DSD in complete rehabilitation in cases of failed maxillary dentitions.

DSD in complete rehabilitation in cases of failed maxillary dentitions.

by Dr. Kamsiah G. Haider, BDS , MDSc Guillermo Manzano, Francis Coachman

Any dental treatment involving aesthetics from restorative to orthonagthic, it is best to look at the patient’s aesthetics from a Smile Design before Treatment Planning . So that each project is in harmony with the face and lip dynamics. 1-7

Treatment planning should be a process to try to find the best procedures to make this project possible. This means that in Facially Driven Dentistry, Smile Design should come before Treatment Planning.

Digital tools can be used to facilitate this process. Digital drawings can be made over facial photos of the patient to develop what we call the Smile Frame.

A visual guide that will suggest the best 3D position of the Teeth and Gingiva according to lips and face. This 2D smile frame can be calibrated to STL files and CBCT’s. This process allows us to perform a facially driven diagnostic wax-up before even planning the case.

On full mouth rehabilitation with implants on failed dentition cases, : the digital teeth setup can be overlapped to the CBCT to plan the implant position and bone reduction.

The digital setup will also be used to digitally design and fabricate the surgical guides, bone reduction guides and immediate loading prosthesis, maintaining a predictable relationship between the initial design and the final prosthetic outcome.

All the devices fabricated to perform the treatment—guides, splints, appliances, components, and restorations—should facilitate the process of maintaining precision between the initial plan and the final outcome .

Failed dentition moving towards edentulouslism

The journey patient begins with photography/video sessions. Patients were presented with the motivational mock-up of the treatment plan. Most of the time patient approves the plan because this is probably the plan that makes most sense to rehabilitate their failing dentition. Most of these patients were not interested in the transitional dentures.

The procedures performed in a completely digital flow integrating the initial smile design project into the guided implant surgery, and restorative procedures.

All the devices fabricated to perform the treatment from surgical to restorative were facilitate from the confirmed design and to the end of maintaining precision between the initial plan and the final outcome.

All the patients chosen for these treatment were in need of extraction of the remaining compromised teeth were rehabilitated with the NobelActive implants. Each subject received an immediately loaded, fixed, complete-arch provisional prosthesis on the day of implant placement according to the All-on-Four technique. The definitive prostheses were delivered within 6 to 8 months after implant insertion.

Patients could not be treated according to the technique if they had insufficient bone quality and quantity for placement of endos- seous implants, exhibited severe parafunctional habits, or had a compromised medical history that would affect implant placement (eg, bisphophonates, chemotherapy).

Pretreatment, DSD, DSD Laboratory 

A cone-beam computerized tomographic scan (CBCT; Carestream ) was taken prior to surgery, and the bone profile, which included the bone quality and bone volume, was assessed . All the preliminary and consented treatment via Dropbox , emails and Whatsapp between the operator and designers.

Surgical procedures

Only local anesthesia were articaine hydrochloride 4% and epinephrine bitartrate 1:100 000 (Septodent, Paris, France), local anesthesia that was administered in both block and infiltration technique. None of the patients were administered general anesthesia.

Patients were started on a course of antibiotic (Rodogyl , Calif), 2 times a day, on the day of the surgical procedure Postoperatively, all patients were given the same antibiotic 2 times per day over a period of 5 days. were also used as an analgesic along with anti-inflammatory medication, methylprednisolone, 4-mg dose pack (Medrol, Dispensing Solutions).

Implant placement

NobelActive implants were inserted by (C.A.B.) according to the manufacturer’s guidelines (manual No. 21279-GB085, Nobel Biocare Services 2008). Each subject received 2 distally tilted implants in the posterior region followed by 2 anterior implants in the maxilla . In the maxilla, the tilted implants were positioned just anterior to the maxillary sinus . Implant placement was assisted by the All- on-Four surgical guide (DSD 4). The guide allowed for optimal positioning, alignment, parallelism, and inclination of the implants for subsequent anchorage and prosthetic support. The drill protocol fol- lowed the manufacturer’s guidelines (All-on- Four procedures and products, manual No. 16896 Lot GB 0603, Nobel Biocare Services, 2006).

The implant sites were usually underprepared avoiding countersink- ing to engage as maximum cortical support bone as possible. The recommended drill sequences for soft bone type IV, medium type II and type III, and dense type I bone were followed. A manual surgical torque wrench (Nobel Biocare) was used to check the final torque of the implant, which was carefully documented (Table 1). In cases of immediate implant placement, the soft tissues were readapted to obtain a primary closure around the abutments and fresh extraction sites and then sutured back into position with interrupted resorbable 4.0 chromic sutures (Salvin Dental Specialties, Charlotte, NC). Local bone grafting to cover exposed threads and/or other osseous de- fects associated with extraction sockets was performed at implant sites with just autogenous bone from the local surgical area.

Straight, 17u multiunit abutment, internal (Nobel Biocare), and 30u angulated multiunit abutments, internal (Nobel Biocare), were used to achieve relative parallelism of the implants so that a rigid prosthesis would seat in a passive manner.

Prosthetic protocol

Prefabricated provisional PMMA9 were placed and connected immediately to the multiunit temporary cylinders ( Nobel Biocare) Patients were instructed to avoid brushing and to use warm water rinses for the first postoperative week. A cold or room- temperature soft diet for the first 24 hours following surgery was recommended, followed by a semisolid diet for the next 3 months. Patients were given antibiotics and analgesics as listed in the surgical protocol. A CBCT scan was taken immediately postoperatively to verify the implant positions and the prosthetic components.


The prosthesis survival rate was 100%. This is in accordance with studies on biomechanical measurements, which demonstrated that tilted implants, when part of a prosthetic support, do not have a negative effect on the load distribution.16,46,47 In addition, a biomechanical rationale in tilting distal implants allows a reduction in cantilever length due to the more posterior position of the tilted implants, resulting in a more favorable stress distribution.47,48

The methodology of using titled implants maximizing the use of the available bone without grafting has been reported, leading to successful clinical outcomes.35,41,42 This is in comparison to the traditional implant treatment in which insufficient bone in the posterior region requires bone-grafting pro- cedures involving greater chair time for the patient as well as increased cost and increased number of procedures.


The overall survival rate using the All-on- Four immediate function treatment concept using an implant with a tapered body and a variable thread design can be considered a viable treatment concept for patients presenting with immediate placement. This cases were made possible by respecting the biological principles, and knowledge of aesthetic and functional references . These are keys to the success of the digital workflow, just as they always have been for the conventional workflow in a failed dentition treated with immediate implant using the DSD concept , software and design of the prosthesis.


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9. https://3dprintingindustry.com/news/dentures-get-3d-printed-boost-with-dentcas-fda-approval-55274/

16. Bellini CM, Romeo D, Galbusera F, et al. Comparison of tilted versus nontilted implant-support- ed prosthetic designs for the restoration of the edentuous mandible: a biomechanical study. Int J Oral Maxillofac Implants. 2009;24:511–517.

35. Aparicio C, Perales P, Rangert B. Tilted implants as an alternative to maxillary sinus grafting: a clinical, radiologic, and periotest study. Clin Implant Dent Relat Res. 2001;3:39–49.

41Pomares C. A retrospective clinical study of edentulous patients rehabilitated according to the ‘‘all on four’’ or the ‘‘all on six’’ immediate function concept. Eur J Oral Implantol. 2009;2(1):55–60.

42. Testori T, Del Fabbro M, Capelli M, Zuffetti F, Francetti L, Weinstein RL. Immediate occlusal loading and tilted implants for the rehabilitation of the atrophic edentulous maxilla: 1-year interim results of a multi- center prospective study. Clin Oral Implants Res. 2008;19:227–232.

46. Parel S, Branemark PI, Ohrnell LO, Svensson B. Remote implant anchorage for the rehabilitation of maxillary defects. J Prosthet Dent. 2001;86:377–381.

47. Bellini CM, Romeo D, Galbusera F, et al. A finite element analysis of tilted versus nontilted implant configurations in edentulous maxilla. Int J Prosthodont. 2009;22:155–157.

48. Zampelis A, Rangert B, Heijl L. Tilting of splinted implants for improved prosthodontic support: a two- dimensional finite element analysis [published correc- tion appears in J Prosthet Dent. 2008;99:167]. J Prosthet Dent. 2007;97(6 suppl):S35–S43.

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