Osseointegrated implants are now one of the most widely used medical devices in the world, and perhaps also among the most overused. Their insertion in patients who are unaware of their potential or inadequately supported by a valid maintenance program can result in multiple failures, resulting in significant loss of bone support and subsequent severe jaw atrophy.
With this presentation, we want to highlight this condition by presenting the case of a 67-year-old patient who, after repeated implant failures in the upper jaw, was forced to insert four zygomatic implants in order to support a fixed rehabilitation. Despite this, he was not included in an adequate oral hygiene maintenance protocol, which resulted in the failure of all the implants in the lower arch and the remaining dentition. It was therefore necessary to proceed with a complete restoration of the arch and the insertion of five implants in the symphyseal area to create an immediately loaded fixed prosthesis. This, by replacing the worn elements of the upper prosthesis, allowed the patient to smile again with correct intermaxillary relationships.
Fig.1
65-year-old patient with severe jaw atrophy rehabilitated several years ago with 4 zygomatic implants and an aesthetically and occlusally inappropriate prosthesis which determines a loss of vertical dimension: “Popeye face”.
Fig.2
Radiographic situation showing the complete failure of all the implants in the lower arch and the presence of the 4 upper zygomatic implants.
Fig.3
Clinical situation after the preparatory extraction of all failed implants in the lower arch.
Fig.4
Surgical plan for the insertion of 5 Dental Tech 3.75 x 13mm FTK post extraction implants in the symphyseal area.
Fig.5
Computer-guided surgery guide (Biotech) with dental support and fixed with 3 pins.
Fig.6
After extracting all the residual teeth, the surgical guide is positioned and the 5 implant sites are prepared.
Fig.7
At the end of the implant preparations, the 5 3.75×13 Dental Tech FTK implants are progressively inserted, taking care to avoid compression of the cortical bone and trying to reach a final insertion torque of at least 32 Ncm.
Fig.8
The impression was made using a special impression tray produced with a 3D printer that allows the correct vertical dimension and centric occlusion of the patient to be recorded simultaneously.
Fig.9
Clinical image of the impression obtained using polyether material with analogically technique.
Fig.10
Thanks to the occlusal wax detected during the impression phases, the completely worn dental elements of the upper prosthesis were replaced and reassembled in the new vertical dimension and centric occlusion.
Fig.11
In the lower arch, an immediate loading Toronto Bridge type prosthesis was made with a fiberglass reinforcement CAD-CAM milled from solid.
Fig.12
Intraoral clinical situation 24 hours after surgery.
Fig.13
Clinical situation with 2 temporary prostheses screwed onto the implants.
Fig.14
Xray exam to check the correct adaptation of the two screwed prostheses.
Fig.15
Comparison of the patient’s aesthetic appearance before and after the insertion of immediate-load implants in the lower arch and the subsequent repositioning of the upper denture teeth to the new vertical dimension and centric occlusion.
The disappearance of the so-called “Popeye face” is immediately observed.
Conclusions
Rehabilitation of a patient with osseointegrated implants requires adequate planning and patient awareness of the chosen solution. If these conditions are lacking, coupled with the patient’s failure to enter an implant maintenance program, failures are inevitable.
These failures may be prosthetic in nature, and therefore easily remedied, but when all the implants are lost, bone atrophy often occurs, which can complicate the insertion of further dental implants.
In clinical conditions such as that of this patient, who also appears very distrustful of implant therapy, it is crucial to plan and design each case correctly in order to achieve proper rehabilitation from an aesthetic, phonetic, and occlusal perspective, thus ensuring the patient’s fully restored social life.
Finally, the patient should be included in a maintenance program that allows for constant monitoring of the health of the implants.
Bibliography
- Bone Quality and Quantity and Dental Implant Failure: A Systematic Review and Meta-analysis. Bruno Ramos Chrcanovic, Tomas Albrektsson, Ann Wennerberg Int. J. of Proshodontic 2017 30(3) 219-237.
- Effectiveness of zygomatic implants using the externalized technique in the rehabilitation of atrophic maxillae. A systematic review with meta-analysis H. Rebelo, P. Sales, P. Silva, J. Leao, P. Cravalho, Med. Oral Pat. Oral Circ. Bucal. 2025 1;30 (6) 774-786.
- Occlusal vertical dimension: treatment planning decisions and management considerations M.Calamita, C. Coachmen, N. Sesma, J.Kois 2019 Int. J. esthetic Dentistry 14(2) 166-181.
