Surgical and prosthetic management of ridge deficiency for an implant-supported restoration in the esthetic zone Dimitrios E. V. Papadimitriou, DDS,a Konstantinos M. Chochlidakis, DDS,b Daniel S. Weitz, DDS,c Berge Wazirian, DMD,d and Carlo Ercoli, DDSe Eastman Institute for Oral Health, School of Medicine and Dentistry, University of Rochester, Rochester, NY; Kornberg School of Dentistry, Temple University, Philadelphia, Pa; McGill University, Montreal, Canada This clinical report presents the surgical and prosthetic management of a patient with complex needs involving anterior implants. After extraction and ridge augmentation, unexpected ridge resorption occurred. Two implants were placed in conjunction with an allograft skin material. Upon healing, 2 additional soft tissue augmentation procedures were performed with autologous pedicle connective tissue grafts to correct the residual ridge deficiency. At the second stage surgery, a modified flap approach was used to further enhance the soft tissue volume and contour. Definitive implant-supported splinted crowns with minimal interproximal pink ceramic material were provided. (J Prosthet Dent 2014;-:---)
In reconstructive dentistry, the goal is to replace and optimize hard and soft tissues so that the definitive restoration has function, appearance, and comfort comparable to the natural dentition.1 Therefore, the contour and height of the facial gingival margins should be in harmony with the adjacent ones, the papillae should completely fill the interproximal areas, and the prosthesis should reproduce the anatomy and color of the natural teeth.2 This is relatively easy to achieve in a healthy periodontium when a single tooth is missing and the facial bony plate is intact and relatively thick ( 1 mm).3 In these situations, the integrity of the periodontal ligaments of the adjacent teeth is the main determinant in ensuring the height and volume of surrounding papillae.4,5 When the soft and hard tissues are compromised or multiple teeth are missing (often in combination), the
successful rehabilitation of these patients becomes more complex because of less than ideal alveolar ridge height or width (or both).6,7 To achieve a functional and esthetic result, these anatomic limitations can be overcome
with surgical manipulations, prosthetic designs, or a combination of the two.7-11 The purpose of this clinical report was to present the surgical and prosthetic management of an anterior edentulous area with 2 adjacent missing
1 Occlusal view of anterior maxilla, where concavity is evident on apicolabial surface.
a Clinical Assistant Professor, Division of Periodontics, Eastman Institute for Oral Health, School of Medicine and Dentistry, University of Rochester. b Clinical Assistant Professor, Department of Restorative Dentistry, Kornberg School of Dentistry, Temple University. c Resident, Division of Periodontics, Eastman Institute for Oral Health, School of Medicine and Dentistry, University of Rochester. d Faculty lecturer, McGill University. e Associate Professor, Chair, and Program Director, Division of Prosthodontics, Eastman Institute for Oral Health, School of Medicine and Dentistry, University of Rochester.
Papadimitriou et al
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teeth where a series of complications occurred after tooth extraction.
CLINICAL REPORT A 45-year-old black woman with an unremarkable medical history was referred for treatment to the Division of Periodontology at the Eastman Institute for Oral Health, University of Rochester, Rochester, NY. Her chief complaints were a missing maxillary right central incisor and a fractured right lateral incisor. Upon clinical examination, the missing central incisor and the lateral incisor, fractured 1 mm coronal to the gingival margin, were noted (Fig. 1). Extraoral examination found that the patient had an average to high smile line with a slight display of her anterior papillae.12 The occlusal view showed a concavity apical to her missing maxillary central incisor (see Fig. 1), and a radiograph of the lateral incisor revealed previous endodontic treatment (Fig. 2). Treatment options were discussed with the patient, including orthodontic extrusion of the lateral incisor and the subsequent fabrication of a post and core and crown; however, she declined this treatment option. Consequently, the decision was made to extract her lateral incisor and perform simultaneous alveolar ridge augmentation followed by the placement of 2 implants in the lateral and central incisor areas. A staged approach was planned with 2 implant-supported crowns because adequate mesiodistal space was available.13 After the atraumatic extraction of the fractured tooth, the edentulous ridge was split with a sonic instrument (Komet sonic handpiece SF1LM; Komet) to a depth of 12 mm, then expanded buccolingually with osteotomes (Stoma). The socket and space created in the split ridge were grafted with small-particle freeze-dried bone allograft (Puros; Zimmer Dental), and a xenograft material (Bio-Oss; Geistlich Pharma AG) was placed at the labial surface of the ridge. The entire area was covered with a collagen barrier (BioMend Extend; Zimmer Dental), and
2 Radiograph of anterior maxillary right 3 Radiograph 3 months after implant area at initial appointment. placement. primary closure was achieved. An immediate interim resin partial removable dental prosthesis, relieved in the ridge area to avoid any tissue contact at the surgical site, was inserted. The initial postoperative healing was uneventful, with no flap dehiscence. Four months later at the implant placement appointment, the augmented alveolar ridge appeared horizontally and vertically collapsed. With the aid of a surgical guide, 2 implants (SLA 3.310 mm; Institut Straumann AG) were placed with cover screws and submerged. Clinically, the bone appeared to
The Journal of Prosthetic Dentistry
be Type D1-D2 during preparation of the osteotomies.14 To compensate for the horizontal and vertical ridge resorption, a skin freeze-dried allograft was placed crestally over the implants (Dermis; Zimmer Dental), and primary closure was achieved. The initial immediate interim resin partial removable dental prosthesis was adjusted to avoid any tissue contact with the surgical site. Three months after surgery, the vertical ridge deficiency was still evident (Figs. 3, 4). To correct the deficiency, 2 additional soft tissue surgeries (3 months apart from each other) were
4 Clinical facial view 3 months after implant placement. Lack of vertical height is evident, especially at future interproximal area between missing teeth.
Papadimitriou et al
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2014
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5 Modified surgical flap design was applied to create papilla.
performed with pedicle autogenous connective tissue grafts by using the Sclar technique9 and the patient’s right palate as the harvest site. The immediate interim resin partial removable dental prosthesis was adjusted to ensure pressure relief of the surgical site. After 3 months of healing, the horizontal and vertical dimensions of the ridge appeared significantly improved. During implant uncovering, palatally oriented incisions were used to create a surgical papilla, and 2 resin interim splinted crowns were fabricated and inserted (Figs. 5, 6). Intraoral occlusal adjustments ensured a lack of contact in maximal intercuspation and lateral excursions. Suture placement used the connector of the prosthesis as a suspending anchor in the area of the
6 Splinted screw-retained resin interim crowns were inserted, and flap was sutured with combination of interrupted and suspensory sutures.
papilla (Fig. 6). Two months later, the height of the papillary soft tissues partially collapsed. At this point, the decision was made to restore the implants. A resin-retained prosthesis was chosen because of the buccal inclination of the implants’ long axis. Thus, the definitive prosthetic plan consisted of 2 screw-retained metal ceramic abutments and splinted resinretained lithium disilicate crowns (Figs. 7-11). Metal ceramic abutments were chosen to increase fracture and fatigue resistance while achieving an esthetic appearance of the finished abutment surface that could also be etched and bonded to the definitive restoration.15 The crowns were connected so that pink porcelain material could be added in the embrasure
7 Screw-retained metal ceramic abutments on definitive cast.
Papadimitriou et al
between the crowns to avoid a black triangle. At insertion, the seating of the metal-ceramic abutments was assessed radiographically, and the abutments were torqued with a force of 35 Ncm. Cementation was performed with resin (Maxcem Elite; Kerr Corp), and care was taken to thoroughly remove any excess.16 The occlusion was checked, and another radiograph was taken (Fig. 8). Four weeks after insertion, the patient was satisfied with the functional and esthetic results (Figs. 9-11).
8 Radiograph of definitive restoration after cementation.
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9 Intraoral view 4 weeks after insertion.
DISCUSSION The resorption of the bone graft material and the decrease in alveolar ridge width and height seen in this patient were significantly greater than the averages reported in the literature8,17 and may be explained by the quality of bone encountered surgically. Typically, bone in the anterior maxillary region is Type D314; however, it was clinically evaluated as Type D1-D2 in this patient, and a minimum amount of bleeding was observed. This may have reduced the blood supply needed for the grafting materials to survive and consolidate with native bone. Other plausible reasons for the hard tissue loss could be the length of the surgery or pressure from the immediate interim resin partial removable dental prosthesis during the healing period; however, the surgical time was not excessive, and care was taken to appropriately relieve the prosthesis.
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10 Occlusal view 4 weeks after insertion. The loss of the interproximal papilla observed after the initial insertion of the resin interim splinted crowns may have been caused by the multiple removals and replacements necessary to modify restoration contour. The selection of narrow implants was based on the presence of adequate mesiodistal space but limited buccolingual ridge width. Another viable option could have been the placement of 1 implant in the area of the central incisor and the use of a cantilever pontic for the lateral incisor.13 This design results in a longer interproximal papilla and might have reduced the need for soft tissue augmentation.4 Regarding determining the need for surgical augmentation, the authors feel that the patient’s smile is an important factor to consider.12 The transition from the restorative margin to the mucosa or the artificial papillae is visible in patients with high or average smile
lines, so attempts to augment the height of the tissues may be beneficial. However, in spite of surgical efforts, prosthetic materials might still be required to achieve ideal esthetics. This was the clinical situation presented in this article. Although a prosthetic solution incorporating pink porcelain into the definitive prosthetic design might have been adopted earlier, the rationale for the multiple surgeries was to eliminate the need for pink porcelain or alternatively decrease its volume to facilitate patient-performed plaque removal. Another important consideration was the duration of treatment, which was approximately 2 years from the initial examination to insertion of the definitive prosthesis. Because the treatment was performed in an educational institute, treatment times were expected to be longer than those in private practice. Although a patient could become frustrated with such a lengthy treatment, this patient demonstrated exceptional compliance, highlighting patient motivation as a key factor when evaluating treatment options.
SUMMARY
11 Smile 4 weeks after insertion.
The Journal of Prosthetic Dentistry
This clinical report describes the correction of an unexpected loss of horizontal and vertical ridge volume in the anterior maxilla. By using a combination of surgical and prosthetic techniques, a satisfactory esthetic result was achieved.
Papadimitriou et al
-
2014 REFERENCES
1. Belser UC, Schmid B, Higginbottom F, Buser D. Outcome analysis of implant restorations located in the anterior maxilla: a review of the recent literature. Int J Oral Maxillofac Implants 2004;19:30-42. 2. Phillips K, Kois JC. Aesthetic peri-implant site development: the restorative connection. Dent Clin North Am 1998;42:57-70. 3. Spray R, Black G, Morris F, Ochi S. The influence of bone thickness on facial marginal bone response: stage 1 placement through stage 2 uncovering. Ann Periodontol 2000;5: 119-28. 4. Salama H, Salama MA, Garber D, Adar P. The interproximal height of bone: a guidepost to predictable aesthetic strategies and soft tissue contours in anterior tooth replacement. Pract Periodontics Aesthet Dent 1998;10:1131-41. 5. Grunder U, Gracis S, Capelli M. Influence of the 3-D bone-to-implant relationship on esthetics. Int J Periodontics Restorative Dent 2005;25:113-9. 6. Seibert JS. Reconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts, part I: technique and wound healing. Compend Contin Educ Dent 1983;4:437-53.
Papadimitriou et al
5 7. Palacci P, Nowzari H. Soft tissue enhancement around dental implants. Periodontol 2000 2008;47:113-32. 8. Chiapasco M, Casentini P, Zaniboni M. Bone augmentation procedures in implant dentistry. Int J Oral Maxillofac Implants 2009;24:237-59. 9. Sclar AG. Soft tissue and esthetic considerations in implant therapy. Chicago: Quintessence; 2003. p. 163-8. 10. Tarnow DP, Chu SJ. Surgical and prosthetic correction of two adjacent anterior implants: a clinical case report. Clin Adv Periodontics 2011;1:174-81. 11. Simon H, Raigrodski AJ. Gingival-colored ceramics for enhanced esthetics. Quintessence Dent Technol 2002;25:155-72. 12. Hochman MN, Chu SJ, Tarnow DP. Maxillary anterior papilla display during smiling: a clinical study of the interdental smile line. Int J Periodontics Restorative Dent 2012;32: 375-83. 13. Tymstra N, Raghoebar GM, Vissink A, Meijer HJ. Dental implant treatment for two adjacent missing teeth in the maxillary aesthetic zone: a comparative pilot study and test of principle. Clin Oral Implants Res 2011;22:207-13. 14. Misch CE. Contemporary implant dentistry. 3rd ed.St Louis: Mosby; 2008. p. 130-46.
15. Kim S, Kim H, Brewer J, Monaco E. Comparison of fracture resistance of pressable metal ceramic custom implant abutments with CAD/CAM commercially fabricated zirconia implant abutments. J Prosthet Dent 2009;101:226-30. 16. Wadhwani C, Piñeyro A. Technique for controlling the cement for an implant crown. J Prosthet Dent 2009;102:57-8. 17. Van der Weijden F, Dell’Acqua F, Slot DE. Alveolar bone dimensional changes of postextraction sockets in humans: a systematic review. J Clin Periodontol 2009;36:1048-58. Corresponding author: Dr Dimitrios Papadimitriou 625 Elmwood Ave Rochester, NY 14642 E-mail: [email protected] Acknowledgment The authors thank Mr Nondas Vlachopoulos, CDT (laboratory technician, Athens, Greece) for fabricating the prosthesis. Copyright ª 2014 by the Editorial Council for The Journal of Prosthetic Dentistry.
In reconstructive dentistry, the goal is to replace and optimize hard and soft tissues so that the definitive restoration has function, appearance, and comfort comparable to the natural dentition.1 Therefore, the contour and height of the facial gingival margins should be in harmony with the adjacent ones, the papillae should completely fill the interproximal areas, and the prosthesis should reproduce the anatomy and color of the natural teeth.2 This is relatively easy to achieve in a healthy periodontium when a single tooth is missing and the facial bony plate is intact and relatively thick ( 1 mm).3 In these situations, the integrity of the periodontal ligaments of the adjacent teeth is the main determinant in ensuring the height and volume of surrounding papillae.4,5 When the soft and hard tissues are compromised or multiple teeth are missing (often in combination), the
successful rehabilitation of these patients becomes more complex because of less than ideal alveolar ridge height or width (or both).6,7 To achieve a functional and esthetic result, these anatomic limitations can be overcome
with surgical manipulations, prosthetic designs, or a combination of the two.7-11 The purpose of this clinical report was to present the surgical and prosthetic management of an anterior edentulous area with 2 adjacent missing
1 Occlusal view of anterior maxilla, where concavity is evident on apicolabial surface.
a Clinical Assistant Professor, Division of Periodontics, Eastman Institute for Oral Health, School of Medicine and Dentistry, University of Rochester. b Clinical Assistant Professor, Department of Restorative Dentistry, Kornberg School of Dentistry, Temple University. c Resident, Division of Periodontics, Eastman Institute for Oral Health, School of Medicine and Dentistry, University of Rochester. d Faculty lecturer, McGill University. e Associate Professor, Chair, and Program Director, Division of Prosthodontics, Eastman Institute for Oral Health, School of Medicine and Dentistry, University of Rochester.
Papadimitriou et al
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Volume
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Issue
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teeth where a series of complications occurred after tooth extraction.
CLINICAL REPORT A 45-year-old black woman with an unremarkable medical history was referred for treatment to the Division of Periodontology at the Eastman Institute for Oral Health, University of Rochester, Rochester, NY. Her chief complaints were a missing maxillary right central incisor and a fractured right lateral incisor. Upon clinical examination, the missing central incisor and the lateral incisor, fractured 1 mm coronal to the gingival margin, were noted (Fig. 1). Extraoral examination found that the patient had an average to high smile line with a slight display of her anterior papillae.12 The occlusal view showed a concavity apical to her missing maxillary central incisor (see Fig. 1), and a radiograph of the lateral incisor revealed previous endodontic treatment (Fig. 2). Treatment options were discussed with the patient, including orthodontic extrusion of the lateral incisor and the subsequent fabrication of a post and core and crown; however, she declined this treatment option. Consequently, the decision was made to extract her lateral incisor and perform simultaneous alveolar ridge augmentation followed by the placement of 2 implants in the lateral and central incisor areas. A staged approach was planned with 2 implant-supported crowns because adequate mesiodistal space was available.13 After the atraumatic extraction of the fractured tooth, the edentulous ridge was split with a sonic instrument (Komet sonic handpiece SF1LM; Komet) to a depth of 12 mm, then expanded buccolingually with osteotomes (Stoma). The socket and space created in the split ridge were grafted with small-particle freeze-dried bone allograft (Puros; Zimmer Dental), and a xenograft material (Bio-Oss; Geistlich Pharma AG) was placed at the labial surface of the ridge. The entire area was covered with a collagen barrier (BioMend Extend; Zimmer Dental), and
2 Radiograph of anterior maxillary right 3 Radiograph 3 months after implant area at initial appointment. placement. primary closure was achieved. An immediate interim resin partial removable dental prosthesis, relieved in the ridge area to avoid any tissue contact at the surgical site, was inserted. The initial postoperative healing was uneventful, with no flap dehiscence. Four months later at the implant placement appointment, the augmented alveolar ridge appeared horizontally and vertically collapsed. With the aid of a surgical guide, 2 implants (SLA 3.310 mm; Institut Straumann AG) were placed with cover screws and submerged. Clinically, the bone appeared to
The Journal of Prosthetic Dentistry
be Type D1-D2 during preparation of the osteotomies.14 To compensate for the horizontal and vertical ridge resorption, a skin freeze-dried allograft was placed crestally over the implants (Dermis; Zimmer Dental), and primary closure was achieved. The initial immediate interim resin partial removable dental prosthesis was adjusted to avoid any tissue contact with the surgical site. Three months after surgery, the vertical ridge deficiency was still evident (Figs. 3, 4). To correct the deficiency, 2 additional soft tissue surgeries (3 months apart from each other) were
4 Clinical facial view 3 months after implant placement. Lack of vertical height is evident, especially at future interproximal area between missing teeth.
Papadimitriou et al
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2014
3
5 Modified surgical flap design was applied to create papilla.
performed with pedicle autogenous connective tissue grafts by using the Sclar technique9 and the patient’s right palate as the harvest site. The immediate interim resin partial removable dental prosthesis was adjusted to ensure pressure relief of the surgical site. After 3 months of healing, the horizontal and vertical dimensions of the ridge appeared significantly improved. During implant uncovering, palatally oriented incisions were used to create a surgical papilla, and 2 resin interim splinted crowns were fabricated and inserted (Figs. 5, 6). Intraoral occlusal adjustments ensured a lack of contact in maximal intercuspation and lateral excursions. Suture placement used the connector of the prosthesis as a suspending anchor in the area of the
6 Splinted screw-retained resin interim crowns were inserted, and flap was sutured with combination of interrupted and suspensory sutures.
papilla (Fig. 6). Two months later, the height of the papillary soft tissues partially collapsed. At this point, the decision was made to restore the implants. A resin-retained prosthesis was chosen because of the buccal inclination of the implants’ long axis. Thus, the definitive prosthetic plan consisted of 2 screw-retained metal ceramic abutments and splinted resinretained lithium disilicate crowns (Figs. 7-11). Metal ceramic abutments were chosen to increase fracture and fatigue resistance while achieving an esthetic appearance of the finished abutment surface that could also be etched and bonded to the definitive restoration.15 The crowns were connected so that pink porcelain material could be added in the embrasure
7 Screw-retained metal ceramic abutments on definitive cast.
Papadimitriou et al
between the crowns to avoid a black triangle. At insertion, the seating of the metal-ceramic abutments was assessed radiographically, and the abutments were torqued with a force of 35 Ncm. Cementation was performed with resin (Maxcem Elite; Kerr Corp), and care was taken to thoroughly remove any excess.16 The occlusion was checked, and another radiograph was taken (Fig. 8). Four weeks after insertion, the patient was satisfied with the functional and esthetic results (Figs. 9-11).
8 Radiograph of definitive restoration after cementation.
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9 Intraoral view 4 weeks after insertion.
DISCUSSION The resorption of the bone graft material and the decrease in alveolar ridge width and height seen in this patient were significantly greater than the averages reported in the literature8,17 and may be explained by the quality of bone encountered surgically. Typically, bone in the anterior maxillary region is Type D314; however, it was clinically evaluated as Type D1-D2 in this patient, and a minimum amount of bleeding was observed. This may have reduced the blood supply needed for the grafting materials to survive and consolidate with native bone. Other plausible reasons for the hard tissue loss could be the length of the surgery or pressure from the immediate interim resin partial removable dental prosthesis during the healing period; however, the surgical time was not excessive, and care was taken to appropriately relieve the prosthesis.
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Issue
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10 Occlusal view 4 weeks after insertion. The loss of the interproximal papilla observed after the initial insertion of the resin interim splinted crowns may have been caused by the multiple removals and replacements necessary to modify restoration contour. The selection of narrow implants was based on the presence of adequate mesiodistal space but limited buccolingual ridge width. Another viable option could have been the placement of 1 implant in the area of the central incisor and the use of a cantilever pontic for the lateral incisor.13 This design results in a longer interproximal papilla and might have reduced the need for soft tissue augmentation.4 Regarding determining the need for surgical augmentation, the authors feel that the patient’s smile is an important factor to consider.12 The transition from the restorative margin to the mucosa or the artificial papillae is visible in patients with high or average smile
lines, so attempts to augment the height of the tissues may be beneficial. However, in spite of surgical efforts, prosthetic materials might still be required to achieve ideal esthetics. This was the clinical situation presented in this article. Although a prosthetic solution incorporating pink porcelain into the definitive prosthetic design might have been adopted earlier, the rationale for the multiple surgeries was to eliminate the need for pink porcelain or alternatively decrease its volume to facilitate patient-performed plaque removal. Another important consideration was the duration of treatment, which was approximately 2 years from the initial examination to insertion of the definitive prosthesis. Because the treatment was performed in an educational institute, treatment times were expected to be longer than those in private practice. Although a patient could become frustrated with such a lengthy treatment, this patient demonstrated exceptional compliance, highlighting patient motivation as a key factor when evaluating treatment options.
SUMMARY
11 Smile 4 weeks after insertion.
The Journal of Prosthetic Dentistry
This clinical report describes the correction of an unexpected loss of horizontal and vertical ridge volume in the anterior maxilla. By using a combination of surgical and prosthetic techniques, a satisfactory esthetic result was achieved.
Papadimitriou et al
-
2014 REFERENCES
1. Belser UC, Schmid B, Higginbottom F, Buser D. Outcome analysis of implant restorations located in the anterior maxilla: a review of the recent literature. Int J Oral Maxillofac Implants 2004;19:30-42. 2. Phillips K, Kois JC. Aesthetic peri-implant site development: the restorative connection. Dent Clin North Am 1998;42:57-70. 3. Spray R, Black G, Morris F, Ochi S. The influence of bone thickness on facial marginal bone response: stage 1 placement through stage 2 uncovering. Ann Periodontol 2000;5: 119-28. 4. Salama H, Salama MA, Garber D, Adar P. The interproximal height of bone: a guidepost to predictable aesthetic strategies and soft tissue contours in anterior tooth replacement. Pract Periodontics Aesthet Dent 1998;10:1131-41. 5. Grunder U, Gracis S, Capelli M. Influence of the 3-D bone-to-implant relationship on esthetics. Int J Periodontics Restorative Dent 2005;25:113-9. 6. Seibert JS. Reconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts, part I: technique and wound healing. Compend Contin Educ Dent 1983;4:437-53.
Papadimitriou et al
5 7. Palacci P, Nowzari H. Soft tissue enhancement around dental implants. Periodontol 2000 2008;47:113-32. 8. Chiapasco M, Casentini P, Zaniboni M. Bone augmentation procedures in implant dentistry. Int J Oral Maxillofac Implants 2009;24:237-59. 9. Sclar AG. Soft tissue and esthetic considerations in implant therapy. Chicago: Quintessence; 2003. p. 163-8. 10. Tarnow DP, Chu SJ. Surgical and prosthetic correction of two adjacent anterior implants: a clinical case report. Clin Adv Periodontics 2011;1:174-81. 11. Simon H, Raigrodski AJ. Gingival-colored ceramics for enhanced esthetics. Quintessence Dent Technol 2002;25:155-72. 12. Hochman MN, Chu SJ, Tarnow DP. Maxillary anterior papilla display during smiling: a clinical study of the interdental smile line. Int J Periodontics Restorative Dent 2012;32: 375-83. 13. Tymstra N, Raghoebar GM, Vissink A, Meijer HJ. Dental implant treatment for two adjacent missing teeth in the maxillary aesthetic zone: a comparative pilot study and test of principle. Clin Oral Implants Res 2011;22:207-13. 14. Misch CE. Contemporary implant dentistry. 3rd ed.St Louis: Mosby; 2008. p. 130-46.
15. Kim S, Kim H, Brewer J, Monaco E. Comparison of fracture resistance of pressable metal ceramic custom implant abutments with CAD/CAM commercially fabricated zirconia implant abutments. J Prosthet Dent 2009;101:226-30. 16. Wadhwani C, Piñeyro A. Technique for controlling the cement for an implant crown. J Prosthet Dent 2009;102:57-8. 17. Van der Weijden F, Dell’Acqua F, Slot DE. Alveolar bone dimensional changes of postextraction sockets in humans: a systematic review. J Clin Periodontol 2009;36:1048-58. Corresponding author: Dr Dimitrios Papadimitriou 625 Elmwood Ave Rochester, NY 14642 E-mail: [email protected] Acknowledgment The authors thank Mr Nondas Vlachopoulos, CDT (laboratory technician, Athens, Greece) for fabricating the prosthesis. Copyright ª 2014 by the Editorial Council for The Journal of Prosthetic Dentistry.
