Educational aims and anticipated outcomesThe reader will:

• Closelyfollowthiscasestudythrougheverystageoftreatment.

•Recalltheconsiderationsthatmustbekeptinmindwhenplanningtreatment.

•Understandwhatconstitutesbestpracticewhencarryingoutthisprocedure.

•Considerwhataspectsofthistreatmentplanmayhavecontributedto thesuccess.

•Gainadetailedunderstandingoftheprocedurebyreferenceto34pictures.

Single tooth restoration on a Straumann® Implant

Case Study: Dental ImplantsImplantdentistryhasbecomeastandardoptionfortherehabilitationoffullyandpartiallyedentulouspatients.Thesuccessofimplanttherapyisnolongerjudgedbyosseointegrationalone,butalsobythedeliveryofsuccessfullongtermfunctionalandaestheticoutcomes.

Thekeytoachievingpredictablefunctionalandaestheticresultsisbasedonperformingacomprehensivepre-operativeanalysissuchthatallriskfactorsareidentifiedandanassessmentmadeofthelikelihoodofachievingthedesiredaestheticoutcome.

In2007,theITIestablishedaconsensuspaperidentifyingallthesignificantdiagnosticfactorswhichcouldinfluencethetreatmentoutcome,providinga‘checklist’fortheclinicianandanAestheticRiskProfileforeachpatient.

Bysystematicallyassessingallthecriteriainvolved,ariskprofiletableiscreatedwhichshouldhelpthecliniciandiagnosethecaseappropriately,identifythelevelofdifficultyoftheplannedtherapyandminimizethepotentialsurgicalandrestorativepitfalls.

Thereforethegoalofcreatingariskprofileistoidentifythosepatientswhereimplanttherapycarriesahighriskofanegativeoutcomeandwhichmayultimatelybeassociatedwithunacceptableaestheticresults.

Thiscasehighlightstheuseofanindividualisedaestheticriskprofiletablebasedonadetailedpreoperativeanalysis.Thedegreeofaestheticriskwasdeterminedallowingtheclinicianandthepatienttodevelopreasonabletreatmentexpectations.InJanuary2007,an18yearoldfemalepatient,anonsmoker,wasreferredforanimplantsolutiontoreplaceherrecentlylostupperleftcaninetooth.

The history included a sporting accident threemonthsearlier,wherethetoothsufferedavulsion.

Unfortunatelythetoothcouldnotbefoundandre-implantation was not possible. Additionally,pulpnecrosisensued in theadjacentupper leftlateralincisorandherdentistprovidedrootcanaltherapyforthistooth.

As an interim measure, she was also providedwith a single toothed partial denture and herdentist subsequently discussed the long termoptionsfortoothreplacement.Boththepatientandherdentistdecidedthatsingletoothimplanttherapy was the best therapeutic approachas it represented the least invasive treatmentmodality(preservedhardtissueatadjacentteeth)whilst providing an approach that was highlypredictable.

Her medical history was without significantfindings and the patient was in good generalhealth.

At the time of examination, the site had fullyhealed although a soft tissue induration onthecrestalandbuccalbordersof theridgewas

CPD QuestionsThere are a set of seven questions relating to the article. The group of questions is equivalent to three hours of verifiable CPD if answered satisfactorily.

To get your CPD certificate:

1. Answer the questions on this form and fill in your details.

2. TAKE A PHOTOCOPY - then simply send your questionnaire booklet to:

ITI Education Centre 3 Pegasus Place Gatwick Road Crawley West Sussex RH10 9AY Fax 01293 651239

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Questions1.Whatisthekeytoachievingpredictablefunctionalandaestheticresultsinimplantdentistry?A:

2.Wherewasthebuccalconcavitynoted?A:

3.Whatwasthepatient’sgingivalphenotype?A:

4.AccordingtoTarnowandco-workerswhatisthemaximumdistancenecessarybetweentheinterproximalbonecrest andthecontactpointofthefutureimplantcrown?A:

5.Howmanyweeksafterimplantplacementwasthesitere-assessed?A:

6.Whataretheadvantagesofplacinganindividualisedimpressioncoping?A:

7.Atthethreeyearfollow-upwasthereachangetothemidfacialgingivalmargin?A:

Robertqualifiedin1987

andhasbuiltalarge

referralbaseforthe

aesthetictreatmentof

complexrestorativecases

involvingprosthodontic,

implantandorthodontic

disciplines.

In2002Robbecameanimplantmentorfor

adentalcorporategroupandhastaught

manydentistsonaone-to-onebasisonall

aspectsofimplanttherapy.

In2006,Robopenedanimplantreferral

centrecalledPentangleDentalTransformations

inNewbury,Berkshire.Thispurposebuilt

practicehasdedicatedimplanttheatres,CT

scanningfacilitiesandlivevideolinksfor

interactiveimplanttraining.

ThePentanglenowattractsover150referring

dentistsandrunsregularin-housemodular

coursesonallsurgicalandrestorativeaspects

ofimplantdentistry.

Roblectureswidely,haspublishedseveral

articlesonimplanttechniques,isamentor

andfacultyeducatorfortheADIandisalso

amentorandlecturerforStraumannUK.

Formoreinformationaboutthisarticleor

theservicesprovidedbyPentangleDental

Tranformations

Phone:01635550353

Email:consulting1@pentangledental.co.uk

Rob Oretti BDS MGDS RCS MFDS RCS MFDS RCPS

Theclinicalsituationbeforetreatment

Theclinicalsituationaftertreatment

CPD 3

CPD Quality Control - This is your opportunity to give feedback on what you think of this verifiable CPD opportunity. Does the CPD live up to the learning objectives stated at the beginning of the article?

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After reading the article did it deliver the educational outcomes you expected?

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Pentangle Dental TranformationsPark StreetNewburyBerkshire RG14 1EATel : 01635 550353

Pentangle Dental TranformationsPark Street

NewburyBerkshire RG14 1EA

Tel : 01635 550353

Case Study: Dental Implants

notedduetoexcesspressure fromthe removable prosthesis. Theneighbouring lateral incisor had asmall palatal composite (followingroot canal therapy) but had notsufferedfurthercollateraldamage.

At full smile, thepatient presentedwith a moderate lip line situation,exposingthemajorityoftheanteriormaxillary teeth and the associatedfacialgingivaltissue.

An obvious buccal concavity wasnoted in the 23 region indicatinga moderate horizontal deficiencywas present. This was noted andwould require correction with anaugmentation procedure at thesame time as implant placementif an aesthetic outcomewas to beachieved.

Thepatient’sgingivalphenotypewasmediumthickandhighlyscalloped.Therealsoappearedtobeanexcess

of soft tissue in the interproximalregions and this was attributedto mild gingival hyperplasia – thepatienthadjustcompletedalengthycourseoffixedorthodontictherapy.However, the band of keratinisedtissuewasrelativelynarrow.

Periodontal probing revealedthat the probing depths both onthe distal aspect of tooth 22 andthe mesial aspect of tooth 24did not exceed 5mm. This wasconfirmed radiographically wherethe interproximal bone-crest levelsof the adjacent teeth were wellmaintained.

According to Tarnow and co-workers (1992), if the distancebetween the interproximal bonecrest and the contact point of thefuture implant crown does notexceed5mm,thencompletepapillainfillistobeexpected.Therisksforthedevelopmentof‘blacktriangles’

–whichwould affect the aestheticoutcome –were considered low inthisparticularcase.

However,thepatient’scrownshapewasmostly triangularwhichwouldincrease the risks for this patient’saestheticprofile.

The above findings led to thefollowingaestheticriskprofilewhichcould be classified asmedium andwasthusassociatedwithamoderateaestheticrisk.

A slightly palatal incision on thecrestwaschosenandafullthicknessmucoperiosteal flap was elevated.A distal relieving incision wasincorporated into the flap designassomeformofaugmentationwasanticipated.Thebonydefectinbotha vertical andhorizontal dimensionwas found to be minimal and aStraumannStandardPlus4.1mmRNSLAx12mmimplantwasplacedin

an ideal three-dimensional positionwithnothreadexposure.

The implant shoulder was placedapproximately 1.5mmapical to theintended future gingival marginin a coronoapical dimension andapproximately 1mm palatal of thepointofemergenceoftheadjacentteeth in the orofacial dimension.Additionally, the implant axis wasangulated through the cingulumof the future crown to ensure thata screw retained restoration waspossible.

As the thickness of the remainingfacial bonewallwas approximately2mmindimension,itwasconsideredunnecessary to perform any hardtissue augmentation procedure.A facial bone wall thickness of2mm or more (following implantplacement) is a well documentedclinical parameter required toprovide long term stability of the

implant/restoration and support fortheoverlyingsofttissue.

Althoughnobonegraftingprocedurewasrequired,afreeconnectivetissuegrafttakenfromthepalatewasusedtoimprovethethicknessandcontourof the facialmucosa–as indicatedby the risk profile. The graft wasplaced on the facial aspect of theimplant site, sutured to the palataltissuesaroundthehealingcap,andthe overlying mucoperiosteal flapmobilised to allow for tension-freeprimary wound closure over theincreasedvolume.

No attempt was made to obtaincomplete soft tissue coverage andtheflapswereapproximatedaroundthehealingcapforsemi-submergedhealing.

Eightweeksafterimplantplacement,the site was re-assessed and dueto a favourable facial profile, nofurther augmentation was deemed

necessary.Excesssofttissuecoveringthehealingcapwasremovedwithascalpelandanimpressionwastakentofabricateaprovisionalcrown.

Thelaboratorymadescrewretainedtemporary crown was under-contoured sub-gingivally on thefacial aspect (with a mild concaveemergenceprofile)toensureminimalpressure on the soft tissues at thisearlystage.Nevertheless,somesofttissueblanchingwasevidentwhichdissipatedwithinfiveminutes.

Over three appointments at twoweekly intervals, the emergenceprofile of the crown was modifiedwith a light curing compositematerial.Eachadditionofcompositeinfluenced the shape and formof the overlying mucosa with animprovement in the tissue outlineandprofile.

Following this staged protocolallows the peri-implant mucosa to

be conditioned in a gentlemannertowards and eventually matchingtheemergence lineandcontourofthemarginalgingivaof thecontra-lateraltooth.

At this time the desired shapeand emergence profile had beenachieved and another impressionwas taken. To capture and transferthis soft tissue information to thetechnician as precisely as possible,an individualised impression capprocedure was performed whichcopied the temporary crown’scervicalportion.

Index of the temporary crownand modification of a ‘standard’impression coping with flowablecomposite - to replicate the exactshape of the temporary crown’semergenceprofile.

The placement of an individualisedimpressioncopingnotonlypreventsthe peri-implant mucosa from

collapsing inwards (followingremovalofthetemporarycrown)butcaptures the conditioned shape ofthesofttissuesinaprecisemanner.

Theresultwasanewdefinitivemastermodel that fully communicates thediagnosticfindingsandpastclinicalprocedures to the technician andultimatelyareplicationofthecervicalportionofthetemporarycrown.

The final treatment outcome witha screw retained ceramo-metalcrownwaspleasing for thepatientand integrated harmoniously withthenaturaldentition.Theperiapicalradiograph demonstrated stableperi-implantbonecrestlevels.

Thethreeyearfollow-upbelowdemonstratesexcellentstabilityofaestheticperi-implantsofttissues.Thefacialmucosamaintaineditsconvexcontourandtheheightofthemidfacialgingivalmarginremainedunchanged.

Thepatientssmile Theclinicalsituation Intactneighbouringteeth Theedentuloussitepresentswithgoodhardandsofttissuearchitecture

The Patient had high aesthetic expectations.Toothexposureduringsmilingwasmoderate

‘Medium’gingivalphenotype TriangularshapedteethXrayofsite

Idealthreedimensionalimplantpositioning Idealthreedimensionalimplantpositioning

Connective tissue graft required to correct thesofttissuedeficiency

Connective tissue graft required to correct thesofttissuedeficiency

AestheticRiskfactors/MedicalStatusChart Connective tissue graft required to correct thesofttissuedeficiency

The healed site demonstrates adequate softtissuevolume

The healed site demonstrates adequate softtissuevolume

Soft tissue contouring created with stagedamendmentstotheprovisionalrestoration

Soft tissue contouring created with stagedamendmentstotheprovisionalrestoration

The conditioned mucosa demonstrating anappropriatetissueshapeandprofile

The conditioned mucosa demonstrating anappropriatetissueshapeandprofile

Indexofthetemporarycrownandmodificationofa‘standard’impressioncopingwithflowablecomposite-toreplicatetheexactshapeofthetemporarycrown’semergenceprofile

Capturingtheconditionedshapeofthemucosaandtransferofinformationtothetechnician

Replicationoftheclinicalsituationinthedentallaboratory

Replicationoftheclinicalsituationinthedentallaboratory

Replicationoftheclinicalsituationinthedentallaboratory

Thedefinitivescrewretainedcrown Thedefinitivescrewretainedcrown

Theclinicalsituationatthetwoyearfollowup Theclinicalsituationatthetwoyearfollowup The implant restoration three years afterplacement

The implant restoration three years afterplacement

Capturingtheconditionedshapeofthemucosaandtransferofinformationtothetechnician

Capturingtheconditionedshapeofthemucosaandtransferofinformationtothetechnician

Aesthetic Risk Factors Low Medium High

Medical Status Heathy with intact immune system

Reduced immune system

Smoking Habit Non smoker Light smoker Heavy Smoker

Patient’s Aesthetic Expectations

Low Medium High

Lip Line Low Medium High

Gingival Biotype Low - scalloped, thick

Medium - scalloped, medium- thick

High - scalloped, thin

Shape of tooth crowns Rectangular Triangular

Infection at implant site None Chronic Acute

Bone Level at adjacent teeth

‹ 5mm to contact point

5.5 to 6.5mm to contact point

› 7mm to contact point

Restorative Status of neighbouring teeth

Virgin Restored

Width of edentulous span

1 tooth (› 7mm)1 tooth (› 5.5mm)

1 tooth (‹ 7mm)1 tooth (‹ 5.5mm)

2 teeth or more

Soft-tissue anatomy Intact Defects

Bone anatomy of alveolar crest

Alveolar crest without defects

Horizontal bone defects

Vertical bone defects