Computer-guided implant surgery and tooth-mirroring digital workflow to treat an esthetically compromised clinical case

Abstract

Background: In multidisciplinary dentistry, it is common to observe clinical cases that present multiple complications at the end of orthodontic therapy, such as differences in gingival height, alterations in size and shape of the teeth, and reduced residual spaces for implant therapies. Aim: The aim of the study was to solve an esthetic case with the help of digitally assisted prosthetic and surgical design. Methods: A young patient had been treated orthodontically for the agenesis of tooth 12 and the conoid shape of tooth 22. Previous therapy consisted of opening the space for tooth 12 by positioning a Maryland-type composite bridge, followed by reconstruction with a composite of tooth 22. Various composite reconstructions on teeth 11 and 21 were no longer adequate. Furthermore, both elements had discordant coronal axes, the diastema was observed at the incisal level, and tooth 21 was approximately 1 mm longer than tooth 11. Radiographic analysis revealed that the roots of teeth 11 and 13 converge, providing sufficient space for the insertion of a small-diameter implant. An intraoral scan and cone-beam computed tomography (CBCT) were performed; both data files were merged using surgical design software. A surgical guide was developed for the insertion of an implant in site 12. After insertion, the composite bridge, which was no longer suitable, was removed and a new temporary metal-composite Maryland bridge was positioned. Using an artificial intelligence tool of the design software, tooth 22 was isolated, mirrored, inserted in site 12 to reproduce the gingival profile, and subtracted from the digital impression. A technician then copied this emergence profile to build a zirconia prosthetic crown to be screwed on the implant. Teeth 22, 11, and 21 were restored with a lithium disilicate crown and two veneers, respectively. Results: The initial digital design and the use of a guided surgery procedure allowed for the insertion of a small diameter implant without damaging the roots of the adjacent teeth. The prosthetic design procedure, using the digital tools of the design program, made it possible to standardize and create symmetrical gingival profiles of teeth 12 and 22. The overall composition was completed by the use of minimally invasive adhesive prosthetic techniques on teeth 11, 21, and 22. Conclusion: Digital resources have become essential tools for dental professionals. The knowledge and use of technologies like intraoral scanning and CBCT, combined with various innovations such as artificial intelligence in prosthetic and implant design software, enable dentists to manage even the most complex interdisciplinary clinical cases with greater confidence. Relevance for Patients: Digital techniques are now widely used across all fields of dentistry. This has led to the need for operators of all ages to adjust their decision-making process compared to traditional techniques. These new techniques have also improved communication with patients, allowing the dental team to have a clearer understanding of the clinical path to follow and consequently offer their patients precise dentistry solutions.