to wait until the very end to suture. We just published an article on this called “the full arch healing abutment”. The idea is that if you pre-design the intaglio to be perfectly contoured and simply suture the tissue TO THE PROSTHETIC at the very end, the tissue will have to form itself to the shape of the prosthetic which makes it more cleansable and gives a more natural emergence profile as if it’s coming out of the tissue.

(Pics from a different case) The way Danny does it is he completes the pickup and removes the indexing guide. He’ll do any grafting needed and then place 2 prf slugs over each implant site.

Then he’ll screw down the prosthesis THROUGH the PRF sandwiching it into place and stabilizing it. Then just a large horizontal mattress suture on each side of the arch to pull the flap edges up against the temp. If the flap moves any at the midline when they move their tongue, you should add one more at the midline. That’s it! Usually 2 and at most 3 sutures! DO NOT TRY TO REAPPROXIMATE THE TISSUE EDGES!

This is the beauty of the full arch healing abutment technique………you get massive gains in keratinized gingiva as a byproduct. Think about it……you have the temp pinning down a ton of PRF that is sitting directly atop the bone. The eliminates a lot of the pain, keeps the bone from being exposed, protects any graft, and speeds healing and vascularization. The flap edges will be far apart from one another sitting on either side of the prosthesis. However, we know from the old perio lit that if you’ve made an incision entirely within KG, it doesn’t matter how far apart the tissue edges are left to heal, it will always close the entire gap with KG. Here we’re exploiting that to get a large fibrous bed of KG with the added benefit that it’s properly shaped itself to the temp. There’s simply no easier way to get such huge gains in KG or to develop a proper emergence profile that is cleansable for long term maintenance.

The goal is to make the conversion so easy that an asst. could do it.

Here you can see the hole size where the temp cylinders will emerge. Cylinder is about 3-3.5 mm and hole is 5mm

Finally, we create a set of CYA dentures just in case the implants don’t torque enough to immediately load.

Conclusion:

That’s it! Hopefully I explained it well enough but I’ll tell you anecdotally that we’ve done tons of cases like this now……..many in front of 20-30 people in live surgery courses and the speed and accuracy at which we can finish a case like this is insane. At the last course at Danny’s office, we did a complete lower arch with this protocol in 1 hr exactly from incision to pt leaving with an immediate load prosthesis. I hope you can see why when I hear the old, tired guided vs non-guided debate, I just roll my eyes at this point. It’s not a question of “can you do a really nice job freehand?”……..of course you can! However, there’s no way you can do it to this level of precision or speed. THAT is the reason we do these guided.