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

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。

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).

Doctor Peng Dong, the expert of tooth implantation in Peking University International Hospital and president of Beijing Hedu Stomatological Clinic Co., Ltd

病例概要

上颌牙齿牙槽骨吸收明显，根尖周大面积暗影，根吸收达根长1/3~1/2，诊断侵袭性牙周炎，经上颌窦外提升术后，拔除患牙，即刻植入C-Tech种植体，型号：EL-3509、EL-4309、EL-5109，共8颗，后期氧化锆烤瓷冠桥修复。

治疗计划

上颌牙槽骨宽度理想，骨高度不足，双侧上颌窦外提升术后2个月，拔除患牙，即刻植入C-Tech种植体EL-3509、EL-4309、EL-5109，共8颗，同期植骨后，植体支持的固定临时义齿修复。

治疗内容

1、常规消毒铺巾。上颌术区局部浸润麻醉。
2、行右上7远中斜行切口+右上7牙槽嵴顶近远中向切口+右上6543沟内切口+右上2~左上1牙槽嵴顶近远中向切+左上234沟内切口+左上5~7牙槽嵴顶近远中向切口，左上8沟内切口，翻瓣，暴露骨面，钳除右上6543和左上234清创，咬骨钳+大球钻降低平整骨面。
3、右上1定点，级差备洞+骨挤压至3.0*11mm，植入C-Tech种植体EL-3509+EL-4504P peek基台，扭力45N，边缘骨高度M1.5D1.5B1.5L1。右上3和左上1、3 定点，级差备洞+骨挤压至3.0*1 1mm，植入C-Tech种植体EL-3509+EL-4504P peek基台，左上1扭力45N，边缘骨高度M 2.5D2B1.5L2。左上3扭力45N，边缘骨高度M 1.5D1.5B-1.5L1.5。右上3扭力45N，边缘骨高度M 2D1.5B2L1.5。右上4定点，级差备洞至3.8*11mm，植入C-Tech种植体EL-4309+EL-4504P peek基台，扭力45N，边缘骨高度M1.5D2B1.5L1.5。左上4定点，级差备洞至3.8*11mm，植入C-Tech种植体EL-4309，扭力10N，边缘骨高度M1.5D-8B1.5L1.5。左右上6定点，级差备洞至3.8*11mm，各植入C-Tech种植体EL-5109+覆盖螺丝，左上6扭力25N，边缘骨高度M1D1B1.5L0.5。右上6扭力45N，边缘骨高度M1.5D1.5B1.5L1.5。将骨粉Bio-Oss分别置于右上3、1和左上1、3、4骨缺损出及唇侧骨板处，覆盖Bio-Gide于植骨处，及右上6拔牙处，拉拢并间断缝合关闭创口。
4、利用右上4、3、1和左上1、3放置临时基台，制作上颌即刻义齿，调颌，抛光。
5、九个月后取模，更换修复基台，粘接固定，氧化锆烤瓷冠桥永久修复。

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.

Dr. Luigi Ciacci, Odt. Andrea Sessa

Introduction:
Modern dentistry depends on comprehensive diagnostics and careful planning to achieve the desired result and meet the expectations of both the patient and the dentist.
Digital planning and guided surgery based on three-dimensional X-ray data and digitized intraoral recording are of great help. They provide valuable information and allow for accurate backward planning to optimize the implant-prosthetic outcome, making the restoration more predictable in terms of function, aesthetics and biology.

Dr Fabrizia Luongo, DDS, MS, Periodontist, Rome, Italy

Introduction
The evolution of digital dentistry and the development of a digital workflow has concentrated on digital planning with the use of Cone Beam CT scanning as well as using digital restorative tools to combine DICOM (Digital Imaging Communication in Medicine) and .stl (stereolithography) files to virtually plan, place and restore implants before using this plan to treat patients. The resulting benefits are reduced chair time, high precision and predictable aesthetic results often with immediate fixed provisional restorations available at time of surgery and corresponding high levels of patient satisfaction.
Intra-oral scanning to create digital ‘virtual impressions’ is also becoming more prevalent with the information being stored in the .stl file format. This information can be utilised by appropriate CAD/CAM (computer-aided design and computer aided manufacturing) software to design and manufacture a dental restoration (either by milling or 3D printing).
One area that is sometimes overlooked is the use of digital technology in occlusal analysis and adjustment of the restored dental implant. The following case study examines the occlusal management of a conventionally placed implant.

A 55 year old female patient was referred to our office for a full mouth rehabilitation. Upon clinical examination and a CBCT, we have decided to implant 4 EL C-Tech conical Morse tapered connection implants in the upper jaw for a bar retained over denture and due to financial considerations; was to perform extraction of all remaining lower teeth and immediate post extraction implantation of SD C-Tech mini dental implants. A full muco-periosteal flap was released, teeth were extracted, an alveotomy was performed to achieve an optimal bone platform for the SD mini dental implants and to obtain a bigger vertical dimension for the overdenture!

A 58 years old female patient has come to our clinic for lower jaw rehabilitation. After the clinical examination and OPG, We have decided to extract tooth 33, which is the only one remaining. As thepatient has not accepted a big augmentation procedure, we have decided to implant 4 C-Tech SD mini dental implants for retention and stabilization of the lower denture.