Anterior Implant

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242THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY

A Multi-faceted Treatment Approach

for Anterior Reconstructions Using

Current Ceramics, Implants, and

Adhesive Systems

Jan Hajtó, Dr Med Dent

Specialist in esthetic dentistry (DGÄZ), Munich, Germany

Uwe Gehringer, CDT

Private practice, Munich, Germany

Mutlu Özcan, Prof Dr Med Dent, PhD

University of Zurich Dental Materials Unit, Switzerland

Correspondence to: Jan Hajtó

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Abstract

Of all developments in dental technol

ogy, fulfilling the esthetic and functional

demands of the patient, especially re

garding anterior reconstructions, is still

a challenge for both dentists and dental

technicians. This becomes more diffi

cult for patients with a previous treat

ment history that is not ideal. This case

presentation demonstrates reconstruc

mandible with a combined treatment ap

proach utilizing veneers for harmonized

space distribution on the abutment teeth

dental prosthesis in the anterior seg

ment of the maxilla. Adhesive cementa

tion of the restorations is also presented

the current state of the art.

(Eur J Esthet Dent 2010;5:242–259)


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Introduction

Today, prosthetic and operative treat

ment concepts could be categorized as

sive (partially reversible), and (more) in

various materials. Dentistry, perhaps,

has the unique distinction of using the

widest variety of materials, ranging from

composites and ceramics. Develop

ments, especially in the field of polymers

and ceramics, have largely eliminated

the use of metals in the mouth. In spite of

all the advances, clinicians should real

ize the drawbacks before selecting the

most appropriate material for a particu

lar situation. Concentrating only on the

nicians should be mindful of the best ap

plication method. As the esthetic aspect

of dental care becomes increasingly im

portant to patients, the dental practitioner

should be aware of the applications and

restorative materials or systems and bal

ance these with the ethical aspects of

the invasive applications.

Fortunately, the dental profession has

profited from remarkable technological

advances in the substitution of missing

dental tissues and teeth. However, we

are still faced with the challenge of rep

licating the tooth tissues, mechanically,

physically, biologically, and optically.

With the increased options, the choice of

material is also becoming more difficult.

When a qualified ceramist is engaged,

pressed ceramics provide outstanding

results for a single anterior fixed dental

prosthesis (FDP), more so than almost

all other restorative options, with suitable

marginal fit, minimal abrasion, and con

servative tooth preparation. Yet they are

not as effective as reinforced ceramics

in preventing premature failure. On the

can be achieved using milled aluminous

or zirconia copings. However, the pres

ence of the relatively opaque internal

ceramic core may provide an impedi

ment to matching some tooth colors.

Although minimally invasive applica

tions are possible using direct compos

the drawbacks of composites involve the

loss of surface lustre. This may require

repolishing, refinishing, or relayering.

This is commonly found to be the case

after several years of clinical function,

and therefore the maintenance of the

surface characteristics of composites,

even after finishing and polishing, is an

ongoing issue.

Minimally invasive applications are

also possible using ceramic veneers.

According to the majority of studies, it

is clear that from the mechanical point

of view, retention of laminates is not

seen to be problematic.4 Clinical stud

ies rarely report debonding, indicating

that the adhesion of the luting cement,

not only to dental tissues but also to the

ic, is very reliable. Therefore the choice

mechanical retention reasons cannot be

justified.

preferable to metal ceramics due to be

ing minimally invasive, and also for es

thetic reasons. Nevertheless, teeth sur

rounded by healthy periodontal tissues

generally have a very high longevity, up

5 Therefore, the

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utmost care should be taken to preserve

the cementoenamel junction. This may

not always be achieved, however, due to

required tissue sacrifice for esthetic rea

will continue to dominate when choosing

one restoration type over another, or the

most suitable restorative materials for

the patient.

The situation becomes even more

complex when the patient has a history

of several treatment concepts that have

failed. This case presentation could be

considered an example of the most mini

mally invasive and durable approach

being practiced, according to the cur

rent state of the art and considering the

patient’s demands.

Materials and methods

with an implant placed alio loco at tooth

rarily rehabilitated situation in the max

a permanent rehabilitation in both the

maxilla and the mandible as quickly as

possible. Since she had already been

through extensive therapy, her explicit

wish was to limit therapy as much as

possible, but at the same time accom

plish the best possible result. Among

others, the previous treatments involved

implantation and explantation in the re

tissue augmentation in the region of teeth

as very sensible, nervous, critical, and

unsure about the treatment outcome.

in the maxilla

In the maxilla, both bone loss and soft tis

sue loss were observed. The implant was

positioned correctly. However, despite

the previously accomplished soft tissue

augmentation, the implant shoulder was

an individualized zirconium oxide (ZrO )

and a short external hex connector of

®

NP) was made. The problem with this

ance against loading of the connection.

During cyclic loading, vibrations and

the two participating materials occurs

with the consequence of material loss at

the surface. For the wear process, not

only the roughness but also the hard

ness of the material plays a role. ZrO

Fig 1

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mm , being relatively harder than that of

).6 For external hex

loose fit between the implant body and

various tested abutments were deter

mined.7,8

terface can never be avoided. Also in

this case, wear of the titanium surface on

the ZrO

debris and biofilm on the inner surface

of the abutment were indicators of the

presence of an insufficient connection.

The high rotational forces of the can

tilever pontic are another unfavorable

factor in such a material combination.

Changing the implant geometry by

grinding must be considered a major

complication since, in the case of a re

pair, the new restoration would require

a direct impression followed by manu

facturing and inserting an individually

cast abutment. In the described case,

beyond (cervically) the finishing line of

pontic showed a correct contact surface

to the gingiva.

The therapy concept

tion, it was decided to construct a new

abutment bonded onto

a titanium base, and to thin the titanium

base on the labial side to the minimum

thickness possible. In such difficult cas

es, the crown margin should be posi

tioned labially and cervically, as much

as possible, in order to avoid any expo

sure of the zirconium abutment. If fur

ther recession occurs, the finishing line

between crown and abutment would be

visible.

Accomplishing a perfect harmony

from an esthetic standpoint is more diffi

cult when fewer teeth are subject to treat

ment in a given segment of the dental

arch. In the presented case, the baseline

situation exhibited asymmetric positions

Fig 3 The already existing individualized ZrO

abutment with traces of worn titanium and food de

bris at the inner side.

Fig 2der is hardly covered with gingiva.

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Fig 4 The digital modeling of the new ZrO abut

ment. Note that due to the low implant depth, the

shoulder of the titanium adhesive base had to be

designed short. With this approach the metal mar

gins were achieved almost invisibly.

Fig 5 The new finished individual ZrO abutment

Fig 6 framework.

With ZrO fixed dental prostheses, it is important

a rounded cervical transition shape from abutment

to the pontic.

of the lateral incisors due to soft tissue

loss and the rotation of the lateral inci

sors. In order to fulfill the high esthetic

demands of the patient, it was decided

to involve these two teeth in the recon

as an abutment tooth was planned (Figs

4–8). This relatively invasive treatment

option was chosen for two reasons: (1)

sion bridge seemed questionable, and

(2) a harmonious optimal closure of the

possible. In such a case, with several

extracted neighboring teeth, the papilla

preservation of the pulp. In the anterior

area, it is considered an appropriate

clinical practice to reduce the zirconium

In so do

ing, it is possible to achieve a good es

thetic outcome even with minimal space

Fig 7 The labial position of the connector requires

precise planning. In this case, the waxup yielded a

palatal position of the connectors to obtain a maxi

mum thickness strength also at the proximal areas.

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is one of the most important steps of the

treatment and should be practiced sev

eral times if necessary. During bisque

taken into consideration:

fit of the abutments n

proximal contacts n

basal shape and contact of the pon n

tics with the gingiva

occlusion n

perception of the reconstruction with n

the tongue

phonetics n

esthetics. n

Fig 8 The labial surface of the ZrO

maximum thickness of the veneering ceramic.

Fig 11 Temporarily cemented fixed dental pros

thesis (bridge) for several days with the veneer on

mandible.

Fig 10 The finished individualized ZrO abutment Fig 9

unchanged, which is too narrow and tilted distally,

is an esthetic compromise. With the consent of the

patient, a labial veneer was placed to improve the

esthetics.

a b

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The control of the position of the pon

tics in relation to the gingiva is especially

important. Corrections can be made by

removing ceramic or by adding material,

and the correct relationship should be

communicated to the dental technician.

The veneers had to be made twice since

the form did not suit the clinical require

ment at the first attempt and the color

was too light. (With veneers, the color

of the ceramic should be correct right

composite gives only very limited scope

for change. For this reason, it is pre

ferred to remake a veneer if the color is in

sure about the final treatment outcome,

despite great care and individual adjust

ments, the finished work was cemented

is rarely performed due to possible dam

age occurring during the temporarization

period or during removal of the restora

tion. It is, however, sometimes necessary

if the patient specifically requests it.

in the mandible

The missing tooth could be replaced

The question was which design would be

best. Extension of the wings over more

than one abutment tooth has yielded

clinically unfavorable outcomes, the dis

tally connected tooth showing delamina

tion over time. The question of whether

by Kern. Clinical data have clearly

However, it is the present authors’ expe

design functions very well. For this rea

the mandible, the gap was significantly

larger than the usual width of the man

the best esthetics are achieved when

the width is distributed equally to each

tooth. As to how this can be realized, the

theoretical possibilities are as follows:

enlarge the abutment teeth with n

composite

enlarge the abutment teeth with n

ceramic as an integrated part of the

bridge

make separate additional veneers. n

The therapy concept

In order to close the proximal gap as

much as possible towards the cervical,

the authors’ preference was the last op

would have required firing on veneer

ing ceramic without an adequate sup

porting substructure, which seemed

questionable from a technical point of

view. Furthermore, the required inser

tion path would have created problems

cervically. The possible aging of the

composite was the reason for rejecting

the first option. The contact points of the

determined using a laboratory paralel

lometer. Additional veneers are virtually

invisible on teeth as long as the finishing

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However, finishing lines perpendicular

to the tooth’s long axis may be visible in

some cases. After adhesive cementa

tion of the veneers, a new impression

was made. The construction of the ZrO

framework was achieved using an es

The surface treatment of the ZrO for

adhesive cementation can be achieved

ing primer and the corresponding ce

ment. Of all possible alternatives,

ing effect.

is not etchable, a clean and rough sur

face is obtained that ensures wetting of

the surface, which is a prerequisite for

Fig 13 Waxup of the required enlargement of the

neighboring teeth.

Fig 12 The wax setup on the prepared tooth

serves as a quick impression of the width discrep

ancy and the gap between the abutment teeth (set

up system: Anteriores Set, Wichnalek, Augsburg,

Germany).

Fig 15 Additional ceramic veneers (Creation

Classic) on the plaster model.

Fig 14 For a better visualization of the width distri

bution, gold powder was used on the waxup.

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Fig 19dental prosthesis.

Fig 18

quite invisibly.

coat the cementation surfaces with Co

Germany) silanization and then use

clinical study available on the effect of

ceramics on clinical behavior. Aging

was reported to have a detrimental ef

In the case presented, the whole lin

gual surfaces of the teeth and the proxi

mal cementation surfaces of the veneers

®, Ultradent

Products, South Jordan, UT, USA) and

Fig 17 Proximal veneers. Fig 16 The already accomplished lingual prep

aration is completed with additional veneers. The

sharp finishing line is placed backwards behind

the middle in order to enable a smooth adaptation

between the etched feldspathic ceramic and the

ZrO framework. Central positioning grooves in the

preparation make cementation easier.

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Fig 21two wings (two bonded retainers). ZrO framework

retainers were not veneered.

Fig 20dental prosthesis on the model.

Fig 23 Application of the silane coupling agent

(Monobond S, Ivoclar Vivadent, Schaan, Liechten

Fig 25Max, EMS).

Fig 22 Silica coating of the cementation surfac

Seefeld, Germany).

Fig 24posite (Variolink II, Ivoclar Vivadent, Schaan, Liech

bonded fixed dental prosthesis.

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Fig 27ter the adhesive cementation in situ.

Fig 26 Cementation of the ZrO

fixed dental prosthesis and photopolymerization.

Fig 28 The final treatment result.

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conditioned, followed by the application

tem (Syntac, Ivoclar Vivadent, Schaan,

Liechtenstein). The cementation was

cement (Variolink® II, Ivoclar Vivadent)

final treatment result.

Discussion

Unfortunately, there is rarely a single so

lution for all problems in dentistry and

dental technology. In most cases, den

tists find solutions for individual situa

tions and individual complications. The

presented case involved several such

challenges and indicates that esthetics

in reconstructive dentistry is an extremely

demanding discipline requiring experi

ence and knowledge, and the poten

tial to apply both. The esthetic aspect

of treatment always adds an additional

requirement to the medical basics, and

sometimes competes with them, mak

ing the whole treatment more difficult.

Good esthetics do not happen neces

sarily as a consequence of correct den

tal and medical treatment. Often there

is a need to do more. Furthermore, the

individual patient’s wishes need to be

taken into consideration. Patients with

high esthetic demands require good

management, which can create chal

lenging situations.

The present case illustrates, from dif

ferent angles, the demanding daily task

of the practicing dentist to apply modern

and advanced methods and at the same

time assess their benefits and risks. With

the increasing complexity of cases, the

responsibility of the clinician is increas

ing. The solutions demonstrated should

not be considered the most correct

thought process during the planning of

such complex cases. Whilst almost two

decades ago the missing teeth in such

FDPs, with the preparation of at least four

abutment teeth, today there is the pos

sibility of using implants and zirconium

oxide frameworks, but these also require

sidering hard and soft tissue augmen

tation and the indications for implants,

their number, position, system, design,

and the dental material itself need to be

considered in the treatment planning, as

well as time management on the part of

the dental professional.

saying a decade ago but it is not true

frame

works and glass ceramic restorations

(eg, lithium disilicate) are more reliable

produced ceramics. Today, the follow

ing statement is more valid: “High es

The more esthetic the material is, or the

more translucent the ceramic, the weak

er it is. Moreover, the higher the esthetic

demands, the more difficult it is to es

tablish static and mechanically strong

restorations. Today, ZrO implants and

ZrO abutments that are screwed direct

ly onto the titanium implants are still an

experimental solution.

The pressure from the market is trig

gering sales of such untested medical

products, and every practitioner needs

such progressive alternatives should be

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applied in their own practice. With the

presented adhesive abutment solution

in the maxilla, it is clearly shown that

even in such challenging situations it is

possible to offer, in borderline cases, a

relatively safe and clinically proven so

lution. The most probable risk here is

the debonding of the ZrO restorations.

an easy solution. Adhesion of ZrO abut

ments to titanium bases is successful

in vitro and has become successful

clinical practice for years in the authors’

office as well as in many others.

Regarding the mechanical stability of

the components, the alternative titanium

abutment in combination with metal

frameworks is considered the most reli

able option with the longest track record.

The chosen material combination in the

presented case must still prove its lon

gevity in the clinic. However, experience

with several such cases is promising.

The most difficult decision in this case

issue was discussed intensively with the

patient. A series of review articles tried to

supported FDPs or combined implant–

restorations.

studies that met the inclusion criteria

indicated an estimated survival rate for

tion. The survival rates for the implants

to Pröbster a prosthetic restoration sys

tem can be regarded as successful if it

tion. Against the high survival rates for

the first 5 years in the same study.

These included chippings and loosen

ing or fracture of screws. The term “suc

unchanged and free of all complications

over the entire observation period. The

reported complication rates indicate that

ally carry a high risk of retreatment and

require maintenance services. In a

that met the inclusion criteria, combined

a significantly lower estimated survival

However, the complication rates related

to the implants alone ranged between

that presented a figure considerably low

restorations.

In the present case, the issue in ques

have a higher survival and lower com

FDP supported by a single implant.

Thus the decision made for this case

deviates from the situations analyzed

in the dental literature. Although trends

can be observed, the literature does not

supported cantilever FDPs show lower

survival rates and higher complication

rates than those of conventional FDPs

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CASE REPORT

supported by at least two abutments.

This indicates that the leverage forces

created by a cantilever should, in gen

eral, be regarded as mechanically prob

lematic.

Due to the fact that the diameter of

the implant and of the external hex was

small and that the vertical dimension of

the prosthesis was high, and that there

fore strong leverage forces were to be

expected, the conventional bridge solu

pontic. This assessment was confirmed

by the fact that the temporary restora

tions showed multiple debondings. The

implant situation was given and, accord

ing to today’s possibilities, correct as

well. The presence of two neighboring

implants in the anterior region is a de

manding esthetic challenge for the pros

thodontist, due to the soft tissue (ie, pa

pillae) problems. In fact, an implant can

the abutment tooth and at the same time

replace the missing tooth. Therefore the

decision to incorporate a crown on tooth

from an ethical standpoint as well.

The situation in the mandible is a clas

cially true after an already failed implant

FDP would require much hard tissue

loss. In cases where there are soft tissue

recessions in combination with small root

diameters at the gingival level, a correct

crown preparation is almost impossible.

ics have been shown to be a successful

treatment option. The disadvantage

where an unnoticed fracture, debond

ing, or delamination occurs, second

ary caries on the abutment tooth could

occur.

ity record, other options are not justi

fied in such a situation. The most com

lateral incisors in the maxilla. Splinting

the central incisor with the canine of the

to be not physiologic. The experience of

the maxilla has shown unilateral debond

ings in many cases. A possible reason

for these debondings could be stress at

the adhesive interfaces due to uneven

tooth mobility of the anterior maxillary

teeth under physiologic functional load.

of observation, no unilateral debonding

cate.

made specially with proximal grooves

but no wings. This indicates that in the

mandible, the load is directed axially

rather than lingually, which may explain

cessful. Similarly, Kern et al found all

maxilla. The question remains whether,

under the assumption that in the mandi

ble both options could function clinically,

a second wing is necessary. Even if the

potential danger of a connector fracture

is present, in the present authors’ opinion

it allows for thinner connectors.

The discussion above clearly un

derlines the difficulty of the practicing

dentist to make the right decisions to

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Also, the question regarding durabil

ity of the adhesive cementation with a

ide ceramic remains unanswered. The

longest clinical experience exists with

ics. The results with this material indi

abrasion using alumina, and the use of

a primer and adhesive with bifunctional

(MDP) monomers, yields a good clinical

survival rate. However, in vitro micro

tensile tests showed unfavorable results

Ceram®

after artificial aging conditions. For

pure zirconium oxide, such information

is limited in the literature. In general,

etchable ceramics would behave simi

from in vitro studies, the aging effect on

the adhesive interfaces and thereby the

durability of the adhesion is the Achilles’

heel of such therapies.

A possible structural change through

air abrasion in the stabilized zirconium

oxide could be a concern. Limited in

formation is available on the possible

negative effects of air abrasion on zir

conium oxide. The opinions on this

aspect are controversial. Neverthe

less, chairside application of silicatiza

tion was claimed to be less hazardous

on the material properties of zirconium

oxide than laboratory air abrasion utiliz

ing alumina.

Air abrasion could be expected to

create damage in the form of delamina

tion or total fracture according to cur

rent knowledge. However, it depends

on several other parameters. It was,

however, claimed that the cleaning of

cementation surfaces is best achieved

with air abrasion. Since oxide ceram

ics do not contain silica, as an alternative

containing cements, chairside silica

coating and silanization could be con

sidered in combination with dual polym

Which

method for the cementation of zirconium

oxide would be clinically more success

ful needs to be determined. Therefore,

such cases are currently under review

in the present authors’ practice.

Conclusions

Missing teeth can be restored both func

tionally and esthetically utilizing treat

ment modalities such as veneers and

implants and zirconia suprastructures.

The durability of such restorations can

be achieved through adhesive cementa

tion, based on the current state of the art

derived from both clinical and laboratory

studies. This clinical example illustrates

the particular challenge for any clini

cian when confronted with exceptional

situations, where former experience or

scientific evidence may not followed. It

is important to learn from previous unfa

vorable applications and inappropriate

assessments or decisions affecting the

individual and to keep an open mind re

garding treatment concepts in the light

of new findings and experiences.

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THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY

258

CASE REPORT

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Anterior Implant

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