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 Table of Contents  
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 189-196

Predictability and surgical precision in the placement of multiple post-extraction implants for hybrid prostheses using reverse planning: A case report

1 Postgraduate Department, CHANGE Research Working Group, Faculty of Health of Sciences, Universidad Cientifica del Sur, Lima, Peru
2 Postgraduate Department, Faculty of Stomatology, Universidad Peruana Cayetano Heredia, Lima, Peru; Academic Department, School of Stomatology, Universidad Privada San Juan Bautista, Lima, Peru
3 School of Dentistry, Faculty of Dentistry, Universidad Nacional Mayor de San Marcos, Lima, Peru
4 Academic Department, Faculty of Dentistry, Universidad Nacional Federico Villarreal, Lima, Peru

Date of Submission27-Sep-2020
Date of Decision28-Oct-2020
Date of Acceptance03-Mar-2021
Date of Web Publication17-Apr-2021

Correspondence Address:
Dr. Frank Mayta-Tovalino
Postgraduate Department, CHANGE Research Working Group, Faculty of Health of Sciences, Universidad Cientifica del Sur, Avenue Paseo de la República 5544, Miraflores 15074, Lima.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jioh.jioh_305_20

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Nowadays, it is very important to guarantee correct healing and stabilization of the soft tissues after extraction after the placement of dental implants, and this is achieved only with due planning by using a reverse protocol. This study describes a 78-year-old patient presenting with predictability and surgical precision in the placement of multiple post-extraction implants for hybrid prostheses by using reverse planning. In summary, the placement of implants in a totally edentulous area is quite challenging since in the absence of teeth, there is no parameter for correct three-dimensional placement of implants. The present case provides evidence of the clinical importance of using a surgical guide at all times to obtain optimal results in the prosthetic phase.

Keywords: Post-extraction Implants, Predictability, Reverse Planning, Surgical Precision

How to cite this article:
Mayta-Tovalino F, Rosas J, Munive-Degregori A, Portal N, Alvitez-Temoche D, Mauricio F. Predictability and surgical precision in the placement of multiple post-extraction implants for hybrid prostheses using reverse planning: A case report. J Int Oral Health 2021;13:189-96

How to cite this URL:
Mayta-Tovalino F, Rosas J, Munive-Degregori A, Portal N, Alvitez-Temoche D, Mauricio F. Predictability and surgical precision in the placement of multiple post-extraction implants for hybrid prostheses using reverse planning: A case report. J Int Oral Health [serial online] 2021 [cited 2022 Aug 17];13:189-96. Available from:

  Introduction Top

Conventional prostheses usually present a lack of stability and retention, thus becoming one of the main problems presented by patients. For example, in the lower jaw bone resorption is usually the worst clinical scenario for prosthetic rehabilitation after serial extraction. In addition to inadequate chewing force, the prosthesis has the worst clinical performance.[1],[2],[3],[4] However, studies in this regard show that fixed prostheses on implants subjected to chewing load present more encouraging results. Furthermore, the availability of better, more precise digital tools and the advances in imaging techniques and software provide more predictable and safe reverse protocols.[1]

Surgical guides have multiple advantages, such as improving the precision of dental implant placement, reducing surgical time, and facilitating the surgical technique. Guides made with three-dimensional (3D) technology are especially useful and have been gaining interest in the clinical field,[2] because they are able to reduce the risk of generating linear and angular deviations when inserting dental implants. Further, the ability to attach to bone structures provides precision in implantation based on a reverse diagnostic planning protocol.[3],[4],[5]

On the other hand, post-extraction implant placement can present multiple challenges during implantation and rehabilitation, and in chewing function. This surgical technique requires greater precision in the management of the total edentulous patients. However, implant placement in recent extraction areas has recently become a predictable surgical technique because of its advantages, including a reduction in surgical time, the development of minor inflammatory processes, and the preservation of peri-implant tissues.[6],[7] Furthermore, post-extraction placement of the implant allows the placement of a provisional prosthetic restoration on the implant not yet osseointegrated, significantly improving tissue preservation.[8],[9],[10]

The purpose of this case report was to present the predictability and surgical precision of the placement of multiple post-extraction implants for hybrid prostheses by using reverse planning.

  Case Report Top

A 78-year-old male presented with a deteriorated removable partial denture in the upper jaw, who attended the postgraduate department of the Universidad Peruana Cayetano Heredia, Lima, Peru. According to the patient’s medical history, he had a history of controlled arterial hypertension but no other systemic diseases. When removing the prosthesis to perform the clinical examination, the remaining abutments of pieces 17, 11, 21, and 25 showed Miller grade 2 and 3 dental mobility [Figure 1]. The surgical guide was fabricated through duplication of the provisional prosthesis by using transparent acrylic. After periodontal diagnosis, the patient was informed that these teeth had to be extracted, and the treatment plan consisted of placing post-extraction implants to be later rehabilitated by using a hybrid prosthesis on implants in the upper jaw. Radiological and tomographic analysis showed no oral ethology in either jaw.
Figure 1: Partial edentulous patient

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After intrasulcural incision with a 15c scalpel blade to separate teeth from the periodontal tissues, atraumatic extraction of the mentioned pieces was carried out with the help of a Satin Steel PT2 periotome curettage (Hu-Firedy, Chicago, IL, USA) that was introduced into the gingival sulcus to detach the periodontal fibers. Then, with the help of thin straight elevators 304W (Hu-Firedy, Chicago, IL, USA), syndesmotomy was performed until expulsion of the teeth was achieved. Thereafter, the integrity of the bone tables was verified with the help of a periodontal probe, and the alveoli were curetted thoroughly to eliminate the presence of any infectious process [Figure 2].
Figure 2: Atraumatic dental extraction

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After serial extractions, the previously prepared and sterilized surgical guide was placed in the upper jaw. This guide indicates the exact position in which the dental implants are to be placed to maintain a correct 3D position [Figure 3] and [Figure 4]. A full-thickness crestal incision was made from quadrant I to II with the help of a 15c scalpel blade. The mucoperiosteal flap was lifted with PR-3 Prichard curettage (Hu-Friedy®, Chicago, IL, USA), and the stability of the surgical guide was tested before performing the drilling protocol for the dental implants. The guide was stabilized until total contact with the bone support was achieved. Since it was a conventional surgical guide, there was no need to use mini-screws for fixation [Figure 5] and [Figure 6].
Figure 3: Preparation of the surgical guide

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Figure 4: Position of the surgical guide in the upper jaw

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Figure 5: Full-thickness flap in the upper jaw

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Figure 6: Location of the surgical guide on bone tissue of the upper jaw

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In the upper jaw, a drilling protocol for the Neodent® (Curtiba-Basil) dental implant system (A Straumann Group Brand) was performed, and 6 Titamax Ex Neodent®, Curitiba- Brazil 4 × 13 mm implants were placed. The Titamax Ex is a cylindrical impactor with an external hexagon connection that is indicated for type III and IV bone. The protocol started with the lance drill, Titamax Neodent®, Curitiba - Brazil, 2.0 drill, Titamax 2.8 drill, and Titamax 3.0 drill. Throughout the entire process of drilling and implant placement, parallelization pins were used to guarantee the 3D position of the dental implants on insertion into their respective surgical beds [Figure 7] and [Figure 8]. It was decided to use a screw-retained hybrid prosthesis, because it is a fixed prosthesis that has reversibility so that it can be removed for a maintenance and cleaning phase of the prosthesis over time.
Figure 7: Protocol for preparing and verifying the parallelism of the dental implants

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Figure 8: Placing dental implants in a three-dimensional position

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Finally, the implant sites were sutured with 3-0 black silk (Tagumedica) that was sterilized with ethylene oxide and clindamycin 300 mg every 12 hours for 7 days; dexamethasone 4 mg and ketorolac 30 mg every 12 hours for 3 days were prescribed. It was decided to use a black silk suture since according to the scientific literature it is a biomaterial that offers great resistance to tension. As in the clinical case a wide flap was made for the surgery, it was decided to suture with this material by means of a continuous suture. It was observed that after 15 days some suture stitches were released, so it was decided to remove the loose stitches previously made. In this case, it was decided not to place a provisional prosthesis because it could generate some kind of pressure on the implants that were previously placed and alter the osseointegration process.

After surgery, unhealthy soft tissues were showing signs of healing; thus, to ensure proper healing of the tissues, the patient was instructed to perform mouthwashes with chlorhexidine 0.12% twice a day every 12 hours for a period of 2 weeks. After 15 days, the sutures were removed and periodic follow-up was carried out over six months, demonstrating correct stabilization and healing of the white tissues, allowing the patient to enter the prosthetic rehabilitation phase with the hybrid prosthesis because it mixes the metal part with acrylic structures due to the reversibility that this type of prosthesis presents [Figure 9] and [Figure 10].
Figure 9: Control and removal of sutures at 15 days

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Figure 10: Control of hard, soft tissues around osseointegrated implants at the six-month follow-up

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  Discussion Top

Reverse planning was carried out in this patient by means of a diagnostic wax-up and the making of a provisional prosthesis that was duplicated in transparent acrylic material.[1] Our results demonstrate that the use of a surgical guide reduces the surgical time and improves the aesthetic results of the soft and hard tissues due to the precision achieved with the use of these guides. In this case, six implants were placed equidistant, three on the right side and three on the left side, to guarantee a correct distribution of forces when the dental implants enter into masticatory function. Surgical and prosthetic guides, especially in 3D, are frequently used as shown in other studies.[2]

The use of surgical guides is also important for mandibular surgeries, such as resection and grafts, as well as for reconstruction processes of any missing portion. Favorable and similar results have been described with the use of guides before and during oral surgeries. However, some studies question the frequent and systematic use of these guides, arguing that the associated costs are increased, suggesting that their use only be indicated in highly complex cases. Finally, 3D devices can be used to guide the placement of dental implants for hybrid prostheses.[2]

Taking into account the generally invasive nature of dental implant procedures, different clinical approaches have been proposed to minimize bad positioning of dental implants. The use of guides allows a favorable prognosis, resulting in more aesthetic and functional prostheses supported by implants.[11] Placing a post-extraction implant and performing immediate prosthetic restoration has certain advantages in that this allows the peri-implant tissues to be acceptably adapted during the healing process.[12],[13]

Several studies have shown that immediate implant placement has more advantages compared with late implant insertion. Immediate placement involves implants in fresh extraction sites that can be placed in the same location as the extracted tooth, minimizing the need for angled abutments, more favorable osseointegration, and bone receptors are preserved by preventing alveolar ridge atrophy, thus avoiding recession of mucous and gingival tissues. Post-extraction placement of the implants greatly reduces waiting times for osseointegration and healing of peri-implant soft and hard tissues, and provisional restorations can also be provided, thereby improving the aesthetic component.[14] Tissue collapse after tooth extraction is known to be imminent and most often associated with bone remodeling and resorption, therefore the use of a barrier membrane is recommended.[15]

Several studies have reported various prosthetic complications that are associated with permanent, hybrid prostheses.[1],[3] This is initially caused by poor reverse planning before the placement of dental implants. Fixed full-arch prostheses (hybrid) usually have a cantilever and induce high stress load on the implants that are the abutments of these fixed prostheses. These studies concluded that the tensional forces around the bone-implant interface increased more at the level of the overloaded distal implants during masticatory forces, making it extremely important to successfully place dental implants in a 3D position.[15],[16] In addition, there are other methods such as the reverse planification that mention that dental implants are good options in edentulous patients for better retention of the dental prosthesis and that the need for soft and hard tissue grafts should also be evaluated to avoid peri-implantitis, which is a very common health problem, mainly due to the accumulation of plaque that encourages the onset of inflammation. On the other hand, it is important for the alternative design of a strong structure to be fixed to a full arch supported by dental implants.[17],[18],[19],[20]

The main limitation of this case report was that only one clinical case was evaluated and other variables that could influence the correct location of dental implants at the time of surgery were not controlled. Further, only externally connected implants were used due to the availability and type of hybrid prosthesis suggested for use. Further studies involving other types of connections are needed to verify that the angulation of the future prosthetic abutments is independent of the connection used. Another limitation of this case report is that the manufacture of the surgical guide was a duplication of the diagnostic wax-up, so this type of guide could not guarantee the ideal position of the implants. The CAD/CAM surgical guide would be the ideal type of surgical guide in cases of totally edentulous patients; however, this is a technique that demands a considerable increase in cost and a specialized CAD/CAM laboratory that often does not exist in underdeveloped countries.

  Conclusion Top

Within the limitations of this case report, it can be concluded that proper planning uses a reverse protocol in which a surgical guide is prepared to guide the 3D position of dental implants in a fully edentulous jaw, and it has a direct effect on the success of the hybrid prosthesis.


The authors wish to thank the Universidad Peruana Cayetano Heredia for allowing them to make this case report.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

Author contributions

Study conception was by FMT and JR; data collection by FMT, JR, and NP; data acquisition and analysis by FMT and JR; data interpretation by DAT, JR, NP, FM, and FMT; and article writing by FMT, SL, FM, NP, and DAT.

Ethical policy and institutional review board statement

Patients who attended the postgraduate service signed an informed consent before beginning any type of surgical or prosthetic treatment. The study respects the rights of the patients. The Declaration of Helsinki was followed.

Patient declaration of consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/ have given his/ her/ their consent for his/ her/ their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Data availability statement

The data or photos that support the study results are available from the author (Dr. Frank Mayta-Tovalino, e-mail: [email protected]) on request.

  References Top

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Tack P, Victor J, Gemmel P, Annemans L 3D-printing techniques in a medical setting: A systematic literature review. Biomed Eng Online 2016;15:115.  Back to cited text no. 2
Kim J, Lee JS, Chang J, Millstein P, Wright RF A method for adapting existing removable complete dentures to immediate implants. J Mass Dent Soc 2011;60:36-7.  Back to cited text no. 3
Mendoza-Azpur G, Gallo P, Mayta-Tovalino F, Alva R, Valdivia E A case series of vertical ridge augmentation using a nonresorbable membrane: A multicenter study. Int J Periodontics Restorative Dent 2018;38:811-6.  Back to cited text no. 4
Vasak C, Watzak G, Gahleitner A, Strbac G, Schemper M, Zechner W Computed tomography-based evaluation of template (NobelGuide™)-guided implant positions: A prospective radiological study. Clin Oral Implants Res 2011;22:1157-63.  Back to cited text no. 5
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]


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