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9 Fig. 6: After the extraction sockets had healed, the virtual implant planning was carried out. Fig. 5: The temporary prosthesis was inserted after the extrac- tion of the abutment teeth in the upper jaw. Fig. 4: To enable optimal chewing function, the lower jaw bridge had to be replaced on the left and the gap in the fourth quadrant needed to be closed. treatment options to the patient, she opted for a fixed reconstruction. Using a set-up on the models, we prepared the fol- lowing integrated treatment plan in close consultation with the surgeon, the dental technician, and the patient [2, 3]: - Extraction of the non-retainable abutment teeth in the upper jaw - Removable prosthesis in the upper jaw during the healing phase - 3D implant diagnostics - Virtual implant planning - Preparation of the surgical template for the implant insertion - Implant surgery - Implant exposure, soft tissue manage- ment and contouring with a direct screw-retained plastic bridge - Implant impression taking - Insertion of the temporary restoration and fine-tuning of the esthetics - Preparation in the lower jaw including taking an impression of the natural teeth - Fabrication of zirconia bridges on eight individual CAD/CAM titanium abutments - Try-in of the upper and lower jaw restoration to check the function and esthetics - Insertion of the final restoration Our dental technician used the set-up as a guide to fabricate a prosthesis for the tem- porary restoration for the extraction ap- pointment in October 2013. After query- ing the general health of the patient and examining the current oral situation, we carried out the atraumatic extraction of all non-retainable abutment teeth in the up- per jaw apart from tooth 27 in our clinic. We were particularly cautious when ext- racting the anterior teeth so that we could preserve the very thin vestibular bone la- mella as completely as possible. Because we planned to insert the implants about four months later, we allowed bleeding in the extraction sockets. The blood clots favor the migration of growth cells from the surrounding vessels so that about eight weeks after the extraction the sockets were filled with freshly formed cancellous bone and closed over with stable epitheli- al tissue [4]. This bone will then undergo various remodeling processes over the fol- lowing months. After the primary wound closure, we fitted the temporary prosthe- sis. It prevents the accumulation of traces of food in the extraction sockets (Fig. 5) . Virtual implant planning In the lateral area of the upper jaw, certain criteria must be considered for esthetic restoration using bridges. Special attention must be placed on the soft tissue situation here. So that saliva bubbles do not form in the interdental spaces or to prevent traces of food being trapped here, im- plants should be designed to satisfy the prosthetic requirements and positioned with optimal distance between them. They not only stabilize the bone but also sup- port the surrounding soft tissue. Thanks to the pontic element of the bridge, pseudo- papillae can be reconstructed, creating a natural transition from the ceramic resto- ration to the soft tissue. CAD/CAM tech- nologies offer us a number of options to satisfactorily take these conditions into ac- count in many cases. For optimal planning of the restoration and positioning of the implants, the dental technician fabricated a wax try-in without the vestibular gingival section in the anterior area. Using this set- up, we checked the esthetics, clarified the length of the anterior teeth, and defined the occlusal planes. The temporary resto- ration was relined and adjusted to the new occlusal position. Using the set-up, a radiology template was prepared and the patient was transferred to the radiologist for a CT scan. During the CT scan, the patient wore a restoration pre- pared from radiopaque material with an ana- tomical emergence profile that showed the desired subsequent prosthetic situation in the CT images. Using the med 3D software and together with specialists from the labo- ratory, we evaluated the images and defined the optimal implant positions and lengths. We planned four implants in the first quad- rant in the lateral area regio 14, 15, each of Ø 3.8 mm × 11 mm length and Ø 3.3 mm × 13 mm long implant in regio 12, in regio 16 Ø 5.0 mm × 11 mm. In the second quadrant two implants are inserted in the lateral area regio 24 (Ø 3.8 mm × 11 mm length) and 26 (Ø 3.8 mm × 9 mm length) as well as two implants in regio 22 and 23 (each with Ø 3.8 mm × 11 mm length) (Fig. 6) . Using the data acquired, the planning specialists fabri- cated a surgical template with the two-part CAMLOG CT-tubes for implantation. In February 2014 the implantation was performed in the oral surgery clinic of Dr. Grundl. After induction of local anes- thesia, the surgeon exposed the jaw bone in the surgical field. When exposing the bone, ensure that the drilling template can be positioned stably. He made alveo- lar ridge incisions oriented slightly palatal (inside the linea alba) that end distally at regio 16 and around tooth 27 with pa- ramedial curve-shaped relief incisions. To minimize the risk of absorption in the anterior esthetic zone, the surgeon left a central ridge of about one centimeter of soft tissue, a technique introduced by S. Schmidinger in 1981 in Vienna (Fig. 7 and 8) [5]. The minimal bleeding tendency and the stability of the wound margin with a crestal incision are beneficial for the rest of the operation and good wound healing. CASE STUDY