The initial clinical examination revealed a long-span Porcelain-Fused-to-Metal (PFM) FDPs of teeth 14-25 fixed with temporary cement since 2009 at private hospital (Fig 1,2). The patient had maxillary hard and soft tissue defects associated with alveolar ridge resorption and loss of lip support. Removable Acrylic Gingival Veneer (AGV, Fig 3.) was used to cover those FDPs in order to improve extra-oral soft tissue profile (Fig 4.). Without AGV, the patient has concave profile (Fig 5.). FDPs were removed to evaluate the existing abutments condition (Fig 6.). Abutment teeth 13,24,25 had first degree mobility. Panoramic XRAY (Fig 7.) revealed that tooth 13 had cast post and core with vertical root fracture. Tooth 25 was endodontically treated with a  periapical lesion. After thorough diagnosis and analysis, the treatment plan was presented to the patient with the following phased treatment approach: 

1) Aesthetic evaluation
2) Restorative phase with fabrication of provisional full arch bridge
3) Flapless guided-surgery with immediate loading protocol 

Phase 1
Aesthetic evaluation
Aesthetic analysis was performed with evaluation of the smile line, incisal profile, length and proportion. Diagnostic wax-up was fabricated according to the aesthetic evaluation. (Fig. 8)

Phase 2
Provisional full arch bridge fabrication (Fig. 8 - 19)
Preparation cast with a diagnostic wax-up ca st was sent to a local laboratory for scanning and transforming into STL (Stereolithography) digital impression file. (Fig 8,9.) Two sets of STL impressions were super-imposed in the software in order to subtract the overlapping data. This process was done in order to transform the diagnostic wax-up into the STL digital impression. Consequently, the STL data was sent to the laboratory for milling. (Fig10.) A monochromatic milled-PMMA temporary bridge was fabricated in a local laboratory and returned to the dentist for composite layering. (Fig 11.) Gingival cutback was made to create sufficient gingival space for pink composite layering (Fig 12). Prior to composite layering  CeraResin Bond 1 was applied and left for 10 seconds to prime the surface, followed by application of CeraResin Bond 2 for 10 seconds and light cured for 20 seconds (Fig 13.). Ceramage Indirect Composite gingival shade GUM-O (GUM Opaque) was applied to mask the color of PMMA (Fig 14.). GUM-D (GUM Dark) was applied on the attached gingiva area to the buccal flange (Fig 15.). GUM-L (GUM Light) was applied in the region of free gingiva (Fig 16.). F-GUM-R (Flowable GUM Red) and F-W (Flowable GUM White) were painted to mimic the mucogingival junction and vascular alveolar mucosa (Fig 17.) GUM-T (GUM Translucent) was applied to reproduce of reddish translucent gingiva areas (Fig 18) to achieve natural gingival aesthetics.

Contouring, Finishing and Polishing of temporary restoration
Meticulous finishing and polishing of the restoration is a crucial step to achieving the desired aesthetics. Dura-Green stone was used to contour the macro anatomical details while the Robot Carbide Fissure Bur was used to shape the interproximal and papilla areas. The course silicone points followed by Dura-Polishing paste Al2O3 with a medium strong brush was used to finish and pre-polish the restoration. Dura-Polish DIA, diamond polishing paste was applied with a fine brush followed by the cotton buff to achieve the final high-luster polishing (Fig 19.)¹.

Phase 3
Flapless guided-surgery with immediate loading protocol
The questionable teeth (13, 24 and 25) were extracted under local anaesthesia. The surgical guide was secured in place on the maxillary arch with two anchor pins. (Figs. 21) Flapless surgery was performed using guided tissue punch. Sequential drilling were made according to the manufacturer’s protocol. All implants were placed through the surgical template. All implants were torqued 35 NCm to ensure primary stability. The extraction socket were filled with small particle Xenograft (Bio-Oss, Geistlich) and covered with resorbable collagen plug (Collar plug, Zimmer Biomet). Straight and angle multi-unit abutments were seated and torqued 15 NCm on each implants (Fig. 23)

The existing provisional bridge was utilized for converting to a provisional screw-retained prosthesis. An immediate loading protocol was utilised². Metal temporary abutments were connected on each implant. Provisional full arch bridge was perforated to match the position of the metal temporary abutments, placed in their correct position and OVD, relined with self-cure acrylic resin. All surfaces were fine-polished. A light-cure denture sealant (Palaseal, Kulzer) was applied on the intaglio surface. The provisional bridge was delivered to the patient’s mouth. (Figs. 23-27) Post-operative panoramic XRAY revealed that implants were placed according to the pre-operative planning (Fig. 22) Suture was removed after surgery 14 days. A final profile protheses3 will be fabricated after implant osseointegration.

Conclusion
When treatment planning for resorbed maxilla, it is important to consider a holistic approach which includes replacement of missing teeth, restoration of significant segments of missing alveolar bone and soft tissue contours to achieve optimal aesthetics. This case helps to showcase the benefits of using a provisional profile prosthesis fabricated with CERAMAGE Gum Colors to help improve extra-oral soft tissue profile of the patient and result in an aesthetically pleasing maxillary full arch restoration. 

Editorial note: A list of references can be obtained from the publisher.