This was a preliminary stage before the first surgical corticotomy (performed with a piezo device).

A microsurgical corticotomy was mandatory to assist orthodontic tipping and intrusion of elements 16 and 17. This surgical procedure was performed by a piezo approach (Fig. 9).

A total width flap was elevated to make the cortical subapical and longitudinal bone cut possible. The surgeon had to respect a minimum of 3-mm distance from the apex and 1 mm from the periodontal ligament. A triangular-shaped corticotomy was performed with inserts OT7 0.55 mm and OT7 special 0.35 mm to accelerate orthodontic tooth movements (Fig. 10). The bone cut design was conceived to surgically reduce the amount of bone among root surfaces and assist orthodontic tooth movement.

Moreover, a mesiobuccal root surface exposure of element 16 due to a bone defect was evident. It required bone regeneration through Bio Oss and bone chip application (Figs. 11 and 12).

Orthodontic therapy involved immediate application of strong intrusive forces (>250 g) after corticotomy surgery. A NiTi 18 × 22 diameter archwire was applied to the brackets. It ensured mobilization of the bone maxillary block. The tipping movement of elements 16 and 17 took approximately 12 weeks. The patient was controlled weekly for the first 2 months and twice in the third month. No complications involving the periodontal ligaments or endodontic vessels were observed in the weekly follow-ups.

After 7 months, a secondary surgical phase was planned: five Camlog Screw (Line Promote Plus) implants were placed with a minimum 35 N torque in 24 (4.3 mm × 13 mm), 36 (3.8 mm × 13 mm), 37 (3.8 mm × 13 mm), 46 (3.8 mm × 13 mm), and 47 (3.8 mm × 11 mm) sites. This feasible technique provided dedicated inserts for implant site preparation: OP5, IM2, OT4, and IM3 (correctly in sequence) (Figs. 13 and 14) and ensured minimally invasive and stressed implant site preparation. All implants received immediate healing screws (Fig. 15).

The orthodontic treatment took approximately 16 months. After that, the prosthodontic phase took place (Fig. 16). When tooth alignment was completed, all brackets were removed and the definitive restorations were placed. Implants were used for implant-retained prostheses (abutment-cemented crowns), and a three-unit fixed partial denture pontic (crowns 25–27) was placed (Figs. 17 and 18).

Treatment results

The left side could not be restored to an ideal class I relationship due to the pontic prosthesis (Figs. 19 and 20). A dental class I occlusion was established only on the right side (Fig. 21). The original collapsed right posterior occlusion was corrected. A stable posterior occlusion was established, and the balancing interference was eliminated. Centric relation and centric occlusion were established at the same vertical dimension of occlusion. The cephalometric analysis and clinical aspect at the end of treatment showed that the patient had improvements in overbite and overjet.