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).

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

左上1桩冠松动，拔除后，即刻植入C-Tech种植体，型号为：EL-4311，后期氧化锆烤瓷冠修复。

治疗计划

左上1颊舌径为9.17mm，骨高度为13.5mm，拔除后即刻植入C-Tech种植体EL-4311，常规植入同期植骨，活动义齿修复。

治疗内容

1、取静脉血20ml 制作CGF备用。
2、常规消毒铺巾，微痛局麻术区，沿左上1沟内切口，微创拔除患牙，根完整，彻底搔刮清创。
3、左上1定点，先锋钻达工作长度，扩孔钻逐级备洞至3.7*13mm （近中）， 植入C-Tech植体 EL-4311 +封闭螺丝， 扭力45N，骨粉Bio-Oss置于唇侧骨缺失处， 盖Bio -Gide膜，减张缝合，关闭创口。
4、六个月后取模，更换修复基台，型号为EL-4503F，粘接固定，氧化锆烤瓷冠永久修复。

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

下颌2、1、1、2因松动拔除三个月，身体健康，未见其他手术禁忌症。口腔检查：下颌2-2缺失，牙槽骨吸收明显，粘膜无红肿；左下3、右下3及上颌2-2无龋齿，不松，牙龈无红肿；上下前牙为深覆颌Ⅱ度；全口卫生状况良好（牙周刮治后一周），结石（-），色素（-），软垢（-），牙龈退缩明显。CT显示：右下2牙槽骨宽度为5.0mm，骨高度为15.2mm；左下2牙槽骨宽度为4.5mm，骨高度为15.8mm。

治疗计划

左右下2常规植入C-Tech植体ND-3009二颗，同期简单植骨；五个月后取模氧化锆烤瓷桥永久修复。

治疗内容

1、术前取血制作CGF备用；
2、常规心电监护下消毒铺巾，左右下4区域无痛局部浸润麻醉，沿牙槽嵴顶近远中水平切口+左右下3沟内切口，分龈翻瓣，见牙槽骨吸收明显，大球钻平整骨面；
3、左右下2定点，先锋钻达工作长度，扩孔钻逐级备洞达2.6*13.0mm，植入C-Tech植体ND-3009*2+封闭螺丝，扭力均为20N，于左右下2颊侧植入骨粉Bio-Oss+骨膜Bio-Gide+CGF膜，严密缝合，咬无菌纱布卷止血。嘱术后注意事项，口服抗生素5天，4次/日氯己定漱口水漱口两周。
4、10天后拆线，创口愈合良好，缝合线存，软垢（+)，软组织稍红肿。
5、5个月后取模，置换修复基台，型号为ND-3025-2*2，氧化锆烤瓷冠桥粘接固定，永久修复。

结论

1、患者对当前的牙齿状况感到满意，义齿在功能和外观方面都很好。
2、种植后无疼痛，无感觉异常，无感染或损害发生。
3、临床观察期间未见牙龈萎缩。
4、X线片所见：观察期间左下2、右下2植体颈部的骨吸收均小于0.2mm。

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：右上8、2和左上1、2、8Ⅱ~Ⅲ°松动，右上5、4、3和左上3、4、5不同程度牙龈萎缩，Ⅰ~Ⅱ°松动。同时拔除后，即刻植入C-Tech种植体，型号为：EL-3511/EL-4311/EL5111，共8颗。
下颌：右下3、4、5和左下4、5不同程度牙龈萎缩，Ⅰ~Ⅱ°松动，同时拔除后,即刻植入C-Tech种植体,型号为：EL-4311/EL5109/EL5111，共6颗。
后期氧化锆全冠桥修复。

治疗计划

上颌2、3、5、6牙槽骨宽度和骨高度理想，拔除患牙后，即刻植入C-Tech种植体EL-3511/EL-4311/EL-5111，共8颗，植体支持固定临时义齿修复。
一个月后种植下颌
下颌3、4、6牙槽骨宽度和骨高度理想，拔除患牙后，即刻植入C-Tech种植体EL-4311/EL5109/EL5111，共6颗，植体支持固定临时义齿修复。

治疗内容

上颌种植手术

1、常规消毒铺巾。微痛局部浸润麻醉上颌全牙列。暂时保留右上8。

2、左上7至右上7沿牙槽嵴顶切口，右上5、4、3、2和左上3、4、5沟内切口，翻瓣。拔除患牙。骨钳去除牙槽间隔，大球钻平整骨面。

3、左右上6定点，级差备洞至4.7*13，均植入C-Tech种植体5.1*11mm，左上6扭力不足。右上5、3、2和左上2、3、5定点，级差备洞，左右上2至2.8*13mm，均植入C-Tech种植体EL-3511。级差备洞，左右上3、5至3.7*13mm，均植入C-Tech
种植体EL-4311。利用右上6 5 3 2和左上2 3 5 植体，安装peek临时基台，左上6+封闭螺丝，骨粉Bio-Oss覆盖左上6牙槽嵴顶及右上3~4骨间隙，盖骨膜Bio-Gide。严密缝合。

4、利用上颌总义齿及右上6 5 3 2和左上2 3 5 植体制作临时义齿。调颌。

下颌种植手术

左1、常规消毒铺巾。无痛推麻仪局部浸润麻醉下颌全牙列。

2、左下7~右下7牙槽嵴顶近远中水平切口，右下5、4、3和左下4、5沟内切口，分龈翻瓣，拔除患牙，咬骨钳去除薄锐牙槽嵴顶边缘，球钻平整股骨面。

3、左下6定点，先锋钻达工作长度，扩孔钻逐级备洞至4.7*12mm，植入C-Tech种植体EL-5111+peek基台Φ4.5H3，扭力60N，边缘骨高度M1D1B0.5L0.5。右下3、4和左下3、4，级差备洞3.7*13mm，植入C-Tech种植体EL-4311, 左下4+封闭螺丝，扭力20N，边缘骨高度M2D2B1L2。左下3+peek基台Φ4.5H3，扭力60N，边缘骨高度M0.5D0.5B0.5L0.5。右下3+peek基台Φ4.5H3，扭力60N，边缘骨高度M1.5D1.5B0.5L1。
右下4+封闭螺丝，扭力20N，边缘骨高度M1.5D1.5B1L1.5。右下6定点，级差备洞至4.7*11mm，植入C-Tech种植体EL-5109+peek基台Φ4.5H3，扭力为：60N，边缘骨高度M-0.5D-1B0L-0.5。左下3、4和右下4、6 植入骨粉Bio-Oss,+骨膜Bio-Gide，严密缝合，压迫止血。

4、利用 右下3、6和左下3、6做基台，行下颌即刻过度义齿。调颌。

5、十个月后取模，更换修复基台，粘接固定，氧化锆烤瓷冠永久修复。

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

上前牙固定桥松动，微创拔除右上2和左上1。愈合后，右上2和左上1植入C-Tech种植体，5个月后氧化锆烤瓷桥修复。

治疗计划

右上2牙槽骨宽度为7.6mm，骨高度为13.4mm：左上1牙槽骨宽度为7.4mm，骨高度为14.5mm，分别植入C-Tech种植体EL-4311，常规植入，简单植骨。五个月后二期手术。

治疗内容

1、术前抽取静脉血制备 CGF 备用。
2、常规消毒铺巾，上颌前牙区无痛局浸麻醉。沿右上2至左上1牙槽嵴顶水平切口，右上3至左上2沟内切口，右上3唇侧远中减张，翻瓣，彻底搔刮清创，见右上2及左上1唇侧骨壁缺损。
3、右上2、左上1定点，级差备洞至3.7*13mm分别植入C-Tech植体EL-4311 +封闭螺丝， Bio-Oss骨粉+CGF混合物填入骨隙内及穿孔唇侧，盖Bio+Gide，牙槽嵴顶盖Bio+Gide，再盖CGF膜。严密缝合。
4、6个月取模，置换修复基台，型号：EL-4503F*2，粘接固定，氧化锆烤瓷桥永久修复。

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。

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

Dott. Alexandre Minis, France

Case description:
The 55 years old female patient has a lack of prior medical history and is a non-smoker.
There is a fracture under the crown of #12 with infection and vestibular fistula for which a temporary extraction with a valplast for 3 months is performed.
On the control CBCT, low bone volume and evidence of a radiolucent vestibular image initially suggesting fenestration linked to the fistula present before the extraction, or, of the bone being formed.

Surgical dental history:
The surgery is performed using a surgical guide, designed on 3Shape Implant Studio, dentition supported guide 3D printed on a Phrozen Shuffle printer.

by Dr. Nikos MARDAS, Dr. Nikolaos Tatarakis, Dr. Christos TSAMIS

by Doctor Henriette Lerner, HL-DENTCLINIC DR. STOM. MEDIC.