Volume 4, No. 3 May/June 2012 The Journal of Implant & Advanced Clinical Dentistry Immediate Maxillary Molar Implants Better Esthetics with Angled Abutments
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The Journal of Implant & Advanced Clinical Dentistry Volume 4, No. 3 • May/June 2012 Table of Contents19 Immediate Implant Considerations for Interradicular Bone in Maxillary Molars: Case Reports Miguel A Iglesia-Puig, Fernando Jimenez Solana, Dan Holtzclaw, Nicholas Toscano35 C linical Protocols for the Simplified Application of Implant Angled Access Abutments Paul Apfel, Neil Meredith The Journal of Implant & Advanced Clinical Dentistry • 5
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The Journal of Implant & Advanced Clinical Dentistry Volume 4, No. 3 • May/June 2012 Table of Contents49 A lveolar Bone Regeneration Using DentoGen® After Bone Loss Surrounding a Dental Implant Dr. M. Chen, Dr. J. Chesnoiu-Matei, Dr. N. Tovar, Dr. S. Mamidwar57 A n Evaluation of the Accuracy of Multiple Implant Impression Techniques: An in Vitro Study Dr. Manesh Lahori, Dr. Lanka Mahesh, Dr. Rahul Nagrath, Shweta Singh The Journal of Implant & Advanced Clinical Dentistry • 7
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The Journal of Implant & Advanced Clinical Dentistry Volume 4, No. 3 • May/June 2012Publisher Copyright © 2012 by SpecOps Media, LLC. All rightsSpecOps Media, LLC reserved under United States and International Copyright Conventions. No part of this journal may be reproducedDesign or transmitted in any form or by any means, electronic orJimmydog Design Group mechanical, including photocopying or any other informationwww.jimmydog.com retrieval system, without prior written permission from the publisher.Production ManagerStephanie Belcher Disclaimer: Reading an article in JIACD does not qualify336-201-7475 the reader to incorporate new techniques or procedures discussed in JIACD into their scope of practice. JIACDCopy Editor readers should exercise judgment according to theirJIACD staff educational training, clinical experience, and professional expertise when attempting new procedures. JIACD, itsDigital Conversion staff, and parent company SpecOps Media, LLC (hereinafterNxtBook Media referred to as JIACD-SOM) assume no responsibility or liability for the actions of its readers.Internet ManagementInfoSwell Media Opinions expressed in JIACD articles and communications are those of the authors and not necessarily those of JIACD-Subscription Information: Annual rates as follows: SOM. JIACD-SOM disclaims any responsibility or liabilityNon-qualified individual: $99(USD) Institutional: $99(USD). for such material and does not guarantee, warrant, norFor more information regarding subscriptions, endorse any product, procedure, or technique discussed incontact [email protected] or 1-888-923-0002. JIACD, its affiliated websites, or affiliated communications. Additionally, JIACD-SOM does not guarantee any claimsAdvertising Policy: All advertisements appearing in the made by manufact-urers of products advertised in JIACD, itsJournal of Implant and Advanced Clinical Dentistry (JIACD) affiliated websites, or affiliated communications.must be approved by the editorial staff which has the rightto reject or request changes to submitted advertisements. Conflicts of Interest: Authors submitting articles to JIACDThe publication of an advertisement in JIACD does not must declare, in writing, any potential conflicts of interest,constitute an endorsement by the publisher. Additionally, monetary or otherwise, that may exist with the article.the publisher does not guarantee or warrant any claims Failure to submit a conflict of interest declaration will resultmade by JIACD advertisers. in suspension of manuscript peer review.For advertising information, please contact: Erratum: Please notify JIACD of article discrepancies [email protected] or 1-888-923-0002 errors by contacting [email protected] Submission: JIACD publishing guidelines JIACD (ISSN 1947-5284) is published on a monthly basiscan be found at http://www.jiacd.com/author-guidelines by SpecOps Media, LLC, Saint James, New York, USA.or by calling 1-888-923-0002. The Journal of Implant & Advanced Clinical Dentistry • 11
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The Journal of Implant & Advanced Clinical DentistryFounder, Co-Editor in Chief Founder, Co-Editor in Chief Dan Holtzclaw, DDS, MS Nicholas Toscano, DDS, MS Editorial Advisory BoardTara Aghaloo, DDS, MD Robert Horowitz, DDS Giulio Rasperini, DDSFaizan Alawi, DDS Michael Huber, DDS Michele Ravenel, DMD, MSMichael Apa, DDS Richard Hughes, DDS Terry Rees, DDSAlan M. Atlas, DMD Mian Iqbal, DMD, MS Laurence Rifkin, DDSCharles Babbush, DMD, MS Tassos Irinakis, DDS, MSc Georgios E. Romanos, DDS, PhDThomas Balshi, DDS James Jacobs, DMD Paul Rosen, DMD, MSBarry Bartee, DDS, MD Ziad N. Jalbout, DDS Joel Rosenlicht, DMDLorin Berland, DDS John Johnson, DDS, MS Larry Rosenthal, DDSPeter Bertrand, DDS Sascha Jovanovic, DDS, MS Steven Roser, DMD, MDMichael Block, DMD John Kois, DMD, MSD Salvatore Ruggiero, DMD, MDChris Bonacci, DDS, MD Jack T Krauser, DMD Henry Salama, DMDHugo Bonilla, DDS, MS Gregori Kurtzman, DDS Maurice Salama, DMDGary F. Bouloux, MD, DDS Burton Langer, DMD Anthony Sclar, DMDRonald Brown, DDS, MS Aldo Leopardi, DDS, MS Frank Setzer, DDSBobby Butler, DDS Edward Lowe, DMD Maurizio Silvestri, DDS, MDDonald Callan, DDS Shannon Mackey Dennis Smiler, DDS, MScDNicholas Caplanis, DMD, MS Miles Madison, DDS Dong-Seok Sohn, DDS, PhDDaniele Cardaropoli, DDS Lanka Mahesh, BDS Muna Soltan, DDSGiuseppe Cardaropoli DDS, PhD Carlo Maiorana, MD, DDS Michael Sonick, DMDJohn Cavallaro, DDS Jay Malmquist, DMD Ahmad Soolari, DMDStepehn Chu, DMD, MSD Louis Mandel, DDS Neil L. Starr, DDSDavid Clark, DDS Michael Martin, DDS, PhD Eric Stoopler, DMDCharles Cobb, DDS, PhD Ziv Mazor, DMD Scott Synnott, DMDSpyridon Condos, DDS Dale Miles, DDS, MS Haim Tal, DMD, PhDSally Cram, DDS Robert Miller, DDS Gregory Tarantola, DDSTomell DeBose, DDS John Minichetti, DMD Dennis Tarnow, DDSMassimo Del Fabbro, PhD Uwe Mohr, MDT Geza Terezhalmy, DDS, MADouglas Deporter, DDS, PhD Dwight Moss, DMD, MS Tiziano Testori, MD, DDSAlex Ehrlich, DDS, MS Peter K. Moy, DMD Michael Tischler, DDSNicolas Elian, DDS Mel Mupparapu, DMD Tolga Tozum, DDS, PhDPaul Fugazzotto, DDS Ross Nash, DDS Leonardo Trombelli, DDS, PhDScott Ganz, DMD Gregory Naylor, DDS Ilser Turkyilmaz, DDS, PhDDavid Garber, DMD Marcel Noujeim, DDS, MS Dean Vafiadis, DDSArun K. Garg, DMD Sammy Noumbissi, DDS, MS Emil Verban, DDSRonald Goldstein, DDS Arthur Novaes, DDS, MS Hom-Lay Wang, DDS, PhDDavid Guichet, DDS Charles Orth, DDS Benjamin O. Watkins, III, DDSKenneth Hamlett, DDS Jacinthe Paquette, DDS Alan Winter, DDSIstvan Hargitai, DDS, MS Adriano Piattelli, MD, DDS Glenn Wolfinger, DDSMichael Herndon, DDS Michael Pikos, DDS Richard K. Yoon, DDS George Priest, DMD The Journal of Implant & Advanced Clinical Dentistry • 13
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Editorial Commentary What is that Smell?“Our product is a Mercedes™ and theirs is a Kia™.” was a line that these highly respected dentists are provided some sales rep dropped on me honorariums or other benefits to lecture about your product?”a few weeks ago in regards to one of their She said that no one was paid to speak aboutcompetitors’ products. In return I replied, “Is that their products which I knew was an outrightso? Could you please back that up with a little falsehood. “I think you may need to go back andscience?” The sales rep got this gleeful look in check your facts.” I said. “I personally know oneher eye and said, “Our product has been around of the guys that speaks about your products and Imuch longer than theirs has and we have many know that he gets paid.” The rep was getting morehighly respected dentists that lecture about our flustered by the minute and said that she wouldproducts!” She reclined in her chair, smiling need to go back and check on that.arrogantly at the answer she just belched forth. “Do you have any actual scientific literatureI had to stifle my laugh at this pitiful response to back up your claims of your product being aand calmly noted, “So, you are saying that yours Mercedes™ and that your competitor is a Kia™?”is better because it has been around longer? So, The sales rep pulled out brochure and began toam I to assume that you think the periodontist open it. “Stop right there.” I said. “Are you seriouslydown the street is better than I am because he going to show me one of your company brochuresis older than me?” The sales rep choked up a bit as your evidence to back up your claims?”and said, “Of course not. I hear you are a very “Look, don’t go around trashing othergood surgeon.” company’s products when you really don’t have“Who told you that?” I asked. “Also, you any way to back up what you say. I know yourjust told me that older meant better. If that is no company is big, old, and spends lots of moneylonger the case, why is your product better?” wining and dining docs. However, that doesI could see the sales rep starting to squirm a bit not make your product better. When you haveas she tried to come up with a response to my something real to show me, come back and I willqueries. Finally, after a brief pause, she noted be ready to listen. Until that time, however, don’t“Your reputation precedes you. I have seen many come around here trying to sell me a line of BS.of your papers in the literature and I know that you I am from Texas and I have smelled plenty of BSspeak a lot. Also, as you may know from being on in my day. In fact, I smell it right now…” The repthe lecture circuit, there are many highly regarded packed up and left, but she did leave a very nicespeakers that lecture on our product.” lunch for the office! ●I could tell that the sales rep was getting abit agitated with me, but I was not going to lether get away with this line of baloney, especiallyif she wanted me to buy her products. “So, youadmit that older does not mean better and nowyou tell me that your product is better because Dan Holtzclaw, DDS, MS Nick Toscano, DDS, MSmany highly respected dentists lecture about Founder, Co-Editor-In-Chief Founder, Co-Editor-In-Chiefyour product. Can you tell me how many of The Journal of Implant & Advanced Clinical Dentistry • 15
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Immediate Implant Considerations for Wilcko et alInterradicular Bone in Maxillary Molars: Case ReportsMiguel A Iglesia-Puig, DDS1 • Fernando Jimenez Solana MD, DDS1 Dan Holtzclaw, DDS, MS2 • Nicholas Toscano, DDS, MS3 AbstractImplant placement into fresh extraction sock- makes the interradicular bone anatomy vary in ets is currently a choice to replace missing each case. In some cases there is enough avail- teeth for anterior and molar sites. In maxillary ability of bone in the interradicular maxillarymolar sites the technique involves numerous chal- ridge to place an immediate implant. This articlelenges related to site-specific anatomic, occlusal, reports on the surgical-prosthetic treatment ofand biomechanical factors. There is a wide vari- patients with immediate implants placed in theability in the anatomy of maxillary molars, which interradicular bone of the maxillary first molars.KEY WORDS: Immediate dental implants, maxillary molars, extraction, case report 1. Private practice, Zaragoza, Spain 2. Private practice, Austin, Texas, USA3. Private practice, New York, New York, USA The Journal of Implant & Advanced Clinical Dentistry • 19
Iglesia-Puig et al Introduction Figure 1: Preoperative radiographic image of the first right upper molar in case one.Implant placement into fresh extraction sock-ets has become increasingly routine. Tra- vary in width and the socket entrances can beditional protocols for placing oral implants, situated at different vertical distances fromespecially in cases of single-tooth replace- the cemento-enamel junction in each root.11ment, have been revised to meet subjective This makes the interradicular bone anatomyand objective requirements for fewer surgi- vary in each case, and it should be individu-cal interventions and shorter implant treatment ally diagnosed in the preoperative study.times.1 Healing and implant integration mayalso benefit from the inherent potential for bone In some cases there is enough availabilityrepair triggered by the extraction process.2 of bone in the interradicular maxillary ridge to place an immediate implant. This article reports Immediate implant placement is cur- on the surgical-prosthetic treatment of patientrently a very popular choice to replace a miss- with an immediate implant placed in the inter-ing single tooth in the esthetic zone of the radicular bone of the maxillary right first molar.mouth,3 and several authors have showedthat success rates can be achieved similar to CASE REPORT 1those obtained by delayed implants placed A 67-year old male patient presented to theinto healed extraction sockets.4,5 In these clinic of author MI-P in Spain with mobility andcases appropriate case selection is important, pain in his first and second right upper molars,because improper case choice is the most sig- with periodontal bone loss and the furcationnificant reason for potential complications.6 was affected in the first molar. After clinical, diagnostic casts and x-ray examination, thera- Neither significant difference in implant peutic planning was performed including extrac-failure has been found between immedi- tion of both molars, but only the first was goingate and delayed implant placement in molarsites.7,8 However, the immediate placementof a single implant in molar regions involvesnumerous challenges related to site-specificanatomic, occlusal, and biomechanical fac-tors.1 The possibility of predictable outcomeswith immediate implantation in maxillary molarsites is additionally compromised becauseof the larger extraction sockets, poor qualityof bone,9 and less bone apical to the socketbecause of the proximity of the maxillary sinus.10 There is a wide variability in the anatomyof maxillary molars, and in particular there iscomplexity in their furcation topography. Theinterradicular bone of the maxillary first molars20 • Vol. 4, No. 3 • May/June 2012
Iglesia-Puig et alFigure 2: Intact interradicular bone preserved after Figure 3: Interradicular bone preparation with a low-atraumatic extraction. speed drilling technique.Figure 4: Checking the three-dimensional position of the Figure 5: Immediate implant placed in interradicularfuture implant. bone.to be replaced, because the second did not formed in a flapless approach, so that the rootshave opposing teeth. The x-ray diagnosis found could be individually extracted atraumaticallyenough bone availability in the interradicular with a periotome. This technique preservedbone of the first right upper molar, so an imme- intact the interradicular bone (Fig. 2), anddiate implant was planned in that tooth (Fig. 1). after extraction this bone was prepared care- fully with a low-speed drilling technique (Fig. Careful sectioning of the tooth was per- The Journal of Implant & Advanced Clinical Dentistry • 21
Iglesia-Puig et alFigure 6: Healing abutment and sutures. Figure 7: After a 3-month osseointegration period.Figure 8: Titanium cast framework laser-welded to a Figure 9: Porcelain fused to metal final restoration.machined abutment. After a 3-month osseointegration period3). When the interradicular bone was prepared the implant was ready to load (Fig. 7), and aand the three-dimensional position of the future titanium cast framework was laser-welded toimplant was checked, (Fig. 4) one rough-sur- a machined abutment (Fig. 8), and then cov-faced acid-etched self-tapping tapered implant ered with ceramic (Fig. 9). Finally a screw-(Osseotite NT; Biomet 3i, Palm Beach Gardens, retained single unit prosthesis was deliveredFL, USA) was placed, according to the treat- and placed on the implant (Figs. 10,11).ment planning with 35N of torque (Figs. 5,6).22 • Vol. 4, No. 3 • May/June 2012
Iglesia-Puig et alFigure 10: Case one final restoration. Occlusal view. Figure 11: Case one final restoration. Buccal view.CASE REPORT 2 performed (Figs. 15-16). After that a 4 x 10 mmA 34-year old female patient presented with a implant (SLA Esthetic Plus; Straumann, Villeret,vertical fracture in her first left upper molar, in Switzerland) was placed, according to the treat-which an endodontic treatment was previously ment planning with 40N of torque (Figs. 17-19).performed 4 years before. After clinical (Fig. 12)and X-ray examination, extraction of the molar After a 2-month osseointegration periodwas planned. The X-ray diagnosis (Fig. 13) the implant was ready to load (Figs. 20-21),showed a long palatal root entering the maxil- and a titanium porcelain fused to metallary sinus, and both buccal roots shorter and crown was delivered and screwed on a Syn-slightly separated, suggesting enough bone Octa (Straumann) abutment (Figs. 22-25).availability in the interradicular ridge of this firstleft upper molar, so an immediate implant was CASE REPORT 3planned for that tooth. Only 2-3mm of bone A 65 year old African American female pre-height was available apical to the buccal roots. sented to the clinic of author DH in Texas with a non-restorable maxillary right first molar due Careful sectioning of the tooth was per- to significant recurrent decay on the palatalformed in a flapless approach, extracting all aspect of the tooth (Figs. 26, 27). The patientthe roots atraumatically with a periotome. This desired a dental implant to be placed imme-allowed preservation of the interradicular bone diately if possible. The patient was a heavy(Fig. 14), which was prepared carefully in a min- smoker (1 pack per day with a 45 year pack his-imally invasive approach with a low-speed drill- tory) and was taking medication for glaucoma.ing technique. In order to achieve better primarystability and with the aim of placing a 10mm Following the administration of local anes-implant, sinus lift elevation with osteotomes was thesia, the tooth was sectioned into three pieces (Fig. 28) so the roots could be individu- The Journal of Implant & Advanced Clinical Dentistry • 23
Iglesia-Puig et alFigure 12: Case two preoperative clinical image of the Figure 13: Case two preoperative radiographic image offirst left upper molar. the first left upper molar.Figure 14: Intact interradicular bone preserved afteratraumatic extraction. Figure 15: Sinus lift elevation with a 2 mm osteotome.24 • Vol. 4, No. 3 • May/June 2012
Iglesia-Puig et al Figure 17: Immediate implant placed in interradicular bone.Figure 16: Sinus lift elevation with a 3 mm osteotome. Figure 18: Radiograph of immediate implant placed in interradicular bone.ally extracted with minimal trauma to the under-lying bone. Inspection of the extraction socketfollowing removal of the roots revealed sep-tal bone of adequate dimensions for immedi-ate implant placement (Fig. 29). A 5x11.5mmrough-surfaced acid-etched self-tapping dentalimplant (MIS, New Jersey, USA) was placedinto the septal bone (Fig. 30). Particulatedbone allograft (Community Tissue Services,Dayton, Ohio, USA) was used to graft theremaining root sockets (Fig. 31). The implantand grafted socket were then covered with anon-resorbable polytetrafluoroethylene (PTFE)barrier (Osteogenics, Lubbock, Texas, USA)and primary closure was not attempted (Fig. The Journal of Implant & Advanced Clinical Dentistry • 25
Iglesia-Puig et alFigure 19: Healing abutment and sutures. Figure 20: After a 2-month osseointegration period.Figure 21: Healing abutment removed after a 2-month Figure 22: Synocta abutment placement.osseointegration period. over the extraction socket demonstrated com-32). The patient admitted to heavy smoking plete keratinization (Fig. 35) and further maturedduring the early healing phase, which was evi- by 3 months (Fig. 36). Second stage surgerydent in stains seen on the PFTE barrier (Fig. demonstrated a significant band of keratinized33). Removal of the PTFE barrier at 21 days tissue around the healing abutment (Fig. 37).revealed immature granulation tissue that com- ISQ measurements taken with an Osstell Unitpletely covered the bone graft (Fig. 34). Six (Osstell, Gothenburg, Sweden) at the secondweeks after the PTFE barrier removal, the tissue26 • Vol. 4, No. 3 • May/June 2012
Iglesia-Puig et alFigure 23: Final restoration X-ray of case two. Figure 25: Case two final restoration. Buccal view.Figure 24: Case two final restoration. Occlusal view. stage surgery revealed values of 74 and 76 and radiographs appeared within normal limits (Fig. 38). At one year after fixture restoration, peri- implant bone levels remained stable (Fig. 39). DISCUSSION A key point in successfully applying the imme- diate implant placement technique is the development of appropriate case selection criteria, with adequate residual ridge archi- tecture for implant placement in a prostheti- cally driven position with sufficient primary stability.2 For maxillary molars, the ideal restor- ative position is in the center of the restora- tion, regarding force distribution and patient’s plaque control.12 It is not advisable to place implants directly into one of the sockets of an upper molar, as the implant would invariably be located in an inappropriate restorative posi- tion.13 In the proposed technique ideal three- dimensional position of the implant is achieved, and initial implant stability is also obtained by positioning the implant in the interradicular The Journal of Implant & Advanced Clinical Dentistry • 27
Iglesia-Puig et alFigure 26: Presurgical radiograph of Case 3, maxillary first Figure 27: Recurrent decay on palatal root of tooth #3molar.Figure 28: Sectioned tooth #3 prior to extraction. Figure 29: Setpal bone at site #3 remains intact following tooth removalbone and beyond the apex of the tooth socket. In the first case presented in this paper, Also adjunctive use of bone-grafting tech- bone grafting was avoided, simplifying surgi- cal technique and improving patient’s postop-niques to correct residual horizontal defects erative comfort. The implant is surrounded byof more than 2 mm between an implant natural bone, allowing the socket to heal with-and the walls of an intact extraction socket out affecting the implant osseointegration.is usually needed in immediate implants.228 • Vol. 4, No. 3 • May/June 2012
Iglesia-Puig et alFigure 30: Placement of dental implant into maxillary Figure 31: Placement of bone allograft.septal bone.Figure 32: Placment of PTFE barrier. No primary closure Figure 33: Initial 10 day follow up visit. Note the heavyattempted. stain on the PTFE barrier to heavy smoking by the patient during the early healing phase. In the second case presented in thispaper, bone grafting with freeze dried bone heavy smoking habit, the PTFE barrier ade-allograft was utilized with a non-resorbable quately protected the surgical site during thePTFE barrier. The PTFE barrier was used early phase of healing, allowing a natural bar-to avoid the need for primary closure of the rier of gingival tissue to form over the boneextraction socket. In spite of the patient’s graft. Upon further healing, this tissue formed a thick band of keratinized tissue. The ISQ The Journal of Implant & Advanced Clinical Dentistry • 29
Iglesia-Puig et alFigure 34: Removal of PTFE barrier at 21 days reveals Figure 35: Tissue keratinization at 6 weeks after surgery.immature granulation tissue covering grafted extractionsite.Figure 36: Continued maturation of keratinized tissue at Figure 37: Note the significant band of keratinized gingivasurgical site 3 months after surgery. surrounding the healing abutment following second stage surgery.values taken at the second stage implantsurgery demonstrate stability of the implant. cially in molars. But sometimes, if correctly diagnosed, a favorable anatomy in the inter- The morphology of the socket at the time radicular bone can be found and taken advan-of extraction may complicate optimal place- tage of placing an immediate implant easily.ment and initial stability of the implant, espe-30 • Vol. 4, No. 3 • May/June 2012
Iglesia-Puig et alFigure 38: Radiograph 4 months after initial surgery. Figure 39: Case three radiograph with final restoration 1 year after placement. CONCLUSION Correspondence:If an appropriate and precise preoperativediagnosis is performed, cases of maxillary Dr. Miguel Iglesia-Puigmolars with enough availability of interradicu- ODONTÓLOGO - Col. 5000621 lar bone can be detected. This allows immedi- Residencial Paraíso 1, esc B, 1ºC / 50008ate implant placement which fulfills all criteria ZARAGOZA, Spainto appropriate function and osseointegration, Tel.: 976 233 448taking advantage of immediate implants. ● www.clinicamaip.net [email protected] Disclosure • Dr. Iglesia reports no conflicts of interest with anything mentioned in this paper. 7. Cafiero C, Annibali S, Gherlone E, et al. Immediate transmucosal implant • Dr. Holtzclaw is a consultant with Community Tissue Services and lectures for placement in molar extraction sites: A 12-month prospective multicenter cohort study. Clin Oral Impl Res 2008; 19: 476-482. MIS Dental Implants. 8. P eñarrocha-Diago M, Carrillo-García C, Boronat-López A, García-Mira B. References Comparative study of wide-diameter implants placed alter dental extraction and 1. Atieh MA, Payne AGT, Duncan WJ, da Silva RK, Cullinan MP. Immediate implants positioned in mature bone for molar replacement. Int J Oral Maxillofac Impl 2008; 23: 497-501. placement or immediate restoration/loading of single implants for molar tooth replacement: A systematic review and meta-anlysis. Int J Oral Maxillofac Impl 9. B ryant SR. The effects of age, jaw, site, and bone condition on oral implant 2010; 25: 401-415. outcomes. Int J Prosthodont 1998; 11: 470-490. 2. Leziy SS, Miller BA. Esthetics in implant therapy: A blueprint for success. In : Cohen, M (ed). Interdisciplinary treatment planning. Principles, design, 10. Block MS, Kent JN. Placement of endosseous implants into tooth extraction implementation. Ed Quintessence Publ Co, Chicago; 2008: 81-122. sites. J Oral Maxillofac Surg 1991; 49: 1269-1276. 3. Wheeler S. Implant complications in the esthetic zone. J Oral Maxillofac Surg 2007; 65(suppl): 93-102. 11. Svardstrom G, Wennström JL. Furcation topography of the maxillary and 4. West JD, Oates TW. Identification of stability changes for immediately placed mandibular first molars. J Clin Periodontol 1998; 15: 271-275. dental implants. Int J Oral Maxillofac Impl 2007; 22: 623-630. 5. Romeo E, Lops D, Rossi A, Storelli S, Rozza R, Chiapasco M. Surgical and 12. Prosper L, Crespi R, Valenti E, Capparé P, Gherlone E. Five-year follow-up of prosthetic management of interproximal region with single-implant restorations: wide-diameter implants placed in fresh molar extraction sockets in the mandible: 1-year prospective study. J Periodontol 2008; 79: 1048-1055. immediate versus delayed loading. Int J Oral Maxillofac Impl 2010; 25: 607-612. 6. Kan JY, Rungchrassaeng K, Lozada J. Immediate implant and provisionalization of maxillary anterior single implants: 1-year prospective study. Int J Oral Maxillofac 13. Chen S, Buser D. Advantages and disadvantages of treatment options for Impl 2003; 18: 31-39. implant placement in post-extraction sites. In: Chen S, Buser D (eds.). ITI treatment guide. Volume 3. Implant placement in post-extraction sites. Treatment options. Quintessence Publ Co. Berlin, 2008: 38-42. The Journal of Implant & Advanced Clinical Dentistry • 31
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Wilcko et alClinical Protocols for the Simplified Application of Implant Angled Access Abutments Paul Apfel, DDS1 • Neil Meredith, BDS, MSc, PhD2 AbstractAngulated dental implant abutments gives the opportunity to optimize the path of are now relatively commonplace insertion of the prosthesis and locate access in the prosthetic reconstruction of screw holes in an aesthetically and occlus-patients requiring implant treatment. They are ally favorable position. This paper reportsmost commonly applied in multiple implant on two clinical cases utilizing a novel jig andscrew retained full arch cases and the abil- abutment system to optimize accuracy inity to alter the alignment of the implant fixture the passive seating of the overall prosthesis.KEY WORDS: Dental implants, abutment, prosthetics, asthetics 1. Private practice, Huntington, USA2. Director of Research, Neoss Ltd, Harrogate, UK and Professor of Prosthodontics, University of Queensland Dental School, Brisbane, Australia. The Journal of Implant & Advanced Clinical Dentistry • 35
Apfel et al INTRODUCTION Figure 1a: 10° Access Abutment with its internal prosthetic housing.Today’s complex dental implant supported res-torations require treatment protocols based on a relatively commonplace in the prosthetic recon-multitude of diagnostic information. Typically this struction of patients requiring implant treat-is collected from clinical examination, radiographs, ment. A number of studies1,2 have reporteddiagnostic casts and jaw relation records. Func- comparable success rates between the use oftional wax-ups, esthetic wax-ups, and computer angulated abutments and standard abutmentsimaging often add supplementary information. in reconstruction. Parameters measured inProvisional and final implant-supported prosthe- these studies included probing depths, gingivalses are typically designed to create a harmonious level, gingival index, mobility and survival andand functional occlusion, good phonetics, effec- no significant differences were found in param-tive oral hygiene and a pleasing esthetic outcome. eters or survival between the use of standard and angled abutments. Angled abutments are Critical to our ability to successfully fab- probably most appropriately applied in multiplericate a complex implant supported esthetic implant screw retained full arch cases. Theprosthesis is the surgical precision in the place- ability to alter the alignment of the implant fix-ment of dental implants as they relate to the ture gives the opportunity to optimize the pathfinal prosthesis. Unfortunately, in even with our of insertion of the prosthesis and locate accessbest attempts to insert implants in anatomical screw holes in an aesthetically and occlus-positions which would permit laboratory fab- ally favorable position. One of the challengesrication of the proposed restoration accord- of working with angled abutments however,ing to an “ideal” functional and esthetic design, is the appropriate orientation and placementit is often necessary to accept compromisesto avoid adjacent or nearby anatomical struc-tures. Examples include insufficient bone vol-ume, proximity of the mental foramen or inferiordental canal or location of the maxillary sinus. As a result, this “less-than-favorable” implantinsertion position can initiate compromises inthe design of the final restoration with respect tothe desired esthetic final tooth positions as wellas the occlusal scheme. Screw retained pros-theses are especially vulnerable to undesirableimplant angulations since the acrylic or ceramicmaterials may be placed at increased risk of frac-ture. A screw access hole at a cusp tip or onthe facial surface and incisal edge creates diffi-culty in achieving an aesthetic or functional result. Angulated dental implant abutments are now36 • Vol. 4, No. 3 • May/June 2012
Apfel et alFigure 1b: 10° Access Abutment with its internal Figure 1c: Access Abutment fully seated into the Neossprosthetic housing. dental implant.of all abutments at the time when the prosthe- reported that significant angulation of implantssis is seated and fitted. Coward & Watson3 may cause strain and distortion of impressionssuggested a simple laboratory made acrylic related to their wider divergence on impressionguide to aid seating and accurate recording removal. It is therefore very important to haveof an impression. Dixon & Breeding4 went on a standardized technique which minimizes theto describe a surgical guide to assist fabrica- introduction of such possible errors. This papertion and placement. It would seem that trans- reports on two clinical cases utilizing a novelfer indexes are useful in accurately transferring jig and abutment system to optimize accuracythe ideal position of several abutments from in the passive seating of the overall prosthesis.the master cast to the mouth in a predictableway. Nicholson5 describes such a method for The Neoss Access Abutment (Neoss Lim-17º angulated abutments. Such abutments ited, Harrogate, UK) offers a low profile, highhave now been refined in design and offer a precision internal implant connection with 0, 10,range of angulations (10º, 20º and 30º) and are 20 and 30 degree angulations, and fits Neossmore compact needing less occlusal clearance implant diameters of 3.5-5.5mm. Figures 1a & b(5mm) and have larger retention screws (Neoss show a 10° Access Abutment with its internalAccess Abutment, Harrogate, UK). Sorrentino prosthetic housing. Figure 1c shows the angledet al.6 has discussed the dimensional accuracy abutment fully seated into the Neoss dentalof implant impressions in relation to the affect implant. A plastic carrier was used to trans-of implant angulation, length and material and fer the Access Abutment to the implant, with the driver engaged into the prosthetic screw. The Journal of Implant & Advanced Clinical Dentistry • 37
Apfel et al CASE REPORTS Figure 2: Implant fixtures six months post placement.Case 1 After the healing period of approxi-An 82 year old male presented with a chief mately six months (Fig. 2), a closed traycomplaint of missing most of his upper and full arch impression (Express™ STD, 3Mlower teeth, and an inability to chew most ESPE, Seefeld-Germany) was taken usingof his foods. His past medical history was Neoss impression copings. The master castsignificant for a hip replacement and he was then verified radiographically with anwas taking Fosamax and Allopurinol. The acrylic splint (GC America Inc., Alsip, IL).patient expressed a desire to have his mouthrestored, and preferred to have fixed prosthe- The preferred restoration of choice wasses supported by dental implants if possible. a screw-retained full arch cast metal frame “hybrid” prosthesis. Critical to the esthetic A complete clinical examination was per- tooth requirements in the anterior region andformed, x-rays and clinical photographs taken, the integrity of the occlusal surface anatomyand impressions recorded for study casts. of the posterior acrylic teeth is the optimalCustom acrylic trays (Orthodontic resin- placement of the screw access holes. A labo-Caulk Dentsply, Milford, DE) were fabricated ratory surveyor analysis of the master implantand on the second visit additional impres- fixture-level cast using a clear vacuform stentsions were taken. A face-bow registration was which was fabricated over a stone cast of therecorded, and wax-occlusion rims were fabri- desired tooth set-up revealed implant angu-cated to mount the master casts on an adjust- lations which would result in screw accessable articulator (Stratos 300, Ivoclar Vivadent). holes positioned too far labially to fulfill the esthetic and functional requirements for this Diagnostic tooth set-ups were performed prosthesis (Fig. 3). Impression screws wereby the dental laboratory (Marotta Dental Stu-dios, Farmingdale, NY), and evaluated in thepatients mouth. Lip line, speech, freewayspace and occlusion were meticulously evalu-ated. The patient subsequently had a CT-scanof his maxilla and mandible to evaluate bonevolume for dental implant placement. The den-tal laboratory subsequently fabricated a pro-visional maxillary complete denture, as well asa provisional mandibular acrylic bridge witha lingual Rexillium frame for immediate pro-visionalization following the extraction of hisremaining teeth and implant insertion. Thispaper focuses on the restoration of his maxil-lary arch, which required implant angulationcorrection at the prosthetic component level.38 • Vol. 4, No. 3 • May/June 2012
Apfel et alFigure 3a: Model with diagnostic matrix and impression Figure 3b: Model with diagnostic matrix and impressioncopings showing implant angulation. copings showing implant angulation.seated into position and they emerge through systems with multiple platform dimensions.the clear vacuform labial to the tooth sur- To further facilitate the seating of multiplefaces revealing excessive labial inclinationsof implants in positions #6, 7, 10, 13 and 14. Access Abutments intra-orally in their cor-Angled Neoss Access Abutments were rect orientations, which were determined bytherefore selected to provide angled correc- the prosthetic dental laboratory, a position-tion of the screw access holes lingually to ing device was fabricated. This is essentially amore favorable anatomical positions accord- verification positioning resin-based splint whiching to the desired prosthetic tooth set-up. rigidly connects each seated Access Abut- ment’s plastic carrier to each other on the mas- Neoss Access angled abutments were uti- ter implant cast. Resin (GC America Inc., Alsip,lized in 10° and 20° angulations. The Access IL) is applied to each plastic Access Abutmentabutments are packaged with a plastic tab “car- carrier, and bridged together as a single verifi-rier” which via a frictional internal seat, is used able positioning component. This permits theto transfer the angled abutment to the master clinician to lift off and carry multiple angledcast and mouth for seating within the implant’s abutments and simultaneously insert them cor-internal connection. Once it is stabilized, the rectly in the mouth (Figs. 4a & b). Figure 4cAccess Abutment screw is tightened and shows the resin positioning device after it is dis-torqued to 30Ncm. Of particular importance engaged from the seated Access Abutments.in the design of the Access Abutment is thesingle platform concept of the Neoss implant Once the Access Abutment positioningsystem. This facilitates a simpler selection of device is transferred to the mouth, and eachmachined components as compared to implant Access Abutment is positioned inside the respective implant internal connection, the The Journal of Implant & Advanced Clinical Dentistry • 39
Apfel et alFigure 4a: Resin transfer jig to permit accurate transport Figure 4b: Resin transfer jig to permit accurate transportand seating of abutments. and seating of abutments.Figure 4c: Resin transfer jig to permit accurate transport Figure 4d: Resin transfer jig to permit accurate transportand seating of abutments. and seating of abutments.screw tightening procedure commences. The gage from its splinted plastic carrier, creatingAccess Abutment is designed to engage the the potential for rotation and thus an incorrectlywalls of the implant’s internal connection and seated position. This is especially significant infully seat only when its screw is completely situations where the Access Abutment seats totightened. If the clinician sequentially attempts a deeper subgingival position, making visualiza-to completely tighten one Access Abutment in tion of its orientation difficult. The proper clini-the positioning device at a time, it may disen- cal protocol therefore is to engage the driver40 • Vol. 4, No. 3 • May/June 2012
Apfel et alFigure 5: Jig seated in mouth. Figure 6: Access abutments in final position.Figure 7: Final framework and prosthesis in position. from its plastic carrier, as they are inserted. The removal process is simply the reverseinto each Access Abutment screw and turnonly approximately 180 degrees at a time for of the insertion sequence. The driver tool iseach angled abutment, repeating sequentially sequentially rotated counter-clockwise 180for each Access Abutment that is connected degrees at a time, for each Access Abut-to the verification positioning device, until each ment that is connected to the resin posi-abutment is completely seated. This will ensure tioning device. This is necessary to ensurethat each angled abutment does not separate that the angled abutments remain attached to their respective plastic carriers when, for example they are removed from the mas- ter implant cast to transfer to the mouth. Neoss Access Abutments were selected by the dental laboratory based on the amount of angled correction necessary. Figure 5 illustrates the resin positioning device with six Access Abutments secured in place in the maxillary arch. Figure 6 shows the Access Abutments in their final positions, which will permit the dental laboratory to fabricate the final prosthesis with all screw access holes correctly positioned. After the Neoss Angled Abutments were fully seated, the screws were torqued accord- The Journal of Implant & Advanced Clinical Dentistry • 41
Apfel et alFigure 8a: Final prosthesis. not separate from the retentive placement tool, each of which is attached to the resin position-Figure 8b: Final prosthesis. ing device. The laboratory will complete the pro- cessing of the screw-retained prosthesis, whiching to the manufacturer’s specifications to will be delivered over the secured Access Abut-30 Ncm. The framework with tooth set-up ments. The final framework screw access holeswas secured into position over the Access are now well positioned on both the occlusalAbutments and passive seating verified and lingual surfaces, thereby permitting maxi-using x-ray confirmation and a Sheffield test. mum esthetics without compromise to the struc- tural integrity of the individual resin teeth (Fig. At this point the framework with tooth set- 7). The final prosthetic screw is subsequentlyup in wax was removed and the laboratory resin torqued to 20 Ncm, and the access holespositioning device repositioned to remove and closed with rolled Teflon (PTFE) white tapereturn the Access Abutments to the master and composite resin. Figure 8 shows the finalcast. Sequential 180 degree counter-clockwise implant supported screw-retained prosthesis.rotation of the torque wrench is again neces-sary to ensure that each angled abutment does Case 2 Case No. 2 is that of an eighty year old female who presented with a chief complaint of miss- ing her maxillary “back teeth”, and an inability to chew foods well (Fig. 9). Her past medical history was significant for controlled hyperten- sion, and well controlled diabetes Type II. The patient went through the same protocol of diag- nostic casts, occlusion rim fabrication for cen- tric jaw relation records, esthetic and functional maxillary arch tooth set-up, and a CT-scan. Since a flange was not required for lip sup- port on this patient, the preferred restoration of choice was a screw-retained full arch porce- lain-fused-to-metal bridge. An acrylic full arch laboratory provisional bridge “shell” with a Rexil- lium lingual frame was fabricated using the trial tooth set-up as a guide. Eight Neoss implants were placed at surgery in tooth positions #3, 4, 5, 6, 11, 12, 13, &14, and a closed- tray fixture-level impression was taken for next42 • Vol. 4, No. 3 • May/June 2012
Apfel et alFigure 9a: Eighty year old female initial presentation. Figure 9b: Eighty year old female initial presentation.Figure 10: Provisional prosthesis occlusal surface. Figure 11: Provisional prosthesis fit surface.day laboratory processing of her provisional fabricated by connecting each Access Abut-acrylic bridge, supported by eight titanium ment’s plastic carrier to an adjacent impres-temporary implant abutments (Fig. 10 & 11). sion coping with resin (GC America Inc., Alsip, IL), after it was fully seated into the stone The dental laboratory determined that cast analog (Fig. 12). This provides a simpleimplants in tooth positions #6 and #14 would and effective means of transferring the Accessrequire angulation corrections to the screw Abutment to the mouth to prevent the possibilityaccess positions for both the provisional and of rotation. Both the impression coping screwfinal prostheses. Therefore, Neoss Access and Access Abutment screws were tightenedAbutments of 20° angulation were selected for approximately 360° at a time, in a sequentialeach position and inserted at the time of provi- manner, thereby allowing the angled abutmentsionalization. Two separate positioning jigs were The Journal of Implant & Advanced Clinical Dentistry • 43
Apfel et alFigure 12: Resin jig to support abutments. Figure 13: Provisional restoration in patient.Figure 14: Implants five months post healing. ments. Figure 13 shows the provisional acrylic restoration in place one week post-surgery.to fully seat within the implant’s internal hous-ing simultaneously as the impression coping After a healing period of 5 months, whenscrew is also fully tightened. This again will the gingival tissues have reached theirprevent separation of Access Abutment from final healthy contours (Fig. 14), an open-the plastic carrier prior to being fully seated. tray full arch impression was taken to cre- ate the master implant cast (Figs. 15 & 16). The laboratory processes the provisional Neoss Access Abutment impression cop-restoration using specific titanium Access pro- ings were used for both seated Access Abut-visional abutments for tooth positions #6 & ments, and implant fixture level impression14, while the other six implants were loaded copings were used for all other implants.with Neoss titanium temporary implant abut- The master implant cast was verified radio- graphically, and then mounted on a Stratus 300 articulator for fabrication of the metal framework. An index of the provisional acrylic bridge was recorded intraorally and posi- tioned on the master cast as a means of evaluating final tooth position and contours (Fig. 17.) Also note that this Figure shows the Neoss Access Abutments seated in the master cast in tooth positions #6 and 14. After try-in and verification of a passive seat of the metal framework (Fig. 18.), the labora- tory completed the porcelain application for final insertion (Fig. 19). The Access Abutment44 • Vol. 4, No. 3 • May/June 2012
Apfel et alFigure 15a: Resin impression jig. Figure 15b: Resin impression jig.Figure 16a: Impression tray and impression. Figure 16b: Impression tray and impression.Figure 17: Tooth position index from provisional. The Journal of Implant & Advanced Clinical Dentistry • 45
Apfel et alFigure 18a: Metal framework. Figure 18b: Metal framework.Figure 19: Final prosthesis in place. Figure 20: Completed prosthesis.screws were torqued according to the manufac- Conclusionturer to 30ncm and the direct-to-fixture screwswere torqued to 35ncm. The screw access The Neoss Access Abutment is a low pro-holes were subsequently closed with rolled Teflon file component offered in 0°, 10°, 20°, andwhite tape and composite resin. Figure 20 shows 30° of angulation with as little of 4.5 of inter-the completed esthetic screw-retained prosthesis. occlusal space. Its clinical application per- mits a simplified approach for the correction of dental implant angulations which can oth- erwise compromise the esthetic and func- tional results of the final prosthesis. While46 • Vol. 4, No. 3 • May/June 2012
Apfel et alangled abutments are not suited for every Correspondence:situation, especially when superficial implant Dr. Paul Apfelheads co-exist with a high smile lip line ante- 124 Main Streetriorly, they significantly ease the burden of Suite 5relying on ideal implant placement in the pres- Huntington, NY 11743ence of anatomical restrictions, as well as the 631-427-4095need for costly and often bulky sub-frames as Email: [email protected] means of coping with unfavorably locatedaccess holes in screw-retained prostheses. ●Disclosure References 4. D ixon DL, Breeding LC. Surgical guide fabricationNeil Merideth is the Director of Research for Neoss. 1. Balshi TJ, Ekfeldt A, Stenberg T, Vrielinck L. for an angled implant. J Prosthet Dent 1996; 75(5):562-5.Acknowledgements Three-year evaluation of Branemark implantsThe author wishes to thank Marotta Dental Studios, connected to angulated abutments. Int J Oral 5. N icholson L. Transfer index of multiple angulatedFarmingdale, NY, for their expertise in dental implant Maxillofac Implants 1997; 12(1):52-8. abutments in the restoration of an edentulousprosthetic design, as well as for the fabrication of the maxilla. J Prosthet Dent 1997; 78(6):605-8.resin Access Abutment positioning jig. 2. Eger DE, Gunsolley JC, Feldman S. Comparison of angled and standard abutments and their effect 6. Sorrentino R, Gherlone EF, Calesini G, Zarone F.The author also wishes to thank Jeffrey S. Kopman, on clinical outcomes: a preliminary report. Int J Effect of implant angulation, connection length,DDS, Melville, NY, for his surgical expertise in the Oral Maxillofac Implants 2000; 15(6):819-23. and impression material on the dimensionalplacement of dental implants for these patients. accuracy of implant impressions: an in vitro 3. Coward TJ, Watson RM. Locating angulated comparative study. Clin Implant Dent Relat Res abutments: a technical note. Int J Oral Maxillofac 2010; 12(Suppl 1):e63-76. Implants 1997; 12(1):82-3.ATTENTION PROSPECTIVE AUTHORSJIACD wants to publish your article!For complete details regarding publication in JIACD, please refer to our author guidelines at the following link: http://www.jiacd.com/authorinfo/author-guidelines.pdf or email us at: [email protected] The Journal of Implant & Advanced Clinical Dentistry • 47
esthetics enhanced by technology Laser-Lok® dental implant at 8 years post-restoration showing superior crestal bone & tissue maintenance. Case courtesy of Cary A. Shapoff, DDS (Surgical); Jeffrey A. Babushkin, DDS (Restorative)Laser-Lok®microchannelsBioHorizons is known for using science and innovation to create unique implants with proven surgical and esthetic results.Laser-Lok microchannels exemplify our dedication to evidence-based research and development.Laser-Lok microchannels is a proprietary dental implant surface treatment developed from over 20 years of researchinitiated to create the optimal implant surface. Through this research, the unique Laser-Lok surface has been shown toelicit a biologic response that includes the inhibition of epithelial downgrowth and the attachment of connective tissue(unlike Sharpey fibers). This physical attachment produces a biologic seal around the implant that protects and maintainscrestal bone health. Implants with the Laser-Lok technology have been shown in post-market studies to be more effectivethan other implant designs in reducing bone loss.*Laser-Lok is available on Single-stage, Internal, Tapered Internal and Laser-Lok 3.0 implants. For more information, contact BioHorizons Customer Care: 888.246.8338 shop online at www.biohorizons.com* Please see BioHorizons document ML0606 for a complete list of the Laser-Lok studies.SPMP09051 REV G SEP 2010
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