The management of a severely resorbed

edentulous maxilla using a bone graft

and a CAD/CAM-guided immediately
loaded definitive implant prosthesis:
A clinical report
Ansgar C. Cheng, BDS, MS,a Neo Tee-Khin, BDS, MS,b Chan
Siew-Luen, BDS, MDS,c Helena Lee, BDS, MSc,d and Alvin G.
Wee, BDS, MS, MPHe
Mount Elizabeth Hospital, Singapore; National University of
Singapore, Singapore; University of Nebraska Medical Center,
Omaha, Neb
Functional reconstruction of an occlusion with severe residual ridge resorption is a clinical challenge. Removable pros-
theses are unsuccessful in situations with severe bone resorption. A patient with an edentulous maxilla received bone
grafts from the anterior iliac crest to augment the maxillary alveolar residual ridges. The maxilla underwent bilateral
sinus lift in the posterior area and onlay bone graft on the anterior maxilla using platelet-rich plasma. Eight endosse-
ous implants were placed using a CAD/CAM surgical template approximately 6 months after the bone augmentation
procedure. A prefabricated definitive implant-supported fixed complete denture was connected immediately after
implant placement using a CAD/CAM-guided surgical implant placement protocol. (J Prosthet Dent 2008;99:85-90)

The original Branemark protocol
required a period of a few months for
osseointegration of the endosseous
implants before the connection of
definitive dental prostheses.1-3 When
compared with the surgical phase,
implant prosthesis fabrication is rela-
tively time consuming.4
Changes in macroscopic implant
morphology and surface treatments
have resulted in the reduction of heal-
ing time and the concept of immedi-
ate loading of implants.5-14 Immediate
implant loading is a successful proto-
col in selected situations.15-20 As long
as sufficient bone volume is available,
flapless surgical implant placement is
predictable,21,22 and patients experi-
ence minimal postsurgical discom-
fort.23
Immediate prosthesis protocols
generally include conversion of an ex-
isting denture.24 Immediate prosthe-
ses can also be made in a laboratory
using a prefabricated framework and
complete denture that are connected
in situ after implant surgery.4,12,25-27
Recently, a treatment protocol (Teeth-
in-an-Hour; Nobel Biocare USA, Yor-
ba Linda, Calif ) was introduced which
allows the simultaneous placement of
endosseous implants and a comput-
er-assisted design/computer-assisted
manufacturing (CAD/CAM)-guided,
immediately loaded, definitive pros-
thesis.28-31 A high cumulative survival
rate has been reported for this proto-
col.27,29
A high success rate for osseointega-
tion has been reported for placement
of implants into grafted bone sites.32-
34
It has been shown that endosseous
implants placed in inlay and onlay
bone grafts demonstrate similar sur-
vival rates in the maxilla.35,36 The low
failure rate may be attributed to the
fact that implants with greater lengths
were placed.32,33,37 This clinical report
describes the prosthodontic rehabili-
tation of a patient with a severely re-
sorbed maxilla using a combination
of platelet-rich plasma, autogenous
bone graft, xenograft material, and a
CAD/CAM-guided, immediately load-
ed, definitive prosthesis.
CLINICAL REPORT
A 67-year-old man presented with
an edentulous maxillary arch at a hos-
pital-based, private practice setting.
The patient reported difficulties in us-
ing his maxillary removable complete
denture and was exploring the option
of a fixed maxillary prosthesis.
A clinical examination and a ra-
diographic assessment were con-
ducted. The preliminary examination
revealed that the fit of the maxillary

a
Consultant Prosthodontist, Mount Elizabeth Hospital; Adjunct Associate Professor, Graduate Prosthodontics, National University
of Singapore.
b
Consultant Prosthodontist, Mount Elizabeth Hospital; Adjunct Assistant Professor, Restorative Dentistry, National University of
Singapore.
c
Consultant Oral Surgeon, Mount Elizabeth Hospital.
d
Private practice, Singapore.
e
Associate Professor and Director, Division of Oral Facial Prosthetics/Dental Oncology, Department of Otolaryngology-Head and
Neck Surgery, University of Nebraska Medical Center.
Cheng et al
86
complete denture prosthesis was in-
adequate (Fig. 1). The mandibular
implant prostheses had been made
less than 3 years before. Upon remov-
al and examination, the mandibular
implant prostheses were found to be
in acceptable condition. The patient
was not experiencing any difficulties
with the mandibular prostheses. The
maxilla had generalized severe alveo-
lar bone resorption. A computerized
tomographic examination of the max-
illa revealed that the maxillary alveo-
lus bone volume was insufficient for
endosseous implant placement. The
patient’s medical history was other-
wise noncontributory.
Various treatment alternatives
such as conventional and implant-
supported fixed or removable prosth-
odontic options were discussed, and
the patient consented to have a bilat-
eral sinus lift and onlay bone graft in
1 A, Pretreatment frontal. B, Occlusal intraoral view showing significant alveolar bone resorption in anterior maxilla.
2 A, Panoramic radiographs showing pretreatment view. B, Bone-grafted maxilla.
The Journal of Prosthetic Dentistry
his anterior maxilla, placement of en-
dosseous implants in the maxilla, and
a CAD/CAM-guided, immediately
loaded, definitive implant prosthesis.
The implant protocol is only briefly
described in this report, as it has been
described in detail elsewhere.29-31,38,39
A new maxillary complete denture
was made in the conventional man-
ner40 to improve the fit of the maxil-
lary prosthesis and evaluate the es-
thetic and occlusal vertical dimension
requirements. The patient received a
bilateral lateral sinus lift in his poste-
rior maxilla and a mono-cortical on-
lay bone graft in his anterior maxilla
using bone harvested from his right
anterior iliac crest (Fig. 2). In the si-
nus augmentation, 20% of xenograft
material (Bioss; Geistlich Pharma AG,
Wolhusen, Switzerland) was used in
conjunction with the particulated iliac
crest bone graft. Platelet-rich plasma
A B
A B
Volume 99 Issue 2
was used in the bone augmentation
using the Marx protocol.41,42
The day after the bone augmenta-
tion procedure, the maxillary denture
was fitted intraorally using pressure-
indicating paste (Pressure Indicating
Paste; Mizzy Inc, Cherry Hill, NJ). The
intaglio surface was adjusted so that
no excessive pressure was applied to
the surgically treated areas. The max-
illary prosthesis was relined with a tis-
sue-conditioning material (Visco-Gel;
Dentsply DeTrey GmbH, Konstanz,
Germany). Patient follow-up visits oc-
curred every 2 weeks until 6 months
after the bone augmentation proce-
dures. Eight 2-mm-diameter gutta-
percha (Mynol; GlaxoSmithKline
Consumer Healthcare, Research Tri-
angle Park, NC) markers were placed
into the denture base of the maxil-
lary denture to serve as radiographic
markers. A centric relation record was
Cheng et al
February 2008
made with a vinyl polysiloxane materi-
al (Regisil PB; Dentsply Intl, York, Pa).
The patient was referred for a maxil-
lary computerized tomography (CT)
scan. The patient was scanned with
the denture and interocclusal record
in situ. The denture was subsequently
rescanned separately. The reformat-
ted digital CT-scan data was returned
to the treatment team to determine
the implant positions.
An implant-planning software
program (Procera Software; Nobel
Biocare USA) allowed the clinicians
to study the bone bed in relation to
the position of the artificial teeth.
Six regular platform (Branemark Mk
III Groovy; Nobel Biocare USA) and
2 wide platform (Branemark Mk III
Groovy; Nobel Biocare USA) dental
implants were placed on the comput-
er bone model18 (Fig. 3). The planning
data was transmitted via the Internet
to a laboratory with CAD/CAM capa-
bility (Procera; Nobel Biocare USA) to
fabricate the stereo-lithography surgi-
cal template with the preplanned sur-
gical sites of the dental implants.
Upon receipt of the surgical tem-
plate from the laboratory, the im-
plant replicas were placed in the tem-
plate using guided cylinders and pins
(Branemark System; Nobel Biocare
USA). A maxillary cast was poured in
type IV dental stone (Fujirock EP; GC
America, Alsip, Ill) to form a definitive
cast. The maxillary cast was mounted
with the opposing cast using the sur-
gical template and an interocclusal re-
cord on an articulator (Hanau Wide-
Vue 183; Water Pik Technologies, Ft.
Collins, Colo) (Fig. 4). Using the de-
finitive cast, guided laboratory abut-
ments and guided temporary copings
(Branemark System; Nobel Biocare
USA) were connected to the implant
87
replica using guide pins (Branemark
System; Nobel Biocare USA). This
definitive cast was used for the pre-
surgical fabrication of the definitive
prosthesis (Fig. 5). The surgical tem-
plate was retained for the future clini-
cal procedures. The original maxillary
denture was used as a reference for
fabrication of the framework and se-
lection of acrylic resin artificial teeth
(Dentacryl HXL; Dentsply, Petropolis,
Brazil) for the definitive prosthesis.
The prosthesis was fabricated conven-
tionally43 with a cast metal framework
(Olympia; J.F. Jelenko, Armonk, NY)
on the definitive maxillary stone cast
using guided copings (Branemark
System; Nobel Biocare USA).
The implant surgery was per-
formed under local anesthesia.44,45
The surgical template was positioned
with the patient occluding into the
centric relation record. The 1.5-mm

A B
3 A, Maxillary removable complete denture prosthesis with gutta-percha marks on denture base prior to comput-
erized tomography. B, Computer model of maxillary denture superimposed onto maxilla computer model. Eight
endosseous implants were planned.

A B
4 A, Completed maxillary surgical template. B, Establishment of occlusal relationship using surgical template and
silicone elastomer occlusal registration material.
Cheng et al
88
5 A, Maxillary dental stone cast was fabricated using surgical template. B, Occlusal view of maxillary dental stone cast.
6 A, Panoramic radiograph of completed maxillary prosthesis. B, Frontal view of completed prosthesis.
twist drill (Nobel Biocare USA) was
used to create stabilization channels
for the guided anchor pins (Brane-
mark System; Nobel Biocare USA).
Three guided anchor pins were used
to maintain the accurate position of
the surgical template during the sur-
gical procedure. The horizontal stabi-
lization pins were placed through the
surgical template in a preplanned hor-
izontal direction into the osseous tis-
sues with a 1.5-mm drill (Nobel Bio-
care USA). The pins were positioned
to secure the surgical template. Once
the surgical template was secured in
place, the patient was instructed to
open his mouth fully. The implants
were placed using the surgical tem-
plate following the predetermined di-
rection and depth based on the com-
puter model planning.
After the implant placement, the
prefabricated definitive prosthesis
was inserted using guided abutments
The Journal of Prosthetic Dentistry
A B
A B
(Branemark System; Nobel Biocare
USA). This adjustable abutment ac-
commodates minor dimensional
discrepancies to ensure a clinical fit
between the newly placed implants
and the prosthesis framework after
the abutments are torqued down.
The regular platform abutments were
torqued to 32 Ncm and the wide plat-
form abutments were torqued to 45
Ncm. The canine-protected occlusion
was evaluated, and the patient was in-
structed to maintain a soft diet for 6
to 8 weeks (Fig. 6). At the 12-month
postoperative follow-up visit, no ad-
verse clinical signs or symptoms were
noted. The patient reported satisfac-
tory function.
DISCUSSION
Intraoral onlay grafting is a pre-
dictable procedure with high success
rates that improves bone width and
Volume 99 Issue 2
height in healthy patients.46 A CAD/
CAM-guided, immediately loaded
implant procedure combined with
flapless implant placement and im-
mediate occlusal loading has a high
implant survival rate.27,29,31 Applica-
tion of this treatment protocol in an
atrophic maxilla with a bone graft is
seldom reported in a hospital-based
private practice.
The advantages of the treatment
described include shorter implant
treatment times, minimally invasive
implant surgery, and the immediate
usage of a prefabricated fixed defini-
tive prosthesis. The disadvantages of
this approach include the necessity
of a new computer planning software
and potential implant loss. Also, brux-
ism is not easily diagnosed in patients
with 1 or more edentulous arches. In
these situations, bruxism may only be
diagnosed after the placement of im-
plants and the definitive implant pros-
Cheng et al
February 2008
thesis. In addition, no esthetic trial
evaluation of the definitive prosthesis
was made before the completion of
the definitive prosthesis. This saves 1
clinical step at the beginning, but the
potential time and financial require-
ments to address esthetic concerns at
the postinsertion stage should not be
overlooked. Occasionally, a second
definitive prosthesis is needed to ad-
dress significant esthetic modifica-
tion. Also, the surgical drills are over
10 mm longer than conventional im-
plant drills. Placement of implants in
the posterior maxilla may be limited
by the maximum oral opening of the
patient.
SUMMARY
This article described the manage-
ment of a severely atrophic maxilla us-
ing a bone graft, CT scan, computer-
based treatment planning, CAD/CAM
fabrication of a surgical guide, mini-
mally invasive flapless implant place-
ment, and immediate insertion of a
prefabricated definitive prosthesis.
This protocol allowed a patient with
an edentulous maxilla from severe re-
sorption, with inadequate prosthesis
support, to have an implant-support-
ed maxillary fixed complete denture
prosthesis placed. The advantages of
this technique included computer-
based presurgical planning, a mini-
mally invasive flapless procedure, rap-
id recovery, minimal posttreatment
discomfort, and an immediate regain
of occlusal function.
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Corresponding author:
Dr Ansgar C. Cheng
3 Mount Elizabeth #08-10
SINGAPORE
228510
Fax: 65-67336032
E-mail: drcheng@bitepros.com
Copyright © 2008 by the Editorial Council for
The Journal of Prosthetic Dentistry.

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The Journal of Prosthetic Dentistry Cheng et al