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AestheticRestorationfor Single-ToothImplantsMultidisciplinary Approach

B1Dm4 PoR~DDS

Many practitioners are uncomfort-able about placing single-toothimplants in the anterior area Cortheir patients. The source of hasi-

I tancy is'because of the intricacies of meetingthe demanding requirements of anterior aes-thetics. The surgical procedure Corthe place-ment of the implant followed by the integra-tion of the implant are not the limiting factorsCorsuccess. Instead, the overall aesthetics ofthe case needed to produce an excellent resulthas been limited by the restorative optionsavailable. In addition, other elements of ante-rior design aesthetics involving single-toothreplacement include shade mapping. langtblwidth ratio, golden proportion, incisal edgepoeition, arch Conn, gingival symmetry, lipline, papilla height, contact gradient, emer-gence profile, and occlusal relationships suchas centric. anterior guidance, ovetjet, andoverbite.

Many practitioners are uncomfortable about

placing single-tooth implants in the anterior area

for their patients.

Implant systems have advanced tremen-dously over the past 15 years. There are manyexcellent implant systems available today. Theevolution of these systems has been dictatedby evolution of the demands for final t'eStora-tive aesthetics. In addition, there are bettertechniques for preparation of the implant Bite,with grafI:ing techniques not onJy for bone butalso final gingival contour and papilla man-agement. The bone and soft tissue can be builtto where the final restoration should be.Surgeons are able to place implants very pre-cisely, and thus give the restorative doctor theideal setting to proceed with the final phase oftreatment.

However, implant abutments have beencriticized for not being aesthetic. Traditionalporcelain and metal crowns used to restoresingle-implant abutments have many aesthet-ic limitatione. The optical effects of light with

. porea1ainand metal frequently cause a com-promise in even the most detailed shade map-ping. Also, the passage of light through gingi-val tissue at the margin can cause a darkeningeft'ect, resulting in patient dissatisfaction and

IIIIN'I1STRY1OIIAY' JANU\aY-

FiguIe 3. A new implant insert was placed, andproper seating was confirmed.

~

FiguIe 2. The insert for the implant replacing toothNo. 7 was not sea1lld completely. Also, .. periapi-

clllleslon'MIS suspected on tooth No.7..

FiguIe 6. CervicIII and body shades went matchedwith the IIPIJIOIIriate shIIde tabs/guide.

FiguIe 7. Final restorations on teeth Nos. 7 and 10.

AESTHETICS

case failure even with thebest-placed implant and res-toration. In many casesmatching shades of porcelainand metal crowns to acijacentnatnral teeth is not only diffi-cult but also sometimes im-possible.

The following case studyinvolves all the restorativechallenges deseribed, andinvolves a multidiscip1inaryapproach to treatment in-volving oral surgery, ortho-dontics, endodontics, andanterior restorative princi-ples for aesthetics as taughtat the Las Vegas Instituteand the Pacific AestheticContinuum.

CASE HISTORYA 16-year-old female present-ed with a desire to improveher smile. She felt her smilewas unattractive because ofthe size, shape, and color ofteeth Nos. 7 and 10. She stat-ed that she was unhappywith these teeth to thedegree that she no longersmiled. Porcelain and metalcrowns had been placed onthese teeth the year before,and the results were notacceptable to her.

We conducted a completeclinical and diagnostic evalu-ation which included 3S-mmphotos, diagnostic models,radi0gt'8phs, diagnostic wax-up provisional restorations,smile evaluation forms,shade mapping, and 36-mmphotos with shade tabs. Hermedical history was nega-tive. Periodontally her bonelevel and gingival tissue werein excellent health. Her homecare was also excellent. ToothNo. 7 was a peg lateral andtooth No. 10 was congenitallymissing, and an implant hadbeen placed the previousyear. She had finished ortho-dontics, and porcelain-metalcrowns were placed on teethNos. 7 and 10. Her concernwas the aesthetics of thesecrowns in terms of size,shape, and shade. The porce-lain was bluish-grey com-pared with acijacent teeth.She felt they lacked the con-tour of normal teeth. Thelength/width ratio of toothNo.7 was 97.2'Jiwith a widthof 7 mm and length of 7.2mm. The length/width ratioof tooth No. 10 was 100%with length and width of 7.3mm. Because the length!width ratio of teeth Nos. 8

and 9 was 79% with width of

7.9 nun and length of 10 mm,teeth Nos. 7 and 10 resem-bled small central incisors

(Figure 1). Radiographically,it was noted that the insert

for the implant was not seat-ed completely. Also. a periapi-cal lesion was suspected atthe apex of tooth No.7(Figure 2).

TREATMENT PLANAt the consultation appoint-ment, we again reviewed thepatient's concerns, the etiolo-gy behind these concerns,and the treatment necessaryto achieve ths desired correc-tions and obtain the desired

aesthetic goal. The conditionsto be addressed were:

(1) Correcting the length!width ratio of teeth Nos. 7and 10.

(2) Finding an aU-ceramic

In 11lflny case~, m(Jtt;h:c

i~g lhai!~sof .rpqrcelain and metal"qrQwnf to adjo,e'ent

"natural teeth is not

~n1y dtjficultbutil40

;sometimes...impossible.

I.

restoration that would beappropriate for implants aswall as natnral. teeth, andincorporating aU the aesthet-ic advantages of aU-ceramicversus porcelain-metal.

(3) Idealizing the lineangles and incisal edge con-tours.

(4) Forming the correctemergence profile, arch form,and axial inclinations, andbaving the curvature of thelower lip follow the curve ofthe incisal edges of the max-illary teeth.

(6) Achieving proper gin-gival symmetry and soft;tis-sue h9ight with teeth Nos. 6through 11.

(6) Achieving proper in-terproximal papilla height.

(7) Using shade mappingto harmoniu with acijacantteeth.

(8) Orthodontically redu-cing the mesial-distal dimen-sion of the space for teethNos. 7 and 10.

(9) Replacing the partial-ly seated implant insert fortooth No. 10.

(10) Endodontically treat-ing tooth No.7.

The laboratory we select-ed to fabricate the ideal wax-

up, provisionsl restorations,and final ceramic crowns wasStmrise Dental Laboratory inLas Vegas, Nevada. MikeMilne, the owner, worksclosely with the Las VegasInet;;tnte and is very experi-enced in communicating theelements of smile design. Thefinal wax-up he made simu-lated the finished restora-tions and was used as a tem-plate for provisionals thatwould be worn during ortho-dontic space closure.

TREATMENTDr. David Bojrab of FortWayne, Indiana performedthe surgical placement of theimplant the previous year.Implant placement is criticalfor later aesthetic restora-tions. The mesial-distal posi-tion, apical-coronal position,buccal-lingual position, andangulation determined thisplacement. Also, a 3-mm sul-cus depth is required to pr0-vide the subgingival dimen-sion for the restoration. Thebuccal edge of the implantplatform was about 1 mm lin-gual to the free gingival mar-gin to give adequate tissuesupport. The selection ofimplant diameter was basedon the diameter of the root ofthe tooth at that level. Also,the platform of the implantcompared very closely withthe dimensions of the naturalroot in order to provide pre-dictable scft tissue support.Qsseointegration as wall asthe position of the implantwere excellent.

Dr. Todd Mabry of FortWayne, Indiana performedendodontic therapy on toothNo.7. Tooth No. 7 was a peglateral with a small clinicalcrown and under-developedroot form. The canal spacewas difficult to demonstrateradiOgt'aPhiceJ1y.In addition,there was evidem:e of a peri-apical lesion. Alternatives toendodontics were discussedwith the patient. This includ-ed removing the tooth andlater placing either a fured

bridge or an implant. It wasdecided that preserving nat-ural tooth structnre shouldbe our goal, and that ourtreatment OPtions be as con-servative as possible.

Dr. AxonDellinger of FortWayne, Indiana performedthe orthodontics in the case.The goals that he accom-pljshed finalized the midline,ensured horizontal and verti-cal alignment, placed the rootof tooth No.7 and theimplant for tooth No. 10 cen-trally in the space, andreduced the mesial-distaldimensions for teeth Nos. 7and 10 to 5.9 to 6.1 rom.Afterthese goals were met, retain-ers were made to maintainthe space for the 3 to 4 weeksduring which the finalrestorations were made. Also.retainers were made afterfinal cementation to preventspaces from reopening.

The process offabricatingthe final restorations, whichSunrise Laboratory created,was unique not only inmethod but materials. Theceramic for the crowns wasIPS Empress UvocIar VIV&-dent). Howevm;a vectris cop-ing was made for tooth No.10, opaqued to mask themetal of the implant, andbonded inside the crown.Thecrown and coping were to bedelivered as one piece andcemented with glass ionomercement. Because the provi-sional restorations were to beworn 6 to 8 months, theywere also fabricated at thelab with processed acrylicfor proper size, contour,strength. and marginal fit.

After administration oftopical and local anestheticand placementof a rubberdam. the porcelain and metalcrowns for Nos. 7 and 10were removed using a dia-mond 585O-U16 <BrasselerUSA) and carbide HIJ4.012(Brasseler USA)with copiouswater irrigation. The partial-ly seated insert for theimplant was removed.A newinsert LA3l4 (Paragon) wasplaced, and a film was takento confirm that it fully seatedin the implant (Figure 3).This was contoured to have2.5-mm clearance with theopposing teeth. and torquedinto place using 30Nlcm.

A post preparation wasmade for tooth No. 7 and aLuscent anchor (Dentatus)

was bonded into place withVariolink (Ivoclar Vivadent).The canal space was etchedwith 30% phosphoric acid,washed, and primed withExcite Primer (lvoclarVlVadent). Variolink wasplaced in the canal and theLucite post was light curedfor 1 minute. Heliomolartooth No.7 was cementedwith Temp Bond Clear (Kerr)(Figure 4). The occlusion waschecked in centric and lateraleJtCW'sions,and an appoint-ment to begin orthodonticspace closure was made. Thisorthodontic correction lastedapproximately 8 months, andachieved the desired goals asdeseribed previously. Thefinal restorations for teethNos. 7 and 10 could now be 6mm wide and 8 mm long.

Final shade mapping wasaccomplished with the appro-priate shade tabs and pho-tographed with a 35-mmcamera. The photos weresent to the lab with shadetabs (Chromascop, Ivoc1arVivadent) (Figure 5). Aftertopical and local anesthetic,the provisional restorationswere removed, and the gingi-val tissue arehitecture wasrefined with a diode laser.Upper and lower full-uchimpressions W6!'e takenusing a vinyl polysiloxanelight- and heavy-body im-pression material (Examix,GC America). The cervicaland body shades werematched with the appropri-ate ahade tab guide (Figure6), A stick bite registrationwas recorded with Blu-Moueee fast aet (Parkell), andthe provisional restorationswere replaced. The writtenprescription, maxillary andmandibular fuU-arcb impres-

.sions, shade mapping, pre-operative study models, diag-nostic wax-up. 36-mm photos(full-face. natural smile. andclose-up) were sent toSunrise Laboratory.

The restorations werereturned &om the laboratoryand tried on the dies and~ctory models to evaluatefit and contour. The restora-tions were moistened andchecked against the shadeguide. The patient was anes-thetized, the provisionalsremoved, and the prepara-tions cleaned with the ICBbrush ((]!tradent) to removedebris. The marginal fit andaestheti~ of the restorations

AESTHETICS

were evaluated. The opaquevectris coping for tooth No.10 had V61'Ysuccessfullymasked the implant metal.The teeth were isolated witha rubber dam, and therestoration was cementedwith ProTec Cem (IvoclarVivadent). The crown fortooth No.7 was etched for 1minute with phosphoric acid(Ultratech,Ultradent),rinsed,and dried.Theceramicprimer(RelyX, 3M ESPE) was placedfor 1 minute and air dried.The preparation for tooth No.7 was rinsed with Concepsisfor 30 seconds, etched with30% phosphoric acid for 15seconds, rinsed, and excesswater was removedwith suc-tion, leaving a moist surface.Excite primer (Ivoclar Viva-dent) was applied,dried, andlight cured for 20 seconds.Visual inspection revealed aglossysurface, indicating theformation of the desiredhybrid layer of dentin.Variolink,shade translucent,was placed inside the crown,wbichwas seated, and excesswas removed with BendaBrush (Centrix)and a rubbertip, and spot tacked with acuring light at the cervicalfor 5 seconds. The contactswere cleaned with noss,Deox (Ultradent) was placedaround the margin, and finalcure was done for 4()secondson each side.The rubber damwas removed, and the occlu-sion checked in centric andlateral excursions. Gingivalmargins were finished withthe 134 EF finishing dia-

Dr. RelohWlgO has pracflcedfamily dentistry In Fort Wayne,Ind for 29 years. During the past5 years he has completed post.graduate courses In laser den-tistry, and advanced cosmstic,periodonte!. and rastorative den-tistry through the PacificAesthetic Continuum, the Lasvegas Institute for AdvancedDentel Studies, the J.P.Consultants Institute. and theAcadamy of Leser Dentistry.ProfessIonal membershipsInclude the Academy ofOperative Dentistry, Academy ofLeser Dentistry, American Dente!AssocIation, Indlena Dente.AssocIation, and Isaac KnappDistllct Dental Socie~ He hasserved organized dentistry onboth slate and Iocallevals, endIs past pres1dent of the IsaacKnapp DIstrict.

mond, and final polish waswith Dialite tips (BrasselerUSA) (Figure 7).

CONCWSION

The vitality and aesthetics ofall-ceramic restorations al-low clinicians to successfullycreate a natural appearencein order to harmonize withadjacent teeth. These all-ceram.ic systems also give cli-nicians a wide range of choic-es and treatment opportuni-ties in aesthetic dentistrywhen faced with multidisci-plinary treatment plans. Thisarticle shows a reliable alter-native for using opaque cop-ings to bide the metal ofimplants and to be able totake advantage of the aes.thetics of the all-ceramicrestorations. +