Surgical technique

The patient underwent implant therapy in stages under general anesthesia with immediate load protocol. Intravenous access was obtained, and the patient was anesthetized under general anesthesia by our anesthesiologist. Carpules of 2% lidocaine with 1:100,000 epinephrine, 4% articaine hydrochloride with 1:100,000 epinephrine (Septocaine), and 0.5% bupivacaine hydrochloride with 1:200,000 epinephrine (Marcaine) were used as needed. For each site, a 15 blade was used to make a sulcular incision from the mesial to the distal aspect of the tooth. A full thickness mucoperiosteal flap was elevated with a periosteal elevator exposing the buccal alveolus. Buccal bone was removed using a surgical fissure bur to allow for osteotomes and elevators to atraumatically elevate and deliver the teeth, while preserving lingual, mesial, and distal walls. Next, a straight elevator was positioned between the alveolus and the root surface. The tooth was elevated, and the periodontal ligament was separated from the alveolus. The tooth was extracted using a no. 150 upper universal forcep. The socket was curetted and irrigated with copious amounts of normal saline solution. A bone file and rongeur were used to smoothen the alveolus.

To deliver implants, all bony walls were checked with a perio probe to verify the depth. A series of osteotomy burs were used at 1000 RPM and 50 Ncm of torque with copious sterile normal saline irrigation. At each step, angulation was checked. Once the final osteotomy was completed, the site was checked to verify that all bony walls were stable. A NobelActive implant was torqued into position at greater than 30 Ncm followed by placement of a cover screw. In instances where grafting was necessary, the graft material was positioned to obliterate the bony defect using a periosteal elevator and curette to place in the bony voids. The gingival tissues were repositioned using an Adson Tissue Forcep. A tension-free closure was attained with a periosteal release technique. The sites were closed with interrupted 3-0 gut sutures. All procedures were accomplished without any further complications.

Prosthetic procedure

The standard immediate loading procedures were followed as the patient met the guidelines of a minimum torque value of 35 Ncm. All fixtures placed had intraoperative open tray impressions taken. Impressions were sent to the laboratory, and fabrication of a screw-retained temporary was completed. Temporaries were placed within 24 h of surgery and were torqued at 15 Ncm. Following a 6-month period of functioning in temporary prostheses, final impressions were taken via open-tray technique. He was placed in his final prostheses with no complications. Our patient settled on final prostheses consisting of a four-unit bridge cemented at sites number 3 through number 6; individual crowns placed at sites number 7, number 8, number 9, number 10, and number 11; and a screw-retained, three-unit bridge placed at sites number 12 through number 14 (Figs. 3, 4, 5, 6, and 7). The restorative dentist placed a polymethyl methacrylate (PMMA) prosthesis on the left side, and our patient will transition to his final crowns once he is financially ready.

Follow-up

Regular hygiene visits show that our OI patient has greatly improved his overall home care routine. No areas of gingival inflammation were found. Probing depths have remained 2–4 mm with no bleeding or purulent drainage at the fixtures sites. There have been no issues with implant mobility, and all healing post-operatively was uneventful.