Catarina G. Rodrigues, DDS, MSc – Manuel D. Marques, DDS

A 57-year-old woman presented to a private practice with the chief complaint being “I’m self-conscious about the appearance of my teeth. Also, I’ve lost most of my teeth and I cannot eat well because of that”. The clinical and radiographic examination revealed the absence of all teeth except the central incisors and right lateral incisor in the upper. In the lower, partial edentulism, severe bone loss, and multiple periapical infections were diagnosed. Also, the patient’s function and aesthetics were seriously compromised (Fig 1-11).

Catarina G. Rodrigues, DDS, MSc – Manuel D. Marques, DDS

患者男性、30岁。24号、25号和26号牙齿缺失，牙周情况良好、咬合空间尚可。c 治疗计划：２４号、２６号牙位植入两颗种植体，种植桥修复。
在数字化导板的引导下，植入两颗西泰克美学种植体。
西泰克美学植体、斜肩台加平台转移、保证美学效果，多种螺纹增加初期稳定性。
选择戴入两颗穿龈高度为３的最新的西泰克“ONETIME”基台、并在基台上端加上覆盖螺钉
术后X光片、角度位置良好。

Catarina G. Rodrigues, DDS, MSc – Manuel D. Marques, DDS

一名67岁的女性患者，临床和放射学检查显示13号和15号牙齿存在广泛龋齿和根管治疗失败史。此外，1４号、１６号牙缺失。

Catarina G. Rodrigues, DDS, MSc – Manuel D. Marques, DDS

A 66-year-old man presented to a private practice seeking a fixed restoration to replace his terminal dentition. The intraoral and radiographic examination revealed partially edentulous arches, the presence of periapical infections and extensive carious lesions on several teeth, significant attachment loss, and tooth mobility (Fig.1-3).

Both aesthetics and function were compromised. The vertical dimension of occlusion was reduced due to loss of posterior support and excessive wear. Following a proper diagnosis, the treatment plan proposed was the extraction of all the remaining teeth, placement of five implants in the maxilla and six implants in the mandible, immediate loading of the implants, and – as final restorations – full arch screw-retained prosthesis (Fig.4).

In order to perform proper pre-surgical planning of the case, initial records of the patient were obtained: intra and extra-oral photographs, digital impressions, and CBCT. A 2D facially driven digital smile design was made to aid in the planning of the position and dimension of the teeth for the future interim prosthesis.

Then, using a specific 3D CAD software, a digital diagnostic wax-up was generated and 3D printed. A silicone index was obtained from the 3D printed model and filled with bis-acryl resin to produce trial restorations and evaluate the 2D smile planning on the patient’s mouth (Fig.5-7).

The approved try-in was then scanned and superimposed with the preoperative intra-oral scan and CBCT to digitally plan the implant surgery. Once the future implant positions were defined, they were translated into the design of the surgical templates (Fig.9-10).

The prosthetic abutments were also planned in the same software as the implants.
Due to the patient’s systemic conditions, was decided to perform first the upper surgery and 3 months after the lower one. In the upper arch, after extraction of all maxillary hopeless teeth, implant sites were prepared through the guide according to a specific drilling protocol, and using C-Tech guided surgery kit, followed by implant placement.

All implants were torqued with at least 45Ncm to ensure enough primary stability for immediate loading. After implant placement, multi-unit abutments were inserted and torqued in place with 25 Ncm. A full arch provisional screw restoration was delivered the same day (Fig.8).

The implant surgery in the mandible was carried out 3 months after. To improve the precision of lower implant surgery, two surgical guides were used to place the implants.

The first guide was placed before any extraction and used to place implants on the molars region and right premolar region. Then, the first guide was removed, all teeth but the canines were extracted, and the second guide was seated and used to place implants on the anterior and left premolar regions (Fig. 11-13).

After implant placement, Omni system abutments were inserted and torqued in place with 25 Ncm. A full arch provisional screw restoration was delivered the same day. Post-op periapical x-rays and a panoramic x-ray were taken to ensure proper adaptation of the interim prosthesis to the implant abutments. Intra and extra-oral pictures of the immediate prosthesis were obtained (Fig. 14-19).

Three months after the lower, and six months after the upper surgery and immediate loading, we proceed with final impressions. In an occlusal view, after removing the lower fixed provisional prosthesis, we can appreciate a healthy appearance of the soft tissue (Fig. 20,21).

Finally, we deliver a full arch screw retained fixed prosthesis over multi-unit abutments in the upper arch, and a full arch screw retained fixed prosthesis over Omni system abutments in the lower arch (Fig. 22-25).

Dr. Catarina G. Rodrigues, DDS, MSc – Dr. Manuel D. Marques, DDS

One of the main challenges during implant treatment is adequate maintenance of peri-implant soft tissues. This will have a tremendous influence on the longevity of the implant, and aesthetics of the final implant-supported restoration.

In some clinical situations, the shape of pre-fabricated healing abutments is not adequate to obtain a proper emergence profile, as they differ from the shape of the natural tooth. That will happen most of the times when placing immediate implants, right after a tooth extraction.

The use of a custom healing abutment, not only will preserve the natural soft tissue architecture, but will also, later on, facilitate the work of the restorative dentist and lab technician on the fabrication of the final crown, as the soft tissue is already developed to accept a crown with a natural size and contour (Fig. 1).

The present clinical case illustrates how to obtain a custom healing abutment using a temporary metal abutment and light-cured flowable resin composite (Fig. 2,3).

For this clinical situations, there are mainly three reasons for choosing a metal abutment over a peek one. First, the metal connection is stronger. Given the fact that we will need to screw and unscrew the abutment several times, by using an abutment with a stronger implant connection there is less risk of deforming it. Second, the surface characteristics and design of the metal temporary abutment facilitate the process of adding and retaining the resin composite. Lastly, when using the temporary metal abutment it is possible to confirm with a periapical x-ray the position of the abutment on the implant, while with peek abutments that will not be possible.

The patient presented with complaints on tooth 4.6. After a proper clinical and radiographic examination, a large apical cyst was found, besides signs of failed endodontic treatment, extensive structural loss and multiple cracks (Fig.4,5).

Given that the tooth was considered to have an unfavorable long-term survival, extraction and immediate implant placement was recommended as the ideal treatment plan.

The surgical procedure consisted of atraumatic extraction of tooth 4.6, followed by immediate implant placement (Fig.6,7).

Then, a temporary metal abutment was screwed on the implant and the flowable resin composite was attached to the abutment, creating a “spider web” to help on reproducing the shape of the extraction socket to the design of the custom healing abutment (Fig.7).

Then, the abutment was unscrewed (Fig.8), more flowable composite was add, within the limits previously defined, to create a proper emergence profile (Fig.9), and the finishing and polishing procedures were undertaken (Fig 10-12).

Finally, the socket was filled with a xenograft bone substitute and the custom healing abutment was screwed on the implant. No sutures were necessary as, due to its shape, the abutment itself closed the socket completely (Fig.13-15).

At one week post-operative control appointment we could appreciate a proper healing of the tissues (Fig. 16).

Three months after implant placement, we proceed with the final impressions. After removing the custom healing abutment, we can observe the maintenance of soft tissue contour thanks to the shape of the abutment itself (Fig.17,18).

The final impressions were done digitally using an intra-oral scanner. The scanner allow not only the record of the implant position, but also, of the soft tissue anatomy, with great detail (Fig 19,20).

The final crown was fabricated fully digitally in monolithic zirconia. At the time of crown delivery, we could appreciate, in an oclusal view, a proper gingival thickness, and in a lateral view, a very natural soft tissue contour and maintenance of the interdental papilla (Fig. 21,22).

Dr. Catarina G. Rodrigues, DDS, MSc – Dr. Manuel D. Marques, DDS

A 50-year-old woman presented to a private practice very unhappy with the aesthetics of her smile. The patient said that her front teeth were always misaligned, but recently they had worsened considerably. In the initial extra-oral photographs we can note that the right central incisor is excessively inclined towards the buccal side and also extruded (Fig.1,2).

The initial intra-oral pictures revealed wrong tooth proportions and the presence of several spaces between the upper anterior teeth, which obviously compromised the aesthetics of her smile (Fig. 2-5).

The radiographic examination revealed that the bone support of tooth 1.1 was very compromised. Also, clinically we detected grade II mobility (Fig. 6,7).

Following a proper diagnosis and given the fact that the patient asked for a minimal invasive approach, we proposed the following treatment plan: prophylaxis, direct composite restorations on teeth 1.2, 2.1 and 2.2, to help managing the interdental spaces and improve aesthetics, extraction of tooth 1.1 with immediate implant placement and immediate loading, and finally a ceramic crown over implant (Fig.8).

To perform a proper planning of the case, several records of the patient were obtained. Besides intra and extra-oral pictures, we did also full arch IOS impressions and CBCT (Fig. 9).

Since the original position of tooth 1.1 was not correct, this tooth was digitally extracted on the STL file and a 3D wax-up of a new central incisor with correct position, and proportions was digitally made to aid on the planning of the position and dimension of the future implant.

Then – using a specific software to plan the guided surgery – the STL files from the initial scan, the 3D wax-up and the CBCT were all superimposed, allowing the planning of the implant position accordingly to the planned future restoration (Fig.10).

At the time of the surgery, tooth 1.1 was extracted using an atraumatic technique not to damage the bone or the soft tissues (Fig. 11,12).

After that, the stability and adaptation of the guide were checked, followed by guided preparation of the implant site according to a specific drilling protocol and using C-Tech guided surgery kit. (Fig.13,14).

Finally, the implant was inserted through the guide and a connective tissue graft was preformed (Fig. 15-17).

The immediate fixed provisional restoration was made with a titanium provisional abutment and the patient’s own tooth. The root of the extracted tooth was cut and prepared to be bonded to the titanium abutment. Then, the provisional crown was finished and polished (Fig. 18,19).

The 1-month follow-up appointment revealed very good healing and adequate aesthetics of the interim prosthesis. Also, on the periapical x-ray we can note the subcrestal position of the implant, ideal for the aesthetic zone once it allows proper emergence profile of the implant restoration and helps with long-term aesthetic stability (Fig. 20,21).

While we waited for the osseointegration of the implant, we proceeded with the direct composite restorations of teeth 1.2, 2.1 and 2.2. We selected the shade of the composite resin and then completed the direct restorations under rubber dam (Fig. 22-24).

Later, 3 months after the implant surgery, we proceeded with the final impressions. To help the lab technician with the reproduction of the critical and subcritical contour of the provisional crown, I scanned first the provisional on the mouth and then the provisional crown alone (Fig 25).

Finally we delivered the final restoration, a screw-retained layered zirconia crown over implant (Fig. 26-28).

When comparing the initial situation of the patient and her final pictures, we can appreciate an important improvement on the aesthetics of her smile (Fig. 29-31).

Catarina G. Rodrigues, DDS, MSc – Manuel D. Marques, DDS

In the present clinical case, the upper left lateral incisor presented with a vertical fracture. Following a proper clinical and radiographic analysis, the tooth was considered hopeless. The treatment plan consisted of the extraction of the lateral incisor and immediate implant placement. It is well described in the literature that delayed loading, in contrast with immediate or immediate- delayed loading, can lead to predictable results in all clinical situations.

Catarina G. Rodrigues, DDS, MSc  – Manuel D. Marques, DDS

A 74-year-old woman presented to a private practice with the chief complaint being that she did not want to use dentures anymore and have more comfort and better appearance. The clinical and radiographic examination revealed the absence of all teeth except the two upper canines (Fig 1-4).

Dr. Catarina G. Rodrigues, DDS, MSc • Dr. Manuel D. Marques, DDS