CLINICAL REPORT

Three-dimensional facial esthetics-driven computer-assisted

osteotomy and implant placement for immediate restoration
of a failing dentition with a protruded maxilla
Xiaojiao Fu, BDS,a Jingwen Yang, DDS, PhD,b Jia Luo, DDS, PhD,c and Yu Zhang, DDS, PhDd

For patients presenting with a ABSTRACT

failing dentition, immediate
The rehabilitation of facial esthetics when transitioning from a failing dentition in a patient with
cross-arch implant-supported maxillary protrusion is challenging. This clinical report described such a patient treated with an
fixed prostheses have become immediate cross-arch implant-supported fixed prosthesis. The ideal virtual upper lip position was
popular.1 A failing dentition used to predict the sagittal and vertical position of the restoration. A stackable device was
combined with maxillary pro- fabricated to guide the osteotomy and implant placement. (J Prosthet Dent 2020;-:---)
trusion is a common clinical
problem, often associated with excessive gingival display image management have been widely applied in
and a disharmonious lip-tooth relationship.2 The treat- orthodontic treatment and orthognathic surgery.12
ment plan for patients with a failing dentition and However, these software programs are incompat-
maxillary protrusion often involves an osteotomy. How- ible with dental laboratory or dental implant simu-
ever, insufficient or excessive reduction of bone can result lation software programs, which are essential for
in prosthetic and surgical problems.3-5 tooth arrangement and implant planning. Thus,
Computer-assisted design has simplified the engineering software programs for 3D systems, such
prosthetic procedure and improved the predictability as Geomagic Studio, play a key role in connecting
and esthetics of the smile line in the vertical po- different dental software programs.13,14
6-10
sition. However, the change in facial profile in The present clinical report describes a digital work-
the sagittal position after the osteotomy and flow for 3D facial esthetics-driven computer-assisted
arrangement of the artificial teeth is still difficult to osteotomy and implant placement. Through computer-
predict. A systematic review reported on the pro- assisted facial profile and smile design, a treatment
portion of soft-to-hard tissue movement in maxillary plan combining esthetics, restoration, and remaining
orthognathic surgery.11 This proportion can provide bone considerations was completed. A stackable device
a reference for tooth arrangement with computer- was used to transfer the virtual design to the surgical
assisted 3D facial analysis. Commercially available procedure for implant placement guidance and for the
software programs providing facial analysis and osteotomy.

Support provided by the Oral Reconstruction Foundation (Reference ORF 41801); and the Peking University School and Hospital of Stomatology (grant PKUSSNCT-19B11).
X.F. and J.Y. contributed to the work equally and should be regarded as co-first authors.
a
Graduate student, Department of Oral Implantology, Peking University School and Hospital of Stomatology & National Clinical Research Center for Oral Diseases & National
Engineering Laboratory for Digital and Material Technology of Stomatology & Beijing Key Laboratory of Digital Stomatology, Beijing, PR China.
b
Attending Doctor, Department of Prosthodontics, Peking University School and Hospital of Stomatology & National Clinical Research Center for Oral Diseases & National
Engineering Laboratory for Digital and Material Technology of Stomatology & Beijing Key Laboratory of Digital Stomatology, Beijing, PR China.
c
Attending Doctor, Department of Oral Implantology, Peking University School and Hospital of Stomatology & National Clinical Research Center for Oral Diseases & National
Engineering Laboratory for Digital and Material Technology of Stomatology & Beijing Key Laboratory of Digital Stomatology, Beijing, PR China.
d
Associate Professor, Department of Oral Implantology, Peking University School and Hospital of Stomatology & National Clinical Research Center for Oral Diseases &
National Engineering Laboratory for Digital and Material Technology of Stomatology & Beijing Key Laboratory of Digital Stomatology, Beijing, PR China.

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Figure 1. Pretreatment facial views: left lateral, left 45-degree-angled, frontal, right 45-degree-angled, right lateral. A, Static images. B, Maximum smile
images.

CLINICAL REPORT defect, visible residual ridge, and adequate bone volume,
an osteotomy was determined to be necessary.16
A 46-year-old woman was referred to Peking University
School of Stomatology, Department of Oral Implantol- Facial profile and smile design procedures were per-
ogy, with nonrestorable maxillary anterior teeth and formed. The digital imaging and communications in
bilateral posterior missing teeth. She was seeking to medicine (DICOM) file of the CBCT scan was converted
correct her maxillary protrusion. She had been provided into a standard tessellation language (STL) file (File A) by
with a cross-arch implant-supported fixed restoration in using an STL software program (Materialise Magics;
the mandible in the department 6 months previously. Materialise). The first 3D image with File A was registered
The facial examination showed protruded maxillary with a surface registration technique with a reverse engi-
anterior teeth producing a lip-tooth relationship that neering software program (Geomagic Studio 2012; 3D
lacked harmony, excessive tooth visibility in the rest Systems).10,15 The 3D lip position images were registered
position, and 4 to 5 mm of gingival display during her with surface registration, and definitive digital images
maximum smile (Fig. 1). An intraoral examination iden- were obtained.17 The flowchart (Fig. 3) shows the
tified severe periodontitis with anterior teeth splaying analyzing and reconstruction of an ideal profile as per the
and Miller grade II-III mobility of the remaining teeth normal range of NLA (approximately 80 to 110 degrees in
(Fig. 2). A stable occlusal relationship and adequate Chinese people with normal occlusion), and the labrale
restorative space were determined. superius of the ideal profile was marked as point LS and
Impressions of the arches, extraoral and intraoral established near the esthetic plane. As a result, NLA was
photographs, 3D facial images (FaceScan; ISRA Vision), a designed as 107.8 degrees and LS was designed to move
cone beam computed tomography (CBCT) scan (0.20 1.2 mm palatally (Fig. 3B). Based on the position change of
mm, NewTom VGi; Quantitative Radiology) with an LS, the movement of the maxillary incisor in the sagittal
occlusal device and facebow,15 and a cephalometric direction was calculated as per the ratio of 0.6:1 (LS to
radiograph (CS 8000C; Carestream) were made before maxillary incisor).11 The maxillary incisors were relocated 2
mandibular surgery. The cephalometric analysis showed mm palatally (Fig. 4A). Because horizontal space was
that the sella-nasion-point A (SNA) angle was 87.1 de- created by the mandibular restoration, it was possible to
grees, the sella-nasion-point B (SNB) angle was 81.5 retract the maxillary incisors. The lip position was then
degrees, and the nasolabial angle (NLA) was 100.2 de- evaluated, and the maxillary incisors were set 2 mm below
grees. The CBCT scan showed a composite defect and the upper lip in the rest position (Fig. 4A). The occlusal
adequate bone volume, as per the Bedrossian pretreat- plane was set parallel to the ala-tragus line and the
ment screening method.16 Three-dimensional facial im- interpupillary line (Fig. 4B). The bone cutting line was set 4
ages included an image with an occlusal device and mm above the maximum smile line (Fig. 4B), and the basal
facebow (first image)15 and different lip position images point of the prosthesis (F-point) was 1 mm apically to the
(rest position, slight smile, and maximum smile). maximum smile line (Fig. 4A). Based on the settled
Different treatment options were presented, and she maxillary incisor point, F-point, and occlusal plane, a
elected to receive an immediate cross-arch implant- virtual diagnostic tooth arrangement was created in
supported fixed prosthesis. Because of the composite the computer-aided design and computer-aided

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Figure 2. Pretreatment intraoral examination. A, Frontal view. B, Maxillary occlusal view. C, Mandibular occlusal view.

Figure 3. Virtual facial profile design. A, Pretreatment lateral profile: lateral profile adjusted to ideal position in Adobe Photoshop CC 2018. B, After virtual
facial profile design: NLA increased to107.8 degrees, upper lip length unchanged, and LS closer to esthetic line. LS, labrale superius; NLA, nasolabial angle.

Figure 4. A, Diagram of corresponding points and movement distance between prosthesis and upper lip. In sagittal direction, LS moved 1.2 mm and
maxillary incisor moved 2 mm palatally. In vertical direction, F was about 1 mm above upper lip during maximum smile and maxillary incisor was 2 mm
below upper lip during rest position. B, Virtual diagnostic tooth arrangement in lateral view. Confirmation of occlusal plane was paralleled to ala-tragus
line, ideal incisor edge determined in Figure 4A and bone cutting line 4 mm above maximum smile line. LS, labrale superius.

manufacturing (CAD-CAM) software program (exocad; and software programs (Materialise Magics and Geomagic
exocad GmbH) (Fig. 5A, 5B). Studio 2012) were used to design the anchor guide, implant
The STL data of diagnostic teeth were then super- placement guide, and tooth-supported framework (Fig. 6A,
imposed on the DICOM file of the CBCT scan in an implant 6B). Finally, the designed templates were exported into STL
planning software program (6D Dental Planning Software; file format and sent to a dental laboratory for fabrication of
Hangzhou 6D Dental Tech Co). The surgical plan was the stackable device from cobalt-chromium alloy powder
determined based on all the diagnostic data (Fig. 5C, 5D), with selective laser melting (Fig. 6C).

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Figure 5. Facial esthetic driven implantation surgical plan. A, Frontal view of virtual tooth arrangement during maximum smile. B, Lateral view of virtual
tooth arrangement during maximum smile. C, Frontal view of virtual implant plan. D, Lateral view of virtual implant plan.

Figure 6. Surgical templates and surgical procedures. A, Virtual anchor guide and tooth-supported framework. B, Virtual anchor guide and implant
placement guide. C, Selective laser melted stackable device: anchor guide, tooth-supported framework, and implant placement guide. D, Surgical
procedures: stackable device (tooth-supported framework and anchor guide) fitted over alveolar ridge and remaining teeth. E, Implant placement with
guidance from stackable device (implant placement template and anchor guide). F, Implant placement in prosthetically guided position.

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Figure 7. Posttreatment photographs. A, Frontal view. B, Maxillary occlusal view.

Figure 8. Post-treatment facial views: left lateral, left 45-degree-angled, frontal, right 45-degree-angled, right lateral. A, Static images. B, Smile images.

The surgery was performed under local anesthesia. The improve facial esthetics, and to increase the precision of
stackable device was positioned over the remaining teeth both osteotomy and implant placement for a patient with
(Fig. 6D). The alveolar crests were trimmed as per the a failing dentition and maxillary protrusion. Based on the
index of the anchor guide. Six implants (Camlog Promote; facial profile prediction, the maxillary incisor position,
Camlog Biotechnologies GmbH) were inserted after the smile line, and occlusal plane information were obtained,
implant placement template (Fig. 6E, 6F). A 3D-printed which were later used for the design of the realignment
model from the STL data of virtual tooth arrangement was of artificial teeth. The prosthetically driven implant
used for assisting the diagnostic waxing and fabricating placement and osteotomy plan was then based on the
the interim restoration. Clinical examination confirmed realignment design.
that she had the same occlusal vertical dimension as Predicting facial profile change for patients with a
before the treatment. After the maxillary restoration, a failing dentition and maxillary protrusion is challenging.
cephalometric analysis showed a palatal shift of maxillary Software programs have been marketed that offer pre-
incisors of 2 mm. The post-treatment NLA (109 degrees) dictions of facial soft tissue movement for patients under
and movement of LS (1.0 mm) were aligned with the orthodontics or orthognathic surgeries.18,19 However, the
designed facial profile, determining the predictability of software predictions are often rudimentary, and the
the workflow. Reexamination showed that the facial pro- software program requires a lengthy learning curve.18,19
file was satisfactory and the prosthesis-tissue junction was For the present patient, the ratio of soft-hard tissue
not visible during a maximum smile (Figs. 7, 8). movement in the sagittal direction in orthognathic
treatment was calculated, providing a more direct and
DISCUSSION feasible method of predicting facial change.11
The purpose of this clinical report was to describe a novel The execution of the design was via stackable surgical
digital workflow for the design of a facial profile, to devices with a tooth-supported component, which fit the

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reproducible landmarks of teeth for support and reten- 12. Resnick CM, Dang RR, Glick SJ, Padwa BL. Accuracy of three-dimensional
soft tissue prediction for Le Fort I osteotomy using Dolphin 3D software: a
tion.20,21 This method has been determined to be accu- pilot study. Int J Oral Maxillofac Surg 2017;46:289-95.
rate in laboratory, cadaver, and clinical studies.22 With 13. Peng MJ, Xu H, Chen HY, Lin Z, Li X, Shen C, et al. Biomechanical analysis
for five fixation techniques of Pauwels-III fracture by finite element modeling.
the indication for osteotomy, the present procedure Comput Methods Programs Biomed 2020;193:105491.
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SUMMARY Surg 2020;145:963e-74e.
15. Xia JJ, Shevchenko L, Gateno J, Teichgraeber JF, Taylor TD, Lasky RE, et al.
Outcome study of computer-aided surgical simulation in the treatment of patients
The present clinical report demonstrates a novel 3D facial with craniomaxillofacial deformities. J Oral Maxillofac Surg 2011;69:2014-24.
esthetics-driven digital workflow that predictably treated 16. Bedrossian E, Sullivan RM, Fortin Y, Malo P, Indresano T. Fixed-prosthetic
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