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case_images: Pre-operative presentation. (A) Close-up Smile. (B) Retracted MIP.
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case_images: A 41-year-old male patient presented to the prosthodontics department seeking the replacement of missing teeth (Figure 1).
case_images: Digital planning steps. (A) Initial maxillary teeth set-up. (B) Gingival design. (C) Maxillary wax up opposing mandibular cast, which was aligned with the CBCT. (D) Transfer of maxillary wax-up to mandibular occlusion based on saved coordinates of the articulated model scans. (E) Design of mandibular wax-up. (F) Finalized maxillary and mandibular wax ups and implant planning.
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case_images: All necessary records were transferred to an implant planning software (Blue Sky Plan 4.0, Blue Sky Bio, IL, USA), and digital planning was performed (Figure 2).
case_images: Guide designing sequence for mandibular arch. (A) Adaptation guide and base guide designs. (B) Virtual extractions completed for mandibular arch. (C) Virtual alveoloplasty completed based on implant positions and restorative space requirements. (D) Design of osteotomy guide. (E) Design of prosthetic loading guide.
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case_images: Once the implant positions were finalized, each component of the stackable surgical guide was designed in the planning software (Blue Sky Plan 4.0; Blue Sky Bio, IL, USA) using the associated CAD tools (Figure 3).
case_images: Implant timing demarcation for the distally angulated implants. (A) Implant planning illustrating the desired anteroposterior spread and angle correction required. (B) Importing the planned implant position and osteotomy guide into the 3D design open-source software (Meshmixer 3.5, Autodesk, CA, USA). (C) Marking the desire implant timing into the osteotomy guide using CAD sculpt tools. (D) Frontal view after marking desired implant timing.
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case_images: Type A, Institut Straumann AG, Switzerland). Timing markers were incorporated by exporting the osteotomy guide and implant position into an open-source 3D design software program (Meshmixer 3.5; Autodesk, CA, USA) and utilizing the "sculpt tools" function within the software (Figure 4).
case_images: Attaching the different components of each surgical guide. (A) Mandibular base guide and adaptation guide imported into a 3D design open-source software (Meshmixer 3.5, Autodesk, CA, USA). (B) Attaching the interlocking and retentive components with their corresponding parts onto the base guide. (C) Transparent illustration of the patrix/matrix complex with 500 microns spacer to allow for ease of fit. (D) Attaching the patrix component to the adaptation guide utilizing the "add tube" function.
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case_images: After designing all the guides, they were exported as STL files and then imported into the same open-source 3D design software program (Meshmixer 3.5, Autodesk, CA, USA) to create attachment and retentive mechanisms (Figure 5).
case_images: Assembling the different components of each surgical guide after 3D printing. (A) Mandibular adaptation guide and base guide. (B) Mandibular osteotomy guide and base guide. (C) Mandibular prosthetic loading guide and base guide. (D) Maxillary adaptation guide and base guide. (E) Maxillary osteotomy guide and base guide. (F) Maxillary prosthetic loading guide and base guide.
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case_images: After printing, post-processing was performed according to the manufacturer's instructions, and the fit of the guides was verified (Figure 6).
case_images: Model surgeries. (A) Adaptation guide used to orient the base guide. (B) Base guide seating and fixation with metallic posts. (C) Extractions and alveoloplasty simulation. (D) Confirmation of alveoloplasty level. (E) Osteotomy guide seating. (F) Prosthetic loading guide seating.
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case_images: Finally, to verify the accuracy of the surgical guides and prepare for the surgical date, a complete model surgery was performed on the articulated stone casts (Figures 7 and 8).
case_images: Occlusal equilibration completed on a semi-adjustable articulator (Artex CPR, Amman Girrbach, Germany).
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case_images: Finally, to verify the accuracy of the surgical guides and prepare for the surgical date, a complete model surgery was performed on the articulated stone casts (Figures 7 and 8).
case_images: Mandibular surgery and loading protocol. (A) Base guide fixation. (B) Extractions and alveoloplasty completed to the level of the base guide. (C) Osteotomy guide seating. (D) Implant placement through the osteotomy guide. (E) Final implant positions. (F) Pick-up procedure completed.
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case_images: Maxillary and mandibular surgeries were performed under local anesthesia on 2 consecutive days (Figures 9 and 10).
case_images: Maxillary surgery and loading protocol. (A) Base guide oriented into place using the adaptation guide. (B) Base guide fixation. (C) Mucoperiosteal flap elevation followed by re-orienting and fixating the base guide. (D) Osteotomy guide seating after completion of extractions and alveoloplasty. (E) Final implant positions. (F) Preparation for pick-up procedure.
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case_images: Maxillary and mandibular surgeries were performed under local anesthesia on 2 consecutive days (Figures 9 and 10).
case_images: Post-operative records. (A) Close-up smile. (B) Retracted intra-oral MIP.
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case_images: The patient was discharged with over-the-counter analgesics and instructed to complete the previously prescribed antibiotic course (Figure 11).
case_images: Radiographs. (A) Pre-operative panoramic radiograph. (B) Post-operative panoramic radiograph.
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case_images: Post-operative radiographs were made (Figure 12), and follow-up appointments were scheduled at intervals of 1 week, 2 weeks, 1 month, 3 months and 5 months.