CASE REPORT

Complex fixed implant-supported

restoration in a site compromised
by periodontitis: a case report
Arndt Happe, DMD, PhD, DDS
Private Practice, Mnster, Germany
Department of Oral and Maxillofacial Plastic Surgery and Implantology,
University of Cologne

Andreas Kunz, DMT

Private Dental Lab, Berlin, Germany

Correspondence to: Priv.-Doz. Dr. Arndt Happe

Schtzenstr. 2, 48143 Mnster, Germany; Tel: 0049 251 45057; E-mail: a.happe@dr-happe.de

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Abstract

metal-based provisional xed partial

dentures (FPDs) for about a year, while

Periodontal disease presents a big chal-

her compliance and oral hygiene were

lenge for clinicians placing dental im-

evaluated. During this period, the oc-

plants. Besides the implant treatment,

clusal relations remained stable and the

additional surgical procedures such as

good condition of the hard and soft tis-

grafting or sinus oor elevation are of-

sue was maintained. In the maxilla, the

ten necessary to achieve a satisfactory

nal restoration incorporated custom zir-

result. Patient compliance is also impor-

conia abutments and a zirconia frame-

tant for achieving long-term treatment

work fabricated using CAD/CAM tech-

success. In the case presented here,

nology. Titanium abutments and a cast

digital planning and computer-aided

non-precious metal framework were fab-

surgery facilitated placement of the im-

ricated for the mandible.

plants and fabrication of the prosthetic

superstructures. The patient then wore

(Int J Esthet Dent 2016:11:186202)

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CASE REPORT

Introduction

be to allow the patient to function for an

extended period with a provisional res-

For various reasons, periodontal dis-

toration, during which time the patient

eases with attachment loss pose great

can be closely monitored regarding

challenges for dental clinicians placing

compliance and oral hygiene. Another

implants. For one thing, vertical bone

advantage of long-term provisional res-

defects may prohibit implant place-

torations is that they enable functional

ment. To create an implant bed of suf-

pretreatment, thus creating conditions

cient dimensions, it may be necessary

conducive to denite restoration.

to augment the site with autogenous or

allograft bone, bone substitutes, or a
combination of these materials.1,2 If the

Case report

posterior maxillary ridge is atrophic, a

sinus oor elevation may be required.3,4

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Another problem affecting implant

patient in good general health presented

placement in periodontally damaged

for replacement of her existing maxillary

sites is the predisposition of patients to

denture, which had functional decien-

developing peri-implantitis, as peri-im-

cies. The crowned teeth in her anterior

plant inammations are attributed to the

mandible were also loose and showed

same pathogens that cause periodonti-

excessive attachment loss (Fig 1). She

tis.5-8

Sufcient pretreatment and patient

requested a xed maxillary restoration,

cooperation are indispensable to avoid

and complained in particular about her

this. If patient compliance and adequate

long maxillary teeth. She wanted to im-

oral hygiene at home cannot be guaran-

prove her esthetic appearance and did

teed, a removable, implant-supported

not want any metal parts of her new res-

denture is recommended. While decid-

toration to be visible.

ing whether the patient would be better

The panoramic radiograph sent by

served by a xed or removable deni-

the referring dentist showed the partially

tive restoration, a useful approach can

edentulous maxilla and mandible before

Fig 1

Fig 2

Initial situation after extraction of teeth 32

to 42.

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Initial radiograph before extraction of the

anterior mandibular teeth.

HAPPE/KUNZ

Fig 3a and b

Initial clinical situation in the maxilla with and without the denture.

Fig 4a and b

Initial clinical situation in the mandible with and without the denture.

extraction of the anterior mandibular teeth

sufcient vertical posterior mandibular

(Fig 2). When the patient presented at

bone was particularly challenging.

the authors practice, teeth 32 to 42 had

A decision was thus made to use

already been removed, and the denture

cone

had been extended into the newly eden-

(CBCT) data to digitally plan the im-

tulous eld. The remaining dentition was

plant positions, especially for relatively

classied irrational to treat, although

short 8mm-long implants in the posterior

it was decided that some teeth should

mandible (Fig 5). Although grafting and

serve as abutments for the dentures as

placement of longer implants would have

a provisional during the healing phase

been possible, the use of short, minimal-

of the implant treatment. Figures 3 and

ly invasive implants in the mandible has

4 show the initial clinical situation, with

shown good success rates, particularly

insufcient telescopic partial dentures

for splinting with other implants.9-13 This

in the maxilla and the mandible. The in-

option was therefore chosen.

beam

computed

tomography

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CASE REPORT

Fig 5

Digital planning of implant positions in the

Fig 6

Implants placed in sites 32 and 42.

Fig 8

Gingiva former on the implants after stage-

mandible.

Fig 7a and b

Implants placed in maxillary sites

24 and 25 after sinus grafting.

two surgery.

Using CBCT planning data, the dental

right, including bone spreading and

laboratory produced a surgical template

augmentation with a bone substitute

with guiding sleeves for the mandible.

(BioOss, Geistlich). Three XiVE implants

This was connected to the telescopic

with a diameter of 3.8 mm and a length

crowns of teeth 33 and 43. Subse-

of 11 mm were placed in sites 14, 15,

quently, two 3.4x11 mm XiVE implants

and 17. On the left in the maxilla, a sinus

(Dentsply Implants) were placed in sites

oor elevation and augmentation with


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bone substitute (BioOss) were carried

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out, a Jason membrane (botiss biomat-

and 3.8x11 mm implants were placed

erials) was used as a barrier, and two

in sites 34 and 44.

3.8 x 8 mm XiVE implants were placed

Bone

management

in

the

maxilla

in sites 24 and 25 (Figs 7a and b). Lat-

involved a sinus oor elevation on the

er, two 3.8x13 mm XiVE implants were

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HAPPE/KUNZ

Fig 9

Pre-impression with reposition impression

copings.

Fig 11 and 12

Fig 10

Tension-free splinted impression copings

in the mouth.

After extraction of the unsalvageable maxillary and mandibular teeth, ridge preservation

was carried out at site 27 to prepare for additional implant placement.

placed in sites 12 and 22, and the muco-

covering, a pre-impression was made

sa above the implants was sutured with

using reposition impression copings to

a saliva-proof closure for submerged

prepare splinted impression copings

healing.

(Fig 9). Impression copings were splint-

During minimally invasive uncovering

ed with resin in the laboratory and sepa-

of the implants 12 weeks after place-

rated afterwards. In the mouth, pattern

ment, gingiva formers were screwed to

resin was used to achieve a tension-free

the implants, and connective tissue was

and absolutely stable splinting of the im-

transferred from the palatal area to the

pression copings (Fig 10).

vestibular area to enhance the quality

After the impression was made, the

of the peri-implant soft tissue and thus

unsalvageable

substantially

long-term

dibular teeth were extracted (Figs 11

prognosis (Fig 8). Three weeks after un-

and 12). Subsequently, a resin, screw-

improve

the

maxillary

and

man-

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CASE REPORT

retained, metal-reinforced provisional

xed partial denture (FPD) was luted to
the temporary abutments (EsthetiCaps,
Dentsply Implants) and directly tted to
the maxilla (Fig 13). Figure 14 shows the
resin, screw-retained, metal-reinforced
FPD tted in the mandible.
The patient wore the provisional FPDs
for a year, during which time the dental hygienist carried out aftercare every
3 months, and parameters such as the
Fig 13

Provisional xed partial denture (FPD) in

the maxilla.

patients function, oral hygiene, phonetics, and esthetics were evaluated.

The patient was very satised with the
function, phonetics, and esthetics of the
FPDs. The lip appearance showed an
incisal wear at 22, indicating premature
contact in lateral protrusion (Fig 15).
However, removal of the denture revealed peri-implant soft tissue that was
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of the patients apparent willingness to
maintain the denture sufciently. Resin
provisional dentures are more difcult
to maintain than ceramic dentures be-

Fig 14

Provisional FPD in the mandible. After-

wards, the screw access holes were closed with

composite resin.

cause of the high afnity of resin for

plaque.
Twelve months after placing the provisional FPDs, the recontoured soft tissue was impressed again using prepared splinted impression copings and
custom-made trays to incorporate the
changed tissue form into the denitive
restoration (Fig 17a and b). Casts of the
maxilla and mandible with a removable
gingival mask were manufactured. The
primary structures were manufactured
using CAD/CAM technology (Fig 18a
and b).

Fig 15

The provisional maxillary denture after a

year of wear. The incisal fracture of the left lateral

incisor indicates functional problems in lateral protrusion.

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HAPPE/KUNZ

Fig 16a and b

After taking out the provisional denture, the soft tissue was seen to be free of inamma-

tion. An additional implant was placed in site 27.

Fig 17a and b

A new impression was made of the recontoured soft tissue.

Fig 18a and b

The primary structures were fabricated using CAD/CAM technology.

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CASE REPORT

Fig 19a and b

Individual gingival mask on the maxillary cast with zirconium oxide abutments.

Figure 19 shows the individual gingi-

vidual abutments were chosen to guar-

val mask on the maxillary cast with ti-

antee a common insertion direction and

tanium bonding bases (TitaniumBase,

to create an emergence prole allowing

Dentsply Implants) and zirconium oxide

for ideal cleaning of the restoration. Fig-

abutments. A fully ceramic denture was

ures 20 and 22 show the clinical view

chosen because the patient had high

of the individual zirconium abutments in

esthetic requirements and was adamant

the maxilla, and the individual titanium

about not wanting any metal parts to be

abutments in the mandible.

visible in the maxilla.

To achieve a passive t of the dental

In the mandible, the abutments were

works, transfer copings made of pattern

constructed using Atlantis CAD software

resin were manufactured and placed

(Dentsply Implants), and were individu-

onto the abutments (Fig 23). The cop-

ally milled from titanium (Fig 21). Indi-

ings were collected using a transfer tray,

and were polymerized to the tray with
pattern resin (GC) (Figs 24 and 25a).
New model analogs were screwed onto
the primary abutments in the laboratory
and repositioned into the pattern resin
copings. The model analogs were treated with non-expanding stone (ZERO
arti, Dentona). The cast served as an
accurately tting model for drilling and
extraoral luting (Fig 25a to c).
Bite registration was done using the
provisional restoration. As occlusion and
bite position had been tested over a pe-

Fig 20

Clinical view of the individual abutments

in the maxilla.

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riod of 12 months, this position was also

used for the nal restoration after minor

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Fig 21

Construction of the mandibular abutments

Fig

22

Completed titanium abutments in the

using Atlantis CAD software.

mandible.

corrections of dynamic occlusion. Artic-

design15 was modeled and cast on

ulation of the new working casts was also

top of the abutments. This modular de-

done using the provisional restorations

sign results in a thin (0.5-mm) and sta-

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ble framework. Unlike zirconium oxide

visional restorations were duplicated to

frameworks, the connectors for these

the working cast to transfer the exact ex-

frameworks

ternal contours of the restorations to the

delicately to obtain more space for the

analog/digital process (Fig 27a and b).

tongue. A framework tray was modeled

can

be

designed

more

In the mandible, Galvano copings

from pattern resin, imbedded, and cast

were galvanized to the titanium abut-

according to the duplicated provisional

ments (Fig 28) to achieve a passive

restoration on hand (Fig 29a and b). Af-

t14

(Galva TK 210, Goldquadrat). A

ter the non-precious framework was built

non-precious framework in Monocoque

and veneered with veneering ceramics

Fig 23

Fig 24

Transfer copings made of pattern resin on

Trays after collection of the copings.

the maxillary abutments.

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CASE REPORT

Fig 25a

Model analogs positioned in the copings

(maxilla).

Fig 25c

Fig

25b

Manufacturing a luting model using

model analogs (mandible).

Completed cast with model analogs

Fig 27a and b

Fig 26

Articulation of the new working casts us-

ing the provisional restorations.

(mandible).

Duplication of the provisional restoration.

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(Initial, GC) (Fig 30), the Galvano copings were luted to the non-precious construction in the luting model (AGC Cem,
Wieland). These copings close the marrow space arising from the modular design and guarantee an accurate t of the
superstructure (Fig 31). For retention, a
horizontal bolting screw (Security-Lock,
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Fig 28

Customized titanium abutments on the

master cast.

Fig 29a

Fig 30

Framework tray made of pattern resin.

Veneering of the non-precious framework.

Fig 29b

Fig 31

Cast non-precious framework.

Galvano copings were luted to the pros-

thesis on the luting model.

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CASE REPORT

Fig 32

Complete work in the mandible with clean-

Fig 33

Scan of the cast with zirconium oxide abut-

ing channels.

ments and design of the zirconium oxide framework.

Fig 34

Fig 35

Separation of the framework between

crowns 4 and 5 for smaller units.

The framework was milled from a zirco-

nium oxide blank.

Figure 32 shows the complete work

works were milled from Organic Zirkon

on the master cast. Cleaning channels

Blanks (R+K CAD/CAM), and were n-

are visible, which have to be adjusted

ished and customized by veneering ce-

individually in the mouth. The maxillary

ramics (Initial) (Figs 35 to 37).

cast with the zirconium oxide abutments

Figure 38 shows the completed maxil-

was scanned, and a zirconium oxide

lary bridge on the master cast. Horizontal

framework was constructed according

boltings (Security-Lock) were added to

to the template of the duplicated thera-

them. This allows cementing with semi-

peutical restoration by means of CAD

permanent cement without running the

software (3Shape) (Fig 33). The con-

risk of the patient losing or damaging

struction was sectioned on both sides

the restoration. The pontics are basally

between crowns 4 and 5 to gain small

convex and highly polished to guaran-

units (Fig 34). Subsequently, the frame-

tee ideal care (Fig 39).

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Fig 36

Veneering of the zirconia framework.

Fig 37

Horizontal screw housing luted into the

bridgework.

Fig 38

Completed bridge on the master cast.

Fig 40a and b

Fig 39

Basally convex pontics for ideal care.

Clinical view of the tted works in the maxilla and mandible.

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CASE REPORT

Figure 40a and b shows the clinical

view of the integrated superstructures.
TempoCem NE (DMG), a semi-permanent implant cement, was spread very
thinly and only used to seal the microgap. The nal radiograph illustrates the
exact t of the nal restorations (Fig 41).
The lateral and anterior lip appearance of the integrated superstructures
shows harmonious lip dynamics, even
with a maximum smile (Figs 42 and 43).
Fig 41

Panoramic radiograph of the tted works

in the maxilla and mandible.

Discussion
Bone defects in periodontally damaged
dentition pose a number of challenges
to dentists treating these patients. The
defects must be augmented to create
an implant bed of sufcient dimensions.
In addition, good patient compliance
and thorough oral hygiene must be
achieved. A xed implant-based restoration is only possible if these conditions
are met. In the present case, judicious
bone grafting and allowing the patient
Fig 42

Harmonious lip appearance.

to wear the provisional prostheses for a

sufciently long time made it possible to
create xed, implant-supported restorations.
The patient requested a prosthetic
maxillary restoration with no visible metal parts. Therefore, a fully ceramic denture was created on custom zirconium
oxide abutments luted to titanium bases.
The advantage of such two-stage abutments is that they combine the esthetic
nature of zirconium oxide and the solidity of metal abutments.  Custom
titanium abutments were manufactured
for the mandible. Individual abutments

Fig 43

Portrait of the patient after completion of

treatment.

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make it possible to achieve an anatomical shape that is similar to the shape of

HAPPE/KUNZ

a prepared tooth, hence entailing sub-

Summary

stantially lower risk of prosthetic complications because the cementation gap

Fixed

can be accessed easily and the pros-

can be used in periodontally compro-

thetic reconstruction is ideally support-

mised dentition to achieve esthetically

ed in terms of anatomy.18

satisfactory results. This treatment op-

implant-supported

prostheses

Treating patients with existing perio-

tion requires proper planning, appro-

dontal conditions and substantial bone

priate surgical pretreatment, thorough

loss requires a multistage procedure

oral hygiene, and patient compliance.

with grafting, sinus oor elevation, and

Important factors for achieving this ob-

functional measures for rehabilitation

jective are computer-assisted implant

with implants. In the present case, these

placement, CAD/CAM-based manufac-

measures were carried out to achieve

turing of the prosthesis, and custom-

the best possible functional and esthetic

made abutments to avoid complications

results.

of the dental superstructure.18

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