IMMEDIATE PROTOCOLS AND GUIDED SURGERY … · AND GUIDED SURGERY FOR ESTHETIC SUCCESS WITH...

The ultimate goal for all surgical and restora-tive dental interventions is an optimal, long-lasting outcome. Numerous techniques and

technologies are available to increase the qualityand predictability of dental treatment, even inseverely compromised patients. These tools in-clude immediate implant treatment protocols,minimally invasive surgical procedures, guided im-plant placement, and computer-aideddesign/computer-assisted manufacture(CAD/CAM)–fabricated all-ceramic implant com-ponents and restorations.

There is now ample clinical evidence in supportof immediate implant placement as a safe treat-ment option1–4 that preserves peri-implant boneand limits postsurgical resorption. However, in thepresence of extensive periodontal or periapical le-sions, a conventional multiple-step extraction andimplant placement approach is still recommended.

It is also evident that flapless implant placementlimits chair time and postoperative complications5

and seems to prevent soft and hard tissue resorp-tion. Flapless implant placement, however, re-quires sound knowledge of the individual bonemorphology and fabrication of orientation guidesto stay within these anatomic confines. Guidedsurgery allows proper implant selection and pre-cise placement with a flapless approach.6 Theexact implant dimensions, position, and angulationare planned on the computer, based on a comput-erized tomography (CT) scan, and transferred to asurgical template.

The soft tissue collar around dental implants isvery fragile, and repeated disconnection and con-nection of implant abutments disturbs this delicateenvironment and may lead to soft tissue reces-sions.7–10 Therefore, it is advisable to connect the

1Clinical Assistant Professor, Department of Preventive andRestorative Sciences, University of Pennsylvania School ofDental Medicine, Philadelphia, Pennsylvania, USA; PrivatePractice, San Sebastian, Spain.

2Professor and Chairman, Department of Preventive andRestorative Sciences, University of Pennsylvania School ofDental Medicine, Philadelphia, Pennsylvania, USA.

Correspondence to: Dr Iñaki Gamborena, Resureccion made azkue, 6 20018 San Sebastian, Spain. E-mail: [email protected]

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IMMEDIATE PROTO CO LSAND GUIDED SURGERY FO RESTHET IC SUCCESS WITH FULL-MOUTH IMPLANT REHABILITAT IONS

Iñaki Gamborena, DMD, MSD, FID1

Markus B. Blatz, DMD, PhD2

definitive implant abutment at the time of implantplacement.

The shape and dimensions of the abutment alsoplay a role in preventing hard and soft tissue re-sorption. This concept led to the development ofthe platform switching protocol, in which abut-ments with smaller diameters are connected tolarger implant platforms.11–15 In addition, zirconiumoxide ceramics have demonstrated favorable softtissue response and esthetics, making them thepreferred abutment material, especially in the es-thetic zone.16,17

The immediate restoration of dental implantsprovides multiple advantages. These advantages,including postoperative patient comfort, are mostpronounced in full-mouth rehabilitations.18,19 Func-tion and esthetics can be established immediatelywith provisional restorations, which also providevaluable information for the definitive restora-tions.19 Therefore, the provisional restorationsshould always be fabricated as closely as possibleto the desired final outcome to evaluate and verifyall functional and esthetic parameters.

All of these techniques and technologies aregeared toward optimal, predictable, and stablelong-term esthetic and functional results. Further,they share one common goal: to limit the invasive-ness and number of clinical steps during treatmentand to preserve or enhance existing oral condi-tions. The following case presentation illustratesthe implementation of these concepts in a clinicalfull-mouth rehabilitation. Teeth were extracted,dental implants were placed with guided surgery(flapless), custom-made final abutments were in-serted (platform shifting), and provisional restora-tions were relined and cemented in a single clinicalappointment. While the clinical outcome and lim-ited chair time are convincing, a comprehensivestep-by-step treatment plan and meticulouspreparation of multiple components in the labora-tory are still necessary before surgery. The treat-ment plan must include waxups, provisionalrestorations, radiographic guides, CT scans, surgi-cal templates, master casts, final zirconia abut-ments created by scanning customized composite

abutments, and finally provisional shells fabricatedin acrylic resin for direct relining in the mouth.

CASE REPORTA 57-year-old male patient presented in goodgeneral health. He was a nonsmoker with accept-able oral hygiene and a history of bruxism. He washighly motivated, seeking a fixed restoration de-spite a history of unsuccessful dental restorationsin the past. According to the patient, “Everythingthat was ever done with my teeth broke,” includ-ing removable partials dentures (RPDs), which hecould not tolerate. The intraoral and radiographicexamination revealed partially edentulous archesand failing restorations on the remainingteeth/roots with periapical pathologies (Figs 1 to4). There were two failing porcelain-fused-to-metalfixed partial dentures (FPDs) in the anterior maxillawith bilateral distal ball attachments for anchorageof an RPD. The missing posterior teeth in themandible were replaced with a conventional RPD.The remaining anterior teeth were severely com-promised with failing restorations, periapical le-sions, and suppuration on the mandibular right ca-nine. The vertical dimension of occlusion (VDO)was collapsed due to excessive wear and loss ofposterior occlusal support.

As a result of the compromised functional situa-tion, one of the primary goals was to first increasethe VDO while establishing proper anterior guid-ance and group function. The anterior guidanceshould be as flat as possible, while at the sametime providing posterior disclusion and distribu-tion of occlusal forces on all anterior teeth.

Waxup

The desired functional parameters were imple-mented in a diagnostic waxup (Figs 5 to 8), whichalso corrected the anterior diastema. The first stepsof the diagnostic waxup included establishment ofthe proper occlusal plane, which was clinically eval-

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Immediate Protocols and Guided Surgery for Full-Mouth Implant Rehabilitations

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CASE REPORT

1 2

5 6

7 8

Figs 1 to 4 Preoperative situation of a 57-year-old male patient.

Figs 5 to 8 Mounted preoperative casts, abutment casts with increased VDO, additive waxup, and final waxup.

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uated and transferred to the articulator with a waxrim layer. The Kois Dento-Facial Analyzer System(Panadent, Grand Terrace, CA, USA) was used tofacilitate direct mounting of the maxillary cast andtransfer of the incisal edge position in reference tothe hinge axis. The diagnostic cast was mountedon the mounting platform with the occlusal planewax rim fabricated during the clinical esthetic eval-uation. The mandibular cast was then mountedagainst the maxilla with the interocclusal records.The 9-mm-wide central incisor Golden ProportionWaxing Guides (Panadent) were used to start themaxillary waxup on the Analyzer mounting platformto achieve a balanced and harmonious anteriortooth arrangement. After establishing the occlusalplane in the maxilla, the VDO was increased toachieve proper anterior guidance. Therefore, themandibular waxup was started in the anterior re-gion and then completed in the posterior region.The waxup was duplicated with a polyvinyl siloxane(PVS) impression (Virtual putty base regular set andextra–light–body fast set, Ivoclar Vivadent, Schaan,Liechtenstein) and poured with dental stone (Fig 9).The same PVS impression was used to fabricate in-direct provisional restorations (Integrity, Dentsply,York, PA, USA), which were relined with acrylic resinin the patient’s mouth and occlusally adjusted incentric relation and all excursions (Figs 10 and 11).

After an exact occlusal equilibration and estheticevaluation, pickup PVS impressions were made forfabrication of radiographic stents for the Nobel-Guide (Nobel Biocare, Göteborg, Sweden) surgicalprocedures.

Template for Guided Surgery

The PVS impressions of the adjusted provisionalrestorations were poured with stone (GC Fuji-rockEP Pearl white color, GC, Alsip, IL, USA) to createmaster casts for radiographic guide fabrication(Figs 12 and 13). Cold-curing acrylic resin denturebase material (Pink Acrylic, Candulor, Wangen,Switzerland) was added to form bilateral posteriorbuccal flanges in the maxilla while avoiding thepalatal aspect of the six anterior teeth. This wasnecessary to allow for evaluation of the completetooth contours in the subsequent scanning pro-cess for ideal implant placement in respect to thedesired tooth position. Strategically distributed 1-mm-wide holes were ground into the pink acrylicresin and filled with gutta percha (GuttaperchaPoints, Dentsply DeTrey, Konstanz, Germany) forthe scanning procedure and posterior matching ofthe two CT images (Figs 14 to 16). The first CTscan was taken with the radiographic guides

Fig 9 PVS impression of the maxillary and mandibular waxup for provisional fabrication.

Fig 10 Direct reline of the acrylic resin shell provisional restorations.

Fig 11 Occlusal and functional parameters were verified and adjusted to achieve proper anterior guidance.

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in place. Then, the guides were scanned sepa-rately to allow for matching of the images of theguides and the individual patient information in asingle three-dimensional virtual model to achieveideal implant placement and positioning (Figs 17to 19). The desired implant dimensions and posi-tions were planned virtually with Procera software

(NobelGuide, Nobel Biocare). For the 12 plannedmaxillary implants, two surgical templates weredesigned and ordered from the manufacturer. Thesix remaining anterior teeth needed to be ex-tracted at the time of implant placement. In addi-tion to these six implants, three were planned inthe right and left maxillary posterior regions. One

Fig 12 Pickup impressions of therelined provisional restorations.

Fig 13 Master cast for radiographic

Figs 14 to 16 The diagnosticwaxup and setups were transferredinto fixed and removable restora-tions in the maxilla and an over-denture, retained by two immedi-ate provisional implants, in themandible.

Figs 17 to 19 Radiographic guidesand virtual implant placement.

implant per tooth in the anterior esthetic zone isideal to support and maintain the existing hardand soft tissues. Another supportive factor for thistreatment plan was an ideal biotype with flat andthick bony and gingival tissues.

A different approach was selected for themandible. All mandibular anterior teeth needed tobe extracted due to severe perioendodonticpathologies, which created less than ideal hardand soft tissue conditions. An immediate overden-ture supported by two immediate provisional im-plants (Immediate Provisional Implant System,Nobel Biocare) and relined with soft reline acrylicresin was fabricated (see Fig 16). The overdenturewas planned and prefabricated from the previousdiagnostic waxup and set up using the same den-ture teeth. In the maxilla, a provisional restorationwas fabricated from canine to canine, and the RPDwas adjusted to fit these new restorations. Dentureteeth from the previous RPD were replaced bynew acrylic resin teeth from the diagnostic waxupto create an exact replica of the waxup and to ver-ify the desired occlusal situation. The final treat-ment plan for the mandible included placement ofeight implants at the sites of the first molars, firstpremolars, canines, right lateral incisor, and leftcentral incisor, and fabrication of four three-unitFPDs.

Fabricating a Master Cast from the Sur-gical TemplateAfter receiving the surgical templates (NobelGuide)from the manufacturer, master casts were fabri-cated from the templates with the guided cylindersthat were holding the laboratory analogs in posi-tion. Care was taken to orient the laboratoryanalogs in the exact same way as for the prospec-tive implant placement. Implant orientation is of ut-most importance when immediate function isplanned to achieve well-fitting prefabricated pros-theses. Maxillary and mandibular master casts werefabricated differently from each other. The conven-tional NobelGuide protocol was followed for themandible to create the master cast during implantplacement. Laboratory analogs were connected tothe surgical template (Fig 20). Transfer copings withreduced diameters were selected for a reducedemergence profile. It is crucial to properly connectand orient the laboratory analogs. When a tri-lobeinternal connection—as featured in the NobelRe-place system (Nobel Biocare)—is used, one of theinternal connection lobes should be oriented to-ward the buccal aspect and in the same orientationas is planned for clinical placement. As an aid,black lines were painted with a permanent markeron the cast to orient the implant lobe duringsurgery (Figs 21 and 22).

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Figs 20 to 22 Conventional fabrication of the mandibular master cast: modified guide cylinders inserted inthe surgical template and connected to the laboratory analogs before pouring with stone. Orientation of labo-ratory analogs with one of the lobes toward the buccal aspect was marked with a black line for optimal transferand accurate delivery of the immediate restoration.

The master cast for the maxilla was fabricatedusing an alternative approach (Figs 23 to 27) topreserve the soft tissue architecture as present inthe pickup impression of the relined maxillary pro-visional restorations. The tissue and tooth mor-phology already created with the provisionalrestorations allowed for accurate fabrication ofcustomized zirconia abutments in respect to softtissue and crown support as well as finishing lineconfiguration and depth. A tungsten bur was usedto carefully hollow each root/implant site in theposterior region to allow for perfect fit of the tem-plate and 12 laboratory analogs. The transfers

were undercontoured with a bur to fit the socket,prevent distortion of the soft tissue architecture,and create an ideal emergence profile. It is impor-tant for this master cast fabrication technique togenerate the radiographic guide from the samecast to ensure accurate fit when the surgical tem-plate is retrofit to the cast. Once the radiographicguide was exactly positioned on the master cast, itwas secured and glued with wax. Stone was mixedand then poured from the apical portion of thecast between the analog and the carved holesuntil set. Type II snow-white plaster (Kerr, Orange,CA, USA) was used to limit distortions.

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Figs 23 to 27 Two surgical tem-plates were fabricated for guidedplacement of 12 implants in themaxilla (NobelGuide). The firsttemplate was used for strategic in-sertion of the first 5 implants. Thesecond template was retained bythe 5 implants already in place foraccurate insertion of the remaining7 implants. A master cast was fabri-cated with the surgical template,modified guide cylinders, and cor-

Abutment Fabrication

The implant abutments were fabricated based onthe master cast with its ideal implant positions.PVS matrices (Zetalabor laboratory high-precisioncondensation silicone, Zhermack, Badia Polesine,Italy) were made from the provisional pickup im-pressions to design and scan the abutments forthe posterior areas, which were ultimately made ofzirconia. Temporary plastic abutments (Nobel Bio-care) were customized circumferentially with com-posite resin (Fig 28) until the final shape wasachieved (Tetric Ceram, Ivoclar Vivadent). Thesecustomized abutments were then prepared andpolished for scanning (Procera forte scanner,Nobel Biocare) and transferred into zirconia abut-ments (Fig 29). The zirconia abutments were or-dered with smaller-diameter platforms than thesupporting implants to take advantage of the plat-form shifting (PS) concept. PS adapters (Nobel Bio-care) were later connected intraorally to convertregular-platform implants into narrow-platformabutments as well as wide-platform implants intoregular-platform abutments. Once the abutments

were received and polished, impressions weremade of each abutment with a PVS material (Vir-tual putty base regular set and extra-light–bodyfast set, Ivoclar Vivadent) to fabricate a duplicatecast with epoxy resin (Exakto-form, Bredent,Senden, Germany) and a precise master cast fromthe eventual final impression. These steps aimedto circumvent any future abutment disconnectionafter insertion and, therefore, to avoid any distur-bance of the fragile abutment/bone/soft tissue in-terface. The impression copings were deemednecessary for stable positioning of the duplicateepoxy resin abutments on the final PVS impressionand to avoid any micromovements of the dupli-cate abutments during pouring of the impression.Each coping was fabricated from the zirconia abut-ments with GC Pattern Resin LS (GC, Tokyo,Japan) and verified on the corresponding epoxyresin duplicates. Small retentive wings were de-signed on each coping for mechanical retention ofthe PVS impression (Figs 30 to 32). A provisionalshell was fabricated with acrylic resin (Integrity,Dentsply) for the maxilla and mandible, complet-

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Figs 30 to 32 Resin impression copings for stable transfer and precise positioning of the duplicate epoxyresin abutments in the final impression. All zirconia abutments were duplicated.

Fig 28 Temporary plastic abut-ment modified with compositeresin to achieve the ideal shapeand contour according to provi-sional restorations.

Fig 29 Definitive customized zirco-nia abutments. Platform shiftingconcept was applied with PSadapters.

ing all prerequisites and components for the surgi-cal steps.

Surgery and Immediate ProvisionalRestorationsImplant placement was performed without elevat-ing full-thickness flaps and exposing the support-ing bone. Some soft tissue preparations were per-formed to simplify the subsequent procedures orto enhance local soft tissue support. Split-thicknessflaps were prepared close to the bone to allow fastand effective insertion of the PS zirconia abut-ments during the final stages of the surgical proce-dure. The modified roll technique was used in theareas of the right and left first premolars and firstmolars to increase the available soft tissue. The in-ternal aspects of the flange areas of the surgicaltemplate were carefully relieved. After extractionof the maxillary left central incisor, the first surgicalguide, now resting on the remaining teeth, was se-cured in place with anchor pins according to thevirtual planning. A consecutive placement protocol

was followed starting with the insertion of the im-plant in the area of the right first premolar, fol-lowed by left first premolar, first molars, and finallythe left central incisor to avoid any rocking and toensure optimal stability of the surgical templateduring implant insertion (Figs 33 to 35). After re-moval of the template, a roll flap was prepared inthe posterior areas to move as much soft tissue aspossible from the occlusal ridge to the buccal as-pect. Once the first five implants were inserted,the remaining teeth were extracted and the sec-ond surgical template was placed. The templatewas secured and stabilized by the five implants al-ready in place to accurately guide the insertion ofthe seven remaining implants (Figs 36 and 37).

All implants were torqued with 50 Ncm to en-sure primary stability. Care was taken to orient oneof the lobes of the trilobe internal implant connec-tion toward the buccal aspect. The surgical tem-plate was marked with a line during the laboratorystage to indicate orientation of the analogs in themaster cast. The definitive zirconia abutmentswere inserted with the corresponding PS adaptersand torqued in place with 35 Ncm. Screw access

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Figs 33 to 37 The first surgicaltemplate in position after the ex-traction of the maxillary left centralincisor. The template was stabilizedby the remaining teeth and anchorpins and used to place five im-plants. The remaining implantswere placed with a second surgicaltemplate.

openings were closed with temporary restorativematerial (Fermit, Ivoclar Vivadent). All abutmentswere painted with petroleum jelly before reliningthe complete-arch provisional shell restorationswith self-curing acrylic resin. It is recommended toverify functional parameters such as centric occlu-sion before relining to limit possible occlusal ad-justments. The provisional shell should rest on thefree gingival margin surrounding the implant abut-ments to create an ideal emergence profile fromthe preparation finish line of the zirconia abut-ments. After complete polymerization of theacrylic resin, the provisional restoration was refinedand polished in the laboratory.

Definitive implant surgery in the mandiblestarted with the removal of the immediate provi-sional implants placed earlier in the mandibular ca-nine sites. The surgical template was secured inplace with three anchor pins. References weremarked with a periodontal probe, creating bleed-ing points in the planned implant sites through theopenings of the surgical stent. To preserve as muchgingival tissue as possible, the template was re-moved, a crestal incision was made, and a split-thickness flap was raised to move the tissues later-ally. The template was reinserted, and a similarsequencing protocol to the one applied in themaxilla was followed. The first implant was placedin the middle of the stent anteroposteriorly in thearea of the left first premolar, followed by the rightfirst premolar, first molars, canines, and finally thecentral incisors. Dense bone burs were used due to

the high bone density, especially for the narrow-platform implants that were placed for themandibular central incisors. Once the implantswere placed, the corresponding PS adapters withthe zirconia abutments were inserted, and a seriesof periapical radiographs was taken to verify all pa-rameters. Abutments were secured with a torque of35 Ncm. The provisional restoration was completedthe same way as in the maxilla. Maxillary andmandibular provisional restorations were cementedone at a time with temporary cement (Temp-BondNE, Kerr). Abutments, radiographs, and completedprovisional restorations are shown in Figs 38 to 40.

Definitive Restorations

Periapical radiographs were taken at 4, 6, and 12months to evaluate the progression of the boneremodeling and the effect of the platform shifting.Figures 41 to 43 reveal the intraoral situation andsoft tissue response 1 month, 4 months, and 7months after implant placement and provisional in-sertion. Small recessions were detected on themaxillary left incisors. A retraction cord and handinstruments were used to carefully displace themarginal gingiva apically and to reprepare theabutment with diamond burs. A silicone impres-sion was made (Virtual putty base regular set andextra-light-body fast set, Ivoclar Vivadent) of bothabutments to fabricate new impression copingsand accurate die duplicates for rescanning. Of the

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Figs 38 and 39 Postsurgical views with all implants and corresponding custom zirconia abutments in place.

Fig 40 Intraoral situation immediately after placement of the implants and immediate provisional restorations.

20 zirconia abutments delivered on the day of thesurgery, only these 2 abutments needed slightmodification of the finish line. The impression cop-ings were directly relined on the abutments withself-cure acrylic resin (GC Pattern resin) to adjustthe copings to the minimal modifications made tothe zirconia abutments.

After a healing period of 9 months, final pickupPVS impressions (virtual VPS putty base regular setand extra-light–body fast set, Ivoclar Vivadent) weremade of both arches using impression copings (GC

Pattern) positioned on the corresponding zirconiaabutments (Figs 44 to 46). Afterward, both full-archprovisional restorations were relieved posterior to thecanines to maintain the desired VDO while recordingcentric occlusion (Fig 47) with wax (bite registrationwax sheets, Almore International, Portland, OR, USA).Casts were cross-mounted to transfer the provisionalinformation for fabrication of the definitive prosthe-ses. Alginate impressions were also made of bothprovisional restorations, and a facebow transfer wasperformed to communicate all necessary information

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Figs 41 to 43 (left to right) Intraoral situation 1 month, 4 months, and 7 months after implant placement andprovisionalization. The slight gingival recessions on the maxillary left incisors were eliminated via intraoralpreparation of the abutments and relining of the provisional restoration. A new final impression was made.

Figs 44 to 46 Impression copings in place before final pickup impressions were made with PVS impressionmaterial.

Fig 47 Interocclusal records for accurate VDO transfer and cross-mounting of casts.

Figs 48 and 49 Master casts with duplicated epoxy dies.

to the dental technician. Duplicate epoxy dies of allabutments were integrated in the master cast (Fig 48and 49). All definitive restorations were made with zir-conia substructures in the form of single crowns (Pro-cera Zirconia Crown, Nobel Biocare) in the maxillaand four three-unit FPDs (Procera Zirconia Bridge,Nobel Biocare) in the mandible. Copings were madewith silicone matrices taken from the alginate impres-sions of the provisional restorations, which facilitatedthe double-scanning technique and supportive cop-ing designs. Acrylic resin copings (GC Pattern LS)were fabricated, and wax was added to create idealsupport for the veneering ceramic (Fig 50). The mini-mum thickness of the definitive copings (Fig 51) was0.6 mm, and the connector areas for the FPDs wereat least 9 mm2. The acrylic resin framework patterns

for the mandibular FPDs were verified intraorally (Fig52) and then modified for optimal support for the ve-neering ceramic (Fig 53). The double-scanning tech-nique was used in the same manner as for the maxil-lary copings (Fig 54). A pressable veneering ceramicwas applied on all zirconia copings and frameworks(NobelRondo Press, Nobel Biocare) for increasedfracture resistance. Posterior restorations werepressed to full contour and stained, while the anteriorrestorations were slightly cut back. The incisal edgeswere completed with a conventional layering tech-nique to achieve optimal esthetics (Figs 55 to 62). APVS pickup impression was made from the restora-tions at the bisque-bake try-in to communicate subtledetails of tooth contour, contact points, emergenceprofiles, and occlusal additions. All definitive restora-

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Figs 52 to 54 Fit of the frame-works for the mandibular FPDs wasverified intraorally. Wax was addedto the framework patterns for opti-mal support of the veneering ce-ramic. Frameworks were designedwith a double-scan technique andfabricated from zirconia.

Fig 50 Customized resin patterncopings for ideal support of the ve-neering ceramic.

Fig 51 Definitive zirconia copings.

tions were cemented with RelyX Unicem (3M ESPE,St Paul, MN, USA). Final occlusal parameters wereevaluated and adjusted after cementation. Alginateimpressions were made in both arches, and two dif-

ferent types of night guards were fabricated. Thesenight guards varied in respect to disclusion and VDOto prevent adaptation, as typically occurs when onlyone night guard is used. Periodic follow-up visits

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Figs 55 to 58 Application of a pressable veneering ceramic to finalize the maxillary restorations. Incisal areasof the anterior teeth were layered conventionally. Posterior restorations were pressed to full contour andstained.

Figs 59 to 62 Completion of mandibular restorations with pressable veneering ceramics (NobelRondo Press).

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Fig 63 Postoperative radiograph.

Figs 64 to 67 Occlusal views of the maxillary and mandibular definitive zirconia restorations on custom im-plant abutments.

Figs 68 and 69 Definitive maxillary anterior implant-supported restorations (six implants) on the master castand after insertion.

Figs 70 and 71 Definitive mandibular anterior implant-supported restorations (four implants) on the mastercast and after insertion.

Fig 72 Final outcome.

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were scheduled at 6-month intervals. Figures 63 to75 show the preoperative conditions, restorations onthe master casts, and final result.

CONCLUSIONNew techniques and technologies, including mini-mally invasive procedures, immediate implant pro-tocols, guided implant placement, platform shift-ing, and CAD/CAM implant components andrestorations, are geared toward optimal and pre-dictable functional and esthetic success. The imple-mentation of these techniques in only a few clinicalappointments requires comprehensive planningand meticulous fabrication of numerous compo-nents in the laboratory before the surgical phase.This article illustrates the step-by-step implementa-tion of such protocols in a clinical case that re-quired comprehensive full-mouth rehabilitation.

ACKNOWLEDGMENTSThe authors thank Nobel Biocare for the support provided inthis case, Mr Jordi Demestre for the help provided in orderingthe different stents, Mrs Berit Adielson for the help in estab-lishing the exact surgical protocol, and Mr Iñigo Casares forthe beautiful porcelain work featured in the case presentation.

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