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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 12  |  Issue : 2  |  Page : 57-61

Esthetic rehabilitation of a partially edentulous patient with implants and porcelain laminate veneers – A Minimally invasive approach


Department of Prosthodontics and Implantology, Government Dental College, Thiruvananthapuram, Kerala, India

Date of Submission05-Mar-2022
Date of Decision16-Apr-2022
Date of Acceptance18-Jun-2022
Date of Web Publication23-Aug-2022

Correspondence Address:
Puvvadi Kalyani
Department of Prosthodontics and Implantology, Government Dental College, Thiruvananthapuram, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_8_22

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   Abstract 

For the rehabilitation of patients with edentulous jaws, immediate loading of endosseous implants is becoming a widespread therapeutic procedure. Over the conventional open flap technique, minimally invasive surgical implant placement has numerous advantages. Several techniques to restore anterior teeth have been developed as a result of increasing demand of patients looking for esthetics. This case report describes esthetic rehabilitation of a partially edentulous patient following the principles of minimally invasive implant dentistry as well as esthetic dentistry.

Keywords: Esthetic rehabilitation, immediate loading, minimally invasive implant dentistry


How to cite this article:
Kalyani P, Kumar K H, Balkhis A S, Ravichandran R. Esthetic rehabilitation of a partially edentulous patient with implants and porcelain laminate veneers – A Minimally invasive approach. J Interdiscip Dentistry 2022;12:57-61

How to cite this URL:
Kalyani P, Kumar K H, Balkhis A S, Ravichandran R. Esthetic rehabilitation of a partially edentulous patient with implants and porcelain laminate veneers – A Minimally invasive approach. J Interdiscip Dentistry [serial online] 2022 [cited 2022 Dec 2];12:57-61. Available from: https://www.jidonline.com/text.asp?2022/12/2/57/354454


   Clinical Relevance to Interdisciplinary Dentistry Top


  • The present case report describes the complete esthetic rehabilitation of the patient which involves surgical, restorative, and conservative techniques
  • Surgical implant placement was done in relation to 14, 16, 44, and 46 regions followed by restoration with porcelain fused metal crowns
  • Midline diastema closure was accomplished with veneers in relation to 11, 12, 21, and 22
  • Conservative diastema closure was done on lower anteriors with direct composite restorations.



   Introduction Top


For the replacement of the missing dentition, dental implants are proven to be the treatment of choice. The key factors for long-term clinical success of implants are the maintenance of the bone during extraction, primary stability of the implant, careful control of the soft tissues, and proper manufacturing of the provisional prosthesis.[1] The conventional open flap technique allows a surgeon a direct visual and instrumental access to create a congruent osteotomy for implant site preparation. However, when compared with less invasive methods, this technique increases morbidity of the postoperative recovery period.[2] A better understanding of oral biology had led to minimally invasive or atraumatic, flapless surgical procedures.[3]

The concept of esthetics is a judgment about beauty and the stellar. The presence of diastemas, accompanied by differences in tooth size are the deviations in smile esthetics.[4] Several techniques to restore anterior teeth were developed due to increasing demand of patients looking for esthetics. For esthetic problems involving morphological changes, conservative treatments should always be the first therapeutic option.[5] Depending on the size of the diastema, closure with composite resin or indirect ceramic restorations represents an excellent treatment alternative; hence, correct diagnosis and planning are essential.[4]

This case report describes esthetic rehabilitation of a partially edentulous patient following the principles of minimally invasive implant dentistry as well as esthetic dentistry.


   Case Report Top


A 43-year-old female patient presented to the department of prosthodontics and implant dentistry, seeking replacement of missing teeth in relation to 14, 15, 16, 44, 46, 36, and 37 regions [Figure 1]. The patient's dental history revealed that the teeth were extracted due to caries at different periods of time, with 16 being extracted 3 weeks before. Moreover, thus, the patient presented with a healing socket in relation to 16 region. The patient was not aware of the immediate implant placement at the time of extraction. However, she was not ready for prolonged waiting time and requested implant reconstruction at the time of consultation. Usually, implants are placed either immediately after extraction or 3–4 months after extraction allowing the socket to heal completely. In this case, fixed partial denture (FPD) was not indicated because of long edentulous span, and the patient was not willing for a removable prosthesis. Since the patient was young and prolonged edentulous periods may affect the quality of life of the patient, decision was made to place implants in incompletely healed sockets. The patient was then informed of the immediate and delayed loading protocols of which she choose the former method.
Figure 1: (a) Preoperative maxillary arch, (b) preoperative mandibular arch

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In addition to the missing teeth, the patient expressed dissatisfaction with the esthetics of her maxillary and mandibular anterior teeth. Direct composite bonding was considered as the treatment of choice for mandibular incisors and indirect porcelain veneers for maxillary incisors.

A presurgical radiographic evaluation was carried out with panoramic radiographs and cone-beam computed tomography [Figure 2] and [Figure 3]. The radiographic examination revealed D3 type bone density.[6] Sufficient bone height and width were observed in the edentulous sites for implant placement except in relation to 16 region. A routine blood test was also advised before any treatment.
Figure 2: Preoperative orthopantamogram

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Figure 3: Preoperative cone-beam computed tomography

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Minimally invasive implant surgery

The surgery was performed under local anesthesia (2 × 2 ml lidocaine-adrenaline 20 mg/0.01 mg/ml injection). No flaps were reflected. Implant osteotomies were prepared transmucosally by tapping with k wires and mallet. Implant dimensions of 4 mm × 12 mm (14 region), 4 mm × 10 mm (44 region), and 4.5 mm × 10 mm (16 and 46 region) were selected according to the radiographic assessment. Implants (GenXT implants, Switzerland) were placed with a plastic carrier through the transmucosal osteotomies and were rotated clockwise, until the plastic carrier could no longer rotate the implant. A hex driver with a ratchet wrench was used to complete the seating of the implants. It was then placed and seated until the first thread was flush with the crestal bone [Figure 4]. The decision to go for immediate loading was made after attaining good primary stability. The provisional acrylic resin restorations (Ashvin, Delhi) were fabricated at chair side. Care was taken to achieve a smooth contour for the provisional teeth, to avoid irritation of the soft tissues, as well as to condition the soft tissue profile. After making sure that the provisional crowns were out of contact occlusally, they were temporarily cemented with zinc oxide eugenol cement (DPI, India) [Figure 5]. The patient was instructed to consume soft foods and avoid directly biting on the provisional restoration for 2 months.
Figure 4: (a) Osteotomy in relation to 14, (b) implant placement in relation to 14, (c) osteotomy in relation to 16, (d) implant placement in relation to 16, (e) osteotomy in relation to 44, (f) implant placement in relation to 44, (g and h) using torque wrench to facilitate implant placement in relation to 44 and 46

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Figure 5: (a and b) Immediate loading with acrylic restorations

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Restorative phase

After a 3-month healing period, osseointegration was verified clinically by lack of mobility [Figure 6]. The provisional acrylic resin restorations were removed. The maxillary incisors were prepared minimally to receive porcelain laminate veneers (PLVs) [Figure 7], and impressions for the definitive prosthesis were made (Avue™ GUM, Dental Avenue, Korea). Final implant prosthesis [Figure 8] was cemented using glass ionomer cement (GC Luting and Lining Cement, GC Corporation, Tokyo, Japan), and the resin cement (Fusion Ultra D/C, PREVEST DenPro Limited, India) was used to cement the PLVs (emax) [Figure 9].
Figure 6: Postoperative orthopantomagram

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Figure 7: Porcelain laminate veneer preparation done in relation to 11, 12, 21, and 22

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Figure 8: (a) Definitive prosthesis, (b) Porcelain laminate veneers

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Figure 9: (a) Postoperative maxillary arch, (b) postoperative mandibular arch, (c) frontal view

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The intaglio surface of the veneers was etched using 30% hydrofluoric gel, rinsed, and then coated with a silane coupling agent. The prepared tooth was well isolated, etched with 37% orthophosphoric acid (Any-Etch™, MDCLUS, Korea), and rinsed, and the bonding agent (Tetric N-Bond Total-Etch Dental Adhesive) was applied following the manufacturer's instructions. Resin luting cement (Fusion Ultra D/C, PREVEST DenPro Limited, India) was used for the cementation of the PLVs. Once all gross excess was removed, the luting resin was cured using visible light activation unit for 40 s each. PLVs were finished using rotating abrasive disks (Soflex discs). In the mandibular arch, the incisors were etched with 37% phosphoric acid solution (Any-Etch™, MDCLUS, Korea), and dentin bonding agent was applied. Direct resin restorations (Tetric N-Ceram filling material, Ivoclar Vivadent) were applied to the mesial surfaces of the central incisors to close midline diastema and lateral incisors to close the spacings and to create a more acceptable morphology. Clinical examinations and radiographic evaluations were done preoperatively, postoperatively, and at periodic 3-month follow-ups. The patient was esthetically and functionally satisfied with the prosthetic rehabilitation.


   Discussion Top


For the rehabilitation of patients with edentulous jaws, immediate loading of dental implants is becoming a widespread therapeutic procedure.[7] The results of an immediate implant loading may be influenced by several factors. These could be divided into the following categories: surgery, implant, host, and occlusion-related factors. Surgical factors include primary implant stability and surgical technique. Host factors consist of quality and quantity of bone and wound healing. Implant factors comprise the surface textures, macro- and micro-designs, and dimensions of the implant. The quality and quantity of force and prosthetic design are the occlusal factors.[8]

The prime benefits of transmucosal flapless procedure are minimal swelling and pain, with no occurrence of hematoma, and also, patients required only minimal postoperative medications. A very high increase in the patient acceptance and satisfaction has been observed with this treatment modality. It was reported that by maintaining a better blood supply to the marginal bone, flapless surgery reduced the likelihood of bone resorption.[9],[10] The need for placing healing collars was eliminated by one-piece implant design, which makes it possible to avoid manipulation of the soft tissue portion after initial healing. In a two-piece implant design, the implant abutment junction constitutes a structural weakness that may complicate the procedure.[10] For immediate loading or immediate restorations, the primary stability of 40–80 Ncm is completely satisfactory.[3] Minimally invasive implant surgery can be an excellent reserve to the traditional FPD.[11]

The techniques that can deliver exceptional results in an efficient manner will continue to change conventional restorative dentistry as the demand for esthetic dentistry continues to grow. Being a very conservative treatment, nowadays, the treatment with ceramic laminates rehabilitation is in use in a large scale, especially in young patients, where the wear of the dental element is minimal preserving the dental structure.[5]


   Conclusion Top


Establishing a careful and realistic treatment plan, taking into account the patient's wishes, is most important in clinical cases. Since some patients want to solve their problem in the shortest time possible, the time factor is often determinant for the selection of the treatment plan. Thus, it can be concluded that the procedure performed correlated well with expectations of the patient and satisfactory result was obtained.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Danza M, Lauritano D, Carinci F. Successful rehabilitation of partial edentulous maxilla and mandible with new type of implants: Molecular precision implants. Case Rep Med 2014;2014:307364.  Back to cited text no. 1
    
2.
Tee YL. Minimally invasive surgical placements of nonsubmerged dental implants: A case series report, evaluation of the surgical technique and complications. J Oral Implantol 2011;37:579-87.  Back to cited text no. 2
    
3.
Rajput N, Siyad KP, Rathinavelu G, Chandrasekaran SC, Mohammed J. Minimally invasive transmucosal insertion and immediate provisonalization of one-piece implant in partially edentulous posterior mandible. J Clin Diagn Res 2013;7:2070-3.  Back to cited text no. 3
    
4.
Soares PV, Spini PH, Carvalho VF, Souza PG, Gonzaga RC, Tolentino AB, et al. Esthetic rehabilitation with laminated ceramic veneers reinforced by lithium disilicate. Quintessence Int 2014;45:129-33.  Back to cited text no. 4
    
5.
Silva G, Normandes AC, Barros Júnior E, Gatti J, Maranhão K, Reis AC, et al. Ceramic laminate veneers for reestablishment of esthetics in case of lateral incisor agenesis. Case Rep Dent 2018;2018:4764575.  Back to cited text no. 5
    
6.
Misch CE. Bone character: Second vital implant criterion. Dent Today 1988;7:39-40.  Back to cited text no. 6
    
7.
Testori T, Del Fabbro M, Galli F, Francetti L, Taschieri S, Weinstein R. Immediate occlusal loading the same day or the after implant placement: Comparison of 2 different time frames in total edentulous lower jaws. J Oral Implantol 2004;30:307-13.  Back to cited text no. 7
    
8.
Gapski R, Wang HL, Mascarenhas P, Lang NP. Critical review of immediate implant loading. Clin Oral Implants Res 2003;14:515-27.  Back to cited text no. 8
    
9.
Fortin T, Bosson JL, Isidori M, Blanchet E. Effect of flapless surgery on pain experienced in implant placement using an image-guided system. Int J Oral Maxillofac Implants 2006;21:298-304.  Back to cited text no. 9
    
10.
Hahn J. Single-stage, immediate loading, and flapless surgery. J Oral Implantol 2000;26:193-8.  Back to cited text no. 10
    
11.
Gibney JW. Minimally invasive implant surgery. J Oral Implantol 2001;27:73-6.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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