Dr. Mohamed Garhy
Candidate at the Prosthodontics Department, Faculty of Dentistry, Nahda University, Beni Suef, Egypt, and Zain Dental Clinic, 42 Mossadak Street, Dokki, Giza, Egypt.
In the evolving field of prosthetic rehabilitation, the paradigm has shifted towards prosthetically driven planning, where the final prosthetic outcome dictates the implant position. This approach ensures optimal functional and esthetic results, as the implants are placed in the most advantageous locations to support the restoration. By integrating the prosthetic design into the surgical phase, clinicians can minimize complications and achieve long-term success. Furthermore, this methodology enhances predictability and simplifies the overall treatment process for both the dental team and the patient (Smith et al., 2025).
Expanding on this philosophy, the concept of facial driven prosthesis prioritizes facial aesthetics and harmony as the primary guiding principle (Ricketts, 1982). By analyzing the patient's facial features, smile line, and lip dynamics, clinicians can design restorations that blend seamlessly with the natural anatomy, resulting in a more youthful and natural appearance. This facial centric approach ensures that the prosthetic outcome not only functions correctly but also complements the patient's unique facial characteristics.
Furthermore, a comprehensive occlusal analysis is fundamental in full mouth rehabilitation, as it establishes the foundation for stable and long-lasting function (Dawson, 2007). By evaluating the centric relation, vertical dimension, and occlusal schemes, the clinician can correct discrepancies, reduce wear, and prevent future issues related to the temporomandibular joint.
A 48-year-old female patient presented with a chief complaint of multiple missing teeth, functional impairent during mastication, and severe dissatisfaction with her dental aesthetics. Clinical examination revealed a partially edentulous condition with significant loss of mandibular anterior and posterior teeth. The remaining dentition exhibited generalized severe chronic periodontitis, characterized by marked gingival recession, attachment loss, and varying degrees of tooth mobility. Furthermore, multiple cervical and occlusal carious lesions were present, alongside the supra-eruption of unopposed maxillary teeth, resulting in a collapsed occlusal vertical dimension.
Radiographic assessment via panoramic X-ray confirmed severe generalized horizontal and vertical bone loss, particularly pronounced in the mandibular anterior and posterior segments. The definitive diagnosis was partial edentulism complicated by severe generalized chronic periodontitis, multiple dental caries, and a loss of occlusal stability and vertical dimension.
Figure 1: (A) Pre-operative extraoral photographs showing the collapsed lower third of the face and compromised aesthetic smile.
Figure 1 (B) Intraoral views detailing the partial edentulism, severe chronic periodontitis, and occlusal collapse.
Figure 1: (C) Pre-operative panoramic radiograph confirming severe generalized bone resorption.
Under local anesthesia only, a full-mouth extraction of all remaining hopeless teeth was performed. In the maxilla, a surgical guide was utilized to place four conventional dental implants along with two pterygoid implants in the posterior region, following the B.A.T. protocol for optimized bite stability.
To ensure absolute precision in the prosthetic phase, specialized photogrammetry scan bodies were attached to the implants. A photogrammetry system was utilized to capture the precise three-dimensional spatial orientation of the implants, eliminating the dimensional distortions common in traditional impressions. Concurrently, a 3D facial scan was acquired using the Metismile Face Scanner. A comprehensive digital facial analysis was performed utilizing the Shining 3D software. Key facial parameters—including the facial angle, pupillary line parallelization, and gnathion deviation—were meticulously evaluated. This data guided the virtual diagnostic design, ensuring the final occlusal plane and smile arc were perfectly harmonious with the patient's unique facial dynamics.
Figure 2: Surgical phase. (A) Application of the surgical guide in the maxilla for precise implant positioning.
Figure 2: Surgical phase. (B) Post-placement intraoral views showing the distribution of four conventional and two pterygoid implants in the maxilla, and six implants in the mandible following the All-on-6 protocol.
All digital data, including the CBCT, intraoral scans, photogrammetry records, and the 3D extraoral facial scan, were imported into Exocad dental CAD software. A precise superimposition of these datasets allowed for a fully integrated virtual environment. Utilizing the Smile Creator module, a virtual diagnostic wax-up was meticulously designed. The 3D facial scan served as the primary reference to determine the ideal incisal edge position, midline harmony, and smile arc, ensuring a true facially driven prosthetic design. The final full-arch screw-retained prostheses were then milled and prepared for delivery.
Figure 3: Digital data acquisition. (A, B) Intraoral views of the photogrammetry scan bodies attached to the maxillary and mandibular implants.
Figure 3: Digital data acquisition. (C) The corresponding 3D digital rendering capturing the precise spatial orientation of the implants.
Figure 4: Digital facially driven planning using Shining 3D software. The extraoral facial scan is integrated with intraoral data to evaluate facial proportions, pupillary line orientation, and structural deviations, dictating the harmonious design of the final prosthesis.
Following the virtual design, the definitive full-arch prostheses were milled using a 5-axis CAD/CAM milling machine. To ensure optimal biomechanical durability and aesthetic outcomes, 3Y-TZP Zirconia blanks (Zircaglow 3Y ZR) were selected. This material provides a high flexural strength of 1200 MPa, which is mechanically sufficient to withstand immediate and long-term full-arch occlusal loads while maintaining natural translucency.
The surgical procedure was completed successfully without any intraoperative complications. Post-operative CBCT imaging confirmed the accurate three-dimensional positioning of the four conventional and two pterygoid implants in the maxilla, as well as the six implants in the mandible, strictly adhering to the pre-surgical digital plan.
The integration of the Shining 3D photogrammetry and Elite intraoral scanner allowed for the immediate fabrication of a provisional prosthesis with a highly accurate passive fit. Furthermore, the aesthetic evaluation using the Metismile Face Scanner ensured that the prosthetic design was in complete harmony with the patient's facial features. Upon delivery of the immediately loaded prostheses, the patient reported immediate satisfaction with both the functional restoration and the dramatic aesthetic improvement, as evidenced by the harmonious smile line and restored lip support.
Beyond aesthetic satisfaction, the functional rehabilitation was objectively quantified. Using the Innobyte bite force measurement device, the patient's maximum bite force was recorded at 293 N, with a stable bilateral distribution. This quantitative data clinically validates the success of the bite deprogramming protocol and confirms the restoration of a healthy, functional masticatory capacity without overloading the implants.
In the mandible, a full-arch rehabilitation was carried out following the All-on-6 protocol, involving the precise insertion of six implants distributed strategically to support an immediately loaded full-arch fixed provisional prosthesis.
Post-surgical digital records were captured using the Shining 3D intraoral scanner, photogrammetry, and Metismile Face Scanner to ensure passive fit and optimal aesthetics for the final restorations.
Upon delivery, the final screw-retained prostheses demonstrated an impeccable passive fit and excellent soft tissue adaptation. Intraoral occlusal evaluation, guided by the initial bite deprogramming, confirmed a stable and harmonious occlusal scheme. Extraorally, the prostheses successfully restored the collapsed lower facial third, providing optimal lip support. Macro-aesthetic evaluation of the smile revealed a natural emergence profile and a perfectly integrated smile line, resulting in immense functional and psychological satisfaction for the patient.
Full-mouth rehabilitation in patients with severe bone resorption and collapsed occlusal vertical dimensions presents a complex biomechanical and aesthetic challenge. Traditional methods often require extensive bone grafting procedures, such as sinus floor elevation, which increase morbidity and treatment time.
In this case, the utilization of pterygoid implants in the maxilla provided crucial posterior cortical anchorage, bypassing the need for sinus augmentation and allowing for immediate loading. The implementation of the B.A.T. (Bone Anchored Template) protocol was pivotal in maintaining a stable reference for the bite, ensuring that the pre-planned occlusal vertical dimension was accurately transferred to the surgical field.
The novelty of this case lies in the seamless integration of a fully digital, facially driven workflow. By combining intraoral scanning with photogrammetry, the spatial position of the implants was captured with micron-level precision, eliminating the dimensional inaccuracies associated with conventional impressions. Additionally, aligning these records with the patient's facial data enabled a prosthetic design that dynamically complemented her facial aesthetics.
To ensure the longevity of the rehabilitation, proper occlusal management was critical. The use of the Enobite device for bite deprogramming and biting force analysis allowed for the establishment of a harmonious, interference-free occlusal scheme, thereby mitigating the risk of biomechanical overload on the immediately loaded implants.
The integration of a facially driven digital workflow—utilizing advanced scanning, photogrammetry, and bite deprogramming technologies—combined with strategic implant placement, such as pterygoid and All-on-6 protocols, offers a highly predictable and efficient approach to complex oral rehabilitations. This protocol not only minimizes surgical morbidity by avoiding extensive grafting but also delivers immediate, superior aesthetic and functional outcomes, significantly enhancing the patient's quality of life.
1. Tulasne JF. (1989) Osseointegrated fixtures in the pterygoid region. In: Albrektsson T, Zarb GA, editors. The Brånemark osseointegrated implant. Quintessence.
2. Busenlechner D, Mailath-Pokorny G, Haas R, et al. (2016) Graftless full-arch implant rehabilitation with interantral implants and immediate or delayed loading: reconstruction of the edentulous maxilla. The International Journal of Oral & Maxillofacial Implants, 31(4): 900-905.
3. Di Fiore A, Meneghello R, et al. (2020) Full-arch rehabilitation with immediately loaded dental implants: a retrospective clinical study.
4. Jemt T. (2016) Fixed implant-supported prostheses in the edentulous maxilla: a five-year follow-up report. Clinical Implant Dentistry and Related Research.
5. Revilla-León M, Özcan M. (2019) Dental applications of photogrammetry: a review of the literature. The Journal of Prosthetic Dentistry