PMC8026321_01
Clinical images of the patient's smile.
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Periodontology with the main complaints of dissatisfaction with the use of a total upper denture (Figures 1(a)-1(d)). Patient medical records were not significant, and she denied use of alcohol or smoking.
Intraoral images of the prosthesis in placement (a). After prosthesis removal, it is possible to observe gingival inflammation and swelling of the implants (b). Panoramic and periapical radiographies show evident bone resorption around the implant threads and severe pneumatization of the maxillary sinuses (c, d).
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Clinical and radiographic examination revealed poor oral hygiene and the presence of three dental implants in the anterior area with gingival bleeding, swelling, and localized calculus in the implant surface (Figures 2(a) and 2(b)). Panoramic radiography showed extensive pneumatization of the maxillary sinuses, a radiolucent area around the remaining implant threads, and alveolar bone loss around the implant threads near the apical third of the fixation (Figures 2(c) and 2(d)).
Prosthetic procedures were carried out to install a provisional prosthesis attached to two short implants by means of o-ring connection (a-d).
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The prosthetic procedures are represented by Figures 3(a)-3(d).
The first step in the surgical procedures was to expose the area where the implants were installed, and then, the implants were removed (a-c). After implant removal, two short implants were immediately installed. An appropriate abutment was installed in each of the implants to allow provisional prosthesis installation with appropriate retention (d-i).
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Subsequently, two remote vertical releasing incisions were performed in the alveolar crest followed by a crestal incision on the area where the implants were installed (Figures 4(a) and 4(b)). Periapical radiography was taken to evaluate the implants (Figure 4(c)). Then, two short implants were installed in the remaining alveolar bone crest (Figures 4(d)-4(f)) (Conexao  Sistema de Protese, external hexagons, 5.0 x 5.5 and 4.3 x 5.5 mm). The prosthetic abutment connection was installed, and the soft tissue was closed by means of simple suture (Figures 4(g) and 4(h)). The o-ring connection was able to assist the retention of the provisional total prosthesis (Figure 4(i)).
The second surgical procedure was carried out to augment the maxillary sinuses. DBBM plus L-PRF was used to fill the sinuses aiming at increasing bone height to allow proper implant length installation (a-c). Panoramic radiography shows the maxillary sinuses immediately after bone graft (d).
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After the surgical procedure, a panoramic radiography was taken to evaluate the maxillary sinus bone gain (Figure 5(d)).
The third surgical approach was to install an onlay autogenous block bone graft harvested from the mandibular ramus. The graft was split and was installed in the receptor area in the posterior maxilla to augment the alveolar crest width and consequently to allow implant installation in an ideal tridimensional position (a-f). Panoramic radiography was taken immediately after graft placement (g).
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The mucoperiosteal flap was repositioned, and the defect was sutured with Vicryl 4-0 thread (Figures 6(a)-6(d)). Thereafter, the autogenous bone was split in two parts and then were placed in position in the receptor area and fixed with cortical screws (Figures 6(e) and 6(f)). Panoramic radiography was taken immediately after graft placement (Figure 6(g)).
After a healing period of 8 months from the maxillary sinus augmentation procedure, the implants were installed by means of guided surgery. Seven implants were planned and installed in the posterior area of the maxilla (a-h).
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The diameter, length, and positioning of the implants were defined, and the files were sent to Bioparts (Brasilia, DF, Brazil) to manufacture the surgical templates (Figures 7(a)-7(c)). After implant installation, the cover screws were installed to all implants (due to low insertion torque) and a healing period of 3 months was set to tissue healing (Figures 7(d)-7(h)).
The implants were allowed to heal for 4 months, and then, the procedures to expose the implants were initiated (a, b). The cover screws of all implants were removed with the aid of the surgical template (c-f). Appropriate abutments were chosen and installed (g, h).
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After the healing period of 3 months, the implants were exposed and the cover screws were removed (Figures 8(a)-8(d)). A miniconical abutment was chosen for all implants, and the mini pillars were then installed (Figures 8(e)-8(h)).
Prosthetic procedures to manufacture the definitive prosthesis were performed. All the necessary steps to create the definitive prosthesis were carried out (a-j).
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Finally, definitive prosthesis was carried out following all the necessary steps of prosthesis fabrication (Figures 9(a)-9(j)).
The definitive prosthesis was installed.
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The definitive prosthesis was installed in the patient (Figures 10(a)-10(d)).
(a-c) One-year follow-up shows the successful functional and esthetic outcomes and proper osseointegration of the implants without any signs of infection.
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After one year of follow-up, the patient was satisfied with the final result in relation to the esthetics and function (Figures 11(a)-11(c)). Panoramic radiography was taken after one year to show the implants without any signs of infection and proper osseointegration (Figure 11(d)).