UNIVERSIDADE ESTADUAL PAULISTA
“JÚLIO DE MESQUITA FILHO”
Instituto de Ciência e Tecnologia
Campus de São José dos Campos
ORIGINAL ARTICLE DOI: https://doi.org/10.4322/bds.2024.e4293
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Braz Dent Sci 2024 Apr/June;27 (2): e4293
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Rehabilitation of a Full-Arch Patient with Cemented Metal-Ceramic
Multiple Prostheses on Implants: A Case Report
Reabilitação de paciente de arco completo com Próteses Múltiplas Metalocerâmicas Cimentadas sobre Implantes – relato de caso
Adérico Santana GUILHERME1 , Yasmin Milhomens MOREIRA2 , Rhadija Victoria Mendonça MARTINS2 ,
Bárbara Lima de AGUIAR2
1 - Universidade Federal de Goiás, Faculdade de Odontologia, Departamento de Prevenção e Reabilitação Oral. Goiânia, GO, Brazil.
2 - Universidade Federal de Goiás, Faculdade de Odontologia, Curso de Graduação em Odontologia. Goiânia, GO, Brazil.
How to cite: Guilherme AS, Moreira YM, Martins RVM, Aguiar BL. Rehabilitation of full-arch patient with Cemented Metal-Ceramic
Multiple Prostheses on Implants - case report. Braz Dent Sci. 2024;27(2):e4293. https://doi.org/10.4322/bds.2024.e4293
ABSTRACT
Objective: To report a clinical case of a female patient rehabilitated with Cemented Metal-Ceramic Multiple
Prostheses on Implants in the upper arch. Materials and Methods: A multidisciplinary approach was employed,
utilizing various clinical skills to achieve satisfactory outcomes in the rehabilitation of a fully edentulous patient.
The treatment plan involved the use of cemented metal-ceramic prostheses, with a focus on optimizing the
positioning of the crown margins to ensure periodontal health. Results: The use of cemented metal-ceramic
multiple prostheses effectively addressed the patient’s aesthetic concerns by eliminating screw access holes and
ensuring the continuity of the ceramic material. The supragingival positioning of the crown margins prevented
excess cement in the peri-implant sulcus, promoting periodontal health. The nal prostheses provided excellent
aesthetics and functionality, leading to enhanced patient satisfaction. Conclusion: The choice of cemented
implant-supported prostheses represents a highly effective approach for treating edentulism. This method offers
clinical benets, such as increased retention and improved esthetic outcomes, while also positively impacting
the patient’s quality of life.
KEYWORDS
Dental implants; Dental implant-supported prosthesis; Fixed partial prosthesis; Prostheses and implants; Oral
rehabilitation.
RESUMO
Objetivo: Relatar um caso clínico de uma paciente feminina reabilitada com Próteses Metálicas-Cerâmicas
Cimentadas em Implantes na arcada superior. Materiais e Métodos: Foi empregada uma abordagem multidisciplinar,
utilizando várias habilidades clínicas para alcançar resultados satisfatórios na reabilitação de um paciente
totalmente edêntulo. O plano de tratamento envolveu o uso de próteses metálicas-cerâmicas cimentadas, com
foco na otimização do posicionamento das margens das coroas para garantir a saúde periodontal. Resultados: O
uso de próteses metálicas-cerâmicas cimentadas abordou efetivamente as preocupações estéticas da paciente ao
eliminar os orifícios de acesso para parafusos e garantir a continuidade do material cerâmico. O posicionamento
supragengival das margens das coroas preveniu o excesso de cimento no sulco peri-implantar, promovendo a
saúde periodontal. As próteses nais proporcionaram excelente estética e funcionalidade, resultando em maior
satisfação do paciente. Conclusão: A escolha de próteses suportadas por implantes cimentadas representa uma
abordagem altamente ecaz para o tratamento da edentulismo. Este método oferece benefícios clínicos, como
maior retenção e melhores resultados estéticos, além de impactar positivamente a qualidade de vida do paciente..
PALAVRAS-CHAVE
Implantes dentários; Prótese dentária xada por implante; Prótese parcial xa; Próteses e implantes; Reabilitação oral.
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Braz Dent Sci 2024 Apr/June;27 (2): e4293
Guilherme AS et al.
Rehabilitation of full-arch patient with Cemented Metal-Ceramic Multiple Prostheses on Implants - case report
Guilherme AS et al. Rehabilitation of full-arch patient with Cemented Metal-Ceramic
Multiple Prostheses on Implants - case report
INTRODUCTION
The options available for rehabilitating fully
edentulous patients with implant-supported
prostheses vary based on the number and
positioning of implants, as well as the type
of retention—either removable or fixed [1].
The selection of these options depends on several
factors, including the patient’s clinical conditions,
technical feasibility, personal preferences, and
nancial considerations [2]. Oral rehabilitation
through the replacement of missing teeth is
crucial for restoring masticatory function, occlusal
stability, the maintenance of support structures,
phonetics, and aesthetics. Additionally, it aims to
provide comfort to the patient and restore balance
to the stomatognathic system [3].
Implant-supported rehabilitations are a
reliable choice for replacing single or multiple
missing teeth, signicantly contributing to the
restoration of masticatory function and overall
quality of life [4]. There are different philosophies
regarding the type of nal connection used in
implant-supported prosthetic rehabilitations,
namely screw-retained and cement-retained [5].
Generally, this choice is based on the clinical
situation encountered and the preference of the
professional for one system over the other. These
systems can be applied in unitary, partial, or full-
arch rehabilitations [6].
Literature highlights the advantages
and disadvantages associated with each type
of prosthetic connection. Cement-retained
prostheses differ from screw-retained primarily
in their retention method, where cement-retained
prostheses are xed using provisional or denitive
cement, whereas screw-retained prostheses rely
solely on the mechanical retention of the screw
within the implant or prosthetic abutment [7].
The fabrication of cement-retained
prostheses on implants follows the principles of
conventional xed dental prostheses, requiring
less technical complexity and therefore being
more cost-effective compared to screw-retained
alternatives [7]. Among the advantages of
cemented retention is its ability to compensate
for discrepancies in implant positioning, achieve
passive t during seating, enhance aesthetics by
eliminating screw access holes, and facilitate
occlusal adjustments [8]. However, a notable
drawback is the challenge of removing excess
cement from subgingival areas, which can lead
to the development of periodontal diseases like
peri-implantitis and mucositis, posing additional
risks to treatment outcomes [8].
The use of cement-retained prostheses
is recommended in cases where prosthetic
connections are mechanically stable, such as with
Cone Morse implants, or when poorly positioned
implants make screw retention difcult via the
occlusal or cingulum aspects [9]. Both retention
types have their advantages and limitations,
underscoring the importance for clinicians to
carefully select the most suitable method for
each patient. Understanding the success rates
and potential clinical complications associated
with each retention system is crucial in making
informed decisions and optimizing the success of
rehabilitation treatments.
Based on these considerations, this article
aims to present a clinical case report on Cemented
Metal-Ceramic Multiple Prostheses on Implants,
conducted as part of a specialization course in
dental prosthetics with a focus on implantology
at the Faculty of Dentistry, Federal University of
Goiás.
MATERIAL AND METHODS
A 65-year-old female patient, partially
edentulous in both the upper and lower arches,
was presented to the specialization course
in dental prosthetics with an emphasis on
implantology at the Federal University of Goiás-
School of Dentistry seeking oral rehabilitation.
In the upper arch, the patient had complete
rehabilitation using single-unit implant-
supported prostheses screwed onto metal-resin
abutments. The prostheses were supported by
eight external hexagon (HE) type implants,
each with a platform diameter (abutment) of
4.1 mm (Figures 1A and B). The clinical and
radiographic examination indicated satisfactory
osseointegration with favorable spacing and
parallelism between the implants. However,
the prostheses became unstable due to screw
loosening, and the esthetics were compromised
by resin deterioration in color and wear, leading
to changes in tooth shape. Additionally, the
screw access holes, especially in the anterior
region, were located on the vestibular surfaces,
affecting the esthetics and posing difculties in
screw access, complicating the removal of the
prosthesis (Figures 2A and B).
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Guilherme AS et al.
Rehabilitation of full-arch patient with Cemented Metal-Ceramic Multiple Prostheses on Implants - case report
Guilherme AS et al. Rehabilitation of full-arch patient with Cemented Metal-Ceramic
Multiple Prostheses on Implants - case report
Initial steps included a thorough anamnesis,
clinical examination, and imaging with
panoramic and periapical radiographs (Figure 3).
The favorable osseointegration condition of the
implants was conrmed through radiographic
examination and periodontal probing in the
peri-implant region. Based on these ndings, a
rehabilitation plan was proposed.
The treatment plan involved a new
rehabilitation with multiple metal-ceramic
cemented prostheses instead of the previous single-
unit screw-retained prostheses. This decision was
inuenced by the emergence of prosthesis screws
outside the implant insertion axis. Opting for
screw-retained prostheses might compromise
esthetics due to the screws’ vestibular location
in future prostheses. Additionally, the external
hexagon (HE) platform implants (Figure 1C) could
lead to unfavorable outcomes with single-unit
prostheses due to biomechanical complications,
such as screw loosening and fracture. Therefore,
a system of multiple cemented prostheses was
chosen to avoid potential complications related
to the biomechanics of single-unit screw-retained
prostheses, commonly observed with external
hexagon platforms.
Before any procedure, a comprehensive
medical-dental evaluation was requested from the
patient, along with general health supplementary
exams. Preliminary impressions of the arches
were then taken using irreversible hydrocolloid
(Jeltrate/Dentsply – USA) to create study models
for occlusion analysis, vertical and horizontal
overlap, the curves of Spee and Wilson, and
identication of crossbite.
The subsequent treatment plan involved
several carefully planned stages. Initially, a
clinical assessment was performed, followed by
Figure 1 - (A and B) - Frontal and occlusal views of the rehabilitation condition
of prostheses on single-screwed metal-resin implants supported by eight implant
screws. These screws are of the external hexagon type with a platform diameter
of 4.1 mm.
Figure 2 - Vestibular view of the openings providing access to the screws of the
prostheses in the anterior region, causing aesthetic compromise and difficulty in
both accessing the screws and removing the prosthesis (Figures 2A and 2B).
Additionally, a view of the inter-occlusal space dimension (Figure2C).
Figure 3 - Eight implant screws are of the external hexagon type
with a platform diameter of 4.1 mm.
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Guilherme AS et al.
Rehabilitation of full-arch patient with Cemented Metal-Ceramic Multiple Prostheses on Implants - case report
Guilherme AS et al. Rehabilitation of full-arch patient with Cemented Metal-Ceramic
Multiple Prostheses on Implants - case report
the removal of the screw-retained prosthesis.
The integrity of the implant platforms, implant
parallelism, periodontal health in each implant
region, and inter-maxillary space dimensions
were assessed (Figures 1C and 2C).
After this stage, the upper arch and implant
platform molding procedure was carried out to
obtain the working model. Polyether impression
material (3M ESPE Impregum Soft - USA) with
regular consistency was used for this, employing
the drag impression technique with an individual
open acrylic tray and square transfer copings.
The performed molding involved the
external hexagon (HE) platforms of the implants
(Figures 4A, B, and C) and the prosthetic areas
of interest in the upper arch. After fixing the
square transfer copings on the implant platforms
using transfer guide screws and a 1.2 mm
hexagonal driver, the molding procedure itself
was prioritized (Figures 4A, B, and C).
To implement the technique, dental oss
was initially used to create a loop between the
external surfaces of the square transfer copings.
Subsequently, a resin bridge was constructed over
the dental oss using self-polymerizing acrylic
resin (Pattern Resin LS GC – USA), employing the
brush and powder-liquid resin technique [10] to
promote bonding between the transfer copings
(Figures 4A, B and C).
Next, the resin bridge was individualized
using a biphase diamond disc (Sorensen ES/
Br) attached to the straight handpiece of the
micromotor. After separation, the bridge was
reconnected using the same resin (Pattern
Resin LS GC – USA) to mitigate the degree of
resin contraction commonly observed after its
polymerization.
Next, the molding process commenced
with the initial application of universal adhesive
(Polyether Adhesive 3M ESPE -USA) to the
internal and external surfaces of the individual
acrylic tray to facilitate the bonding of the molding
material to the tray (Figures 4A, B, and C).
The window created on the upper surface of the
individual tray to access the guide screws of the
transfer copings was covered with a No. 7 slice of
wax sheet to contain the molding material when
seating the tray on the dental arch.
After three minutes of adhesive application,
the polyether impression material (Impregum
Soft 3M ESPE -USA) was manipulated. The tray
was filled with the impression material, and
the remaining material was collected with a
JON syringe (Jon Industry and Commerce –
Figure 4 - Vestibular and occlusal views of the bridge created for
the abutments using dental floss and autopolymerizing acrylic resin
(Figures4AandB). Individual tray and the impression obtained after
removing it from the patient’s mouth (Figure 4C). Mold with the
analogs related to the abutments (Figure4D).
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Rehabilitation of full-arch patient with Cemented Metal-Ceramic Multiple Prostheses on Implants - case report
Guilherme AS et al. Rehabilitation of full-arch patient with Cemented Metal-Ceramic
Multiple Prostheses on Implants - case report
SP/Brazil). Next, the impression material was
injected around the transfer copings on both
the buccal and palatal surfaces using the JON
syringe. The loaded tray was then placed on the
dental arch, and a six-minute wait ensued for
the complete polymerization of the impression
material. At the time of tray placement on the
arch, the guide screws of the transfer copings, still
xed on the hexagon platforms of the implants,
were passed through the wax sheet, leaving their
upper surfaces exposed in the oral cavity.
After achieving the polymerization of the
impression material, the guide pin screws of the
transfer copings were loosened, and the mold was
subsequently removed from the patient’s mouth.
The mold’s quality was then assessed followed
by its disinfection and the association of analogs
with transfer copings using a 1.2mm hexagonal
driver. After obtaining the mold, the union of
impression copings and analogs was carried out
(Figures 4A, B, C, and D). The articial gingiva
was then fabricated over the impression material
and around the cervical surfaces of the impression
copings. After the artificial gingiva material
polymerized, which also took 6 minutes, the mold
was poured with type IV special stone plaster
(Herostone – Vigodent SP/Br). Once the plaster
had set, which occurred after forty minutes, the
guide screws of the transfer copings in the union
of transfer copings and analogs were loosened
with the 1.2 mm hexagonal driver, and the mold
was then removed to obtain the working model
(Figures 5A and B).
Next, attention was given to the maxilloman-
dibular relationship (OVD) registration procedure.
For this, bases of self-polymerizing acrylic resin
(Resina Jet Clássico – SP/Br) were crafted on the
working model over the analogs of the implants.
Titanium cylinders, used in the fabrication of tem-
porary prostheses, served as supports (Figure 6).
After creating the resin bases, the OVD was
recorded. Initially, the crowns on implants from
one of the hemi-arches were removed, and one
of the resin bases was xed on the implants in
this hemi-arch (Figure 7A). In the other hemi-
arch, the implant-supported prostheses were kept
xed, providing information on the height of the
inter-maxillary space where the resin base was
attached (Figure 7B). To obtain this record, the
Nealon technique [10] was used again. Initially,
the resin was brushed onto the occlusal/incisal
surface of the resin base, and the patient was
instructed to occlude on the resin base until the
resin polymerized after isolating the opposing
teeth with Vaseline. The patient was kept in
occlusion, and then the OVD record for one of
the hemi-arches was obtained (Figure 7B). After
recording the rst hemi-arch, the same procedure
was repeated for the other hemi-arch.
After obtaining the records, the models
were mounted on the semi-adjustable articulator
(ASA) with the aid of the facebow. Following
the mounting, the inter-maxillary space and
occlusion were evaluated. For a more accurate
Figure 5 - (A and B) - Occlusal view of the working model with
analogs of external hexagon implants with a diameter of 4.1 mm.
Figure 6 - Occlusal view of the working model with a self-
polymerizing acrylic resin (base) for recording the maxillo-
mandibular relationship.
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Rehabilitation of full-arch patient with Cemented Metal-Ceramic Multiple Prostheses on Implants - case report
Guilherme AS et al. Rehabilitation of full-arch patient with Cemented Metal-Ceramic
Multiple Prostheses on Implants - case report
analysis of the occlusal condition, the laboratory
technician was requested to perform a diagnostic
setup of the future prosthesis using Biotone
prefabricated teeth (Dentsply Sirona Lab, Brazil)
with screw-retained retention (Figure 8A).
When the diagnostic setup was completed, it
was installed on the implant platforms using a
1.2 mm hexagonal driver, allowing the xation of
screws onto the implants. After accommodating
the setup in the dental arch, an assessment was
made of the midline, dental and gingival smile,
buccal corridor, lip support, tooth size, and
occlusion (Figures 8B and C), ensuring that all
these requirements were considered acceptable.
After this trial, the technician was instructed
to create a silicone wall on the vestibular surface
of the diagnostic setup using a dense condensation
silicone material (Zetalabor Zhermack -Italy).
This wall (matrix) served as a guide for the
correct positioning of the abutments that were
custom-made by the laboratory technician, as well
as the metal frameworks of the xed prostheses
during their fabrication (Figures 9A and B) and
(Figures 10A and B).
The intermediate abutments were fabricated
based on the UCLA Abutment, and from these
burnout cylinders, the waxing and casting
process was carried out using Ni-Cr alloy
(Figures 9A and B). To achieve the casting
process of the abutments, information on the
position of the silicone wall on the working
model was used to provide information on
the occlusion and esthetics. After casting the
intermediate abutments, their adaptation (passive
Figure 7 - View of the self-polymerizing acrylic resin base positioned
over the implants and used to record the maxillo-mandibular
relationship (Figure 7A). Registration was obtained in one of the
hemi-arches with the addition of autopolymerizing resin onto the
resin base. It is noticeable that the implant-supported prosthesis
indicates the height of the intermaxillary space for obtaining the
registration (Figure7B).
Figure 8 - View of the diagnostic setup of the future prosthesis
using prefabricated teeth (Figure8A). Placement of the prosthesis
mounted on implants in the dental arch, considering the midline,
dental and gingival smile, buccal corridor, lip support, tooth size,
and occlusion (Figure8B). It is possible to observe the smile height,
buccal corridor, and lip support (Figure 8C).
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Guilherme AS et al. Rehabilitation of full-arch patient with Cemented Metal-Ceramic
Multiple Prostheses on Implants - case report
t) was tested on the implant platforms in the
patient’s mouth (Figure 11). After conrming
this condition, they were repositioned on the
working model. Subsequently, the technician
proceeded to fabricate the metal frameworks of
the xed prostheses which were cast in Ni-Cr alloy
(Figures 10A, B, and C). Again, the information
on the position of the silicone wall on the working
model was used to preserve the information on
the occlusion and esthetics obtained during the
diagnostic wax-up trial.
Once the casting of the xed prostheses was
completed (Figures 10A, B, and C), a trial for them
was carried out in the patient’s mouth. Initially,
the intermediate abutments were attached to
the implants, and then the xed prostheses were
adapted to them, evaluating their passive t.
With the adaptation certified, functional
adjustments were made, taking into consideration
centric movements, protrusion, and right
and left lateral movements. The prosthetic
structures were worn down using numbers
4138 and 3118 diamond burs in high rotation.
This procedure allowed for the desired space for
the ceramic material with a diameter ranging
from 1.5 to 2.0 mm.
After the functional adjustments, the
procedure for recording the OVD was initiated.
Initially, the metal framework of the implant-xed
prosthesis was kept seated on the implants in one
hemi-arch. In the other hemi-arch, the implant-
supported prostheses were kept xed, providing
information on the height of the inter-maxillary
space where the metal framework of the implant-
xed prosthesis was located (Figures 12A and B).
To obtain the inter-maxillary space record
(OVD), the Nealon technique [10] was used.
The resin was brushed onto the occlusal/incisal
surface of the metal framework of the prosthesis,
and the patient was guided to occlude on the
resin base until polymerization was achieved,
Figure 9 - (A and B) - Frontal and occlusal views of the customized
abutments obtained from the UCLA abutment on the working model.
Figure 10 - (A, B, and C) - View of the metal frameworks of the
fixed implant-supported prosthesis, seated on the working model
after assembly in the articulator. Additionally, a view of the metal
frameworks was obtained in three units.