Case 1
CC
A 55-year-old female, who used to be a heavy smoker and had loss of her teeth in her early 20s, presents for dental implants and fixed hybrids.
HPI
The patient was treated in our center 13 years earlier for lower All-on-4 implants with success; however, her severe maxillary atrophy limited the treatment to just her lower jaw, and she declined the option of sinus lifts and staged surgeries.
PMH
The PMH was unremarkable, but the smoking and chronic obstructive pulmonary disease have improved since the patient stopped smoking 7 years ago. She has no allergies and is not taking medications other than vitamins.
Clinical evaluation
Alert and in no distress; anxious about the possible treatment.
Vital signs. Vital signs are within normal limits.
Maxillofacial. Unremarkable.
Oral. Maxillary edentulous with signs of pressure because of the upper denture; she has never removed the denture except to clean it. The lower jaw shows All-on-4 hybrid teeth in perfect condition.
Imaging
Images show severe maxillary atrophy in zones 1, 2, and 3. The only bone available is in the piriform rims, zygomas, and pterygoids areas.
Assessment
Severe maxillary atrophy with Class I skeletal relationship between the upper and lower jaws.
Treatment
The prosthodontist evaluated the patient, and the remaining maxillary alveolar bone was well above the smile transitional line; the upper lip would cover in excess the junction between the hybrid dental bridge and the soft tissues. The desired vertical dimension was obtained, and there was no request for bone reduction for the maxilla. A provisional teeth prosthesis was obtained using the dental scan and it was digitally printed from the three-dimensional (3D) scanner. An unrestricted surgical guide was provided with a groove behind the teeth to allocate the implant abutments ( Fig. 35.1 , eFig. 35.2 , Figs. 35.3 and 35.4 ).
Under general anesthesia in our clinic, five zygoma implants were inserted in the piriform rims and body of the zygomas. All implants were 45 Ncm or more, four of the implants had bone at the alveolar site and bone above, and one zygoma presented no bone around the neck of the implant at the alveolar bone level. The latter implant was grafted using a sandwich technique, collagen membrane, and the lateral fat pad around the implant. The same technique was also used on the other maxillary side to prevent lateral implant exposure and oroantral communication. The fifth implant was to be uncovered 6 months later to deliver the final prosthesis. The prosthodontist performed the conversion, and temporary teeth were delivered the day of the surgery, following the teeth in a day protocol ( Figs. 35.5 and 35.6 ).
The fifth implant was uncovered 6 months later under local anesthesia. It is important to mention that the abutment was selected during the time of surgery, showing adequate parallelism with the others. This implant will not rotate during the second stage because of the osseointegration. A temporary cap was placed, and 2 weeks later, final impressions were made. The final teeth were delivered a few days later ( Figs. 35.7–8 , eFig. 35.9 and Fig. 35.10 ).
Case 2
CC
A 65-year-old female presents for dental implants and fixed bridges. She has visited several dentists and surgeons who did not recommend maxillary implants because of her severe atrophy.
HPI
The patient presents with a severe maxillary atrophy in zones 1, 2, and 3 on clinical examination. The prosthodontist predicts bone reduction of her maxillary bone to make her transitional line higher. Part of her cortical bone will be lost after the reduction of the maxillary bone when using the surgical reduction guide.
The patient is wearing ill-fitting upper total dentures and partial removable dentures in the mandible. The inferior teeth are seen well above the lower lip level; progressive extrusion secondary to maxillary edentulism is present. These patients have a very high transition smile line for the mandible; therefore, the patient needs 5 mm or more of bone reduction in her atrophic maxillary arch and mandibular arch, leaving less bone in height and less cortical bone for implant placement. This makes conventional implant placement more challenging ( eFigs. 35.11 and 35.12 ).
PMH
The patient has controlled hypertension. She has no allergies and is not taking medications other than hormones and vitamins.
Examination
The patient is alert and in no distress. She is anxious about the possible treatment.
Vital signs. Blood pressure is 130/85 mm Hg, heart rate is 70 bpm, and respirations are 13 breaths per minute.
Maxillofacial. Unremarkable.
Oral. The patient is completely edentulous wearing dentures. The dentures have become progressively more unstable, and the patient was only wearing them socially.
On smile evaluation, she shows no maxillary or mandibular alveolar ridges. She shows healthy mucosa and normal temporomandibular joint function.
Imaging
The patient has severe maxillary atrophy in zones 1, 2, and 3.
The only bone available left after bone reduction was the piriform rims, zygomas, and pterygoids areas. A short implant in the maxillary midline was considered ( eFig. 35.13 ).
Assessment
Severe maxillomandibular atrophy with Class I skeletal relationship between the upper and lower jaws.
Treatment
The prosthodontist evaluated the patient and found no maxillary cant; a Class I intermaxillary relationship; and severe maxillary atrophy in zones 1, 2, and 3. The desired vertical dimension was obtained, and no bone reduction was indicated because there was 34-mm intermaxillary distance anteriorly and posteriorly, and the transitional smiling line was at 13 mm. A provisional teeth prosthesis was fabricated using the dental scanner, and it was printed from the 3D scan. An unrestricted surgical guide was provided with a groove behind the teeth to guide the implants and the abutments ( eFigs. 35.14 and 35.15 ).
