Multidisciplinary oral aesthetic rehabilitation: periodontics, implantology and prosthesis

AUTHORS: Prof. Bernardo Born Passoni, Prof. Rodrigo Melim Ferreira, Prof. Edwin Andrés Ruales Carrera, Prof. Dr. Ricardo de Souza Magini Prof. Dr. Cesar Augusto Magalhães Benfatti

RECORD
42-year-old female patient.

COMPLAINT
Internal and external reabsorption of element 21 (noted by the family dentist) and “greyish gum” around the lateral incisors.

ANAMNESIS
42-year-old patient, motivated and apt for the proposed surgical procedures.

PLANNING
For the surgical step, the plan was the installation of an implant with immediate load on element 21 and subepthelial connective tissue graft for tissue volume gain in the vestibular area of elements 12 and 22. After the healing period, the aesthetic rehabilitation would consist of 4 crowns and 6 metal-ceramic veneers.

INTRODUCTION
Implants have been of great importance for many people who have lost their teeth to trauma, cavities, internal/external radicular reabsorption or root fracture (Quirynen et al., 2005). The biological benefits of not preparing the adjacent teeth for making a fixed partial prosthesis have to be emphasized. The conservation of the dental tissues, the preservation of the vitality of the pulp, the respect to the periodontal area and the maintenance of the residual crest are the most important factors to be considered (Quaranta et al., 2010).

Concerning the area to be rehabilitated through implants, it is known that after the exodontia of a dental element, there is a remodeling of the vestibular bone wall that has to be taken into account during the prosthetic and surgical planning (Araújo and Lindhe, 2005). The installation of the implant into a fresh exodontic alveolus and the immediate provisioning were proposed as alternatives to maintain the volume and contour of the soft tissue, decreasing the cost and duration of the treatment (Park, 2010). However, the professional must always fill the gap between the surface of the implant and the vestibular wall, searching to prevent or decrease the loss of volume that is inherent to the bone remodeling of the vestibular wall. Another factor that has to
be considered is the surgical technique, that, in elastic areas, should, as much as possible, respect the palatal approach and the non lifting of the graft.

Besides the carefull pink aesthetics, the white aesthetics has a fundamental role in the success of the anterior sector rehabilitation treatments. The restorative treatment begins with the appropriate use of temporary restorations that allow for the preparation of the gingival architecture and an appropriate emergency profile (Bulser et al., 2011). For final restorations, ceramic materials are recommended in aesthetic dentistry, allowing for a biometric approach when they allow for the maintenance of the dental tissue and the use of adhesive systems, achieving longevity and superior aesthetic results (Tirlet et al., 2013). Ceramic materials have important characteristics that include physical-chemical stability, biological compatibility, compression resistance, reproduction of visual properties and color stability (Pini et al., 2012). However, in face of clinical cases in which there are different substrates, the selection of the restorative material and its thickness are critical (Volpato et al., 2009). Therefore, the multidisciplinary planning of the treatment and the communication with the patient play a crucial role for the aesthetic result of complex cases.

CASE REPORT
42-year old female patient, good systemic condition, came to the Implantodontics Specialization Course at Unique Ensino Odontológico, complaining specially about internal and external reabsorption in element 21 (identified by her private dentist), and consequent need for a dental implant. During the anamnesis, the patient also complained about the darkening of the gums around elements 12 and 22.

During the clinical examination (Figures 1A, 1B and 1C), the professional noticed that the patient had 4 zirconia crowns on the 4 upper incisors, made approximately 6 years ago, and also temporary
composite veneers on elements 23 and 24. The cone beam CT scan revealed that there was enough bone height and thickness for the immediate installation of the implant. After diagnostic waxing, the
aesthetic rehabilitation plan consisted of 4 metal-ceramic crowns on the incisors (being the one on 21 over an implant) and 6 feldspathic veneers from the canines to the pre-molars.

The first surgical step taken was the minimally traumatic exodontia of element 21 through intrasulcular incision with a 15C blade, periotome and forceps (Figures 2A, 2B and 2C). The exodontia
was followed by the curettage of the alveolus and irrigation with 0.12% chlorhexidine. The surgery proceeded according to the manufacturer’s standards (FGM) for the installation of 3.3 x 13mm Arcsys Morse Taper Implant. Sub-instrumentation was carried out through a single drilling with a 2.4mm drill (Figs. 3A and 3B) for 15mm. In search for the primary stability for the application of immediate load, the drilling was done using the palatal approach technique in order to search for anchorage on the palatal wall of the extraction alveolus. The implant was installed 2mm below the vestibular wall and 5mm from the gingival margin (Fig. 4A, 4B and 4C). As a the prosthetic component, a 3.3 x 6 cement-retained foldable abutment was installed (Figs. 5A and 5B), it was activated by means of three hits with the Arcsys Abutment Placement Tool. However, thanks to the correct tridimensional placement of the implant, the angulation of the component was not necessary. The surgical part of the process was followed by the subepithelial conjunctive grafts in the areas of element 12 and 22, to mask the color of the roots that were showing from below the gingiva (Figs. 6A and 6B) and the filling of the gap left between the surface of the implant and the vestibular wall with xenogeneic biomaterial (Fig. 7).

The temporary prosthesis was made according to an old crown (Fig. 8) and captured in a burn-out coping of the abutment to cementretained restoration with the help of a composite guide manufactured previous to the surgery (Fig. 9). The crown was united to the coping with flowable composite, resulting in an adequate emergency profile (Figs. 10A and 10CB).

60 days after the surgery (Fig. 11), a CT scan was requested to evaluate the peri-implantar bone maintenance/neo-formation (Fig. 12) and begin the permanent rehabilitation procedures, which consisted in the change of the old crowns over elements 11, 12 and 22 and manufacture of veneers on elements 13, 14, 15, 23, 24 and 25. In that case, it was not necessary to carry out the diagnostic waxing, because the patient wanted to keep the size and format of the teeth and old prosthesis. Teeth 11, 12, 21 and 22 were prepared on a plaster model and the veneers in stock were adapted over those elements, maintaining the same length of the old crowns. Then, a composite guide was manufactured on the incisal edge of teeth 13 to 23 for the veneers to be adapted in the mouth over the preparations (Fig. 13).

The gingival conditioning of 21 was carried out in order to copy the format of the gingival zenith of 11. Besides, the impression cap of the molding was customized with flowable composite in order to copy the gingival architecture during the tissue conditioning process. After that, the molding was accomplished in 2 steps by means of the double cord technique (Fig. 14) The choice for metal-ceramic crowns is related to the presence of a cast metallic nucleus in teeth 12 and 22 (Figures 15A and 15B). In case the choice were dissilicate, it would be necessary to use different layers in the crowns and veneers to mask the darkened substrates, which could generate a color mismatch between the pieces, therefore, the option chosen was to do all the work in feldspathic ceramic.

The following section comprised the metallic coping transference molding and the molding of the preparations of the veneers (Fig. 16) and color selection that, with the agreement of the patient was set as BL4. 10 days later, the pieces (Fig. 17A, 17B and 17C) that were made by Laboratório Vieira (Curitiba/PR, Brazil) were checked, and the first dry proof for the verification of the fitting of the pieces and the wet proof with Allcem Veneer Try-in (FGM) were carried out.

For the preparation of the veneers, the professional used 10% hydrofluoric acid Condac Porcelana 10% (FGM) for 1 minute (Fig. 18A), 37% phosphoric acid Condac 37 (FGM) application for removing
residue of the acid etching (Fig. 18B), and application of silane Prosil (FGM) (Fig. 18C) and Ambar (FGM) adhesive. For the treatment of the tooth, acid etching was carried out for 30 seconds on enamel and for 15 seconds on the dentine with Condac 37 (FGM), application of Ambar (FGM) adhesive and Allcem Veneer (FGM) cement in color A1. The cementation of the crowns was made with dual resinous cement Allcem (FGM) following the manufacturer’s instructions. In spite of the complexity of the case, the treatment was carried out in a relatively short time, needing only four months between the surgery for the installation of the implant untill the cementation of the permanent pieces (Figs. 19A, 19B and 19C).

CONCLUSION:
Aesthetic oral rehabilitation is extremely predictable, once the multidisciplinary reverse planning steps are respected.