Integrating Implant Function and Esthetics

VOLUME 2, NO. 4 MAY 2010 The Journal of Implant & Advanced Clinical Dentistry Integrating Implant Function and Esthetics E ective Dentist to Lab Communication

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The Journal of Implant & Advanced Clinical Dentistry VOLUME 2, NO. 4 • MAY 2010 Table of Contents 19 The Reverse Pathway: Parameters for the Integration of Function and Aesthetics with Implants Sergio Rubinstein, Maurice A. Salama, David A Garber, Henry Salama 33 A New Approach for Post Extractive Site Preservation by using a Free Gingival Graft: A Case Report Carlo Maiorana, Stefano Speroni, Marco Cicciù 43 Rehabilitation of Complex Cases Using Obturator Prostheses and Zygomatic Implants: A Report of 2 Cases Eduardo José de Moraes The Journal of Implant & Advanced Clinical Dentistry • 5

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The Journal of Implant & Advanced Clinical Dentistry VOLUME 2, NO. 4 • MAY 2010 Table of Contents 55 Removal of a Fractured Implant Abutment: A Case Report Nikitas Sykaras 65 The Predominant Cultivable Micro ora Around Implants in Papillon-Lefevre Syndrome Khaled Abdel Ghaffar, Salah Abdel Fatah, Ronald S. Brown, Ashraf Abdel Monaem 77 E ective Dentist / Dental Lab Communication for Complex Cases Uwe Mohr 87 Severe Hereditary Gingival Fibromatosis A ecting the Deciduous and Permanent Dentitions: A Case Report Dwight E. McLeod, Jeffrey V.A. Burch, Elio Reyes Rosales, Alvin R. Sams, Art Misischia The Journal of Implant & Advanced Clinical Dentistry • 7

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The Journal of Implant & Advanced Clinical Dentistry VOLUME 2, NO. 4 • MAY 2010 Publisher Copyright © 2010 by SpecOps Media, LLC. All rights SpecOps Media, LLC reserved under United States and International Copyright Conventions. No part of this journal may be reproduced Design or transmitted in any form or by any means, electronic or Jimmydog Design Group mechanical, including photocopying or any other information www.jimmydog.com retrieval system, without prior written permission from the publisher. Production Manager Stephanie Belcher Disclaimer: Reading an article in JIACD does not qualify 336-201-7475 the reader to incorporate new techniques or procedures discussed in JIACD into their scope of practice. JIACD Copy Editor readers should exercise judgment according to their JIACD staff educational training, clinical experience, and professional expertise when attempting new procedures. JIACD, its Digital Conversion staff, and parent company SpecOps Media, LLC (hereinafter NxtBook Media referred to as JIACD-SOM) assume no responsibility or liability for the actions of its readers. Internet Management InfoSwell 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 liability Non-qualified individual: $99(USD) Institutional: $99(USD). for such material and does not guarantee, warrant, nor For more information regarding subscriptions, endorse any product, procedure, or technique discussed in contact [email protected] or 1-888-923-0002. JIACD, its affiliated websites, or affiliated communications. Additionally, JIACD-SOM does not guarantee any claims Advertising Policy: All advertisements appearing in the made by manufact-urers of products advertised in JIACD, its Journal of Implant and Advanced Clinical Dentistry (JIACD) affiliated websites, or affiliated communications. must be approved by the editorial staff which has the right to reject or request changes to submitted advertisements. Conflicts of Interest: Authors submitting articles to JIACD The 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 result made by JIACD advertisers. in suspension of manuscript peer review. For advertising information, please contact: Erratum: Please notify JIACD of article discrepancies or [email protected] or 1-888-923-0002 errors by contacting [email protected] Manuscript Submission: JIACD publishing guidelines JIACD (ISSN 1947-5284) is published on a monthly basis can 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



The Journal of Implant & Advanced Clinical Dentistry Founder, Co-Editor in Chief Founder, Co-Editor in Chief Dan Holtzclaw, DDS, MS Nicholas Toscano, DDS, MS Editorial Advisory Board Tara Aghaloo, DDS, MD Robert Horowitz, DDS Michele Ravenel, DMD, MS Faizan Alawi, DDS Michael Huber, DDS Terry Rees, DDS Michael Apa, DDS Richard Hughes, DDS Laurence Rifkin, DDS Alan M. Atlas, DMD Debby Hwang, DMD Georgios E. Romanos, DDS, PhD Charles Babbush, DMD, MS Mian Iqbal, DMD, MS Paul Rosen, DMD, MS Thomas Balshi, DDS Tassos Irinakis, DDS, MSc Joel Rosenlicht, DMD Barry Bartee, DDS, MD James Jacobs, DMD Larry Rosenthal, DDS Lorin Berland, DDS Ziad N. Jalbout, DDS Steven Roser, DMD, MD Peter Bertrand, DDS John Johnson, DDS, MS Salvatore Ruggiero, DMD, MD Michael Block, DMD Sascha Jovanovic, DDS, MS Henry Salama, DMD Chris Bonacci, DDS, MD John Kois, DMD, MSD Maurice Salama, DMD Hugo Bonilla, DDS, MS Jack T Krauser, DMD Anthony Sclar, DMD Gary F. Bouloux, MD, DDS Gregori Kurtzman, DDS Frank Setzer, DDS Ronald Brown, DDS, MS Burton Langer, DMD Maurizio Silvestri, DDS, MD Bobby Butler, DDS Aldo Leopardi, DDS, MS Dennis Smiler, DDS, MScD Donald Callan, DDS Edward Lowe, DMD Dong-Seok Sohn, DDS, PhD Nicholas Caplanis, DMD, MS Shannon Mackey Muna Soltan, DDS Daniele Cardaropoli, DDS Miles Madison, DDS Michael Sonick, DMD Giuseppe Cardaropoli DDS, PhD Carlo Maiorana, MD, DDS Ahmad Soolari, DMD John Cavallaro, DDS Jay Malmquist, DMD Neil L. Starr, DDS Stepehn Chu, DMD, MSD Louis Mandel, DDS Eric Stoopler, DMD David Clark, DDS Michael Martin, DDS, PhD Scott Synnott, DMD Charles Cobb, DDS, PhD Ziv Mazor, DMD Haim Tal, DMD, PhD Spyridon Condos, DDS Dale Miles, DDS, MS Gregory Tarantola, DDS Sally Cram, DDS Robert Miller, DDS Dennis Tarnow, DDS Tomell DeBose, DDS John Minichetti, DMD Geza Terezhalmy, DDS, MA Massimo Del Fabbro, PhD Uwe Mohr, MDT Tiziano Testori, MD, DDS Douglas Deporter, DDS, PhD Dwight Moss, DMD, MS Michael Tischler, DDS Alex Ehrlich, DDS, MS Peter K. Moy, DMD Michael Toffler, DDS Nicolas Elian, DDS Mel Mupparapu, DMD Tolga Tozum, DDS, PhD Paul Fugazzotto, DDS Ross Nash, DDS Leonardo Trombelli, DDS, PhD Scott Ganz, DMD Gregory Naylor, DDS Ilser Turkyilmaz, DDS, PhD David Garber, DMD Marcel Noujeim, DDS, MS Dean Vafiadis, DDS Arun K. Garg, DMD Sammy Noumbissi, DDS, MS Emil Verban, DDS Ronald Goldstein, DDS Arthur Novaes, DDS, MS Hom-Lay Wang, DDS, PhD David Guichet, DDS Charles Orth, DDS Benjamin O. Watkins, III, DDS Kenneth Hamlett, DDS Jacinthe Paquette, DDS Alan Winter, DDS Istvan Hargitai, DDS, MS Adriano Piattelli, MD, DDS Glenn Wolfinger, DDS Michael Herndon, DDS George Priest, DMD Richard K. Yoon, DDS Giulio Rasperini, DDS The Journal of Implant & Advanced Clinical Dentistry • 11

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Editorial Commentary NXTBOOK This page will come later this week Dan Holtzclaw, DDS, MS Nick Toscano, DDS, MS Founder, Co-Editor-In-Chief Founder, Co-Editor-In-Chief The Journal of Implant & Advanced Clinical Dentistry • 13



Letters to the Editors JIACD has been a great addition for and a camaraderie building experience with your dentists to learn about the latest in peers. Additionally, you can receive feedback techniques and interdisciplinary care. from readers in over 80 countries in as quickly as The thing that has impressed me the most 3 to 6 months following submission. TRY IT! about this journal is that the information Dr. Tom Wilcko, Erie, Pennsylvania, USA is online, easy to access, and the quality of the photos and case presentations is JIACD brings to all aspects of dentistry some amazing. things that are lacking with other journals. Dr. Paul Rosen, Philadelphia, The articles are timely, relate to all aspects of Pennsylvania, USA dentistry, and are relevant to all readers. As a researcher and clinician, I appreciate the I really appreciate JIACD because it’s a timeliness of getting my articles published fundamental tool for both practitioner and AND reading the current research performed researcher in the field of Periodontology and by others in the field. This is what dentistry dental implant continuing education. What I has needed for a long time to help us all move prefer most is the reliability, the friendly use, and forward more quickly to deliver the best, latest, the extremely high quality of the images and the state-of-the-art care to our patients. interesting topics. Clinicians and scientists can Dr. Robert Horowitz, Scarsdale, New York, USA find clear clinical suggestions and solutions to new and old problems for daily practice. My complements on what you have Dr. Giulio Rasperini, Italy accomplished with this online publication. Content has been superb. What a service JIACD is a very informative and educational to implantology. online journal. Each issue educates with cutting Dr. Gary Henkel, Horsham, Pennsylvania, USA edge clinical technology. The best advantages of JIACD are unlimited openness to clinicians After reading several informative, well written all over the world. I highly recommend dental articles by highly respected educators and clinicians to become subscribers of JIACD. clinicians I was inspired to submit my own article Dr. Dong-Seok Sohn, Republic of Korea to JIACD. The editorial process was speedy and painless and the reviewers made some very The internet is now the medium of choice helpful suggestions actually improving my original for the timely distribution and collection of submission. I intend to continue writing for the knowledge. The editors and reviewers of journal as I am anxious to be a part of this superb JIACD understand the concept of “timely”. The online educational process. JIACD review process is thorough but streamlined Dr. Michael Toffler, New York, New York, USA The Journal of Implant & Advanced Clinical Dentistry • 15



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esthetics enhanced by technology Laser-Lok® Laser-Lok® dental implant at 8 years post-restoration showing superior microchannels crestal bone & tissue maintenance. Case courtesy of Cary A. Shapoff, DDS (Surgical); Jeffrey A. Babushkin, DDS (Restorative) BioHorizons 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. The effectiveness of Laser-Lok has been proven with over 15 years of in vitro, animal, and human studies at leading universities.† This patented precision laser surface treatment is unique within the industry as the only surface treatment shown to inhibit epithelial downgrowth, attract a true, physical connective tissue attachment to a predetermined zone on the implant and preserve the coronal level of bone; long term.‡ Laser-Lok is available on Tapered Internal, Single-stage, and Internal Implants. For more information, contact BioHorizons Customer Care: 1.888.246.8338 or shop online at www.biohorizons.com †Clinical References available. ‡Human Histologic Evidence of a Connective Tissue Attachment to a Dental Implant. M Nevins, ML Nevins, M Camelo, JL Boyesen, DM Kim. The International Journal of Periodontics & Restorative Dentistry. Vol. 28, No. 2, 2008. SPMP09051 REV D JUN 2009

The Reverse Pathway: Rubinstein et al Parameters for the Integration of Function and Aesthetics with Implants Sergio Rubinstein, DDS1 • Maurice A. Salama, DMD2 David A Garber, DMD2 • Henry Salama, DMD2 Abstract Implant Dentistry has evolved dramatically the restorative-esthetic final goal of therapy since it’s inception as an anchor for the to the beginning of the case where the initial fully edentulous patient population. Today, decisions are being made. Restorative driven more than ever, implants are being utilized for implant based decision making by the sur- the partially edentulous patient as segmen- geon will lead to the correct augmentation and tal or single tooth replacements where long implant selection for the specific needs of the term function and esthetics are of prominent patient. This “reverse pathway” approach is importance. The dental implant specialist must the protocol featured in this article to achieve therefore attempt to work backwards from excellent results and avoid complications. KEY WORDS: Dental implants, treatment planning, occlusion, prosthetics 1. Private practice, Skokie, Illinois, USA 2. Private practice, Atlanta, Georgia, USA The Journal of Implant & Advanced Clinical Dentistry • 19

Rubinstein et al Figure 1: Final crown on upper right central temporarily Figure 1a: Custom abutment torque tightened to 35 Ncm. cemented. Laboratory work by Fujiki Toshi, RDT. Soft tissue emergence pro le created with the provisional restoration. Laboratory work by Fujiki Toshi. Figure 1b: Ovate pontic after 3 weeks healing time created Figure 1c: Lateral view of poor tting crown with gingival with a provisional bonded restoration. Gingival margin recession on a tooth with hopeless prognosis. is higher than adjacent central because patient refused orthodontic treatment to supraerupt hopeless tooth. Bone grafting in addition to tissue molding with the provisional prosthesis was required to create the best possible soft tissue pro le. INTRODUCTION Knowledge, vision, ability, interdisciplinary treatment and technical support enable us to envi- Contemporary implant dentistry is more than sion the design of the final prosthesis for patients providing a patient with a titanium fixture and in the midst of complex problems with sequential restoration. When replacing a missing tooth, solutions as soon as a diagnosis is established. patients’ expectations are high from an aes- thetic, functional and health perspective. Suc- Before the introduction of the osseoin- cess is achieved in a reverse pathway by working tegrated implant, dentists often resorted to from an aesthetic goal to a healthy, support- heroic measures to maintain teeth with guarded ive foundation (Figures 1, 1a, 1b, 1c, 1d, 1e). or poor prognoses because quality replace- 20 • Vol. 2, No. 4 • May 2010

Rubinstein et al Figure 1d: Initial radiograph showing hopeless prognosis Figure 1e: Final radiograph showing Implant and nal of upper right central incisor. restoration. Implant placed by Dr. Maurice Salama. ments were not available. Endodontic treat- THE EVOLUTION OF IMPLANTS ment and prosthetic and surgical techniques AND CASE SELECTION such as hemisection and root amputation were employed to preserve tooth function and bone Osseointegrated titanium dental implant technology support.1-4 Today implant technology has revo- has made enormous progress since its introduction lutionized dentistry and improved the quality of in the early 1980s.7 A common problem with older life for patients with missing and nonviable teeth implants without anti-rotational properties and even by aesthetically restoring function and providing some that used an external anti-rotation hexagon long-term periodontal and peri-implant health.5,6 was screw loosening on the abutments, which led to instability of the overlying crown. The develop- The Journal of Implant & Advanced Clinical Dentistry • 21

Rubinstein et al ment of implants with external and internal anti-rota- ment27 while creating a seal that reduces bac- tion, improvements in abutment and screw design, terial invasion.28 When evaluating for optimum abutments with conical seals, and the availability bone preservation around an implant, we cannot of screw torque devices have enhanced the sta- separate from the implant design and its surface bility of abutments and prosthetic components.8-10 treatment its direct correlation to the prosthetic Surface treatments that promote osteoblast differ- component and connection.29 Furthermore, there entiation and new bone formation have shortened are too many variables to conclude that the pros- the time to osseointegration.11,12 Advances in bone thetic materials selected will have a more favorable grafting13,14 used to augment supporting bone or negative impact on the outcome.30,31 Among which often is thin or narrow and osteodistraction the variables with the current restorative materials techniques used to increase bone height15-18 have is acrylic, composite, gold, titanium, zirconia and expanded prosthetic options and optimized results. porcelain. It must be also considered the amount In addition, the use of 3-dimensional computed of implants, implant position, location and or angu- tomography assists in diagnosis and treatment lation, length and width, quantity and quality of planning, thus reducing surprises during surgery.19 bone. Understanding patient’s existing occlusion as well as parafunctional habits could influence on Appropriate case selection is critical to the overall treatment plan and material selection.31 avoid complications and achieve successful osseointegration. Visualizing the final restora- With no evidence based on the best occlu- tion before the treatment commence, allows the sal design and restorative material to be selected dentist to develop a treatment plan that cre- for the implant supported prosthesis and due to ates the infrastructure necessary for a durable the lack of a periodontal ligament, we must also implant prosthesis. Such treatment plans may consider factors that could negatively affect include orthodontia to supraerupt teeth in order the long term success and bone preservation to improve the quality and quantity of bone for of the implant-prosthetic unit such as: occlu- the future implant bed.16,20-25 This strategy may sal design, occlusal forces to prevent overload- reduce the size of the bone graft or eliminate the ing, large cantilevers, premature contacts.32 need for such surgical intervention altogether. Preserving Bone PARADIGM SHIFT FOR Postoperative bone preservation is key to implant OSSEOINTEGRATION success and must be continually evaluated both clinically (demonstrated by healthy, stable tissue) Minimizing Micromovement and and radiographically. Contributors to bone pres- Enhancing Occlusion ervation include the use of implants with exter- A growing trend in implant dentistry is to use an nal microthreads,33-35 loading of the implant to implant immediately after placement, with or with- a conical sealed abutment,36,37 and use of a nar- out a nonfunctional provisional.26 When immediate rower abutment-crown to implant connection38 use of the implant is planned, the choice of com- which directs the loading forces closer to the ponents must be guided by the need to minimize center of the implant and away from the exter- micromovement between the implant and abut- 22 • Vol. 2, No. 4 • May 2010

Rubinstein et al Figure 2: Implants placed with a 3 mm separation at bone Figure 3: Implants placed too close together can lead to level. Implants placed by Dr. Sidney Peskin. poor oral hygiene and bone loss. Figure 4: Implants placed more than 3 mm apart, which nal and most coronal threads, thereby helping requires over-contouring of the crowns to provide soft to reduce implant-abutment micromovement.27 tissue support. Implant Spacing: 3 mm versus 2 mm Since the introduction of the Branemark implant,7 bone loss at the uppermost coronal threads has been the norm, particularly for implants with flat-to- flat connections versus those with internal conical seals.37 To address one variable in this problem, there has been consensus in the literature that the recommended distance between 2 implants is 3 mm (Figure 2). This distance is sufficient to pre- vent implant encroachment and subsequent bone loss at the top threads (Figure 3).37 In addition, the 3 mm distance provides sufficient subgingi- val tissue support for the creation of papillae39-41 regardless of the gingival biotype (thick or thin) surrounding the implants.42,43 When implants are placed more than 3 mm apart, over-contouring of the crowns is necessary to provide papillae support (Figure 4). Even with such contouring, the resultant papillae will have a flatter architec- ture and will be in a more gingival location. On The Journal of Implant & Advanced Clinical Dentistry • 23

Rubinstein et al Figure 5: Radiograph showing implants replacing Figure 5a: Initial occlusal view of a lower right rst molar the mesial and distal roots on a rst molar. While the with a vertical fracture. interproximal placement is ideal, the implants could have been positioned an additional 1-2 mm subgingival. Implants placed by Dr. Nolen L. Levine. Figure 5b: Initial periapical radiograph. Figure 5c: Radiograph showing extraction of the rst molar due to a vertical fracture. Note the anatomic the other hand, spacing implants closer than 3 landmark of the original roots in the bone. mm may be advantageous in some scenarios. able (Figure 5).44-46 Short-term results suggest When the implants used provide optimal that 2 mm spacing does not compromise papil- bone preservation at the upper threads and, lae formation and offers excellent function and thus, achieve an excellent soft tissue response, a aesthetics. The 2 mm distance is also recom- 2mm distance between implants may be accept- mended when replacing missing anterior teeth. Considering the options of restoring two missing 24 • Vol. 2, No. 4 • May 2010

Rubinstein et al Figure 5d: Lateral view of the healing caps. Figure 5e: Occlusal view showing the abutment in place on the implant replacing the mesial root. The emergent soft tissue pro le from the implant replacing the distal root has been created by the healing cap. Figure 5f: Both abutments in place on each implant. Figure 5g: Occlusal view of metal try-in procedure. Only one screw is used to verify a passive t. anterior teeth with two implants and two crowns lae support will yield a more predictable result.39 versus one implant and two crowns, avoiding the cantilevered crown will enhance support without Retaining or Removing Molars compromising the aesthetic result. When one The decision to retain or remove a molar is based implant is supporting two crowns and one is can- on several factors: anatomy, periodontal, endodon- tilevered, following guidelines for proper papil- tic, and occlusal status, tooth position, quality The Journal of Implant & Advanced Clinical Dentistry • 25

Rubinstein et al Figure 5h: Radiograph showing proper t during metal Figure 5i: Occlusal view of nal crowns splinted and screw try-in. access covered with composite. Figure 5j: Buccal view of the nal crowns screw-retained. tooth influence treatment planning. The design Laboratory work by Fujiki Toshi, RDT. of all implants resembles a single root, whereas upper and lower molars generally have multiple and quantity of the remaining tooth structure roots. Furthermore, the burs used to prepare including existing microfractures, the ability to the implant bed typically produce cylindrical create a ferrule effect during tooth preparation, shapes with parallel or tapered walls. Con- the crown-to-root ratio, cost, and the anticipated sequently, in some instances a missing lower longevity of the tooth compared with that of an molar is best replaced with 2 implants to better implant (Figures 5a, 5b, 5c). When a molar is fit the extracted mesial and distal roots (Figure missing or must be extracted, anatomical dif- 5). The mesial-distal dimensions of the lower ferences between the implant and the natural molar require that the size of each implant be sufficiently thick to withstand occlusal forces while respecting the distance from the implant to a natural tooth and from implant to implant.41,42 Creating a Tissue Profile The tissue profile emerging from the implant is often created with a healing cap (Figure 5d) or an abutment (Figures 5e and 5f). Modification of the profile with a provisional may be necessary, and the final impression should not be taken until the correct soft tissue profile is created. 26 • Vol. 2, No. 4 • May 2010

Rubinstein et al Figure 7: Occlusal view showing implants with abutments in place. A milled and tapped telescopic crown is permanently cemented to a natural tooth. Figure 6: A tooth with a telescopic crown has intruded and Figure 7a: Occlusal view with the prosthesis in place screw pulled away from the prosthesis. retained on the implant abutments and telescopic crown of the molar to prevent intrusion and separation of the molar Impression Accuracy from the prosthesis. Figure 2 is the radiograph showing Impression techniques and proper material selec- excellent t and bone preservation around the tooth and tion are critical in order to accurately reproduce implants. on a model the position of the osseointegrated implant(s). While no significant differences are oral hygiene.31 When implants are connected described between polyether and vinyl polysi- prosthetically, it is essential that a passive fit be loxane materials47,48 the polyether material pro- verified clinically and in the laboratory.51-53 This vides superior detail reproduction in the presence is more easily accomplished if only one screw is of moisture,49 the direct impression technique used54 (Figures 5g and 5h). The assessment can is preferable to the indirect one as well as the be done clinically unless the crowns have subgin- polyether impression material being the most gival margins, in which case radiographic verifica- precise with the direct impression technique.50 tion is necessary.55,56 Figures 5i and 5j show the completed treatment, with the two premolars of Connecting Implants the implant restoration replacing one natural molar. The decision to connect implants prosthetically is determined by the quality of the bone, the char- Whether to connect implants and natural teeth acteristics of the implant, the patient’s occlu- sion, occlusal habits, existing restorations, and The Journal of Implant & Advanced Clinical Dentistry • 27

Rubinstein et al is controversial.57,58 Such connection can be Disclosure accomplished by using attachments, cementation The authors report no conflicts of interest with anything mentioned in this article. or screws. Connecting natural teeth to an implant- supported fixed partial denture with a cemented References restoration or semi-precision attachments may 1. Amen CR: Hemisection and root amputation. Periodontics 1966;4:197-204. result in separation and intrusion from the tooth (Figure 6 ).59 To avoid these complications, the 2. Abrams L, Trachtenberg DI: Hemisection: technique and res- natural tooth can have a crown accepting a lin- toration. Dent Clin North Am 1974;18(2):415-444. gual screw60 or must have a milled telescopic crown permanently cemented (Figure 7), and the 3. Goldman H, Cohen W: Periodontal Therapy. 5th edition. St. Louis, MO, fixed partial denture should be screw-retained G.V. Mosby Company, 1973. onto the telescopic crown and onto the implant abutments (Figure 7a, Figure 2). By retaining 4. Weine F: Endodontic Therapy. 2nd edition. St. Louis, MO, the implant supported prosthesis with a screw, C.V. Mosby Company, 1976. the need for using a cementation technique is eliminated, thus sustaining evaluation for over 14 5. Kois JC, Kan JY: Predictable peri-implant gingival aesthetics: surgical and years the hypothesis that such prosthetic designs Prosthodontic rationales. Pract Proced Aesthet Dent can prevent intrusion of the natural tooth/teeth.58 2001 Nov-Dec;13(9):691-698;quiz 700,721-722. CONCLUSION 6. Saadoun AP, LeGall M, Touati B: Selection and ideal tridimensional implant position for soft tissue aesthetics. Pract Proced Osseointegrated dental implants have dramati- Aesthet Dent 1999 Nov-Dec; 11(9):1063-1072; quiz 1074. cally advanced dental care by aesthetically restor- ing function in patients with missing and nonviable 7. Branemark PI, Zarb GA, Albrektson T: Tissue-Integrated Prostheses teeth. Implant success is influenced by appropriate Osseointegration in Clinical Dentistry. Chicago, IL, Quintessence case selection, visualizing the final result before the Publishing Company, 1985. treatment begins, and adherence to established parameters designed to reduce complications, max- 8. Burguete RL, Johns RB, King T, et al: Tightening characteristics for screwed imize bone preservation, and achieve durable res- joints in osseointegrated dental implants. J Prosthet Dent torations. As experience accumulates and implant 1994;71(6):592-599. technology evolves, paradigms are shifting. 9. Haack JE, Sakaguchi RL, Sun T, et al: Elongation and preload stress in dental Correspondence: implant abutment screws. Int J Oral Maxillofac Implants 1995;10(5):529-536. Dr. Sergio Rubinstein 4905 Old Orchard, Suite #420 10. Jorneus L, Jemt T, Carlsson L: Loads and designs of screw joints for Skokie, IL 60077 single crowns supported by osseointegrated implants. Int J Oral Maxillofac Telephone: 847-673-9292 Fax: 847-674-4696 Implants 1992;7(3):353-359. e-mail: [email protected] 11. Ellingsen JE: Pre-treatment of titanium implants with fluoride improves their retention in bone. J Mater Sci: Mater Med 1995;6:749-753. 12. Isa ZM, Schneider GB, Zaharias R, et al: Effects of fluoride-modified titanium surfaces on osteoblast proliferation and gene expression. Int J Oral Maxillofac Implants 2006;21(2):203-211. 13. Misch CM, Misch CE, Resnik RR, et al: Reconstruction of maxillary alveolar defects with mandibular symphysis grafts for dental implants: a preliminary procedural report. Int J Oral Maxillofac Implants 1992;7(3):360-366. 14. Scipioni A, Bruschi GB, Calesini G: The edentulous ridge expansion technique: a five-year study. Int J Periodontics Restorative Dent 1994;14(5):451-459. 15. Samchukov ML, Cope JB, Cherkashin AM: Craniofacial Distraction Osteogenesis. St. Louis, MO, Mosby, 2001. 16. Rubinstein S, Nidetz A, Hoshi M: A multidisciplinary approach to single-tooth replacement. Quintessence Dental Technology (QDT) 2004:157-175. 17. Jensen OT: Distraction osteogenesis and its use with dental implants. Dent Implantol Update 1999;10(5):33-36. 18. Kluemper TG, Van Sickels JE: Atlas of the Oral and Maxillofacial Surgery Clinics of North America: Orthodontic Perspectives in Surgical Orthodontics March 2001;9(1): 111-139. 19. Mandelaris GA, Rosenfeld AL: The expanding influence of computed tomography and the application of computer-guided implantology. Pract Proced Aesthet Dent 2008;20(5):297-305. 20. Salama H, Salama M: The role of orthodontic extrusive remodeling in the enhancement of soft and hard tissue profiles prior to implant placement: a systematic approach to the management of extraction site defects. Int J Periodontics Restorative Dent 1993;13(4):312-333. 21. Korayem M, Flores-Mir C, Nassar U, et al: Implant site development by orth- odontic extrusion: A systematic review. Angle Orthod 2008;78(4):752-760. 28 • Vol. 2, No. 4 • May 2010

Rubinstein et al 22. Ghezzi C, Masiero S, Silvestri M, et al: Orthodontic treatment of periodontally 43. Saadoun AP, Touati B: Soft tissue recession around implants: is it still involved teeth after tissue regeneration. Int J Periodontics unavoidable? - Part I. Pract Proced Aesthet Dent 2007;19(1):55-62. Restorative Dent 2008 Dec;28(6):559-567. 44. Rubinstein S, Nidetz A, Heffez L, et al: Prosthetic management of implants 23. Maeda S, Ono Y, Nakamura K, et al: Molar uprighting with extrusion for with different osseous levels. Quintessence Dental Technology (QDT) implant site bone regeneration and improvement of the periodontal environ- 2006:147-156. ment. Int J Periodontics Restorative Dent 2008 Aug;28(4):375-381. 45. Moscovitch M: Molar Restorations Supported by 2 implants: An Alternative 24. Ogihara S, Marks MH: Enhancing the regenerative potential of guided tis- To Wide Implants. J Can Dent Assoc 2001;67(9):535-539. sue regeneration to treat an intrabony defect and adjacent ridge deformity by orthodontic extrusive force. J Periodontol 2006 Dec;77(12):2093-2100. 46. Balshi TJ, Hernandez RE,Pryslak MC, et al: A Comparative study of one implant versus two replacing a single molar. Int J Oral Maxillofac Implants 1996; 25. Rubinstein S, Bery P: Endodontic-restorative symbioses: Diagnosis 11(3):372-378. and treatment. Roots Journal, Vol.2, 2007, pp 31-38. 47. Lee H, So JS, Hochstedler JL, et al: The accuracy of implant impressions: 26. Tarnow DP, Emtiaz S, Classi A: Immediate loading of threaded implants at a systematic review. J Prosthet Dent 2008 Oct;100(4):285-291. stage 1 surgery in edentulous arches: ten consecutive case reports with 1 to 5-year data. Int J Oral Maxillofac Implants 1997;12(3):319-324. 48. Daoudi MF, Setchell DJ, Searson LJ: A laboratory investigation of the accuracy of two impression techniques for single-tooth implants. 27. Zipprich H, Weigl P, Lange B, et al: Micromovements at the implant-abutment Int J Prosthodont 2001 Mar-Apr;14(2):152-158. interface: measurement, causes, and consequences. Implantologie 2007;15(1):31-46. 49. Walker MP, Petrie CS, Haj-Ali R, et al: Moisture effect on poly- ether and polyvinylsiloxane dimensional accuracy and detail 28. Dibart S, Warbington M, Su MF, et al: In vitro evaluation of the implant-abutment reproduction. J Prosthodont 2005 Sep;14(3):158-163. bacterial seal: the locking taper system. Int J Oral Maxillofac Implants 2005;20(5):732-737. 50. Bambini F, Ginetti L, Mem L, et al: Comparative analysis of direct and indirect impression techniques an in vitro study: An in vitro study. 29. Norton MR: Marginal bone levels at single tooth implants with a conical fixture Minerva Stomatol 2005 Jun;54(6):395-402. design: The influence of surface macro-and microstructure. Clin Oral Implants Res 1998 Apr;9(2):91-99. 51. Duyck J, Van Oosterwyck H, Vander Sloten J, et al: Pre-load on oral implants after screw tightening fixed full prostheses: an in vivo study. 30. Carlsson GE: Dental occlusion: modern concepts and their application J Oral Rehabil 2001 Mar;28(3):226-233. in implant prosthodontics. Odontology 2009 Jan;97(1):8-17. 52. Natali AN, Gasparetto A, Carniel EL, et al: Interaction phenomena 31. Stanford CM: Issues and considerations in dental implant occlusion: between oral implants and bone tissue in single and multiple implant what do we know, and what do we need to find out? J. Calif Dent Assoc 2005 frames under occlusal loads and misfit conditions: A numerical approach. Apr;33(4);329-336. J Biomed Mater Res B Appl Biomater 2007 Nov;83(2):332-339. 32. Kim Y, Oh TJ, Misch CE,et al: Occlusal considerations in implant therapy: 53. de Sousa SA, de Arruda Nobilo MA, Henriques GE, et al: Passive fit of frame- clinical guidelines with biomechanical rationale. Clin Oral Implant Res 2005 works in titanium and palladium-silver alloy submitted the laser welding. Feb;16(1):26-35. J Oral Rehabil 2008 Feb;35(2):123-127. 33. Hansson S: The implant neck: smooth or provided with retention elements. 54. de Torres EM, Rodrigues RC, de Mattos Mda G, et al: The effect of A biomechanical approach. Clin Oral Implants Res 1999;10(5):394-405. commercially pure titanium and alternative dental alloys on the marginal fit of one-piece cast implant frameworks. J Dent 2007 Oct;35(10):800-805; 34. Hansson S, Werke M: The implant thread as a retention element in cortical Epub 2007 Sept 6. bone: the effect of thread size and thread profile: a finite element study. J Biomech 2003;36(9):1247-1258. 55. Wee AG, Aquilino SA, Schneider RL: Strategies to achieve fit in implant prosth- odontics: a review of the literature. Int J Prosthodont 1999;12(2):167-178. 35. Lee DW, Choi YS, Park KH, et al: Effect of microthread on the maintenance of marginal bone level: a 3-year prospective study. Clin Oral Implants 56. Polack MA, Mahn DH: The aesthetic replacement of mandibular inci- Res 2007;18(4):465-470. sors using an implant-supported fixed partial denture with gingival-colored ceramics. Pract Proced Aesthet Dent 2007;19(10):597-603; quiz 604. 36. Puchades-Roman L, Palmer RM, Palmer PJ, et al: A clinical, radiographic, and microbiologic comparison of Astra Tech and Branemark single 57. English CE: Implant-supported versus implant-Natural-tooth sup- tooth implants. Clin Implant Dent Relat Res 2000;2(2):78-84. ported fixed partial dentures. J Dent Symp 1993 Aug;1:10-15. 37. Hansson S: Implant-abutment interface: biomechanical study of flat 58. Fugazzotto PA, Kirsche A, Ackerman KL,et al: Implant/tooth-connected restora- top versus conical. Clin Implant Dent Relat Res 2000;2(1):33-41. tions utilizing screw-fixed attachments: a survey of 3,096 sites in function for 3-14 years. Int J Oral Maxillofac Implants 1999 Nov-Dec;14(6):819-823. 38. Baumgarten H, Cocchetto R, Testori T, et al: A new implant design for crestal bone preservation: initial observations and case 59. Sheets CG, Earthman JC: Tooth intrusion in implant-assisted prostheses. report. Pract Proced Aesthet Dent 2005;17(10):735-740. J Prosthet Dent 1997;77(1):39-45. 39. Salama H, Salama MA, Garber D, et al: The interproximal height of bone: a 60. Spear F: Connecting teeth to implants: The truth about a debated technique. guidepost to predictable aesthetic strategies and soft tissue contours in anterior J Am Dent Assoc 2009 May;Vol 140:587-593. tooth replacement. Pract Periodontics Aesthet Dent 1998;10(9):1131-1141. 40. Tarnow DP, Cho SC, Wallace SS: The effect of inter-implant distance on the height of inter-implant bone crest. J Periodontol 2000;71(4):546-549. 41. Elian N, Jalbout ZN, Cho SC, et al: Realities and limitations in the management of the interdental papilla between implants: three case reports. Pract Proced Aesthet Dent 2003;15(10):737-744. 42. Mathews DP: Soft tissue management around implants in the esthetic zone. Int J Periodontics Restorative Dent 2000;20(2):141-149. The Journal of Implant & Advanced Clinical Dentistry • 29

Maiorana et al

every [email protected]



A New Approach for Post Extractive Site PreservMataiioornana et al by using a Free Gingival Graft: A Case Report Carlo Maiorana MD, DDS1 • Stefano Speroni, DDS, PhD2 Marco Cicciù, DDS, PhD2 Abstract Background: The role of the keratinized gery was needed to increase keratinized tissue mucosa is a controversial issue and is still around the implants. Final prosthetic restoration being studied by clinicians. The alveolar bone was achieved 12 months after the first surgery. resorption after teeth extraction is a condition that could influence the planning of future den- Results: At the 24-month follow-up visit, tal implant positioning. This case report docu- the implants were osseointegrated. Clini- ments a new procedure termed “the snake cal and radiological investigation con- technique” for peri-implant soft tissue manage- firmed no infection, no bone loss around the ment in an aesthetic area after teeth extraction. implants and good healing of the soft tissues. Methods: Treatment of this case involved sev- Conclusion: The preservation of the dimen- eral surgeries. At the first surgery, 4 periodon- sion of periodontal soft tissue structures such tally diseased maxillary incisors were extracted; as, alveolar bone and supracrestal connec- at the same time a soft tissue tunnel between tive tissue is a hotly debated topic in recent lit- each alveolar area was created by the surgeon erature. This case reports demonstrates how and a free gingival graft was placed inside. final aesthetic outcomes cannot be related Three weeks later, total preservation of the to a single parameter, but that all surgical and ridge’s tridimensional volume was obtained. prosthetic stages are important to obtain good Six months after the surgery, 2 dental implants results. The new technique presented in this were placed and bone tissue was regenerated report seems to be useful for the preservation using guided bone regeneration. Before pros- of hard and soft tissue after teeth extraction. thesis positioning, an additional soft tissue sur- KEY WORDS: Soft tissue, teeth extraction, dental implants, gingival graft 1. Chairman and Head, Department of Oral Surgery and Implantology, University of Milan, Milan, Italy 2. Department of Oral Surgery and Implantology, University of Milan, Milan Italy The Journal of Implant & Advanced Clinical Dentistry • 33

Maiorana et al INTRODUCTION Figure 1: Preoperative intraoral view of periodontally involved dentition. The progressive involution of the alveolar bone begins following tooth loss and it is accompanied neic and alloplastic bone grafts have been used in by a reduction in both the quality and quantity attempts to preserve the alveolar ridge following of hard and soft tissues. To estimate the appro- tooth extraction, but none guarantee total preser- priate time for implant insertion, it is essential to vation of the socket after tooth extraction.3,4,13-15 understand the healing events that occur after Some clinicians have suggested covering post- tooth extraction.1 After extracting natural teeth, extraction socket bone grafts with free gingival the greatest reduction of the alveolar bone occurs grafts to maintain the alveolar bone volume.16-19 in the first 6 months to 2 years.2-4 An estimate Consequently, a systematic review of the recent of 25% decrease in buccopalatal width occurs literature confirms that nothing is mentioned within the first year.4-8 For this reason, within the about a free gingival graft placed onto the alveo- last decade, the ‘gold standard’ implant treatment lar socket without bone substitute in order to pre- protocol has been challenged by experiments aim- serve the organization of the clot. The aim of this ing at shortening the treatment period and reduc- report was to suggest a new technique obtained ing the number of surgical procedures. A review with a gingival free graft inserted in a post of dental literature demonstrates that it is no lon- extraction site with a tunnel-fashion procedure. ger needed to wait for complete healing of the extraction socket before implant placement.9-12 CASE REPORT Surgical diagnosis and analysis before starting A 42 year old female was referred to the Implan- implant therapy are assuming a great position of tology Department of the University of Milan for significance above all else in aesthetic areas. The evaluation of the upper incisors and the conse- achievement of proper soft tissue architecture with quent aesthetic rehabilitation of the frontal area. respect tooth-to-gingiva ratio should be consid- The clinical examination revealed the presence ered in order to achieve a gratifying clinical result of periodontal disease of the upper incisors for the patient and surgeon. Different pre-implant with severe mobility. Radiographic examination surgical procedures are available in the case of tooth extraction to maintain an excellent quantity of mucosa and avoid soft tissues collapse. During the healing process following tooth extraction, the edentulous site will undergo a remarkable change; the walls of the socket will reduce and the change of the buccal wall will be more pronounced than that of its lingual/palatal counterpart. Moreover, the space previously occupied by the root of the tooth and its periodontal ligament will be replaced mainly by the bone marrow. Various graft mate- rials including autogenous, allogenous, xenoge- 34 • Vol. 2, No. 4 • May 2010

Maiorana et al Figure 2: Fresh sockets after teeth extraction. Figure 3: A connection between each alveoli is performed. Figure 4: A free gingival graft is harvested from the palate Figure 5: Harvested free gingival graft. area. Figure 6: Graft placed inside subpapillary tunnel and xed revealed an insufficient quantity of bone in the by suture. upper incisors area (figure 1). A treatment plan involving teeth extraction, fresh socket preserva- tion by a free gingival graft (harvested from the palate and inserted in a tunnel created under the papillae), bone reconstruction and dental implant placement was proposed to the patient by the surgical team. The patient agreed to undergo treatment and informed consent was signed. The patient was started on antimicro- bial therapy 1 day prior to surgery with 1,000 mg amoxicillin (Zimx® PFIZER ITALIA) twice per The Journal of Implant & Advanced Clinical Dentistry • 35

Maiorana et al Figure 7: Three weeks after suture removal. Soft tissue Figure 8: Dental implants positioned. healing. Occlusal view. Figure 9: Healing at 3 months after surgery. Occlusal view. Figure 10: Healing at 3 months after surgery. Frontal view. Quantity of buccal keratinized mucosa was determined to day. At surgery, local anaesthesia was induced be insu cient. by infiltration with 4% articaine with 1:200,000 epinephrine. Extractions of the maxillary incisors quantity of soft tissue was needed to simplify the were performed (figure 2). Next, a free gingival regenerative manoeuvres. In fact, a simple extrac- graft was harvested from the palate and a tunnel tion without graft positioning would have led to was created by the surgeon to connect the papilla a collapse of the tissue with insufficient soft tis- of each socket (figure 3). In order to promote cor- sue available. This particular technique promotes rect healing of the graft, epithelium was removed a preservation of the clot and a better healing of from the graft where it tunnelled beneath papil- the bone wound. Simple 4-0 absorbable and 5-0 lae (figures 4-6). The presence of an adequate non-resorbable sutures were used to stabilize the position of the graft and to facilitate a good healing of the wound. Finally, a provisional resin 36 • Vol. 2, No. 4 • May 2010

Maiorana et al Figure 11: Half thickness ap was elevated and connective Figure 12: Connective tissue from palatal area is buccally tissue from palatal area is buccally placed. placed. Occlusal view. Figure 13: Provisional prosthetic crowns positioned for Figure 14: Soft tissue healing at the time of positioning tissue conditioning. de nitive prosthetic crowns. prosthetic restoration was placed over the defect. upper canines and two Astra® dental implants Sutures were removed at the second week were positioned with a prosthetic guide (figure 8). The surgical area was irrigated with saline of follow up. The three week clinical control solution, bovine deproteinized bone (Bio-Oss showed that the soft tissue healing was une- Geistlich CH®) was used for ridge reconstruc- ventful (figure 7) and a provisional Maryland tion, and two resorbable membranes were type bridge was maintained. Three months after positioned upon the bone grafts. Post surgical extraction of the teeth, the second surgery was analgesic treatment was achieved with 100 mg performed. After local anaesthesia induction, a Nimesulide (Aulin®, Roche CH) twice per day for mucoperiostal flap was elevated with an incision 5 days and sutures were removed 14 days later. running on the middle of the crest between the The Journal of Implant & Advanced Clinical Dentistry • 37

Maiorana et al Figure 15: De nitive ceramic crowns with patient’s normal Figure 16: Final prosthetic restoration. smile. gration of the dental implants (figures 15,16). Soft tissue healing at 14 days was within normal limits, no infection was apparent, and DISCUSSION provisional resin crowns were positioned. After three months of healing (figure 9), the quan- The technique used in this clinical case consid- tity of buccal keratinized mucosa was deter- ers the guidelines and concepts of mucogingi- mined to be insufficient (figure 10). For this val therapy originally introduced in the 1980’s. reason, a connective tissue graft was taken In those clinical studies, techniques of soft tis- from the palate and buccally positioned to sue thickness augmentation and root coverage increase the keratinized mucosa at the time with palatal grafts were described.20-23 Oth- of the implant uncovering (figures 11,12). erwise, the literature justifies the use of bone Next, the transfers were placed over the grafting materials in freshly extracted sock- implants to take position impressions. Four ets. When demineralized freeze-dried bone weeks later, provisional prosthetic crowns allograft (DFDBA) is used in conjunction with were placed for better soft tissue condition- a collagen membrane in extraction sites, stud- ing over definitive abutments (figure 13). ies show that alveolar ridge width is relatively preserved, while it decreases significantly Approximately 12 months after teeth extrac- when no graft is used.24 Even with no barrier tion, the removal of the provisional prosthesis membranes, a socket fill of nearly 85% can be revealed excellent soft tissue healing (figure achieved by placing porous bovine bone min- 14). Gingivoplasty was performed on the buc- eral in fresh extraction sites. However, the cal surface to reduce excess tissue bulk and application in the fresh socket of deprotein- the final ceramic crowns were cemented. At ized bovine bone or bovine collagen seems 24 months after extraction, the patient showed to have the potential to limit but not avoid a good amount of keratinized mucosa and the the post-operative contour shrinkage.25-27 radiographic investigation revealed osseointe- 38 • Vol. 2, No. 4 • May 2010

Maiorana et al CONCLUSION to assist the clinician in achieving an ideal aes- thetic treatment result. Maintenance of an Dimensional changes following tooth extrac- extraction socket for future implant therapy tion often result in a bone resorption that com- does not exclude immediate implant placement, plicates restorations with implants or traditional but knowledge and experience are needed prostheses. Preservation of alveolar dimen- to determine the best treatment modality. sions following tooth extraction is crucial to achieve optimal aesthetic and functional prosth- Correspondence: odontic results. Additionally, with the increas- Dr Marco Cicciù ingly frequent use of dental implants to replace Department of Oral Surgery, non-restorable teeth, preservation of the exist- Dental Clinic, IRCCS, Milan ing alveolus is essential to maintain adequate Via Commenda n°10, 20122, Milano, Italy. bone volume for placement and stabilization of Tel.: 0039-02-55032621 the implants. Atraumatic extraction and socket Fax: 0039-02-666686 preservation techniques have been introduced E-mail: [email protected] to minimize bone resorption after tooth extrac- tion. Numerous techniques for surgical hard and soft tissue management are available today Disclosure 10. Oltramari PV, Navarro R, Henriques JF, Taga 19. Fowler EB, Breault LG, Rebitski G.Ridge The authors report no conflicts of interest with R, Cestari TM, Janson G, Granjeiro JM. preservation utilizing an acellular dermal allograft anything mentioned in this article. Evaluation of bone height and bone density and demineralized freeze-dried bone allograft: References after tooth extraction: an experimental study in Part I. A report of 2 cases. J Periodontol 1. Bianchi AE, Sanfilippo F. Single-tooth minipigs. Oral Surg Oral Med Oral Pathol Oral 2000;71(8):1353-1359. Radiol Endod 2007;104(5):9-16. replacement by immediate implant and connective 20. Langer B. Calagna L. Subephitelial tissue graft: a 1-9-year clinical evaluation. Clin 11. Shi B, Zhou Y, Wang YN, Cheng XR. Alveolar connective tissue graft: a new approach to the Oral Implants Res 2004;15(3):269-277. ridge preservation prior to implant placement enhancement of anterior cosmetics. Int J 2. Carlsson GE, Ragnarson N, Astrand P. Changes with surgical-grade calcium sulfate and platelet- Periodontics Rest Dent 1982;2:23. in height of the alveolar process in edentulous rich plasma: a pilot study in a canine model. Int J segments. A longitudinal clinical and radiographic Oral Maxillofac Implants 2007;22(4):656-665. 21. Rosenberg E, Garber DA, Malinowski A. study of full upper denture cases with residual Considerations in the utilization of the free lower anteriors. Odontol Tidskr 1967;75(3):193- 12. Irinakis T, Tabesh M. Preserving the socket gingival graft. Quintessence Int Dent Dig 208. dimensions with bone grafting in single sites: 1981;12(9):927-932. 3. Araújo MG, Sukekava F, Wennström JL, Lindhe J. an esthetic surgical approach when planning Ridge alterations following implant placement in delayed implant placement. J Oral Implantol 22. Caffesse RG, Espinel MC. Lateral sliding fresh extraction sockets: an experimental study in 2007;33(3):156-163. flap with a free gingival graft technique in the the dog. J Clin Periodontol 2005;32(6):645-652. treatment of localized gingival recessions. Int J 4. Araújo MG, Lindhe J. Dimensional ridge 13. Cobankara FK, Ungor M. Replantation after Periodontics Restorative Dent 1981;1(6):22-29. alterations following tooth extraction. An extended dry storage of avulsed permanent experimental study in the dog. J Clin Periodontol incisors: report of a case. Dent Traumatol 23. Matter J. Free gingival grafts for the treatment of 2005;32(2):212-218. 2007;23(4):251-256. gingival recession. A review of some techniques. 5. Tallgren A. The continuing reduction of the J Clin Periodontol 1982;9(2):103-114. residual alveolar ridges in complete denture 14. Babbush CA. A new atraumatic system for tooth wearers: a mixed-longitudinal study covering 25 removal and immediate implant restoration. 24. Iasella JM, Greenwell H, Miller RL, Hill M, Drisko years. J Prosthet Dent 1972; 27(2):120-132. Implant Dent 2007;16(2):139-145. C, Bohra AA. Ridge preservation with freeze- 6. Misch CE. Dental education--meeting the dried bone allograft and a collagen membrane demands of implant dentistry. J Am Dent Assoc 15. Rothamel D, Schwarz F, Herten M, Chiriac G, compared to extraction alone for implant site 1990; 121(3):334-338. Pakravan N, Sager M, Becker J. Dimensional development: a clinical and histologic study in 7. Landsberg CJ. Implementing socket seal surgery ridge alterations following tooth extraction. An humans. J Periodontol 2003;74(7):990–999. as a socket preservation technique for pontic site experimental study in the dog. Mund Kiefer development: surgical steps revisited--a report of Gesichtschir 2007;11(2):89-97.German. 25. Artzi Z, Tal H, Dayan D. Porous bovine bone two cases. J Periodontol 2008;79(5):945-954. mineral in healing of human extraction sockets. 8. John V, De Poi R, Blanchard S. Socket 16. Irinakis T. Rationale for socket preservation after Part 1: histomorphometric evaluations at 9 preservation as a precursor of future implant extraction of a single-rooted tooth when planning months. J Periodontol 2000;71(6):1015-1023. placement: review of the literature and for future implant placement. J Can Dent Assoc case reports. Compend Contin Educ Dent 2006;72(10):917-922. 26. Fickl S, Zuhr O, Wachtel H, Stappert CF, Stein 2007;28(12):646-653. JM, Hürzeler MB. Dimensional changes of the 9. Keith JD Jr, Salama MA. Ridge preservation and 17. Hong HH, Tsai AI, Liang CH, Kuo SB, alveolar ridge contour after different socket augmentation using regenerative materials to Chen CC, Tsai TP, Lu CF. Preserving pulpal preservation techniques. J Clin Periodontol enhance implant predictability and esthetics. health of a geminated maxillary lateral incisor 2008;35(10):906-913. Compend Contin Educ Dent 2007;28(11):614-621 through multidisciplinary care. Int Endod J 2006;39(9):730-737. 27. Carmagnola D, Adriaens P, Berglundh T. Healing of human extraction sockets filled with Bio-Oss. 18. Fowler EB, Breault LG, Rebitski G. Ridge Clin Oral Implants Res 2003; 14(2):137–143. preservation utilizing an acellular dermal allograft and demineralized freeze-dried bone allograft: Part II. Immediate endosseous implant placement. J Periodontol 2000;71(8):1360-1364. The Journal of Implant & Advanced Clinical Dentistry • 39





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Rehabilitation of Complex Cases Using Obturator Moraes Prostheses and Zygomatic Implants: A Report of 2 Cases Eduardo José de Moraes, MSc 1 Abstract Defects in the maxilla associated with oro- contributes to inadequate stability. The literature antral and oronasal communications demonstres that intra-oral endosseous implants generally affect patient’s function and help in retaining the obturator prosthesis with sat- esthetics leading to emotional imbalance. Recon- isfactory results. The present article is a report of 2 structive surgery is an option, but sometimes pres- clinical cases in which patients were rehabilitated ents unsatisfactory results. Rehabilitation using with obturator prostheses over conventional and obturator prostheses in edentulous patients often zygomatic implants, with a follow-up of 2 years. KEY WORDS: zygomatic implants, complex cases, obturator prostheses 1. Associated professor, post graduate program, oral implantology course, UNIFESO- Centro Universitario Serra dos Órgãos, Teresópolis, Rio de Janeiro, Brazil. The Journal of Implant & Advanced Clinical Dentistry • 43

Moraes INTRODUCTION of 4 zygomatic implants has been referred in the literature as a viable alternative and with high suc- The difficulty in rehabilitating edentulous patients cess rates.15,16 The bone density presented by with maxillary defects is a recurrent theme in the lit- the zygomatic bone favors good initial anchorage erature mainly due to the limitations generated for of the implant, thus enabling rehabilitation with these patients.1 Partial resections of the maxilla for prostheses over implants submitted to immediate removal of tumors generally affect speech, masti- load.17-20 Some authors believe that the use of cation, deglutition (swallowing) and facial esthetics zygomatic implants enables better stabilization of and leads to emotional imbalance.2,3 Obturation of obturator prostheses in the post ressected maxilla the oroantral communication in the maxilla through promoting better quality of life to the patient.14,21 plastic surgery with the use of myocutaneous or osteomyocutaneous graft surgery is a feasible This article consists of a presentation of treatment option but depends on the size of the clinical cases in which patients presented post resection defect and frequently presents wth oroantral communications and were unsatisfactory results in some situations.4,5 In some rehabilitated with obturator prostheses over cases obturator prostheses in patients with oro- conventional and zygomatic implants. Fol- antronasal defects represent the only chance for low up period was approximately 2 years. fistula occlusion with the possibility of improving their general conditions.6 However, the absence CASE 1 of teeth often contributes to inadequate stability of an obturator prosthesis thus jeopardizing its func- In April 2005, patient A.H.J, male, 76 years old, tion and esthetics.7 Some authors demonstrated complained about the presence of an oroantral that the use of endosseous implants can improve communication which was affecting the stabili- retention of obturators in the maxilla.3,7-9 Weischer zation of a standard total prosthesis. He said he et al demonstrated that intra-oral endosseous had been submitted to an unsuccessful recon- implants placed in a ressected region close or structive surgery with onlay graft from the iliac anchored to the zygomatic bone help in retaining crest for closure of the oroantral communication. the obturator prosthesis with satisfactory results. During the physical exam an oroantral fistula was found with exposure of the fixed bone blocks Zygomatic implants were initially proposed that presented loosening with signs of necrosis. by Brånemark with the objective of rehabilitat- According to the patient, he had been submit- ing patients with defects and severe maxillary ted to reconstructive surgery with extra-oral graft atrophies.10 Zygomatic implants are currently from the iliac crest at which point the bone blocks an important option for rehabilitation of atro- were installed for closure of the fistula (Figure 1). phic ridges. The classic technique proposes the use and placement of standard implants in the After clinical evaluation, a treatment plan was anterior region of the maxilla with 2 zygomatic proposed together with imaging studies - pan- implants installed, one on each side anchored oramic X-Ray and CT. A steriolithographic model to the zygoma and remaining maxillary osseous was also used in the treatment plan which was crest.11-14 In more critical conditions the utilization generated based on a three-dimensional (3D) edi- tion of computed tomography (CT) data (Figure 2). 44 • Vol. 2, No. 4 • May 2010

Moraes Figure 1: Clinical view of iliac bone blocks with signs of Figure 2: Stereolithographic model for Case 1. necrosis in Case 1. implants, a pediculated flap with bilateral buccal Treatment plan fat pad was made.22 All standard and zygomatic Surgery for the installation of zygomatic implants implants were anchored with a 45 N.cm torque. was proposed because of the patient’s critical con- dition and was performed in April 2006. A supra- During surgery, micro-unit type abutment pros- crestal midline incision was made with the patient thetic components at 30 degree angles in zygo- under general anesthesia, broad detachment for matic implants and straight abutments in standard exposure of the zygomatic bones bilaterally and the implants were installed. Then, transfers were placed remaining bilateral region of the maxilla. The tita- for molding and registers with a multifunctional nium micro-screws were removed and two implants acrylic guide were done after suturing the flap. From Sistema Conic (Conexão Sistema de Prótese – this register a cast model and gold metallic super- São Paulo – Brazil) of 3.5 mm diameter and 10 mm structures were manufactured. Initially, two milled length were installed in the pterygopalatine region metallic structures in gold screwed separately over bilaterally. Four zygomatic implants with inner hexa- the zygomatic implant abutments were installed, gon Sistema Zigomax (Conexão Sistema de Pró- one on each side. Another telescopic supra-struc- tese – São Paulo – Brazil) of 4.0 mm diameter and ture was also made and screwed onto the abut- 30 mm length were also installed – 2 on each side. ments of the standard implants bilaterally and Due to the extension of the oroantral communica- placed on the milled supra-structures previously tion, we noticed an absence of remnant maxillary fixed onto the zygomatic implants. This telescopic bone. Thus, given the magnitude of the defects, the structure was manufactured in gold with a metal- zygomatic implants only acquired anchorage in the lic counter–bar and two precision attachments body of the zygoma, as opposed to the traditional from the MK 1 System (MK 1 Dental-Attachment technique. So as to increase the amount of tissue GmbH – Zetel – Germany) installed bilaterally. An and mucosal scar retraction near the zygomatic “overdenture” acrylic prosthesis was made and The Journal of Implant & Advanced Clinical Dentistry • 45

Moraes Figure 3: Cast model with two milled gold superstructures. Figure 4: Telescopic gold structure. Figure 5: Intra-oral view of two milled gold Figure 6: Intra-oral view of telescopic structure in Case 1. superstructures in Case 1. with the loss of one implant, the supra-struc- installed fifteen days after surgery (Figures 3-8). ture and the prosthesis were maintained. The The patient had a monthly follow up and the patient was followed up for 2 years without pre- senting problems in the implants (Figures 9-12). superstructure was removed after 6 months.19 Osseointegration of the implants was tested CASE 2 through a reverse torque test (10 Ncm) which is an indicator of clinical stability and percus- In July 2006, patient D.H, 45 years old, female, sion over the abutment.14 No implants presented reported having been submitted for hemi- loosening, except for a standard implant in the maxillectomy for resection of a benign maxil- pterygopalatine region on the left side which lary tumor performed about 30 years ago. She presented loosening and was removed. Even 46 • Vol. 2, No. 4 • May 2010

Moraes Figure 7: The overdenture with Counter-bar. Figure 8: The prosthesis installed with the MK 1 system. Figure 9: Final radiographic image of Case 1. Figure 10: The esthetic condition of patient in Case 1. was using an obturator prosthesis, complained Treatment plan about prosthesis instability and phonatory dif- Under general anesthesia, an incision in the ficulties. The physical exam showed an oro- remaining zygomatic region on the right side was antral communication and the presence of performed with a vertical medial incision, detach- remaining bone on the left side only (Figures 13,14). ment of the flap and installation of two long implants of 4.0 mm diameter and 21 mm length A treatment plan was proposed after the clinical of inner hexagon. On the left side a supracrestal evaluation together with imaging tests – panoramic incision was made, detachment and installation of X-Ray and CT. A stereolithographic model that was two zygomatic implants of 4.0 mm diameter and generated based on three-dimensional (3D) CT 30 mm length of outer hexagon. The implants images was also included in the plan (Figure 15). The Journal of Implant & Advanced Clinical Dentistry • 47

Moraes Figure 11: Intra-oral view of telescopic structure after 2 Figure 12: Radiographic exam of Case 1 after 2 years. years. Figure 13: Case 2 intra-oral view with oronasal Figure 14: Case 2 original prosthesis. communication. acrylic guide that had been made previously by installed were of Sistema Conexão (Conexão reproducing the patient’s former prosthesis. A Sistemas de Prótese – São Paulo – Brazil) were working model and a metallic superstructure in placed, two on each side. An important piece of nickel-chrome were produced. The structure was information to bear in mind is that the implants screwed onto the implant abutments so as to were anchored with a 45 Ncm torque (Figure 16). make an overdenture with the bar and clip sys- tem installed five days after surgery. The patient Micro-unit type abutment prosthetic compo- was monitored every month and the superstruc- nents were inserted in the zygomatic implants. ture was removed after 6 months.19 Osseointe- Later on, transfers were fixed for impression and registers were performed with a multifunctional 48 • Vol. 2, No. 4 • May 2010

Moraes Figure 15: Stereolithographic model for Case 2. Figure 16: Implants placed during surgery on Case 2. Figure 17a: The metallic superstructure after a period of 2 Figure 17b: The esthetic condition of Case 2 after a period years in Case 2. of 2 years. gration of implants was tested utilizing a reverse sive oroantral communications is a big challenge torque test (10 Ncm) which is an indicator of clini- because of the critical conditions caused by this cal stability and percussion over the abutment.14 type of defect.3 Although onlay grafts and myo- No implant presented loosening and the patient cutaneous and osteomyocutaneous grafts are was followed up for 20 months without presenting referred to as treatment options, they imply more complications with the implants (Figures 17a,17b). invasive surgery and the need for surgical access to other donor sites with unpredictable results.4,5,21 DISCUSSION Standard obturator prostheses have been Prosthetic rehabilitation of patients with exten- used but are unsatisfactory because they limit the The Journal of Implant & Advanced Clinical Dentistry • 49

Moraes patient’s esthetic and functional conditions and a viable and predictable option compatible with may lead to emotional problems.6,3 Other authors the results found in the literature.15,16 It is important consider that the results presented in the literature to emphasize that the zygomatic bone presents for rehabilitation with 2 and 4 zygomatic implants good bone density and favors an initial anchor- are encouraging.11,12,14-16 Landes et al. demon- age of 45 Ncm, which enables immediate load as strated that rehabilitation with obturator pros- was shown in this paper, thus proving statements theses made over zygomatic implants presented in the literature regarding this proposal.17,18,19,20 satisfactory stability, thus improving patients’ qual- On the other hand, complex obturator prostheses ity of life. This paper proves this point with the over zygomatic implants installed in an atypical presentation of 2 cases in which patients with way generates unfavorable biomechanical condi- oroantral communications and standard obtura- tions for the implants.21 More conclusive scientific tor prostheses were not satisfied with the condi- studies are necessary to prove this statement. tions of the prostheses. The proposed treatment presented in this paper with the use of osseointe- Correspondence: grated implants for stabilizing obturator prostheses Dr. Eduardo Jose de Moraes corroborates other authors’ statements.3,7,8,9,14 The Rua Figueiredo Magalhães, 437 apto 701 two modalities of “overdentures” utilized with two Copacabana, Rio de Janeiro types of attachment systems presented satisfac- Brazil, 22031-010 tory results from an esthetic and a functional point e-mail: [email protected] of view. The use of 4 zygomatic implants associ- ated, or not, to standard implants proved that it is Disclosure 9. Roumanas E, Nishimura R, Beumer III J, Moy 16. Peñarrocha M, Garcia B, Marti E, Boronat A. The author reports no conflicts of interest with P. Carniofacial defects and osseointegration Rehabilitation of severely atrophic maxillae anything mentioned in this article. implants six-year follow-up on the success rates of with fixed implant-supported prostheses using craniofacial implants at UCLA. Int J Oral Maxillofac zygomatic implants placed using sinus slot References Implants 1994; 9: 579-585. technique: Clinical report on a series of 21 1.Desjardins RP. Obturator prosthesis design for patients. Int J Oral Maxillofac Implants 2007; 22: 10. Stella J, Warner M. Sinus slot technique for 645-650. acquired maxillary defects. J Prosth Dent 1978; 39: simplification and improved orientation of 434-435. zygomaticus dental implants: a technical note. Int 17. Moraes, E.J. & Moraes, N.B. Treatment of 2.Goiato M, Piovezan A, Santos D, Genari Filho H. et J Oral Maxillofac Implants 2000; 15: 889-893. atrophic maxillae and complex cases with al.Fatores que levam a utilização de uma prótese zygomatic implants. Clin Oral Impl Res 18 5 obturadora. Revista Odontológica de Araçatuba 11. Ahlgran F, Storksen K, Tornes K. A Study of 25 [Poster Presentation]. European Association for 2006; 27(2): 101-106. Zygomatic Dental Implants with 11 to 49 Months’ Osseointegration, Barcelona, Spain, 2007 3. Weischer T, Schettler D, Mohr, C. Titanium Follow-up After Loading. Int. J. Oral Maxillofac Implants in the Zygoma as retaining Elements after Implants 2006; 21: 421-425. 18. Maló P, Rangert B, Nobre M. All-on-4 immediate hemimaxillectomy. Int J Oral Maxillofac Implants function concept with Branemark system 1997; 12: 211-214. 12. Farzard P, Andersson L, Gennarsson S, implants for completely edentulous maxillae: A 4. Izzo S, Berger J, Joseph A, Lazow S. Johansson B. 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