4Professor at the Okan University Faculty of Dentistry, Department of Prosthodontics, Gulbahar Mh, Turkey
Received: August 03, 2017; Published: August 09, 2017
Corresponding author: Hakan Bilhan, Associate Professor at the Okan University Faculty of Dentistry, Department of Prosthodontics, Gulbahar Mh, Oya Sok No: 23/A, Mecidiyekoy, Sisli, Istanbul 34394, Turkey
Immediate Loading is mostly appreciated by patients, since they do not have to stay edentulous until the osseointegration. For this purpose
there must be an implant system providing abutments suitable for screw retention and a prefabricated restoration. In this case report the
procedures for this treatment modality are described in a detailed way. Additionally, the return from fixed to removable upon request of the
patient due to easier cleaning was explained, too. The lab procedures and the makeover to a telescopic denture was looked into in this case
A 70 year old male patient with mandibular teeth showing
a poor prognosis due to chronic generalised periodontitis was
chosen to treat with a fixed detachable prosthesis  supported
with 4 implants after extraction of all remaining teeth. Since the
lower jaw was causing the main problem, the maxillary treatment
was postponed for later on.
Preoperative phase and preparations
Figure 1: Matching and Planning.
A preoperative 3-D planning was performed with the help of
Dental Volumetric Tomographies (DVT, Galileos Comfort Plus,
Dentsply Sirona, Bensheim, Germany) and with the planning
software for Guided Surgery (Magellan, Medentis Medical, Bad
Neuenahr – Ahrweiler, Germany) (Figure 1).
Based on the planning a printed model (Figure 2), surgical
guides and a CAD/CAM milled PMMA provisional (Figure 3) were
Figure 2: 3D printed model.
Figure 3: PMMA Provisional, view from facial.
The Operation and Immediate Loading by a Detachable Denture
The surgical part was achieved with surgical guides making
the placement of dental implants flapless and exactly in the same
position as originally planned [2,3]. Implantation in the positions
34, 32, 42, 44 with immediate loading via a milled prefabricated
PMMA provisional which is a high performance acrylic (ICX- Smile
Bridge, Medentis Medical, Bad Neuenahr – Ahrweiler, Germany)
was accomplished. This technique is not new; it was introduced
by Malo and colleagues . Following this protocol, the implants
in the positions 32 and 42 were placed straight, whereas the distal
implants were placed with an angle of 35 degrees (positions 34 and
44). The use of angulated implants gives the possibility to prevent
complicated sinus lifting or augmentation procedures and protect
anatomic structures such as the foramen mentale. The used implant
system gives the possibility to use two different degrees: 17 or 35.
It is important to achieve a primary stability of the implants of
at least 35 Ncm, to be able to load them immediately [5-7].
The next step was to mount the occlusally screwed abutments
(Multi Abutment, Medentis Medical, Bad Neuenahr – Ahrweiler,
Germany) on the implants and take care of the right gingival height.
After checking the fit and occlusal stability of the Smile-Bridge,
the fixation intraorally was succeeded with an autopolymerising
denture repair polymer of diacrylate base (QU-resin,Bredent,
Senden, Germany). After torque-wrenching of the fixation screws,
the screw holes were closed with a light-cured provisional material
(TELIO CS Inlay, Ivoclar Vivadent,Schaan,Liechtenstein).
3 months later, it was time for the definitive prosthetic
treatment. Although a detachable prosthesis was planned
originally, the treatment direction was changed, since the patient
was complaining of food trapping and difficulties in cleaning
Since the used system was providing the possibility of
fabricating and working on occlusally screwed abutments for Ti
Base supported telescopic prosthesis, it was possible to workon workon
on abutment level. On the model with the abutment level
implant analogues, Ti-Bases were used for the fabrication of
conical abutments with 20 of divergence angle. The margins of
the telescopic crowns were established 1mm supragingivally. The
height of the primary crown structures were arranged at 6mm’s
and the insertion pathway was determined (Figure 4). The milled
(CAD/CAM-System: inLab SW 15.0, Dentsply Sirona, Bensheim,
Germany) zirconia (IPS E.max ZirCAD, Ivoclar Vivadent, Schaan,
Liechtenstein) structure (Figure 5a) was bonded to the titanium
basis (Hera Attachment Bond, Heraeus Kulzer GmbH, Hanau,
Germany). The removable structure was fabricated upon these
abutments carrying the Galvano produced secondary parts. The
galvano secondaries (Figure 5b) were cemented in the removable
part intraorally (Figure 6a-6c) in order to prevent any tension and
to achieve a passive fit . The CrCo-alloy substructure (Figure 7)
was cast from a 3-D printed premodel (Figure 8).
Figure 4: Computer Aided Design.
Figure 5a: Zirkonia abutments.
Figure 5b: Galvanos in situ.
Figure 6a:Mixing the dualcure cement.
Figure 6b:Zirkonia abutments.
Figure 6c:Fixation of the tertiary structure intraorally.
Figure 7:Superstructure made of nonprecious alloy during try-in.
Figure 8:3-D printed pre-model.
The different approach during the whole removable prosthesis
part, was the use of single Emax crowns (IPS E.max CAD, Ivoclar
Vivadent, Schaan, Liechtenstein) instead of prefabricated porcelain
denture teeth (Figure 9). It was a more economic solution in this
case, since the clinic owned a lab with its own CAD/CAM and milling
unit. The Emax crowns offered great esthetics and toughness, as
well as ease of repair, since the related data were recorded and kept
for remaking any time.
Immediate Loading with a fixed solution is a well appreciated
treatment for patients, since the osseointegration time is overlapped
with teeth mimicking real life and esthetic and functional demands
are successfully fulfilled. Today preimplantolgical diagnostic and
planning possibilities enable clinicians to prepare fully for the postimplantation
It should be kept in mind that, not seldom, patients can be
unhappy or disappointed with their fixed detachable dentures due
to missing buccal flanges causing an unsupported lip, phonation
problems depending on a fully open palate or difficult cleaning
procedures with the fixed solution.
In this manner, clinicians should be flexible in switching to the
removable denture option. For this purpose, it is advisable to use
a system which allows working on occlusally screwed abutment
level, so that the same abutments may be used for the locators or
Another innovative step in this case was to use lithium disilicate
crowns instead of prefabricated porcelain crowns. This was for a
dental clinic owning a milling unit and an own lab, a more economic
and safe way to go. The saved data can be used any time to replace a
chipped or fractured porcelain tooth. Telescopic dentures are a well
documented treatment alternative among removable dentures. The
use of Ti-Base supported zirconia conus abutment is a cost effective
It seems to be an important issue to investigate what percent
of the edentulous patients is satisfied with the delivered fixed
restoration and how many of them prefer to return to the removable