| 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.
