Dr. Giuseppe Marano
• Graduated in Dentistry and Dental Prosthetics. He also first attended the Course of Oral Implantology and then obtained the specialization in Odontostomatological Surgery (University of Rome “La Sapienza”).
• Master in Legal Dentistry at the University of Florence with honors.
• Professor of:
– the ‘Advanced implantology’ course held in Verona (partnered by University of Modena & Reggio Emilia)
– the II level Master’s degree in ‘Fixed prosthesis on natural teeth and on implants’ (University of Rome “La Sapienza “)
– II level Master’s degree in ‘Clear Aligner Therapy’ (University of Naples)
• Member of the IAO (Italian Academy of Osteointegration)
• Member & Certified Speaker of the Digital Dentistry Society
• Member & President (for the years 2022/23) of the Digital Implant & Restorative Academy
Tommaso Weinstein, Selvaggia Brigo, Raman Aulakh
prosthetic rehabilitation
Choosing prosthetic rehabilitation over dental implants has revolutionised modern dentistry, providing an effective solution for replacing missing teeth. However, achieving optimal function and aesthetic outcomes relies heavily on precise planning and execution of the treatment protocol.
Orthodontic interventions are pivotal in creating the appropriate alignment
and distribution of available space within the dental arch. Orthodontics establishes a solid foundation for successfully integrating dental implants and designing a harmonious and functional occlusion by addressing malocclusions, irregular spacing, and misalignments before implant placement. Moreover, adopting orthodontic techniques allows for a more conservative approach, preserving tooth structure and minimising the need for extensive restorations.
Through a case report, this article explores the significance of incorporating preparatory orthodontic treatment before initiating prosthetic rehabilitation over dental implants, specifically focusing on achieving ideal spacing.
introduction
introduction
Dental implants have revolutionised modern dentistry, offering a reliable
and durable solution for replacing missing teeth. Choosing prosthetic rehabilitation over dental implants has become standard, restoring function and aesthetics and improving the quality of life of countless patients.
However, the long-term success and natural appearance of the final prosthesis depend heavily on careful planning and precise execution of the treatment protocol. One critical aspect that merits special attention is establishing appropriate spacing for the implant-supported prosthetic restoration [1].
In recent years, a growing body of evidence and clinical experience has emphasised the indispensable role of preparatory orthodontic treatment before initiating prosthetic rehabilitation over dental implants [2]. Orthodontic interventions aim to create the ideal alignment and distribution of available space within the dental arch, ensuring optimal conditions for successful implant integration and achieving harmonious and functional occlusion. This approach represents a paradigm shift in implant dentistry, moving away from solely focusing on implant placement and instead addressing the broader context of overall dental aesthetics and occlusal stability.
The primary objective of orthodontic treatment before prosthetic rehabilitation is to correct malocclusions, irregular spacing, and misalignments that might have resulted from tooth loss, dental trauma, or natural development [3]. By doing so, orthodontics creates a solid foundation for the subsequent placement of dental implants and the design of a well-fitting and aesthetically pleasing prosthesis. Moreover, addressing spacing issues through orthodontic techniques allows for a more conservative approach, preserving tooth structure and minimising the need for extensive restorations.
This scientific article delves into the vital significance of incorporating orthodontic treatment as a preliminary step in the overall treatment plan for patients undergoing prosthetic rehabilitation with dental implants. It will explore the advantages and benefits of achieving correct spacing through orthodontics, including enhanced soft tissue support and optimised aesthetic outcomes. It will also examine how orthodontic interventions can contribute to long-term oral health by facilitating better oral hygiene practices and reducing the risk of future dental complications.
the case
the case
This female patient was only 17 years old when treatment began. When she was six years old, she experienced an extra articulation of the upper left central incisor while playing with her twin brother, which was devitalised and re-implanted. However, over the years, that tooth has undergone root resorption and chromatic variations that were no longer tolerable by a young teenager, with buccal gum recession (Figs. 1 and 2). However, given her young age, we decided to proceed with extracting the element and implementing socket preservation techniques and wait until the end of craniofacial development before rehabilitating the missing tooth with an implant.
After collecting informed consent from her parents, I performed local anaesthesia with articaine before atraumatically extracting tooth 2.1 and, after careful curettage of the socket, grafting heterologous bovine particulate bone with 10% collagen (Bio-Oss® Collagene, Geistlich Biomaterials Italia) [4]. Next, I covered the bone graft with an autologous epithelial-connective graft harvested from the palate (Fig. 3). Then, I applied a metal-ceramic Maryland bridge previously prepared by the laboratory (Fig. 4).
Once the hard and soft tissues had healed and matured (Figs. 5–6) and, above all, the patient’s craniomaxillofacial development had completed, after about two years, I inserted an implant with platform switching (Biomet 3I T3 Prevail Certain 4/3×11.5; Fig. 7) and simultaneously took a digital impression with an iTero Elements 2 5D intraoral scanner (Align Technologies; Figs. 8-9).
Within 24 hours, the dental laboratory had created a fixed resin prosthesis screwed onto the implant (Fig. 10), with the sole purpose of rehabilitating the aesthetic and phonatory function, but wholly discluded in centric occlusion and protrusive and lateral Case Report: Optimizing prosthetic rehabilitation over dental implants movements (Fig. 11). This made it possible to avoid the risk of the Maryland bridge detaching, which had already occurred during the previous two years, and allowed for optimal modelling of the soft tissues around the new prosthesis.
Once osseointegration occurred (Fig. 12), six months after implant insertion, I took a new digital impression of the implant’s position using a scanbody and the prosthesis’s transgingival path (Figs. 13–14). At this point, the laboratory fabricated and delivered a metal-ceramic screw-retained prosthesis.
However, when the prosthesis was tried-in, the patient immediately perceived the contact between the buccal surface of the new tooth and the upper lip as if the prosthesis was not aligned (Fig. 15). When I asked for an explanation, the dental technician stated that, unfortunately, they did not have sufficient space in the buccal-oral direction to correctly stratify the ceramic on top of the metal structure due to the excessive proclination of tooth 3.1 (Fig. 16).
Indeed, the prolonged use of prostheses had favoured the proclination and crowding of the lower incisors. Therefore, I decided to use the newly made metal-ceramic prosthesis as a new temporary prosthesis.
After performing a new scan of both arches, I shared the possible alignment of both arches with the laboratory using the iTero scanner’s Invisalign Outcome Simulator tool (Fig. 17), asking if that position would satisfy the space requirements for correct prosthetic rehabilitation.
Once I received an affirmative answer from the laboratory, I sent the prescription and scans to Invisalign to create a Clin-Check (i.e. a 3D simulation of the movement obtainable thanks to the transparent Invisalign aligners; Fig. 18) [5].
With only seven aligners (changed weekly), the Invisalign Go Express
system restored the correct spaces for a correct prosthetic rehabilitation,
precisely as designed in the project phase (Fig. 19). At this point, I once
again took a new digital impression, which allowed the laboratory to conduct an excellent rehabilitation (Figs. 20–21).
DISCUSSION
discussion
Pre-prosthetic alignment refers to orthodontic procedures that are performed before placing dental prosthetics, such as crowns, bridges, or implants. It aims to optimise the position and alignment of the existing teeth, allowing for the successful integration and longevity of the prosthetic restorations.
Various orthodontic techniques, including traditional braces or clear aligners, may be used during pre-prosthetic alignment. The treatment choice depends on the individual patient’s needs, the complexity of the case, and the preference of the treating orthodontist or dentist. The dental professional can ensure that the final restorations fit accurately, function optimally, and blend seamlessly with the surrounding dentition by achieving the proper alignment and spacing of the teeth before prosthetic rehabilitation.
Invisalign Go is a specific treatment option offered by Align Technology, the company behind Invisalign, a popular brand of clear aligners used for orthodontic treatment. Invisalign Go is a variation of the traditional Invisalign system designed for mild to moderate orthodontic cases. General practitioners typically use it for cases requiring minor to moderate teeth straightening or correction of some dental issues, such as mild crowding, spacing, or simple bite problems. It is a more streamlined and cost-effective version of the complete Invisalign treatment, making it suitable for patients with less complex orthodontic needs.
Like the standard Invisalign system, Invisalign Go uses a series of clear, custom-made aligners to gradually move the teeth into their desired positions. The aligners are virtually invisible, removable, and comfortable to wear. Patients receive a set of aligners to wear for about 1–2 weeks each before moving on to the next set in the series. The treatment process with Invisalign Go usually involves fewer aligners and appointments than the traditional Invisalign treatment, making it a convenient option for some cases.
In the context of pre-prosthetic alignment, Invisalign Go can be used to correct mild misalignments or spacing issues in the dentition before placing dental prostheses. By aligning the teeth properly, it creates a solid foundation for the subsequent prosthetic restorations, ensuring a more precise and aesthetically pleasing final result. The Invisalign Outcome Simulator allows orthodontists and dentists to create a 3D simulation of a patient’s teeth alignment transformation using the Invisalign treatment. It helps patients visualise the potential results of their Invisalign treatment before they start wearing the aligners.
“It is crucial for dental practitioners to recognize the pivotal role of orthodontics in achieving predictable and successful outcomes for patients seeking prosthetic rehabilitation over dental implants.”
Patients can better understand the process and expected outcome by seeing a virtual representation of how their teeth will gradually move into the desired position during the treatment.
The Invisalign Outcome Simulator also offers several advantages for clinicians in interdisciplinary treatments, where multiple specialists collaborate to provide comprehensive care for a patient. Below are some of its key benefits:
1. Treatment Planning Coordination
Interdisciplinary treatments may involve different specialists, such as orthodontists, prosthodontists, periodontists, and oral surgeons. The Outcome Simulator helps these specialists coordinate their treatment plans effectively. They can work together to ensure that each aspect of the treatment aligns with the overall treatment goals, resulting in a more efficient and cohesive approach.
2. Predictability and Precision
The simulator uses advanced algorithms and data from previous successful cases to accurately predict the expected outcome of the Invisalign treatment. This level of predictability and precision is crucial in interdisciplinary treatments, where precise tooth movement and alignment are essential for successful outcomes.
3. Identifying Challenges
Certain cases may present unique challenges or complexities during interdisciplinary treatments. The Outcome Simulator allows clinicians to identify potential issues in the treatment plan beforehand and make the necessary adjustments to address them. This proactive approach helps reduce the risk of unexpected complications during the actual treatment.
4. Improved Patient Understanding
The 3D simulation provided by the Outcome Simulator enhances patient understanding of the treatment process and the expected results. Patients can visualise their treatment journey, making it easier for them to remain motivated and committed to the treatment plan.
5. Customisation and Personalisation
The Invisalign system is highly customisable, and the Outcome Simulator takes this a step further by allowing clinicians to tailor treatment plans to each patient’s specific needs and preferences. This level of personalisation is invaluable in interdisciplinary treatments, where a patient may have multiple dental concerns that require a comprehensive approach.
6. Time and Cost Efficiency
By using the Outcome Simulator to plan the treatment precisely, clinicians can potentially reduce the treatment time and the number of required aligners, improving treatment efficiency and cost-effectiveness.
Overall, the Invisalign Outcome Simulator is crucial in enhancing communication, collaboration, and treatment planning in interdisciplinary cases. It empowers clinicians to provide more effective, personalised, and coordinated patient care, resulting in better treatment outcomes and patient satisfaction.
conclusion
conclusion
As the field of implant dentistry continues to advance, dental practitioners must recognise the pivotal role of orthodontics in achieving predictable and successful outcomes for patients seeking prosthetic rehabilitation over dental implants. By shedding light on the importance of proper spacing through orthodontic techniques, this article aims to encourage interdisciplinary collaboration and underscore the value of comprehensive treatment planning to elevate the standard of care in implant dentistry. Ultimately, our shared commitment to delivering the best possible results for our patients drives us to explore innovative and evidence-based approaches for optimising prosthetic rehabilitation over dental implants.
SOURCES
1) Bashir t. Orthodontic Correction for Prosthetic Rehabilitation to Improve Esthetics in Anterior Region: A Case Report of Interdisciplinary Approach. EAS J Dent Oral Med; 2023, 5(2): 30-33 doi:10.36349/easjdom.2023.v05i02.001
2) Houb-dine A, Regragui A, Benkaddour A, Bahoum A, Zaoui F. Pre-prosthetic Orthodontic Implant for an Aesthetic Rehabilitation : A Case Report. Integr J Med Sci [Internet]. 2020 Nov. 28 [cited 2023 Jul. 30];8. Available from: https://mbmj.org/index.php/ijms/article/view/276
3) Weinstein T, Marano G, Aulakh R. Five-to-five clear aligner therapy: predictable orthodontic movement for general dentist to achieve minimally invasive dentistry. BMC Oral Health. 2021 Dec 29;21(1):671. doi: 10.1186/s12903-021-02034-9. PMID: 34965879; PMCID: PMC8717640.
4) Scheyer ET, Heard R, Janakievski J, Mandelaris G, Nevins ML, Pickering SR, Richardson CR, Pope B, Toback G, Velásquez D, Nagursky H. A randomized, controlled, multicentre clinical trial of post-extraction alveolar ridge preservation. J Clin Periodontol. 2016 Dec;43(12):1188-1199. doi: 10.1111/jcpe.12623. Epub 2016 Oct 21. PMID: 27617409; PMCID: PMC5132058.
5) Alswajy, W.; Baeshen, H.; Al-Turki, G.; Alsulaimani, F. The Reliability of ClinCheck® Accuracy before and after Invisalign® Treatment—A Multicenter Retrospective Study. Appl. Sci. 2023, 13, 4670. https://doi.org/10.3390/app13084670