ALY VIRANI, BDS MJDF RCS(Eng) Dip Imp Dent RCSEd MSc

Aly Virani, a Cardiff University graduate, holds a Diploma in Implant Dentistry from the Royal College of Surgeons of Edinburgh and an MSc in Clinical Oral Implantology from Ulster University. He focuses on dental implants. Aly is on the executive committee of the Independent Dental Association Wales, has been a Young ITI ambassador, and served on the ADI board. He is a member of the Royal College of Surgeons (England) and the ADI, and lectures nationally.

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Introduction

A patient presented with significant dental issues, including unrestorable caries in UR6, a porcelain fracture, and multiple apical infections on root-treated abutments of a 10-unit maxillary bridge. Given the limited bone width in zone 1 and the absence of bone in zones 2 and 3, an immediate load full arch treatment was chosen. This case marked the first use of Navident dynamic navigation for pterygoid implants in the United Kingdom.

Patient Background

The patient, diagnosed with osteoporosis, had several dental challenges: unrestorable caries in UR6, a porcelain fracture, and multiple apical infections on root-treated abutments. Additionally, the pre-operative CBCT revealed caries, apical radiolucencies, and pneumatized sinuses, necessitating a comprehensive treatment plan.

Pre-Operative Planning

The treatment began with a thorough assessment and imaging. The OPG view of the pre-operative CBCT provided a detailed view of the dental issues, including caries and apical radiolucencies. Combined 3D digital images of the pre-operative situation and a digital wax-up were created to visualize the treatment plan accurately. This digital wax-up, combined with the implant plan, ensured the feasibility of the procedure, leading to the creation of a prosthetic envelope and bone reduction guide by the laboratory.

Surgical Procedure

On the day of the surgery, Ustomed screws were placed in the palate before a CBCT scan. These screws served a dual purpose: they acted as tracing points for the Navident dynamic navigation system and provided reference points for the immediate load restoration. An ultra-low dose CBCT (Planmeca) confirmed the screws' positions, and four Ustomed screws were used for trace registration while the patient was tracked using a head tracker, achieving a registered accuracy of 0.1mm.

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The osteotomy preparations adhered to the protocol of a single harpoon drill, using a W&H zygoma handpiece fitted with a tracker. Deviations from the planned position were carefully monitored. Following the preparations, right and left pterygoid implants were placed with >50Ncm torque, and 30D MUAs were inserted.

After the pterygoid placement, the bridge was removed in one piece, and the remaining roots were extracted individually before ridge reduction. A 24D co-axis ex hex implant was placed on the left side using a palatal approach due to limited bone width. BBBT was inserted into the wide nasopalatine canal once the contents were obliterated, followed by the insertion of a platform-switched MUA. All implants achieved >50Ncm insertion torque and CTV >120Ncm.

Post-operatively, an intraoral scan was used to assess soft tissue and calibrate to the digital wax-up.

Photogrammetry scans were taken to determine implant positions, and the effect of angle correction with 30D MUAs, 24D co-axis implants, and straight MUA was evaluated. The proposed temporary prosthetic design, including oral hygiene channels, was sent by the lab (DK Lab), and a 3D printed direct-to-MUA prosthesis was sent by DK Lab for next-day fitting. An immediate post-operative Planmeca Ultra Low Dose CBCT was performed, and the temporary prosthesis was fitted two months prior.

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