Case Presentation CASE REPORT. Pedro Couto Viana, DMD. André Correia, DMD, PhD. Manuel Neves, DMD. Zsolt Kovacs, CDT. Rudiger Neugbauer, CDT

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1 CASE REPORT Cse Presenttion Pedro Couto Vin, DMD Prosthodontist, Dr Mnuel Neves Dentl Clinic, Porto, Portugl André Correi, DMD, PhD Dentist, Dr Mnuel Neves Dentl Clinic, Porto, Portugl Invited Assistnt Professor, Fculty of Dentl Medicine, University of Porto nd Portuguese Ctholic University, Portugl Mnuel Neves, DMD Implntologist nd Clinicl Director, Dr Mnuel Neves Dentl Clinic, Porto, Portugl Zsolt Kovcs, CDT Mster Cermist nd Technicl Director, Dentl L DentlMi, Cstelo d Mi, Portugl Rudiger Neuguer, CDT Dentl Technicin nd Director, Dentl L DentlMi, Cstelo d Mi, Portugl Correspondence to: Dr Pedro Couto Vin Clínic Dr Mnuel Neves, Ru do Amil 283 r/c, Porto, Portugl Tel: ; E-mil: pedrocoutovin@netco.pt 310

2 COUTO VIANA ET AL Astrct Rehilittion of edentulous spces in esthetic res is chllenge to the clinicin due to the loss of soft tissues. In these clinicl situtions, it would e desirle to evlute nd predict the gingivl rchitecture to recover in the orl rehilittion. To fulfill this need, the dignostic wx should nticipte the finl rehilittion with the integrtion of hrd nd soft tissue. Thus, it is essentil to produce dignostic wxup tht integrtes these two components tht re simultneously seeking to recrete the hrmony of white nd pink esthetic. This dignostic wxup will e the sis for the cretion of the provisionl prosthesis nd soft tissue mock-up. After plcing the provisionl prosthesis in the mouth, the soft tissue mock-up cn e pplied to ssess its esthetic impct t fcil nd introrl level. Dentist nd ptient should ojectively ssess the ppernce of the finl result. After pprovl of this rehilittion concept, the virtul surgicl plnning cn e performed nd the surgicl guide cn e designed, llowing the tretment to tke plce. This protocol llows the development of rigorous tretment pln sed on the integrtion of teeth nd gingiv component. The wxup nd the soft tissue mock-up ply significnt role, since they llow n erlier evlution of the esthetic result, etter prosthetic nd surgicl plnning, nd it llows us to nticipte the need for gingiv-colored cermics use. The uthors present clinicl cse report of the importnce of the wx-up nd soft tissue mock-up in the tretment pln. (Eur J Esthet Dent 2012;7: ) 311

3 CASE REPORT Introduction Bone resorption is physiologicl consequence of tooth loss or compromised periodontl conditions. In these situtions, the lveolr crest suffers chnge in its verticl nd horizontl dimensions, resulting in n unfvorle gingivl rchitecture with mjor consequences in esthetic rehilittion. 1 In these clinicl situtions, it would e desirle to evlute nd predict the gingivl rchitecture to recover in the orl rehilittion. To fulfill this need, the dignostic wx should nticipte the finl rehilittion, not only with the tooth crowns, 2-4 ut lso with the integrtion of soft tissue. Thus, it is essentil to produce dignostic wxup tht integrtes these two components tht re simultneously seeking to recrete the hrmony of white nd pink esthetic. This dignostic wxup will e the sis for the cretion of the provisionl prosthesis nd soft tissue mock-up. Only fter the study of this dignostic wxup cn it e possile to estlish tretment pln, where two generl clinicl pproches my e considered: surgicl or prosthetic. The former cn e considered s more iologicl, or nturl, nd my chieve excellent results tht mimic the ntomy of the dentogingivl complex. However, it requires more surgicl interventions, with guided one nd soft tissue regenertions. These re more time consuming, more trumtic, nd re less predictle due to the physiologicl heling process, especilly when lrge volumes of soft nd hrd tissue re missing. 1,5 Compred to the surgicl pproch, the prosthetic rehilittion with gingivcolored cermics is fster, much more predictle nd not trumtic. However, it requires specil considertions y the dentist/prosthodontist nd the dentl technicin in order to chieve nturl integrtion with n esthetic nd functionl hrmony etween the periodontl tissues, the rtificil gingiv nd the dentl crown. 1 Although this is current topic in the dentl science community, literture serch in Medline out gingiv-colored cermics retrieved smll numer of ppers pulished in dentl journls in the lst 10 yers Most of the re- Fig 1 Extrorl ppernce. Detiled view of drooping of lil commissure. 312

4 COUTO VIANA ET AL Fig 2 Pnormic rdiogrph. Fig 3 Front view of the mxillomndiulr reltions. trieved rticles re concerned with clinicl reports nd, with exception to Cochmn nd Slm, do not descrie protocol to estlish correct dignosis of these situtions. Aim With this clinicl cse report, we intend to propose new concept of dignostic wxup nd mock-up tht includes reconstruction of the gingivl rchitecture nd conventionl dentl reconstruc- tion. This pproch is more complete nd comprehensive, enling etter tretment plnning. Cse presenttion Medicl nd dentl history A femle ptient, 47 yers old, helthy nd non-smoker hd long history of dentl tretments strting from n erly ge. This resulted in good orl hygiene, with periodontl levels considered norml. Fig 4 Right nd left view of the mxillomndiulr reltions. 313

5 CASE REPORT Chief complint Essentilly, the ptient did not like hving removle denture nd ws concerned with her ppernce, intr- nd extrorlly. Extrorl findings Fig 5 Fceow registrtion. The ptient presented decresed fcil height of the lower third of the fce nd drooping of the lil commissure, due to reduced verticl dimension (Fig 1). c d Fig 6 Teeth wxup in the mxill nd mndile. 314

6 COUTO VIANA ET AL Introrl findings nd rdiogrphic nlysis Introrl exmintion nd rdiogrphic nlysis reveled the sence of teeth 16 to 14, 21 to 26, 36 to 37 nd 46 to 47. Teeth 17, 12, 11, 38 nd 48 hd dentl restortions, nd tooth 13 hd n crylic crown with post. A reduced verticl dimension ws oserved, with high overite in the nterior teeth, nd n extremely reduced prosthetic spce in the edentulous res (Figs 2 to 4). Dignostic csts (study models) In the first visit, preliminry impressions were performed nd fceow ws used (Fig 5) to ccurtely trnsfer the mxill position to semi-djustle rticultor. In the study models otined, the dentl technicin creted hrd nd soft tissue wxup (Figs 6 nd 7), nticipting wht should e the finl result. The soft tissue wxup hd thickness of 4 to 5 mm, height of 11 mm nd width of 38 mm, pproximtely (Fig 8). c Fig 7 Detil of teeth nd soft tissue wxup in the study model. Mjor horizontl discrepncy in the second qudrnt covered y wx simulting gingiv. 315

7 CASE REPORT 4.5 mm 4 mm 5 mm 11 mm 38 mm Fig 8 Soft tissue wxup dimensions. The hrd tissue wxup ws then converted to rdiogrphic guide (Fig 9). This guide hd fillet of composite resin in the middle-uccl wll of the teeth. Then cone-em computed tomogrphy (CT) scn ws performed to study the implnts plcement in virtul implnt plnning softwre (Simplnt Mterilise, Fig 10). The fillet of resin composite llows us to esily identify the correct position of the teeth s uccl wll, llowing prostheticlly driven implnt surgery. This nlysis reveled the need to increse the one width, in order to otin sufficient one in the uccl wll to llow prostheticlly driven implnt surgery. Two options were then considered: Two-stge pproch: reconstruction of the trophic mxill with n utogenous one grft surgery (eg Ilic crest one, or other donor site) Fig 9 Rdiogrphic guide plced in ptient s mouth. 316

8 COUTO VIANA ET AL Fig 10 3D imges from implnt surgery plnning in Simplnt Mterilise softwre. c d Fig 11 Provisionl fixed prtil denture in gypsum models. 317

9 CASE REPORT Fig 12 Provisionl prosthesis plced in ptient s mouth. to llow one ugmenttion nd provide n environment for etter implnt plcement in second surgery intervention. This pproch needs longer tretment time, ut llows for etter outcome of long-term stility of hrd nd soft tissues. One-stge pproch: implnt plcement in the trophic mxill with uccl entrnce to mintin the pltl verticl one dimension. Due to the reduced uccl lingul dimension, the surgery will entil full exposure of the implnts in the uccl wll nd, consequently, the need for guided one regenertion procedures with xenogenous one grft performed y highly skilled surgeon. Tretment pln Following the evlution of the wxup nd CT scn, the two options of the surgery intervention were explined to the ptient. Due to the ptient s desire for shorter tretment time, nd the clinicl tem s opinion tht successful tretment could e chieved with onestge pproch, the following tretment pln ws estlished: 1. Provisionl fixed prtil denture (t sites 17, 13, 12, 11, nd 27) reinforced with cst metl. 2. Dentl implnts in positions 16, 14, 21, 23, nd 26, with guided one regenertion procedures in the second qudrnt. 3. Fixed prtil denture over implnts t sites 16 to 14, 21 to 23, nd Fixed prtil denture over tooth utments t sites 13, 12, nd

10 COUTO VIANA ET AL Fig 13 Clinicl sitution 5 months fter implnt surgery with GBR. 5. Metl-cermic crowns t sites 17 nd Fixed prtil denture over teeth t sites 33, 34, 37, nd 43, 44, 45, nd 47. The previously descried wxup ws converted into provisionl fixed prtil denture (Fig 11). A gingivl epithesis, cting s mock-up, ws plced in the mouth during the second visit, in order to otin the ptient s opinion out the expected rehilittion, nd to confirm functionl nd esthetic prmeters relted to teeth nd soft tissue rchitecture (Fig 12). This protocol llows the development of rigorous tretment pln in which the plcement of implnts, tissue regener- Fig 14 Left imge: initil sitution with epithesis; right imge: clinicl sitution fter 5 months of heling. 319

11 CASE REPORT c Fig 15 Top imge: working model of teeth nd implnt utments; middle imge: metl frmework of ll fixed prosthesis components; ottom imge: metl-cermic fixed prosthesis. tion, nd rehilittion of the dentl rches is mde from the integrted rehilittion of the tooth nd gingiv component. The wxup nd the soft tissue mock-up ply significnt role. Three dys lter, the ptient underwent implnt surgery nd guided one regenertion procedures took plce to fill up the soft tissues in the second qudrnt. Due to the uccl one resorption verified in the trophic mxill, the implnt surgery technique selected ws lterl entrnce in the uccl one wll. In this wy, the pltl one crest is spred, nd this one height cn e mintined. An implnt surgicl intervention with the implnt entrnce in the one crest would hve led to one crest verticl resorption nd, consequently, more complex surgicl intervention to gin not only one width, ut lso height. The implnts t sites 21 nd 23 were plced with the neck more lilly, ut without compromising the prosthetic rehilittion tht ws predicted y the wxup nd the provisionl prosthesis. The gingivl epithesis previously plnned nd executed in the dignostic phse llows the orl surgeon to esily predict the necessry mount of one for this procedure. Five months lter, the ptient ws reclled in order to evlute the position of hrd nd soft tissues compred to the initil sitution. Although there ws gin in the volume of hrd nd soft tissues, with significnt chnge in its position (Fig 13), lck of soft tissue in the interproximl res of the provisionl prosthesis teeth ws lso oserved (Fig 14). No nturl gingivl rchitecture could e visulized. 320

12 COUTO VIANA ET AL Fig 16 Finl sitution. The fixed dentl prosthesis with gingiv-colored cermic ws cemented over the teeth nd implnt utments. Therefore, fter discussing the sitution with the dentl technicin, the ptient ws informed of the tretment options of cermic fixed prosthesis with teeth component nd gingiv-colored cermic to simulte the nture of the gingivl rchitecture. With the ptient s greement, we hve initited the common clinicl nd lortoril steps of fricting fixed metl-cermic rehilittion (Fig 15). The finl sitution of this rehilittion cn e oserved in Figures 16 to 18. The gingiv-colored cermic llows the prosthodontist/cermist to recrete nturl nd stle gingivl rchitecture, compensting for the low predictility of this type of orl surgery. Discussion These clinicl situtions require creful multidisciplinry pproch in order to estlish the correct tretment pln. To reuild the lost nturl hrmony of the tissues, the first key element to e produced is the dignostic wxup, n essentil element in developing tretment pln. However, most of the studies on the dignostic wxup nd the consequent mock-up, re only concerned with teeth reconstruction, 2-4 nd do not include the soft tissues, which currently represent mjor prt of the esthetic rehilittion. Cochmn et l nd Slm et l pulished three-prt pper out Prosthetic gingivl reconstruction in fixed prtil restortions where they descrie how to perform correct dignosis nd tretment pln (Prt 2), nd the lortory procedures nd mintennce (Prt 3). The protocol descried in the dignosis prt 18 includes wxup of soft tissues together with rdiogrphic templte tht mimics this sitution. However, no soft tissue mock-up of the gingiv teeth rchitecture hs een developed tht shows the trnsitions of hrd nd soft tissues, nor gingivl epithesis to help the orl surgeon efore the surgery. This gingivl mock-up llows us to evlute the need for gingiv-colored cermics in the finl prosthetic rehilittion in two seprte tretment phses: t the eginning of the tretment, nd lso t re-evlution t the surgery follow-up. 321

13 CASE REPORT Fig 17 Ptient s smile with nturl ffernce of the gingiv-colored cermics rehilittion. The study of clinicl cse should integrte soft tissue plnning together with teeth plnning, in order to produce more predictle prosthetic rehilittion. The wxup nd the soft tissue mock-up llow n erly evlution of the esthetic result, the development of etter prosthetic nd surgicl pln, nd t lst, it permits us to nticipte the need for using gingiv-colored cermics. Fig 18 Pnormic rdiogrph of the rehilittion with fixed dentl prosthesis over teeth nd implnts. 322

14 COUTO VIANA ET AL References 1. Cochmn C, Grer D, Slm M, Slm H, Crl G, Clmit M. Restortive dentistry: the incorportion of tissue colored composite nd zirconium utment to solve n esthetic soft tissue symmetry. Inside Dentistry 2008;(10): Gurel G. Porcelin lminte veneers: miniml tooth preprtion y design. Dent Clin North Am 2007;51: , ix. 3. Mgne P, Belser UC. Novel porcelin lminte preprtion pproch driven y dignostic mock-up. J Esthet Restor Dent 2004;16:7 16, discussion Simon H, Mgne P. Cliniclly sed dignostic wx-up for optiml esthetics: the dignostic mock-up. J Clif Dent Assoc 2008;36: Brzily I, Tmlyn I. Gingivl Prosthesis review. J Cn Dent Assoc 2003;69: Gllucci GO, Grutter L, Nedir R, Bischof M, Belser UC. Esthetic outcomes with porcelin-fused-to-cermic nd ll-cermic single-implnt crowns: rndomized clinicl tril. Clin Orl Implnts Res 2011;22: Smll BW. The use of pink porcelin for gingivl defects in restortive dentistry: cse report. Gen Dent 2010;58: Mitrni R, Adolfi D, Tcher S. Adjcent implnt-supported restortions in the esthetic zone: understnding the iology. J Esthet Restor Dent 2005;17: , discussion Grci LT, Verrett RG. Metl-cermic restortions custom chrcteriztion with pink porcelin. Compend Contin Educ Dent 2004;25:242, 244, 246 pssim. 10. Zwt C. Fixed prtil dentures with n ll-cermic system: cse report. Quintessence Int 200;32: Kim TH, Cscione D, Knezevic A, Nowzri H. Restortion using gingiv-colored cermic nd ridge lp pontic with circumferentil pressure: clinicl report. J Prosthet Dent 2010;104: Polck MA, Mhn DH. The esthetic replcement of mndiulr incisors using n implnt-supported fixed prtil denture with gingivl-colored cermics. Prct Proced Aesthet Dent 2007;19: ; quiz Cp N. An lterntive tretment pproch to gingivl recession: gingiv-colored prtil porcelin veneers: clinicl report. J Prosthet Dent 2007;98: Kmlkidis S, Pniz G, Kng K, Hirym H. Nonsurgicl mngement of soft tissue deficiencies for nterior single implnt-supported restortions: A clinicl report. J Prosthet Dent 2007;97: Hgiwr Y, Nkjim K, Tsuge T, McGlumphy E. The use of customized implnt frmeworks with gingivcolored composite resin to restore deficient gingivl rchitecture. J Prosthet Dent 2007;97: Cochmn C, Slm M, Grer D, Clmit M, Slm H, Crl G. Prosthetic gingivl reconstruction in fixed prtil restortion. Prt 1: introduction to rtificil gingiv s n lterntive therpy. Int J Periodontics Restortive Dent 2009;29: Cochmn C, Slm M, Grer D, Clmit M, Slm H, Crl G. Prosthetic gingivl reconstruction in fixed prtil restortions. Prt 3: lortory procedures nd mintennce. Int J Periodontics Restortive Dent 2010;30: Slm M, Cochmn C, Grer D, Clmit M, Slm H, Crl G. Prosthetic gingivl reconstruction in the fixed prtil restortion. Prt 2: dignosis nd tretment plnning. Int J Periodontics Restortive Dent 2009;29: