A 67-year-old gentleman was referred to me from his general practitioner to discuss the possibility of providing a fixed implant solution to replace his failing dentition. The patient was keen to avoid dentures if at all possible as he had been forced to wear a lower partial denture due to several infections to his lower incisors.
A full medical history was taken and there were no causes for concern. OPG and CT scans showed enough bone to
support upper and lower rehabilitation using the Diem2 protocols. Upper implants would have to be angled and 30 degree low profiles placed.
Lip line was low enough to use Diem 2 procedures in both arches. The Diem 2 guidelines for the fully edentulous mandible and maxillae have been developed for clinicians by consensus from a peer leading group of implant surgeons and restorative dentists. It is intended to provide clinicians interested in treating patients with immediate occlusal loading, using 3i Osseotite Implants and new line of low profile abutments, with guidelines relative to patient selection, diagnostic work-ups, surgical parameters and restorative techniques. The guidelines have been specifically developed to emphasise simplicity and flexibility in multiple clinical situations. Patients may be edentulous or dentulous on the day of surgery. If they are edentulous, implants can be placed crestally or sub-crestally. If the patient presents with a hopeless mandibular dentition, the teeth will be extracted and an alveolectomy performed in order to obtain optimal surgical sites for implant placement. In addition, it is the responsibility of the implant clinician to determine the benefits and limitations of a particular treatment protocol for each patient.
Diem 2 guidelines are intended to serve as a roadmap to immediate loading. Once the doctor has become comfortable performing immediate load procedures they may take a variety of personally selected detours to enhance their technique.
Our plan was to complete upper and lower immediate loads on same day and replace these in six months’ time with fixed bridges.
Treatment
Our treatment planning included full records being taken to ensure the most aesthetic result for the provisional bridge, including a full aesthetic series of photos, mounted study models, and a centric relation bite.
Our key plan for the provisional bridge was:
- To maintain the incisal edge position.
- To mount the occlusion in centric relation.
- To correct the class 3 occlusion to class 1 by mounting occlusion in centric.
The surgical day
8am
– Extracted all remaining teeth. Started with upper immediate load to ensure level incisial plane.
– Placed a total of eight implants (four uppers and four lowers). Low profile abutments in all implants for alignment: upper distal implants were at 30 degrees, the remaining were a combination of straight and 17 degrees.
– Took low profile impressions with a rigid setting material.
– Linked two temporary cylinders to denture passed to the technician to convert to bridge.
10am
– Started lower immediate load.
– Placed implants, low profiles and took impressions.
11am
– Fitted upper immediate bridge.
– Recorded bite from newly fitted upper bridge to lower denture and link up two cylinders.
12 noon
– At 12 noon we were able to fit the lower immediate bridge.
Post op
Post op instructions included information on a soft diet, ice packs and antibiotics. Healing was uneventful, the soft tissue responded well and the patient was very pleased.
When placing the final bridges we assessed aesthetics, function and completed a full series of records again. The patient was happy with the general appearance.
Six months post surgery the final impressions taken from low profile abutments and a series of appointments were made to verify and check aesthetics, function, comfort and fit.
In conclusion the patient looks fantastic and has told me that this is the best thing that he’s ever done – he can smile with confidence.