CASE REPORT

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Case Presentation
Pedro Couto Viana, DMD
Prosthodontist, Dr Manuel Neves Dental Clinic, Porto, Portugal

André Correia, DMD, PhD

Dentist, Dr Manuel Neves Dental Clinic, Porto, Portugal
Invited Assistant Professor, Faculty of Dental Medicine,
University of Porto and Portuguese Catholic University, Portugal

Manuel Neves, DMD

Implantologist and Clinical Director, Dr Manuel Neves Dental Clinic,
Porto, Portugal

Zsolt Kovacs, CDT

Master Ceramist and Technical Director, Dental Lab “DentalMaia,”
Castelo da Maia, Portugal

Rudiger Neugbauer, CDT

Dental Technician and Director, Dental Lab “DentalMaia,”
Castelo da Maia, Portugal

Correspondence to: Dr Pedro Couto Viana

Clínica Dr Manuel Neves, Rua do Amial 283 r/c, 4200-060 Porto, Portugal

Tel: 00 351 22 834 77 60; E-mail: [email protected]

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Abstract pact at facial and intraoral level. Dentist

and patient should objectively assess
Rehabilitation of edentulous spaces in the appearance of the final result. After
esthetic areas is a challenge to the clin- approval of this rehabilitation concept,
ician due to the loss of soft tissues. In the virtual surgical planning can be per-
these clinical situations, it would be de- formed and the surgical guide can be
sirable to evaluate and predict the gin- designed, allowing the treatment to take
gival architecture to recover in the oral place.
rehabilitation. To fulfill this need, the di- This protocol allows the development of
agnostic wax should anticipate the final a rigorous treatment plan based on the
rehabilitation with the integration of hard integration of teeth and gingiva com-
and soft tissue. Thus, it is essential to ponent. The waxup and the soft tissue
produce a diagnostic waxup that inte- mock-up play a significant role, since
grates these two components that are they allow an earlier evaluation of the
simultaneously seeking to recreate the esthetic result, better prosthetic and
harmony of white and pink esthetic. This surgical planning, and it allows us to
diagnostic waxup will be the basis for anticipate the need for gingiva-colored
the creation of the provisional prosthesis ceramics use.
and a soft tissue mock-up. The authors present a clinical case re-
After placing the provisional prosthesis port of the importance of the wax-up and
in the mouth, the soft tissue mock-up soft tissue mock-up in the treatment plan.
can be applied to assess its esthetic im- (Eur J Esthet Dent 2012;7:310–323)

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 CASE REPORT

Introduction surgical or prosthetic. The former can be

considered as more biological, or nat-
Bone resorption is a physiological con- ural, and may achieve excellent results
sequence of tooth loss or compromised that mimic the anatomy of the dento-
periodontal conditions. In these situa- gingival complex. However, it requires
tions, the alveolar crest suffers a change more surgical interventions, with guid-
in its vertical and horizontal dimensions, ed bone and soft tissue regenerations.
resulting in an unfavorable gingival These are more time consuming, more
architecture with major consequences traumatic, and are less predictable due
in esthetic rehabilitation.1 to the physiological healing process, es-
In these clinical situations, it would pecially when large volumes of soft and
be desirable to evaluate and predict hard tissue are missing.1,5
the gingival architecture to recover in Compared to the surgical approach,
the oral rehabilitation. To fulfill this need, the prosthetic rehabilitation with gingiva-
the diagnostic wax should anticipate colored ceramics is faster, much more
the final rehabilitation, not only with the predictable and not traumatic. However,
tooth crowns,2-4 but also with the inte- it requires special considerations by the
gration of soft tissue. Thus, it is essential dentist/prosthodontist and the dental
to produce a diagnostic waxup that in- technician in order to achieve a natural
tegrates these two components that are integration with an esthetic and func-
simultaneously seeking to recreate the tional harmony between the periodon-
harmony of white and pink esthetic. This tal tissues, the artificial gingiva and the
diagnostic waxup will be the basis for dental crown.1
the creation of the provisional prosthesis Although this is a current topic in the
and a soft tissue mock-up. dental science community, a literature
Only after the study of this diagnostic search in Medline about gingiva-color-
waxup can it be possible to establish a ed ceramics retrieved a small number
treatment plan, where two general clin- of papers published in dental journals
ical approaches may be considered: in the last 10 years.6-18 Most of the re-

a b

Fig 1 Extraoral appearance. Detailed view of drooping of labial commissure.

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 COUTO VIANA ET AL

Fig 2 Panoramic radiograph. Fig 3 Front view of the maxillomandibular rela-

tions.

trieved articles are concerned with tion. This approach is more complete
clinical reports and, with exception to and comprehensive, enabling better
Coachman and Salama,16-18 do not de- treatment planning.
scribe a protocol to establish a correct
diagnosis of these situations.
Case presentation

Aim Medical and dental history

With this clinical case report, we intend A female patient, 47 years old, healthy and
to propose a new concept of diagnostic a non-smoker had a long history of dental
waxup and mock-up that includes a re- treatments starting from an early age. This
construction of the gingival architecture resulted in good oral hygiene, with peri-
and a conventional dental reconstruc- odontal levels considered normal.

a b

Fig 4 Right and left view of the maxillomandibular relations.

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 CASE REPORT

Chief complaint

Essentially, the patient did not like hav-

ing a removable denture and was con-
cerned with her appearance, intra- and
extraorally.

Extraoral findings

The patient presented a decreased facial

height of the lower third of the face and a
Fig 5 Facebow registration.
drooping of the labial commissure, due
to a reduced vertical dimension (Fig 1).

a b

c d

Fig 6 Teeth waxup in the maxilla and mandible.

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 COUTO VIANA ET AL

Intraoral findings and Diagnostic casts (study models)

radiographic analysis
In the first visit, preliminary impressions
Intraoral examination and radiographic were performed and a facebow was
analysis revealed the absence of teeth used (Fig 5) to accurately transfer the
16 to 14, 21 to 26, 36 to 37 and 46 to 47. maxilla position to a semi-adjustable ar-
Teeth 17, 12, 11, 38 and 48 had dental ticulator.
restorations, and tooth 13 had an acrylic In the study models obtained, the
crown with a post. A reduced vertical dental technician created a hard and
dimension was observed, with a high soft tissue waxup (Figs 6 and 7), antici-
overbite in the anterior teeth, and an ex- pating what should be the final result.
tremely reduced prosthetic space in the The soft tissue waxup had a thickness
edentulous areas (Figs 2 to 4). of 4 to 5 mm, a height of 11 mm and a
width of 38 mm, approximately (Fig 8).

a b

Fig 7 Detail of teeth and soft tissue waxup in the study model. Major horizontal discrepancy in the second
quadrant covered by wax simulating gingiva.

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 CASE REPORT

≈ 4.5 mm ≈ 4 mm ≈ 5 mm
≈ 11 mm ≈ 38 mm

a b

Fig 8 Soft tissue waxup dimensions.

The hard tissue waxup was then convert- lowing a prosthetically driven implant
ed to a radiographic guide (Fig 9). This surgery.
guide had a fillet of composite resin in This analysis revealed the need to in-
the middle-buccal wall of the teeth. Then crease the bone width, in order to obtain
a cone-beam computed tomography sufficient bone in the buccal wall to allow
(CT) scan was performed to study the a prosthetically driven implant surgery.
implants’ placement in a virtual implant Two options were then considered:
planning software (Simplant® Material- "!Two-stage approach: reconstruc-
ise, Fig 10). The fillet of resin composite tion of the atrophic maxilla with an
allows us to easily identify the correct autogenous bone graft surgery (eg
position of the teeth’s’ buccal wall, al- Iliac crest bone, or other donor site)

Fig 9 Radiographic guide placed in patient’s mouth.

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a b

Fig 10 3D images from implant surgery planning in Simplant® Materialise software.

a b

c d

Fig 11 Provisional fixed partial denture in gypsum models.

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 CASE REPORT

Fig 12 Provisional prosthesis placed in patient’s mouth.

to allow bone augmentation and Treatment plan

provide an environment for better im-
plant placement in a second surgery Following the evaluation of the waxup
intervention. This approach needs a and CT scan, the two options of the sur-
longer treatment time, but allows for gery intervention were explained to the
a better outcome of long-term stabil- patient. Due to the patient’s desire for a
ity of hard and soft tissues. shorter treatment time, and the clinical
"!One-stage approach: implant place- team’s opinion that a successful treat-
ment in the atrophic maxilla with ment could be achieved with a one-
a buccal entrance to maintain the stage approach, the following treatment
palatal vertical bone dimension. plan was established:
Due to the reduced buccal–lingual 1. Provisional fixed partial denture (at
dimension, the surgery will entail a sites 17, 13, 12, 11, and 27) reinforced
full exposure of the implants in the with cast metal.
buccal wall and, consequently, the 2. Dental implants in positions 16, 14,
need for guided bone regeneration 21, 23, and 26, with guided bone re-
procedures with a xenogenous bone generation procedures in the second
graft performed by a highly skilled quadrant.
surgeon. 3. Fixed partial denture over implants at
sites 16 to 14, 21 to 23, and 26.
4. Fixed partial denture over tooth abut-
ments at sites 13, 12, and 11.

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Fig 13 Clinical situation 5 months after implant surgery with GBR.

5. Metal-ceramic crowns at sites 17 and mouth during the second visit, in order
27. to obtain the patient’s opinion about the
6. Fixed partial denture over teeth at sites expected rehabilitation, and to confirm
33, 34, 37, and 43, 44, 45, and 47. functional and esthetic parameters re-
lated to teeth and soft tissue architecture
The previously described waxup was (Fig 12).
converted into a provisional fixed partial This protocol allows the development
denture (Fig 11). A gingival epithesis, of a rigorous treatment plan in which the
acting as a mock-up, was placed in the placement of implants, tissue regener-

a b

Fig 14 Left image: initial situation with epithesis; right image: clinical situation after 5 months of healing.

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 CASE REPORT

ation, and rehabilitation of the dental

arches is made from the integrated re-
habilitation of the tooth and gingiva com-
ponent. The waxup and the soft tissue
mock-up play a significant role.
Three days later, the patient under-
went implant surgery and guided bone
regeneration procedures took place
to fill up the soft tissues in the second
quadrant.
Due to the buccal bone resorption
verified in the atrophic maxilla, the im-
a plant surgery technique selected was
a lateral entrance in the buccal bone
wall. In this way, the palatal bone crest
is spared, and this bone height can be
maintained. An implant surgical inter-
vention with the implant entrance in the
bone crest would have led to bone crest
vertical resorption and, consequently,
a more complex surgical intervention
to gain not only bone width, but also
height. The implants at sites 21 and 23
were placed with the neck more labially,
but without compromising the prosthetic
rehabilitation that was predicted by the
b waxup and the provisional prosthesis.
The gingival epithesis previously
planned and executed in the diagnostic
phase allows the oral surgeon to easily
predict the necessary amount of bone
for this procedure.
Five months later, the patient was re-
called in order to evaluate the position
of hard and soft tissues compared to
the initial situation. Although there was
a gain in the volume of hard and soft
tissues, with a significant change in its
c position (Fig 13), a lack of soft tissue in
the interproximal areas of the provision-
Fig 15 Top image: working model of teeth and
al prosthesis teeth was also observed
implant abutments; middle image: metal framework
of all fixed prosthesis components; bottom image: (Fig 14). No natural gingival architecture
metal-ceramic fixed prosthesis. could be visualized.

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a b

Fig 16 Final situation. The fixed dental prosthesis with a gingiva-colored ceramic was cemented over
the teeth and implant abutments.

Therefore, after discussing the situation ment plan. However, most of the studies
with the dental technician, the patient on the diagnostic waxup and the con-
was informed of the treatment options sequent mock-up, are only concerned
of ceramic fixed prosthesis with a teeth with teeth reconstruction,2-4 and do not
component and a gingiva-colored cer- include the soft tissues, which currently
amic to simulate the nature of the gin- represent a major part of the esthetic re-
gival architecture. With the patient’s habilitation. Coachman et al and Salama
agreement, we have initiated the com- et al16-18 published a three-part paper
mon clinical and laboratorial steps of about “Prosthetic gingival reconstruction
fabricating a fixed metal-ceramic reha- in fixed partial restorations” where they
bilitation (Fig 15). describe how to perform a correct diag-
The final situation of this rehabilitation nosis and treatment plan (Part 2), and
can be observed in Figures 16 to 18. the laboratory procedures and mainten-
The gingiva-colored ceramic allows the ance (Part 3). The protocol described in
prosthodontist/ceramist to recreate a the diagnosis part18 includes a waxup of
natural and stable gingival architecture, soft tissues together with a radiographic
compensating for the low predictability template that mimics this situation. How-
of this type of oral surgery. ever, no soft tissue mock-up of the gin-
giva–teeth architecture has been devel-
oped that shows the transitions of hard
Discussion and soft tissues, nor a gingival epithesis
to help the oral surgeon before the sur-
These clinical situations require a care- gery. This gingival mock-up allows us to
ful multidisciplinary approach in order evaluate the need for gingiva-colored
to establish the correct treatment plan. ceramics in the final prosthetic rehabili-
To rebuild the lost natural harmony of tation in two separate treatment phases:
the tissues, the first key element to be at the beginning of the treatment, and
produced is the diagnostic waxup, an also at a re-evaluation at the surgery
essential element in developing a treat- follow-up.

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 CASE REPORT

Fig 17 Patient’s smile with a natural affearance of the gingiva-colored ceramics’ rehabilitation.

The study of a clinical case should in-

tegrate soft tissue planning together
with teeth planning, in order to produce
a more predictable prosthetic rehabili-
tation. The waxup and the soft tissue
mock-up allow an early evaluation of the
esthetic result, the development of a bet-
ter prosthetic and surgical plan, and at
last, it permits us to anticipate the need
for using gingiva-colored ceramics.

Fig 18 Panoramic radiograph of the rehabilitation

with fixed dental prosthesis over teeth and implants.

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