Q U I N T E S S E N C E I N T E R N AT I O N A L
IMPLANTOLOGY
Paolo Cardelli
Immediate postextraction implant with simultaneous buccal plate augmentation, restored with lithium disilicate abutment and veneer: A clinical report Paolo Cardelli, DDS1/Milko Belletti, MDT2/Giovanna Murmura, MD, DMD, PhD3 Objective: To describe the successful use of biphasic calcium sulfate for improving the buccal plate thickness in an immediate postextraction implant, and its final restoration with custom lithium disilicate abutment and veneer. Summary: A hopeless lateral incisor was replaced with an immediate postextraction implant in conjunction with a buccal plate aug-
mentation based on biphasic calcium sulfate. Satisfactory soft tissue height and quality were maintained following healing. The final restoration managed the severely reduced prosthetic space due to deep bite, and allowed an adhesive luting procedure. (Quintessence Int 2014;45:757–762; doi: 10.3290/j.qi. a32441)
Key words: adhesion, buccal augmentation, calcium sulfate, dental implant, lithium disilicate, postextraction implant, veneer
Implant-supported single crowns demonstrate good long-term survival with regard to both surgical and prosthetic aspects.1 Moreover, pink esthetic score/ white esthetic score (PES/WES) evaluations have been used to examine soft tissue-related and crown-related aspects in the anterior zone.2 In a recent paper, the esthetic long-term scores were satisfactory for anterior single implant restorations.3 When a hopeless anterior tooth has yet to be extracted, immediate postextraction implants may reduce the number of surgical procedures; however, this approach has proven unsuccessful in preventing 1
Research Fellow, Department of Medical, Oral and Biotechnological Sciences, University “G. D’Annunzio” of Chieti-Pescara, Italy.
2
Dental Technician, Private Dental Laboratory “Dental Worked”, Alba Adriatica, Italy.
3
Aggregate Professor, Department of Medical, Oral and Biotechnological Sciences, University “G. D’Annunzio” of Chieti-Pescara, Italy.
Correspondence: Dr Paolo Cardelli, Department of Medical, Oral and Biotechnological Sciences, University “G. D’Annunzio” of Chieti-Pescara, Via dei Vestini 31, 66100 Chieti, Italy. Email: paolo.cardelli@ unich.it
VOLUME 45 • NUMBER 9 • OCTOBER 2014
bone remodeling following tooth extraction.4 Delayedimmediate implants, placed 6 to 8 weeks after extraction, allow complete soft tissue coverage of the site for simultaneous guided bone regeneration (GBR);5 this approach, although proving beneficial,3 requires a removable interim prosthesis or a transitional Maryland bridge that could detach in cases of unfavorable occlusion.6 Immediate postextraction implants can instead support an immediate provisional restoration to avoid different transitional restorations.7 However, simultaneous bone and/or soft tissue augmentation may be needed to obtain an acceptable esthetic outcome.8 The buccal plate-implant gap should be grafted if wider than 2 mm.9 Moreover, the placement of grafting material over the intact buccal bone plate may improve the hard and soft tissue outcomes.10 Implant treatment in the esthetic zone can be challenging due to space-related difficulties. From a surgical viewpoint, implant placement can be complicated
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Fig 2 Intraoral periapical radiography showing periapical lesion on left maxillary lateral incisor. Fig 1
Preoperative intraoral situation.
or hampered by limited interradicular space.11 Furthermore, many problems can occur due to the limited three-dimensional prosthetic space: mesiodistal, buccolingual, or interocclusal relationships can lead to dimensionally inadequate abutments; then a screwretained restoration with buccal screw access would be needed, with esthetic impairment and lower long-term esthetic stability.12 Adhesive porcelain veneers over custom metal-ceramic screwed abutments have already been proposed as a viable solution to limited prosthetic space and/or unfavorable prosthetic axis.13 Other abutment-veneer combinations have also been reported, ie zirconia-ceramic, composite-ceramic, and zirconia-composite.14,15 This clinical report describes the placement of an immediate postextraction implant in the esthetic zone, simultaneous buccal plate augmentation with biphasic calcium sulfate combined with hydroxyapatite/betatricalcium phosphate, and the placement of an immediate implant-retained provisional restoration. Due to deep bite, the final restoration was performed with a custom lithium disilicate screwed abutment and an adhesively attached lithium disilicate veneer.
CASE REPORT A 44-year-old healthy woman, who was a non-smoker, visited a private practice for treatment due to a failed metal-ceramic crown on her left maxillary lateral incisor. Extraoral examination showed a low smile lip line. The tooth was previously restored with a cast post and core, which lost retention due to severe secondary car-
758
ies. Adjacent teeth were unrestored. Anterior deep bite was observed (Fig 1). A clear radiographic image of chronic periapical infection was visible around the apex of the left maxillary lateral incisor (Fig 2). The patient had already received fixed dental prostheses, crowns, and implants in other areas of the mouth. The periodontal condition was within normal limits. Comprehensive information was given regarding orthodontic pretreatment to reduce the deep bite and thus increase the prosthetic space. The patient was also informed of different treatment options, such as a tooth-supported fixed dental prosthesis. The final choice was an implant-supported single restoration without orthodontic pretreatment. To allow correct evaluation, a radiologic template was fabricated to evaluate the bone morphology from a prosthesis-related viewpoint with cone beam computed tomography (CBCT) (Fig 3a). The exam indicated that good primary stabilization with a postextraction implant was possible, using adequate palatal bone wall and accepting a final cemented restoration to avoid buccal screw access (Fig 3b). The very thin (< 1 mm) buccal bone plate suggested the need for bone augmentation to avoid postextraction ridge remodeling. A buccal full-thickness flap with a distal vertical release incision and papillae preservation was raised. No palatal incision was made (Fig 4). The tooth was extracted and the granulation tissue was removed. Implant bed preparation was performed using manufacturer’s drills combined with piezosurgical tools (Piezosurgery OT4, Mectron), to improve the preparation axis and work selectively on the palatal wall. The
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Q U I N T E S S E N C E I N T E R N AT I O N A L Cardelli et al
a
Fig 4
b
Single-flap approach design.
a
Fig 5
b
implant (C1 3.75 × 10 mm; MIS Implant Technologies) was placed 1 mm below the buccal bone level. The buccal plate was augmented with a composite graft of biphasic calcium sulfate (BondBone, MIS Implant Technologies) and hydroxyapatite/beta-tricalcium phosphate (HA/β-TCP) (Bone Ceramic, Straumann). The two grafting materials were mixed in a 2:1 ratio, using saline solution in a sterile metal cup, in accordance with the manufacturer’s recommendations. No collagen membrane was used to cover the graft. After setting of the composite graft, the screwed provisional restoration was seated without occlusal contacts. The buccal gap between implant threads and the buccal plate was filled with HA/β-TCP (Bone Ceramic), as it was larger than 2 mm (Fig 5). A periosteal incision was made in the inner part of the buccal flap to
VOLUME 45 • NUMBER 9 • OCTOBER 2014
Fig 3a Radiologic template in place. Fig 3b Cross-sectional CBCT image of site of left maxillary lateral incisor with implant template.
Provisional placement and buccal gap compensation.
Fig 6a Healing 2 weeks postoperatively. Fig 6b Healing 3 months postoperatively.
allow tension-free wound closure with interrupted 6-0 resorbable sutures (Serafit, Serag-Wiessner). The screw hole was closed with a cotton pellet and composite resin (Miris 2, Coltène/Whaledent). After 2 weeks, satisfactory soft tissue healing was seen and the sutures were removed (Fig 6a). On examination at 1, 2, and 2.5 months, the soft tissue showed improving maturation. Three months postoperatively, acceptable soft tissue maturation was obtained (Fig 6b) and a final polyether impression with customized open tray and pick-up transfer was acquired (Impregum Duosoft Quick H and L, 3M ESPE). The provisional emergence profile was recorded after seating the provisional restoration onto an implant replica and surrounding it with impression silicone (Virtual, Ivoclar Vivadent). After stone cast production and evaluation, a final lithium
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Fig 7a Custom screw-retained lithium disilicate abutment. Fig 7b Abutment in place.
a
disilicate custom abutment and lithium disilicate veneer was planned as final restoration, to avoid severe height limitations for a crown and abutment due to deep bite. A titanium straight abutment was reduced to become a titanium base, and the veneer-prepared abutment was waxed on it. After thermopressing, the lithium disilicate abutment (e.max Press, Ivoclar Vivadent) (Fig 7) underwent a preliminary clinical trial with a transitional fixation to its base (Virtual Extra Light Body Fast Set, Ivoclar Vivadent). Occlusal and interproximal contact points were verified. A slight apical repositioning of the finishing line was planned and performed in the dental laboratory. The inner surface of the lithium disilicate superstructure was treated with 5% hydrofluoric acid for 20 seconds (IPS Ceramic, Ivoclar), while the titanium base was sandblasted with low-pressure Al2O3 particles. Both surfaces were then treated with a silane agent for 60 seconds (Monobond Plus, Ivoclar Vivadent). The lithium disilicate superstructure was luted to its titanium base with a self-adhesive, dual-curing composite cement (Multilink Implant, Ivoclar Vivadent). The veneer was waxed and thermopressed. Final shade adjustment was performed with colors and glazed (IPS e.max Shade and Glaze, Ivoclar Vivadent). Before intraoral delivery, the abutment and the veneer were treated with 5% hydrofluoric acid for 20 seconds (IPS Ceramic, Ivoclar). The abutment was torqued at 30 Ncm in accordance with the manufacturer’s recommendations. The screw hole was closed with composite resin with a shade as close as possible to the ceramic (Miris 2, Coltène/Whaledent). After surface cleaning (Ivoclean, Ivoclar Vivadent), the abutment was ready for cementation. The inner veneer surface was treated with silane agent for 60 sec-
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b
Fig 8
Veneer luting.
onds (Monobond Plus). The luting procedure was performed with dual-curing self-adhesive cement (SpeedCEM, Ivoclar Vivadent) (Fig 8). One month after restoration delivery, the implant was healthy both clinically and radiographically (Fig 9), combined with the ongoing healing process of the previously infected periapical area. The soft tissue contour was satisfactory from a clinical and patient-oriented viewpoint. Four months after final delivery, the periapical radiolucency was no longer visible and soft tissue heights were comparable to those seen preoperatively (Fig 10).
DISCUSSION Single restorations in the esthetic zone represent a major challenge in implant dentistry. Soft tissue quality and quantity, together with restorative parameters, are of the utmost importance. Bone support is also a major factor. For better three-dimensional evaluation and implant position planning, a volumetric exam such CBCT is usually performed.16 A recent report indicated
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Q U I N T E S S E N C E I N T E R N AT I O N A L Cardelli et al
a a
b b
Fig 9a Final restoration 1 month after delivery. Fig 9b Radiographic aspect 1 month after restoration delivery.
c
Figs 10a to 10c Soft tissue comparison: preoperative, 4 months postoperatively, 7 months postoperatively.
that the exclusive use of orthopantomography in implant planning resulted in selection of wider and longer implants than those that would be selected on cross-sectional CBCT images.17 In the present clinical report, the three-dimensional template-assisted examination evidenced an adequate palatal bone plate and the intact, albeit thin, buccal bone wall for a predictable immediate implant placement. A delayed-immediate implant placement (6 to 8 weeks after tooth extraction) with simultaneous GBR is frequently suggested for the esthetic zone.8 This approach would have required a provisional resin-bonded restoration, with risk of debonding due to unfavorable occlusion.6 This was avoided by using an immediate postextraction implant with an immediate provisional. Adequate insertion torque (> 25 Ncm) was achieved to allow the seating of a provisional restoration without occlusal contact, avoiding the use of a different transitional solution.18 Moreover, this approach can support interproximal soft tissue during healing.19 To improve soft and hard tissue support concomitant to tooth extraction and implant placement, various approaches
VOLUME 45 • NUMBER 9 • OCTOBER 2014
have been proposed, as simultaneous implant placement itself has proven ineffective for avoiding bone remodeling.4 Use of a connective tissue graft (CTG)20 and autologous bone or bone substitute placement over the buccal bone plate are the most common approaches.21 Buccal plate augmentation with a synthetic graft composed of biphasic calcium sulfate and HA/βTCP allowed satisfactory soft tissue contour. The singleflap approach allowed adequate access to the buccal plate, preserving acceptable vascularization of the site thus facilitating smoother soft tissue healing.22 A horizontal platform-switched implant with a discrepancy of 0.3 mm on each side was used that allowed good crestal bone contour preservation. A recent report indicated that a horizontal switched implant-abutment connection improved crestal bone preservation, even in single-implant placement procedures.23 With regard to the final restorative approach, the deep bite would have limited the palatal space available for the crown-abutment complex, leading to inadequate abutment height and/or prosthetic space for the ceramic crown.24 To overcome space-related re-
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storative issues in the esthetic zone, the use of a porcelain veneer combined with a screw-retained metalceramic custom abutment has been proposed.13 However, with the exception of the composite-composite interface, the subsequent material combinations that have been investigated did not allow an adhesive approach between the abutment and the veneer. The use of lithium disilicate for the abutment and the veneer allowed hydrofluoric acid/silane treatment of both surfaces. While retaining the esthetic advantages of the metal-free approach, this combination could improve adhesion between the two restorative components over many proposed abutment/veneer combinations.25 Moreover, it also offers a reduced depth of cement excess removal without reducing the esthetic outcome of the restoration in the anterior zone compared to all-ceramic single crowns and abutments.
CONCLUSION The use of biphasic calcium sulfate in conjunction with HA/β-TCP proved effective for preserving adequate soft tissue esthetics around an immediate postextraction implant. The use of a “veneer prepared” lithium disilicate abutment that allows surface conditioning of both interfaces, combined with a lithium disilicate veneer, could be a viable solution for single-implant restoration in the esthetic zone, especially in cases of deep occlusion.
REFERENCES 1. Wittneben JG, Buser D, Salvi GE, Bürgin W, Hicklin S, Brägger U. Complication and failure rates with implant-supported fixed dental prostheses and single crowns: a 10-year retrospective study [epub ahead of print 2 Apr 2013]. Clin Implant Dent Relat Res doi: 10.1111/cid.12066. 2. Belser UC, Grütter L, Vailati F, Bornstein MM, Weber HP, Buser D. Outcome evaluation of early placed maxillary anterior single-tooth implants using objective esthetic criteria: a cross-sectional, retrospective study in 45 patients with a 2- to 4-year follow-up using pink and white esthetic scores. J Periodontol 2009;80:140–151. 3. Buser D, Chappuis V, Bornstein MM, Wittneben JG, Frei M, Belser UC. Long-term stability of contour augmentation with early implant placement following single tooth extraction in the esthetic zone a prospective, cross-sectional study in 41 patients with a 5- to 9-year follow-up. J Periodontol 2013;84:1517–1527. 4. Araújo MG, Wennström JL, Lindhe J. Modeling of the buccal and lingual bone walls of fresh extraction sites following implant installation. Clin Oral Implants Res 2006;17:606–614. 5. Buser D, Halbritter S, Hart C, et al. Early implant placement with simultaneous guided bone regeneration following single-tooth extraction in the esthetic zone: 12-month results of a prospective study with 20 consecutive patients. J Periodontol 2009;80:152–162.
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6. Berekally TL, Smales RJ. A retrospective clinical evaluation of resin-bonded bridges inserted at the Adelaide Dental Hospital. Aust Dent J 1993;38:85–96. 7. Schwartz-Arad D, Laviv A, Levin L. Survival of immediately provisionalized dental implants placed immediately into fresh extraction sockets. J Periodontol 2007;78:219–223. 8. Chen ST, Buser D. Clinical and esthetic outcomes of implants placed in postextraction sites. Int J Oral Maxillofac Implants 2009;24(Suppl):186–217. 9. Paolantonio M, Dolci M, Scarano A, et al. Immediate implantation in fresh extraction sockets. A controlled clinical and histological study in man. J Periodontol 2001;72:1560–1571. 10. Caiazzo A, Brugnami F, Mehra P. Buccal plate preservation with immediate post-extraction implant placement and provisionalization: preliminary results of a new technique. Int J Oral Maxillofac Surg 2013;42:666–670. 11. Davarpanah M, Martinez H, Tecucianu JF, Celletti R, Lazzara R. Small-diameter implants: indications and contraindications. J Esthet Dent 2000;12:186–194. 12. Freitas AC Jr, Bonfante EA, Rocha EP, Silva NR, Marotta L, Coelho PG. Effect of implant connection and restoration design (screwed vs. cemented) in reliability and failure modes of anterior crowns. Eur J Oral Sci 2011;119:323–330. 13. Magne P, Magne M, Jovanovic SA. An esthetic solution for single-implant restorations - type III porcelain veneer bonded to a screw-retained custom abutment: a clinical report. J Prosthet Dent 2008;99:2–7. 14. Magne P, Paranhos MP, Burnett LH Jr, Magne M, Belser UC. Fatigue resistance and failure mode of novel-design anterior single-tooth implant restorations: influence of material selection for type III veneers bonded to zirconia abutments. Clin Oral Implants Res 2011;22:195–200. 15. Magne P, Oderich E, Boff LL, Cardoso AC, Belser UC. Fatigue resistance and failure mode of CAD/CAM composite resin implant abutments restored with type III composite resin and porcelain veneers. Clin Oral Implants Res 2011;22:1275–1281. 16. Tyndall DA, Price JB, Tetradis S, Ganz SD, Hildebolt C, Scarfe WC; American Academy of Oral and Maxillofacial Radiology. Position statement of the American Academy of Oral and Maxillofacial Radiology on selection criteria for the use of radiology in dental implantology with emphasis on cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol 2012;113:817–826. 17. Correa LR, Spin-Neto R, Stavropoulos A, Schropp L, da Silveira HE, Wenzel A. Planning of dental implant size with digital panoramic radiographs, CBCTgenerated panoramic images, and CBCT cross-sectional images. Clin Oral Implants Res 2014;25:690–695. 18. Degidi M, Piattelli A, Gehrke P, Felice P, Carinci F. Five-year outcome of 111 immediate nonfunctional single restorations. J Oral Implantol 2006;32:277–285. 19. Malchiodi L, Cucchi A, Ghensi P, Nocini PF. Evaluation of the esthetic results of 64 nonfunctional immediately loaded postextraction implants in the maxilla: correlation between interproximal alveolar crest and soft tissues at 3 years of follow-up. Clin Implant Dent Relat Res 2013;15:130–142. 20. Cosyn J, De Bruyn H, Cleymaet R. Soft tissue preservation and pink aesthetics around single immediate implant restorations: a 1-year prospective study. Clin Implant Dent Relat Res 2013;15:847–857. 21. Fu PS, Wu YM, Wang JC, et al. Optimizing anterior esthetics of a single-tooth implant through socket augmentation and immediate provisionalization: a case report with 7-year follow-up. Kaohsiung J Med Sci 2012;28:559–563. 22. Farina R, Simonelli A, Rizzi A, Pramstraller M, Cucchi A, Trombelli L. Early postoperative healing following buccal single flap approach to access intraosseous periodontal defects. Clin Oral Investig 2013;17:1573–1583. 23. Calvo-Guirado JL, Ortiz-Ruiz AJ, López-Marí L, Delgado-Ruiz R, Maté-Sánchez J, Bravo Gonzalez LA. Immediate maxillary restoration of single-tooth implants using platform switching for crestal bone preservation: a 12-month study. Int J Oral Maxillofac Implants 2009;24:275–281. 24. Saleh Saber F, Abolfazli N, Nuroloyuni S, et al. Effect of abutment height on retention of single cement-retained, wide- and narrow-platform implantsupported restorations. J Dent Res Dent Clin Dent Prospects 2012;6(3):98–102. 25. Zelos L, Bevis RR, Keenan KM. Evaluation of the ceramic/ceramic interface. Am J Orthod Dentofacial Orthop 1994;106:10–21.
VOLUME 45 • NUMBER 9 • OCTOBER 2014
IMPLANTOLOGY
Paolo Cardelli
Immediate postextraction implant with simultaneous buccal plate augmentation, restored with lithium disilicate abutment and veneer: A clinical report Paolo Cardelli, DDS1/Milko Belletti, MDT2/Giovanna Murmura, MD, DMD, PhD3 Objective: To describe the successful use of biphasic calcium sulfate for improving the buccal plate thickness in an immediate postextraction implant, and its final restoration with custom lithium disilicate abutment and veneer. Summary: A hopeless lateral incisor was replaced with an immediate postextraction implant in conjunction with a buccal plate aug-
mentation based on biphasic calcium sulfate. Satisfactory soft tissue height and quality were maintained following healing. The final restoration managed the severely reduced prosthetic space due to deep bite, and allowed an adhesive luting procedure. (Quintessence Int 2014;45:757–762; doi: 10.3290/j.qi. a32441)
Key words: adhesion, buccal augmentation, calcium sulfate, dental implant, lithium disilicate, postextraction implant, veneer
Implant-supported single crowns demonstrate good long-term survival with regard to both surgical and prosthetic aspects.1 Moreover, pink esthetic score/ white esthetic score (PES/WES) evaluations have been used to examine soft tissue-related and crown-related aspects in the anterior zone.2 In a recent paper, the esthetic long-term scores were satisfactory for anterior single implant restorations.3 When a hopeless anterior tooth has yet to be extracted, immediate postextraction implants may reduce the number of surgical procedures; however, this approach has proven unsuccessful in preventing 1
Research Fellow, Department of Medical, Oral and Biotechnological Sciences, University “G. D’Annunzio” of Chieti-Pescara, Italy.
2
Dental Technician, Private Dental Laboratory “Dental Worked”, Alba Adriatica, Italy.
3
Aggregate Professor, Department of Medical, Oral and Biotechnological Sciences, University “G. D’Annunzio” of Chieti-Pescara, Italy.
Correspondence: Dr Paolo Cardelli, Department of Medical, Oral and Biotechnological Sciences, University “G. D’Annunzio” of Chieti-Pescara, Via dei Vestini 31, 66100 Chieti, Italy. Email: paolo.cardelli@ unich.it
VOLUME 45 • NUMBER 9 • OCTOBER 2014
bone remodeling following tooth extraction.4 Delayedimmediate implants, placed 6 to 8 weeks after extraction, allow complete soft tissue coverage of the site for simultaneous guided bone regeneration (GBR);5 this approach, although proving beneficial,3 requires a removable interim prosthesis or a transitional Maryland bridge that could detach in cases of unfavorable occlusion.6 Immediate postextraction implants can instead support an immediate provisional restoration to avoid different transitional restorations.7 However, simultaneous bone and/or soft tissue augmentation may be needed to obtain an acceptable esthetic outcome.8 The buccal plate-implant gap should be grafted if wider than 2 mm.9 Moreover, the placement of grafting material over the intact buccal bone plate may improve the hard and soft tissue outcomes.10 Implant treatment in the esthetic zone can be challenging due to space-related difficulties. From a surgical viewpoint, implant placement can be complicated
757
Q U I N T E S S E N C E I N T E R N AT I O N A L Cardelli et al
Fig 2 Intraoral periapical radiography showing periapical lesion on left maxillary lateral incisor. Fig 1
Preoperative intraoral situation.
or hampered by limited interradicular space.11 Furthermore, many problems can occur due to the limited three-dimensional prosthetic space: mesiodistal, buccolingual, or interocclusal relationships can lead to dimensionally inadequate abutments; then a screwretained restoration with buccal screw access would be needed, with esthetic impairment and lower long-term esthetic stability.12 Adhesive porcelain veneers over custom metal-ceramic screwed abutments have already been proposed as a viable solution to limited prosthetic space and/or unfavorable prosthetic axis.13 Other abutment-veneer combinations have also been reported, ie zirconia-ceramic, composite-ceramic, and zirconia-composite.14,15 This clinical report describes the placement of an immediate postextraction implant in the esthetic zone, simultaneous buccal plate augmentation with biphasic calcium sulfate combined with hydroxyapatite/betatricalcium phosphate, and the placement of an immediate implant-retained provisional restoration. Due to deep bite, the final restoration was performed with a custom lithium disilicate screwed abutment and an adhesively attached lithium disilicate veneer.
CASE REPORT A 44-year-old healthy woman, who was a non-smoker, visited a private practice for treatment due to a failed metal-ceramic crown on her left maxillary lateral incisor. Extraoral examination showed a low smile lip line. The tooth was previously restored with a cast post and core, which lost retention due to severe secondary car-
758
ies. Adjacent teeth were unrestored. Anterior deep bite was observed (Fig 1). A clear radiographic image of chronic periapical infection was visible around the apex of the left maxillary lateral incisor (Fig 2). The patient had already received fixed dental prostheses, crowns, and implants in other areas of the mouth. The periodontal condition was within normal limits. Comprehensive information was given regarding orthodontic pretreatment to reduce the deep bite and thus increase the prosthetic space. The patient was also informed of different treatment options, such as a tooth-supported fixed dental prosthesis. The final choice was an implant-supported single restoration without orthodontic pretreatment. To allow correct evaluation, a radiologic template was fabricated to evaluate the bone morphology from a prosthesis-related viewpoint with cone beam computed tomography (CBCT) (Fig 3a). The exam indicated that good primary stabilization with a postextraction implant was possible, using adequate palatal bone wall and accepting a final cemented restoration to avoid buccal screw access (Fig 3b). The very thin (< 1 mm) buccal bone plate suggested the need for bone augmentation to avoid postextraction ridge remodeling. A buccal full-thickness flap with a distal vertical release incision and papillae preservation was raised. No palatal incision was made (Fig 4). The tooth was extracted and the granulation tissue was removed. Implant bed preparation was performed using manufacturer’s drills combined with piezosurgical tools (Piezosurgery OT4, Mectron), to improve the preparation axis and work selectively on the palatal wall. The
VOLUME 45 • NUMBER 9 • OCTOBER 2014
Q U I N T E S S E N C E I N T E R N AT I O N A L Cardelli et al
a
Fig 4
b
Single-flap approach design.
a
Fig 5
b
implant (C1 3.75 × 10 mm; MIS Implant Technologies) was placed 1 mm below the buccal bone level. The buccal plate was augmented with a composite graft of biphasic calcium sulfate (BondBone, MIS Implant Technologies) and hydroxyapatite/beta-tricalcium phosphate (HA/β-TCP) (Bone Ceramic, Straumann). The two grafting materials were mixed in a 2:1 ratio, using saline solution in a sterile metal cup, in accordance with the manufacturer’s recommendations. No collagen membrane was used to cover the graft. After setting of the composite graft, the screwed provisional restoration was seated without occlusal contacts. The buccal gap between implant threads and the buccal plate was filled with HA/β-TCP (Bone Ceramic), as it was larger than 2 mm (Fig 5). A periosteal incision was made in the inner part of the buccal flap to
VOLUME 45 • NUMBER 9 • OCTOBER 2014
Fig 3a Radiologic template in place. Fig 3b Cross-sectional CBCT image of site of left maxillary lateral incisor with implant template.
Provisional placement and buccal gap compensation.
Fig 6a Healing 2 weeks postoperatively. Fig 6b Healing 3 months postoperatively.
allow tension-free wound closure with interrupted 6-0 resorbable sutures (Serafit, Serag-Wiessner). The screw hole was closed with a cotton pellet and composite resin (Miris 2, Coltène/Whaledent). After 2 weeks, satisfactory soft tissue healing was seen and the sutures were removed (Fig 6a). On examination at 1, 2, and 2.5 months, the soft tissue showed improving maturation. Three months postoperatively, acceptable soft tissue maturation was obtained (Fig 6b) and a final polyether impression with customized open tray and pick-up transfer was acquired (Impregum Duosoft Quick H and L, 3M ESPE). The provisional emergence profile was recorded after seating the provisional restoration onto an implant replica and surrounding it with impression silicone (Virtual, Ivoclar Vivadent). After stone cast production and evaluation, a final lithium
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Q U I N T E S S E N C E I N T E R N AT I O N A L Cardelli et al
Fig 7a Custom screw-retained lithium disilicate abutment. Fig 7b Abutment in place.
a
disilicate custom abutment and lithium disilicate veneer was planned as final restoration, to avoid severe height limitations for a crown and abutment due to deep bite. A titanium straight abutment was reduced to become a titanium base, and the veneer-prepared abutment was waxed on it. After thermopressing, the lithium disilicate abutment (e.max Press, Ivoclar Vivadent) (Fig 7) underwent a preliminary clinical trial with a transitional fixation to its base (Virtual Extra Light Body Fast Set, Ivoclar Vivadent). Occlusal and interproximal contact points were verified. A slight apical repositioning of the finishing line was planned and performed in the dental laboratory. The inner surface of the lithium disilicate superstructure was treated with 5% hydrofluoric acid for 20 seconds (IPS Ceramic, Ivoclar), while the titanium base was sandblasted with low-pressure Al2O3 particles. Both surfaces were then treated with a silane agent for 60 seconds (Monobond Plus, Ivoclar Vivadent). The lithium disilicate superstructure was luted to its titanium base with a self-adhesive, dual-curing composite cement (Multilink Implant, Ivoclar Vivadent). The veneer was waxed and thermopressed. Final shade adjustment was performed with colors and glazed (IPS e.max Shade and Glaze, Ivoclar Vivadent). Before intraoral delivery, the abutment and the veneer were treated with 5% hydrofluoric acid for 20 seconds (IPS Ceramic, Ivoclar). The abutment was torqued at 30 Ncm in accordance with the manufacturer’s recommendations. The screw hole was closed with composite resin with a shade as close as possible to the ceramic (Miris 2, Coltène/Whaledent). After surface cleaning (Ivoclean, Ivoclar Vivadent), the abutment was ready for cementation. The inner veneer surface was treated with silane agent for 60 sec-
760
b
Fig 8
Veneer luting.
onds (Monobond Plus). The luting procedure was performed with dual-curing self-adhesive cement (SpeedCEM, Ivoclar Vivadent) (Fig 8). One month after restoration delivery, the implant was healthy both clinically and radiographically (Fig 9), combined with the ongoing healing process of the previously infected periapical area. The soft tissue contour was satisfactory from a clinical and patient-oriented viewpoint. Four months after final delivery, the periapical radiolucency was no longer visible and soft tissue heights were comparable to those seen preoperatively (Fig 10).
DISCUSSION Single restorations in the esthetic zone represent a major challenge in implant dentistry. Soft tissue quality and quantity, together with restorative parameters, are of the utmost importance. Bone support is also a major factor. For better three-dimensional evaluation and implant position planning, a volumetric exam such CBCT is usually performed.16 A recent report indicated
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Q U I N T E S S E N C E I N T E R N AT I O N A L Cardelli et al
a a
b b
Fig 9a Final restoration 1 month after delivery. Fig 9b Radiographic aspect 1 month after restoration delivery.
c
Figs 10a to 10c Soft tissue comparison: preoperative, 4 months postoperatively, 7 months postoperatively.
that the exclusive use of orthopantomography in implant planning resulted in selection of wider and longer implants than those that would be selected on cross-sectional CBCT images.17 In the present clinical report, the three-dimensional template-assisted examination evidenced an adequate palatal bone plate and the intact, albeit thin, buccal bone wall for a predictable immediate implant placement. A delayed-immediate implant placement (6 to 8 weeks after tooth extraction) with simultaneous GBR is frequently suggested for the esthetic zone.8 This approach would have required a provisional resin-bonded restoration, with risk of debonding due to unfavorable occlusion.6 This was avoided by using an immediate postextraction implant with an immediate provisional. Adequate insertion torque (> 25 Ncm) was achieved to allow the seating of a provisional restoration without occlusal contact, avoiding the use of a different transitional solution.18 Moreover, this approach can support interproximal soft tissue during healing.19 To improve soft and hard tissue support concomitant to tooth extraction and implant placement, various approaches
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have been proposed, as simultaneous implant placement itself has proven ineffective for avoiding bone remodeling.4 Use of a connective tissue graft (CTG)20 and autologous bone or bone substitute placement over the buccal bone plate are the most common approaches.21 Buccal plate augmentation with a synthetic graft composed of biphasic calcium sulfate and HA/βTCP allowed satisfactory soft tissue contour. The singleflap approach allowed adequate access to the buccal plate, preserving acceptable vascularization of the site thus facilitating smoother soft tissue healing.22 A horizontal platform-switched implant with a discrepancy of 0.3 mm on each side was used that allowed good crestal bone contour preservation. A recent report indicated that a horizontal switched implant-abutment connection improved crestal bone preservation, even in single-implant placement procedures.23 With regard to the final restorative approach, the deep bite would have limited the palatal space available for the crown-abutment complex, leading to inadequate abutment height and/or prosthetic space for the ceramic crown.24 To overcome space-related re-
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storative issues in the esthetic zone, the use of a porcelain veneer combined with a screw-retained metalceramic custom abutment has been proposed.13 However, with the exception of the composite-composite interface, the subsequent material combinations that have been investigated did not allow an adhesive approach between the abutment and the veneer. The use of lithium disilicate for the abutment and the veneer allowed hydrofluoric acid/silane treatment of both surfaces. While retaining the esthetic advantages of the metal-free approach, this combination could improve adhesion between the two restorative components over many proposed abutment/veneer combinations.25 Moreover, it also offers a reduced depth of cement excess removal without reducing the esthetic outcome of the restoration in the anterior zone compared to all-ceramic single crowns and abutments.
CONCLUSION The use of biphasic calcium sulfate in conjunction with HA/β-TCP proved effective for preserving adequate soft tissue esthetics around an immediate postextraction implant. The use of a “veneer prepared” lithium disilicate abutment that allows surface conditioning of both interfaces, combined with a lithium disilicate veneer, could be a viable solution for single-implant restoration in the esthetic zone, especially in cases of deep occlusion.
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