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The Journal of Implant & Advanced Clinical Dentistry

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The Journal of Implant & Advanced Clinical Dentistry • 3

The Journal of Implant & Advanced Clinical DentistryVolume 5, No. 9 • September 2013

Table of Contents

Advancing the science of dental implant treatmentThe aim at Neoss has always been to provide an implant solution for dental professionals enabling treatment in the most safe, reliable and successful manner for their patients.

The Neoss Esthetiline Solution is the first to provide seamless restorative integration all the way through from implant placement to final crown restoration. The natural profile developed during healing is matched perfectly in permanent restorative components; Titanium and Zirconia prepapble abutments, custom abutments and copings and CAD-CAM solutions.

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Esthetiline- the complete anatomicalrestorative solution

11 Multidisciplinary Approach to Maxillary Anterior Dental Implant Therapy: A Case Report Sherman Lin

17 Advanced Surgical and Restorative Therapies Aimed at Rehabilitation of a Severe Dentoalveolar Defect in the Esthetic Zone Barry P. Levin, Sergio Rubinstein, Hal Rosenthaler, Toshi Fujiki, Peter Tawil



Table of Contents

29 Management of Soft Tissue with an Emergence Profile Pontic Design for Maxillary Implant-Supported Restorations Yvan Fortin, Burton Langer, Richard M. Sullivan

45 Subperiosteal Twin Implant Maxillary Tuberosity-Bound to Increase Stability Antonio T. Di Giulio, Giancarlo Di Giulio, Enrico Gallucci

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IntroducIng

Less pain for your patients.1

Less chair side time for you.1

Mucograft® is a pure and highly biocompatible porcine collagen matrix. The spongious nature of Mucograft® favors early vascularization and integration of the soft tissues. It degrades naturally, without device related inflammation for optimal soft tissue regeneration. Mucograft® collagen matrix provides many clinical benefits:

For your patients...

Patients treated with Mucograft® require 5x less Ibuprofen than

those treated with a connective tissue graft1

Patients treated with Mucograft® are equally satisfied with esthetic outcomes when compared to connective tissue grafts2

For you...

Surgical procedures with Mucograft® are 16 minutes shorter in duration on average when compared to those involving connective tissue grafts1

Mucograft® is an effective alternative to autologous grafts3, is ready to use and does not require several minutes of washing prior to surgery

For full prescribing information, please visit us online at www.osteohealth.com or call 1-800-874-2334

References: 1Sanz M, et. al., J Clin Periodontol 2009; 36: 868-876. 2McGuire MK, Scheyer ET, J Periodontol 2010; 81: 1108-1117. 3Herford AS., et. al., J Oral Maxillofac Surg 2010; 68: 1463-1470. Mucograft® is a registered trademark of Ed. Geistlich Söhne Ag Fur Chemische Industrie and are marketed under license by Osteohealth, a Division of Luitpold Pharmaceuticals, Inc. ©2010 Luitpold Pharmaceuticals, Inc. OHD240 Iss. 10/2010

Mucograft® is indicated for guided tissue regeneration procedures in periodontal and recession defects, alveolar ridge reconstruction for prosthetic treatment, localized ridge augmentation for later implantation and covering of implants placed in immediate or delayed extraction sockets. For full prescribing information, visit www.osteohealth.com

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Tara Aghaloo, DDS, MDFaizan Alawi, DDSMichael Apa, DDSAlan M. Atlas, DMDCharles Babbush, DMD, MSThomas Balshi, DDSBarry Bartee, DDS, MDLorin Berland, DDSPeter Bertrand, DDSMichael Block, DMDChris Bonacci, DDS, MDHugo Bonilla, DDS, MSGary F. Bouloux, MD, DDSRonald Brown, DDS, MSBobby Butler, DDSNicholas Caplanis, DMD, MSDaniele Cardaropoli, DDSGiuseppe Cardaropoli DDS, PhDJohn Cavallaro, DDSJennifer Cha, DMD, MSLeon Chen, DMD, MSStepehn Chu, DMD, MSD David Clark, DDSCharles Cobb, DDS, PhDSpyridon Condos, DDSSally Cram, DDSTomell DeBose, DDSMassimo Del Fabbro, PhDDouglas Deporter, DDS, PhDAlex Ehrlich, DDS, MSNicolas Elian, DDSPaul Fugazzotto, DDSDavid Garber, DMDArun K. Garg, DMDRonald Goldstein, DDSDavid Guichet, DDSKenneth Hamlett, DDSIstvan Hargitai, DDS, MS

Michael Herndon, DDSRobert Horowitz, DDSMichael Huber, DDSRichard Hughes, DDSMiguel Angel Iglesia, DDSMian Iqbal, DMD, MSJames Jacobs, DMDZiad N. Jalbout, DDSJohn Johnson, DDS, MSSascha Jovanovic, DDS, MSJohn Kois, DMD, MSDJack T Krauser, DMDGregori Kurtzman, DDSBurton Langer, DMDAldo Leopardi, DDS, MSEdward Lowe, DMDMiles Madison, DDSLanka Mahesh, BDSCarlo Maiorana, MD, DDSJay Malmquist, DMDLouis Mandel, DDSMichael Martin, DDS, PhDZiv Mazor, DMDDale Miles, DDS, MSRobert Miller, DDSJohn Minichetti, DMDUwe Mohr, MDTDwight Moss, DMD, MSPeter K. Moy, DMDMel Mupparapu, DMDRoss Nash, DDSGregory Naylor, DDSMarcel Noujeim, DDS, MSSammy Noumbissi, DDS, MSCharles Orth, DDSAdriano Piattelli, MD, DDSMichael Pikos, DDSGeorge Priest, DMDGiulio Rasperini, DDS

Michele Ravenel, DMD, MSTerry Rees, DDSLaurence Rifkin, DDSGeorgios E. Romanos, DDS, PhDPaul Rosen, DMD, MSJoel Rosenlicht, DMDLarry Rosenthal, DDSSteven Roser, DMD, MDSalvatore Ruggiero, DMD, MDHenry Salama, DMDMaurice Salama, DMDAnthony Sclar, DMDFrank Setzer, DDSMaurizio Silvestri, DDS, MDDennis Smiler, DDS, MScDDong-Seok Sohn, DDS, PhDMuna Soltan, DDSMichael Sonick, DMDAhmad Soolari, DMDNeil L. Starr, DDSEric Stoopler, DMDScott Synnott, DMDHaim Tal, DMD, PhDGregory Tarantola, DDSDennis Tarnow, DDSGeza Terezhalmy, DDS, MATiziano Testori, MD, DDSMichael Tischler, DDSTolga Tozum, DDS, PhDLeonardo Trombelli, DDS, PhDIlser Turkyilmaz, DDS, PhDDean Vafiadis, DDSEmil Verban, DDSHom-Lay Wang, DDS, PhDBenjamin O. Watkins, III, DDSAlan Winter, DDSGlenn Wolfinger, DDSRichard K. Yoon, DDS

Editorial Advisory Board

Founder, Co-Editor in ChiefDan Holtzclaw, DDS, MS

Founder, Co-Editor in ChiefNicholas Toscano, DDS, MS

The Journal of Implant & Advanced Clinical Dentistry

IntroducIng

Less pain for your patients.1

Less chair side time for you.1

Mucograft® is a pure and highly biocompatible porcine collagen matrix. The spongious nature of Mucograft® favors early vascularization and integration of the soft tissues. It degrades naturally, without device related inflammation for optimal soft tissue regeneration. Mucograft® collagen matrix provides many clinical benefits:

For your patients...

Patients treated with Mucograft® require 5x less Ibuprofen than

those treated with a connective tissue graft1

Patients treated with Mucograft® are equally satisfied with esthetic outcomes when compared to connective tissue grafts2

For you...

Surgical procedures with Mucograft® are 16 minutes shorter in duration on average when compared to those involving connective tissue grafts1

Mucograft® is an effective alternative to autologous grafts3, is ready to use and does not require several minutes of washing prior to surgery

For full prescribing information, please visit us online at www.osteohealth.com or call 1-800-874-2334

References: 1Sanz M, et. al., J Clin Periodontol 2009; 36: 868-876. 2McGuire MK, Scheyer ET, J Periodontol 2010; 81: 1108-1117. 3Herford AS., et. al., J Oral Maxillofac Surg 2010; 68: 1463-1470. Mucograft® is a registered trademark of Ed. Geistlich Söhne Ag Fur Chemische Industrie and are marketed under license by Osteohealth, a Division of Luitpold Pharmaceuticals, Inc. ©2010 Luitpold Pharmaceuticals, Inc. OHD240 Iss. 10/2010

Mucograft® is indicated for guided tissue regeneration procedures in periodontal and recession defects, alveolar ridge reconstruction for prosthetic treatment, localized ridge augmentation for later implantation and covering of implants placed in immediate or delayed extraction sockets. For full prescribing information, visit www.osteohealth.com

Ask about our limited time, introductory special!

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Wilcko et al

T he following case report demon-strates a multidisciplinary approach to restore a maxillary anterior den-

tal implant. A combination of restorative and orthodontic treatments were used to prepare the maxillary anterior site for den-

tal implant placement. Following placement of the dental implant, periodontal crown lengthening was performed prior to final prosthetic restoration of the dental implant to achieve a harmonious and esthetic final result that has remained stable for 7 years.

Multidisciplinary Approach to Maxillary Anterior Dental Implant Therapy:

A Case Report

Sherman Lin, DDS1

1. Private practice San Diego, California, USA

Abstract

KEY WORDS: Dental implants, maxilla, prosthetics, orthodontics


12 • Vol. 5, No. 9 • September 2013

Lin

CASE REPORTA 44 year old male in good physical condition was admitted to the clinic for a loose crown on left maxillary central incisor (#9). The patient also wished to have a better alignment and esthetics of his anterior teeth. Clinical and radiographic evalu-ation revealed a fractured tooth that was endodon-ticaly treated many years ago (Fig.1). The tooth was deemed non-restorable without undergoing crown lengthening to expose more tooth structure. In doing so, however, the esthetic result would have been severely compromised. The patient agreed and chose to do other available options. Limited orthodontic therapy to better align the anterior teeth followed by extraction, immediate implantation and temporization of tooth #9 was proposed to the patient. The patient concurred and wished to proceed with the treatment plan.

The crown of tooth #9 was removed, an end-odontic post was placed (Fig.2), and a tempo-rary composite crown was fabricated on top of the post (Fig.3). Orthodontic brackets with a straight arch wire were placed from tooth #6 to tooth #11 to better align the anterior teeth (Fig.4). After 6 months of limited orthodon-tic treatment, the patient was satisfied with the alignment of his anterior teeth (Fig.5). Occlu-sion was checked and remained uneventful. The patient was then prepped for extraction of tooth #9 with immediate implantation. The orthodon-tic wire was removed and tooth number #9 was carefully elevated out of the socket with minimal trauma by using periosteal instruments and piezo-electric unit. No gingival flap was raised. The socket was left well intact, with a slight buccal dehiscence detected. A titanium dental implant fixture (Dentium Company) of 4.3mm body, 4.5 mm platform, and 10mm in length was inserted

into the socket. Excellent primary stability was achieved. The surrounding socket space around the fixture was filled with allograft bone graft mate-rial (Oragraft by Salvin Dental) that consists of 50/50 mixture of cortical and cancellous particles of 250 to 500 microns. A collagen membrane was sutured in place with 5-0 chromic gut resorb-able suture to cover the socket opening and con-tain the graft within. Orthodontic arch wire was placed back on the anterior teeth with a tempo-rary crown attached to the wire on the #9 posi-tion. A radiograph was taken following surgery (Fig.6), and the patient was dismissed with post-operative instructions and antibiotic regiment.

A ten day post-surgical check revealed uneventful healing for the patient. At 5 months after the initial placement of implant, the patient was recalled for restorative procedure of implant #9. The orthodontic archwire was removed and a round tissue punch of 4.5 mm in diameter was used to uncover the implant. A final impression was taken at implant level with a transfer post. Gingival depth was measured, and an appropri-ate shade was selected. The case was sent to a laboratory for fabrication of the final crown. The patient was dismissed with a temporary abut-ment and a composite temporary crown. The orth-odontic arch wire was reattached to the anterior teeth. Ten days later patient was readmitted for final cementation of the crown. A 4.5mm diam-eter dual abutment (Dentium) and gingival height of 2.5mm was screw retained on to the fixture and the final crown was cemented on to the abutment (Fig7). Gingival recontouring of teeth #’s 7, 8, and 10 was accomplished with an electrosurgical unit for more esthetic gingival architecture (Fig.8). All orthodontic apparatus were removed and the teeth were polished. A radiograph was taken for


Lin

evaluation prior to cementing to check the fit. The patient was dismissed with a prefabricated orth-odontic retainer and instructions for care. Patient was scheduled to be checked at every 6 month interval during the hygiene recall visits. A 3year (Fig.9), and a 7 year post- op radiograph and pho-tograph was taken and shown on record (Fig.10, 11). The patient was very pleased with the final treatment result. The recovery phase of implant therapy was uneventful. Radiographic analysis of subsequent years showed well preserved crestal bone level. Dense cortical formation of the crestal bone surrounding the implant was also evident. ●

Figure 1: Pre-surgical radiograph of tooth #9.

Figure 2: Endodontic post insertion on tooth #9.

Figure 3: Temporization of tooth #9 after post insertion.


Lin

Figure 4: Radiograph of orthodontic archwire placement.

Figure 5: Anterior tooth alignment after 6 months of orthodontic treatment.

Figure 6: Radiograph following dental implant and bone allograft placement at site #9.

Figure 7: Radiograph immediately following delivery of abutment and permanent crown.


Lin

Figure 8: Gingivectomy of teeth 7, 8, and 10.

Figure 9: Radiograph at 3 years after treatment.

Figure 10: Radiograph at 7 years after treatment.

Figure 11: Clinical presentation at 7 years after treatment.

DisclosureThe author reports no conflicts of interest with anything mentioned in this article.

Correspondence:Dr. Sherman Lin • 12925 El Camino Real J-28 • San Diego, California, USA 92130 • Tel: 818-995-7971

Wilcko et al

This case report demonstrates 3-dimen-sional restoration of a severely-damaged alveolar ridge. Prior extraction, surgi-

cal trauma and infection resulted in total loss of facial and palatal cortices in an estheti-cally-critical area of the dentition. The com-promised restorative and endodontic status of the adjacent canine precluded a conven-tional fixed bridge. Cytokine-enhanced stimu-

lation of mesenchymal stem cells, combined with a resorbable rigid scaffold reconstructed the alveolar ridge, facilitating implant place-ment. Additional grafting at implant place-ment provided the restorative dentist with two osseointegrated fixtures. The residual soft tissue deficiency was compensated for with ceramics combined with CAD/CAM technol-ogy to provide an esthetic fixed restoration.

Advanced Surgical and Restorative Therapies Aimed at Rehabilitation of a Severe Dentoalveolar

Defect in the Esthetic Zone

Barry P. Levin, DMD1 • Sergio Rubinstein, DDS2 Hal Rosenthaler, DMD, FAGD3 • Toshi Fujiki, RDT4 • Peter Tawil, DDS, MS5

1. Private practice Elkins Park, Pennsylvania, USA; Clinical Associate Professor, University of Pennsylvania; Dept. of Periodontology, Philadelphia, Pennsylvania, USA

2. Private practice Skokie, Illinois, USA

3. Clinical Assistant Professor, University of Pennsylvania, Dept. of Restorative Dentistry, Philadelphia, Pennsylvania, USA

4. Laboratory Director, Oral Rehabilitation Center, P.C., Skokie, Illinois, USA

5. Private practice, Beirut, Lebanon

Abstract

KEY WORDS: Bone graft, growth factors, prosthetics, dental implants



InTRODucTIOnTooth loss will predictably result in 3-dimen-stional loss of hard and soft tissue volume.1,2 Not only does this complicate the place-ment of implants according to the restor-ative treatment plan, but long-term hygienic complications can result from less than ideal fixture-positioning. When possible, many clini-cians choose to place implants either at the time of extraction or shortly thereafter, attempt-ing to minimize these complications.3 The lit-erature contains numerous studies, case series and animal studies supporting this modality.4,5

Often, extraction sockets are augmented to prevent much of this localized atrophy.6,7 When teeth are previously removed, these opportuni-ties for earlier placement are lost, and often favorable hard and soft tissue volume has been lost as well. Reconstructive procedures exist to restore lost bone and soft tissue, pro-viding the surgeon with an opportunity to place implants in restorable positions.8,9 Pro-cedures including autogenous, allogeneic or xenogeneic block grafts, guided bone regen-eration (GBR) with and without particulate bone grafts, rigid meshes and biologic media-tors such as PRP, recombinant proteins, etc have been presented by surgeons.10,11 All of these modalities have the potential to regener-ate alveolar bone capable of osseointegration.

A complication rarely reported in the lit-erature, is what occurs when one of the above-mentioned procedures completely fails, and the resultant defect is more severe than the original one being treated. This case report describes the treatment of a 45 year-old female, who unsuccessfully under-went a regenerative procedure, which

became infected and led to the loss of sig-nificant alveolar bone and an additional tooth.

cASE REPORTA 45 year-old female patient, with a history of smoking, presented to a private periodontal practice after experiencing an unsuccessful ridge-augmentation procedure at a university periodontal clinic. Originally, tooth #7 was surgically extracted and the socket was aug-mented. This procedure was not successful due to soft tissue complications and possibly smoking. She subsequently underwent a sur-gical procedure involving the use of a titanium mesh, combined with a bone allograft hydrated with rhPDGF-BB. Early exposure of the mesh and local site infection resulted in the removal of the mesh and debridement of non-incorpo-rated bone graft materials. This resulted in a significant ridge-defect (Fig. 1). One of the tita-nium fixation tacks was left in place at this time. The patient was provisionalized from tooth #6 through #11 with a fixed restoration. Her gen-eral dentist determined tooth #8 to be non-restorable due to caries. She was referred to

Figure 1: Clinical presentation of initial ridge defect in the maxillary anterior sextent.

Levin et al


a private periodontal office for extraction of the carious central incisor and ridge-augmentation in the #7 and #8 locations. Previous endodon-tic therapy and guarded crown-to-root ratio of #6 was determined to be a questionable dis-tal bridge abutment for a long-span fixed par-tial denture (FPD), and implant therapy was requested by the restorative dentist and patient.

The first surgery was geared towards extrac-tion of the carious root of tooth #8, the removal of the fixation tack left behind by the previous surgeon and bone augmenation. The plan was to combine an osteoconductive, resorbable bone graft of FDBA (Life Net; Virginia Beach) with an osteoinductive graft of rhBMP-2/ACS (Infuse; Medtronic). One of the challenges presented was the lack of facial and palatal bone for vasuclarity and graft containment.

After reflection of a full-thickness mucoperi-osteal flap, tooth #8 was carefully extracted, attempting to preserve the thin walls of the socket, the tack was easily removed and all

loose graft particles were debrided from the defect (Fig. 2). The rhBMP-2/ACS was pre-pared according to the manufacturer’s specifi-cations regarding soak-loading the absorbable collagen sponge (ACS) for at least 15 minutes prior to its application. Strips of various sizes were cut of the sponge and mixed homog-enously as possible with FDBA particles. This composite graft allowed uniform distribu-tion of osteoinductive (rhBMP-2) and osteo-conductive (FDBA) elements throughout the graft. After molding of this cohesive graft into the alveolus of #8 and the #7 defect (Fig. 3) a PLGA resorbable mesh (RapidSorb; Syn-thes) was warmed in a sterile water bath of 70 degrees Celsius and fixed with two resorb-able screws consisting of the same PLGA material (Fig. 4). A connective tissue graft from the palatal flap was utilized to provide crestal coverage of the mesh and a facial periosteal releasing incision was performed to provide nearly-complete closure (Fig. 5).

Figure 2: Following flap-reflection, extraction of the #8 root tip and removal of the retained tack, the loose, non-incorporated DBBM graft particles were debrided until a firm, bleeding osseous surface was identified.

Figure 3: The 2-walled defect in the lateral incisor position, and the extraction socket of tooth #8 was obturated with a composite graft consisting of rhBMP-2/ACS and FDBA.

Levin et al


Approximately four months after bone aug-mentation surgery, a subepithelial connec-tive tissue graft was performed in increase the width and thickness of keratinized mucosa in the anticipated implant-placement sites (Fig. 6). At about 8 weeks following soft tis-

sue augmentation and 6 months after bone grafting, dental implant surgery was per-formed. Prior to surgery, a CBCT revealed sig-nificant hard tissue regeneration in the lateral and central incisor positions (Figs. 7A & 7B).

The regenerated height of the ridge mea-sured between 8mm-9mm (Fig. 8). Facial-palatal width was determined to be adequate for implant placement of 3.0mm and 3.5mm implant diameters for the lateral and central incisors, respectively. The plan was to place the implants to the cortical base of the nasal floor and utilize the fixtures and healing abut-ments as “tent poles” to support the same com-posite bone graft used in the first procedure (Fig. 9). A large portion of the osteoinductive ACS was applied over the graft and 2.0mm tall healing abutments (Fig. 10), then an amnion-chorion membrane (BioXclude; Snoasis) was applied crestally to aid in soft tissue matura-tion (Fig. 11) and the site was closed with monofilament sutures (PTFE; Gore) (Fig. 12).

Figure 4: A resorbable PLGA mesh was thermoplastically-shaped based on a metal template extra-orally. It was then secured apically with two PLGA screws, providing graft-containment and stable 3-dimensional space-maintenance.

Figure 5: The thick palatal mucosa was thinned apically, maintaining blood-supply coronally and sutured to the facial flap, providing primary closure of the grafted site.

Figure 6: Approximately 4 months after hard tissue grafting, a soft tissue graft was secured from the palatal mucosa of the premolar region. This was done to increase the zone of keratinized mucosa and increase mucosal thickness.

Levin et al


After approximately 2 months healing, both healing abutments are partially-exposed. When the healing abutment on the #7 position implant was loosened, there was detectable movement of the implant fixture. The healing abutment was re-tightened. The #8 healing abutment was easily removed and a fixture level impres-

sion was taken. A screw-retained provisional restoration, supported by the single, central incisor implant was indirectly fabricated. An additional healing period of 8 weeks preceded utilization of this implant for fixation of the tem-porary restoration. During this time, a restor-ative post and core and new temporary crown

Figures 7a and 7b: Cross-sectional images of the proposed #7 and #8 implant sites from the CBCT taken approximately 6 months after bone grafting. Planning software is utilized to select implant sizes and positions.

Levin et al


Figure 8: Re-entry demonstrates significant 3-dimensional regeneration of the severe alveolar defect.

Figure 9: Implant insertion prior to additional bone grafting . Implants were purposely not over-seated, to facilitate restorative treatment and avoid hygienic challenges after restoration.

Figure 10: Additional bone grafting, utilizing the same composite graft of rhBMP-2/ACS & FDBA was performed to cover the supra-crestal threads of both implants. Short (2.0mm) healing abutments, rather than cover screws, were utilized to support the overlying flaps and achieve maximum vertical regeneration.

was fabricated to improve retention of a sin-gle-unit provisional crown on tooth #6. The provisional FPD was sectioned between #6 and #7 and the patient presented for implant temporization. A minor mucoplasty around the #8 implant was done to facilitate access to the healing abutment and it’s removal.

Prior to seating the cantilevered pro-visional restoration, the healing abutment on the #7 implant was painlessly removed and re-tightened without any tactile move-ment of the implant or discomfort. The pro-visional restoration, which incorporated pink and tooth-colored composite resin was adjusted and tightened to 15 ncm (Figs. 13-15). The patient was referred back to the restorative dentist to begin definitive restor-ative therapy in the maxillary anterior sextant.

Restorative therapy entailed conventional crown preparation on the natural teeth, com-bined with a transfer impression of the two implant fixtures Fig. 16). A wax-up was per-

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Figure 11: Application of an amnion-chorion membrane over the grafted site.

Figure 12: Closure. Note that primary closure was intentionally not achieved. This was the reason for the application of the amnion chorion membrane.

Figure 13: Four months after implant placement, a screw-retained provisional restoration was placed, supported by the implant in the #8 position. This was done following post and core placement in tooth #6 and fabrication of a single, temporary crown on the canine.

Figure 14: Occlusal view of provisional restoration.

formed of the anticipated restorative outcome (Fig. 17), and computer-assisted abutments (Atlantis; Dentsply) were fabricated for the two implants (Fig. 18). Splinted porce-lain fused-to-metal crowns were created for teeth #9-#11, a single PFM crown was fab-ricated for tooth #6 and splinted, cement-

retained crowns, incorporating pink ceramics were designed for the two implants (Figs. 19, 20A, 20B). A periapical radiograph demon-strated crestal bone present at the level of the implant platforms, suggesting successful regeneration and osseointegration (Fig. 21).

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Figure 15: Facial view of provisional restoration. Figure 16: Maxillary polyvinylsiloxane impression.

Figure 17: Diagnostic wax-up. Anticipated volume of soft tissue necessary to be compensated for with pink ceramics. Symmetrical tooth contours right and left also planned at the waxing stage of treatment.

Figure 18: Two CAD/CAM (Atlantis, Dentsply) abutments were digitally-fabricated and seated on two implant replicas. GC resin copings on the adjacent natural teeth are also fabricated.

DIScuSSIOnSevere ridge defects, whether associated with tooth loss and/or failed surgical procedures, can present unique and difficult challenges for the implant team. Often, a combined surgical and restorative approach accomplishes greater achievement than a single entity. Pertaining to management of extraction sites, most clini-cians prefer either immediate or early implant placement to better position fixture-insertion

prior to the inevitable ridge resorption.12-14 When this is not possible, augmentation of the alveolus can prevent significant bone loss.15-17

The site of tooth #8 was managed with site preservation in this case report. This was the more predictable component of the case pre-sented in this paper. The challenge was regen-erating horizontal and vertical height of viable bone in the lateral incisor location, capable of osseointegration. The lack of osseous walls

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Figure 19: Conventional, PFM crowns are fabricated for the 4 natural teeth in the pre-maxilla. Soft tissue colored ceramics are used on the right canine, as well as the implant-retained restoration to compensate for vertical discrepancies between the right and left sides of the esthetic zone.

Figure 20a: Final restorations in place.

Figure 20b: Patient’s natural lip position at full smile.

capable of graft containment and providing a source for vascularity to an inert bone graft was the primary obstacle to overcome. Therefore, a graft with osteoinductive properties, capable of chemotaxis of mesenchymal stem cells from the defect’s periphery, as well as differentiation was a requirement for success in the author’s opinion. The production of vascular endothelial growth factor (VEGF) from invading cells was also critical for the revascularization of the bone graft an eventual modeling and bone remodel-ing necessary for the regeneration of vital bone in the defect area. BMP-2 has been shown to increase the osteoinductivity of allograft bone in the animal model.18 This material has been successful in the regeneration of bone human extraction sockets, capable of osseointegra-tion with titanium implants.19,20 The only FDA-approved carrier for rhBMP-2 is an absorbable collagen sponge. The manufacturer guidelines

provide the sponge be “soak-loaded” with the reconstituted protein for at least 15 minutes prior to it’s insertion in situ. The claim is that the rhBMP-2 is released from the ACS over an approximately 14 day period. The biggest disadvantage to this delivery method is the near-total lack of space-maintenance of the ACS. Clinicians have reported on incorporat-ing space-providing modalities with rhBMP-2 to compensate for this disadvantage.21-23 The addition of particulate bone grafts increases graft volume, but not necessarily stability in situ.

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A rigid mesh is capable of containing the graft without obstruction of nutrients from the sur-rounding tissues associated with membranes. The authors have combined mineralized allograft bone with rhBMP-2/ACS to add an osteocon-ductive component to the inductive rhBMP-2/ACS graft. For purposes of graft containment and more importantly, space-maintenance, a resorbable mesh was implemented to provide

long-lasting support for the underlying regener-ative process. The virtue of the resorbable mesh is mainly the biodegradation, facilitating less-invasive flap reflection for implant placement since the mesh and fixation screws/tacks do not require removal. A porous PLGA material, simi-lar to that used in this case, was shown to facili-tate bone regeneration in experimental sites in dogs.24 Numerous reports of titanium mesh being used as space-maintenance have been published. The incidence of premature expo-sures and compromised outcomes have also been reported.25 The resorbable mesh utilized in this case report has demonstrated easier management of early mesh exposures compared to titanium scaffolds in the author’s experience.

cOncluSIOnMeeting the patient’s esthetic expectations are at least as challenging as the clinical pro-cedures often faced surgically and prostheti-cally. In order to provide a result the patient will be satisfied with, even when heroic surgi-cal treatment has been accomplished, we must depend on the prosthetic team to make up for any deficiencies surgery did not accomplish. These scenarios could be for example due to the type of defect, loss of adjacent periodontal ligament and existing blood supply, thus result-ing in some instances in different bone height and corresponding soft tissues. Among the prosthetic objectives for the final restoration are: duplication of color, shape, translucency and texture. Even when these previous con-cepts are accomplished, patient’s expectations may still not be met, especially when the result-ing crown will have a long gingival-incisal anat-

Figure 21: Periapical radiograph taken approximately 2 weeks after delivery of the final restorations. Excellent bone regeneration associated with the two implants, #7 in particular, is appreciated.

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omy. Therefore, to overcome this problem, and with the attempt to have a correct proportion between the final restoration and adjacent teeth, pink porcelain or composite is often utilized, thus enabling us to have the appearance of a normal size tooth with the correct proportion as it relates to adjacent teeth and just as impor-tant to be pleasing to the patient’s smile.26-30 ●

correspondence:Dr. Barry P. Levin7848 Old York Rd.Elkins Park, PA 19027(215) 635-0465 phone(215) 635-2751 [email protected]

DisclosureThe author reports no conflicts of interest with anything mentioned in this article.

References1. Reich KM, Huber CD, Lippnig WR, Ulm C,

Watzek G, Tangl S. Atrophy of the residual alveolar ridge following tooth loss in an historical population. Oral Diseases 2011;17:33-44.

2. Atwood DA. Postextraction changes in the adult mandible as illustrated by microradiographs of midsagittal sections and cephalometric roentgenograms. J Prosthet Dent 1963;13:810-824.

3. Paoloantonio M, Doci M, Scarano A, e’Archivio D, di Placido G, Tumini V, Piattelli A. Immediate implantation in fresh extraction sockets. A controlled clinical and histological study in man. J. Periodontol. 2001;72:1560-1571.

4. Botticelli D, Berglundh T, Lindhe L. Hard tissue alterations following immediate implant placement in extraction sites. J Clin Periodontol 2004;31:820-828.

5. Sanz M, Cecchinato D, Ferrus J, Pjetursson EB, Lang NP, Lindhe J. A prospective, randomized-controlled clinical trial to evaluate bone preservation using implants with different geometry placed into extraction sockets in the maxilla. Clin Oral Impl Res. 2010;21:13-21.

6. Araujo MG, Liljenberg B, Lindhe J. B-tricalcium phosphate in the early phase of socket healing: an experimental study in the dog. Clin Oral Impl Res. 2010;21:445-454.

7. Iasella JM, Greenwell H, Miller RL, Hill M, Drisko C, Bohra AA, Scheetz JP. Ridge preservation with freezed-dried bone allograft and a collagen membrane compared to extraction alone for implant site development: A clinical and histologic study in humans. J Periodontol. 2003;74:990-999.

8. Von Arx T, Buser D. Horizontal ridge augmentation using autogenous block grafts and the guided bone regeneration technique with collagen membranes: a clinical study with 42 patients. Clin Oral Impl Res. 2006;17:359-366.

9. Misch CM, Misch CE. The repair of localized severe ridge defects for implant placement using mandibular bone grafts. Implant Dent. 1995;4:261-267.

10. Nevins M, Al Hezaimi K, Schupbach P, Karimbux N, Kim DM. Vertical ridge augmentation using an equine bone and collagen block infused with recombinant human platelet-derived growth factor-BB: A randomized single-masked histologic study in non-human primates. J Periodontol 2012;83:878-884.

11. Bianchini MA, Buttendorf AR, Benfatti CAM, Bez LV, Ferreira CF, de Andrade RF. The use of freeze-dried bone allograft as an alternative to autogenous bone graft in the atrophic maxilla: A 3-year clinical follow-up. Int J Periodontics Restorative Dent 2009;29:643-647.

12. Evans CDJ, Chen ST. Esthetic outcomes of immediate implant placemens. Clin Oral Impl Res 2008;19:73-80

13. Meltzer AM. Immediate implant placement and restoration in infected sites. Int J Periodontics Restorative Dent 2012;32:e169-e173.

14. Levin BP. Immediate temporization of immediate implants in the esthetic zone: Case reports evaluating survival and bone maintenance. Compend Contin. Ed Dent 2011;32:52-62.

15. Barone A, Ricci M, Toneli P, Santini S, Covani U. Tissue changes of extraction sockets in humans: a comparison of spontaneous healing vs. ridge preservation with secondary soft tissue healing. Clin Oral Impl Res 2012;0:1-7.

16. Perelman-Karmon M, Kozlovsky A, Lilov R. Socket site preservation using bovine bone mineral with and without a bioresorbable collagen membrane. Int J Periodontics Restorative Dent 2012;32:459-465.

17. Scheyer ET, Schupbach P, McGuire MK. A histologic and clinical evaluation of ridge-preservation following grafting with demineralized bone matrix, cancellous bone chips, and resorbable extracellular matrix membrane. Int J Periodontics Restorative Dent 2012;32:543-552.

18. Boyan BD, Ranly DM, Schwartz Z. Use of growth factors to modify osteoinductivity of demineralized bone allografts: Lessons for tissue engineering of bone. Dent Clinics N America 2006;50:217-228.

19. Cochran DL, Jones AA, Lilly LC, Fiorellini JP, Howell H. Evaluation of recombinant human bone morphogenetic protein-2 in oral applications including the use of endosseous implants: 3-year results of a pilot study in humans. J Periodontol 2000;71:1241-1257.

20. Fiorellini JP, Howell TH, Cochran D, Malmquist J, Lilly LC, Spagnoli D, Toljanic J, Jones A, Nevins M. Randomized study evaluating recombinant human bone morphogenetic protein-2 for extraction socket augmentation. J Periodontol 2005;76:605-613.

21. Tarnow DP, Wallace SS, Froum SJ, Motroni A, Prasad HS, Testori T. Maxillary sinus augmentation using recombinant bone morphogenetic protein-2/acellular collagen sponge in combination with a mineralized bone replacement graft: A report of three cases. Int J Periodontics Restorative Dent 2010;30:139-149.

22. Misch CM. Bone augmentation of the atrophic posterior mandible for dental implants using rhBMP-2 and titanium mesh: clinical technique and early results. Int J Periodontics Restorative Dent 2011;31:581-589.

23. Levin BP. Horizontal alveolar ridge augmentation: the importance of space maintenance. Compend Contin Ed Dent 2011;32:12-22.

24. Matsumoto G, Hoshino J, Kinoshita Y, Sugita Y, Kubo K, Maeda H, Arimura H, Matsuda S, Ikada S. Evaluation of guided bone regeneration with poly(lactic acid-co-glycolic acid-co-e-caprolactone) porous membrane in lateral bone defects of the canine mandible. Int J Oral Maxillofac Implants 2012;27:587-594.

25. Miyamoto I, Funaki K, Yamauchi K, Kodama T, Takahashi T. Alveolar ridge reconstruction with titanium mesh and autogenous particulate bone graft: Computed tomography-based evaluations of augmented bone quality and quantity. Clin Impl Dent Rel Res 2012;14:304-311.

26. Coachman C, Calamita M. The reconstruction of pink and white esthetics. Int Dent SA, 2010;12(3):88-93.

27. Coachman C, Salama M, Garber DA, Calamita M, Salama H, Cabral G. Prosthetic gingival reconstruction in a fixed partial restoration. Part 1: Introduction to artificial gingival as an alternative therapy. Int. J. Periodontics & Restor. Dent. 2009;29:471-477.

28. Salama M, Coachman C, Garber DA, Calamita M, Salama H, Cabral G. Prosthetic gingival reconstruction in a fixed partial restoration. Part 2: Diagnosis and treatment planning. Int. J. Periodontics & Restor. Dent. 2009;29:573-581.

29. Coachman C, Salama M, Garber DA, Calamita M, Salama H, Cabral G. Prosthetic gingival reconstruction in a fixed partial restoration. Part 3: Laboratory procedures and maintenance. Int. J. Periodontics & Restor. Dent. 2010;30:19-29.

30. Priest GF, Lindke L. Gingival-colored porcelain for implant-supported prostheses in the aesthetic zone. Practical Periodontic & Aesthetic Dentistry 1998;10:1231-1240.

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Wilcko et al

Background: Currently the two most prev-alent pontic designs for anterior esthetics are the modified ridge lap and ovate types. This article describes a new, mildly compres-sive design that follows the contours of the residual osseous ridge crest and displaces more of the soft tissue into the labial, pala-tal, and interproximal areas, better repro-ducing a natural tooth-emergence profile.

Methods: As the actively directed soft tis-sue flows into the proximal areas and circum-ferentially over the pontic line angle borders, a lack of through-and-through access from

labial to palatal results. To avoid disrupt-ing the pontic/soft tissue interface, patients are instructed not to floss. Instead they need only brush the teeth for routine oral hygiene, a regime that most patients can easily maintain.

Results: The authors have documented long-term (up to 15 years) maintenance of the soft-tissue health under Emergence Profile Pontics (EPPs). Conclusion: When sufficient residual soft tis-sue volume is available, this design can be rec-ommended for pontics supported by both natural tooth and implant abutments in esthetic areas.

Management of Soft Tissue with an Emergence Profile Pontic Design for Maxillary

Implant-Supported Restorations

Yvan Fortin, DMD1 • Burton Langer DMD2 • Richard M. Sullivan DDS3

1. Private Practice, Montreal, Quebec

2. Private Practice, New York, New York

3. Vice President, Clinical Technologies, Nobel Biocare Americas

Abstract

KEY WORDS: Dental implants, prosthetics, pontic design, papilla, esthetics, emergence profile



IntRODuCtIOnIn the history of pontic development and tissue management associated with crown-and-bridge rehabilitation, a longstanding objective has been to avoid any compression of the soft tissue that might result in blanching, blood-supply com-promise, and necrosis of the compressed tis-sues. Another concern has been to allow dental hygiene access for periodontal health.1,2 Esthetic results can be challenging to achieve with pontics because tooth extraction often is associated with hard- and soft-tissue site resorption. The reduced residual tissue volume can make it difficult or impossible to reproduce the ideal gingival con-tours associated with the cervical-labial area of the tooth or teeth being replaced.3,4 Even if implant placement has been optimal and the optical properties and other characteristics of the pros-thetic restoration are excellent, if the relationship between the soft-tissue interface relative to both

implant crowns and any intervening pontics is not harmonious, both the esthetic outcome and long-term hygienic maintenance may be compromised.

The types of pontics used in fixed partial dentures have evolved gradually over the years. Early pontic were sanitary, allowing easy access for brushing, but they had little esthetic appeal. Saddle pontics (Figure 1a) that approximated the ridge crest were able to give the illusion of a tooth emerging from the ridge but have largely been abandoned due to the oral hygiene com-promise associated with their design. To meet growing demand for a more esthetic alternative, ridge-lap pontics were developed that extended the cervical margins labially (Figure 1b). This allowed the host tissue to be visible interproxi-mally, resembling a papilla. Although more visu-ally appealing, ridge-lap pontics required the use of floss or other adjunctive measures to thoroughly clean under the bridge. Recently

Figure 1a: Saddle pontics can be esthetic but have largely been abandoned due to the oral hygiene compromises they require. Figure 1b: Ridge-lap pontics require a significant patient commitment to oral hygiene maintenance. Figure 1c: Although ovate pontics initially create the appearance of a true emergence form the pontic site, they do not add to the vertical papillary height. Figure 1d: T he Emergence Profile Pontic design uniformly compresses the tissue, paralleling the residual osseous ridge crest and displacing soft tissue over the pontic line angle borders. In this illustration, the gray areas represent labial and palatal tissue displaced by compression.

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Fortin et al

Kim, Cascione, and Knezevic described using a ridge-lap pontic design that compresses tissue circumferentially with the strategy of displace-ment to develop “pseudo” interdental papillae.5

Ovate pontics represent another attempt to produce natural looking pontic emer-gence.6-13 The tissue-contacting surface of this design is convex relative to the soft tis-sue (Figure 1c), compressing it against the ridge crest. Soft tissue outside the area under compression is displaced away from the pon-tic. Although this creates a true initial emer-gence from the pontic site, it does not add to vertical papilla height. Luc and Patrick Rut-ten have listed primary objectives for the use

of ovate pontics14 that could as well apply to pontics in general. These objectives include:

● Achieving a natural look that is unde-tectable as a dental restoration.

● Creating the most natural emergence profile possible. The bridge pontic should look like it is growing out of the gingiva, with the gingiva and crown(s) in alignment.

● Bridge pontics should not retain pieces of food.The aim of this article is to present an alter-native pontic design that was developed over a 15 year period for maxillary screw-retained dental-implant-supported resto-rations. This design includes not only the

Figure 1e: Animation showing gingival tissue recontouring with the use of an Emergence Profile Pontic.


pontics themselves but also all intervening connections to redistribute the entire three-dimensional soft-tissue volume dynamically and esthetically, without compromising the oral hygiene or causing tissue inflammation.

thE EMERgEnCE PROfIlE POntIC

The Emergence Profile Pontic (EPP) (Fig-ure 1d) was developed to apply pressure in a selective and strategic manner to the underly-ing soft tissue, directing the compressed tis-sue to flow into the surrounding areas in such a way as to reproduce a natural looking tooth-

emergence profile, while maintaining tissue health (Figure 1e) . Achieving this requires a more complex topography than that embod-ied in earlier pontic designs. As Figure 2 illus-trates, the labial-to-palatal (or labial-to-lingual) contours of the pontic body (illustrated by the green lines) are concave in the center and convex as they approach the labial and lin-gual, roughly mirroring the contours of the osseous ridge crest. This shape is intended to compress the soft tissue uniformly against the residual bone crest. Typically the height of the soft tissue between the pontic and the bone crest is reduced by 1.5mm; under no circum-stances should the compression reduce the tissue height by more than half. The compres-sion displaces the soft tissue toward the entire pontic periphery – labial, palatal, and proximal.

The mesial-to-distal contours of the EPP, illustrated by the red lines, are convex through-out the tissue-contacting surface of the pon-tic body. This convexity echoes the facial appearance of a natural tooth as it emerges from the soft tissue (longer in the mid-cervi-cal area and shorter at the interproximal junc-tions). But it differs significantly from the mesial-to-distal convexity of the ridge-lap pon-tic depicted in Figure 1b; that mesial-to-distal convexity only involves the portion of the pon-tic covering the labial aspect of the ridge.

The third important element of the EPP design is the shape of the labial-to-palatal junction between the pontic and the ele-ments adjoining, either other pontics or implant-supported crowns (illustrated by the black lines in Figure 2). Unlike the centrally concave labial-to-palatal pontic body con-

Figure 2: The Emergence Profile Pontic design simultaneously directs tissue from the midcrestal position toward the interproximal, labial, and palatal areas by selective compression of available soft tissue. The labial-palatal contours are concave in the center and convex as they approach the labial and lingual, roughly mirroring the contours of the osseous ridge crest. The plane from mesial to distal (red) is convex throughout the tissue-contacting surface of the pontic body. The proximal connections (black) are convex to effectively direct the flow of the compressed tissue toward the labial and the palatal proximal areas in the shape of a papilla.

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tours, the junctional contour is uniformly con-vex, with the contour peaking in the middle of the connection. This shape creates addi-tional space on the labial and palatal sides of the pontic into which the compressed soft tis-sue can flow, while applying some additional compression to direct the soft- tissue volume to the labial and palatal in the papilla area.

To achieve optimal results, it is helpful to understand the cross-sectional anatomy of the edentulous site receiving an EPP, as well as the dynamics of blood flow as tissue is compressed and redirected. When gingi-val tissue is compressed, it does not simply disappear. Instead, tissues are displaced by the source of compression, gradually adapt-ing to it as long as adequate vasculariza-tion is maintained. Should vascularization be inhibited by compression for too long, varying degrees of tissue necrosis will ensue. In con-trast, when compression is minimal and con-trolled, local circulation and tissue oxygenation

resume, and capillary remodeling occurs, lead-ing to vascular remodeling.15 Depending on the situation, harmonious vascular remodel-ing and reorganization of the tissue mass may require successive phases of compression and relaxation until the pontic is in its final posi-tion, and the tissues are properly vascularized through newly formed shunts.16,17 When this occurs, the color of the compressed tissue will again match that of the surrounding tissue.

The following section describes the steps necessary to create a maxillary screw-retained porcelain-to-zirconia bridge incorporating EPPs.

Clinical Preparation of the PatientIt is recommended that impressions be per-formed only when the soft tissue is stable, whether following delivery of a provisional res-toration or healing abutments. The impres-sion may be made at the implant or abutment level, following the principles for precise-fitting screw-retained implant restorations.

Figure 3a: The restoration framework is designed either virtually or by scanning an acrylic design. The EPP contours are designed with proper emergence to the solid cast.

Figure 3b: After the framework is produced in zirconia, porcelain is added to the tissue-contacting surface. The final contours are refined with a disc.

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The authors’ experience has been limited to open-tray impressions with splinted non-engaging impression copings or non-engag-ing titanium cylinders. The impression is made over the luted cylinders or impres-sion copings and is removed as one unit.

Dental laboratory ProcedureThe first pour of the impression with appro-priate implant or abutment replicas attached is for production of a scanning model to be used in the framework-production process. This is made with impression plaster, follow-ing the manufacturer’s directions. A second pour of the impression with new replicas is then made with the possibility for removable soft tissue to be incorporated into the model for mounting and overall framework design. A third pour of the impression with replicas is then made, with the edentulous areas that will receive the pontics reproduced in solid stone.

The restoration framework is then designed, either virtually on a computer or as a resin pro-

Figure 4a: Porcelain to zirconia implant-level restoration marked to show tissue compression strategy. Green demonstrates pontic concavity, red pontic convexity, and black connection convexity to tissue surface.

Figure 4b: Soft tissue immediately upon removal of porcelain to zirconia restoration adjacent to natural teeth. The bridge has been in place for 3 months and was removed for photographic demonstration purposes only. No oral hygiene other than toothbrush has been used, as access under bridge is impeded by soft tissue. Continued growth of interproximal tissue resembling a papilla can be expected to improve over time.

Figure 4c: Emergence profile pontic design with labial and interproximal displacement of tissue. Compressed depth to half the distance to the residual ridge crest with observant delivery will maintain vitality of the soft tissue and bone while redistributing soft tissue where directed by the pontic contours.

Fortin et al


totype to be scanned (Figure 3a). The soft-tis-sue-contacting areas of the pontics are refined to create optimal emergence profiles from the ridge crest for the intended restorations (which at this point resemble saddle pontics or the underside of denture teeth). The tissue-con-tacting area should roughly follow the curvature of the residual ridge crest, as produced on the solid stone model. The connections of the pon-tics either to other pontics or to the implant- or abutment-retained elements are designed as described above with the convex contour peak-ing in the middle of the connection. The apex of this convex contour should extend as far toward the ridge crest as the emergence-profile contours of the restoration design will allow.

The framework is now ready for fabrication in zirconia. When the completed framework is returned to the laboratory, the patient is sched-uled for try-in. Because there is no compres-sion at this time, the framework should seat fully, with radiographic confirmation. Once full seating has been established, long guide pins are substituted for prosthetic screws. The framework is then picked up in an open tray impression to produce a new cast relat-ing the framework to the soft tissue. This new cast aids in precise addition and contour-ing of porcelain relative to the soft tissue.

The technician then applies the normal esthetic veneering and adds porcelain to the pontic compression areas. In adding the por-celain, it should be kept in mind that tissue will be directed from the area of most compression toward the areas of relief. Although the center of the pontic will compress the most, within that central area, the intention is to uniformly compress the soft tissue against the resis-

tance of the typically convex alveolar crest by paralleling it with the concave pontic surface.

The process then continues with porcelain added in lesser amounts on either side of the central compressive area (similar in concept to the development of “blunted” triangular ridges on maxillary premolar cusps). This introduces both a labial and palatal convexity to the pontic under-side, with both planes sloping toward each other to produce a concavity that continues to paral-lel the ridge. Again, this serves to concentrate the compression in the center of the pontic, with lesser amounts of compression applied to the soft tissue as it is directed toward the proximal con-nections. The simultaneous compression of the sloping pontic interface and the apical convex-ity of the connections redirects tissue toward the relieved open areas, thus forming papillae. Tissue also flows circumferentially over the pontic bor-der, submerging it within a soft tissue cuff. The fact that the soft tissue is moved to now overlap both pontic borders and connections creates a situation in which traditional oral hygiene using an implement is no longer possible because of the lack of direct through-and-through access.

At this point, the framework will no longer seat on the solid cast, so a cast with removable soft tissue must be used for further mounting proce-dures. After firing, the pontic area is contoured with a wheel (Figure 3b) to refine the mesial/dis-tal convexity that will direct the flow of the soft tis-sue toward the entire periphery – interproximally as well as labially and palatally (Figures 4 a-c).

Clinical ProcedureBecause the EPP Pontic is overextended api-cally relative to the current soft-tissue crest, it cannot be expected to seat fully on the first

Fortin et al


Figure 5a: Flat tissue topography before initial placement of a screw-retained porcelain-to- zirconia restoration with EPPs.

Figure 5b: Initially, the bridge cannot be fully seated, with obvious blanching due to the tissue compression. The bridge is loosened to allow blood to repenetrate and then seated again. This process is repeated until full seating on implants occurs.

Figure 5c: Approximately one hour after initial bridge delivery, the bridge has been fully seated with minimal blanching, and the patient can be discharged. Papilla fill will occur over the next several months. The patient will maintain oral hygiene with brushing only.

Figure 5d: Six months later, the EPPs have created a highly natural soft-tissue appearance around the bridge, which has not been removed since the initial delivery.

Figure 5e: Facial view of the soft tissue after removal of the bridge (for photographic purposes only) six months after delivery.

Figure 5f: The occlusal view of the soft tissue six months after delivery of the bridge with EPPs compares strikingly with the appearance of the tissue in Figure 5a.

Fortin et al


attempt. After initial placement of the bridge and gentle fastening against the resistant soft tissue, blanching typically occurs. After 10 min-utes, the bridge is loosened for two to three minutes to allow blood to re-penetrate the com-pressed area. This sequence is then repeated three to four times. The blanching should grad-ually lessen, indicating progressive adaptation of the soft tissue to the pontic, with normal gin-gival color returning by the end of the visit (Fig-ures 5 a-f). In the event of blanching continuing for an extended period (more than an hour), the clinician may choose between three alternatives:

1. Modify the bone underlying the pontic site.2. Modify the underside of the pontic.3. Insert a needle into the blanched area to

stimulate new blood sup-ply through angiogenesis.18-20

To avoid over-compression, the return of blood flow after the blanching process must be observed before the patient is dis-charged.21-23 The patient leaves with instruc-tions that only a toothbrush (manual or electronic) is to be used for oral hygiene. The gingiva will continue adapting to the pontic contours throughout the ensuing year, with tis-sue directed to the labial, palatal, and inter-proximal areas. The authors have documented long-term (up to 15 years) maintenance of the soft-tissue health under EPPs, in the absence of specific hygiene measures directed at this junction (Figures 6a-i, Figures 7 a-d).

DISCuSSIOnTooth extraction in the esthetic zone often leads to a soft-tissue deficit affecting both the labial tissue volume and papillae adjoining any pontic teeth. Given that tissues are displaced by pon-

tics during compression, it is advisable to ori-ent the displacement toward zones that require additional tissue. The design of the EPP described in this article results (Figures 8a, 8b) in relatively significant displacement of tissues directed toward the labial and proximal areas of the pontic crown. To enhance the illusion that these tissues are framing a real tooth that has grown naturally into place, rather than a syn-thetic substitute, it is important that the facial surface of the pontic be oriented along the same axis as the natural tooth being replaced. To accomplish this, a defined line angle is cre-ated between the pontic underside and the labial surface that is less than 90 degrees. An equivalent or very similar angle is created at the junction of the palatal surface to the pon-tic underside. Through clinical and/or empirical observation, it has been found that this angle encourages—or at least does not interfere with—tissue adaptation and restructuring over these line angles of the pontic itself in addition to tis-sue volume directed to the interproximal areas.

The observed response shows that pro-vided the vascularity of residual attached soft tissue is not compromised, the position of the residual tissue will move in response to direc-tion while rapidly developing new blood supply to compensate for the compromise introduced by the compression. Keeping in mind the mor-phology of teeth, ever efficient at reposition-ing food during mastication away from the stamping cusps through sluiceways created by triangular ridges and embrasures, the pon-tic underside similarly nudges the tissue along a similar path. That this repositioning is main-tained is not surprising, since highly scalloped soft tissues underneath pontics have been

Fortin et al


Figures 6a-6c: Ten-year follow-up of Emergence Profile Pontic design. Porcelain-fused-to-gold was previously used before zirconia. The restoration, which was removed for investigative and photographic purposes only, had been in place for 10 years and was maintained with toothbrush only.

observed for decades when fixed partial den-tures supported by teeth have been removed either for replacement or dental extraction. These observations have included many pon-tic sites of high tissue health that have not had a history of routine oral hygiene maintenance. These findings demonstrate that the restorative

undersides of framework pontics and support-ing abutments, at the present and proposed soft-tissue interface, demand as much consid-eration in design and finishing as the occlu-sal surface relative to the opposing dentition.

Multiple adjacent pontics (i.e., side-by-side replacements of two or more missing teeth)

Figure 6d: EPP design with computer graphics superimposes to accentuate the contours, including the interproximal connection concavities (in black).

Figure 6b

Figure 6c

Fortin et al


Figures 6e and 6f: Soft-tissue topography after no oral hygiene measures other than routine tooth brushing.

Figure 6g: Upper left quadrant, photographed before restoration was re-seated.

Figure 6h: Restoration suspended before final seating to show interproximal adaptation of soft tissue.

Figure 6i: Restoration re-seated before screw access-hole closure.

Figure 6f

Fortin et al


Figures 7a-d: Implant restoration with EPPs at 15-year follow-up. Note the appearance of the soft tissue immediately after bridge removal (for photographic purposes only). This restoration had been in place for eight years since the previous removal. No cleaning of the restoration or soft tissue has been performed.

have an additional requirement, namely that the junction zone between the two pontics be designed to permit the formation of a papilla. The complex contours of the EPP’s tissue-contacting surface direct the displaced tissue toward formation of an esthetic papilla at the labial surface. To preserve the newly formed papilla, patients are instructed to use nor-mal brushing methods for oral hygiene and to stimulate the gingival tissue but to avoid pass-ing dental floss underneath the bridge. This regime is also followed at maintenance appoint-

ments with dental hygienists to avoid any dis-ruption of the intimate pontic/gingival interface.

This methodology has allowed predictable reproduction of ideal pontic features accord-ing to the Rutten criteria.14 The EPP initially was used for conventional cemented tooth-sup-ported bridges. However, in that application, it was difficult to verify the three-dimensional condition of the soft tissue beneath the pon-tic over time. Using the EPP in conjunction with dental implants, particularly with screw-retained restorations, facilitates such verifica-

Figure 7a Figure 7b

Figure 7c Figure 7d

Fortin et al


Figures 8a, 8b: Close-up of pontic design. With the residual maxillary ridge providing resistance, the soft tissue is directed over the pontic periphery. This not only gives the appearance of a sulcus, but this tissue repositioning also blocks access for oral hygiene implements.

tion. First, it allows for controlled compression during try-in, enabling a gradual tissue compres-sion and decompression as needed to maintain proper circulation. Second, it enables removal of the bridge at any time after try-in to check the condition of the underlying tissues. The pontic also can be modified by removing and/or adding material as required. This has allowed for more objective validation of the results of using EPPs.

For the past five years, the emphasis has been on porcelain to zirconia restoration with frameworks produced by industrial manufactur-ing. Zirconia frameworks have provided supe-rior fit, and have the added benefit of more simplified porcelain modification or repair. This technique originally began with porcelain-to-gold screw-retained restorations with good results, and the technique described could be modified for these materials. Because of knife-edged ridges and minimal amounts of attached gingiva, evaluation of suitable tech-niques for the lower anterior jaw continues.

It should be noted that use of the EPP can-

not guarantee ideal results in every situation. When restoring patients who have little com-pressible tissue, clinicians have less latitude, and there is greater risk of tissue necrosis. It is thus important to assess whether the tis-sue volume is sufficient to achieve the desired post-compression results. Preparatory work such as a bone contouring, bone augmentation, and/or connective tissue grafts may be advis-able to increase the soft-tissue volume.4,24,25

COnCluSIOnThe use of screw-retained, implant-supported, partial- or full-arch restorations that can be removed for direct observation of soft-tissue response has allowed for verification that active engagement of the residual soft-tissue crest through pontic compression can be ben-eficial. Contour requirements for single and multiple pontic restorations have been identi-fied, and a method to reproduce the critical design elements has been developed. The ability of the Emergence Profile Pontic design

Fortin et al


DisclosureThe authors report no conflicts of interest with anything mentioned in this article.

References1. Becker C, Kaldahl W. Current theories of crown contour, margin placement

and pontic design. J Pros Dent 2005; 93: 112-14, reprinted from J Prosthet Dent 1981; 45: 268-77.

2. Behrend DA. The design of multiple pontics. J Prosthet Dent 1981; 46(6): 634-8.

3. Abrams H, Kopczyk RA, Kaplan AL. Incidence of anterior ridge deformities in partially edentulous patients. J Prosthet Dent 1987; 57(2): 191-94.

4. Studer S, Lehner C, Bucher A, Schärer P. Soft tissue correction of a single-tooth pontic space: a comparative quantitative volume assessment. J Prosthet Dent 2000; 83(4): 402-11.

5. Kim T, Cascione D, Knezevic A. Simulated tissue using a unique pontic design: A clinical report. J Prosthet Dent 2009; 102: 205-10.

6. Nallaswamy D. Textbook of Prosthodontics. New Delhi: Jaypee Brothers Publishers 1996: 510.

7. Spear F. The use of implants and ovate pontics in the esthetic zone. Compendium 2008; 29(2); 72-4, 76-80; quiz 81, 94.

8. Edelhoff D. A review of esthetic pontic design options. Quintessence Int 2002; 33(10): 736-46.

9. Mitrani R, Phillips K, Kois J. An implant-supported, screw-retained, provisional fixed partial denture for pontic site enhancement. Pract Proced Aesthet Dent 2005; 17(10): A-F.

10. Dylina, TJ. Contour determination for ovate pontics. J Prosthetic Dent 1999; 82(2): 136-42.

11. Zitzmann NU, Marinello C, Berglundh T. The ovate pontic design: a histologic observation in humans. J Prosthet Dent 2002; 88(4): 375-80.

12. Al-harbi S. Nonsurgical management of interdental papilla associated with multiple maxillary anterior implants: A clinical report. J Prosthet Dent 2005; 93(3): 212-16.

13. Liu C. Use of a modified ovate pontic in areas of ridge defects: a report of two cases. J Esthet Restor Dent 2004; 16(5): 273-81; discussion 282-3.

14. Rutten L, Rutten P. Crown -- Bridge & Implants -- The Art of Harmony. Fuchstal, Germany: Teamwork Media GmbH; 2006: 230-31.

15. Orsini G, Murmura G, Artese L, Piattelli A, Piccirilli M, Caputi S. Tissue healing under provisional restorations with ovate pontics: a pilot human histological study. J Prosthet Dent 2006; 96(4): 252-7.

16. Kerdvongbundit V. Microcirculation and micromorphology of healthy and inflamed gingivae. Odontology 2003; 91(1): 19-25.

17. Kocabalkan E, Turgut M. Variation in blood flow of supporting tissue during use of mandibular complete dentures with hard acrylic resin base and soft relining: a preliminary study. Int J Prosthodont 2005; 18(3): 210-3.

18. Retzepi M. Comparison of gingival blood flow during healing of simplified papilla preservation and modified Widman flap surgery: a clinical trial using laser Doppler flowmetry. J Clin Periodontol 2007; 34(10): 903-11.

19. Holderfield MT, Hughes CC. Crosstalk between vascular endothelial growth factor, notch, and transforming growth factor-beta in vascular morphogenesis. Circ Res 2008; 102(6): 637-52.

20. Ohno M. Fluid shear stress induces endothelial transforming growth factor beta-1 transcription and production. Modulation by potassium channel blockade. J Clin Invest 1995; 95(3): 1363-9.

21. Patiño-Marín N, Martínez F, Loyola-Rodríguez JP, Tenorio-Govea E, Brito-Orta MD, Rodríguez-Martínez M. A novel procedure for evaluating gingival perfusion status using laser-Doppler flowmetry. J Clin Periodontol 2005; 32(3): 231-7.

22. Bouquot JE. Ischemic osteonecrosis under fixed partial denture pontics: radiographic and microscopic features in 38 patients with chronic pain. J Prosthet Dent 1999; 81(2): 148-58.

23. Kaidar-Person O. Compression anastomosis: history and clinical considerations. Am J Surg 2008; 195(6): 818-26.

24. Calesini G. Edentulous site enhancement: a regenerative approach for the management of edentulous areas. Part 1. Pontic areas. Int J Periodontics Restorative Dent 2008; 28(5): 517-23.

25. Azzi R, Etienne D, Takei H, Fenech P. Surgical thickening of the existing gingiva and reconstruction of interdental papillae around implant-supported restorations Int J Periodontics Restor Dent 2002; 22(1): 71-7.

Fortin et al

to locally reposition soft tissue that remains vital over time has been demonstrated. Ben-efits include increases in labial tissue volume and papilla space soft-tissue fill. At the same time, this design simplifies hygiene mainte-nance, requiring use of a toothbrush only.

The Emergence Profile Pontic design can be recommended for maxillary pontics sup-ported by both natural tooth and implant abut-ments in esthetic areas, with more favorable results being achieved when sufficient residual soft tissue volume is available. Current designs use zirconia frameworks with the apical pontic design computer-milled to precise specifica-tions. Further studies should ideally include histological analysis to determine whether epi-thelial attachment to biomaterials such as zirco-nia and porcelain occurs when those materials are incorporated in EPPs. Optimal designs for lower jaws also await investigation. ●

Correspondence:

Dr. Richard Sullivan

22715 Savi Ranch Parkway

Yorba Linda, California 92887

Phone: 714/282-4820

Fax: 714/998-9236

E-mail: [email protected]

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Wilcko et al

Background: For patients with severe resorbed maxillae who do not want to wear a traditional denture, subperiosteal implants can be an alter-native. In some patients, however, the sever-ity of bone loss in the maxilla precludes even the placement of subperiosteal implants. This report describes a modification of the traditional maxillary subperiosteal implant to provide such patients with a new modified implant referred to as subperiosteal twin implant maxillary tuberosity-bound (subperiosteal twin implant).

Material and methods: All patients who were candidates for subperiosteal twin implant maxillary tuberosity-bound underwent com-puted tomography (CT) scans to reproduce the exact maxilla bone crest in maximum

detail. A stereolithographic model of the max-illa was constructed upon which a subperi-osteal twin implant was then constructed. This was made by two implants, one fitting the palatal part and the other the vestibular part, plus an implant shaped to hold the max-illary tuberosity connected to the abutment of implant body by a metal crown in order to increase the stability of the whole implant.

Conclusion: This implant is considered a further evolution of the subperiosteal den-tal implant and its success, up to now, relies on the opportunity to take advantage of the maxillary tuberosity, so as to become the site of anchorage to confer an additional stabil-ity to the whole body of subperiosteal implant.

Subperiosteal Twin Implant Maxillary Tuberosity-Bound to Increase Stability

Antonio T. Di Giulio1 • Giancarlo Di Giulio1 • Enrico Gallucci2

1. San Babila Day Hospital, via Stoppani 36-Milano, Italy

2. Farmaco-Biologico Department, Università degli Studi di Bari Aldo Moro, Italy

Abstract

KEY WORDS: Subperiosteal dental implant, maxillary tuberosity, stereolithography



Di Giulio et al

IntRODuCtIOnIn daily clinical practice, one often encounters maxillae and /or mandibles with severe atrophy in height and width. The reasons for this are multifactorial, but periodontitis plays an impor-tant role. Although the best advice by clini-cians is stressing the prevention of periodontal disease, we still face ruinous situations due to tooth and bone loss in many patients. Dentures and/or overdentures are not always accepted by patients, and in such cases, implants with fixed prostheses may be the best option. In some patients, however, the morphology of the atrophic bone, the posterior maxilla in particu-lar, poses serious challenges to implant therapy and prothesis rehabilitation. The augmenta-tion of alveolar bone defects in these areas, if possible, is an essential step for successful dental implants. Currently, many possibilities are devoted to this aim including autogenous grafts, allografts, and growth factors such as FC1 ,PRP, cPRP, PRGF, PRF,2 or rhBMP-2.3

Bone and soft tissue grafting have reached a level that can often meet the patients’ and doctors’ best satisfaction. Additionally, the advent of bone allografts has reached a point where, in many cases, autogenous bone graft-ing is no longer required to facilitate the place-ment of dental implants. The use of allografts is often more accepted by patients due to reduced morbidity and the elimination of sec-ondary surgical sites. In some cases, however, bone loss is so extreme that neither allograft nor autogenous grafting techniques can pro-vide enough bone for the placement of dental implants. As this problem still persists in cer-tain patients, the use of subperiosteal dental implants offers a solution for these patients.

The subperiosteal implant has been used since 1940 when Dahl4 first installed it, then Goldberg and Gershkoff,5 and finally Linkow.6 In a previous published paper by DiGuilio et al.,7 long term survival rates of subperiosteal dental implants were reported with good results. In a subsequent paper,8 a modification of the previ-ous implant was described, taking advantage of some characteristics of such as bone undercuts.

This goal of this report is to describe the use of a subperiosteal body implant with an extension shaped as to tie crestal tuberosity, which by connecting the dis-tal abutment of the implant body, firmly locks it, resulting in increased stability.

MAtERIALS AnD MEtHODSSubperiosteal dental implants placed by the authors from 2008 to 2012 examined 120 patients. A total of 65 female patients (mean age of 51.5 ± 11.0 years) and 55 males (mean age of 49.3 ± 12.0 years) were evaluated. All patients treated in this study were com-pletely edentulous and typically presented with severely resorbed maxilla. Furthermore, smok-ers and those suffering from chronic systemic conditions such as diabetes, cardiovascular dis-ease, severe osteoporosis, or those undergo-ing chemo/radiation therapies were excluded. Candidates for subperiosteal implant therapy received panoramic radiographs and computed tomography (CT) scans with 64 multislices (General Electric Co, USA) to reproduce osse-ous structures in maximum detail. Such pre-treatment analysis allowed us to become familiar with the patient’s three-dimensional (3D) bony architecture and critical anatomical struc-tures so as to plan the subperiosteal implant.


Di Giulio et al

This analysis allowed for fabrication of max-illary stereolithographic models used in con-structing custom fabricated subperiosteal dental implants. The exacting detail of the mod-els allowed for fixtures that intimately adapted to the patients’ osseous anatomy before any surgical procedure was ever undertaken. The structure of the maxillary subperiosteal dental implant, constructed of titanium, has a palatal bar connected to the vestibular bars simulat-ing roots of the molars. This can be considered the basic structure at which, as an integra-tion, a subperiosteal implant extension to the crestal tuberosity which is inserted with a cap on the abutment of basic implant, has been added. The advantages of this subperiosteal implant integration abutment are an increase in the surface of contact of the implant struc-ture with the bone and pulling the basic struc-ture so firmly as to block the whole implant.

Initially intravenous dose of midazolam 0.05 mg/kg for sedation and a maintaining dose of 0.03 mg/kg was given every 15 min. At this concentration midazolam does not inhibit cough and breathing reflex. To reduce psycoemotional component during the inter-vention patients were treated with diazepam (initial dose of 5-10 mg and maintenance dose of 2.5mg every 15min). Articaine cloridrate (0.01mg as plexical anaesthesia, Ketorolac (30mg) for management of pain, and desa-metasone (4mg) and ranitidine (30mg) also were used. ECG, arterial pressure and SpO2 were continuously monitored during surgery.

An incision was made on the alveolar crest and mucoperiosteal flaps were elevated to facilitate fixture delivery. Before sutur-ing the gingiva, the implant was covered with hydroxyapatite or demineralized bone allo-graft. Patients underwent panoramic radiog-

Figure 1: Components of the twin implant partially assembled on the stereolithographic model, with exclusion of the two extensions of crestal tuberosity visible on the right.

Figure 2: Components of the twin implant assembled on the stereolithographic model.


Di Giulio et al

raphy. Postsurgical instructions were given to the patients. A 4-month healing period was allowed prior to place prosthetic restorations for full function. The evolution of the treat-ment was evaluated by pulling the implant in all possible directions and additional radio-graphs were taken to identify bone apposi-tion over the implant. Annual check-ups were required to verify the success of the implant. The parameters assessing implant success were based on subjective and objective clini-cal criteria such as: 1) absence of clinically-de-tectable implant mobility; 2) absence of pain; 3) absence of inflammation; 4) comfort of patient; 5) bleeding on probing; 6) pocket-probing depth; 7) absence of foreign body sensation.

RESuLtSFor the 120 patients reviewed in this study during a 3 year period, all maxillary subperi-osteal twin-implants were still in function and the patients were satisfied with their use.

One significant case of a series of twin implants placed is reported. The patient enrolled for maxillary subperiosteal twin-implant pres-ents a severe resorbed maxillary bone. Figure 1 shows the components of the twin-implant, i.e. the vestibular and palatal implants, the metal-lic crown assembled on the lithographic model obtained from a CT data set, excluded the tuberosity implant represented on the right side of the figure. In Figure 2 all the components of the implant are assembled on the lithographic model. After the surgery, panoramic radiograph was performed (Figure 3). After 4 months of healing, prosthetic restoration was delivered.

Figure 3: Postsurgical panoramic radiography.


Di Giulio et al

DISCuSSIOnThis short report is dedicated to a subperios-teal twin-implant tuberosity-bound that can be considered a further evolution of the conven-tional subperiosteal implants used up to now.

The latest implant allows for more stability owing to the possibility to extend and embrace the maxillary tuberosity. This type of implant not only offers a viable alternative treatment option to all the cases that could not be treated either with endosseous implant or subperios-teal traditional model. Moreover, owing to the precise manufacturing of the implant integra-tion, that precisely fits the patient’s osseous tuberosity profile, further ameliorating the sta-bility of the whole implant. So it can be con-sidered a choice for patients whose osseous structure around maxillary sinus bone is subtle.

COnCLuSIOnSIt must be realized that patients with severe resorption of maxillary bone and/or subtle structure around maxillary sinus bone have reduced possibility to wear implant supported prostheses. Sinus augmentation procedures may alleviate the problems of pneumatised sinuses, but many patients refuse this treat-ment option. Additionally, maxillary bone loss is so severe in some cases, that bone augmentation cannot facilitate the place-ment of endosseous dental implants. In such cases, the use of subperiosteal implants may be an alternative solution. This and other studies have demonstrated long term sur-vival of subperiosteal implants. The tech-nique presented in this paper is another step in the evolution of this treatment modality. ●

Correspondence:

Dr. Enrico Gallucci

Dipartimento Farmaco-Biologico

Università degli Studi di Bari Aldo Moro

via E. Orabona 4, 70126 Bari, Italy

Tel/Fax: +39 0805017163

Email: [email protected]

DisclosureThe authors report no conflicts of interest with anything mentioned in this report.

References1. Dohan DM, Choukroun J. How to find your way in the jungle of platelet

concentrates? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 103(3):305-308.

2. Toffler M, Toscano N, Holtzclaw D, Del Corso M, Ehrenfest DD. Introducing Choukroun’s platelet rich fibrin (PRF) to the reconstructive surgery milieu. JIACD 2009, 1(6): 21-31.

3. Urist M. Bone: formation by autoinduction. Science 1965;150:893-899.

4. Dahl G. Dental implant and superplants. Rassegna Trimestrale Odontoiatria 1956; 4: 25-36.

5.Goldberg N, Gershkoff A. Implant lower denture. Dent Dig 1949; 55: 490-494.

6. Linkow L, Wagner J, Chanavaz M. Tripodal mandibular subperiosteal implant: basic sciences, operational procedure, and clinical data. J Oral Implantol 1998; 24:16-36.

7. Di Giulio A.T., Di Giulio G., Gallucci E. Subperiosteal Dental Implants: A 25 Year Retrospective Survival Evaluation. JIACD 2009;1:69-75.

8. Di Giulio A.T., Di Giulio G., Gallucci E. Twin implant: a new subperiosteal dental implant. JIACD 2010;2 (9):63-67.

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