Initial situation

A 70-year-old female patient presented to our practice with an unstable and non-esthetic tooth-supported two-unit bridge. Her chief complain was to recover the function and aesthetics in this posterior area. Additionally, she had very high expectations in regard to the predictability of the treatment and highlighted her wish of a long-term solution, independently of the price.

Her medical history reveled an adenocarcinoma (breast tumor) which was treated 20 years ago and pharmacological controlled cardiovascular diseases with beta-blockers and acetylsalicylic acid. Given her systemic condition, the patient was derived to her cardiologist for an evaluation prior the start of the preparation of the treatment plan.

The positive feedback from the specialist allowed us to continue with the treatment, including surgical procedures and without interfering with the patient’s medication.

The clinical evaluation of the third quadrant showed a tooth-supported two-unit bridge (#34- #37) with apparent signs of unaesthetic coating fracture, breakage of the underlaying metal, infiltration of the underlying abutments and mobility; which  indicated the need of a new restoration, evaluation of the abutments and assessment of the edentulous area (Fig. 1).

In order to do a better assessment and evaluate the abutments, it was decided to remove the bridge prior the x-rays procedures.

The clinical evaluation of the abutments showed a limited amount of keratinized tissue in the premolar region, a regular shape of the edentulous ridge and an acceptable horizontal width. Moreover, an amalgam tattoo was also appreciated on the supracrestal area of position #35 (Fig.  2).

The radiographic evaluation showed images compatible with periodontal ligament widening, root canal treatments and periapical lesions on teeth #34 and #37. Furthermore, vertical bone availability was observed (Fig. 3).

Treatment planning

The patient was derived to the endodontist for the re-treatment of teeth #34 and #35.

For the studying models and the optimal fabrication of the provisional restoration, a digital impression with 3shape TRIOS® intraoral scanner was performed (Fig. 4).

For the final restoration, different treatment options were discussed with patient. Following the evaluation of the treatment options, it was agreed to place an implant-supported fixed bridge in positions #35 and #36 and single tooth-supported crowns on teeth #34 and #36.

Moreover, it was decided to use a ceramic healing abutment for the anterior implant as only a minimal band of keratinized tissue was present, and the patient had a thin biotype.

Surgical procedure

After local anesthesia (Articain 4% with Adrenalin 1:100.000), an intrasulcular and supracrestal incisions were performed. Afterwards, a mucoperiosteal flap was raised avoiding releasing incisions and allowing an optimal visibility of the underlying bone portion (Fig. 5).

Implants’ beds were prepared according to the manufacturer protocol. Paralleling pins were used in order to guarantee the correct 3D implant position (Fig. 6) The distance between implants was 3.0 mm and the implants’ location were at least 1.5 mm from the adjacent natural tooth (Fig. 7).

Following the drilling protocol, two Roxolid® Bone Level Tapered Implants (∅ 4.1 mm RC, SLActive®) of 8mm and 10 mm length were placed in positions #35 and #36, respectively (Figs. 8-10). Afterwards, two healing abutments (RC Ø 4.5mm, H 4mm) were hand-screwed on implant #35 (ceramic) and implant # 36 (titanium) (Fig. 11).

The flaps were closed by the placement of interrupted sutures with Vycril 5/0 (Fig. 12), and provisional crowns were placed on teeth #34 and #37.

After surgery, the patient received oral and written recommendations about medication, oral hygiene maintenance, and diet. The patient was instructed to brush the treated area with minimal trauma and to rinse twice a day with 0.15 mL 0.2% chlorhexidine for 1 minute until sutures were removed (7 days after surgery).

The follow-up visit was made 7 days later, and a clinical evaluation and sutures removal were performed during this visit. The patient reported no pain nor complications and the healing was uneventful (Fig. 13).

Prosthetic procedure

The lockdown due to COVID-19 took place during the healing period, and for this reason the patient was not able to attend to our practice for a period of four months.

During this visit, an intraoral X-ray control was carried out and bone maintenance was appreciated (Fig. 14).

Clinically, the oral hygiene was assessed as very good, and the healing abutments showed an outstanding soft tissue behavior, especially in the anterior area where the initial band of keratinized tissue was limited (Fig. 15).

When both healing abutment were removed, ideal emergency profiles were appreciated around both implants. In addition, it was noted the slight color difference in the transmucosal path with a more natural aspect on location #35 compared to #36. In this case, these findings agreed with an improved vascularization and a greater stabilization of the tissues themselves around the ceramic healing abutment described in the literature (Fig. 16).

Afterwards, a digital impression was taken with 3Shape TRIOS® intraoral scanner prior the placement of the respective scanbodies and gingival retractors around the teeth’s abutments (Fig. 17).

The obtained data was sent to the lab and our dental technician designed and produced the final screwed retained prosthesis using the CAD/CAM technology. The emergency of the chimneys was verified, and we made sure that did not interfere with the aesthetics and the chewing function. (Figs. 18).

We produced stereolithography casts with the analogs of the natural abutments and the BLT implants (Figs. 19 & 20). Both abutments presented a gingival height of 1 mm and were cemented to the crowns (Fig. 21). The crowns were made of Zirconia with a layering technique (Fig. 22).

The final prosthesis was screwed with a torque of 35 N/cm and the single crowns were cemented to the abutments of natural the teeth, making sure that no cement rests remain around them (Fig. 23).

Afterwards, the correct position in occlusion and lateral movements was evaluated, and the verification of the intra-dental spaces for a correct oral hygiene was verified (Fig. 24).

One month after the placement of the final restorations, a new intraoral X-ray scan to control the final position and a correct healing was performed. This X-ray helps as a basis for future x-ray controls. (Fig. 25).

Treatment outcomes

The great advantage of bone level implants is that they allow for a correct management of soft tissues.

Moreover, the ceramic healing abutment has shown an outstanding peri-implant soft tissue healing and a reduced deposit of dental plaque, presumably because of an easier self-oral hygiene. The patient also reported a minor discomfort during the healing process with the Ceramic healing abutments.

Overall, the patient was very satisfied with the esthetic and functional treatment outcomes.

Dr. Scaringi testimonial:

I had an excellent experience using the new ceramic healing abutments. I appreciated that the plaque retention was very minimal, and the tissue behavior was optimal. Furthermore, the color of the ceramic abutment camouflages very well with the gingiva and this is very useful especially in visible esthetic areas