A simplified technique for recording an implant-supported ovate pontic site in the esthetic zone Ariel J. Raigrodski, DMD, MS,a E. Ricardo Schwedhelm, DDS, MSD,b and Yen-Wei Chen, DDS, MSDc School of Dentistry, University of Washington, Seattle, Wash Implant-supported fixed dental prostheses present an esthetic challenge, especially when an ovate pontic site has been progressively developed during the guided soft-tissue healing process with an interim restoration. This article describes a technique for an accurate capturing of the molded ovate pontic site of an implant-supported fixed dental prostheses and for transferring it to the definitive cast, which facilitates the dental ceramist’s ability to design and fabricate an ovate pontic with adequate intaglio contours. (J Prosthet Dent 2014;111:154-158) The success of implant-supported restorations is measured not only by achieving asymptomatic implant osseointegration,1 it also is measured by their integration with the adjacent hard and soft tissues in terms of function, health, and esthetics. Esthetic integration of an implant-supported crown depends on many clinical variables,2 and several researchers have attempted to provide objective assessment tools to measure the integration of such restorations with the surrounding soft tissue.3-5 Patients restored with an implant-supported fixed dental prosthesis (FDP) in the esthetic zone present with a similar challenge. For optimum esthetics, the ridge form must allow the pontic to blend with the adjacent implant-supported abutments and FDP retainers, and to match in terms of softtissue profile, contours, shade, and texture with the adjacent and contralateral dentition.6,7 The challenge is to ideally manipulate the interdental space to avoid open gingival embrasures that might affect speech and esthetics, and that may contribute to food impaction and plaque accumulation.8,9 In addition, the challenge with the creation of an ideal ovate pontic is to allow such a pontic to blend with the pontic site,
which promotes the illusion of the pontic erupting out of the residual alveolar ridge. Moreover, the patient must be able to adequately clean the area while minimizing gingival inflammation.6,7,10 In such scenarios, because residual alveolar ridge resorption occurred, adjunct soft- and hard-tissue augmentation procedures may be necessary.7,11 In addition, surgical techniques are used to create an ideal concave tissue depression in the residual alveolar ridge for facilitating the creation of a concave pontic site and, therefore, a convex ovate pontic. Subsequently, customguided tissue molding by exerting selective pressure with an interim FDP has been a standard part of therapy to enhance the esthetics of the definitive FDP.12-14 Once ideal intaglio contours are established and stabilized with the aid of the interim restoration, clinicians must have the opportunity to communicate this information via the definitive impression and the impression of the interim FDP to the dental ceramist for the fabrication of the definitive restoration. However, once the interim FDP is removed for the purpose of making a definitive impression, the soft tissue at the pontic site, which is no
longer physically supported, tends to collapse coronally. Thus, the impression made may transfer an inaccurate soft-tissue profile of the pontic site to the definitive cast. Clinicians face a similar challenge when making impressions for implant-supported restorations in the esthetic zone in terms of soft-tissue profile transfer. Several researchers described techniques for transferring the soft-tissue profile from the patient’s mouth to the definitive casts for ovate pontics retained by natural dentition and for implantsupported crowns.15-18 Recently, a technique for transferring the ovate pontic site for an implant-supported FDP has been described; however, it still allows for some soft-tissue changes to occur at the pontic site before impression making.19 The purpose of this article is to describe a method for an accurate and detailed transfer of the intaglio contours of an ovate pontic site for an implant-supported FDP. This technique uses the definitive custom abutments and the FDP framework, which have already been fabricated, and the interim FDP with the definitive cast during the framework evaluation phase. In this specific patient treatment, a patient
a
Professor, Department of Restorative Dentistry. Clinical Associate Professor, Acting Chair, Department of Restorative Dentistry. c Assistant Professor, Department of Restorative Dentistry. b
The Journal of Prosthetic Dentistry
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February 2014
155
1 Occlusal view of site to be restored with implant-supported fixed dental prosthesis after interim prosthesis was used for 6 months.
a customized transfer coping as described by Hinds.18 Next, definitive computer-assisted design/computerassisted manufacturing custom zirconia implant abutments for the right maxillary canine and second premolar were designed and fabricated (Atlantis; Dentsply Implants). Subsequently, a 3-unit computer-assisted design/computer-assisted manufacturing zirconia FDP framework (Katana; Kuraray Noritake Dental Inc) was designed and fabricated. The patient was then seen for a framework evaluation and fit verification. The interim restoration was removed and cleaned, and once the fit of the definitive framework was confirmed, the interim restoration along with the definitive abutments and the FDP framework were used to transfer the emergence profile developed at the maxillary right first premolar ovate pontic site, to the definitive cast.
TECHNIQUE
2 Buccal view of interim screw-retained fixed dental prosthesis secured to definitive cast after removal of soft-tissue simulation. presented with missing maxillary right canine and the 2 maxillary right premolars. The patient was planned to be restored with a 3-unit implantsupported FDP with the maxillary first premolar restored as a pontic. Two endosseous implants, 4.0 mm in diameter and 11.5 mm in length, were placed (Osseotite Certain; Biomet 3i) at the sites of the maxillary right canine and the maxillary second premolar. Once osseointegration was confirmed, a
Raigrodski et al
screw-retained interim FDP was fabricated by using bis-acryl composite resin material (Protemp Plus; 3M ESPE). Over a period of 6 months, the soft tissue was selectively molded, which created the desired emergence profile around the implants ovate pontic site (Fig. 1). Once adequate soft-tissue contours were obtained, definitive impressions were made to transfer the implants’ positions and the emergence profile around them by using
1. Remove the soft-tissue simulation material, which was previously used for the fabrication of the definitive implant abutments, from the definitive cast. 2. Clean and disinfect the interim screw-retained implant-supported FDP and secure it to the analogs on the definitive cast to ensure adequate seating (Fig. 2). 3. Remove the interim implantsupported FPD from the definitive cast and syringe light-body polyvinyl siloxane (PVS) impression material (Imprint 3 Light Body; 3M ESPE) onto the definitive cast at the pontic site area (Fig. 3). 4. Immediately secure the interim implant-supported FDP to the analogs while impressing the pontic with the PVS and creating a replica of the clinical pontic site on the definitive cast (Fig. 4). 5. Once the PVS has polymerized, remove the interim screw-retained implant-supported FDP from the implant analogs and leave the PVS pontic site replica on the definitive cast (Fig. 5).
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3 Syringing light body polyvinyl siloxane impression material at area of ovate pontic site.
4 Interim fixed dental prosthesis secured to analogs and impression made of intaglio surface of pontic with polyvinyl siloxane light body impression material.
7. Paint the intaglio surface of the FDP framework pontic with autopolymerizing acrylic resin monomer (GC Pattern Resin; GC America) and apply autopolymerizing acrylic resin at the doughy stage on the intaglio surface of the pontic while creating convex contours. 8. Subsequently, reseat the FDP framework on the implant abutments and register and capture the PVS pontic site replica with the autopolymerizing acrylic resin (Fig. 6). 9. Trim excess autopolymerizing acrylic resin with an abrasive disk (SofLex; 3M ESPE). 10. To verify the contours of the pontic, remove the definitive custom abutments of the definitive cast, and position them in the patient’s mouth. Follow with a trial insertion of the definitive framework to assess the modified pontic and the intraoral pontic site relationship (Fig. 7). 11. Remove the definitive framework and implant abutments, and reinsert the interim FDP intraorally. Instruct the dental ceramist on the fabrication of the definitive restoration with emphasis on layering of porcelain on the intaglio surface of the pontic while using the PVS pontic site replica on the definitive cast as a guide for the definitive intaglio contours. 12. Insert the definitive implantsupported FDP after overall evaluation of the fit of the implant abutments and the FDP. Ensure that adequate intaglio contours of the pontic on the cast and intraorally have been achieved (Fig. 8).
SUMMARY
5 Interim restoration has been removed once impression material has polymerized; note contours of impression material simulating ovate pontic site. 6. Secure the definitive custom abutments to the implant analogs on the definitive cast and place the FDP
framework for evaluation over the new soft-tissue simulation at the pontic site.
The Journal of Prosthetic Dentistry
The technique described was established to provide a simplified step-bystep procedure for transferring the custom molded ovate pontic site from the patient’s mouth to the definitive cast. Because the interim FPD serves as a prototype for the definitive FDP and allows clinicians to test and confirm esthetics, phonetics, and function before the fabrication of the definitive prostheses, it is used in an indirect manner to create an ovate pontic replica on the definitive cast, which
Raigrodski et al
February 2014
157 thus allows the ceramist to fabricate the definitive FDP with adequately designed ovate pontic intaglio contours to facilitate soft-tissue health and esthetics.
REFERENCES
6 Definitive computer-assisted design/computer-assisted manufacturing custom zirconia abutments were secured to implant analogs, and zirconia framework was placed accordingly. Space between intaglio surface of pontic and simulated pontic site was filled with autopolymerizing acrylic resin to capture intaglio contours of pontic site.
7 Buccal view of clinical evaluation of zirconia framework modified at pontic with autopolymerizing acrylic resin.
8 Buccal view of definitive implant-supported fixed dental prosthesis 3 years after delivery.
Raigrodski et al
1. Smith DE, Zarb GA. Criteria for success of osseointegrated endosseous implants. J Prosthet Dent 1989;62:567-72. 2. Kois JC. Predictable single-tooth periimplant esthetics: five diagnostic keys. Compend Contin Educ Dent 2004;25: 895-900. 3. Fürhauser R, Florescu D, Benesch T, Haas R, Mailath G, et al. Evaluation of soft tissue around single-tooth implant crowns: the pink esthetic score. Clin Oral Implants Res 2005;16:639-44. 4. Meijer HJ, Stellingsma K, Meijndert L, Raghoebar GM. A new index for rating aesthetics of implant-supported single crowns and adjacent soft tissuesdthe Implant Crown Aesthetic Index. Clin Oral Implants Res 2005;16:645-9. 5. Belser UC, Grütter L, Vailati F, Bornstein MM, Weber HP, Buser D. Outcome evaluation of early placed maxillary anterior single-tooth implants using objective esthetic criteria: a cross-sectional, retrospective study in 45 patients with a 2- to 4-year follow-up using pink and white esthetic scores. J Periodontol 2009;80: 140-51. 6. Abrams L. Augmentation of the deformed residual edentulous ridge for fixed prosthesis. Compend Contin Educ Gen Dent 1980;1: 205-13. 7. Garber DA, Rosenberg ES. The edentulous ridge in fixed prosthodontics. Compend Contin Educ Dent 1981;2:212-23. 8. Hirshberg SM. The relationship of oral hygiene to embrasure and pontic design: a preliminary study. J Prosthet Dent 1972;27:26-38. 9. Reikie F. Esthetic and functional considerations for the implant restoration of the partially edentulous patient. J Prosthet Dent 1993;70:433-7. 10. Zitzmann NU, Marinello CP, Berglundh T. The ovate pontic design: a histologic observation in humans. J Prosthet Dent 2002;88: 375-80. 11. Tan WL, Wong TLT, Wong MCM, Lang NP. A systematic review of post-extractional alveolar hard and soft tissue dimensional changes is humans. Clin Oral Impl Res 2012;23(suppl 5):1-21. 12. Dylina TJ. Contour determination for ovate pontics. J Prosthet Dent 1999;82:136-42. 13. Abrams H, Kopczyk RA, Kaplan AL. Incidence of anterior ridge deformities in partially edentulous patients. J Prosthet Dent 1987;57:191-4. 14. Howard WW, Ueno H, Pruitt CO. Standards of pontic design. J Prosthet Dent 1981;47:493-5. 15. Neale D, Chee WW. Development of implant soft tissue emergence profile: a technique. J Prosthet Dent 1994;71:364-8.
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Volume 111 Issue 2 16. Jackes LB, Cohelo AB, Halloweg H, Conti PC. Tissue sculpturing; an alternative method for improving esthetics of anterior fixed prosthodontics. J Prosthet Dent 1999;81:630-3. 17. Vasconcelos DK, Volpato CA, Zani IM, Bottino MA. Impression technique for ovate pontics. J Prosthet Dent 2010;105:59-61. 18. Hinds KT. Custom impression coping for an exact registration of the healed tissue in the esthetic implant restoration. Int J Periodont Rest Dent 1997;17:585-91.
19. Schoenbaum TR, Han TJ. Direct custom implant impression copings for the preservation of the pontic receptor site architecture. J Prosthet Dent 2012;107: 203-6. Corresponding author: Dr Ariel J. Raigrodski 1959 NE Pacific Street Box 357456 Seattle, WA 98105 E-mail: [email protected]
The Journal of Prosthetic Dentistry
Acknowledgments The authors thank Caroline Herron DDS, MSD (Clinical Assistant Professor, Department of Periodontics, School of Dentistry University of Washington) for the surgical procedures performed in this patient treatment, and the master ceramists, Mr Nori Kajita, RDT, CDT and Mr Hiro Tokutomi, RDT (Cusp Dental Research, Malden MA) for fabricating the restoration presented. Copyright ª 2014 by the Editorial Council for The Journal of Prosthetic Dentistry.
Raigrodski et al
which promotes the illusion of the pontic erupting out of the residual alveolar ridge. Moreover, the patient must be able to adequately clean the area while minimizing gingival inflammation.6,7,10 In such scenarios, because residual alveolar ridge resorption occurred, adjunct soft- and hard-tissue augmentation procedures may be necessary.7,11 In addition, surgical techniques are used to create an ideal concave tissue depression in the residual alveolar ridge for facilitating the creation of a concave pontic site and, therefore, a convex ovate pontic. Subsequently, customguided tissue molding by exerting selective pressure with an interim FDP has been a standard part of therapy to enhance the esthetics of the definitive FDP.12-14 Once ideal intaglio contours are established and stabilized with the aid of the interim restoration, clinicians must have the opportunity to communicate this information via the definitive impression and the impression of the interim FDP to the dental ceramist for the fabrication of the definitive restoration. However, once the interim FDP is removed for the purpose of making a definitive impression, the soft tissue at the pontic site, which is no
longer physically supported, tends to collapse coronally. Thus, the impression made may transfer an inaccurate soft-tissue profile of the pontic site to the definitive cast. Clinicians face a similar challenge when making impressions for implant-supported restorations in the esthetic zone in terms of soft-tissue profile transfer. Several researchers described techniques for transferring the soft-tissue profile from the patient’s mouth to the definitive casts for ovate pontics retained by natural dentition and for implantsupported crowns.15-18 Recently, a technique for transferring the ovate pontic site for an implant-supported FDP has been described; however, it still allows for some soft-tissue changes to occur at the pontic site before impression making.19 The purpose of this article is to describe a method for an accurate and detailed transfer of the intaglio contours of an ovate pontic site for an implant-supported FDP. This technique uses the definitive custom abutments and the FDP framework, which have already been fabricated, and the interim FDP with the definitive cast during the framework evaluation phase. In this specific patient treatment, a patient
a
Professor, Department of Restorative Dentistry. Clinical Associate Professor, Acting Chair, Department of Restorative Dentistry. c Assistant Professor, Department of Restorative Dentistry. b
The Journal of Prosthetic Dentistry
Raigrodski et al
February 2014
155
1 Occlusal view of site to be restored with implant-supported fixed dental prosthesis after interim prosthesis was used for 6 months.
a customized transfer coping as described by Hinds.18 Next, definitive computer-assisted design/computerassisted manufacturing custom zirconia implant abutments for the right maxillary canine and second premolar were designed and fabricated (Atlantis; Dentsply Implants). Subsequently, a 3-unit computer-assisted design/computer-assisted manufacturing zirconia FDP framework (Katana; Kuraray Noritake Dental Inc) was designed and fabricated. The patient was then seen for a framework evaluation and fit verification. The interim restoration was removed and cleaned, and once the fit of the definitive framework was confirmed, the interim restoration along with the definitive abutments and the FDP framework were used to transfer the emergence profile developed at the maxillary right first premolar ovate pontic site, to the definitive cast.
TECHNIQUE
2 Buccal view of interim screw-retained fixed dental prosthesis secured to definitive cast after removal of soft-tissue simulation. presented with missing maxillary right canine and the 2 maxillary right premolars. The patient was planned to be restored with a 3-unit implantsupported FDP with the maxillary first premolar restored as a pontic. Two endosseous implants, 4.0 mm in diameter and 11.5 mm in length, were placed (Osseotite Certain; Biomet 3i) at the sites of the maxillary right canine and the maxillary second premolar. Once osseointegration was confirmed, a
Raigrodski et al
screw-retained interim FDP was fabricated by using bis-acryl composite resin material (Protemp Plus; 3M ESPE). Over a period of 6 months, the soft tissue was selectively molded, which created the desired emergence profile around the implants ovate pontic site (Fig. 1). Once adequate soft-tissue contours were obtained, definitive impressions were made to transfer the implants’ positions and the emergence profile around them by using
1. Remove the soft-tissue simulation material, which was previously used for the fabrication of the definitive implant abutments, from the definitive cast. 2. Clean and disinfect the interim screw-retained implant-supported FDP and secure it to the analogs on the definitive cast to ensure adequate seating (Fig. 2). 3. Remove the interim implantsupported FPD from the definitive cast and syringe light-body polyvinyl siloxane (PVS) impression material (Imprint 3 Light Body; 3M ESPE) onto the definitive cast at the pontic site area (Fig. 3). 4. Immediately secure the interim implant-supported FDP to the analogs while impressing the pontic with the PVS and creating a replica of the clinical pontic site on the definitive cast (Fig. 4). 5. Once the PVS has polymerized, remove the interim screw-retained implant-supported FDP from the implant analogs and leave the PVS pontic site replica on the definitive cast (Fig. 5).
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Volume 111 Issue 2
3 Syringing light body polyvinyl siloxane impression material at area of ovate pontic site.
4 Interim fixed dental prosthesis secured to analogs and impression made of intaglio surface of pontic with polyvinyl siloxane light body impression material.
7. Paint the intaglio surface of the FDP framework pontic with autopolymerizing acrylic resin monomer (GC Pattern Resin; GC America) and apply autopolymerizing acrylic resin at the doughy stage on the intaglio surface of the pontic while creating convex contours. 8. Subsequently, reseat the FDP framework on the implant abutments and register and capture the PVS pontic site replica with the autopolymerizing acrylic resin (Fig. 6). 9. Trim excess autopolymerizing acrylic resin with an abrasive disk (SofLex; 3M ESPE). 10. To verify the contours of the pontic, remove the definitive custom abutments of the definitive cast, and position them in the patient’s mouth. Follow with a trial insertion of the definitive framework to assess the modified pontic and the intraoral pontic site relationship (Fig. 7). 11. Remove the definitive framework and implant abutments, and reinsert the interim FDP intraorally. Instruct the dental ceramist on the fabrication of the definitive restoration with emphasis on layering of porcelain on the intaglio surface of the pontic while using the PVS pontic site replica on the definitive cast as a guide for the definitive intaglio contours. 12. Insert the definitive implantsupported FDP after overall evaluation of the fit of the implant abutments and the FDP. Ensure that adequate intaglio contours of the pontic on the cast and intraorally have been achieved (Fig. 8).
SUMMARY
5 Interim restoration has been removed once impression material has polymerized; note contours of impression material simulating ovate pontic site. 6. Secure the definitive custom abutments to the implant analogs on the definitive cast and place the FDP
framework for evaluation over the new soft-tissue simulation at the pontic site.
The Journal of Prosthetic Dentistry
The technique described was established to provide a simplified step-bystep procedure for transferring the custom molded ovate pontic site from the patient’s mouth to the definitive cast. Because the interim FPD serves as a prototype for the definitive FDP and allows clinicians to test and confirm esthetics, phonetics, and function before the fabrication of the definitive prostheses, it is used in an indirect manner to create an ovate pontic replica on the definitive cast, which
Raigrodski et al
February 2014
157 thus allows the ceramist to fabricate the definitive FDP with adequately designed ovate pontic intaglio contours to facilitate soft-tissue health and esthetics.
REFERENCES
6 Definitive computer-assisted design/computer-assisted manufacturing custom zirconia abutments were secured to implant analogs, and zirconia framework was placed accordingly. Space between intaglio surface of pontic and simulated pontic site was filled with autopolymerizing acrylic resin to capture intaglio contours of pontic site.
7 Buccal view of clinical evaluation of zirconia framework modified at pontic with autopolymerizing acrylic resin.
8 Buccal view of definitive implant-supported fixed dental prosthesis 3 years after delivery.
Raigrodski et al
1. Smith DE, Zarb GA. Criteria for success of osseointegrated endosseous implants. J Prosthet Dent 1989;62:567-72. 2. Kois JC. Predictable single-tooth periimplant esthetics: five diagnostic keys. Compend Contin Educ Dent 2004;25: 895-900. 3. Fürhauser R, Florescu D, Benesch T, Haas R, Mailath G, et al. Evaluation of soft tissue around single-tooth implant crowns: the pink esthetic score. Clin Oral Implants Res 2005;16:639-44. 4. Meijer HJ, Stellingsma K, Meijndert L, Raghoebar GM. A new index for rating aesthetics of implant-supported single crowns and adjacent soft tissuesdthe Implant Crown Aesthetic Index. Clin Oral Implants Res 2005;16:645-9. 5. Belser UC, Grütter L, Vailati F, Bornstein MM, Weber HP, Buser D. Outcome evaluation of early placed maxillary anterior single-tooth implants using objective esthetic criteria: a cross-sectional, retrospective study in 45 patients with a 2- to 4-year follow-up using pink and white esthetic scores. J Periodontol 2009;80: 140-51. 6. Abrams L. Augmentation of the deformed residual edentulous ridge for fixed prosthesis. Compend Contin Educ Gen Dent 1980;1: 205-13. 7. Garber DA, Rosenberg ES. The edentulous ridge in fixed prosthodontics. Compend Contin Educ Dent 1981;2:212-23. 8. Hirshberg SM. The relationship of oral hygiene to embrasure and pontic design: a preliminary study. J Prosthet Dent 1972;27:26-38. 9. Reikie F. Esthetic and functional considerations for the implant restoration of the partially edentulous patient. J Prosthet Dent 1993;70:433-7. 10. Zitzmann NU, Marinello CP, Berglundh T. The ovate pontic design: a histologic observation in humans. J Prosthet Dent 2002;88: 375-80. 11. Tan WL, Wong TLT, Wong MCM, Lang NP. A systematic review of post-extractional alveolar hard and soft tissue dimensional changes is humans. Clin Oral Impl Res 2012;23(suppl 5):1-21. 12. Dylina TJ. Contour determination for ovate pontics. J Prosthet Dent 1999;82:136-42. 13. Abrams H, Kopczyk RA, Kaplan AL. Incidence of anterior ridge deformities in partially edentulous patients. J Prosthet Dent 1987;57:191-4. 14. Howard WW, Ueno H, Pruitt CO. Standards of pontic design. J Prosthet Dent 1981;47:493-5. 15. Neale D, Chee WW. Development of implant soft tissue emergence profile: a technique. J Prosthet Dent 1994;71:364-8.
158
Volume 111 Issue 2 16. Jackes LB, Cohelo AB, Halloweg H, Conti PC. Tissue sculpturing; an alternative method for improving esthetics of anterior fixed prosthodontics. J Prosthet Dent 1999;81:630-3. 17. Vasconcelos DK, Volpato CA, Zani IM, Bottino MA. Impression technique for ovate pontics. J Prosthet Dent 2010;105:59-61. 18. Hinds KT. Custom impression coping for an exact registration of the healed tissue in the esthetic implant restoration. Int J Periodont Rest Dent 1997;17:585-91.
19. Schoenbaum TR, Han TJ. Direct custom implant impression copings for the preservation of the pontic receptor site architecture. J Prosthet Dent 2012;107: 203-6. Corresponding author: Dr Ariel J. Raigrodski 1959 NE Pacific Street Box 357456 Seattle, WA 98105 E-mail: [email protected]
The Journal of Prosthetic Dentistry
Acknowledgments The authors thank Caroline Herron DDS, MSD (Clinical Assistant Professor, Department of Periodontics, School of Dentistry University of Washington) for the surgical procedures performed in this patient treatment, and the master ceramists, Mr Nori Kajita, RDT, CDT and Mr Hiro Tokutomi, RDT (Cusp Dental Research, Malden MA) for fabricating the restoration presented. Copyright ª 2014 by the Editorial Council for The Journal of Prosthetic Dentistry.
Raigrodski et al
