Journal of Implant and Advanced Clinical Dentistry February 2013

Volume 5, No. 2 February 2013 The Journal of Implant & Advanced Clinical Dentistry CAD/CAM Custom Abutments Crestal Core Sinus Elevation

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The Journal of Implant & Advanced Clinical Dentistry Volume 5, No. 2 • February 2013 Table of Contents15 Crestal Core Elevation with Immediate Implant Placement: A New Technique Nabil Beaini, Mabel Salas, Michael Umaki, Charles Cobb21 A Novel Technique of Impression Making of CAD/CAM Custom Abutments When Fabricating Multi-Unit Implant Prostheses Jan K. Pietruski, Malgorzata D. Pietruska, Robert B. Kerstein, Julian Osorio The Journal of Implant & Advanced Clinical Dentistry • 5

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The Journal of Implant & Advanced Clinical Dentistry Volume 5, No. 2 • February 2013 Table of Contents35 P eri-Implant Bone Defect Resolution Following a Free Gingival Graft: A Case Report with Radiographic Follow Up Daniel Gober, Taeheon Kang43 Immediate Implants: Treatment Planning and Surgical Placement Abdulgani Azzaldeen, Abu-Hussein Muhamad, Sarafianou Aspasia The Journal of Implant & Advanced Clinical Dentistry • 7

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The Journal of Implant & Advanced Clinical Dentistry Volume 5, No. 2 • February 2013Publisher Copyright © 2013 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 • [email protected] 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 • 9

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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 Michael Herndon, DDS Michele Ravenel, DMD, MSFaizan Alawi, DDS Robert Horowitz, DDS Terry Rees, DDSMichael Apa, DDS Michael Huber, DDS Laurence Rifkin, DDSAlan M. Atlas, DMD Richard Hughes, DDS Georgios E. Romanos, DDS, PhDCharles Babbush, DMD, MS Miguel Angel Iglesia, DDS Paul Rosen, DMD, MSThomas Balshi, DDS Mian Iqbal, DMD, MS Joel Rosenlicht, DMDBarry Bartee, DDS, MD James Jacobs, DMD Larry Rosenthal, DDSLorin Berland, DDS Ziad N. Jalbout, DDS Steven Roser, DMD, MDPeter Bertrand, DDS John Johnson, DDS, MS Salvatore Ruggiero, DMD, MDMichael Block, DMD Sascha Jovanovic, DDS, MS Henry Salama, DMDChris Bonacci, DDS, MD John Kois, DMD, MSD Maurice Salama, DMDHugo Bonilla, DDS, MS Jack T Krauser, DMD Anthony Sclar, DMDGary F. Bouloux, MD, DDS Gregori Kurtzman, DDS Frank Setzer, DDSRonald Brown, DDS, MS Burton Langer, DMD Maurizio Silvestri, DDS, MDBobby Butler, DDS Aldo Leopardi, DDS, MS Dennis Smiler, DDS, MScDNicholas Caplanis, DMD, MS Edward Lowe, DMD Dong-Seok Sohn, DDS, PhDDaniele Cardaropoli, DDS Miles Madison, DDS Muna Soltan, DDSGiuseppe Cardaropoli DDS, PhD Lanka Mahesh, BDS Michael Sonick, DMDJohn Cavallaro, DDS Carlo Maiorana, MD, DDS Ahmad Soolari, DMDJennifer Cha, DMD, MS Jay Malmquist, DMD Neil L. Starr, DDSLeon Chen, DMD, MS Louis Mandel, DDS Eric Stoopler, DMDStepehn Chu, DMD, MSD Michael Martin, DDS, PhD Scott Synnott, DMDDavid Clark, DDS Ziv Mazor, DMD Haim Tal, DMD, PhDCharles Cobb, DDS, PhD Dale Miles, DDS, MS Gregory Tarantola, DDSSpyridon Condos, DDS Robert Miller, DDS Dennis Tarnow, DDSSally Cram, DDS John Minichetti, DMD Geza Terezhalmy, DDS, MATomell DeBose, DDS Uwe Mohr, MDT Tiziano Testori, MD, DDSMassimo Del Fabbro, PhD Dwight Moss, DMD, MS Michael Tischler, DDSDouglas Deporter, DDS, PhD Peter K. Moy, DMD Tolga Tozum, DDS, PhDAlex Ehrlich, DDS, MS Mel Mupparapu, DMD Leonardo Trombelli, DDS, PhDNicolas Elian, DDS Ross Nash, DDS Ilser Turkyilmaz, DDS, PhDPaul Fugazzotto, DDS Gregory Naylor, DDS Dean Vafiadis, DDSDavid Garber, DMD Marcel Noujeim, DDS, MS Emil Verban, DDSArun K. Garg, DMD Sammy Noumbissi, DDS, MS Hom-Lay Wang, DDS, PhDRonald Goldstein, DDS Charles Orth, DDS Benjamin O. Watkins, III, DDSDavid Guichet, DDS Adriano Piattelli, MD, DDS Alan Winter, DDSKenneth Hamlett, DDS Michael Pikos, DDS Glenn Wolfinger, DDSIstvan Hargitai, DDS, MS George Priest, DMD Richard K. Yoon, DDS Giulio Rasperini, DDS The Journal of Implant & Advanced Clinical Dentistry • 11

TrAyndAnEGnOrdsaTosrnbeeulooaentWGsa!®umnaXetrendntR®oeSgMgroeleafunmttebirroaantnisev?e Clinically Value Manageable Packs Bone Predictable Volume MaintenanceINTRODUCING Regenerative Treatment Solutions OsseoGuard® Membrane And Endobon® Xenograft GranulesThe NEW OsseoGuard Flex™ Membrane With NEW Packaging Conveniently Packaged Choose Between Two Levels Of In NEW Value Packs Drapability For Ease Of Use In Various Clinical Scenarios NEW NEW OsseoGuard Flex™ PACKAGING Membrane Slow Resorption For Bone Volume Retention Protect Sites ForConsistent Results During Grafting ProceduresOsseoGuard® Membranes And Endobon® Xenograft Granules Provide Clinicians One Solution At A TimeScan With Your Join Follow Watch Download For More InformationAbout BIOMET 3i Smartphone! Us Us Us It Regenerative Treatment Solutions, Contact YourIn order to scan QR codes, your mobile device must have a QR code reader installed. Local Sales Representative Today! In the USA: 1-888-800-8045,Endobon, OsseoGuard and RegenerOss are registered trademarks of BIOMET 3i LLC. Outside The USA: +1-561-776-6700OsseoGuard Flex and Providing Solutions - One Patient At A Time are trademarks ofBIOMET 3i LLC. ©2011 BIOMET 3i LLC. Or Visit Us Online At www.biomet3i.com

BIOMET 3i Welcomes New PresidentBIOMET 3i is pleased to announce that Mr. Doedens holds an M.D. from the Bart Doedens has been appointed as Free University of Amsterdam and an MBA the new President of BIOMET 3i. In tan- from the University of Rochester’s execu-dem, Maggie Anderson has announced her res- tive program at the University of Rotterdam.ignation after four years with the organization. About BIOMET 3i Mr. Doedens’ history with BIOMET 3i BIOMET 3i is a leading manufacturer of den-dates back to 1997 when he joined Implant tal implants, abutments and related products.Innovations Inc. as the Vice President of Since its inception in 1987, BIOMET 3i hasInternational Marketing and Sales. Soon been on the forefront in developing, manu-after Biomet’s acquisition of Implant Innova- facturing and distributing oral reconstructivetions, he was named President of BIOMET products, including dental implant components3i. Mr. Doedens served in that capacity until and bone and tissue regenerative materials.2005 when he was named the President of The company also provides educational pro-Biomet’s spine and bone healing division, grams and seminars for dental profession-now known as Biomet Spine & Bone Heal- als around the world. BIOMET 3i is baseding Technologies. In 2006, he left Biomet in Palm Beach Gardens, Florida, with opera-and joined Sirona Dental Systems in 2007 tions throughout North America, Latin America,as the Vice President of Global CAD/CAM. Europe and Asia-Pacific. For more information about BIOMET 3i, please visit www.biomet3i. Mr. Doedens stated, “I’ve watched com or contact the company at (800) 342-BIOMET 3i grow throughout the years, and 5454; outside the U.S. dial (561) 776-6700. ●the chance to once again work within sucha vibrant, thriving company is fantastic.” The Journal of Implant & Advanced Clinical Dentistry • 13

DID YOU KNOW? Roxolid implants deliver more treatment options Roxolid is optimal for treatment of narrow interdental spaces. Contact Straumann Customer Service at 800/448 8168 to learn more about Roxolid or to locate a representative in your area. www.straumann.us Case courtesy of Dr. Mariano Polack and Dr. Joseph Arzadon, Gainesville, VA

Crestal Core Elevation with Immediate Wilcko et alImplant Placement: A New TechniqueNabil Beaini, DDS1 • Mabel Salas, DDS, MS2 • Michael Umaki, DDS3 Charles Cobb, DDS, PhD4 AbstractImplant placement in maxillary posterior sites is the major complicating factor; in some cases, presents many challenges to clinicians. In ridge height dictates whether the placement of those posterior segments many factors implants at the time of sinus augmentation will beshould be considered and these include: sinus possible or not. This case report presents a tech-anatomy, ridge width, interocclusal and interden- nique of a crestal core elevation into the maxillarytal spaces. Pneumatization of the maxillary sinus sinus followed by placement of a dental implant.KEY WORDS: Maxillary sinus lift, dental implants, crestal core elevation 1. Private Practice, Columbia, MO2. Clinical Assitant Professor. University of Missouri Kansas City 3. Private Practice, Hawaii 4. Professor Emeritus, University of Missouri Kansas City The Journal of Implant & Advanced Clinical Dentistry • 15

Beaini et alFigure 1: Pre operative radiograph. Figure 2: Initial incisions.Figure 3: Edentulous ridge exposed. Figure 4: Trephine in position. Introduction and BackgroundReconstruction of the edentulous posteriormaxilla presents many challenges to clinicians.Pneumatization and enlargement of the maxillarysinuses occurs as a result of the loss of max-illary posterior teeth. In the absence of thoseteeth, resorption and crestal bone loss is accel-erated. The surgical techniques1 to restore andaugment a pneumatized maxillary sinus havebeen described in the literature and include:16 • Vol. 5, No. 2 • February 2013

Beaini et alFigure 5: Bone core elevated into the maxillary sinus. Figure 6: Implant placement.Figure 7: 10 day post operative radiograph.the lateral window approach “direct lift”2, the Figure 8: 4 month post operative radiograph.osteotome technique “indirect lift”3 or a crestalcore elevation technique.4.5 Initially proposedby Summers in 1995, the osteotome tech-nique3,10,11 is more conservative in nature wherethe augmentation of the sinus is more localizedto the area of implant insertion. The lateral win-dow technique was introduced by Tatum andis more technique sensitive.2 Careful eleva-tion of the Schneiderian membrane creates a The Journal of Implant & Advanced Clinical Dentistry • 17

Beaini et aldefined space between itself and the sinus floor kept 2mm away from the floor of the sinus (Figto receive the bone-grafting material of choice. 4). Consequently, an angled osteotome withAn alternative to the traditional two techniques a 4.2mm diameter was used to infracture the(direct and indirect lifts) involves the apical dis- floor of the sinus, therefore elevating the crestalplacement of a crestal core using osteotomes core into the maxillary sinus cavity (Fig 5). Anand a graft when indicated as described by SLA active implant (4.8x8mm WN) was thenToffler in 2002.5 Current literature focuses on inserted (Fig 6). A healing abutment was placedimproving the direct and indirect techniques and the surgical wound was primarily closedfor augmenting maxillary sinuses; however, using Vicryl 4-0 sutures. A peri-apical radio-very few reports focus on the importance of graph (Fig 7) was taken to verify the position ofcrestal core elevation. This case report pres- the implant and the dislocated core in the sinusents the technique and instrumentation of a (Fig 7). The patient was prescribed Amoxicil-crestal core elevation technique followed by lin 875mg bid for a week, a Medrol dose pack,the simultaneous placement of a dental implant. Vicodin 5/500, and a 0.12% chlorhexidine rinse. The patient was given written and oral Case Report instructions and seen at 10 days, one month and 3 months postoperatively (Fig 8). To date,A healthy 64 year-old female presented to the the patient has healed without complication.Graduate Periodontics Clinic at the Universityof Missouri Kansas City for implant placement. ConclusionThe patient lost tooth #14 due to non-restor-able caries approximately 3 years ago. The Crestal core elevation is a challenging and apatient’s medical history was unremarkable. technique sensitive procedure. Sinus lift aug- mentation is the prime choice in augmenting A periapical radiograph demonstrated a pneumatized sinuses. The Summers3 and Tatum2pneumatized maxillary sinus with a crestal ridge approaches have proven to be the gold stan-height of approximately 6mm (Fig 1). The treat- dards in that field. The crestal core approachment plan consisted on implant placement is an alternative, unique, and case selectivewith simultaneous crestal core elevation. The approach. The results of this case report sug-patient’s participation in this study was dis- gest that additional and more comparative stud-cussed and informed consent was obtained. ies are required to confirm the success rate. ●Three carpules of 2% Lidocaine with 1:100,000epinephrine and one carpule of 0.5 % Mar- Correspondence:caine™ (Hospira, Inc., Lake Forest, Illinois, USA) Dr. Nabil Beainiwith 1:200,000 epinephrine were administrated 650 W 25th Street.by infiltration. Full thickness flap reflection was Kansas City, MO 64108performed and the edentulous bony ridge wasexposed (Figs. 2, 3). A short explantation drill,with an outside diameter of 3.5mm, was usedto create a core. The explantation drill was18 • Vol. 5, No. 2 • February 2013

Beaini et alDisclosure 4. K olerman R. Maxillary Sinus Augmentation by the 8. Gapski. Histologic Analyses of HumanThe authors report no conflicts of interest with Crestal Core Elevation Technique. J Periodontol Mineralized Bone Grafting Material in Sinusanything mentioned in this article. 2011; 82: 41-51. Elevation Procedures: A Case Series. Int J Periodontics Restorative Dent 2006; 26:59-69.References 5. T offler M. Staged sinus Augmentation using a1. F ugazzotto P. Augmentation of the posterior crestal core elevation procedure and modified 9. Jensen OT. Report of the Sinus Consensus osteotomes to minimize membrane perforation. Conference of 1996. Int J Oral Maxillofac maxilla: a proposed hierarchy of treatment Pract Proced Aesthet Dent 2002; (14)9: 767-774. Implants 1998; 13(Suppl): 1-41 selection. J Periodontol 2003; 74: 1682-1691. 6. B oyne PJ, James RA. Grafting of the maxillary 10. Hanh, J. Clinical Uses of Osteotomes. Journal of2. T atum H Jr. Maxillary and sinus implant sinus floor with autogenous marrow and bone. J Oral Implantology 1999; (25)1:23-29 reconstructions. Dent Clin North Am 1986; Oral Surg 1980;38: 613-616. 30:207-229. 11. Trombelli. Transcrestal Sinus Floor Elevation 7. Gapski. Histological, Histomorphometric, and With a Minimally Invasive Technique. J3. S ummers RB. A new concept in maxillary implant Radiographic Evaluation of a Sinus Augmentation Periodontol 2010; 81: 158-166. surgery: The osteotome technique. Compendium With a New Bone Allograft: A Clinical Case 1994; 15:152, 154-162. Report. Implant Dent 2008; 17:430–438. The Journal of Implant & Advanced Clinical DentistryATTENTION PROSPECTIVE AUTHORS JIACD 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 • 19

All-Natural, Bioactive ProductsDesigned to Stimulate the Healing Process DynaMatrix® Extracellular • As an ECM, DynaMatrix retains both Membrane is the only intact the 3-dimensional structure and the extracellular matrix (ECM) signaling proteins important for soft designed to remodel soft tissue. tissue regeneration1 Biopsy of Biopsy of • The signaling proteins (growth factors,DynaMatrix autogeneous glycoproteins, glycosaminoglycans) gingival graft communicate with the body to help treated site stimulate the natural healing process2 Accell is an all-natural concentration • Accell has nearly 5 times more BMPs of Bone Morphogenetic Proteins than DBM alone and each lot is validated (BMPs) and Growth Factors with for osteoinductive properties 3,4 Demineralized Bone Matrix (DBM) that directs and charges stem cells • Accell in delivered as an easy-to-handle to acclerate the body’s natural putty in a pre-filled syringe healing response. • Accell is the only allograft product that contains this powerful combination of DBM, BMPs and Growth Factors 1 Hodde J, Janis A, Ernst D, et al. “Effects of sterilization on an extracellular matrix scaffold: part I. Composition and matrix architecture.” J Mater Sci Mater Med. 2007;18(4):537-543. 2 Hodde JP, Ernst DM, Hiles MC.”An investigation of the long-term bioactivity of endogenous growth factor in OASIS Wound Matrix.” J Wound Care. 2005 Jan;14(1):23-5. 3. Effective Design of Bone Graft Materials Using Osteoinductive and Osteoconductive Components. Kay, JF; Khaliq, SK; Nguyen, JT. Isotis Orthobiologics, Irvine, CA (abstract). 4. Amounts of BMP-2, BMP-4, BMP-7 and TGF-ß1 contained in DBM particles and DBM extract. Kay, JF; Khaliq, SK; King, E; Murray,SS; Brochmann, EJl. Isotis Orthobiologics, Irvine, CA (white paper/abstract). Keystone Dental, Inc. Outside the USA 144 Middlesex Turnpike Burlington, MA 01803 USA Call: +1-781-328-3490 Call: 1-866-902-9272 / Fax: 1-866-903-9272 Fax: +1-781-328-3400 [email protected] www.keystonedental.com

A Novel Technique of Impression Making of CAD/CAM CuWstiolcmko et al Abutments When Fabricating Multi-Unit Implant ProsthesesJan K. Pietruski, MD, DDS, PhD1 • Malgorzata D. Pietruska DDS, PhD2 Robert B. Kerstein, DMD3 • Julian Osorio, DMD4 AbstractBackground: This manuscript details the clini- eliminating the compound inaccuracy effectscal steps and advantages of a novel CAD/CAM of implant divergence, inter-implant distance,custom abutment impression making procedure. impression material volume, and the repeatedCAD/CAM technology makes it possible to cre- screwing in, and unscrewing out, of abut-ate matched abutment duplicates that when ments. Duplicate abutments provide the labo-used intraorally and simultaneously in the labo- ratory technician with exact abutment shaperatory, help to counteract many typical mas- and margin configuration for improved overallter cast implant replica positional inaccuracies. final restoration fit. Additional chairside time- savings result from the elimination of retrac-Methods: After a traditional impression of den- tion cord packing that is traditionally employedtal implants, a diagnostic wax up guides the fab- to cleanly impress abutment margin configura-rication of 2 identical sets of custom abutments. tions. This results in improved peri-implant softOne set is installed intraorally and impressed with tissue management throughout the entire case.pre-fitted, connected acrylic copings. The mas-ter cast is poured with the duplicate abutments Conclusions: This duplicate abutment impres-locked into the acrylic copings which were picked- sion procedure offers both clinicians and labora-up intraorally and embedded in the impression. tory technicians improved implant master cast replica positioning for more reliable implant pros-Results: This duplicate abutment impres- thesis fabrication. Duplicate abutments sim-sion technique improves implant replica posi- plify clinical impression making while optimizingtional accuracy within the master cast by the final restoration’s fit and margin adaptation.KEY WORDS: CAD/CAM, implants, abutments, duplicate, impression, accuracy. 1. Prosthodontist, Private Practice Bialystok, Poland. Former assistant clinical professor, Department of Prosthodontics, Medical University of Bialystok, Bialystok, Poland. 2. Periodontist, Head of Department of Periodontal and Oral Mucosa Diseases, Medical University of Bialystok, Bialystok, Poland. Private Practice. 3. Certificate in Prosthodontics. Tufts University School of Dental Medicine, Boston, MA USA Former assistant clinicalprofessor, Department of Restorative Dentistry, Tufts University School of Dental Medicine, Boston, Massachusetts, USA. 4. Certificate in Prosthodontics. Boston University School of Dental Medicine; Former Clinical professor, Department of Restorative Dentistry, Tufts University School of Dental Medicine, Boston, Massachusetts, USA. The Journal of Implant & Advanced Clinical Dentistry • 21

Pietruski et al Introduction and its’ working cast counterpart when sig- nificantly angled implants are impressed whenMany new methods and techniques have compared to more vertically aligned implants.evolved during the past forty years during the Impression accuracy can also be adverselydental implant surgical and restorative evolu- affected by divergence between the implanttion. While numerous studies have focused axis and the final crown axis. This problem hason the successful biologic bone response been somewhat lessened with the use of cus-to osseointegration, the technical imperfec- tom abutments that, within their morphologictions that frequently occur during the fabri- design, can minimize the degree of divergencecation of implant prosthesis have continually between these two restoration components.8-10required Implantology to develop predict-able clinical Prosthodontic solutions.1-5 Custom Abutments provide a biologic andImpression accuracy is one area of ongoing esthetic abutment option that combines idealimplant prosthodontic research and develop- abutment shape, improved-fit features overment, that is attempting to improve the reliabil- stock abutments, that also can guide soft tissueity of transferring the intraoral anatomy to the contouring with the abutment’s emergence pro-laboratory for prosthesis fabrication.6 Despite file.11,12 Another significant advantage of usingthe many impression innovations that have custom abutments is the ease with which thebeen developed in the hopes of improving the preparation margin can be placed just belowaccuracy of the working cast (i.e. splinted cop- the level of the soft tissue crest, which can helping transfers, or transfers of disposable plastic prevent cementitis.13-15 Custom Abutmentscaps), a predictable, dimensionally accurate duplicates can be employed during final pros-impression procedure, has still not been con- thesis master impression making procedures,firmed as “reliably accurate” case-after-case. to improve working cast accuracy. Duplicate abutments are identical copies of the original Research has provided insight into uti- abutment with matching morphology and mar-lizing impression methodologies that will gin designs (Atlantis Abutments and Geminiimprove transfer accuracy. Some studies sug- Duplicate Abutments, Astratech-Atlantis divi-gest that an open tray technique has accuracy sion of Dentsply Corp, Mölndal, Sweden).16advantages, while other studies illustrate thea closed tray technique is superior.6 How- Utilizing splinted custom abutment transferever, the same review concludes that neither copings that fit both the custom abutment andapproach is truly more accurate than its’ alter- its’ duplicate precisely (rather than impress-native.6 It appears that a more important con- ing the abutments themselves) is anothersideration is that metal impression trays have known method to improve replica position-been shown to yield more accurate impres- ing. Using a closed tray with splinted trans-sions than plastic impression trays, likely fer copings impressed with polyvinyl siloxanedue to the reduced flexibility of metal trays.7 further improves accuracy.17,18 Lastly, stud- ies do reveal that when impressing 4 or more Studies indicate that greater cast discrepan- implants, the coping transfer pick-up techniquecies result between the original implant position22 • Vol. 5, No. 2 • February 2013

Pietruski et alperformed with a metal tray, resulted in the by using duplicate custom abutments andbest replica positioning.6 In a complex multi- by incorporating into the impression-mak-unit implant restoration, duplicate abutments ing procedure, the studied factors known tofacilitate the inclusion of all these accuracy fac- reduce implant impression making inaccuracy:tors within the impression making procedure 1. M inimize implant divergence issues byto improve the reliability of the working cast. designing custom abutments that counter Another impression accuracy problem, that the divergence.often adds significant time when performing a 2. U tilize 2 identical sets of custom abut-full mouth implant reconstruction impression, ments which are fabricated prior to the mak-is the repeated screwing in, and unscrew- ing of the final restoration impression.ing out, of temporary healing caps, tempo- 3. M inimize the distance between implantsrary abutments, and definitive abutments. The with the abutments’ anatomical form,initial placement and subsequent removal of which reduces the inter-abutment vol-these differing implant components, is usually ume of impression material required.required to successfully perform final restora- 4. Use custom-created impression copings thattion impression making procedures when mul- precisely fit over the entire preparation surfacetiple implants are involved. These component of the custom abutment. Use a metal tray.insertions and removals can worsen the accu-racy of the created final impression because of STEP 1: Impression of All Implants That Willthe increased likelihood of imperfectly seating Support the Final Restoration.the many different components. Using dupli- An implant level Impression is initially made bycate abutments minimizes the time required to fitting each implant with its’ companion appro-perform the repeated component part insertions priately sized impression coping. All copingsand removals that is common to multi-implant are then positionally captured with polyvinylprosthesis impression making procedures. siloxane impression material (Honigum Light, Honigum Mixtar Mono, DMG, Hamburg, Ger- Clinical Technique many) in a closed tray procedure using a rim lock stock metal tray (Fig. 1). Perfect trans-Two important goals to strive for when fer of the implants positions and angula-performing impression making pro- tions is not crucial at this time, because thecedures for the fabrication of com- cast poured from this impression will be usedplex multi-unit implant restorations are: solely to design the CAD/CAM abutments.1. To minimize the positional inaccuracies These master casts are articulated for scan- ning, waxing and virtual abutment design virtual of the implants and the abutments when (Fig. 2). Any slight positional errors of the rep- captured within the impression material. licas can be compensated for by he design2. To reduce chairside working time while the of abutment wall taper angle. More accu- capturing an accurate multi-unit rate abutment positions will be captured dur- implant working cast impression. These goals can be readily achieved with The Journal of Implant & Advanced Clinical Dentistry • 23

Pietruski et alFigure 1: Impression Copings Impressed with Polyvinyl Figure 2: Articulated master casts made from initialSiloxane impression Material. Polyvinyl Siloxane impressions.Figure 3: Removable Maxillary Diagnostic Wax up. Figure 4: Silicone Matrix of wax up to fabricate provisional restoration.ing the final restoration impression procedure. In order to fabricate the CAD/CAM abut- restoration. The silicone matrix facilitates the fabrication of the provisional restoration (Fig 5).ments, a removable diagnostic wax up (Fig.3), and a silicone matrix (Fig. 4) (Picodent Once the wax up is completed, it is scanned,Esthetic-Gum, Picodent, Wipperfürth, Ger- and combined with scans of the master casts,many) of the wax up, are created upon the first to guide the virtual abutment design (Figs. 6,working cast. The wax up guides the design 7). When virtual design is completed, 2 setsso that each abutment has a preparation con- of the abutments are milled in titanium with sur-tour that fits within the confines of the final face retentive grooves, to increase the retention of the final restoration. One set of abutments24 • Vol. 5, No. 2 • February 2013

Pietruski et alFigure 5: Maxillary provisional made from silicone key. Figure 6: Scanned maxillary wax up silhouette vs. mandibular wax up scan guiding maxillary abutment design.Figure 7: Mandibular scanned provisional wax up guiding Figure 8: Milled titanium abutments installed on masterposterior abutment design. cast.is installed in to the articulated master casts, cal and lingual wings (Fig. 10). These wingsand the other is placed intraorally (Figs. 8, 9). when embedded in the impression, will secure the keys’ position. When there are two or moreSTEP 2: Installation of the Custom Made adjacent implants, it is not necessary to makeAbutments. occlusal surface wings. Because the resin barPrior to installing the custom made abutments, connecting the adjacent abutments will ade-acrylic resin positioning keys are fabricated on quately secure the proper position of abutmentsthe initial working cast (GC Pattern Resin, GC during the upcoming final impression procedure.Corp, Japan) The resin keys should contain buc- The Journal of Implant & Advanced Clinical Dentistry • 25

Pietruski et alFigure 9: Maxillary custom abutments installed intraorally. Figure 10: Resin keys with retentive wings fabricated upon the custom abutments for use in the final restoration impression procedure.Figure 11a: Maxillary resin positioning keys in place. Figure 11b: Mandibular resin positioning keys in place.STEP 3: Impression of the Custom tern Resin. Lastly, in a stock metal rim lock tray,Abutments a 1-step putty and light body polyvinyl siloxaneEach abutment is seated intraorally using the impression of the acrylic bar is made (Honigumpositioning keys (Figs. 11 a, b). At this point, the Light, Honigum Mixtar Mono, DMG, Hamburg,resin keys are sectioned to individualize each Germany). When the impression is fully polym-abutment (Figs. 12 a, b). Next, firmly seat each erized, the tray is removed with the acrylic keyresin key section onto its’ abutment and recon- embedded in the body of the impression. Whatnect the bar sections back together with Pat- is of note here in step 3, is the absence of cord26 • Vol. 5, No. 2 • February 2013

Pietruski et alFigure 12a: Maxillary resin keys are sectioned to Figure 12b: Mandibular resin keys are sectioned toindividualize each abutment. individualize each abutment.Figure 13: Installed provisional restorations made from torations (Fig.13). If the provisional materialsilicone keys developed from original wax up. does not flow completely down to the margin because of its’ subgingival location, the mar-packing to obtain clean restorative margins. gin can be corrected by inserting a duplicateWith duplicate abutment impression technique, abutment into the partially formed provisionalthis very time consuming, and often arduous abutment retainer and flowing composite orclinical procedure, is completely unneces- acrylic over the exposed visible margin of thesary because the duplicates contain the exact duplicate. Once all abutment margins are cor-margins of the intraoral set of abutments. rected in this fashion, the provisional can be installed onto the intraoral set of abutments. The silicone matrix of the abutment designwax-up is used to fabricate the provisional res- STEP 4: Inserting Abutment Duplicates into the Impression. All duplicate abutments are connected to their replicas, and then placed into their respec- tive locations within the acrylic key that is embedded within the impression material (Figs. 14a, b). The duplicates with implant analogues will fit precisely into the acrylic keys in the same way the intraoral set of abut- ments did before the impression was made. The Journal of Implant & Advanced Clinical Dentistry • 27

Pietruski et alFigure 14a: Maxillary analogs connected to the duplicate Figure 14b: Mandibular analogs connected to theabutments, which are installed into the acrylic resin keys duplicate abutments, which are installed into the acrylicthat were “picked up” in the PVS impression. resin keys that were “picked up” in the PVS impression.Figure 15: Articulated master casts with duplicate out to enhance stone release during cast recov-abutments ready for restoration fabrication. ery. The master casts are then articulated (Fig. 15) such that the dental technician can use theSTEP 5: Pouring the Master Cast. duplicate abutments in the same fashion thatThe impression containing the duplicates with traditional stone dies are used to fabricate thetheir analogues attached are poured with artifi- final restoration for intraoral insertion (Figs. 16a,cial silicone gingival (Majesthetic®-Gingiimplant, b, and 17a, b). Note in figures 17a and b, thePicodent, Wipperfürth, Germany) which facili- excellent adaptation of the final restorative mar-tates simpler cast release from the impression. If gins to the peri-implant tissue crests. This is theartificial gingiva is not utilized, subgingival dupli- result of the subgingival placement of the abut-cate abutment contours will need to be waxed ment margins during virtual abutment design. Discussion The described duplicate abutment impres- sion making procedure, can be employed with either titanium (Figs. 8, 9) or nitrate coated tita- nium abutments (Gold-hue, Astratech-Atlantis division of Dentsply Corp, Mölndal, Sweden) (Fig. 19), because metallic abutments do not change shape once they are milled. Metallic duplicates are manufactured by using the same abutment CAD design files to guide the mill-28 • Vol. 5, No. 2 • February 2013

Pietruski et alFigure 16a: Facial view of mandibular completed Figure 16b: Palatal view of completed maxillary prosthesisprosthesis on master cast without tissue replica. on master cast with tissue replica.Figure 17a: Left view of the final restoration placed upon Figure17b: Right view of the final restoration placed uponintraoral set of abutments. intraoral set of abutments.ing of 2 equal-sized abutments. Alternatively, It has been written that whenever possible,because zirconia undergoes sintering shrink- discrepancies between the working cast andage during fabrication, it is not possible to the intraoral condition should be avoided.19 Amake two identical Zirconia abutments. When very important potential improvement of thisa zirconia custom abutment is used intraorally, technique over conventional impression mak-the prosthetic procedures must be performed ing, is the accuracy of data that is capturedin the traditional way, by making the abut- within the impression. Regardless of whetherment level impression with retraction cord. a splinted impression technique is used with The Journal of Implant & Advanced Clinical Dentistry • 29

Pietruski et alFigure 18: Patient prior to implant therapy. Figure 19: Gold hue titanium nitride coated abutments can be duplicated in a similar fashion as titaniuman open or closed tray, angular implant differ- abutments.ences routinely result in inaccurate replica posi-tion.20 In cases where there exists significant in a closed metal tray. Combining all of theseimplant divergence, the CAD/CAM abutments “best accuracy practices” in 1 impression pro-can be designed with near- parallel abutment cedure insures that inaccuracy is kept to a mini-walls of all abutments, so that the implant diver- mum.17,18 Although it has been advocated thatgence is no longer a factor affecting impression polyether materials are more accurate thanaccuracy. The abutment walls now become polyvinyl siloxane materials, the results of somewhat is being impressed (rather than implant studies do not support this contention.6,17 Bothposition within the alveolus) so that the posi- polyether and polyvinyl siloxane can be used totion of divergent implants is not the focus of accomplish the described technique. But whenthe impression. Despite reports that improved using polyvinyl siloxane, the 1-step putty com-impression accuracy has been obtained when bined with a light-body syringe material wasimplant level impressions are made compared more found to accurate than a 2-step polyvinylto those made at the abutment level,21 by less- siloxane impression using a wash technique.6ening the effect implant divergence has onimpression accuracy, the described duplicate In addition to the potential accuracyabutment technique counters the effect implant improvements previously described, there aredivergence has on master cast fabrication. peri-implant tissue health improvements that result from using one-piece custom made CAD/ The described technique’s method includes CAM abutments. First, titanium and titaniumusing a splinted technique with custom trans- nitride are well accepted by the peri-implantfer copings, impressed with polyvinyl siloxane tissues such that studies indicate that tita- nium abutment materials enhance soft tissue maintenance.22,23 The mucosal barrier remains30 • Vol. 5, No. 2 • February 2013

Pietruski et almore stable, and demonstrates more colla- additional removal. When fabricating the finalgen and fibroblasts when peri- implant tissues implant-supported prosthesis, the various pros-rest against titanium and/or zirconia abutments thetic components (framework at try-in, por-in contrast to gold or platinum abutments.10 celain at bisque bake try-in, final restoration at try-in and insertion) can be evaluated without Second, CAD design allows for precise any abutment removal and replacement proce-control over margin placement (Figs. 17 a, b). dures. This saves chair time, protects the deli-Slightly subgingival crown margins, that fol- cate peri-implant soft tissue, and simplifies thelow the architecture of the peri-implant sulcus entire process for the prosthodontist. Addi-crest, can minimize the likelihood of developing tionally, with this method, repeated anesthesiatissue swelling, inflammation (cementits), and delivery visit to visit, is unnecessary becausepossible implant failure.14, 24-27 Cement extru- the abutments are not repeatedly removedsion deep into the peri-implant sulcus, is mini- and replaced. Anesthesia can compromisemized because the restoration margin is placed the patient’s ability to assist in the occlusaljust below the tissue crest. Therefore, cement and esthetic verifications because the patientremoval is simplified. A unique cementing pro- loses occlusal feel capability, and their lips andcedure application of duplicate abutments is face can droop, making any final restorationthey make it possible to remove excess cement esthetic evaluation impossible to reliably judge.extraorally, just prior to seating the final resto-ration intraorally. After placing cement into Conclusionthe crown or bridge units to be cemented, theextraoral set of duplicates can be seated into This manuscript details a novel duplicate abut-the castings, to extrude excess cement prior ment impression technique that combinesto the cement fully setting. The squeezed out together, all of the known, accuracy enhancingexcess cement is quickly removed from the impression making techniques in an attempt toexternal aspects of the restoration, after which improve the dimensional reproduction of thethe duplicates can be withdrawn. Then the final master cast that is used to fabricate the finalrestoration is seated onto the intraoral abut- implant-supported prosthesis. These accuracyments where only a small amount of remaining enhancing factors are: using rigid metal stockcement will extrude slightly into the peri-implant impression trays, using well-fitting custom fit-tissues. Coating each duplicate with a thin film ted impression copings, eliminating implantof petroleum jelly prior to seating them into divergence with near-parallel abutment wallthe castings, helps keep the cement within design, and reducing the impression mate-the casting when the duplicate is withdrawn. rial volume between neighboring abutments. It has been demonstrated that repeated This duplicate abutment impression pro-abutment unscrewing can result in peri-implant cedure offers clinicians significant chairsideattachment apparatus injuries that can lead time-savings resultant from eliminating cordto recession.28, 29 Using the duplicate tech- packing, and minimizing implant componentnique, the installed abutment never requires insertions and removals throughout the entire The Journal of Implant & Advanced Clinical Dentistry • 31

Pietruski et alprocess of prosthesis fabrication. This results in Correspondence:improved peri-implant soft tissue management Dr. Jan K. Pietruskithroughout the entire case. Lastly, duplicate ul. Waszyngtona 1/34, 15-269 Bialystok,abutments simplify final prosthesis fabrica- Polandtion for the laboratory technician, because he/ Tel/fax: +48 85 7447396she is using die(s) that are an exact replication e-mail: [email protected] the abutments that are in present a patient’smouth. This makes final restoration fit and mar-gin fabrication and adaptation highly precise. ●Disclosure 11. P riest G. Virtual-designed and computer-milled 21. Kwon JH, Son YH, Han CH, Kim S. Accuracy ofThe authors report no conflicts of interest with implant abutments. J Oral Maxillofac Surg 2005; implant impressions without impression copings:anything mentioned in this article. 63(9 Suppl 2): 22-32. A three-dimentional analysis. J Prosthet Dent 2011; 105(6): 367-373.References 12. Papazian S, Morgano SM. A laboratory procedure1. L aurell L, Lundgren D. Marginal bone level to facilitate development of an emergence profile 22. Welander M, Abrahamsson I, Berglundh T. with custom implant abutment. J Prosthet Dent The mucosal barrier at implants abutments of changes at dental implants after 5 years of 1998; 79(2): 232-234. different materials. Clin Oral Impl Res 2008; function: a meta-analysis. Clin Impl Dent Rel Res 19(7): 635-41. 2011; 13(1): 19-28. 13. G apski R, Neugeboren N, Pemeraz AZ, Reissner MW. Endosseous implant failure influenced by 23. Tete S, Mastrangelo F, Bianchi A, Zizzari V,2. C anullo L, Fedel GR, Ianello G, Jepsen S. crown cementation: a clinical case report. Int J Scarano A. Collangen fiber orientation around Platform switching and marginal bone-level Oral Maxillofac Implants 2008; 23(5): 943-6. machined tiranium and zirconia dental implant alterations: the results of a randomized-controlled necks: An animal study. Int J Oral Maxillofac trial. Clin Oral Impl Res 2010; 21(1): 115-121. 14. P auletto N, Lahiffe BJ, Walton JN. Complications Implants 2008; 24(1): 52-58. associated with excess cement around crowns3. W agenberg B, Froum S. Prospective study of on osseointegrated implant: a clinical report. Int 24. Danesh-Mayer M: Diagnosis and management of 94 platform-switched implants observed from J Oral Maxillofac Implants 1999; 14(6): 865-8. commonly encountered problems with cemented 1992 to 2006. Int J Periodontics Restorative Dent implant crowns. Australasian Dental Practice 2010; 30(1): 9-17. 15. L inkevicius T, Vindasiute E, Puisys A, 2006; 17; 142-148. Linkeviciene L, Maslova N, Puriene A. The4. Capiello M, Luongo R, Di Iorio D, Bugea C, influence of the cementation margin position 25. Agar JR, Cameron SM, Hughbanks JC, Parker Cocchetto R, Celletti R. Evalutation of peri-implant on the amount of undetected cement. A MH. Cement removal from restorations luted to bone loss around platform-switched implants. Int J prospective clinical study. Clin Oral Implants titanium abutments with simulated subgingival Periodontics Restorative Dent 2008 28(4): 347- Res 2012 Apr 8. Doi: 10.1111/j.1600- margins, J Prosthet Dent 1997;78(1): 43-7. 355. 0501.2012.02453.x. [Epub ahead of print] 26. Wadhwani C, Pineyro A. Technique for5. Mangano C, Mangano F, Piattelli A, Iezzi G, 16. O sorio J, Kerstein RB. Utilizing Computer- controlling the cement for an implant crown. Mangano A, La Colla L. Prospective clinical Generated Duplicate Titanium Custom J Prosthet Dent 2009; 102(1): 57-58. evalutation of 1920 Morse taper connections Abutments to Facilitate Intraoral and Laboratory implants: results after 4 years of functional loading. Implant Prosthesis Fabrication. PPAD 27. G oodacre CJ, Bernal GB, Rungcharassaeng Clin Oral Implants Res 2009; 20(3): 254-261. 2003;15(4); 311-314. K. Cllinical complications with implants and implant prostheses. J Prosthet Dent 2003;6. L ee H, So JS, Hochsteadler JL, Ercoli C. The 17. L orenzoni M, Pertl C, Penkner K, Polansky R, 90(2): 121-32. accuracy of implant impressons: a systematic Seday B, Wegscheider A. Comparison of the review. J Prosthet Dent 2008; 100(4): 285-291. transfer precision of three different impression 28. Ceruti P, Lorezetti M, Barabino E, Menicucci G. materials in combination with transfer caps for Management of prosthetic abutments respecting7. H oyos A, Soderholm K-L. Influence of Try Rigidity the Frialit-2 system. J Oral Rehab 2000; 27(7): peri-implant soft tissues. Minerva Stomatol and Impression Technique in Accuracy of Polyvinyl 629-638. 2005; 54(10): 601-5. Siloxane Impressions. Int J Prosthodont 2011; 24(1): 49-54. 18. F enton AH, Assif FD, Zarb GA. The accuracy 29. Degide M, Nardi D, Piatelli A. One abutment at of implant impression procedures. J Dent Res one time: non-removal of an immediate abutment8. E l Askary Abd El Salam. Fundaments of esthetic 1991;70(special issue):399. and its effect on bone healing around subcrestal implant dentistry. Blackwell Munksgaard 2007. tapered implants. Clin Oral Impl Res 2011; 19. S ahin S, Sehreli MC. The significance of passive 22(11): 1303-1307.9. G omes AL, Montero J. Zirconia abutments: A framework fit in implant prosthodontics. Impant review. Med Oral Patol Cir Bucal 2011; 16(1): Dent 2001; 10(2): 85-92. e50-55. 20. F ilho HG, Mazaro JVQ, Vedovatto E, Assuncao10. A brahamsson I, Berglundh T, Glantz PO, WG, Santos PH. Accuracy of impresson Lindhe J: The mucosal attachment at different technique for implants. Part 2 – comparison abutments. An experimental study in dogs. J Clin of splinting techniques. J Prosthet Dent 2011; Periodontol 1998; 25(9): 721-727. 105(2): 367-373.32 • Vol. 5, No. 2 • February 2013

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Peri-Implant Bone Defect Resolution Wilcko et alFollowing a Free Gingival Graft:A Case Report with Radiographic Follow UpDaniel Gober, DDS1 • Taeheon Kang, DDS, MS2 AbstractThe free gingival graft has been well docu- to correct the mucogingival deformity as a prepa- mented as a treatment to correct mucogin- ratory step to definitive surgery. After complete gival deformities around teeth and implants healing, the peri-implant tissue was free of clinicalbut has not been reported as a treatment option signs of inflammation with a dramatic decreasewhen bone loss is present. The following is a case in probing depths rendering any additional sur-of peri-implantitis with an associated mucogingi- gery unnecessary. After one year, there wasval deformity. A free gingival graft was performed radiographic evidence of bone defect resolution.KEY WORDS: Free gingival graft, implants, mucogingival deformity, peri-implantitis1. Daniel Gober, DDS: Department of Periodontology, Nova Southeastern University, Fort Lauderdale, Florida, USA. 2. Taeheon Kang, DDS, MS: Periodontist, private practice, Fairfax, Virginia, USA. The Journal of Implant & Advanced Clinical Dentistry • 35

Gober et alFigure 1: Initial presentation. Note gross erythema, edema, Figure 2: Periapical radiograph demonstrating severelack of attached tissue by #29 and minimal vestibular vertical bone loss extending from the mesial to distaldepth. surface of #29. INTRODUCTION following healing and limit the long term main- tenance of the implant.2-5 Additionally, properThere are multiple treatment options to consider tissue handling and tension free repositioningwhen presented with a case of peri-implantitis. of tissues in a regenerative approach can beBoth non-surgical therapy, including antibiotic difficult to achieve in the presence of a muco-administration and subgingival debridement, gingival deformity. In this case, a free gingivaland surgical therapy including open flap graft procedure can be employed to correct thedebridement, resective osseous surgery, regen- mucogingival deformity in preparation for defini-erative surgery, and implant removal, have been tive surgery. Historically, the Free Gingival Graftproposed as treatment alternatives. The goal of has been shown to be the most predictableall of these procedures is to control inflamma- method of augmenting a zone of keratinized tis-tion and establish an environment that is ame- sue around natural teeth and dental implants.6,7nable to long term health and maintenance.1 The following is a case report of peri-implan- Often times, employing the aforementioned titis which also presented with mucogingivalsurgical procedures is difficult if the peri- deformities. Because the authors consideredimplant soft tissue complex is compromised. If the peri-implant tissue unsuitable for proper sur-the marginal peri-implant tissue presents with gical therapy aimed at treating the peri-implanti-a very thin profile, a lack of adequate attachedand keratinized tissue, and a shallow vestibulardepth, it presents a challenge to the surgeonand can limit the predictability of the plannedsurgery. An apically positioned flap with osse-ous resective surgery would ignore the cur-rent mucogingival deformity; it would persist36 • Vol. 5, No. 2 • February 2013

Gober et alFigure 3: Recipient Bed Preparation and consequently Figure 4: Following debridement, irrigation, and treatmentexposure of implant surface. of implant surface with tetracycline, cortical perforations made to increase vascularity.tis and for long-term maintenance of peri-implanttissue health, a free gingival graft was employed time of surgery, the implant can be treatedas a preparatory step to definitive surgery. with either resective or regenerative surgery or implant removal. After discussing the impor- CASE REPORT tance of this implant in the scheme of the existing prosthesis, the patient opted to surgi-A 54 year old male presented with a chief com- cally treat the implant in an effort to maintain it.plaint of “the gum around my implants hurt.”He pointed to the buccal gingiva of #29 which Because of the lack of attached and kera-was an abutment for a 3 unit implant-supported tinized tissue and the obvious vestibular pull,bridge. Clinically, the buccal marginal tissue of the surgeon considered the predictability of#29 implant restoration was erythematous and any regenerative or resective surgical therapyedematous. There was no attached nor kera- limited. The patient was informed that the cor-tinized tissue present. There was limited ves- rection of the mucogingival deformity shouldtibular depth and the marginal buccal tissue be addressed in preparation for any resec-was mobile (Figure 1). Pocket depths on the tive or regenerative surgery. A Free Gingivalbuccal ranged from 10-12 mm and the expo- Graft was recommended to increase the widthsure of several implant threads was detect- of keratinized tissue and increase vestibularable with probing. The periapical radiograph depth on the buccal of the implant to prepareshowed severe bone loss around the implant the site for resective or regenerative surgery.(Figure 2). The diagnosis of peri-implantitis withan associated mucogingival deformity around A beveled horizontal incision was made#29 was given. The patient was informed that slightly coronal to the mucogingival junctiondepending on the clinical presentation at the from the distal of #27 to the mesial of #31. A partial thickness flap was dissected to prepare a recipient graft site. Because the buccal tis- The Journal of Implant & Advanced Clinical Dentistry • 37

Gober et alFigure 5: Suturing of palatal free gingival graft to recipient Figure 6: At 4.5 months post op, signs of clinically healthybed and vestibular margin to a more apical position. peri-implant soft tissue. An increase in attached keratinized tissue and vestibular depth evident.sue was continuous with the granulomatous tis- was stabilized with simple interrupted suturessue from the existing peri-implant bone defect, and the vestibular margin of the partial thick-dissection of the partial thickness flap resulted ness flap was sutured apically with periostealin the exposure of alveolar bone, the implant biting sutures. Immobilization of the graft wasthreads and the bone defect (Figure 3). Apical confirmed and the graft was compressed withto the exposed alveolar bone, a partial thick- gauze for 5 minutes (Figure 5). After hemosta-ness flap was extended apically so that the sis was achieved, post-operative instructionsgraft could be sutured to immobile periosteum. were given and the patient was dismissed.The bony defect and all accessible implantsurfaces were debrided of all soft tissue and Healing of the graft progressed unevent-accretions. The buccal surface of the implant fully in accordance with the normal healing pat-was flattened with a long diamond bur to bring terns of free gingival grafts placed on denudedit within the confines of the alveolar housing. alveolar bone.8-10 At 4.5 months, the marginalAfter copious irrigation with saline, the exposed tissue appeared healthy with no signs of inflam-implant surface was treated with tetracycline. mation. There was a significant decrease inCortical perforations were made on the corti- probing depths which were now than 2 mm oncal surface of the recipient bed to increase the buccal aspect of the implant. There wasthe vascularity for the free gingival graft (Fig- an increase in keratinized tissue of 2 mm, theure 4). A free gingival graft was harvested buccal marginal tissue was firmly attached, andfrom the palate and placed passively over the there was an increase in vestibular depth (Fig-exposed bone and implant surface. The graft ure 6). The patient reported no sensitivity in the area which was previously painful. At this point,38 • Vol. 5, No. 2 • February 2013

Gober et alFigure 7: 1 year post-operatively. Notice the healthy Figure 8: Periapical radiograph 1 year post-operatively.appearing peri-implant soft tissue profile which has Notice the increase in radiopacity evident in previous areabeen maintained for up to 1 year. There is also evidence of radiolucency from pre-operative radiograph.of coronal migration of the free gingival margin by #29compared with 4.5 months post-operatively. areas interposed between the alveolar margin and the implant surface along the facial surfacethe peri-implant condition was considered ame- of the implant as the images move from mesialnable to long term health and maintenance. to distal. This suggests that the post-opera-Additional surgery was no longer indicated. tive presentation was due to a combination of shrinkage of the inflamed tissues and fill of the At the 1 year follow up, the peri-implant tis- implant bony defect one year post-operatively.sue continued to present in a healthy conditionwith no signs of inflammation. PD remained at 2 DISCUSSIONmm with no bleeding on probing, and the tissuewas firmly attached. Additionally, the free gingi- Although the literature is replete with reports ofval margin on the buccal of #29 appeared to be the free gingival graft to correct mucogingivalslightly coronal to its position from 4.5 months, deformities around implants, to our knowledge,indicating a creeping attachment (Figure 7). A there has been no case report of the free gingivalnew periapical radiograph was taken and, to the graft as a treatment option for peri-implantitis. Theauthor’s surprise, no longer showed radiolucent above patient presented with peri-implantitis aftermargins indicative of an infrabony defect (Figure the implant had been in function for many years. In8). A CBCT scan which was taken in prepara- conjunction with the peri-implantitis present, a lacktion of a different surgical site showed that the of attached and keratinized tissue and vestibularalveolar bone was continuous with all surfaces depth was also apparent. The goal of therapy wasof the implant, indicative of bone fill in the area not simply to address the peri-implant disease butof the previous defect (Figures 9-10). Had there to also correct the mucogingival deformity aroundbeen no resolution of the defect with bone fill,we would have expected to see radiolucent The Journal of Implant & Advanced Clinical Dentistry • 39

Gober et alFigures 9 & 10: CBCT slices from distal to mesial. Notice continuity of alveolar bone with implant surface and no evidence ofradiolucent areas resembling previous bone defect.the implant to facilitate more predictable handling follow up, the peri-implant tissues remained freeof soft tissues for definitive surgery and facilitate of inflammation and, unexpectedly, there waslong term maintenance of the peri-implant tissue. radiographic evidence of bony defect resolution. Consequently, a peri-implant soft tissue environ- A free gingival graft was performed in order ment amenable to health and long term mainte-to augment the zone of keratinized tissue and nance was established, rendering the need forincrease vestibular depth to prepare the site for any additional surgical procedure unnecessary.any subsequent resective or regenerative therapyindicated. During the preparation of the recipi- It is possible to explain the results of the aboveent bed, the alveolar bone, implant threads and mentioned surgery with a proper understand-bony defect were exposed. Following debride- ing of alveolar bone healing following periodon-ment of all soft tissue and accretions, flattening tal surgery. Numerous studies have shown thatof the buccal surface of the implant, and chemi- when alveolar bone is exposed surgically, evencal treatment of the implant surface, a free gin- without any direct mechanical trauma, such asgival graft was placed. After complete healing, ostectomy or osteoplasty, a process of crestalan increase in the zone of attached and keratin- bone resorption takes place, followed by an appo-ized tissue and vestibular depth was achieved. sitional or rebound phase of bone formation.13,14The peri-implant soft tissue appeared clinically Additionally, it has been reported that follow-health with no signs of inflammation and prob- ing open flap debridement procedures around,ing depths were reduced to 2 mm. At the 1 year a varying degree of osseous fill is expected,40 • Vol. 5, No. 2 • February 2013

Gober et alin favor of those defects which are deep, nar- CONCLUSIONrow and adequate remaining bony walls.15,16 A free gingival graft was performed as a pre- In the above case, the exposure of the paratory step to definitive surgery to address aimplant surface and surrounding alveolar bone case of peri-implantitis with an associated muco-as an outcome of the recipient bed preparation gingival deformity. After complete healing, thefor the planned free gingival graft eventuated in clinical presentation was considered amenablean opportunity to flatten the implant surface to to long-term maintenance, rendering any addi-return it within the confines of the alveolar hous- tional surgery unnecessary. At the 1 year following and debride the bony defect and contami- up, there was radiographic evidence of bonenated implant surface. It is likely that the exposure defect resolution. The free gingival graft in con-of the alveolar bone, cortical perforations, thor- junction with debridement of the contaminatedough debridement of the bony defect and implant implant surface resulted in resolution of the peri-surface may have induced a process of surface implant bone defect. The findings of this singlebone resorption and bone deposition towards the case report suggest the possibility that the Freeimplant surface which was brought back within Gingival Graft may be considered as a treat-the alveolar housing. This could explain the radio- ment alternative in the treatment of peri-implanti-graphic bone defect resolution seen post-oper- tis with an associated mucogingival deformity. ●atively. The application of the free gingival graftover the debrided area and surrounding denuded Correspondence:bone increased the zone of keratinized tissue, Daniel Gober, DDSincreased vestibular depth while at the same Postal address:time achieving dramatic pocket reduction and 3200 S University Driveresolution of the bony defect around the implant. Fort Lauderdale, FL 33328To our knowledge, this is the first reported Fax number: 954-262-1573case of a free gingival graft which resulted in e-mail address: [email protected] resolution of a peri-implant bone defect.Disclosure 5. Bouri A, Bissada N, Al-Zahrani M, Faddoul 11. Dordick B, Coslet JG, Siebert JS. ClinicalThe authors report no conflicts of interest with F, Nouneh I. Width of keratinized gingiva and evaluation of free autogenous gingival grafts placedanything mentioned in this article. health status of the supporting tissues around on alveolar bone. Part I. Clinical predictability. JReferences dental implants. Int J Oral Maxillofac Implants Periodontol 1976;47(10):559-567.1. L indhe J, Meyle J. Peri-implant diseases. 2008;23:323-326. 12. Caffesse RG, Burgett FG, Nasjleti CE, Castelli Consensus Repot of the Sixth European 6. S ullivan HC, Atkins JH. Free Autogenous Gingival WA. Healing of free gingival grafts with and Workshop on Periodontology. J Clin Periodontol Grafts. I. Principles of Successful grafting. without periosteum. Part I. Histologic evaluation. 2008;35 (Supplement 8): 282-285. Periodontics 1968;6(3): 121-129. J Periodontol 1979;50(11):586-594.2. A dibrad M, Shahabuei M, Sahabi M. Significance of the width of keratinized mucosa on the health 7. Han TJ, Klokkevold PR, Takei HH. Strip gingival 13. Donnenfeld OW, Hoag PM & Weissman DP. A status of the supporting tissue around implants autograft used to correct mucogingival problems Clinical Study on the Effects of Osteoplasty. J supporting overdentures. J Oral Implantol around implants. Int J Periodont Rest Dent Periodontol 1970;41:131-141. 2009;35(5):232-237. 1995;15:404-411.3. W arrer K, Buser D, Lang NP, Karring T. Plaque- 14. Wood DI, Hoag PM, Donnenfeld OW & induced peri-implantitis in the presence or 8. G argiulo AW, Arrocha R. Histo-Clinical Rosenfeld LD. Alveolar crest reduction following absence of keratinized mucosa. An experimental evaluation of free gingival grafts. Periodontics full and partial thickness flaps. J Periodontol study in monkeys. Clin Oral Implants Res 1967;5(6):285-291. 1972;43:141-144. 1995;6:131-138.4. C hung D, Oh TJ, Shotwell J, Misch C, Wang 9. O liver RC, Loe H, Karring T. Microscopic evaluation 15. Polson AM, Heijl LC. Osseous repair in infrabony HL. Significance of keratinized mucosa in of the healing and revascularization of free gingival periodontal defects. J Clin Periodontol 5:13-23. maintenance of dental implants with different grafts J Periodont Res 1968;3:84-95. surfaces. J Periodontol 2006;77:1410-1420. 16. Froum SJ, Coran M, Thaller B, Kushner L. Scopp 10. S oehren SE, Allen AL, Cutright DE, Seibert JS. QW and Stahl SS. Periodontal Healing Following Clinical and Histologic studies of donor tissues Open Debridement Flap Procedures. I. Clinical utilized for free grafts of masticatory mucosa. J Assessment of Soft Tissue and Osseous Repair. J Periodontol 1973;44(12):727-741. Periodontol. 1982;53(1):8-14. The Journal of Implant & Advanced Clinical Dentistry • 41

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Immediate Implants: Wilcko et alTreatment Planning and Surgical Placement Abdulgani Azzaldeen, DDS, PhD1Abu-Hussein Muhamad, DDS, MScD, MSc, DPD2 Sarafianou Aspasia, DDS, PhD3AbstractImmediate implants are positioned in socket space and/or cover the membranes. the course of surgical extraction of the The surgical requirements for immediate implan- tooth to be replaced. The percentage tation include extraction with the least traumasuccess of such procedures varies among possible, preservation of the extraction socketauthors from 92.7-98.0%. The main indica- walls and thorough alveolar curettage to elimi-tion of immediate implantation is the replace- nate all pathological material. Primary stability isment of teeth with pathologies not amenable an essential requirement, and is achieved withto treatment. Its advantages with respect to an implant exceeding the alveolar apex by 3-5delayed implantation include reduced post- mm, or by placing an implant of greater diam-extraction alveolar bone resorption, a short- eter than the remnant alveolus. Esthetic emer-ening of the rehabilitation treatment time, and gence in the anterior zone is achieved by 1-3the avoidance of a second surgical interven- mm sub-crest implantation. Regarding guidedtion. The inconveniences in turn comprise a regeneration of the alveolar bone, the literaturegeneral requirement for membrane-guided lacks consensus on the use of membranes andbone regeneration techniques, with the asso- the type of filler material required. While pri-ciated risk of exposure and infection, and mary wound closure is desirable, some authorsthe need for mucogingival grafts to seal the do not consider it to be of great relevance.KEY WORDS: Dental implants, immediate implant placement, tooth extraction 1. Al- Quds University 2. University of Athens 3. University of Athens The Journal of Implant & Advanced Clinical Dentistry • 43

Azzaldeen et al INTRODUCTION (c) Delayed implantation, when the receptor zone is not optimum for either imme-Immediate implants are defined as the place- diate or recent implantation. Bone promotion isment of implants in the course of surgical first carried out with bone grafts and/or barrierextraction of the teeth to be replaced.1 The membranes, followed approximately 6 monthsinsertion of implants immediately after extrac- later by implant positioning (delayed implants).tion is not new, and in the nineteen eighties theUniversity of Tübingen advocated the proce- (d) Mature implantation, when over 9dure as the technique of choice for Tübingen months have elapsed from extraction to implan-and München ceramic implants.2 As a result of tation. Mature bone is found in such situations.the success of the protocol designed by Bråne-mark and his team for their dental implant sys- Studies in dogs and primates have showntem, other procedures were largely relegated that implants positioned immediately afterfor many years. Initially, a healing period of 9-12 extraction can undergo osseointegration, withmonths was advised between tooth extrac- good surface bone adaptation and withouttion and implant placement.3 Nevertheless, as clinically apparent mobility.5 Karabuda et al.6a result of continued research, a number of the in a histological and morphometric study inconcepts contained in the Brånemark proto- canine mandibles, recorded 62.4% bone con-col and previously regarded as axiomatic, such tact in hydroxyapatite-coated implants, ver-as the submerged technique concept, delayed sus 51.3% contact in titanium plasma-sprayedloading, machined titanium surface, etc., (TPS)-surface implants, after 8 weeks. Wilsonhave since been revised and improved upon et al.7 in a histological study of a deceasedeven by the actual creators of the procedure. patient, noted good osseointegration of imme- diate implants, as determined 6 months after Based on the time elapsed between implantation. Cornelini et al.8 in turn car-extraction and implantation, the follow- ried out a clinical and histological study of aing classifications have been estab- non-submerged immediate implant which 8lished relating the receptor zone to months after placement was found to causethe required therapeutic approach:1,4 discomfort requiring explantation. The corre- sponding histological evaluation revealed an (a) Immediate implantation, when the important percentage of bone-implant con-remnant bone suffices to ensure primary sta- tact. Block and Kent9 confirmed good clini-bility of the implant, which is inserted in the cal results with immediate implants - posteriorcourse of surgical extraction of the tooth to studies reflecting percentage successes ofbe replaced (primary immediate implants). between 92.7%10 and 98.0%.11 Grunder et al.12 observed no significant differences in long- (b) Recent implantation, when approx- term success between immediate (92.4%) andimately 6-8 weeks have elapsed from delayed implants (94.7%). Mean bone resorp-extraction to implantation - a time dur- tion in immediate upper maxillary implants wasing which the soft tissues heal, allow- found to be 0.8 mm yearly, versus 0.5 mm ining adequate mucogingival covering of thealveolus (secondary immediate implants).44 • Vol. 5, No. 2 • February 2013

Azzaldeen et althe lower jaw. According to these authors, an involving an acute periodontal abscess asso-increased failure rate was only obtained when ciated with immediate implant placement,immediate implantation was carried out after in a patient in the maintenance phase.19extracting teeth due to periodontal disease. CONTRAINDICATIONS In contrast, according to Tolman andKeller13 immediate implantation affords a lesser The existence of an acute periapical inflam-success rate when compared with implants matory process constitutes an absolute con-positioned in mature bone. Nevertheless, in a traindication to immediate implantation.20,21study published by Schwart-Arad et al.14 involv-ing 380 implants, of which 31% were immedi- In the case of socket-implant diame-ate, the cumulative survival rate after 5 years ter discrepancies in excess of 5 mm, whichwas seen to be 96% and 89.4% for immediate would leave most of the implant withoutand non-immediate implantation, respectively. bone contact, prior bone regeneration and delayed implantation may be considered.16 INDICATIONS OF IMMEDIATE IMPLANTATION ADVANTAGESPrimary implantation is fundamentally indi- One of the advantages of immediate implan-cated for replacing teeth with patholo- tation is that post-extraction alveolar pro-gies not amenable to treatment, such as cess resorption is reduced,22-24 thus affordingcaries or fractures. Immediate implants are improved functional and esthetic results.25,26also indicated simultaneous to the removalof impacted canines and temporal teeth.15,16 Another advantage is represented by a shortening in treatment time, since with imme- Immediate implantation can be carried out diate placement it is not necessary to wait 6-9on extracting teeth with chronic apical lesions months for healing and bone neoformation ofwhich are not likely to improve with endodontic the socket bed to take place. Patient accep-treatment and apical surgery.17 Novaes et al.18 tance of this advantage is good,27 and psy-in a study in dogs, inserted immediate implants chological stress is avoided by suppressingin locations with chronic periapical infec- the need for repeat surgery for implantation.25tion. These authors reported good results andpointed out that despite evident signs of peri- Preservation of the vestibular cortical com-apical disease, implant placement is not con- ponent allows precise implant placement,traindicated if pre- and postoperative antibiotic improves the prosthetic emergence profile,coverage is provided and adequate cleaning of and moreover preserves the morphology ofthe alveolar bed is ensured prior to implantation. the peri-implant soft tissues,27 thereby afford- ing improved esthetic-prosthetic performance While immediate implantation canbe indicated in parallel to the extrac- One inconvenience of immediate implanttion of teeth with serious periodontal placement is the more frequent need for tis-problems,17 Ibbott et al. reported a case sue regeneration and bone promoting tech- niques. The application of bone grafts and/ or barrier membranes to the defect created by The Journal of Implant & Advanced Clinical Dentistry • 45

Azzaldeen et alFigure 1a: Initial presentation case #1 (occlusal view). Figure 1b: Initial presentation case #1 (buccal view).Figure 1c: Presentation case #1 following FPD removal. Figure 1d: Direction check radiograph following tooth extraction.the socket-implant discrepancy contributes toincrease the complexity and cost of treatment.28 In general terms, the placement of mem-branes requires the raising of flaps to cover thelatter - a circumstance that may lead to prob-lems such as disappearance of the interdentalpapillae and the development of peri-implantmucositis over these non-keratinized displacedtissues. The possibility of membrane exposureand subjacent infection produces antiestheticsequelae, and places implant viability at risk.2946 • Vol. 5, No. 2 • February 2013

Azzaldeen et alFigure 1e: Extractions and immediate dental implant Figure 1f: Resorbable collagen membrane placement.placement.Figure 1g: Closure with silk sutures. Figure 1h: MIS Implants 3.75x13mm at both locations. SURGICAL CONSIDERATIONS Ensure that extraction is as least traumatic as possible, to maximize bone integrity. In teethThe most common locations for immediate with multiple roots, dental sectioning is indicated,implant placement comprise the anterior sec- with individualized extraction of the roots. Thetor (canines and incisors) and the premolar socket walls are to be preserved during extrac-regions of both jaws. When the diameter of the tion, particularly the vestibular wall, the level ofroot is less than that of the implant, the result- which should harmonized with that of the neigh-ing primary stability is greater. This situation is boring teeth, to ensure esthetic emergence ofobserved when a periodontically compromised the prosthetic post (figures 1a, 1b, 1c, and 2a).tooth is removed, presenting a bone supportequivalent to les than one-third of the root.30 Before positioning the immedi- ate implant, careful curettage and alveo- The surgical criteria which apply to imme- lar cleaning is required to remove any tracediate implantation include the following: The Journal of Implant & Advanced Clinical Dentistry • 47

Azzaldeen et alof infected or inflamed tissue, together with bone filler material alone. In contrast,remains of the periodontal ligament.31,32 guided bone regeneration should be con- sidered in the event of larger defects.29,36 The implant must possess sufficient pri-mary stability. This is generally ensured by In order to achieve esthetic anterior sectorexceeding the apex by 3-5 mm, or by using an emergence, the implants must be positionedimplant of greater diameter than the socket.33,34 below crest level. In this sense, Bascones and Frías34 propose a distance of 2-3 mm, Implant placement while Lazzara37 and Lang et al.28 refer a loca- tion between 1 and 3 mm apical to the alveo-In anterior teeth, the ideal orientation of the lar crest level. Gelb11 advocates a location 3implant axis does not usually correspond to mm apical to the cementoenamel line of thethat of the socket. Implant placement in the adjacent teeth, while Becker et al.33 prefer adirection of the root would oblige vestibu- position slightly inferior to the alveolar crest.lar emergence of the retention screw or theuse of prosthetic additaments for the change Primary soft tissuein angle. The implant bed is to be prepared closurepalatal, and osteodilators can be used to thiseffect. In the molar region of the upper jaw it Following tooth extraction, a woundis preferable to establish fixation in the pala- remains and primary socket closure is diffi-tal root, since the buccal counterparts are cult. In this sense, while some authors con-covered by a fine bone layer. In the posterior sider immediate closure after implantationmandibular region, the inferior alveolar neu- to be desirable11,33 others are of the opin-rovascular bundle often lies very close to the ion that this is not a priority objective.37,38apices of the premolars and molars, and theroots of the latter tend to be large, thereby If a vestibular flap is used for primary socketprecluding adequate primary fixation of the closure, with two releasing vertical incisionsimplant. A common situation is implant place- and an incision upon the periosteum at the basement in the inter-root septum, which causes of the flap, sufficient mobility can be achievedthe bone bed surrounding the implant to condi- to displace and suture the flap on the extrac-tion very precarious initial stability. This prob- tion site. This technique offers good sealinglem can be solved by using an implant of larger but poses the inconvenience of reducing thediameter,35 waiting for the alveolar space to fill width of the attached gingival tissue around thewith bone, and then performing delayed place- implant, thus adversely affecting the estheticment or positioning two implants to recon- outcome and complicating patient-mediatedstruct a lower molar (figures 1d, 1e, and 2b). care.29 Ladsberg39 described immediate trans- gingival positioning of the implant after tooth In some cases a vestibular crest defect extraction, covering the defect with a full thick-or dehiscence occurs after implant posi- ness graft taken from the palatal region. Thistioning. If the bone defect is small (under author also described a technique for socket4 mm in length), it can be eliminated with sealing where after immediate implant place-48 • Vol. 5, No. 2 • February 2013