A 58-year-old patient presented with a terminal maxillary dentition, generalised mobility and a clear wish to avoid a removable provisional at any stage. The question was not whether implants were indicated, but whether the arch could be loaded on the day of surgery.

Assessment

Clinical examination showed grade II–III mobility across the remaining maxillary teeth with 7–9 mm probing depths. CBCT demonstrated adequate anterior bone volume with pneumatised sinuses posteriorly. Critically, the patient’s occlusal scheme and lip position were recorded before any extraction, so the prosthetic target was fixed before the surgical plan was drawn.

Pre-operative photographFull-face and intraoral seriesFig 1 — Pre-operative presentation. Note the incisal position relative to the resting lip.

Planning

Working backwards from the intended prosthesis, four implants were planned with posterior tilting to engage the anterior sinus wall and avoid grafting. A photogrammetry workflow was selected for impression capture, allowing an accurate framework record without a conventional impression on an unhealed surgical field.

CBCT planning viewCross-sectional and panoramic reconstructionFig 2 — Virtual planning. Implant axes were dictated by the restorative position.

Guide designSurgical guide, seated on boneFig 3 — The guide was designed for bone support following extraction.

Surgery and immediate loading

Atraumatic extraction was followed by alveoloplasty to a flat, predictable platform. Osseodensification burs were used to preserve and compact bone at the osteotomy walls, producing insertion torques of 45–55 Ncm across all four fixtures — the threshold we require before committing to same-day loading.

Multi-unit abutments were placed intra-operatively, photogrammetry markers captured, and a milled provisional delivered the same afternoon. Total chair time was under six hours.

Outcome

At 18 months all four implants remain stable with no measurable bone loss beyond the expected first-year remodelling. The definitive prosthesis was delivered at four months. The patient did not wear a removable appliance at any point.