Original Contributions

Clinical Dentistry
Multistage implantology-orthodontic-
prosthetic treatment
A case report
Beata 
Smielak, DDS, PhD; Iwona Andruch, DDS

ABSTRACT

Background and Overview. Patients increasingly expect esthetic and comfortable fixed resto-
rations on implants, are aware how important it is to maintain healthy tooth tissue, and draw
attention to the final result of treatment.
Case Description. In this case report, the authors describe implantology-orthodontic-prosthetic
treatment provided on a patient who reported symptoms of head, back, and neck pain and had an
impaired prosthetic plane, lack of space for prosthetic crowns after the introduction of the implants and
no good treatment plan, and broken tooth roots of the mandibular anterior teeth. In addition, the
patient wanted to correct the shape and color of the rest of her teeth. The authors present the different
stages of the implantology-orthodontic-prosthetic treatment and the final result after treatment. The
patient was satisfied with the achieved results of the treatment in terms of functionality and esthetics.
She felt a significant reduction in pain in the temporal, masseter, and sternocleidomastoid muscles.
The clenching of teeth at night decreased, and she began to sleep better. Her well-being improved.
Conclusions and Practical Implications. Before the beginning of the treatment, dentists
should make an accurate diagnosis and determine if patients qualify for the treatment and the
appropriate materials are selected. Achieving the desired functional and esthetic effect often
requires cooperation with physicians in various specialties and multistage treatment.
Key Words. Multistage treatment; implantology; esthetic expectations.
JADA 2018:149(9):787-793
https://doi.org/10.1016/j.adaj.2018.04.028

I
n modern dental prosthodontics, the lack of teeth is increasingly supplemented by functional
and comfortable prosthetic constructions supported on dental implants.1-6 Such reconstruction
does not require grinding the hard tissue of teeth and their irretrievable loss (up to 72%).7 In the
case of missing posterior teeth, these reconstructions make it possible to replace uncomfortable
removable partial dentures with fixed restorations, through which better stabilization and retention
and good esthetic and positive psychological effects are possible to achieve. Before placing the
implants, it is essential for the clinician to take into account the eligibility of the patient for surgery.
This assessment should include the patient’s general state of health and the local conditions
(quantity and quality of bone and the type of occlusion). Dentists should plan the optimal pros-
thetic structures from the point of view of biomechanics, which will ensure a balanced occlusion in
the area of dental arches reconstructed on the basis of implants.8
Before providing the patient with an implant-supported restoration, the clinician should obtain
an exact history from the patient and conduct a local examination along with radiographic analysis.
The patient should be given information regarding methods, the treatment plan, what the surgery
involves, costs, possible complications, postoperative hygiene, and the need for follow-up visits. In
addition, the clinician must prepare the patient for prosthetic restorations, which involve sanita-
tizing the oral cavity, obtaining impressions and creating diagnostic models, analyzing occlusion and
Copyright ª 2018
bite registration, defining the type and location of the implants on the models, and drawing up a
American Dental
plan for early and final prosthetic restorations. The last point involves determining the type of Association. All rights
construction for immediate implant-supported prostheses and final solutions, preparation of a reserved.

JADA 149(9) n http://jada.ada.org n September 2018 787

 radiographic template with reference points and templates with preset artificial teeth, execution of
the necessary models and photographic documentation, and preparation of temporary prostheses
that serve also as a model for planning the location of the implants.
In any case, the preliminary prosthetic analysis takes into account factors associated with the correction
of occlusion through elimination of premature contacts and corrective treatments in the field of
occlusion-articulation surface with the elimination of occlusal interferences. This is done by using se-
lective grinding treatment or orthodontic treatment. In difficult cases with severe occlusion-articulation
complications and functional disorders associated with the permanent change of the spatial position of
the mandible, malocclusions, the loss of support zones, generalized pathologic tooth wear, and large tissue
defects, it is necessary to conduct a multistage treatment. The aim of the first stage is a gradual change in
the spatial position of the mandible, taking into consideration the target reconstruction and functional
remodeling of the stomatognathic system. This can be achieved using orthopedic treatment methods.
After positive results of the first stage and the patient’s adaptation to new occlusal conditions,
the second stage of treatment starts. The aim of this stage is the permanent reconstruction of dental
arches based on the final restorations already integrated into the newly adopted functional situation
of the stomatognathic system.8
Before esthetic treatment, the diagnostic wax-up must be made, which involves modeling in wax
the shape of future dental restorations.9-11 On acceptance of the shape of the teeth by the patient, a
silicone index must be made from the first elastomeric layer, which will help provide the patient
with temporaries (mock-ups) made of composite resin. After the polymerization, an analysis of the
length of the teeth with reference to the upper and lower lips needs to be made, paying attention to
the function and phonetics and checking the final effect.11-13 The patient can give an opinion on
the new smile, and the dentist should consider the kind of restorations needed.
Accurate diagnosis before esthetic treatment is of particular importance because, on the one
hand, it avoids false or exaggerated expectations on the part of the patient, and, on the other hand,
it anticipates technical issues and enables them to be solved appropriately.

CASE REPORT
A 38-year-old woman came to the dental office to continue implant treatment (eFigure 1). The
patient had undergone the implantation stage in positions nos. 18, 30, and 31 in another dental
office. The previous dentist refused to proceed with further prosthetic treatment owing to the lack of
vertical space. The main problem was the lack of space for prosthetic crowns in the area of tooth no.
15, which was in contact with the mucous membrane of the mandible. Tooth no. 15, having no
contact, elongated from the alveolus. It also became a point of traumatic premature contact. The
patient felt pain on the part of the stomatognathic system mainly from the temporal, masseter, and
sternocleidomastoid muscles. She reported symptoms of headaches, teeth clenching at night, and
trouble sleeping, as well as of back and neck pain. Ultimately, she was interested in esthetic
treatment (that is, changing the shape and color of the teeth).
Both the shape of the occlusion and the results of a clinical examination indicated dysfunction of the
chewing system: swallowing with the tongue between the teeth and mouth breathing. We heard and felt
clicking in the joints on palpation during a temporomandibular joint examination. We observed
reduction in the lower facial height, together with slight asymmetry and a retruded chin (Figure 1).
The clinical examination revealed missing teeth nos. 13, 18, 30 and 31. The gingival margin in
the area of teeth nos. 24 and 25 was inflamed. Although teeth nos. 24 and 25 had been restored
with porcelain-fused-to-metal (PFM) crowns, they showed grade II pathologic mobility, according
to the Kantorowicz scale. The other anterior teeth were worn and shortened, with cracks in the
enamel parallel to the long axes. We noted a deep overbite and retrusion of the maxillary incisors in
the anterior segment.
The posterior teeth had been restored incorrectly with composite resin. A temporary restoration
had been placed on tooth no. 19. Tooth no. 14 inclined mesially into the space created by missing
ABBREVIATION KEY tooth no. 13, and tooth no. 32 inclined into the space vacated by missing tooth no. 31.
CT: Computed Missing teeth nos. 13 and 31 and incorrect restoration of tooth no. 19 resulted in the loss of
tomographic. position of adjacent teeth and therefore in a distorted prosthetic plane. The occlusion was diagnosed
PFM: Porcelain-fused-to-
as class II, division 2, subdivision 2, according to the Angle classification.
metal.
TMJs: Temporomandibular After obtaining the patient’s medical history and conducting a physical examination, we eval-
joints. uated the patient’s previous panoramic radiograph (eFigure 2) and obtained a computed

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Figure 1. Extraoral view before treatment, left side.

Figure 2. Cast model before treatment, visualization of tooth no. 15 out of ideal position.

tomographic (CT) image. The radiograph showed implants placed in the site of missing teeth nos. 18,
30, and 31. The implants were short, and in the case of the implant in position no. 18 there was bone
loss reaching the second thread. Although we informed the patient about the option of reimplan-
tation, she was not interested in this procedure. She opted for the placement of an abutment and
restoration of the implant with a definite PFM crown. We recommended that a CT scan be performed
once a year to check for bone loss. The roots of teeth nos. 24 and 25 were weakened. There were
fractures present, and the teeth had undergone endodontic treatment. In addition, there was a post in
the root of tooth no. 24. We deemed these teeth as hopeless and recommended extraction followed by
immediate implantation. Tooth no. 19 qualified for endodontic retreatment and temporary prosthetic
restoration to maintain correct occlusal height during orthodontic treatment.
We then obtained alginate impressions (Kromopan, Lascod) and made a bite registration using
bisacrylate (Luxabite, DMG) to fabricate the diagnostic models.
After analyzing the diagnostic models (Figure 2) and CT images and discussing the options with
the patient, we prepared a plan for orthodontic therapy followed by implant-prosthetic treatment.
The orthodontic therapy plan included effecting intrusion of the maxillary and mandibular anterior
teeth to reduce the overbite, achieving the correct relations on the canines, effecting slight
intrusion of tooth no. 15, uprighting the inclined teeth, closing spaces in the posterior segments,
raising the bite, restoring the correct smile arc, and correcting the shape of interdental papillae.
The orthodontic treatment was scheduled for 2 years because it had to go along with the
correction of the prosthetic plane. The aligning of the teeth was accompanied by the placement of
temporary crowns on teeth nos. 24 and 25 on the arch wire due to esthetic and phonetic re-
quirements. The following procedures were planned within the framework of implantology-
orthodontic-prosthetic treatment: extraction of the fractured roots of teeth nos. 24 and 25 with

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 Figure 3. Recording the position of the mandible with respect to temporomandibular joints using a face bow.

Figure 4. Porcelain-fused-to-metal crowns on the stone model.

immediate implant placement, a diagnostic wax-up, endodontic retreatment of tooth no. 19, and
placement of a post and a temporary composite crown. During the second stage, scheduled 4 months
later, PFM crowns were to be placed on implants nos. 18, 30, and 31. Three months after that, and
once the position of the mandible had been stabilized, the plan was to place the final zirconia-
porcelain crowns on hybrid titanium-zirconia abutments on teeth nos. 24 and 25; porcelain ve-
neers on teeth nos. 4 through 12, 22, 23, 26, and 27; and all-ceramic crowns on zirconia copings on
teeth nos. 20, 21, 28, and 29, which would be necessary due to extensive damage of their clinical
crowns. Finally, tooth no. 19 would be extracted and immediate implant placement performed.
After another 4 months, the restoration would be completed with the final PFM crown.
The completion of active treatment with fixed appliances would be followed by a retentive phase
using fixed retainers on palatal surfaces and further preventive treatment of the tongue thrusting
using an elastic myofunctional appliance (Trainer, Myobrace).
The purpose of raising the bite was to improve the function by eliminating clicking in the
temporomandibular joints (TMJs), thereby reducing pain in the joints and in the cervical spine.
The reduction of the overbite also would provide more space for future prosthetic restorations. Last
but not least, the facial esthetics would be improved through protrusion of the chin toward the
Kantorowicz plane, flattening of the mentolabial fold, and improved symmetry.
The orthodontic treatment began with the aligning and leveling of the teeth and the uprighting
of the inclined molars. Then we inserted edgewise utility arch wires. Owing to the existence of gaps
caused by the missing teeth, we replaced them with edgewise wires with the curve of Spee
(eFigure 3). Using microscrews as temporary anchorage devices could have been another option.
The patient used class 2 intermaxillary elastics. After partial reduction of the overbite, we started
raising the bite by means of temporary occlusal buildups. We placed the composite buildups on the

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Figure 5. Implants in positions nos. 31 and 41, with healing abutments and sutures ready to be removed after bone
regeneration.

Figure 6. Maxillary anterior teeth after preparing for veneers.

occlusal surfaces of the uprighted posterior teeth, and they helped stabilize the new occlusal
height.14-16 The initial occlusal buildups proved to be too high. The patient reported pain in the
TMJs as well as problems with speech and opening the mouth. We gradually reduced the occlusal
height until the reported symptoms subsided.
After establishing a new spatial position of the mandible and the occlusal height (Figure 3), we
proceeded to make crowns for implants nos. 18, 30, and 31 (Figure 4). After cementing them, we
began the immediate implant treatment in the area of fractured roots of teeth nos. 24 and 25. The
procedure was performed under local anesthesia (4% Ubisthesin, 3M ESPE). After the elevation of
a mucoperiosteal flap, we extracted the roots of the teeth atraumatically and, after the preparation of
osteotomies, we placed 2 implants (AstraTech EV, Dentsply) with a length of 13 millimeters and a
width of 3.2 mm. We filled the defect in the alveolar bone with natural bone substitute (Allograft,
AlpaBio), covered it with a resorbable collagen membrane (EZ Cure, Biomatlante), and sutured it
with monofilament nonresorbable Teflon threads (PTFE Coreflon, Braun) (Figure 5).
After implantation, we applied temporary composite crowns, attached to the orthodontic arch
wires. After 2 weeks, we removed the sutures. Five months after implantation, we obtained a
panoramic radiograph to evaluate osseointegration and removed the braces, and we proceeded to
prepare teeth nos. 4 through 12 to obtain the impression for veneers. We removed the old resto-
rations and undercuts and smoothed the surface of the teeth (Figure 6). We planned “no-prep”
veneers. After obtaining the impression with polyvinylsiloxane mass (Express, 3M ESPE), we made a
mock-up using the silicone key made on the model with diagnostic wax-up (Figure 7). We obtained
an impression of the opposing arch using alginate mass (Kromopan, Lascod) with the mock-up on the
teeth of the lower arch. We recorded the relation of the mandible to the maxilla with bisacrylate mass
(LuxaBite, DMG) and the spatial position of the mandible to the maxilla with the face bow (Artex,

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 Figure 7. Mock-up made on the teeth.

Figure 8. Final restorations on the stone model.

Amann Girrbach). At the next visit, the veneers made on the draft model were ready (Figure 8), and
after checking color, shape and fit we adhesively cemented it using a composite cement (Panavia F,
Kuraray). Then we obtained the impression using the open tray method with the use of impression
copings for the crowns on implants nos. 24 and 25; porcelain veneers on teeth nos. 22, 23, 26, and
27; crowns on zirconia substructure on teeth nos. 20, 21, 28, and 29; and a metal-ceramic crown on
tooth no. 19. On the next visit, the positions of the abutments were controlled, as well as the metallic
and zirconia copings for crowns and copings for veneers made of lithium disilicate (e.max, Ivoclar).
After a week, we cemented the crowns with glass ionomer cement (Fuji, GC) and the veneers
with composite cement (Panavia, Kuraray).
After another 2 weeks, we obtained a CT image of the mandible (eFigure 4) and performed
immediate implant placement in position no. 36. The procedure was the same as in the mandibular
incisors. After preparation of the osteotomy, we placed an implant 13 mm in length and 4.2 mm in
diameter (AstraTech EV, Dentsply). We augmented the defect in the alveolar ridge with allogenic
bone graft material (Allograft, AlphaBio). We covered the implant with a cover screw and closed
the wound with sutures (Dafilon, Braun). We obtained a control segmental CT image of the im-
plantation area. Four months after implant placement and on the basis of a radiographic evaluation
of the osseointegration process, we obtained impressions and cemented a PFM crown with glass
ionomer cement (Fuji, GC).
For stabilization and esthetic reasons, we left the appliances in place until the end of the pros-
thetic rehabilitation process. This also allowed for any possible spatial corrections to be made in the
placement of the prosthetic crowns.
Once the prosthetic treatment was completed with intercuspation in class I according to the
Angle classification, we removed the orthodontic appliances and placed fixed retainers. We pre-
scribed a trainer (Myobrace A1, Myofunctional Research) to control an improper swallowing

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pattern with the tongue placed between the teeth, introduce nose breathing, and maintain the
treatment results. The total treatment time was 2 years and 3 months. Follow-up visits every 3
months were recommended.
The patient was satisfied with the achieved results of the treatment in terms of functionality and
esthetics (eFigures 5-7). She felt a significant reduction in pain in the temporal, masseter, and
sternocleidomastoid muscles. The clenching of teeth at night decreased, and she began to sleep
better. Her well-being improved.

DISCUSSION
Unrestored edentulous areas or incorrect restorations may lead to the deepening of the bite, which
adversely changes the relation of the mandible to maxilla. Pain appears in the region of the head,
neck, and back, and functioning of the TMJs is impaired.17,18
Reduced occlusal space prevents correct restorative treatment with the use of prosthetic crowns
and restorations and leads to excessive wear of the anterior teeth. Therefore, before prosthetic
treatment is commenced, it is advisable to obtain correct occlusal conditions in 3 planes: vertical,
horizontal, and frontal.
The completed implantology-orthodontic-prosthetic treatment in this case report led to proper
intercuspation of the teeth in the triads and prevented their wear, migration, and tilting. TMJs
regained their normal function. No decompression occurred. Persistent headaches and back and
neck pains were gone.

CONCLUSIONS
For many years, the only predictable and durable method of restoring missing teeth was the use of
bridges. Today, dentists increasingly use dental implants. Thanks to this, dentists are able to
eliminate the irreversible loss of hard tissue. Rather than grinding the teeth for the crowns, dentists
should always consider using veneers. In selected individual clinical cases, they can be used without
any preparation of the teeth. Before the beginning of the treatment, dentists should make an ac-
curate diagnosis, determining if the patient is qualified and the select materials are appropriate.
Achieving the desired functional and esthetic effect often requires cooperation with physicians of
various specialties and multistage treatment. n

SUPPLEMENTAL DATA
Supplemental data related to this article can be found at: https://doi.org/10.1016/j.adaj.2018.04.028.

Dr. 
Smielak is an assistant professor, Department of Dental Prosthetics, Dr. Andruch is in private practice, Lodz, Poland.
Medical University of Lodz, ul. Pomorska 251, 92-213, Lodz, Poland, e-mail Disclosure. Drs. Smielak and Andruch did not report any disclosures.
bsmielak@hotmail.com. Address correspondence to Dr. Smielak.

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 eFigure 1. Baseline.

eFigure 2. Panoramic radiograph.

eFigure 3. Fixed orthodontic appliance after placement.

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eFigure 4. Computed tomographic scan of the mandible before immediate implant placement in position no. 19.

eFigure 5. View of the anterior teeth after treatment.

eFigure 6. Right lateral view after treatment.

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 eFigure 7. Left lateral view after treatment.

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