The Conservative Restoration In Critical Areas

The Conservative Restoration In Critical Areas




A young patient presented to the Author with a traumatic coronal fracture of tooth 21, localized at cervical level at about 1 mm from the cementum-enamel junction.

A standardized periapical radiograph was taken and a careful treatment plan was designed. A multidisciplinary approach was chosen, based on endodontic treatment, temporary conservative restoration, orthodontic treatment and prosthetic rehabilitation of the tooth.

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After the clinical examination, an oblique coronal-apical fracture moving buccally to palatally was evidenced; such fracture extended below the palatal gingival margin causing the complete detachment of the crown.

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The operatory field was isolated by means of rubber and liquid dam and the tooth was subjected to endodontic treatment and three-dimensional obturation of the root canals.

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Then, a glass fiber post was luted using a resin cement.

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After rinse and disinfection of the crown, the fragment was bonded to the root by menas of adhesive techniques, paying careful attetntion to the isolation and inspection of the gingival margin.

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Then, the restored tooth was subjected to orthodontic treatment. A controlled extrusion was performed, progressively reducing the length of the crown at the incisal margin, in order not to create any occlusal interference and keeping a good simmetry of the front teeth.

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The orthodontic extrusion caused a coronal migration of both the marginal and deep periodontal tissues.

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Subsequently, the clinical crown was lengthened by means of periodontal surgery, so as to match the gingival parabola to that of the adjacent tooth.

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The patient was not satisfied by the esthetics of tooth 11 beacuse of a sever milky characterization of the incisal third. Consequently, the appearance of the tooth was corrected with a minimally invasive conservative treatment.

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After healing of the periodontal tissues, the tooth 21 was prepared for a prosthetic restoration and the marginal tissues were conditioned with a temporary resin restoration.

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Finally, the tooth was restored with an all-ceramic single crown.

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The Author would like to thank Dr. Aldo Crescini (Brescia, Italy) for the orthodontic support.



Odontoiatria estetica adesiva. Didattica Multimediale

A. Cerutti, F. Mangani A. Putignano

Quintessenz Verlags-GmbH, Berlin

Invisible Orthodontics: a case report of severe open bite

Invisible Orthodontics: a case report of severe open bite




‪Many adult patients require aligned teeth to improve their aesthetics, as dental exposure and smile are fundamental for the beauty of the face.

For this reason, the orthodontic treatment plan is the result of a careful radiographic examination and related cephalometric tracing, a detailed examination of the dental casts and related space analysis, but also an accurate aesthetic facial analysis.

We want to focus our attention on the exposure of the maxillary incisors with lips at rest. This is critical, for example, when we treat a case with overbite alterations, both in excess and in defect.

The clinical case we introduce is an example of treatment in case of anterior open bite. The patient asked for a fixed invisible lingual orthodontic therapy without brackets, to completely hide the presence of the device without phonetic distortions and tongue irritations.

Ortopantomography, Latero-Lateral Teleradiography, cephalometric study, cephalometric values chart :

open bite


I dental class

first dental class



trac iniz

tab iniziale


‪Despite a negative overbite, exposure of the upper incisal edge was about 2 mm, therefore the correction of the vertical discrepancy could not be obtained by extrusion of the frontal group.

It was also considered that an increased incisal edge exposure at the rest lip position would have already been obtained through the reduction of the excessive flaring of the frontal teeth.

‪The therapy was performed by intrusion of the posterior group and the lingualization of the upper and lower frontal groups.

For this purpose, it was first performed a stripping procedure from the distal surface of 12 to the distal surface of 22 and from the distal surface of 42 to the distal surface of 32, to create the space for the lingualization of the incisors.


Stainless steel sectional wires were bonded onto the cuspid and bicuspid teeth of each quadrant. A retainer was modeled on the frontal group with U-shaped vertical loops between the lateral incisors and cuspids.

6 apparecchio linguale

7 retrazione incisivi

In order to obtain a sliding mechanics in the incisors area, the retainer was isolated with a wax sleeve.


5b. cera ortodonticaJPG

‪Bonding procedure was first accomplished onto the incisors.


‪Subsequently, the retainer was bonded onto the cuspids, opening the loops of about 1.5-2 mm.


‪View of the loop before and after the bonding on 23:

invisible orthodontics

9 retainer attivo

‪The same system applied to the mandibular arch, after the stripping procedure:

lower arch

‪Simultaneously to the retraction of the upper and lower frontal groups to obtain the intrusion of the posterior sectors, two miniscrews were applied at the buccal side between the first and second molars. An elastic chain was tied from one end to the screw while the other end was directly bonded onto the buccal aspect of the second molar.

molar intrusion

11 intrusione settori posteriori

orthodontic microscrew

‪The patient was checked once a month and at each follow-up it was either replaced the intrusion chain and activated the retraction archs.

To perform these activations, it was removed most of the composite covering the wire with a diamond cylindrical bur at low speed leaving a thin composite layer so as not to damage the wire. The last composite layer was removed with a leverage movement made with a dental explorer.

Debonding and rebonding of the loop on the maxillary left cuspid:

8 ansa ortodontica

active retainer

Retraction of the frontal group and gradual reduction of the spaces created by stripping:

14 ortodonzia linguale

anna mariniello invisible orthodontics

‪Frontal view of the progressive reduction of the open bite:

bite closing

17 allineamento dentario

18 livellamento dentario

19 denti dritti

20.sorriso perfettoJPG

Lateral view after several months of activations and gradual reduction of the open bite:

21 visione laterale denti

22 denti sani


24 correzione overjet

25 normalizzazione overbite

26 normalizzazione overjet

‪Comparison of the initial and final frontal views:

27 grave malocclusione

final smile

Ortopantomography, Latero-Lateral Teleradiography, cephalometric study, cephalometric values chart:

ortopantomografia finale

teleradiografia finalejpg

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tab finale



Macchi A, Rania S, Cirulli N. Una proposta per la gestione di disallineamenti anteriori: il mantenitore attivo di contenzione (MAC)”. Mondo Ortodontico 1999;5: 389-393.

Macchi A, Cirulli N. Fixed active retainer for minor anterior tooth movement. J Clinical Orthod 2000;34: 48-49.

Liou EJW, Chen LIJ, Huang CS. Nickel-titanium mandibular bonded lingual 3-3 retainer: for permanent retention and solving relapse of mandibular anterior crowding. Am J of Orthod Dentofacial Orthop 2001;119:443-449.

Mariniello A, Cozzolino F. Lingual active retainers to achieve teeth levelling in orthodontics: case series. International Dentistry SA 2008; Vol 10 N 5, pag. 24-29.

Kluemper GT, Marciani RD, Smith KJ. Biologic response to an intraoral extraosseous implant system: a pilot study. Implant Dent 1995;4:46-49.

Goodacre CJ, Brown DT, Roberts WE, Jeiroudi MT. Prosthodontic considerations when using implants for orthodontic anchorage. J Prosthet Dent 1997;77:162-170.

Huang LH, Shotwell JL, Wang HL. Dental implants for orthodontic anchorage. Am J Orthod Dentofacial Orthop 2005;127:713-722.

Florvaag B, Kneuertz P, Lazar F, Koebke J, Zöller JE, Braumann B, Mischkowski RA. Biomechanical properties of orthodontic miniscrews. An in-vitro study. J Orofac Orthop 2010;71(1):53-67.

Park YC, Lee HA, Choi NC, Kim DH. Open bite correction by intrusion of posterior teeth with miniscrews. Angle Orthod 2008;78(4):699-710.

Moon CH, Lee DG, Lee HS, Im JS, Baek SH. Factors associated with the success rate of orthodontic miniscrews placed in the upper and lower posterior buccal region. Angle Orthod 2008;78(1):101-6.

Fritz U, Diedrich P, Wiechmann D. Lingual technique – patient’ characteristics, motivation and acceptance. Interpretation of a retrospective survey. J Orofac Orthop 2002;63:227-33.

Mauro Fradeani. La riabilitaione estetica in protesi fissa. Analisi Estetica. Quintessensa Edizioni 2004. Volume 1 capitoli 2 e 3.

Zachrisson BU, Minster L, Ogaard B, Birkhed D. Dental health assessed after interproximal enamel reduction: caries risk in posterior teeth. Am J Orthod Dentofacial Orthop 2011;139(1):90-8.

Zachrisson BU, Nyøygaard L, Mobarak K. Dental health assessed more than 10 years after interproximal enamel reduction of mandibular anterior teeth. Am J Orthod Dentofacial Orthop 2007;131(2):162-9.

Complex prosthetic rehabilitation due to severe dental wear

Complex prosthetic rehabilitation due to severe dental wear



In collaboration with Dr. Leonardo Bacherini

Several factors affect the life of a tooth and, consequently, different causes can lead to dental wear. Unfortunately, their effects are cumulative and irreversible and, despite its main cause, tooth wear starts immediately after tooth eruption. As a consequence, clinicians have to diagnose such a condition early, particularly when dental wear occurs suddenly and progressively in young patients. The processes causing tooth wear are attrition, erosion, abrasion, demastication, abfraction and non-carious cervical lesions.


Patient’s expectations

  • Remote pathological anamnesis: bulimia during youth
  • Recent pathological anamnesis: gastro-esophageal reflux disease (GERD)
  • Non smoker
  • Dental anamnesis: the patient complained about severe sensitivity on all teeth and wanted to improve the esthetics of her smile; the teeth were short and abraded

Localized Management of Sinus Floor

Localized Management of Sinus Floor




The Localized Management of Sinus Floor is a surgical technique for transcrestal maxillary sinus floor elevation. Its aim is to create a surgical site for implants by displacing a portion of native residual below bone within the cavity of the maxillary sinus. This particular type of bone is usually found below the sinus floor and, through this technique, is displaced vertically in order to create a new implant alveolar portion. In the final configuration of the surgically created alveolus, the coronal portion of the crest must give primary implant stability. This will be completed by the coronal bone portion – pushed laterally and internally of the sinus cavity – from which, a sort of closed “tent” formed by the sinus membrane, will keep the cavity closed. The latter will be filled by blood produced by the alveolar walls.

Tissue repair of the peri-implant alveolus is totally entrusted to the physiological mechanism of bone repair on the site chosen for the implant osteotomy. 3-4-13-14

The goal is to change the height of available bone by creating an osteotomy tunnel starting from the crestal position and extending, initially transversally and medially, in a direction parallel to the palatine vault. This way, the osteotomy tunnel pushes the spongy bone against the floor of the maxillary sinus and avoids loss of the precious calcified structure.

The initially transverse direction (and not vertical, according to the normal prosthetic axis) is essential to:

1. Increase the height of native bone, interfacing the implant to improve primary stability;

2. Use the higher portion of the sinus floor which is normally found towards the medial side of the sinus cavity.

Preparation of the surgical field

According to the protocol, the preparation of the soft tissues is made with a partial thickness technique that has the objective to leave a thin layer of connective tissue which:

1. Ensures the integrity of the periosteum;

2. Allows to easily read the underlying bony anatomy.

The protection of the periosteum is critical, of course, to maintain the integrity of the blood supply15. Also the layer of connective tissue, and the interposed periosteum between tissue and bone, will be fundamental to promote the peri-implant tissue secondary intention healing. This is one of the main issues of the protocol.

This preparation enables to firmly anchor the keratinized tissue – using the sub-periosteal sutures – in an apical and vestibular position. This residual displaced tissue, previously covering the crest, has been displaced vestibularly14.

The flap preparation begins with a palatally beveled incision which slides along the bone plane, starting from the palatal angle of the crest, exactly where the palatal structure crosses the horizontal portion of the edentulous ridge. This has the aim of exposing the crest and displacing vestibularly the keratinized crestal residual tissue to the future implant emergency. This crestal tissue is the same one which has been previously moved from the palatal aspect of the surgical field. Fig. 01/05


Fig. 01. Clinical aspect of the edentulous ridge of # 24 and # 25. The band of keratinized gingiva is now limited to the crestal position and the mucogingival line is now at the limit of the bucco-coronal angle.


Fig. 02. Intraoral x-rays with the existing bridge and the descending position of the maxillary sinus floor. The latter greatly reduces crestal height in the anatomical position of # 25.
Less than 4mm height in section 17 of the Maxi-Scan Fig. 04a


Fig. 03. Maxi Scan of the left maxilla from the palatal foramen to the distal portion of # 23.


Fig. 04. Maxi Scan of the maxilla area from the left distal section at # 23. The sections involved in the insertion of the implants are the 12/13 for the implant in position # 24 and 15/16 for the implant in position # 25


Fig. 05. The edentulous area was prepared according to the protocol described above, with a partial-thickness flap leaving a thin layer of connective tissue to ensure the periosteal continuity. The parasulcular incision of # 23 delimits the surgical field that can be used for the insertion of the implant and simultaneously maintains its anatomical integrity. An initial bone incision was carried out mesio-distally. The releasing palatal incisions are visible.


To overcome and loosen the muscle fibers over the muco-gingival line enables to completely release the flap.

The preparation on the buccal side of the flap is completed with parasulcular incisions around the adjacent natural teeth to delimit the osteotomy site and also to better mobilize the flap.

The second incision mirrors the first, starting on the palatal edge of the bevel, and continuing through the connective palatal tissue, always running the blade tip on the bone plane with a cut parallel to the profile of the palatal arch. This incision is necessary in order to underline the profile of the palatal curve. Fig. 05

When no adjacent natural teeth are present, elongated relaxing incisions are made always with a large base for the mucosal flap. 14 Fig. 05


Implant site preparation

The thrust of the dislocated spongy bone against the sinus floor creates fault lines of the dome that, simultaneously and gradually, push up the sinus membrane. 3/4/12/14

All this is possible with a sequence of instruments that do not have a cutting, but primary a pushing, capacity. Therefore the correct term for these instruments is “expanders”, rather than “osteotomes”.

The surgical protocol defines a specific set of instruments for the purpose. The first three instruments actually do have cutting capacity and are used with the aim of creating an initial crestal osteotomy where the prosthetic implant palatal emergency is planned. The palatal implant position remains the stable reference point as the bone flap will be distracted in a final buccal position.

This entry point into the bone structure may safely receive the second set of instruments (expanders) that, unlike the first, have rounded tips and are intended to displace the largest possible surface area of bone within the maxillary sinus in the medio-lateral direction. 3/14 Fig. 05

Contrary to the first, the second set of instruments have a rounded tip and have the aim of displacing the largest possible bone surface within the maxillary cavity in a medio-lateral direction.

Crestal bone that will be pushed inside the cavity to create the apical portion of the implant site. So as to say, the intra-sinus native bone alveolus structure that forms the apical portion of the new surgical bone socket. Fig. 06/010


Fig. 06. Intraoperative x-rays with probes in position. The plate is 10mm thick. The first probe has a connective disk of 3.8mm diameter and the second of 4.7 mm. The second probe is inserted with the larger rounder 3mm tip which produced the first disruption of the sinus floor. It is clear that the space between the two initial surgical tunnels must be increased of at least 3mm. This can be done essentially mesializing the # 24 tunnel.


Fig. 07. The first implant of 3.8x13mm is almost in its final position. The second X-ray probe has been left in position so that it can be used as a stable reference point for defining the surgical site for the implant in position # 24.


Fig. 08. Final position of the implants after removing the mounter. The implant in position # 24 is a 3.8x13mm and the implant in position # 25 is a 4.7×10.50mm. The amount of horizontal gain obtained by the combination of horizontal and vertical expansion is clearly visible.
The releasing bone incision comes from the inside of the first mesio-distal bone incision. It is beveled following the radial profile of the # 23 root prominence. This peculiar trace leaves the implant’s vestibular-mesial angle covered by the bone flap, thus maintaining the continuity of vascularization.


Fig. 09. The 2mm high healing screws have been tightened, as required by the protocol to 20 N/cm. It is essential to block a portion of collagen sponge under the palatal incision to prevent bleeding. The keratinized tissue taken from the palatal side of the incision has been adapted buccally to the screws and fixed in that position with subperiosteal sutures. This avoids excessive suture traction.


Fig. 010. Check X-ray with the healing screws and the cemented cantilever bridge. Excess cement under the bridge must be accurately removed. A portion of spongiosa displaced apically over the distal implant is clearly seen on the x-ray image. This creates a new peri-implant alveolus, displacing apically the native residual bone. This tissue was previously found lining the sinus floor.


The protocol does not require the use of burs.

The first cutting tool is the blade of the Beaver # 64 which will be used up to 1mm below the floor of the sinus. Fig. 05/06

After the Beaver # 64, two bone expanders with 90° cutting edges will be introduced in sequence:

1. the BE2 with the 1.5mm tip and, following, 2. the BE3 with the 1.9mm tip.

The BE2 and BE3 define a site for the emergence profile of the implant and an area of initial penetration that is used to guide the successive instruments with rounded tips8. The next bone expander is, in fact, the BE 45/15 with its 2.2mm rounded tip, which will be pushed below the floor of the sinus always transversally. The tunnel created with the BE 45/15 is then used to insert the 10mm length rounded 3mm diameter probe tip that will produce the first cracks in the medial side of sinus floor. Fig. 06/07

This probe will create a 10x3mm surgical tunnel parallel to the palatal vault. Reorientation towards the ideal (verticalized) prosthetic axis is obtained gradually when extracting this – and successive instruments – by forcing the tips of the instruments buccally during removal.

The following instruments, with a progressively increasing diameter, are inserted and then extracted with the same technique. It is very important that the final cavity must remain under dimensioned in both height and width, so that the final thrust is produced by the implant itself, which will be stabilized in the native bone available under the floor of the sinus. Fig 06/07

Before implant insertion, a portion of collagen is inserted and pushed using a Bone Expander in apical position, so that it remains interposed between the apex of the implant and the portion of displaced bone. This will create the apical, intra-sinus portion of the surgical alveolus5-10-11-12-14.

The extent of under sizing will be strictly conditioned by the quality of the bone and by the implant shape.

The changes induced in bone volume, are usually simultaneous to implant insertion.

The implant inserted into native bone will have the advantage of being functionalized at 70 days from insertion.

The reparative osteointegration can be easily followed-up with a clinical check and with a simple periapical x-rays7. Fig. 02/10/11/17/18



Fig. 010. Check X-ray with the healing screws and the cemented cantilever bridge. Excess cement under the bridge must be accurately removed. A portion of spongiosa displaced apically over the distal implant is clearly seen on the x-ray image. This creates a new peri-implant alveolus, displacing apically the native residual bone. This tissue was previously found lining the sinus floor.


Fig 011. The check x-ray after three months of load shows new apical bone structures above the implants. A new cortical line delimits the new sinus floor position. This is a typical functional response to osseointegration.
The implants were loaded, according to protocol, with a functional provisional at about 70 days from insertion, for a period of three months.
Please note that no filler materials are used in the Localized Management of Sinus Floor technique.


Fig. 017. Radiographic appearance two years after implant insertion and after about 18 months of functional load. In the image it is possible to read the new bone density at both the apical and coronal levels, due to the physiological response of the bone to the functional load.


Fig. 018. X-ray situation at four years from implant insertion. Radiographycally it is possible to visualize the new bone density in the zone between #23 and #24. This is also possible in the inter-implant space and in the new cortical line that profiles the sinus cavity.


Apical repositioning and suturing of the flap

After implant insertion the surgical screws are tightened to 20 N/cm to test primary stability and prevent accidental screw loosening. Fig. 09/10

The flap is adapted buccally and compressed for a few seconds to the emergence profile of the healing abutment in order to stabilize it in its final position. This position must be maintained.

The flap is firmly fixed in the desired position with sutures anchored to the periosteum. Fig. 09

The suturing technique must prevent ischemia and tension in the repositioned soft tissues so that the blood flow is not obstructed. This is especially important in the phase in which the post-operative edema reaches its apex.

The choice of the height of the healing abutment is made according to the thickness of the soft tissue; the height must be sufficient to stabilize buccally the keratinized mucosa repositioned from the palate.

The gap that remains between the buccal and palatal edges of the flaps will heal by secondary intention. This will also favor the regeneration of peri-implant keratinized mucosa that, as such, will stabilize itself over time. Fig. 012/013/014/015


Fig. 012. Clinical appearance in an occlusal view at about a year after the insertion of the implants.


Fig. 013. Enlarged view where we can note how the implant profile emergency lies within a volume of cheratinized tissue similar to the physiological one. The muco-gingival line is apically displaced in a position similar to that of the natural contiguous teeth.
The interproximal gingival space between # 23 e # 24, where a deep post-surgical depression was present, has been practically completely filled as a primary result of the secondary intention healing. Compare to Fig. 09a

12102011-Fig.-014a Bruschi-Tif

Fig. 014. Occlusal view with the implant abutments modified according to the Anatomically Modified Abutment (A.M.A.) technique before cementation of the final prosthesis.


Fig. 015. Vestibular view with the A.M.A abutments ready for cementation.


Objectives of the flap technique

  • To adapt the keratinized tissue present on the crest to the implant emergence profile.
  • To increase the thickness and height of the keratinized tissue during implant insertion by avoiding a second surgical stage and probably establishing immediately the peri-implant biological width1-2-6-9.
  • To reduce the surgical trauma and simultaneously re-establish a normal depth of the fornix.
  • To preserve the natural anatomy of the contiguous teeth avoiding damage to the profile of the papillae.
  • To mimic the natural morphology of the gingiva. Fig. 013/014/15/16
  • To better cover the grey color titanium with thicker keratinized mucosa.
  • To facilitate a more effective home care.


Fig. 016. Final crowns in position. The inter-papillar spaces are designed with an ideal emergency so as to enable the gum to adapt itself to the profile of the crowns.


Fig. 017. 4 yrs follow-up.




1. Abrahamsson I, Berglundh T, Lindhe J . “The mucosal barrier following abutment dis/reconnection. An experimental study in dogs”, J Clin Periodont 1997;24 (8) : 568-72

2. Berlundh T, Lindhe J. “Dimension of the periimplant mucosa. Biological width revisited. J Clin Periodontol”, 1996 Oct;23(10):971-3

3. Bruschi GB, Scipioni A, Calesini G, Bruschi E. “Localized Management of Sinus Floor with Simultaneous Implant Placement. A Clinical Report”, Int J Oral Maxillofac Implants 1998;13:219-226

4. Bruschi GB, Crespi R, Capparè P, Bravi F, Bruschi E, Gherlone E. “Localized Management of Sinus Floor Technique for Implant Placement in Fresh Molar Sockets”, Clin. Implant Dent Relat Res. 2011 May 20

5. Buchter A, Kleinheinz J, Wiesmann HP et al. “Biological and Biomechanical evaluation of bone remodeling and implant stability after using an osteotome technique”, Clin. Oral Impl. Res. 16,2005; 1-8

6. Cocharan DL, Hermann JS, Schenk RK, Higginbottom FL, Buser D. “Biologic Width around Titanium Implant. A Histometric Analisis of the Implanto-gingival Junction around Unloaded and Loaded Nonsubmerged Impants in the Canine Mandible”, J Periodontol 1997 Feb; 68(2): 186-98

7. Friberg B.A Comparison between Cutting Torque and Reasonance frequency measurements of maxillary implants. A 20-month Clinical Study”, Int J Oral Maxillofac Surg 1999 Aug; 28 (4):297-303

8. Hartmann GA, Cocharan DL, “Initial implant position determines the magnitude of crestal bone remodeling”, J Periodontol 2004; 75: 572-577

9. Linkevicius T. Apse P, Grybauskas S, Puisys A, “Influence of Thin Mucosal Tissues on Crestal Bone Stability around Implants with Platform Switching: A 1-year Pilot Study”, J Oral Maxillofac Surg 2010 Sep;68(9): 2272-7

10. Nkenke E, Kloss F, et al, “Histomorpfhometric and fluorescence microscopic analysis of bone remodeling after installation of implants using an osteotome technique”, Clin. Oral Impl. Res. 13, 2002; 595-602

11. Nobrega AR, Norton A, Siva JA, Silva JPD, Branco FM, Anitua E, “The osteotome Versus Conventional Drilling Technique for Implant Site Preparation: A Comparative Study in The Rabbit”, Int J Periodontics Rest 2013;32:e109-e115

12. Yilmaz HG, TÖzÜm TF, “Are Gingival Phenotype, Residual Ridge Height, and Membrane Thickness Critical for the Perforation of Maxillary Sinus?”, J Periodontol 2012; 83:420-425

13. Terheyden H, Lang NP, Bierbaum S, Stadlinger B, “Osseointegration – communication of cells”, Clin. Oral Impl. Res. 23, 2012, 1127–1135 doi: 10.1111/j.1600-0501.2011.02327.x


14. Bruschi GB, Crespi R, “Tecniche di espansione ossea in chirurgia implantare”, Quintessenza Edizioni 2012

Contributions to books

15. Wthinson SW. Ten Cate (ed), “Oral Histology”, 4th Edition.

16. Bruschi GB, Scipioni A, “Alveolar augmentation: New application for impants”, In: Heimke G. (ed), “Osseointegrated Implants, Vol I”, Boca Raton, FL CRC Press, 1990;2:35-61




M.D. University of Rome, D.M.D. (specialty in Dentistry) University of Rome. Assistant Professor at Boston University School of Graduate Dentistry Department of Prosthodontics directed by Prof. Martignoni. He has published numerous scientific articles in both national and international peer-reviewed journals. He is co-author of the book “Implantologia Orale” (Ed. Martina, Bologna, Italy). Co-author of the book “Implantoprotesi il ripristino dell’omeostasi tramiti restaurazioni singole” (Ed. Martina, Bologna, Italy). Co-author of the book “Techniques of bone expansion in implant surgery” (Quintessence International). Private practice in Rome limited to Oral Surgery and particularly Implantology and Endodontic Surgery.



For info:

Esthetics in Total Removable Prosthodontics

Esthetics in Total Removable Prosthodontics



From the impression tray to the denture: techniques for fabrication


Patients feel teeth loss as a worsening of the quality of life. Although in the last years prevention in dentistry has reached more and more comfortable levels, the lengthening of average life is often associated with an increase in the incidence of periodontal disease and loss of tooth support, causing complete edentulism over time. The overcoming of problems related to edentulous patients requires specific skills for the clinicians and stimulates the research of innovative technique and restorative materials. In fact, each laboratory and clinical step has to be performed in the respect of traditional concepts, from the extension to the basal areas to the precision of the interface between soft tissues and the impression surface of the denture, from the border molding to the modelling of the prosthesis, from a proper and physiological record of the intermaxillary relationships to the optimal mounting of the artificial teeth.

A 58-year old female patient presented with complete edentulism; she was not a smoker and was in good general health. The patient’s complaints regarded both function and communication, referring a severe discomfort in interpersonal relationships. Consequently, she requested for a radical rehabilitation of her mouth, paying particular attention to esthetics. Consequently, the aim of the prosthetic rehabilitation was the achievement of both optimal functional and esthetical results.

According to a conventional approach, the dentist took the study impressions by means of an irreversible hydrocolloid. The preliminary impressions have to be overextended, so as to record the whole extension of the maxillary and mandibular arch as well as of the adjacent soft tissues.

The impressions were disinfected in the dental laboratory. The borders were covered with wax and the impressions were boxed in order to pour the dental stone; this allowed to achieve detailed and esthetically valid casts.
According to the dentist’s indications, the Passamonti’s technique was chosen to fabricate the customized impression trays. The depth of the fornix was marked using a blue pencil.
The project was completed designing the limits of the impression trays and the tissue stops.




The preparation of the impression trays was completed covering the casts with a controlled thickness of dental wax.
Then, the individual impression trays were fabricated.
According to the conventional procedures, the dentist recorded the final, overextended impressions.

The impressions were poured with Class IV dental stone.

Then, the registration bases were fabricated using light-curing resin; the polymer shrinkage was limited by means of a multi-step polymerization technique.




Il medesimo materiale fotopolimerizzabile veniva, inoltre, utilizzato per produrre una placca per facilitare la registrazione dell’arco facciale con una struttura ritentiva per farla aderire alla forchetta occlusale

The same light curing material was used to produce a maxillary registration base for the facial bow.

The intra- and extra-oral registrations were recorded using a facial bow, so as to check the correctness of the lip support and harmonize the oro-facial relationships.

The casts were carefully blocked in the articulator, in order to not vary the inter-maxillary relationships recorded intraorally. First, the maxillary cast was blocked;
then the mounting in the articulator was completed.


After carefully checking the centric and non-centric movements of the mandible in the presence of total removable dentures, the bilaterally balanced occlusion was chosen as occlusal scheme to improve the stabilization of the prostheses.

On the basis of the intraoral records performed by the clinician on the wax blocks, it was possible to choose the proper dimensions of the maxillary anterior teeth as well as the correct length of each tooth.

Resin teeth Vitapan Plus were used; the customized line of the incisal margin, the natural appearance of the borders and the vitality of the surface texture allow these artificial teeth to be perceived as natural ones. The interdental embrasures allow not only to set a natural configuration of the papillae but also to achieve an easier cleaning of the denture by the patient. The palatal configuration supports the anterior guidance and contributes to a proper speech.

The “substitution” technique was used to mount the front teeth; consequently, the proper amount of was was removed to place the corresponding tooth,


until the setting of the maxillary front teeth was completed.




The mounting technique made the teeth 33 and 43 to be placed so as to guide the sliding of the maxillary canines on the mandibular ones, avoiding diastemata in the posterior segments and obtaining a correct proportion between over jet and overbite.

Once the teeth 33 and 43 were set, the teeth 31 and 41 were placed respecting the midline of the maxillary central incisors.


In the remaining room, the teeth 32 and 42 were finally set.


The mounting was completed balancing the relationship between function and esthetic.


A first intraoral try-in was performed to verify the correctness of the mounting of the front teeth by means of phonetic and esthetic procedures. During these steps, the trust gained by the patient is paramount to make the patient cowork with the dental team. In the respect of the functional parameters, it is even possible to allow the patient to suggest specific esthetic changes finalized to meet his/her expectations.


Then, the mounting of the posterior teeth was performed in a bilaterally balanced occlusion.

The Vita Lingoform teeth were used to set the posterior segments. The univocal reproduction of the centric contacts and the spherical intersection of the interproximal surfaces allow for a controlled mounting of the Lingoform in any bite configuration. Being suitable for any mounting technique, even the lingualized one, particularly in full removable prosthodontics, the Vita Lingoform teeth can prevent the atrophy of the alveolar crests even in the presence of unfavorable static and dynamic mandibular relationships. The occlusal design is suitable for both one-to-one and one-to-two tooth contact. The possibility to widen the space for the tongue and to support the cheeks given by the Vita Lingoform teeth contributes to the patient’s comfort.

Then, the posterior teeth of both arches were mounted: the tooth 14 contacted with both cusps the plan of the mandibular wax block, the tooth 15 was in contact with only the palatal cusp and the tooth 16 with only the mesio-palatal cusp, so as both the Spee’s and Wilson’s curves were set.


Similarly, the contralateral arch was mounted.


Once the maxillary arch was completed, the mounting of the mandibular posterior sectors was performed starting with the tooth 36 in respect of the Angle’s class; then, the teeth 34 and 35 were placed in one-to-two tooth contact, so as to make the cusps of maxillary teeth close in the lower fossae.


Similarly, the contralateral arch was mounted.

Then, the dentist checked again the occlusion, the vertical dimension, the esthetic and phonetic procedures, achieving the best natural appearance and collaboration by the patient.


Successively, the posterior limit of the maxillary denture was identified on the master cast, signing the sealing area and the gypsum to be removed.


Once the amount of gypsum to be removed was quantitatively signed with “ + “ and “ – “ on the master cast, the procedure was carried on in the anterior-posterior direction.

As reported above, in order to achieve the best esthetic result, particular care was dedicated to the proper integration between the gingival margins of the artificial teeth and their color. First, the gingival contours were modelled with wax, so as to imitate the morphology of the natural papillae and gingival scalloping.



The mandibular denture and the posterior resin shields were modelled with the same technique.

86 87

A metal brush was used to obtain a gingival stippling effect.



The dentures modelled with wax were placed in a muffle one by one, in order to properly verify the final mounting in the articulator. Finally, the prostheses were polished and finished to carefully remove any debris.



The esthetic finalization of the dentures was based on the creation of a micro-geography simulating the terminal blood vessels on surface of the artificial alveolar mucosa.



The prosthetic shields were colored with composite materials. Controlled amounts of resin were removed and substituted with composites, in order to evidence the transition between the attached gingiva and the alveolar mucosa.


The finishing of the dentures was carried on with a two-step approach, using both a cleaning machine and hand instruments.







The criteria of esthetic evaluation could be different according to the viewpoint of the observer, being the dentist, the dental technician or the patient. Almost all the patients ask for white, completely straight and perfect teeth. Conversely, the operators look for color, surface texture, characterizations and anatomic modellation, in order to reproduce as closely as possible the natural tissues. Nonetheless, the treatment of completely edentulous patients necessitates to model and customize the prosthetic shields so as to improve the phonetics and to cover crest deformities.




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The author would like to thank Mr. Vincenzo D’Urso, Mr. Luca Di Maglie and Mr. Giovanni Martinelli for their scientific contribution.

CURRICULUM Carlo Montesarchio

Carlo Montesarchio was born in Naples in 1964. He took his Dental Technician certification in 1982; owner of his own dental laboratory since 1983. Author of publications on national and international journals, he participates in formation classes at the University “Federico II” of Naples. Lecturer for ANTLO.

He collaborates with dental industries for material and technology development. Lecturer at Master Courses of Removable Prosthodontics for VITA ZANFABRIK. He focuses all his activity on full removable dentures.

His formation is linked to several experiences dealt with national and international operators.


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