RESEARCH ARTICLE
Esthetic Evaluation of Implants Placed after Orthodontic Treatment in Patients with Congenitally Missing Lateral Incisors CARLO MANGANO, MD, DDS*, LUCA LEVRINI, MD, DDS, MS†, ALESSANDRO MANGANO, DDS‡, FRANCESCO MANGANO, DDS§, ALDO MACCHI, MD, DDS, MS¶, ALBERTO CAPRIOGLIO, DDS, MS†
ABSTRACT Objective: The aim of this retrospective study was to evaluate the esthetic outcome of single tooth Morse taper connection implants used to replace congenitally missing lateral incisors after orthodontic treatment by means of the pink esthetic score (PES) and white esthetic score (WES) index. Materials and Methods: Twenty consecutive patients who were treated with a single tooth Morse taper connection implants (Leone Implant System®, Florence, Italy) were enrolled in this study. An independent calibrated examiner applied the PES/WES index to 20 implant-supported restorations 3 months and 3 years after implant placement. Results: No implants were lost. All 20 implants fulfilled the established success criteria for dental implants with regard to osseointegration and prosthetic complications, with an overall implant-crown success of 100.0%. At the 3 year examination, the mean distance between the implant shoulder and the first visible bone-implant contact was of 0.49 ± 0.18 mm (95% confidence interval 0.41–0.57); the mean PES was 8.15 ± 1.69, and the mean WES was 8.70 ± 0.92. Conclusions: The placement of single-tooth Morse taper connection implants for rehabilitation of congenitally missing lateral incisors after orthodontic treatment represents a successful procedure in the medium term. Further studies are necessary in order to assess the long-term esthetic score.
CLINICAL SIGNIFICANCE This paper evaluates the esthetic outcome of Morse taper connection implants placed to restore congenitally missing lateral incisors after orthodontic treatment. (J Esthet Restor Dent 26:61–71, 2014)
INTRODUCTION Hypodontia is defined as the absence of one to six teeth, excluding the third molars.1 A lack of one or two teeth is mainly found, with the premolars and the upper lateral incisors being the most frequent.2 An incidence
between 4.4% and 8% has been reported with a greater frequency in permanent dentition and with a female predilection established.3,4 The etiology of hypodontia is still unknown, although some authors investigated this condition. Theories have been discussed, but none is capable to explain all the aspects.5 A relationship
*Assistant Professor, Department of Surgical and Morphological Sciences, University of Insubria, Varese, Italy † Professor, Department of Surgical and Morphological Sciences, University of Insubria, Varese, Italy ‡ Resident in Orthodontics, Department of Surgical and Morphological Sciences, University of Insubria, Varese, Italy § PhD Student, Department of Surgical and Morphological Sciences, University of Insubria, Varese, Italy ¶ Professor and Chairman Postgraduate Residency Program in Orthodontics, Department of Surgical and Morphological Sciences, University of Insubria, Varese, Italy
© 2013 Wiley Periodicals, Inc.
DOI 10.1111/jerd.12081
Journal of Esthetic and Restorative Dentistry
Vol 26 • No 1 • 61–71 • 2014
61
ESTHETIC EVALUATION OF IMPLANTS AFTER TREATMENT Mangano et al.
between developmental agenesis of teeth and genes was found in animals models.6 The management of a missing lateral incisor is a very demanding clinical situation that require an interdisciplinary approach. Clinicians can choose to face the problem in different ways:7 • An orthodontic approach mesializing the canine in the lateral incisor area and performing a camouflage of the canine to mimic the lateral incisor8,9 • A restorative approach with a tooth-supported solution or a single tooth implant. Today, there are three types of tooth-supported prosthesis that are resin-bonded fixed partial denture (FPD), a cantilevered FPD, and a conventional full-coverage FPD7 • Opening the space posteriorly and inserting an implant in the premolar area10 Implant therapy in partially edentulous patients has become a well-established treatment modality, in general, and anterior single-tooth replacement has become a highly predictable solution, in particular.11 With a history of nearly 50 years, dental implants have gained a high reputation because of their high success rate.12 In a recent systematic review on single-tooth implants, Jung and colleagues13 reported a survival rate at 5 years of 96.8%. Peri-implantitis and soft tissue complications occurred adjacent to 9.7% of the single crowns and 6.3% of the implants had bone loss exceeding 2 mm over the 5-year observation period; the cumulative incidence of screw or abutment loosening was 12.7%.13 The esthetic outcome in the anterior region is paramount when rehabilitating edentulous patients. Many studies showed very good results in terms of esthetic when dental implants are used.14,15 Different methods for the evaluation of the esthetic results of implants are described in literature. However, the current literature is scarce when it comes to objective outcome evaluation from an esthetic point of view.16 In 1997, Jemt proposed an index (papilla filled index) for assessing the size of the interproximal gingival
62
Vol 26 • No 1 • 61–71 • 2014
Journal of Esthetic and Restorative Dentistry
papilla.16 More recently, a new index for an objective evaluation of peri-implant soft tissue esthetics was proposed by Furhauser and colleagues named the pink esthetic score (PES).17 The PES concept focused mainly on the soft tissue features of an anterior implant restoration. However, more variables play a role for the final esthetic outcome of implant-supported single-tooth replacement, such as crown-related variables; an esthetic implant restoration should be one that resembles a natural tooth in all aspects. For this reason, Meijer and colleagues18 proposed the esthetic implant-crown index, consisting of criteria related to the implant restoration itself and those associated with the surrounding soft tissues. Recently, Belser and colleagues11 introduced the PES/white esthetic score (WES). The PES/WES focused not only on the soft tissue aspects of an anterior implant restoration but also the visible part of the implant restoration itself. Ten variables are evaluated: mesial papilla, distal papilla, curvature of the facial mucosa, level of the facial mucosa, root convexity/soft tissue color and texture at the facial aspect of the implant site, tooth form, volume, color, surface texture, and translucency. A score of 2, 1, or 0 is assigned to all parameters. All parameters are assessed by direct comparison with the natural, contralateral reference tooth, estimating the degree of match or eventual mismatch. The aim of this retrospective study was to evaluate the esthetic outcome of single crown supported by Morse taper connection implants used to replace congenitally missing maxillary lateral incisors after orthodontic treatment.
MATERIALS AND METHODS Patient Population Twenty patients, 11 females and 9 males with a mean age of 21 years, 4 months (range: 19 years, 8 months to 24 years, 2 months) who had been consecutively treated with a Morse taper connection implant because of congenitally missing maxillary lateral incisors after orthodontic space opening from 2004 to 2009 at the
DOI 10.1111/jerd.12081
© 2013 Wiley Periodicals, Inc.
ESTHETIC EVALUATION OF IMPLANTS AFTER TREATMENT Mangano et al.
Dental Clinic of the University of Insubria, were identified from patients chart and included in this study. Inclusion and exclusion criteria are summarized in Table 1. Seven patients did not match the inclusion criteria and were excluded. The biotype was determined by the transparency of a periodontal probe through the gingival margin while probing the buccal sulcus of the upper central incisor.19 Implant treatments including hard/soft tissue grafting before implant placement and periodontally compromised patients were excluded too. All patients read and signed a written consent form for immediate implant placement. The study protocol was conducted in accordance with the Helsinki Declaration of 1975, as revised in 2007.
Surgical and Prosthetic Procedure A complete examination of the oral hard and soft tissues was carried out for each patient, and the implant placement was planned based on clinical and radiographic evaluation. Surgery was performed under a local anesthetic, obtained by infiltrating articaine 4%, containing 1:100,000 adrenaline (Ubistesin R; 3 M TABLE 1. Inclusion and exclusion criteria Inclusion criteria The presence of natural teeth mesial and distal to the implant The presence of the contralateral lateral incisor Adequate bone height and width to place an implant of at least 3.3 mm in diameter and 10.0 mm in length
Clinical Follow-up Examination
Exclusion criteria Uncontrolled diabetes Poor oral hygiene Active periodontal infections Bruxism Smoking habit Presence of a thin-scalloped gingival biotype
© 2013 Wiley Periodicals, Inc.
ESPE, St. Paul, MN, USA). A mesiodistal crestal incision was made, and a full-thickness flap was reflected exposing the alveolar ridge. Preparation of implant sites was carried out with spiral drills of increasing diameter (2.8 mm to place an implant with 3.3 mm diameter, 2.8 and 3.5 mm to place an implant with 4.1 mm diameter, and an additional 4.2 mm drill was used to prepare the site for 4.8 mm diameter implants) under constant irrigation. Implants were positioned at the bone crest level. The implant system used in this study (Leone Implant System®, Florence, Italy) is characterized by a cone Morse Taper Interference Fit (TIF) locking-taper combined with an internal hexagon. The Morse taper presents a taper angle of 1.5°. Temporary abutments were placed and all patients received a temporary acrylic resin crown cemented with a temporary cement (Temp-Bond®; Kerr, Orange, CA, USA). All temporary crowns were not in full contact in centric occlusion. The flaps were properly mobilized and repositioned to cover the implants and were secured in position by interrupted sutures (Supramid®; Novaxa Spa, Milan, Italy). All patients received oral antibiotics (Augmentin®; GlaxoSmithKline Beecham, Brentford, UK) 2 g each day for 6 days. Postoperative pain was controlled by administering 100 mg nimesulide (Aulin®; Roche Pharmaceutical, Basel, Switzerland) every 12 h for 2 days, and detailed instructions about oral hygiene were given, including mouth rinses with 0.12% chlorhexidine (Chlorexidine®;OralB, Boston, MA, USA) administered for 7 days. Suture removal was performed at 8 to 10 days. The temporary restorations remained in situ for 3 months, and after this period, definitive restorations were placed. All single crowns were ceramometallic and were cemented with a temporary cement (Temp-Bond).
DOI 10.1111/jerd.12081
Follow-up visits were scheduled for 2 weeks; 1, 3, and 12 months during the first year postoperatively; and at 24 and 36 months postoperatively. Three years after implant placement at recall visit, the following clinical and radiographic parameters were assessed: presence/absence of pain or suppuration, presence/absence of clinically detectable implant mobility; presence/absence of prosthetic complications
Journal of Esthetic and Restorative Dentistry
Vol 26 • No 1 • 61–71 • 2014
63
ESTHETIC EVALUATION OF IMPLANTS AFTER TREATMENT Mangano et al.
at the implant–abutment interface; presence/absence of peri-implant radiolucency; distance between the implant shoulder and the first visible bone-implant contact distance between the implant shoulder and the first visible bone-implant contact.20 Periapical radiographs were taken at the baseline (immediately after implant insertion) and at the yearly scheduled follow-up session. Radiographs were taken using a Rinn alignment system with a rigid film-object X-ray source coupled to a beam-aiming device to achieve reproducible exposure geometry. Customized positioners, made of polyvinyl siloxane, were used for precise repositioning and stabilization of the radiographic template. To calculate the distance between the implant shoulder and the first visible bone implant contact (DIB), crestal bone level changes were recorded as changes in the vertical dimension of the bone around the implant, so that an evaluation of peri-implant crestal bone stability was gained with time. To correct for dimensional distortion in the radiograph, the apparent dimension of each implant (directly measured on the radiograph) was compared with the true implant length, to establish, with adequate precision, the eventual amount of vertical bone loss at the mesial and distal site of the implant. In this study, the distance between the implant shoulder and the first visible bone contact (DIB) was calculated by means of an ocular grid. The established criteria for implant-crown success were as follows: absence of pain or suppuration, absence of clinically detectable implant mobility; absence of peri-implant radiolucency, distance between the implant shoulder and the first visible bone implant contact DIB
Esthetic Evaluation of Implants Placed after Orthodontic Treatment in Patients with Congenitally Missing Lateral Incisors CARLO MANGANO, MD, DDS*, LUCA LEVRINI, MD, DDS, MS†, ALESSANDRO MANGANO, DDS‡, FRANCESCO MANGANO, DDS§, ALDO MACCHI, MD, DDS, MS¶, ALBERTO CAPRIOGLIO, DDS, MS†
ABSTRACT Objective: The aim of this retrospective study was to evaluate the esthetic outcome of single tooth Morse taper connection implants used to replace congenitally missing lateral incisors after orthodontic treatment by means of the pink esthetic score (PES) and white esthetic score (WES) index. Materials and Methods: Twenty consecutive patients who were treated with a single tooth Morse taper connection implants (Leone Implant System®, Florence, Italy) were enrolled in this study. An independent calibrated examiner applied the PES/WES index to 20 implant-supported restorations 3 months and 3 years after implant placement. Results: No implants were lost. All 20 implants fulfilled the established success criteria for dental implants with regard to osseointegration and prosthetic complications, with an overall implant-crown success of 100.0%. At the 3 year examination, the mean distance between the implant shoulder and the first visible bone-implant contact was of 0.49 ± 0.18 mm (95% confidence interval 0.41–0.57); the mean PES was 8.15 ± 1.69, and the mean WES was 8.70 ± 0.92. Conclusions: The placement of single-tooth Morse taper connection implants for rehabilitation of congenitally missing lateral incisors after orthodontic treatment represents a successful procedure in the medium term. Further studies are necessary in order to assess the long-term esthetic score.
CLINICAL SIGNIFICANCE This paper evaluates the esthetic outcome of Morse taper connection implants placed to restore congenitally missing lateral incisors after orthodontic treatment. (J Esthet Restor Dent 26:61–71, 2014)
INTRODUCTION Hypodontia is defined as the absence of one to six teeth, excluding the third molars.1 A lack of one or two teeth is mainly found, with the premolars and the upper lateral incisors being the most frequent.2 An incidence
between 4.4% and 8% has been reported with a greater frequency in permanent dentition and with a female predilection established.3,4 The etiology of hypodontia is still unknown, although some authors investigated this condition. Theories have been discussed, but none is capable to explain all the aspects.5 A relationship
*Assistant Professor, Department of Surgical and Morphological Sciences, University of Insubria, Varese, Italy † Professor, Department of Surgical and Morphological Sciences, University of Insubria, Varese, Italy ‡ Resident in Orthodontics, Department of Surgical and Morphological Sciences, University of Insubria, Varese, Italy § PhD Student, Department of Surgical and Morphological Sciences, University of Insubria, Varese, Italy ¶ Professor and Chairman Postgraduate Residency Program in Orthodontics, Department of Surgical and Morphological Sciences, University of Insubria, Varese, Italy
© 2013 Wiley Periodicals, Inc.
DOI 10.1111/jerd.12081
Journal of Esthetic and Restorative Dentistry
Vol 26 • No 1 • 61–71 • 2014
61
ESTHETIC EVALUATION OF IMPLANTS AFTER TREATMENT Mangano et al.
between developmental agenesis of teeth and genes was found in animals models.6 The management of a missing lateral incisor is a very demanding clinical situation that require an interdisciplinary approach. Clinicians can choose to face the problem in different ways:7 • An orthodontic approach mesializing the canine in the lateral incisor area and performing a camouflage of the canine to mimic the lateral incisor8,9 • A restorative approach with a tooth-supported solution or a single tooth implant. Today, there are three types of tooth-supported prosthesis that are resin-bonded fixed partial denture (FPD), a cantilevered FPD, and a conventional full-coverage FPD7 • Opening the space posteriorly and inserting an implant in the premolar area10 Implant therapy in partially edentulous patients has become a well-established treatment modality, in general, and anterior single-tooth replacement has become a highly predictable solution, in particular.11 With a history of nearly 50 years, dental implants have gained a high reputation because of their high success rate.12 In a recent systematic review on single-tooth implants, Jung and colleagues13 reported a survival rate at 5 years of 96.8%. Peri-implantitis and soft tissue complications occurred adjacent to 9.7% of the single crowns and 6.3% of the implants had bone loss exceeding 2 mm over the 5-year observation period; the cumulative incidence of screw or abutment loosening was 12.7%.13 The esthetic outcome in the anterior region is paramount when rehabilitating edentulous patients. Many studies showed very good results in terms of esthetic when dental implants are used.14,15 Different methods for the evaluation of the esthetic results of implants are described in literature. However, the current literature is scarce when it comes to objective outcome evaluation from an esthetic point of view.16 In 1997, Jemt proposed an index (papilla filled index) for assessing the size of the interproximal gingival
62
Vol 26 • No 1 • 61–71 • 2014
Journal of Esthetic and Restorative Dentistry
papilla.16 More recently, a new index for an objective evaluation of peri-implant soft tissue esthetics was proposed by Furhauser and colleagues named the pink esthetic score (PES).17 The PES concept focused mainly on the soft tissue features of an anterior implant restoration. However, more variables play a role for the final esthetic outcome of implant-supported single-tooth replacement, such as crown-related variables; an esthetic implant restoration should be one that resembles a natural tooth in all aspects. For this reason, Meijer and colleagues18 proposed the esthetic implant-crown index, consisting of criteria related to the implant restoration itself and those associated with the surrounding soft tissues. Recently, Belser and colleagues11 introduced the PES/white esthetic score (WES). The PES/WES focused not only on the soft tissue aspects of an anterior implant restoration but also the visible part of the implant restoration itself. Ten variables are evaluated: mesial papilla, distal papilla, curvature of the facial mucosa, level of the facial mucosa, root convexity/soft tissue color and texture at the facial aspect of the implant site, tooth form, volume, color, surface texture, and translucency. A score of 2, 1, or 0 is assigned to all parameters. All parameters are assessed by direct comparison with the natural, contralateral reference tooth, estimating the degree of match or eventual mismatch. The aim of this retrospective study was to evaluate the esthetic outcome of single crown supported by Morse taper connection implants used to replace congenitally missing maxillary lateral incisors after orthodontic treatment.
MATERIALS AND METHODS Patient Population Twenty patients, 11 females and 9 males with a mean age of 21 years, 4 months (range: 19 years, 8 months to 24 years, 2 months) who had been consecutively treated with a Morse taper connection implant because of congenitally missing maxillary lateral incisors after orthodontic space opening from 2004 to 2009 at the
DOI 10.1111/jerd.12081
© 2013 Wiley Periodicals, Inc.
ESTHETIC EVALUATION OF IMPLANTS AFTER TREATMENT Mangano et al.
Dental Clinic of the University of Insubria, were identified from patients chart and included in this study. Inclusion and exclusion criteria are summarized in Table 1. Seven patients did not match the inclusion criteria and were excluded. The biotype was determined by the transparency of a periodontal probe through the gingival margin while probing the buccal sulcus of the upper central incisor.19 Implant treatments including hard/soft tissue grafting before implant placement and periodontally compromised patients were excluded too. All patients read and signed a written consent form for immediate implant placement. The study protocol was conducted in accordance with the Helsinki Declaration of 1975, as revised in 2007.
Surgical and Prosthetic Procedure A complete examination of the oral hard and soft tissues was carried out for each patient, and the implant placement was planned based on clinical and radiographic evaluation. Surgery was performed under a local anesthetic, obtained by infiltrating articaine 4%, containing 1:100,000 adrenaline (Ubistesin R; 3 M TABLE 1. Inclusion and exclusion criteria Inclusion criteria The presence of natural teeth mesial and distal to the implant The presence of the contralateral lateral incisor Adequate bone height and width to place an implant of at least 3.3 mm in diameter and 10.0 mm in length
Clinical Follow-up Examination
Exclusion criteria Uncontrolled diabetes Poor oral hygiene Active periodontal infections Bruxism Smoking habit Presence of a thin-scalloped gingival biotype
© 2013 Wiley Periodicals, Inc.
ESPE, St. Paul, MN, USA). A mesiodistal crestal incision was made, and a full-thickness flap was reflected exposing the alveolar ridge. Preparation of implant sites was carried out with spiral drills of increasing diameter (2.8 mm to place an implant with 3.3 mm diameter, 2.8 and 3.5 mm to place an implant with 4.1 mm diameter, and an additional 4.2 mm drill was used to prepare the site for 4.8 mm diameter implants) under constant irrigation. Implants were positioned at the bone crest level. The implant system used in this study (Leone Implant System®, Florence, Italy) is characterized by a cone Morse Taper Interference Fit (TIF) locking-taper combined with an internal hexagon. The Morse taper presents a taper angle of 1.5°. Temporary abutments were placed and all patients received a temporary acrylic resin crown cemented with a temporary cement (Temp-Bond®; Kerr, Orange, CA, USA). All temporary crowns were not in full contact in centric occlusion. The flaps were properly mobilized and repositioned to cover the implants and were secured in position by interrupted sutures (Supramid®; Novaxa Spa, Milan, Italy). All patients received oral antibiotics (Augmentin®; GlaxoSmithKline Beecham, Brentford, UK) 2 g each day for 6 days. Postoperative pain was controlled by administering 100 mg nimesulide (Aulin®; Roche Pharmaceutical, Basel, Switzerland) every 12 h for 2 days, and detailed instructions about oral hygiene were given, including mouth rinses with 0.12% chlorhexidine (Chlorexidine®;OralB, Boston, MA, USA) administered for 7 days. Suture removal was performed at 8 to 10 days. The temporary restorations remained in situ for 3 months, and after this period, definitive restorations were placed. All single crowns were ceramometallic and were cemented with a temporary cement (Temp-Bond).
DOI 10.1111/jerd.12081
Follow-up visits were scheduled for 2 weeks; 1, 3, and 12 months during the first year postoperatively; and at 24 and 36 months postoperatively. Three years after implant placement at recall visit, the following clinical and radiographic parameters were assessed: presence/absence of pain or suppuration, presence/absence of clinically detectable implant mobility; presence/absence of prosthetic complications
Journal of Esthetic and Restorative Dentistry
Vol 26 • No 1 • 61–71 • 2014
63
ESTHETIC EVALUATION OF IMPLANTS AFTER TREATMENT Mangano et al.
at the implant–abutment interface; presence/absence of peri-implant radiolucency; distance between the implant shoulder and the first visible bone-implant contact distance between the implant shoulder and the first visible bone-implant contact.20 Periapical radiographs were taken at the baseline (immediately after implant insertion) and at the yearly scheduled follow-up session. Radiographs were taken using a Rinn alignment system with a rigid film-object X-ray source coupled to a beam-aiming device to achieve reproducible exposure geometry. Customized positioners, made of polyvinyl siloxane, were used for precise repositioning and stabilization of the radiographic template. To calculate the distance between the implant shoulder and the first visible bone implant contact (DIB), crestal bone level changes were recorded as changes in the vertical dimension of the bone around the implant, so that an evaluation of peri-implant crestal bone stability was gained with time. To correct for dimensional distortion in the radiograph, the apparent dimension of each implant (directly measured on the radiograph) was compared with the true implant length, to establish, with adequate precision, the eventual amount of vertical bone loss at the mesial and distal site of the implant. In this study, the distance between the implant shoulder and the first visible bone contact (DIB) was calculated by means of an ocular grid. The established criteria for implant-crown success were as follows: absence of pain or suppuration, absence of clinically detectable implant mobility; absence of peri-implant radiolucency, distance between the implant shoulder and the first visible bone implant contact DIB
