Journal of Oral Implantology Esthetic Considerations for Reconstructing Implant Emergence Profile Using Titanium and Zirconia Custom Implant Abutments: Fifty Case Series Report. --Manuscript Draft-Manuscript Number:
AAID-JOI-D-12-00274R1
Full Title:
Esthetic Considerations for Reconstructing Implant Emergence Profile Using Titanium and Zirconia Custom Implant Abutments: Fifty Case Series Report.
Short Title: Article Type:
Clinical Research
Keywords:
dental implant, titanium, zirconia, custom abutment.
Corresponding Author:
Ahmad Kutkut, D.D.S., MS. University of Kentucky College of Dentistry Lexington, KY UNITED STATES
Corresponding Author Secondary Information: Corresponding Author's Institution:
University of Kentucky College of Dentistry
Corresponding Author's Secondary Institution: First Author:
Ahmad Kutkut, D.D.S., MS.
First Author Secondary Information: Order of Authors:
Ahmad Kutkut, D.D.S., MS. Osama Abu-Hammad, BDS, MSc, Ph.D Richard Mitchell, Ph.D
Order of Authors Secondary Information: Abstract:
Titanium and zirconia custom implant abutments are now commonly used for esthetic implant dentistry. Custom implant abutments allow the clinician to improve an implant's emergence profile, to customize cervical margins in accordance with the anatomy of the natural root, and to compensate for poor implant angulation. All of these are essential for optimum esthetic outcomes. CAD/CAM technology allows the clinician to design custom implant abutment configurations and create natural looking superstructures that are in harmony with the adjacent dentition and soft tissue. The CAD⁄CAM technique provides precise fit, reduces the cost of the procedure, and eliminates dimensional inaccuracies due to conventional waxing and casting technique. The aim of this report is to describe a simplified technique for reconstructing emergence profiles during implant restoration using milled titanium and zirconia custom implant abutments. The results of fifty consecutive cases are reported.
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*Article File
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Esthetic Considerations for Reconstructing Implant Emergence Profile Using Titanium and
2
Zirconia Custom Implant Abutments: Fifty Case Series Report.
3
Ahmad Kutkut, DDS, MS*; Osama Abu-Hammad BDS, MSc, Ph.D**; Richard Mitchell, Ph.D***
4
* Assistant Professor, University of Kentucky, College of Dentistry, Department of Oral Health Practice,
5
Division of Restorative Dentistry, Lexington, KY.
6
** Professor, University of Jordan, Faculty of Dentistry, Department of Prosthodontic Dentistry. Amman,
7
Jordan.
8
***Associate Professor, University of Kentucky, College of Dentistry, Department of Oral Health
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Practice. Lexington, KY.
10
Correspondence to:
11
Ahmad Kutkut, DDS, MS, University of Kentucky, College of Dentistry, Division of Restorative
12
Dentistry, 800 Rose St. D646, Lexington, Kentucky 40536 USA.
13
E-mail: [email protected], [email protected]
14
Word count: 2048
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No. of figures: 18
16
Summary: Custom implant abutments allow the clinician to improve an implant’s emergence
17
profile, which is essential for long-term aesthetic outcomes. Customized cervical margins
18
anatomically shaped to align to the natural tooth root, and to compensate for poor implant
19
angulation are discussed and illustrated.
1
20
ABSTRACT
21
Titanium and zirconia custom implant abutments are now commonly used for esthetic implant
22
dentistry. Custom implant abutments allow the clinician to improve an implant’s emergence
23
profile, to customize cervical margins in accordance with the anatomy of the natural root, and
24
to compensate for poor implant angulation. All of these are essential for optimum esthetic
25
outcomes.
26
CAD/CAM technology allows the clinician to design custom implant abutment configurations
27
and create natural looking superstructures that are in harmony with the adjacent dentition and
28
soft tissue. The CAD⁄CAM technique provides precise fit, reduces the cost of the procedure, and
29
eliminates dimensional inaccuracies due to conventional waxing and casting technique.
30
The aim of this report is to describe a simplified technique for reconstructing emergence
31
profiles during implant restoration using milled titanium and zirconia custom implant
32
abutments. The results of fifty consecutive cases are reported.
33
Key words: dental implant, titanium, zirconia, custom abutment.
34
35
36
37
38
2
39
Introduction
40
Over the past two decades, esthetics has become an increasingly important consideration in
41
implant dentistry. Esthetics is especially important when implant-supported restorations are
42
placed in the anterior maxilla where their visibility creates high patient expectations. Obtaining
43
good esthetics at these locations is challenging because of difficult pre-existing anatomy. The
44
ultimate goal of a dental implant is to restore missing teeth by placing implants that are
45
anatomically correct and esthetically pleasing in functional positions that ensure long-term
46
durability.1 Essential prerequisites to an esthetically successful treatment are; thorough pre-
47
surgical planning, appropriate site development, 3D implant positioning, soft tissue
48
management, provisionalization, and esthetic prosthetic management.2 All of this must be done
49
within the context of the patients’ expectations. Site enhancement and alveolar ridge
50
preservation following tooth extraction have a major impact on the hard and soft tissue volume
51
prior to placement of an implant and the definitive prosthetic implant restoration.3 Custom
52
implant abutments allow the clinician to improve an implant’s emergence profile, to customize
53
cervical margins so that they are anatomically shaped in accordance to the natural tooth root,
54
and to compensate for poor implant angulation.4-6 All of these are essential for optimum
55
aesthetic outcomes.
56
Smile line and gingival biotype play a major role in the final esthetic outcomes. Neighboring
57
tooth position, number of missing teeth, type of provisional prosthesis (fixed or removable),
58
shape and shade of adjacent dentition are positive factors that need to be considered for
59
successful treatment planning.7,
8
When the tooth is non-restorable, positive factors for
3
60
favorable implant restoration9 include gingival tissue that has a flat gingival scallop form and a
61
thick gingival biotype. Other positive factors include square-shape teeth with a high osseous
62
crest.
63
Recent research has provided useful insights into soft tissue changes around implants following
64
implant placement surgery. For example, in one clinical study10 measurements were recorded
65
at stage 2 surgery in 2-stage implant systems and at stage 1 surgery in the 1-stage system.
66
Subsequent measurements were recorded for several interval periods up to 1 year after
67
baseline measurements. The majority of the recession occurred within the first 3 months of
68
healing. 80% of all sites showed recession on the buccal side with average soft tissue recession
69
amount of 0.88 mm. The investigators recommended that soft tissue be allowed to stabilize for
70
3 months after implant placement before selecting a final abutment or making a final
71
impression. As a general rule, a 1 mm of soft tissue recession can be expected after healing
72
abutment connection surgery.10
73
Soft tissue integration around dental implant has not been extensively studied. One study
74
evaluated the implant-gingival junction of unloaded and loaded non-submerged titanium
75
implants. Histological dimensions of the sulcus depth, the junctional epithelium), and the
76
connective tissue contact were measured. Significant changes within tissue compartments
77
occurred over healing time. Sulcus Depth had a mean value of 0.49 mm and 0.50 mm after
78
three and six months of healing. The difference became statistically significant after 15 months
79
with a mean value of 0.16 mm. Similarly, the mean length of the junctional epithelium after
80
three and six months of healing was 1.16 mm and 1.44 mm, respectively. After 15 months, the
4
81
mean values became significantly different at 1.88mm. A different pattern of changes was
82
reported for the length of connective tissue contact. After three months of healing, the mean
83
value was 1.36 mm. This was significant different from the same area after six and 15 months,
84
which were 1.01 mm and 1.05 mm, respectively. These results will inform treatment decisions,
85
since preservation or reconstruction of soft tissue integration around the implant restorations
86
is as important as preservation the hard tissue integration around functioning implants. 11
87
CAD/CAM technology allows the clinician to design custom implant abutment configurations
88
and create an anatomically natural looking superstructure that is in harmony with the
89
surrounding dentition and adjacent soft tissue.12 The CAD⁄CAM technique provides precise fit
90
of the intended prosthetic design, reduces the cost of the procedure, and eliminates
91
dimensional inaccuracies due to conventional waxing and casting techniques.13 The precisely
92
fitting implant custom abutment improves implant longevity and prosthetic success, and
93
simplifies the restoration.12, 13
94
During the past three decades, there has been a considerable research on implant prostheses.
95
In the following, the highlights of the research results for titanium and zirconia abutments will
96
be compared for each of the following topics: in vitro properties, survival, marginal adaptation,
97
bone loss, soft tissue response, esthetic outcomes, and technical complications.
98
Yttria-stabilized zirconia (ZrO₂-Y₂O₃) ceramics is a biocompatible biomaterial for restoration,
99
which has excellent aesthetic and mechanical properties. Recently, zirconia custom abutments
100
have been proposed as an excellent alternative to titanium custom abutments for esthetic
101
implant restorations in the maxillary anterior region. The strength of the zirconia abutment is 5
102
comparable to that of titanium (281N versus 305N), both are strong enough to withstand static
103
and dynamic loads that occur in vivo. The flexure strength of the zirconia abutments is similar
104
to that of titanium abutments; both are strong enough to be used in a cantilever structures. The
105
material is susceptible to undergoing the stress-induced transformation toughening mechanism
106
because of the very fine grain size. The bacterial adhesion was registered by a percentage of
107
bacterial biofilm of 12.1% on the zirconia abutment, compared to 19.3% on the titanium
108
abutment. This is very important in the maintaining of zirconia restorations around dental
109
implant. 14-16
110
The fracture resistance of zirconia implant abutments exceeds the maximal reported incisal
111
forces (90 to 370 N). The maximum load capacity was 484.6 ± 56.6 N for NobelProcera
112
(NobelProcera Abutment Zirconia; Nobel Biocare, Yorba Linda, Calif), 503.9 ± 46.3 N for Aadva
113
(Aadva CAD/CAM Zirconia Abutment; GC Advanced Technologies Inc, Alsip, Ill), and 729.2 ± 35.9
114
N for Lava abutments (Lava Zirconia abutment; 3M ESPE, St Paul, Minn). With standard
115
diameter internal tri-lube connection implants, the maximum load capacity of the Lava
116
abutment was significantly higher than that of the Aadva or NobelProcera abutment. No
117
significant difference in maximum load capacity was noted between Aadva and NobelProcera
118
abutments. The mode of failure among the Aadva, NobelProcera, and Lava abutments was
119
different.17
120
Scanning electron microscopy revealed that titanium implants exhibited more wear after cyclic
121
loading when connected to zirconia abutments (maximum wear 10.2μm) than when connected
122
to titanium abutments (maximum wear 0.7μm).18
6
123
Sailer et al., reviewed the performance of ceramic and metal implant abutments supporting
124
implant restorations and estimated 95% 5-year survival rate for the implants in function. For
125
example, in one study the 5-year rate for soft tissue recession around ceramic abutments was
126
clinically more pronounced than around metal abutments (8.9% and 3.8% respectively). In
127
another study, the estimated 5-year rate for the soft tissue recession was 2.1% for ceramic
128
abutments and 4.1% for metal abutments. The rate for bone loss was higher for implants
129
supporting metal abutments (3.9%) than for those supporting ceramic abutments (1.7%). The
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total estimated 5-year rate for esthetic complications for ceramic and metal abutments
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supporting fixed restorations was 5.4%. Problems with the esthetic outcome were more
132
frequently reported for metal abutments.19 Several articles imply that peri-implant soft tissue
133
aesthetics can be enhanced by controlling the contour of provisional restorations. Clinical and
134
histological studies showed that gold, titanium and zirconia ceramic abutment materials all
135
exhibit excellent biological responses around dental implant restorations.2
136
The marginal bone loss at one-year follow up after prosthetic loading was not significantly
137
different between all-ceramic and metal-ceramic restorations (-0.08 mm ± 0.25mm and -0.10
138
mm ± 0.17mm respectively). The marginal adaptation of the all-ceramic crowns was
139
significantly poorer than the metal-ceramic crowns. The professional-reported color match of
140
all-ceramic crowns was significantly better than metal-ceramic crowns, but other aesthetic
141
parameters showed no statistically significant difference between all-ceramic and metal-
142
ceramic restorations.20 After three years, 100% of zirconia implant abutments and 97% for
143
crowns survived. Marginal bone loss was significantly higher around gold-alloy (0.41 mm ±
144
0.58mm) when compared to zirconia abutments (0.15 mm ± 0.25mm). The professional7
145
reported aesthetic outcome showed superiority in esthetic and color match of all-ceramic over
146
metal-ceramic crowns.21
147
Based on the meta-analysis of forty-six studies, survival of implants supporting single crowns
148
was to 97.2% after five year and 95.2% at 10 years. For example, in one study of implant-
149
supported single crown restorations 96.3% survived 5 years and 89.4% survived 10 years. At the
150
5-year follow up, the cumulative percentage of restorations that exhibited soft tissue
151
complications (mucositis, bleeding, suppuration, and soft tissue dehiscences) was reported to
152
be 7.1%. For the subset of restorations with bone loss >2 mm was reported to be 5.2%. After
153
five years, 8.8% of the restoration exhibited screw-loosening, 4.1% exhibited loss of retention,
154
and 3.5% exhibited fracture of the veneering material. The cumulative 5-year aesthetic
155
complication rate due to soft tissue recessions, an unfavorable color, and visible crown margins
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was reported to be 7.1%. 22
157
The zirconia custom abutments performed well over the five year follow up period.23 The rates
158
of both technical and biological complications were low (1%), and the patients were in general
159
extremely satisfied with the restorations. There were no significant differences for changes in
160
any of the soft tissue measurements. The peri-implant bone level changes from placement to
161
the clinical examination 3-5 years later were small resorption (0.29 mm ± 0.87 mm). 23
162
The bone resorption around transmucosal implants loaded for 12 months was reported by 0.86
163
mm ± 0.99 mm. When prefabricated solid abutment were4 used, the connective tissue and
164
Junctional epithelium was migrated on the transmucosal machined surface of the implants’
165
necks following the resorption of the bone regardless the length of the implant’s neck. 24 8
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The preceding review demonstrates that laboratory research and clinical trials support the use
167
of customized implant abutment. The aim of this report is to describe a simplified technique for
168
reconstruction of the emergence profile at the time of implant restoration, especially in the
169
anterior esthetic zenith, using milled titanium or zirconia custom implant abutments. We
170
describe the outcomes of such treatment based on our experiences with series of 50
171
consecutive cases.
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Materials and Methods
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Fifty implants were restored using computer-milled titanium or zirconia custom implant
175
abutments25 followed by definitive ceramo-metal (for posterior implants) or full ceramic crowns
176
(for anterior implants).
177
Step by step procedures:
178
(Clinical) Patients presented with straight healing abutments (Fig. 1) and treatment
179
removable partial dentures (Fig. 2). All implants were restored by the first author (AK).
180
All prosthetic restorations utilized recommended manufactures’ components and
181
protocols.
182
(Clinical) After approximately three months of healing post-surgery, the healing
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abutment was removed and an impression coping was screwed into the internal
184
connection of the implant and secured with a guide screw (Fig. 3a).
9
185
impression coping to the implant platform (Fig. 3b).
186 187
(Clinical) A periapical radiograph was made to confirm the appropriate fit of the
(Clinical) After that an implant level impression was made using a polyvinyl siloxane
188
material (PVS, 3M ESPE, St. Paul, MN, USA) with the closed tray-impression technique.
189
Facebow and interocclusal relationship were recorded at this time.
190
(Clinical) After removing the impression coping and replacing the healing abutment, an
191
implant replica was connected to the impression coping and inserted back into the PVS
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impression (Fig. 3c).
193
(Laboratory) Just enough gingival mask silicon (Gingifast Elastic, Zhermack Inc., River
194
Edge, NJ) was added around the impression coping and the implant replica to cover the
195
coping-replica junction (Fig. 4a).
196
RockTM, Whip Mix Corporation, Louisville, KY).
197 198
(Laboratory) On the stone model, the gingival mask was modified using a round diamond bur to create the emergence profile of the missing tooth (Fig. 4b).
201 202
(Laboratory) After the stone had set, the impression was retrieved and the working cast trimmed and mounted on an articulator in maximum intercuspation (MI).
199 200
(Laboratory) A stone model was made from the impression using type IV stone (Resin
(Laboratory) A temporary abutment (plastic or titanium) was screwed into the implant
203
replica and secured with the lab screw. A full contour tooth wax-up was made after any
204
necessary modifications had been made to the temporary abutment (Fig. 5).
205 206
(Laboratory) A silicone index to the full-contour tooth wax-up and adjacent teeth was made at this stage. This silicone index will later be used in the fabrication of polymethyl 10
207
methacrylate (PMMA) provisional crowns and subsequently will aid in fabrication of the
208
definitive restorations (Fig. 6).
209
the definitive custom abutment (Fig. 7).
210 211
(Laboratory) A wax-up cut-back was made to create the finish line and final contour of
(Laboratory) The abutment wax-up was then retrieved from the model and scanned
212
with a digital scanner (Procera® Piccolo Scanner, Nobel BiocareTM). A computer-assisted
213
milling machining was used to fabricate either a milled titanium or a milled zirconia
214
custom implant abutment (Fig. 8a and 8b).
215
(Laboratory) The definitive custom implant abutment received from the manufacturer
216
was carefully disinfected and checked for the appropriate emergence profile (Fig. 8c). If
217
a minor modification is required to the fitting surface of the abutment, the titanium
218
custom abutment must be subsequently highly polished with a metal polishing kit.
219
on the model and a provisional crown was made using PMMA (Fig. 9).
220 221
(Laboratory) The definitive custom abutment was then screwed into the implant replica
(Clinical) Approximately two weeks after the implant level impression was made, the
222
patient returned for delivery of the definitive custom abutment and provisional crown.
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If necessary, local anesthesia was administered. Then the straight healing abutment was
224
removed and the disinfected custom abutment was screwed into the implant’s internal
225
connection and torqued to 35 N-cm (Fig. 10).
226
(Clinical) The custom abutment’s screw access was filled with a cotton pellet soaked
227
with chlorhexidine mouth rinse and blocked with a light-curing temporary resin
228
composite (FermitTM; Ivoclar Vivadent, Amherst, NY) (Fig. 10). 11
229
(Clinical) The PMMA provisional crown was then cemented with a zinc oxide-eugenol
230
cement (TempBondTM; Kerr Corporation, Orange, CA) (Fig. 11). Excess cement was
231
carefully removed from around the peri-implant mucosa. All the provisional crowns
232
were placed in function with full contact in centric occlusion.
233
(Clinical) Approximately two weeks after the provisionalization stage, the patient
234
returned for the abutment level impression. During the healing period, the peri-implant
235
mucosa, guided by the emergence profile of the abutment, adapts to the custom
236
abutment.
237
off the definitive custom abutment.
238 239
(Clinical) Next, the provisional crown was removed and remaining cement was cleaned
(Clinical) To retract the peri-implant mucosa, a single retraction cord (00”) was packed
240
around the custom abutment. The cord was left in place for five minutes and then
241
removed immediately prior to making an abutment level impression using PVS
242
impression material (PVS, 3M ESPE,).
243
followed to fabricate the definitive ceramo-metal or full ceramic crown (Fig. 12).
244 245
(Clinical) Two weeks later, a definitive full ceramic or ceramo-metal crown restoration was cemented onto the abutment (Fig. 13 and 14).
246 247
(Laboratory) At this stage, standard crown and bridge laboratory procedures were
(Clinical) The occlusion was checked using an 8 μm foil (Shimstock Occlusion Foil,
248
Patterson Dental, St. Paul, MN) and the occlusion was adjusted so that the foil could be
249
withdrawn unless the patient closed under maximum intercuspation.
250 12
251
Results
252
Clinical results
253
The criteria for implant success included: stability, absence of a radiolucency around the
254
implants, no peri-implant mucositis or inflammation, and the absence of pain. No patients
255
complained of pain and there was no evidence of infection associated with any implants.
256
At the 12-month follow-up, all the implants had survived. No pain or final prosthesis mobility
257
was recorded. The mucosa around the custom abutments was healed within normal limits and
258
finely adapted to the definitive crowns (Fig. 15). No mucositis or irritation was reported.
259
Radiographic results
260
Radiographic evaluation was performed at the provisional stage (Fig. 16a) and twelve months
261
after placement of the definitive restoration (Fig. 16b). Radiograph showing the emergence
262
profile as transferred to the implant by the custom abutment was recorded (Fig. 16c). Vertical
263
bone resorption was not clinically significantly different between the stages of the treatment.
264
Esthetic results
265
An important esthetic outcome was whether or not papillae had re-formed around the custom
266
abutment and the definitive crown. Two other outcomes were whether papillae had changed
267
position and whether papillae had reformed around the emergence profile of the custom
268
abutment. All three of the esthetic outcomes were achieved in all patients. Clinically, all soft
269
tissues appeared pink and healthy (Fig. 14, 15, and 16). All patients were satisfied with the final
270
esthetic outcomes (Fig. 17). 13
271
DISCUSSION
272
Many patients, especially those who need implant prosthesis in the maxillary anterior area,
273
choose implant treatment in hope of better esthetics. This report describes a simplified
274
technique to create an emergence profile that will improve the esthetic outcome of the implant
275
restoration. Esthetic success requires an adequate volume of bone and a sufficient quantity and
276
appropriate quality of soft tissue.26 Natural appearing adaptation of peri-implant mucosa to and
277
around the restoration is critical to achieving an esthetic result.26,
278
exposure of teeth and gingival tissue, restoration of high-smile-line patients is more challenging
279
due to the high esthetic demand. The location of the implant, the relationship of the
280
implant/abutment interface, and the crestal bone around the implant determine whether there
281
will be enough support for the gingival tissue surrounding the implant crown. To achieve an
282
acceptable esthetic result, the mesiodistal and buccolingual implant position and angulation in
283
the residual alveolar ridge, the minimal interocclusal distance, and the maximal interproximal
284
contact point to crestal bone distance each must approximate 6 mm. 28
285
To achieve an optimum esthetic result with implant restorations, the peri-implant soft tissue
286
should be modified to create an appropriate emergence profile and natural contour at the
287
provisional stage.6-9 The implant’s apico-coronal position should be 3 to 4 mm below the
288
gingival line to make room for an emergence profile that aligns well with the adjacent gingival
289
level. Also, the implant’s mesio-distal position should be at least 1 mm from a natural tooth and
290
at least 3 mm from another implant.26, 29-31
14
27
Because of the larger
291
Soft tissue management can be done before implant placement, during stage 1 surgery, during
292
stage 2 surgery, or after the restoration is placed to increase the amount of keratinized tissue
293
and preserve the papilla.32 The bone around adjacent teeth promotes papilla development.
294
This is why papillae are more likely to be associated with single implant restorations than
295
multiple implants restorations.30,
296
from the bone level on the adjacent tooth to the contact point is less than 5 mm, papillae are
297
more likely to reform.29-31 In one study, there was an average of 30 % increase of the volume of
298
the papillae 1 year after prosthesis insertion.32 In most cases, papilla spontaneously
299
regenerated after a few years in function.33 Despite improved surgical techniques that have
300
been recently developed, the factors that encourage regeneration of papillae adjacent to dental
301
implants is still a matter of debate.32
302
Custom abutments can be used to correct implant angulation (Fig. 18), and along with
303
provisional crowns, can improve the implant restoration’s emergence profile 34, 35 Peri-implant
304
soft tissue manipulation is possible if the implant is deep enough and the proper gingival
305
biotype is present. A gradual transfer from the profile of the implant platform to a natural
306
emergence profile can be easily created using a customized implant abutment and implants
307
that are placed 3 to 4 mm subgingivally in a thick soft tissue biotype.2, 30, 36 Shallow implants
308
that are associated with a thin peri-implant soft tissue biotype will make it difficult to create a
309
satisfactory emergence profile 2, 36 and consequently, successful esthetic outcomes will be more
310
difficult to achieve.
31
Several investigations have reported that if the distance
15
311
There are several CAD/CAM technology systems can be used to develop esthetically natural
312
looking implant restorations.37 To minimize undesirable stress concentrations, computer-milled
313
custom abutments must fit accurately.38, 39 There have been several investigations of the fit at
314
the interface between implants with different internal connections and Ti or Zirconia CAD/CAM
315
computer-milled custom abutments.14,24,40-44 Microscopic evaluation of internal systems
316
connected to titanium or zirconia abutments show that the implant–abutment interfaces are
317
well sealed under no-loading conditions.38 A tight interfacial contact is desirable to maximize
318
mechanical stability of abutments and prosthesis.45 In any case because poor adaptation at the
319
implant-abutment interface might produce biological and mechanical complications, it seems
320
desirable to have as close a marginal fit as possible. The customization possible with CAD/CAM
321
abutments allows for more refined prosthetic designs and enhanced the soft tissue contour. It
322
is expected that refined designs will make possible implant-supported restorations that are
323
more esthetic, biologically compatible, and durable.
324
CONCLUSION
325
Optimal esthetic implant restorations depend on thorough pre-surgical planning, accurate three
326
dimensional implant placement, careful soft tissue management, and proper provisional
327
restorations. When titanium and zirconia custom abutments are used at the provisional crown
328
stage of implant construction to modify the emergence profile and natural contour, implant
329
restorations exhibit excellent esthetics and healthy gingival tissues.
330
Since the probability of successful restoration depends on several anatomy-dependent factors,
331
each patient should be counseled about the likelihood of success in his or her particular case. 16
332
References
333
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9. Kois JC. Predictable single-tooth peri-implant esthetics: five diagnostic keys. Compend Contin
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Educ Dent. 2004;25:895-897.
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10. Small PN, Tarnow DP. Gingival recession around implants: a 1-year longitudinal prospective
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study. Int J Oral Maxillofac Implants. 2000;15:527-532.
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11. Hermann JS, Buser D, Schenk RK, Higginbottom FL, Cochran DL. Biologic width around
356
titanium implants. A physiologically formed and stable dimension over time. Clin Oral Implants
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Res. 2000;11:1-11.
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12. Kapos T, Ashy LM, Gallucci GO, Weber HP, Wismeijer D. Computer-aided design and
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computer-assisted manufacturing in prosthetic implant dentistry. Int J Oral Maxillofac Implants.
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2009;24:110-117.
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13. Apicella D, Veltri M, Chieffi N, Polimeni A, Giovannetti A, Ferrari M. Implant adaptation of
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stock abutments versus CAD/CAM abutments: a radiographic and Scanning Electron
363
Microscopy study. Ann Stomatol. 2010;1:9-13.
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14. Nakamura K, Kanno T, Milleding P, Ortengren U. Zirconia as a dental implant abutment
365
material: a systematic review. Int J Prosthodont. 2010;23:299-309.
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15. Gomes AL, Montero J. Zirconia implant abutments: a review. Med Oral Patol Oral Cir Bucal.
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2011;16:e50-55.
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16. Vaquero-Aguilar C, Jiménez-Melendo M, Torres-Lagares D, et al., Zirconia implant
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abutments: microstructural analysis. Int J Oral Maxillofac Implants. 2012;27:785-791.
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17. Kim JS, Raigrodski AJ, Flinn BD, et al., In vitro assessment of three types of zirconia implant
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abutments under static load. J Prosthet Dent. 2013;109:255-263.
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18. Stimmelmayr M, Edelhoff D, Güth JF, et al., Wear at the titanium-titanium and the titanium-
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zirconia implant-abutment interface: a comparative in vitro study. Dent Mater. 2012;28:1215-
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1220.
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19. Sailer I, Philipp A, Zembic A, et al., A systematic review of the performance of ceramic and
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metal implant abutments supporting fixed implant reconstructions. Clin Oral Implants Res.
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2009;20:4-31.
378
20. Hosseini M, Worsaae N, Schiodt M, Gotfredsen K. A 1-year randomised controlled trial
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comparing zirconia versus metal-ceramic implant supported single-tooth restorations. Eur J
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Oral Implantol. 2011;4:347-361.
381
21. Hosseini M, Worsaae N, Schiødt M, Gotfredsen K. A 3-year prospective study of implant-
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supported, single-tooth restorations of all-ceramic and metal-ceramic materials in patients with
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tooth agenesis. Clin Oral Implants Res. 2012, 1–10.
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22. Jung RE, Zembic A, Pjetursson BE, Zwahlen M, Thoma DS. Systematic review of the survival
385
rate and the incidence of biological, technical, and aesthetic complications of single crowns on
386
implants reported in longitudinal studies with a mean follow-up of 5 years. Clin Oral Implants
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Res. 2012;23:2-21.
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23. Ekfeldt A, Fürst B, Carlsson GE. Zirconia abutments for single-tooth implant restorations: a
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retrospective and clinical follow-up study. Clin Oral Implants Res. 2011;22:1308-1314. 19
390
24. Joly JC, de Lima AF, da Silva RC Clinical and radiographic evaluation of soft and hard tissue
391
changes around implants: a pilot study. J Periodontol. 2003;74:1097-1103.
392
25. Priest G. Virtual-designed and computer-milled implant abutments. J Oral Maxillofac Surg.
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2005;63:22-32.
394
26. Tarnow D, Elian N, Fletcher P, Froum S, Magner A, Cho SC, Salama M, Salama H, Garber DA.
395
Vertical distance from the crest of bone to the height of the interproximal papilla between
396
adjacent implants. J Periodontol. 2003;74:1785-1788.
397
27. Boudrias P, Shoghikian É, Morin É, Hutnik P. Esthetic Option for the Implant-Supported
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Single-Tooth Restoration — Treatment Sequence With a Ceramic Abutment. J Can Dent Assoc.
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2001;67:508-514.
400
28. Cooper LF, Pin-Harry OC. "Rules of Six"--diagnostic and therapeutic guidelines for single-
401
tooth implant success. Compend Contin Educ Dent. 2013;34:94-98,100-101;quiz102-117
402
29. LaVacca MI, Tarnow DP, Cisneros GJ. Interdental papilla length and the perception of
403
aesthetics. Pract Proced Aesthet Dent. 2005;17:405-412.
404
30. Tarnow DP, Cho SC, Wallace SS. The effect of inter-implant distance on the height of inter-
405
implant bone crest. J Periodontol. 2000;71:546-549.
406
31. Choquet V, Hermans M, Adriaenssens P, Daelemans P, Tarnow DP, Malevez C. Clinical and
407
radiographic evaluation of the papilla level adjacent to single-tooth dental implants. A
408
retrospective study in the maxillary anterior region. J Periodontol. 2001 Oct;72(10):1364-1371.
20
409
32. Grunder U. Stability of the mucosal topography around single-tooth implants and adjacent
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teeth: 1-year results. Int J Periodontics Restorative Dent. 2000;20:11-17.
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33. Jemt T. Regeneration of gingival papillae after single-implant treatment. Int J Periodontics
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Restorative Dent. 1997;17:326-333.
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34. Cavallaro J Jr, Greenstein G. Angled implant abutments: a practical application of available
414
knowledge. J Am Dent Assoc. 2011;142:150-158.
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35. Wu T, Liao W, Dai N, Tang C. Design of a custom angled abutment for dental implants using
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computer-aided design and nonlinear finite element analysis. J Biomech. 2010;43:1941-1946.
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36. Alani A, Corson M. Soft tissue manipulation for single implant restorations. Br Dent J
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2011;211:411-416.
419
37. Drago CJ. Two new clinical/laboratory protocols for CAD/CAM implant restorations. J Am
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Dent Assoc. 2006;137:794-800.
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38. Sumi T, Braian M, Shimada A, Shibata N, Takeshita K, Vandeweghe S, Coelho PG,
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Wennerberg A, Jimbo R. Characteristics of implant-CAD/CAM abutment connections of two
423
different internal connection systems. J Oral Rehabil. 2012;39:391-398.
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39. Yuzugullu B, Avci M. The implant-abutment interface of alumina and zirconia abutments.
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Clin Implant Dent Relat Res. 2008;10:113-121.
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40. Kerstein RB, Radke J. A comparison of fabrication precision and mechanical reliability of 2
427
zirconia implant abutments. Int J Oral Maxillofac Implants. 2008;23:1029-1036.
21
428
41. Glauser R, Sailer I, Wohlwend A, Studer S, Schibli M, Scharer P. Experimental zirconia
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abutments for implant-supported single-tooth restorations in esthetically demanding regions:
430
4-year results of a prospective clinical study. Int J Prosthodont. 2004;17:285-290.
431
42. Henriksson K, Jemt T. Evaluation of custom-made Procera ceramic abutments for single-
432
implant tooth replacement: A prospective 1-year follow-up study. Int J Prosthodont. 2003;16:
433
626-630
434
43. Canullo L. Clinical outcome study of customized zirconia abutments for single-implant
435
restorations. Int J Prosthodont. 2007;20:489–493.
436
44. Zembic A, Sailer I, Jung RE, Hämmerle CH. Randomized-controlled clinical trial of customized
437
zirconia and titanium implant abutments for single-tooth implants in canine and posterior
438
regions: 3-year results. Clin Oral Implants Res. 2009;20:802-808.
439
45. Lang LA, Sierraalta M, Hoffensperger M, Wang RF. Evaluation of the precision of fit between
440
the Procera custom abutment and various implant systems. Int J Oral Maxillofac Implants.
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2003;18:652-658
442
443
444
445
446
22
447
Figures Legend
448
Fig 1. Straight healing abutments after three months.
449
Fig 2. Treatment removable partial denture used during healing.
450
Fig 3. Implant level impression with impression coping. a. Showing the coping screwed into
451
implant. b. A periapical radiograph confirms fit of the impression coping into implant. c.
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Impression coping and lab analog captured by a PVS impression.
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Fig 4. Gingival mask silicone material used. a. Just enough silicone is added to cover the
454
coping-replica junction. b. Gingival mask modified on stone model.
455
Fig 5. Example of full contour tooth wax-up made after necessary modifications to temporary
456
abutment had been made.
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Fig 6. The silicone index to be used to fabricate a provisional crown and was positioned against
458
the stone model to verify the restorative space.
459
Fig 7. Creating the finish line and final contour of the wax-up cut back.
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Fig 8. Scanning and milling the abutment. a. Scanning wax-up. b. Computer image of the
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scanned abutment. c. Definitive milled titanium abutment.
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Fig 9. The provisional crown made using PMMA.
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Fig 10. Milled custom abutment screwed into implant and tightened using a torque of 35 Ncm.
464
a, b. Facial view for milled titanium and zirconia custom abutments.
23
465
Fig 11. PMMA provisional crown reported after cementation.
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Fig 12. Standard crown and bridge laboratory procedure were followed to fabricate the
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definitive crown restoration.
468
Fig 13. Peri-implant mucosa adapted to the custom abutment guided by its emergence profile.
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Fig 14. The final crowns after cementation
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Fig 15. The fully-healed mucosa around the definitive crown reported after one year in
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function.
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Fig 16. Radiographs. a. Titanium custom abutment at the provisionalization stage. b. at twelve
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months at placement of the definitive restoration. c. Showing the emergence profile that has
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been transferred to the implant via the custom abutment.
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Fig 17. The patient was satisfied with the esthetic outcome.
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Fig 18. Custom abutment can correct implant miss-angulation.
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AAID-JOI-D-12-00274R1
Full Title:
Esthetic Considerations for Reconstructing Implant Emergence Profile Using Titanium and Zirconia Custom Implant Abutments: Fifty Case Series Report.
Short Title: Article Type:
Clinical Research
Keywords:
dental implant, titanium, zirconia, custom abutment.
Corresponding Author:
Ahmad Kutkut, D.D.S., MS. University of Kentucky College of Dentistry Lexington, KY UNITED STATES
Corresponding Author Secondary Information: Corresponding Author's Institution:
University of Kentucky College of Dentistry
Corresponding Author's Secondary Institution: First Author:
Ahmad Kutkut, D.D.S., MS.
First Author Secondary Information: Order of Authors:
Ahmad Kutkut, D.D.S., MS. Osama Abu-Hammad, BDS, MSc, Ph.D Richard Mitchell, Ph.D
Order of Authors Secondary Information: Abstract:
Titanium and zirconia custom implant abutments are now commonly used for esthetic implant dentistry. Custom implant abutments allow the clinician to improve an implant's emergence profile, to customize cervical margins in accordance with the anatomy of the natural root, and to compensate for poor implant angulation. All of these are essential for optimum esthetic outcomes. CAD/CAM technology allows the clinician to design custom implant abutment configurations and create natural looking superstructures that are in harmony with the adjacent dentition and soft tissue. The CAD⁄CAM technique provides precise fit, reduces the cost of the procedure, and eliminates dimensional inaccuracies due to conventional waxing and casting technique. The aim of this report is to describe a simplified technique for reconstructing emergence profiles during implant restoration using milled titanium and zirconia custom implant abutments. The results of fifty consecutive cases are reported.
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*Article File
1
Esthetic Considerations for Reconstructing Implant Emergence Profile Using Titanium and
2
Zirconia Custom Implant Abutments: Fifty Case Series Report.
3
Ahmad Kutkut, DDS, MS*; Osama Abu-Hammad BDS, MSc, Ph.D**; Richard Mitchell, Ph.D***
4
* Assistant Professor, University of Kentucky, College of Dentistry, Department of Oral Health Practice,
5
Division of Restorative Dentistry, Lexington, KY.
6
** Professor, University of Jordan, Faculty of Dentistry, Department of Prosthodontic Dentistry. Amman,
7
Jordan.
8
***Associate Professor, University of Kentucky, College of Dentistry, Department of Oral Health
9
Practice. Lexington, KY.
10
Correspondence to:
11
Ahmad Kutkut, DDS, MS, University of Kentucky, College of Dentistry, Division of Restorative
12
Dentistry, 800 Rose St. D646, Lexington, Kentucky 40536 USA.
13
E-mail: [email protected], [email protected]
14
Word count: 2048
15
No. of figures: 18
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Summary: Custom implant abutments allow the clinician to improve an implant’s emergence
17
profile, which is essential for long-term aesthetic outcomes. Customized cervical margins
18
anatomically shaped to align to the natural tooth root, and to compensate for poor implant
19
angulation are discussed and illustrated.
1
20
ABSTRACT
21
Titanium and zirconia custom implant abutments are now commonly used for esthetic implant
22
dentistry. Custom implant abutments allow the clinician to improve an implant’s emergence
23
profile, to customize cervical margins in accordance with the anatomy of the natural root, and
24
to compensate for poor implant angulation. All of these are essential for optimum esthetic
25
outcomes.
26
CAD/CAM technology allows the clinician to design custom implant abutment configurations
27
and create natural looking superstructures that are in harmony with the adjacent dentition and
28
soft tissue. The CAD⁄CAM technique provides precise fit, reduces the cost of the procedure, and
29
eliminates dimensional inaccuracies due to conventional waxing and casting technique.
30
The aim of this report is to describe a simplified technique for reconstructing emergence
31
profiles during implant restoration using milled titanium and zirconia custom implant
32
abutments. The results of fifty consecutive cases are reported.
33
Key words: dental implant, titanium, zirconia, custom abutment.
34
35
36
37
38
2
39
Introduction
40
Over the past two decades, esthetics has become an increasingly important consideration in
41
implant dentistry. Esthetics is especially important when implant-supported restorations are
42
placed in the anterior maxilla where their visibility creates high patient expectations. Obtaining
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good esthetics at these locations is challenging because of difficult pre-existing anatomy. The
44
ultimate goal of a dental implant is to restore missing teeth by placing implants that are
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anatomically correct and esthetically pleasing in functional positions that ensure long-term
46
durability.1 Essential prerequisites to an esthetically successful treatment are; thorough pre-
47
surgical planning, appropriate site development, 3D implant positioning, soft tissue
48
management, provisionalization, and esthetic prosthetic management.2 All of this must be done
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within the context of the patients’ expectations. Site enhancement and alveolar ridge
50
preservation following tooth extraction have a major impact on the hard and soft tissue volume
51
prior to placement of an implant and the definitive prosthetic implant restoration.3 Custom
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implant abutments allow the clinician to improve an implant’s emergence profile, to customize
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cervical margins so that they are anatomically shaped in accordance to the natural tooth root,
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and to compensate for poor implant angulation.4-6 All of these are essential for optimum
55
aesthetic outcomes.
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Smile line and gingival biotype play a major role in the final esthetic outcomes. Neighboring
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tooth position, number of missing teeth, type of provisional prosthesis (fixed or removable),
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shape and shade of adjacent dentition are positive factors that need to be considered for
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successful treatment planning.7,
8
When the tooth is non-restorable, positive factors for
3
60
favorable implant restoration9 include gingival tissue that has a flat gingival scallop form and a
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thick gingival biotype. Other positive factors include square-shape teeth with a high osseous
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crest.
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Recent research has provided useful insights into soft tissue changes around implants following
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implant placement surgery. For example, in one clinical study10 measurements were recorded
65
at stage 2 surgery in 2-stage implant systems and at stage 1 surgery in the 1-stage system.
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Subsequent measurements were recorded for several interval periods up to 1 year after
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baseline measurements. The majority of the recession occurred within the first 3 months of
68
healing. 80% of all sites showed recession on the buccal side with average soft tissue recession
69
amount of 0.88 mm. The investigators recommended that soft tissue be allowed to stabilize for
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3 months after implant placement before selecting a final abutment or making a final
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impression. As a general rule, a 1 mm of soft tissue recession can be expected after healing
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abutment connection surgery.10
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Soft tissue integration around dental implant has not been extensively studied. One study
74
evaluated the implant-gingival junction of unloaded and loaded non-submerged titanium
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implants. Histological dimensions of the sulcus depth, the junctional epithelium), and the
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connective tissue contact were measured. Significant changes within tissue compartments
77
occurred over healing time. Sulcus Depth had a mean value of 0.49 mm and 0.50 mm after
78
three and six months of healing. The difference became statistically significant after 15 months
79
with a mean value of 0.16 mm. Similarly, the mean length of the junctional epithelium after
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three and six months of healing was 1.16 mm and 1.44 mm, respectively. After 15 months, the
4
81
mean values became significantly different at 1.88mm. A different pattern of changes was
82
reported for the length of connective tissue contact. After three months of healing, the mean
83
value was 1.36 mm. This was significant different from the same area after six and 15 months,
84
which were 1.01 mm and 1.05 mm, respectively. These results will inform treatment decisions,
85
since preservation or reconstruction of soft tissue integration around the implant restorations
86
is as important as preservation the hard tissue integration around functioning implants. 11
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CAD/CAM technology allows the clinician to design custom implant abutment configurations
88
and create an anatomically natural looking superstructure that is in harmony with the
89
surrounding dentition and adjacent soft tissue.12 The CAD⁄CAM technique provides precise fit
90
of the intended prosthetic design, reduces the cost of the procedure, and eliminates
91
dimensional inaccuracies due to conventional waxing and casting techniques.13 The precisely
92
fitting implant custom abutment improves implant longevity and prosthetic success, and
93
simplifies the restoration.12, 13
94
During the past three decades, there has been a considerable research on implant prostheses.
95
In the following, the highlights of the research results for titanium and zirconia abutments will
96
be compared for each of the following topics: in vitro properties, survival, marginal adaptation,
97
bone loss, soft tissue response, esthetic outcomes, and technical complications.
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Yttria-stabilized zirconia (ZrO₂-Y₂O₃) ceramics is a biocompatible biomaterial for restoration,
99
which has excellent aesthetic and mechanical properties. Recently, zirconia custom abutments
100
have been proposed as an excellent alternative to titanium custom abutments for esthetic
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implant restorations in the maxillary anterior region. The strength of the zirconia abutment is 5
102
comparable to that of titanium (281N versus 305N), both are strong enough to withstand static
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and dynamic loads that occur in vivo. The flexure strength of the zirconia abutments is similar
104
to that of titanium abutments; both are strong enough to be used in a cantilever structures. The
105
material is susceptible to undergoing the stress-induced transformation toughening mechanism
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because of the very fine grain size. The bacterial adhesion was registered by a percentage of
107
bacterial biofilm of 12.1% on the zirconia abutment, compared to 19.3% on the titanium
108
abutment. This is very important in the maintaining of zirconia restorations around dental
109
implant. 14-16
110
The fracture resistance of zirconia implant abutments exceeds the maximal reported incisal
111
forces (90 to 370 N). The maximum load capacity was 484.6 ± 56.6 N for NobelProcera
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(NobelProcera Abutment Zirconia; Nobel Biocare, Yorba Linda, Calif), 503.9 ± 46.3 N for Aadva
113
(Aadva CAD/CAM Zirconia Abutment; GC Advanced Technologies Inc, Alsip, Ill), and 729.2 ± 35.9
114
N for Lava abutments (Lava Zirconia abutment; 3M ESPE, St Paul, Minn). With standard
115
diameter internal tri-lube connection implants, the maximum load capacity of the Lava
116
abutment was significantly higher than that of the Aadva or NobelProcera abutment. No
117
significant difference in maximum load capacity was noted between Aadva and NobelProcera
118
abutments. The mode of failure among the Aadva, NobelProcera, and Lava abutments was
119
different.17
120
Scanning electron microscopy revealed that titanium implants exhibited more wear after cyclic
121
loading when connected to zirconia abutments (maximum wear 10.2μm) than when connected
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to titanium abutments (maximum wear 0.7μm).18
6
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Sailer et al., reviewed the performance of ceramic and metal implant abutments supporting
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implant restorations and estimated 95% 5-year survival rate for the implants in function. For
125
example, in one study the 5-year rate for soft tissue recession around ceramic abutments was
126
clinically more pronounced than around metal abutments (8.9% and 3.8% respectively). In
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another study, the estimated 5-year rate for the soft tissue recession was 2.1% for ceramic
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abutments and 4.1% for metal abutments. The rate for bone loss was higher for implants
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supporting metal abutments (3.9%) than for those supporting ceramic abutments (1.7%). The
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total estimated 5-year rate for esthetic complications for ceramic and metal abutments
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supporting fixed restorations was 5.4%. Problems with the esthetic outcome were more
132
frequently reported for metal abutments.19 Several articles imply that peri-implant soft tissue
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aesthetics can be enhanced by controlling the contour of provisional restorations. Clinical and
134
histological studies showed that gold, titanium and zirconia ceramic abutment materials all
135
exhibit excellent biological responses around dental implant restorations.2
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The marginal bone loss at one-year follow up after prosthetic loading was not significantly
137
different between all-ceramic and metal-ceramic restorations (-0.08 mm ± 0.25mm and -0.10
138
mm ± 0.17mm respectively). The marginal adaptation of the all-ceramic crowns was
139
significantly poorer than the metal-ceramic crowns. The professional-reported color match of
140
all-ceramic crowns was significantly better than metal-ceramic crowns, but other aesthetic
141
parameters showed no statistically significant difference between all-ceramic and metal-
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ceramic restorations.20 After three years, 100% of zirconia implant abutments and 97% for
143
crowns survived. Marginal bone loss was significantly higher around gold-alloy (0.41 mm ±
144
0.58mm) when compared to zirconia abutments (0.15 mm ± 0.25mm). The professional7
145
reported aesthetic outcome showed superiority in esthetic and color match of all-ceramic over
146
metal-ceramic crowns.21
147
Based on the meta-analysis of forty-six studies, survival of implants supporting single crowns
148
was to 97.2% after five year and 95.2% at 10 years. For example, in one study of implant-
149
supported single crown restorations 96.3% survived 5 years and 89.4% survived 10 years. At the
150
5-year follow up, the cumulative percentage of restorations that exhibited soft tissue
151
complications (mucositis, bleeding, suppuration, and soft tissue dehiscences) was reported to
152
be 7.1%. For the subset of restorations with bone loss >2 mm was reported to be 5.2%. After
153
five years, 8.8% of the restoration exhibited screw-loosening, 4.1% exhibited loss of retention,
154
and 3.5% exhibited fracture of the veneering material. The cumulative 5-year aesthetic
155
complication rate due to soft tissue recessions, an unfavorable color, and visible crown margins
156
was reported to be 7.1%. 22
157
The zirconia custom abutments performed well over the five year follow up period.23 The rates
158
of both technical and biological complications were low (1%), and the patients were in general
159
extremely satisfied with the restorations. There were no significant differences for changes in
160
any of the soft tissue measurements. The peri-implant bone level changes from placement to
161
the clinical examination 3-5 years later were small resorption (0.29 mm ± 0.87 mm). 23
162
The bone resorption around transmucosal implants loaded for 12 months was reported by 0.86
163
mm ± 0.99 mm. When prefabricated solid abutment were4 used, the connective tissue and
164
Junctional epithelium was migrated on the transmucosal machined surface of the implants’
165
necks following the resorption of the bone regardless the length of the implant’s neck. 24 8
166
The preceding review demonstrates that laboratory research and clinical trials support the use
167
of customized implant abutment. The aim of this report is to describe a simplified technique for
168
reconstruction of the emergence profile at the time of implant restoration, especially in the
169
anterior esthetic zenith, using milled titanium or zirconia custom implant abutments. We
170
describe the outcomes of such treatment based on our experiences with series of 50
171
consecutive cases.
172
173
Materials and Methods
174
Fifty implants were restored using computer-milled titanium or zirconia custom implant
175
abutments25 followed by definitive ceramo-metal (for posterior implants) or full ceramic crowns
176
(for anterior implants).
177
Step by step procedures:
178
(Clinical) Patients presented with straight healing abutments (Fig. 1) and treatment
179
removable partial dentures (Fig. 2). All implants were restored by the first author (AK).
180
All prosthetic restorations utilized recommended manufactures’ components and
181
protocols.
182
(Clinical) After approximately three months of healing post-surgery, the healing
183
abutment was removed and an impression coping was screwed into the internal
184
connection of the implant and secured with a guide screw (Fig. 3a).
9
185
impression coping to the implant platform (Fig. 3b).
186 187
(Clinical) A periapical radiograph was made to confirm the appropriate fit of the
(Clinical) After that an implant level impression was made using a polyvinyl siloxane
188
material (PVS, 3M ESPE, St. Paul, MN, USA) with the closed tray-impression technique.
189
Facebow and interocclusal relationship were recorded at this time.
190
(Clinical) After removing the impression coping and replacing the healing abutment, an
191
implant replica was connected to the impression coping and inserted back into the PVS
192
impression (Fig. 3c).
193
(Laboratory) Just enough gingival mask silicon (Gingifast Elastic, Zhermack Inc., River
194
Edge, NJ) was added around the impression coping and the implant replica to cover the
195
coping-replica junction (Fig. 4a).
196
RockTM, Whip Mix Corporation, Louisville, KY).
197 198
(Laboratory) On the stone model, the gingival mask was modified using a round diamond bur to create the emergence profile of the missing tooth (Fig. 4b).
201 202
(Laboratory) After the stone had set, the impression was retrieved and the working cast trimmed and mounted on an articulator in maximum intercuspation (MI).
199 200
(Laboratory) A stone model was made from the impression using type IV stone (Resin
(Laboratory) A temporary abutment (plastic or titanium) was screwed into the implant
203
replica and secured with the lab screw. A full contour tooth wax-up was made after any
204
necessary modifications had been made to the temporary abutment (Fig. 5).
205 206
(Laboratory) A silicone index to the full-contour tooth wax-up and adjacent teeth was made at this stage. This silicone index will later be used in the fabrication of polymethyl 10
207
methacrylate (PMMA) provisional crowns and subsequently will aid in fabrication of the
208
definitive restorations (Fig. 6).
209
the definitive custom abutment (Fig. 7).
210 211
(Laboratory) A wax-up cut-back was made to create the finish line and final contour of
(Laboratory) The abutment wax-up was then retrieved from the model and scanned
212
with a digital scanner (Procera® Piccolo Scanner, Nobel BiocareTM). A computer-assisted
213
milling machining was used to fabricate either a milled titanium or a milled zirconia
214
custom implant abutment (Fig. 8a and 8b).
215
(Laboratory) The definitive custom implant abutment received from the manufacturer
216
was carefully disinfected and checked for the appropriate emergence profile (Fig. 8c). If
217
a minor modification is required to the fitting surface of the abutment, the titanium
218
custom abutment must be subsequently highly polished with a metal polishing kit.
219
on the model and a provisional crown was made using PMMA (Fig. 9).
220 221
(Laboratory) The definitive custom abutment was then screwed into the implant replica
(Clinical) Approximately two weeks after the implant level impression was made, the
222
patient returned for delivery of the definitive custom abutment and provisional crown.
223
If necessary, local anesthesia was administered. Then the straight healing abutment was
224
removed and the disinfected custom abutment was screwed into the implant’s internal
225
connection and torqued to 35 N-cm (Fig. 10).
226
(Clinical) The custom abutment’s screw access was filled with a cotton pellet soaked
227
with chlorhexidine mouth rinse and blocked with a light-curing temporary resin
228
composite (FermitTM; Ivoclar Vivadent, Amherst, NY) (Fig. 10). 11
229
(Clinical) The PMMA provisional crown was then cemented with a zinc oxide-eugenol
230
cement (TempBondTM; Kerr Corporation, Orange, CA) (Fig. 11). Excess cement was
231
carefully removed from around the peri-implant mucosa. All the provisional crowns
232
were placed in function with full contact in centric occlusion.
233
(Clinical) Approximately two weeks after the provisionalization stage, the patient
234
returned for the abutment level impression. During the healing period, the peri-implant
235
mucosa, guided by the emergence profile of the abutment, adapts to the custom
236
abutment.
237
off the definitive custom abutment.
238 239
(Clinical) Next, the provisional crown was removed and remaining cement was cleaned
(Clinical) To retract the peri-implant mucosa, a single retraction cord (00”) was packed
240
around the custom abutment. The cord was left in place for five minutes and then
241
removed immediately prior to making an abutment level impression using PVS
242
impression material (PVS, 3M ESPE,).
243
followed to fabricate the definitive ceramo-metal or full ceramic crown (Fig. 12).
244 245
(Clinical) Two weeks later, a definitive full ceramic or ceramo-metal crown restoration was cemented onto the abutment (Fig. 13 and 14).
246 247
(Laboratory) At this stage, standard crown and bridge laboratory procedures were
(Clinical) The occlusion was checked using an 8 μm foil (Shimstock Occlusion Foil,
248
Patterson Dental, St. Paul, MN) and the occlusion was adjusted so that the foil could be
249
withdrawn unless the patient closed under maximum intercuspation.
250 12
251
Results
252
Clinical results
253
The criteria for implant success included: stability, absence of a radiolucency around the
254
implants, no peri-implant mucositis or inflammation, and the absence of pain. No patients
255
complained of pain and there was no evidence of infection associated with any implants.
256
At the 12-month follow-up, all the implants had survived. No pain or final prosthesis mobility
257
was recorded. The mucosa around the custom abutments was healed within normal limits and
258
finely adapted to the definitive crowns (Fig. 15). No mucositis or irritation was reported.
259
Radiographic results
260
Radiographic evaluation was performed at the provisional stage (Fig. 16a) and twelve months
261
after placement of the definitive restoration (Fig. 16b). Radiograph showing the emergence
262
profile as transferred to the implant by the custom abutment was recorded (Fig. 16c). Vertical
263
bone resorption was not clinically significantly different between the stages of the treatment.
264
Esthetic results
265
An important esthetic outcome was whether or not papillae had re-formed around the custom
266
abutment and the definitive crown. Two other outcomes were whether papillae had changed
267
position and whether papillae had reformed around the emergence profile of the custom
268
abutment. All three of the esthetic outcomes were achieved in all patients. Clinically, all soft
269
tissues appeared pink and healthy (Fig. 14, 15, and 16). All patients were satisfied with the final
270
esthetic outcomes (Fig. 17). 13
271
DISCUSSION
272
Many patients, especially those who need implant prosthesis in the maxillary anterior area,
273
choose implant treatment in hope of better esthetics. This report describes a simplified
274
technique to create an emergence profile that will improve the esthetic outcome of the implant
275
restoration. Esthetic success requires an adequate volume of bone and a sufficient quantity and
276
appropriate quality of soft tissue.26 Natural appearing adaptation of peri-implant mucosa to and
277
around the restoration is critical to achieving an esthetic result.26,
278
exposure of teeth and gingival tissue, restoration of high-smile-line patients is more challenging
279
due to the high esthetic demand. The location of the implant, the relationship of the
280
implant/abutment interface, and the crestal bone around the implant determine whether there
281
will be enough support for the gingival tissue surrounding the implant crown. To achieve an
282
acceptable esthetic result, the mesiodistal and buccolingual implant position and angulation in
283
the residual alveolar ridge, the minimal interocclusal distance, and the maximal interproximal
284
contact point to crestal bone distance each must approximate 6 mm. 28
285
To achieve an optimum esthetic result with implant restorations, the peri-implant soft tissue
286
should be modified to create an appropriate emergence profile and natural contour at the
287
provisional stage.6-9 The implant’s apico-coronal position should be 3 to 4 mm below the
288
gingival line to make room for an emergence profile that aligns well with the adjacent gingival
289
level. Also, the implant’s mesio-distal position should be at least 1 mm from a natural tooth and
290
at least 3 mm from another implant.26, 29-31
14
27
Because of the larger
291
Soft tissue management can be done before implant placement, during stage 1 surgery, during
292
stage 2 surgery, or after the restoration is placed to increase the amount of keratinized tissue
293
and preserve the papilla.32 The bone around adjacent teeth promotes papilla development.
294
This is why papillae are more likely to be associated with single implant restorations than
295
multiple implants restorations.30,
296
from the bone level on the adjacent tooth to the contact point is less than 5 mm, papillae are
297
more likely to reform.29-31 In one study, there was an average of 30 % increase of the volume of
298
the papillae 1 year after prosthesis insertion.32 In most cases, papilla spontaneously
299
regenerated after a few years in function.33 Despite improved surgical techniques that have
300
been recently developed, the factors that encourage regeneration of papillae adjacent to dental
301
implants is still a matter of debate.32
302
Custom abutments can be used to correct implant angulation (Fig. 18), and along with
303
provisional crowns, can improve the implant restoration’s emergence profile 34, 35 Peri-implant
304
soft tissue manipulation is possible if the implant is deep enough and the proper gingival
305
biotype is present. A gradual transfer from the profile of the implant platform to a natural
306
emergence profile can be easily created using a customized implant abutment and implants
307
that are placed 3 to 4 mm subgingivally in a thick soft tissue biotype.2, 30, 36 Shallow implants
308
that are associated with a thin peri-implant soft tissue biotype will make it difficult to create a
309
satisfactory emergence profile 2, 36 and consequently, successful esthetic outcomes will be more
310
difficult to achieve.
31
Several investigations have reported that if the distance
15
311
There are several CAD/CAM technology systems can be used to develop esthetically natural
312
looking implant restorations.37 To minimize undesirable stress concentrations, computer-milled
313
custom abutments must fit accurately.38, 39 There have been several investigations of the fit at
314
the interface between implants with different internal connections and Ti or Zirconia CAD/CAM
315
computer-milled custom abutments.14,24,40-44 Microscopic evaluation of internal systems
316
connected to titanium or zirconia abutments show that the implant–abutment interfaces are
317
well sealed under no-loading conditions.38 A tight interfacial contact is desirable to maximize
318
mechanical stability of abutments and prosthesis.45 In any case because poor adaptation at the
319
implant-abutment interface might produce biological and mechanical complications, it seems
320
desirable to have as close a marginal fit as possible. The customization possible with CAD/CAM
321
abutments allows for more refined prosthetic designs and enhanced the soft tissue contour. It
322
is expected that refined designs will make possible implant-supported restorations that are
323
more esthetic, biologically compatible, and durable.
324
CONCLUSION
325
Optimal esthetic implant restorations depend on thorough pre-surgical planning, accurate three
326
dimensional implant placement, careful soft tissue management, and proper provisional
327
restorations. When titanium and zirconia custom abutments are used at the provisional crown
328
stage of implant construction to modify the emergence profile and natural contour, implant
329
restorations exhibit excellent esthetics and healthy gingival tissues.
330
Since the probability of successful restoration depends on several anatomy-dependent factors,
331
each patient should be counseled about the likelihood of success in his or her particular case. 16
332
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33. Jemt T. Regeneration of gingival papillae after single-implant treatment. Int J Periodontics
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knowledge. J Am Dent Assoc. 2011;142:150-158.
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computer-aided design and nonlinear finite element analysis. J Biomech. 2010;43:1941-1946.
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36. Alani A, Corson M. Soft tissue manipulation for single implant restorations. Br Dent J
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37. Drago CJ. Two new clinical/laboratory protocols for CAD/CAM implant restorations. J Am
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38. Sumi T, Braian M, Shimada A, Shibata N, Takeshita K, Vandeweghe S, Coelho PG,
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different internal connection systems. J Oral Rehabil. 2012;39:391-398.
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39. Yuzugullu B, Avci M. The implant-abutment interface of alumina and zirconia abutments.
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Clin Implant Dent Relat Res. 2008;10:113-121.
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40. Kerstein RB, Radke J. A comparison of fabrication precision and mechanical reliability of 2
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4-year results of a prospective clinical study. Int J Prosthodont. 2004;17:285-290.
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42. Henriksson K, Jemt T. Evaluation of custom-made Procera ceramic abutments for single-
432
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435
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436
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437
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439
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440
the Procera custom abutment and various implant systems. Int J Oral Maxillofac Implants.
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2003;18:652-658
442
443
444
445
446
22
447
Figures Legend
448
Fig 1. Straight healing abutments after three months.
449
Fig 2. Treatment removable partial denture used during healing.
450
Fig 3. Implant level impression with impression coping. a. Showing the coping screwed into
451
implant. b. A periapical radiograph confirms fit of the impression coping into implant. c.
452
Impression coping and lab analog captured by a PVS impression.
453
Fig 4. Gingival mask silicone material used. a. Just enough silicone is added to cover the
454
coping-replica junction. b. Gingival mask modified on stone model.
455
Fig 5. Example of full contour tooth wax-up made after necessary modifications to temporary
456
abutment had been made.
457
Fig 6. The silicone index to be used to fabricate a provisional crown and was positioned against
458
the stone model to verify the restorative space.
459
Fig 7. Creating the finish line and final contour of the wax-up cut back.
460
Fig 8. Scanning and milling the abutment. a. Scanning wax-up. b. Computer image of the
461
scanned abutment. c. Definitive milled titanium abutment.
462
Fig 9. The provisional crown made using PMMA.
463
Fig 10. Milled custom abutment screwed into implant and tightened using a torque of 35 Ncm.
464
a, b. Facial view for milled titanium and zirconia custom abutments.
23
465
Fig 11. PMMA provisional crown reported after cementation.
466
Fig 12. Standard crown and bridge laboratory procedure were followed to fabricate the
467
definitive crown restoration.
468
Fig 13. Peri-implant mucosa adapted to the custom abutment guided by its emergence profile.
469
Fig 14. The final crowns after cementation
470
Fig 15. The fully-healed mucosa around the definitive crown reported after one year in
471
function.
472
Fig 16. Radiographs. a. Titanium custom abutment at the provisionalization stage. b. at twelve
473
months at placement of the definitive restoration. c. Showing the emergence profile that has
474
been transferred to the implant via the custom abutment.
475
Fig 17. The patient was satisfied with the esthetic outcome.
476
Fig 18. Custom abutment can correct implant miss-angulation.
24
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