University of Groningen

Single-tooth implants in the aesthetic zoneden Hartog, Laurens

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Citation for published version (APA):Hartog, L. D. (2011). Single-tooth implants in the aesthetic zone: a clinical trial of different implant neckdesigns and immediate loading Groningen: s.n.

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This is an edited version of the manuscript: Den Hartog, L., Raghoebar, G.M., Stellingsma, K.,

Meijer, H.J. Immediate loading and customized restoration of a single implant in the maxillary

esthetic zone: a clinical report. Journal of Prosthetic Dentistry 2009; 102: 211-215

6.

Immediate loading and customized restoration

of a single-tooth implant in the maxillary aesthetic

zone: a clinical report

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AbstrAct

The replacement of a single missing anterior tooth with a dental implant is

a demanding therapy. This report describes a treatment in which an ante-

rior maxillary implant was immediately restored with a provisional restora-

tion. During the provisional phase, an optimal emergence profile was cre-

ated by adjusting the provisional restoration. An impression was made with

an individually fabricated impression post for an accurate reproduction of

the established emergence profile and finally a screw-retained all-ceramic

crown was placed. By implementing this protocol, an optimal definitive re-

sult could be achieved together with immediate patient satisfaction. How-

ever, cooperation between several disciplines and careful patient selection

were required.

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IntroductIon

The application of dental implant to restore a missing tooth in the anterior den-

tition is challenging. In the aesthetic zone, both the appearance of the implant

crown and the soft tissue contribute to a successful treatment outcome and

should consequently be in harmony with the surrounding dentition (Chang et al.

1999, Belser et al. 2004). To accomplish the desired result, meticulous pre-op-

erative treatment planning is crucial together with cooperation between several

disciplines during the restorative phase.

In recent literature, several treatment strategies using dental implants have

been reported to replace a missing tooth (Den Hartog et al. 2008). Among these,

interest has been attributed to immediate or early loading protocols in which a

provisional restoration is placed soon after implant placement. Clinical studies of

immediate or early loading have reported favorable treatment outcomes in terms

of implant survival, marginal bone resorption, soft tissue level and the incidence

of complications for treatment in which implants were inserted in healed sites

(Ericsson et al. 2000, Andersen et al. 2002, Cooper et al. 2007, Hall et al. 2007) as

well as implants placed in fresh extraction sockets (Crespi et al. 2008, de Rouck et

al. 2008). However, a recent systematic review (Den Hartog et al. 2008) showed

that well-designed controlled studies that compare these approaches with con-

ventional protocols are scarce and whether or not superior aesthetic outcomes

could be achieved remained inconclusive. Immediate or early implant loading

provides several advantages for the patient including a shorter overall treatment

time, avoidance of a second-stage operation and eliminating the need for a re-

movable prosthesis during the healing phase. However, these protocols require

careful pre-operative planning and patient selection. Furthermore, good primary

implant stability is a prerequisite (Esposito et al. 2007), in addition to the develop-

ment of a protected occlusion to create a non-occluding provisional crown.

Another important development has been the introduction of alumina- and

zirconia-based ceramic abutments made with computer-aided design/compu-

ter-aided manufacturing (CAD/CAM) technology. Ceramic abutments are high-

strength (Sundh & Sjögren 2008, Yüzügüllü & Avci 2008,) biocompatible (We-

lander et al. 2008) and have allowed new options to improve the natural appear-

ance of the implant crown. However, little is known about the long-term clinical

performance of these abutments (Linkevicius & Apse 2008).

The purpose of this clinical report was to demonstrate an immediate implant

loading protocol for restoration of a missing central incisor. After the provisional

restoration phase, an individually fabricated impression post was used and sub-

sequently a definitive screw-retained one piece all-ceramic crown was placed.

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Figure 1. Pre-operative view.

Figure 2. Exposure of the alveolar bone.

Figure 3. Screw-retained provisional crown placed same day after implant surgery.

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Clinical reportA 47-year-old woman consulted the Department of Oral and Maxillofacial Surgery

(University Medical Center Groningen, University of Groningen, Groningen, the

Netherlands) with a missing right central incisor (Figure 1) lost due to a trau-

matic injury. At the time of the consultation she was wearing a removable partial

denture and desired a durable and fixed restoration, without involvement of the

adjacent teeth. The patient was healthy, did not smoke and intraoral examination

revealed a healthy well-maintained dentition. Clinically, adequate bone volume

was present at the future implant site. In all dimensions, sufficient space was

available for an implant crown with an anatomical design. Radiographically, no

pathology of the bone and adjacent teeth was noted. Because of the favorable

starting point, it was decided to use an immediate loading protocol.

Preoperatively, diagnostic casts were made with a diagnostic arrangement

representing the future implant crown in an ideal position. Next, a transparent

acrylic resin template (Vertex Castapress; Vertex Dental, Zeist, the Netherlands)

was fabricated and a guide channel was prepared in the template to aid in proper

implant placement. Care was taken with the surgical guide so that the guidance

channel would direct the implant sufficiently toward the palate to accommodate

a screw-retained restoration.

One day before surgery, the patient started taking antibiotics (amoxicillin 500

mg, 3 times daily for seven days) and used a 0.2% chlorhexidine mouthwash

(Corsodyl; GlaxoSmithKline, Utrecht, the Netherlands) for oral disinfection. Fol-

lowing local anaesthesia (Ultracaine D-S Forte; Aventis Pharma, Hoevelaken, the

Netherlands) a slightly palatal crest-incision was made with extensions through

the buccal and palatal sulcus of the adjacent teeth. A minimal mucoperiosteal

flap was elevated to expose only the ridge crest (Figure 2). Then, an implant (No-

belReplace Tapered RP 16 mm, Nobel Biocare, Gothenburg, Sweden) was placed

according to the procedure prescribed by the manufacturer guided by the surgical

template. The shoulder of the implant was placed at a depth of 3 mm apical to the

buccal and cervical aspect of the prospective clinical crown to provide soft tissue

to develop an adequate emergence profile. Good primary implant stability was

obtained (> 45 Ncm, determined with Osseocare; Nobel Biocare). Next, an open-

tray impression was made at the implant level using a custom resin impression

tray (Lightplast base plates; Dreve Dentamid, Unna, Germany) and a polyether

impression material (Impregum Penta; 3M ESPE, St. Paul, Minnesota, USA.).

Finally, a healing abutment (NobelReplace; Nobel Biocare) was placed and the

wound was closed with sutures (Ethilon 5-0; Johnson & Johnson Gateway, Pis-

cataway, New Jersey, USA).

In the dental laboratory, a screw-retained provisional restoration was fabricated

consisting of an engaging temporary abutment (Temporary Abutment Engaging

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Figure 5. Assembly of provisional crown with implant analog and impres-sion of cervical portion of provisional crown.

Figure 4. View of peri-implant soft tissue after the provisional restoration phase. Note established emergence profile.

Figure 6. Customized impression post.

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NobelReplace; Nobel Biocare) against which composite resin (Solidex; Shofu Inc,

Kyoto, Japan) was modelled. Eight hours post-implant placement, the abutment

was removed and the provisional crown was placed and subsequently torqued to

32 Ncm (Figure 3). Special care was taken to prevent any centric and eccentric

occlusal contacts with the antagonist teeth. Furthermore, the provisional restora-

tion was contoured so that the peri-implant soft tissue was optimally supported.

In particular, the interproximal papillae were given enough space to regenerate.

The patient was instructed to follow a soft diet, to avoid exerting force on the pro-

visional restoration and to continue chlorhexidine rinses (Corsodyl; GlaxoSmith-

Kline, Utrecht, The Netherlands) for seven days. For pain control, ibuprofen 600

mg (Brufen Bruis 600; Abott B.V., Hoofddorp, The Netherlands, three times daily

for time needed) was prescribed and at two weeks post surgery the sutures were

removed.

The patient returned to the prosthodontist once a month for three months for

examination of the implant. During these sessions, implant mobility, oral hygiene

and occlusion were evaluated. Also, an important objective was the creation of an

ideal emergence profile by removing the provisional crown. Extraorally and where

needed, composite resin was removed or added to aspects of the crown to create

more space or more support for the soft tissue. In this process, special attention

was given to the shape of the proximal contour to provide an optimal condition

for the papillae to reach maturity.

Three months later (six months post-implant placement) an implant level im-

pression was made using an impression post (Impression Coping Implant Level

Open Tray NobelReplace; Nobel Biocare) that was customized in a way that the

obtained emergence profile could be transferred to the definitive restoration (Fig-

ure 4). To realize this, the provisional crown was assembled with an implant ana-

log (Implant Replica NobelReplace; Nobel Biocare) embedded in type IV dental

stone (GC Fuji Rock EP; GC Europe N.V., Leuven, Belgium). An addition silicone

impression (Futar D; Kettenbach GmbH & Co KG, Eschenburg, Germany) of the

cervical portion of the crown was made (Figure 5). Next, the latter was substituted

for an impression post and bis acrylic composite resin (Protemp; 3M ESPE, St.

Paul, Minn) was added to the post. After polishing the individualized post (Figure

6) it was inserted into the implant and an open-tray impression was made with a

polyether impression material (Impregum Penta; 3M ESPE) and a custom resin

impression tray (Lightplast base plates; Dreve Dentamid).

In the dental laboratory, a soft tissue cast was prepared. First, a waxing of

the definitive crown was made on a temporary abutment (Temporary Abutment

Engaging NobelReplace; Nobel Biocare). The screw access hole was located suf-

ficiently to the palate to create a screw-retained crown and to prepare an appropri-

ate abutment. Therefore, the waxing was cut back to the desired form and scanned

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Figures 7 & 8. Application of porcelain to individually fabricated Procera zirconia abutment to create a one-piece screw-retained definitive crown.

Figure 9. Clinical view of definitive implant crown 18 months after im-plant placement.

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for fabrication of an individual zirconia abutment (Procera; Nobel Biocare AB).

Porcelain was added directly to the abutment to create a screw-retained one piece

definitive restoration (Figures 7 & 8). The restoration was placed and the abut-

ment screw was torqued with 32 Ncm. Finally, the screw hole was filled with a

cotton pellet and composite resin (Clearfil AP-X; Kuraray Medical Inc, Okayama,

Japan). The restoration has been in service for 18 months without complication

(Figure 9).

dIscussIon

This report describes an immediate loading protocol finalized with the placement

of a screw-retained all-ceramic restoration. A major prerequisite for immediate

loading is a high degree of primary stability in terms of high insertion torque

(Esposito et al. 2007). In this treatment, an initial insertion torque of at least 45

Ncm was reached. Although clinical studies on immediate single-tooth implant

loading reported varying minimal insertion torques for immediate loading, the

authors of this report adopted a threshold of 45 Ncm.

In this patient, a substantial maturation of the papillae occurred during the

provisional phase. Care was taken to ensure that the provisional crown did not

disturb this process, but served as a natural guide. Regeneration of papillae with

time has been reported in several studies (Jemt & Lekholm 2005, Schropp et

al. 2005), but the mechanism behind this phenomenon could not validly be ex-

plained. Some authors believed that this increase might be attributed to remod-

elling potential of the soft tissue to establish a proper biological height after the

surgical manipulation (Chang et al. 1999). It is widely accepted however, that the

interproximal bone level next to the adjacent teeth is important for the future level

of the interproximal papillae of the implant (Belser et al. 2004).

Finally, a screw-retained definitive restoration was fabricated. The advantages

of this type of restoration compared to a cement-retained restoration include

retrievability and no risks for cement remnants thereby excluding possible irrita-

tion of the peri-implant tissues. However, the presence of a screw access opening

decreases fracture resistance of the porcelain (Torrado et al. 2004). Furthermore,

screw-retained restorations necessitate precise implant positioning for a proper

palatal position of the screw access hole that does not interfere with the aesthet-

ics.

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References

Andersen, E., Haanaes, H.R. & Knutsen, B.M. (2002) Im-

mediate loading of single-tooth ITI implants in the anterior

maxilla: a prospective 5-year pilot study. Clinical Oral

Implants Research 13, 281-287.

Belser, U.C., Schmid, B., Higginbottom, F. & Buser, D.

(2004) Outcome analysis of implant restorations located

in the anterior maxilla: a review of the recent literature.

International Journal of Oral and Maxillofacial Implants 19

Suppl, 30-42.

Chang, M., Wennstrom, J.L., Odman, P. & Andersson, B.

(1999) Implant supported single-tooth replacements com-

pared to contralateral natural teeth. Crown and soft tissue

dimensions. Clinical Oral Implants Research 10, 185-194.

Cooper, L.F., Ellner, S., Moriarty, J., Felton, D.A., Paquette

D. & Molina, A. (2007) Three-year evaluation of single-tooth

implants restored 3 weeks after 1-stage surgery. International

Journal of Oral and Maxillofacial Implants 22, 791-800.

Crespi, R., Capparé, P., Gherlone, E. & Romanos, G.E.

(2008) Immediate versus delayed loading of dental implants

placed in fresh extraction sockets in the maxillary esthetic

zone: a clinical comparative study. International Journal of

Oral and Maxillofacial Implants 23, 753-758.

De Rouck, T., Collys, K. & Cosyn, J. (2008) Immediate

single-tooth implants in the anterior maxilla: a 1-year case

cohort study on hard and soft tissue response. Journal of

Clinical Periodontology 35, 649-657.

Den Hartog, L., Slater, J.J., Vissink, A., Meijer, H.J. &

Raghoebar, G.M. (2008) Treatment outcome of immediate,

early and conventional single-tooth implants in the aesthetic

zone: a systematic review to survival, bone level, soft tissue,

aesthetics and patient satisfaction. Journal of Clinical Peri-

odontology 35, 1073-1086.

Esposito, M., Grusovin, M.G., Willings, M., Coulthard, P.

& Worthington, H.V. (2007) Interventions for replacing

missing teeth: different times for loading dental implants.

Cochrane Database of Systematic Reviews 18, CD003878.

Ericsson, I., Nilson, H., Lindh, T., Nilner, K. & Randow, K

(2000). Immediate functional loading of Branemark single

tooth implants. An 18 months’ clinical pilot follow-up study.

Clinical Oral Implants Research 11, 26-33.

Hall, J.A., Payne, A.G., Purton, D.G., Torr, B., Duncan, W.J.

& De Silva, R.K. (2007) Immediately restored, single-tapered

implants in the anterior maxilla: prosthodontic and aesthetic

outcomes after 1 year. Clinical Implant Dentistry and Related

Research 9, 34-45.

Jemt, T. & Lekholm, U. (2005) Single implants and buccal

bone grafts in the anterior maxilla: measurements of buccal

crestal contours in a 6-year prospective clinical study. Clini-

cal Implant Dentistry and Related Research 7, 127-135.

Kan, J.Y., Rungcharassaeng, K. & Lozada, J. (2003) Immedi-

ate placement and provisionalization of maxillary anterior

single implants: 1-year prospective study. International

Journal of Oral and Maxillofacial Implants 18, 31-39.

Linkevicius, T. & Apse P. (2008) Influence of abutment

material on stability of peri-implant tissues: a systematic re-

view. International Journal of Oral and Maxillofacial Implants

23, 449-456

Meijndert, L., Raghoebar, G.M., Meijer H.J. & Vissink, A.

(2008) Clinical and radiographic characteristics of single-

tooth replacements preceded by local ridge augmentation: a

prospective randomized clinical trial. Clinical Oral Implants

Research 19, 1295-1303.

Palmer, R.M., Palmer, P.J. & Smith, B.J. (2000) A 5-year

prospective study of Astra single tooth implants. Clinical

Oral Implants Research 11, 179-182.

Palattella, P., Torsello, F. & Cordaro, L. (2008) Two-year

prospective clinical comparison of immediate replacement

vs. immediate restoration of single tooth in the esthetic

zone. Clinical Oral Implants Research 19, 1148-1153.

Schropp, L., Isidor, F., Kostopoulos, L. & Wenzel, A. (2005)

Interproximal papilla levels following early versus delayed

placement of single-tooth implants: a controlled clinical

trial. International Journal of Oral and Maxillofacial Implants

20, 753-761.

Sundh, A. & Sjögren G. (2008) A study of the bending

resistance of implant-supported reinforced alumina and

machined zirconia abutments and copies. Dental Materials

24, 611-617.

Torrado, E., Ercoli, C., Al Mardini, M., Graser, G.N., Tal-

lents, R.H. & Cordaro L. (2004) A comparison of the

porcelain fracture resistance of screw-retained and cement-

retained implant-supported metal-ceramic crowns. Journal of

Prosthetic Dentistry 91, 532-537.

Welander, M., Abrahamsson, I. & Berglundh T. (2008) The

mucosal barrier at implant abutments of different materials.

Clinical Oral Implants Research 19, 635-641.

Yüzügüllü, B. & Avci, M. (2008) The implant-abutment in-

terface of alumina and zirconia abutments. Clinical Implant

Dentistry and Related Research 10, 113-121.

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ical

rep

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