Journal of Implant and Advanced Clinical Dentistry September 2013

Volume 5, No. 9 Septmeber 2013 The Journal of Implant & Advanced Clinical DentistryGingival Development with New Implant Pontic Design Guided Bone Regeneration with Resorbable Mesh

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The Journal of Implant & Advanced Clinical Dentistry Volume 5, No. 9 • September 2013 Table of Contents11 M ultidisciplinary Approach to Maxillary Anterior Dental Implant Therapy: A Case Report Sherman Lin17 A dvanced Surgical and Restorative Therapies Aimed at Rehabilitation of a Severe Dentoalveolar Defect in the Esthetic Zone Barry P. Levin, Sergio Rubinstein, Hal Rosenthaler, Toshi Fujiki, Peter Tawil The Journal of Implant & Advanced Clinical Dentistry • 3



The Journal of Implant & Advanced Clinical Dentistry Volume 5, No. 9 • September 2013 Table of Contents29 M anagement of Soft Tissue with an Emergence Profile Pontic Design for Maxillary Implant-Supported Restorations Yvan Fortin, Burton Langer, Richard M. Sullivan45 S ubperiosteal Twin Implant Maxillary Tuberosity-Bound to Increase Stability Antonio T. Di Giulio, Giancarlo Di Giulio, Enrico Gallucci The Journal of Implant & Advanced Clinical Dentistry • 5

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The Journal of Implant & Advanced Clinical Dentistry Volume 5, No. 9 • September 2013Publisher Copyright © 2013 by LC Publications. All rightsLC Publications 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 LC Publications (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 LC Publications, Las Vegas, Nevada, USA.or by calling 1-888-923-0002. The Journal of Implant & Advanced Clinical Dentistry • 7

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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 • 9

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Multidisciplinary Approach to Wilcko et alMaxillary Anterior Dental Implant Therapy:A Case ReportSherman Lin, DDS1 AbstractT he following case report demon- tal implant placement. Following placement strates a multidisciplinary approach of the dental implant, periodontal crown to restore a maxillary anterior den- lengthening was performed prior to finaltal implant. A combination of restorative prosthetic restoration of the dental implantand orthodontic treatments were used to to achieve a harmonious and esthetic finalprepare the maxillary anterior site for den- result that has remained stable for 7 years.KEY WORDS: Dental implants, maxilla, prosthetics, orthodontics1. Private practice San Diego, California, USA The Journal of Implant & Advanced Clinical Dentistry • 11

Lin CASE REPORT into the socket. Excellent primary stability was achieved. The surrounding socket space aroundA 44 year old male in good physical condition the fixture was filled with allograft bone graft mate-was admitted to the clinic for a loose crown on rial (Oragraft by Salvin Dental) that consists ofleft maxillary central incisor (#9). The patient also 50/50 mixture of cortical and cancellous particleswished to have a better alignment and esthetics of of 250 to 500 microns. A collagen membranehis anterior teeth. Clinical and radiographic evalu- was sutured in place with 5-0 chromic gut resorb-ation revealed a fractured tooth that was endodon- able suture to cover the socket opening and con-ticaly treated many years ago (Fig.1). The tooth tain the graft within. Orthodontic arch wire waswas deemed non-restorable without undergoing placed back on the anterior teeth with a tempo-crown lengthening to expose more tooth structure. rary crown attached to the wire on the #9 posi-In doing so, however, the esthetic result would tion. A radiograph was taken following surgeryhave been severely compromised. The patient (Fig.6), and the patient was dismissed with post-agreed and chose to do other available options. operative instructions and antibiotic regiment.Limited orthodontic therapy to better align theanterior teeth followed by extraction, immediate A ten day post-surgical check revealedimplantation and temporization of tooth #9 was uneventful healing for the patient. At 5 monthsproposed to the patient. The patient concurred after the initial placement of implant, the patientand wished to proceed with the treatment plan. was recalled for restorative procedure of implant #9. The orthodontic archwire was removed and The crown of tooth #9 was removed, an end- a round tissue punch of 4.5 mm in diameter wasodontic post was placed (Fig.2), and a tempo- used to uncover the implant. A final impressionrary composite crown was fabricated on top of was taken at implant level with a transfer post.the post (Fig.3). Orthodontic brackets with a Gingival depth was measured, and an appropri-straight arch wire were placed from tooth #6 ate shade was selected. The case was sent to ato tooth #11 to better align the anterior teeth laboratory for fabrication of the final crown. The(Fig.4). After 6 months of limited orthodon- patient was dismissed with a temporary abut-tic treatment, the patient was satisfied with the ment and a composite temporary crown. The orth-alignment of his anterior teeth (Fig.5). Occlu- odontic arch wire was reattached to the anteriorsion was checked and remained uneventful. The teeth. Ten days later patient was readmitted forpatient was then prepped for extraction of tooth final cementation of the crown. A 4.5mm diam-#9 with immediate implantation. The orthodon- eter dual abutment (Dentium) and gingival heighttic wire was removed and tooth number #9 was of 2.5mm was screw retained on to the fixture andcarefully elevated out of the socket with minimal the final crown was cemented on to the abutmenttrauma by using periosteal instruments and piezo- (Fig7). Gingival recontouring of teeth #’s 7, 8,electric unit. No gingival flap was raised. The and 10 was accomplished with an electrosurgicalsocket was left well intact, with a slight buccal unit for more esthetic gingival architecture (Fig.8).dehiscence detected. A titanium dental implant All orthodontic apparatus were removed and thefixture (Dentium Company) of 4.3mm body, 4.5 teeth were polished. A radiograph was taken formm platform, and 10mm in length was inserted12 • Vol. 5, No. 9 • September 2013

Lin Figure 2: Endodontic post insertion on tooth #9.Figure 1: Pre-surgical radiograph of tooth #9.evaluation prior to cementing to check the fit. The Figure 3: Temporization of tooth #9 after post insertion.patient was dismissed with a prefabricated orth-odontic retainer and instructions for care. Patientwas scheduled to be checked at every 6 monthinterval during the hygiene recall visits. A 3year(Fig.9), and a 7 year post- op radiograph and pho-tograph was taken and shown on record (Fig.10,11). The patient was very pleased with the finaltreatment result. The recovery phase of implanttherapy was uneventful. Radiographic analysis ofsubsequent years showed well preserved crestalbone level. Dense cortical formation of the crestalbone surrounding the implant was also evident. ● The Journal of Implant & Advanced Clinical Dentistry • 13

LinFigure 4: Radiograph of orthodontic archwire placement. Figure 6: Radiograph following dental implant and bone allograft placement at site #9.Figure 5: Anterior tooth alignment after 6 months oforthodontic treatment. Figure 7: Radiograph immediately following delivery of abutment and permanent crown.14 • Vol. 5, No. 9 • September 2013

LinFigure 8: Gingivectomy of teeth 7, 8, and 10. Figure 10: Radiograph at 7 years after treatment.Figure 9: Radiograph at 3 years after treatment. Figure 11: Clinical presentation at 7 years after treatment.DisclosureThe author reports no conflicts of interest with anything mentioned in this article.Correspondence:Dr. Sherman Lin • 12925 El Camino Real J-28 • San Diego, California, USA 92130 • Tel: 818-995-7971 The Journal of Implant & Advanced Clinical Dentistry • 15



Advanced Surgical and Restorative Therapies Wilcko et al Aimed at Rehabilitation of a Severe Dentoalveolar Defect in the Esthetic Zone Barry P. Levin, DMD1 • Sergio Rubinstein, DDS2Hal Rosenthaler, DMD, FAGD3 • Toshi Fujiki, RDT4 • Peter Tawil, DDS, MS5 AbstractThis case report demonstrates 3-dimen- lation of mesenchymal stem cells, combined sional restoration of a severely-damaged with a resorbable rigid scaffold reconstructed alveolar ridge. Prior extraction, surgi- the alveolar ridge, facilitating implant place-cal trauma and infection resulted in total loss ment. Additional grafting at implant place-of facial and palatal cortices in an estheti- ment provided the restorative dentist with twocally-critical area of the dentition. The com- osseointegrated fixtures. The residual softpromised restorative and endodontic status tissue deficiency was compensated for withof the adjacent canine precluded a conven- ceramics combined with CAD/CAM technol-tional fixed bridge. Cytokine-enhanced stimu- ogy to provide an esthetic fixed restoration. KEY WORDS: Bone graft, growth factors, prosthetics, dental implants 1. Private practice Elkins Park, Pennsylvania, USA; Clinical Associate Professor, University of Pennsylvania; Dept. of Periodontology, Philadelphia, Pennsylvania, USA 2. Private practice Skokie, Illinois, USA3. Clinical Assistant Professor, University of Pennsylvania, Dept. of Restorative Dentistry, Philadelphia, Pennsylvania, USA 4. Laboratory Director, Oral Rehabilitation Center, P.C., Skokie, Illinois, USA 5. Private practice, Beirut, Lebanon The Journal of Implant & Advanced Clinical Dentistry • 17

Levin et al Introduction Figure 1: Clinical presentation of initial ridge defect in the maxillary anterior sextent.Tooth loss will predictably result in 3-dimen-stional loss of hard and soft tissue volume.1,2 became infected and led to the loss of sig-Not only does this complicate the place- nificant alveolar bone and an additional tooth.ment of implants according to the restor-ative treatment plan, but long-term hygienic CASE REPORTcomplications can result from less than ideal A 45 year-old female patient, with a history offixture-positioning. When possible, many clini- smoking, presented to a private periodontalcians choose to place implants either at the practice after experiencing an unsuccessfultime of extraction or shortly thereafter, attempt- ridge-augmentation procedure at a universitying to minimize these complications.3 The lit- periodontal clinic. Originally, tooth #7 waserature contains numerous studies, case series surgically extracted and the socket was aug-and animal studies supporting this modality.4,5 mented. This procedure was not successful due to soft tissue complications and possibly Often, extraction sockets are augmented to smoking. She subsequently underwent a sur-prevent much of this localized atrophy.6,7 When gical procedure involving the use of a titaniumteeth are previously removed, these opportuni- mesh, combined with a bone allograft hydratedties for earlier placement are lost, and often with rhPDGF-BB. Early exposure of the meshfavorable hard and soft tissue volume has and local site infection resulted in the removalbeen lost as well. Reconstructive procedures of the mesh and debridement of non-incorpo-exist to restore lost bone and soft tissue, pro- rated bone graft materials. This resulted in aviding the surgeon with an opportunity to significant ridge-defect (Fig. 1). One of the tita-place implants in restorable positions.8,9 Pro- nium fixation tacks was left in place at this time.cedures including autogenous, allogeneic or The patient was provisionalized from tooth #6xenogeneic block grafts, guided bone regen- through #11 with a fixed restoration. Her gen-eration (GBR) with and without particulate eral dentist determined tooth #8 to be non-bone grafts, rigid meshes and biologic media- restorable due to caries. She was referred totors such as PRP, recombinant proteins, etchave been presented by surgeons.10,11 All ofthese modalities have the potential to regener-ate alveolar bone capable of osseointegration. A complication rarely reported in the lit-erature, is what occurs when one of theabove-mentioned procedures completelyfails, and the resultant defect is more severethan the original one being treated. Thiscase report describes the treatment of a 45year-old female, who unsuccessfully under-went a regenerative procedure, which18 • Vol. 5, No. 9 • September 2013

Levin et alFigure 2: Following flap-reflection, extraction of the #8 Figure 3: The 2-walled defect in the lateral incisor position,root tip and removal of the retained tack, the loose, non- and the extraction socket of tooth #8 was obturated with aincorporated DBBM graft particles were debrided until a composite graft consisting of rhBMP-2/ACS and FDBA.firm, bleeding osseous surface was identified.a private periodontal office for extraction of the loose graft particles were debrided from thecarious central incisor and ridge-augmentation defect (Fig. 2). The rhBMP-2/ACS was pre-in the #7 and #8 locations. Previous endodon- pared according to the manufacturer’s specifi-tic therapy and guarded crown-to-root ratio of cations regarding soak-loading the absorbable#6 was determined to be a questionable dis- collagen sponge (ACS) for at least 15 minutestal bridge abutment for a long-span fixed par- prior to its application. Strips of various sizestial denture (FPD), and implant therapy was were cut of the sponge and mixed homog-requested by the restorative dentist and patient. enously as possible with FDBA particles. This composite graft allowed uniform distribu- The first surgery was geared towards extrac- tion of osteoinductive (rhBMP-2) and osteo-tion of the carious root of tooth #8, the removal conductive (FDBA) elements throughout theof the fixation tack left behind by the previous graft. After molding of this cohesive graft intosurgeon and bone augmenation. The plan was the alveolus of #8 and the #7 defect (Fig. 3)to combine an osteoconductive, resorbable a PLGA resorbable mesh (RapidSorb; Syn-bone graft of FDBA (Life Net; Virginia Beach) thes) was warmed in a sterile water bath ofwith an osteoinductive graft of rhBMP-2/ACS 70 degrees Celsius and fixed with two resorb-(Infuse; Medtronic). One of the challenges able screws consisting of the same PLGApresented was the lack of facial and palatal material (Fig. 4). A connective tissue graftbone for vasuclarity and graft containment. from the palatal flap was utilized to provide crestal coverage of the mesh and a facial After reflection of a full-thickness mucoperi- periosteal releasing incision was performedosteal flap, tooth #8 was carefully extracted, to provide nearly-complete closure (Fig. 5).attempting to preserve the thin walls of thesocket, the tack was easily removed and all The Journal of Implant & Advanced Clinical Dentistry • 19

Levin et alFigure 4: A resorbable PLGA mesh was thermoplastically- Figure 5: The thick palatal mucosa was thinned apically,shaped based on a metal template extra-orally. It was then maintaining blood-supply coronally and sutured to thesecured apically with two PLGA screws, providing graft- facial flap, providing primary closure of the grafted site.containment and stable 3-dimensional space-maintenance.Figure 6: Approximately 4 months after hard tissue sue augmentation and 6 months after bonegrafting, a soft tissue graft was secured from the palatal grafting, dental implant surgery was per-mucosa of the premolar region. This was done to increase formed. Prior to surgery, a CBCT revealed sig-the zone of keratinized mucosa and increase mucosal nificant hard tissue regeneration in the lateralthickness. and central incisor positions (Figs. 7A & 7B). Approximately four months after bone aug- The regenerated height of the ridge mea-mentation surgery, a subepithelial connec- sured between 8mm-9mm (Fig. 8). Facial-tive tissue graft was performed in increase palatal width was determined to be adequatethe width and thickness of keratinized mucosa for implant placement of 3.0mm and 3.5mmin the anticipated implant-placement sites implant diameters for the lateral and central(Fig. 6). At about 8 weeks following soft tis- incisors, respectively. The plan was to place the implants to the cortical base of the nasal floor and utilize the fixtures and healing abut- ments as “tent poles” to support the same com- posite bone graft used in the first procedure (Fig. 9). A large portion of the osteoinductive ACS was applied over the graft and 2.0mm tall healing abutments (Fig. 10), then an amnion- chorion membrane (BioXclude; Snoasis) was applied crestally to aid in soft tissue matura- tion (Fig. 11) and the site was closed with monofilament sutures (PTFE; Gore) (Fig. 12).20 • Vol. 5, No. 9 • September 2013

Levin et alFigures 7a and 7b: Cross-sectional images of the proposed #7 and #8 implant sites from the CBCT taken approximately6 months after bone grafting. Planning software is utilized to select implant sizes and positions. After approximately 2 months healing, both sion was taken. A screw-retained provisionalhealing abutments are partially-exposed. When restoration, supported by the single, centralthe healing abutment on the #7 position implant incisor implant was indirectly fabricated. Anwas loosened, there was detectable movement additional healing period of 8 weeks precededof the implant fixture. The healing abutment utilization of this implant for fixation of the tem-was re-tightened. The #8 healing abutment porary restoration. During this time, a restor-was easily removed and a fixture level impres- ative post and core and new temporary crown The Journal of Implant & Advanced Clinical Dentistry • 21

Levin et alFigure 8: Re-entry demonstrates significant 3-dimensional Figure 9: Implant insertion prior to additional boneregeneration of the severe alveolar defect. grafting . Implants were purposely not over-seated, to facilitate restorative treatment and avoid hygienicFigure 10: Additional bone grafting, utilizing the same challenges after restoration.composite graft of rhBMP-2/ACS & FDBA was performedto cover the supra-crestal threads of both implants. Short was fabricated to improve retention of a sin-(2.0mm) healing abutments, rather than cover screws, gle-unit provisional crown on tooth #6. Thewere utilized to support the overlying flaps and achieve provisional FPD was sectioned between #6maximum vertical regeneration. and #7 and the patient presented for implant temporization. A minor mucoplasty around the #8 implant was done to facilitate access to the healing abutment and it’s removal. Prior to seating the cantilevered pro- visional restoration, the healing abutment on the #7 implant was painlessly removed and re-tightened without any tactile move- ment of the implant or discomfort. The pro- visional restoration, which incorporated pink and tooth-colored composite resin was adjusted and tightened to 15 ncm (Figs. 13-15). The patient was referred back to the restorative dentist to begin definitive restor- ative therapy in the maxillary anterior sextant. Restorative therapy entailed conventional crown preparation on the natural teeth, com- bined with a transfer impression of the two implant fixtures Fig. 16). A wax-up was per-22 • Vol. 5, No. 9 • September 2013

Levin et alFigure 11: Application of an amnion-chorion membrane Figure 12: Closure. Note that primary closure wasover the grafted site. intentionally not achieved. This was the reason for the application of the amnion chorion membrane.Figure 13: Four months after implant placement, a screw- Figure 14: Occlusal view of provisional restoration.retained provisional restoration was placed, supported bythe implant in the #8 position. This was done followingpost and core placement in tooth #6 and fabrication of asingle, temporary crown on the canine.formed of the anticipated restorative outcome retained crowns, incorporating pink ceramics(Fig. 17), and computer-assisted abutments were designed for the two implants (Figs. 19,(Atlantis; Dentsply) were fabricated for the 20A, 20B). A periapical radiograph demon-two implants (Fig. 18). Splinted porce- strated crestal bone present at the level oflain fused-to-metal crowns were created for the implant platforms, suggesting successfulteeth #9-#11, a single PFM crown was fab- regeneration and osseointegration (Fig. 21).ricated for tooth #6 and splinted, cement- The Journal of Implant & Advanced Clinical Dentistry • 23

Levin et alFigure 15: Facial view of provisional restoration. Figure 16: Maxillary polyvinylsiloxane impression.Figure 17: Diagnostic wax-up. Anticipated volume of soft Figure 18: Two CAD/CAM (Atlantis, Dentsply) abutmentstissue necessary to be compensated for with pink ceramics. were digitally-fabricated and seated on two implantSymmetrical tooth contours right and left also planned at replicas. GC resin copings on the adjacent natural teeththe waxing stage of treatment. are also fabricated. Discussion prior to the inevitable ridge resorption.12-14 When this is not possible, augmentation of theSevere ridge defects, whether associated with alveolus can prevent significant bone loss.15-17tooth loss and/or failed surgical procedures,can present unique and difficult challenges for The site of tooth #8 was managed with sitethe implant team. Often, a combined surgical preservation in this case report. This was theand restorative approach accomplishes greater more predictable component of the case pre-achievement than a single entity. Pertaining sented in this paper. The challenge was regen-to management of extraction sites, most clini- erating horizontal and vertical height of viablecians prefer either immediate or early implant bone in the lateral incisor location, capable ofplacement to better position fixture-insertion osseointegration. The lack of osseous walls24 • Vol. 5, No. 9 • September 2013

Levin et alFigure 19: Conventional, PFM crowns are fabricated for Figure 20a: Final restorations in place.the 4 natural teeth in the pre-maxilla. Soft tissue coloredceramics are used on the right canine, as well as theimplant-retained restoration to compensate for verticaldiscrepancies between the right and left sides of theesthetic zone.capable of graft containment and providing a Figure 20b: Patient’s natural lip position at full smile.source for vascularity to an inert bone graft wasthe primary obstacle to overcome. Therefore, provide the sponge be “soak-loaded” with thea graft with osteoinductive properties, capable reconstituted protein for at least 15 minutesof chemotaxis of mesenchymal stem cells from prior to it’s insertion in situ. The claim is thatthe defect’s periphery, as well as differentiation the rhBMP-2 is released from the ACS overwas a requirement for success in the author’s an approximately 14 day period. The biggestopinion. The production of vascular endothelial disadvantage to this delivery method is thegrowth factor (VEGF) from invading cells was near-total lack of space-maintenance of thealso critical for the revascularization of the bone ACS. Clinicians have reported on incorporat-graft an eventual modeling and bone remodel- ing space-providing modalities with rhBMP-2ing necessary for the regeneration of vital bone to compensate for this disadvantage.21-23 Thein the defect area. BMP-2 has been shown to addition of particulate bone grafts increasesincrease the osteoinductivity of allograft bone graft volume, but not necessarily stability in situ.in the animal model.18 This material has beensuccessful in the regeneration of bone humanextraction sockets, capable of osseointegra-tion with titanium implants.19,20 The only FDA-approved carrier for rhBMP-2 is an absorbablecollagen sponge. The manufacturer guidelines The Journal of Implant & Advanced Clinical Dentistry • 25

Levin et alFigure 21: Periapical radiograph taken approximately long-lasting support for the underlying regener-2 weeks after delivery of the final restorations. Excellent ative process. The virtue of the resorbable meshbone regeneration associated with the two implants, is mainly the biodegradation, facilitating less-#7 in particular, is appreciated. invasive flap reflection for implant placement since the mesh and fixation screws/tacks do notA rigid mesh is capable of containing the graft require removal. A porous PLGA material, simi-without obstruction of nutrients from the sur- lar to that used in this case, was shown to facili-rounding tissues associated with membranes. tate bone regeneration in experimental sitesThe authors have combined mineralized allograft in dogs.24 Numerous reports of titanium meshbone with rhBMP-2/ACS to add an osteocon- being used as space-maintenance have beenductive component to the inductive rhBMP-2/ published. The incidence of premature expo-ACS graft. For purposes of graft containment sures and compromised outcomes have alsoand more importantly, space-maintenance, a been reported.25 The resorbable mesh utilizedresorbable mesh was implemented to provide in this case report has demonstrated easier management of early mesh exposures compared to titanium scaffolds in the author’s experience. Conclusion Meeting the patient’s esthetic expectations are at least as challenging as the clinical pro- cedures often faced surgically and prostheti- cally. In order to provide a result the patient will be satisfied with, even when heroic surgi- cal treatment has been accomplished, we must depend on the prosthetic team to make up for any deficiencies surgery did not accomplish. These scenarios could be for example due to the type of defect, loss of adjacent periodontal ligament and existing blood supply, thus result- ing in some instances in different bone height and corresponding soft tissues. Among the prosthetic objectives for the final restoration are: duplication of color, shape, translucency and texture. Even when these previous con- cepts are accomplished, patient’s expectations may still not be met, especially when the result- ing crown will have a long gingival-incisal anat-26 • Vol. 5, No. 9 • September 2013

Levin et alomy. Therefore, to overcome this problem, and Correspondence:with the attempt to have a correct proportion Dr. Barry P. Levinbetween the final restoration and adjacent teeth, 7848 Old York Rd.pink porcelain or composite is often utilized, Elkins Park, PA 19027thus enabling us to have the appearance of a (215) 635-0465 phonenormal size tooth with the correct proportion as (215) 635-2751 faxit relates to adjacent teeth and just as impor- [email protected] to be pleasing to the patient’s smile.26-30 ●Disclosure 11. B ianchini MA, Buttendorf AR, Benfatti CAM, 21. Tarnow DP, Wallace SS, Froum SJ, Motroni A,The author reports no conflicts of interest with Bez LV, Ferreira CF, de Andrade RF. The use of Prasad HS, Testori T. Maxillary sinus augmentationanything mentioned in this article. freeze-dried bone allograft as an alternative to using recombinant bone morphogenetic protein-2/ autogenous bone graft in the atrophic maxilla: acellular collagen sponge in combination with aReferences A 3-year clinical follow-up. Int J Periodontics mineralized bone replacement graft: A report of1. R eich KM, Huber CD, Lippnig WR, Ulm C, Restorative Dent 2009;29:643-647. three cases. Int J Periodontics Restorative Dent 2010;30:139-149. Watzek G, Tangl S. Atrophy of the residual 12. Evans CDJ, Chen ST. Esthetic outcomes of alveolar ridge following tooth loss in an historical immediate implant placemens. Clin Oral Impl 22. Misch CM. Bone augmentation of the atrophic population. Oral Diseases 2011;17:33-44. Res 2008;19:73-80 posterior mandible for dental implants using2. A twood DA. Postextraction changes in the adult rhBMP-2 and titanium mesh: clinical technique mandible as illustrated by microradiographs 13. M eltzer AM. Immediate implant placement and and early results. Int J Periodontics Restorative of midsagittal sections and cephalometric restoration in infected sites. Int J Periodontics Dent 2011;31:581-589. roentgenograms. J Prosthet Dent Restorative Dent 2012;32:e169-e173. 1963;13:810-824. 23. Levin BP. Horizontal alveolar ridge3. Paoloantonio M, Doci M, Scarano A, e’Archivio 14. L evin BP. Immediate temporization of immediate augmentation: the importance of space D, di Placido G, Tumini V, Piattelli A. Immediate implants in the esthetic zone: Case reports maintenance. Compend Contin Ed Dent implantation in fresh extraction sockets. A evaluating survival and bone maintenance. 2011;32:12-22. controlled clinical and histological study in man. Compend Contin. Ed Dent 2011;32:52-62. J. Periodontol. 2001;72:1560-1571. 24. Matsumoto G, Hoshino J, Kinoshita Y, Sugita4. Botticelli D, Berglundh T, Lindhe L. Hard 15. B arone A, Ricci M, Toneli P, Santini S, Covani Y, Kubo K, Maeda H, Arimura H, Matsuda S, tissue alterations following immediate implant U. Tissue changes of extraction sockets in Ikada S. Evaluation of guided bone regeneration placement in extraction sites. J Clin Periodontol humans: a comparison of spontaneous healing with poly(lactic acid-co-glycolic acid-co-e- 2004;31:820-828. vs. ridge preservation with secondary soft tissue caprolactone) porous membrane in lateral5. Sanz M, Cecchinato D, Ferrus J, Pjetursson healing. Clin Oral Impl Res 2012;0:1-7. bone defects of the canine mandible. Int J Oral EB, Lang NP, Lindhe J. A prospective, Maxillofac Implants 2012;27:587-594. randomized-controlled clinical trial to evaluate 16. P erelman-Karmon M, Kozlovsky A, Lilov R. bone preservation using implants with different Socket site preservation using bovine bone 25. Miyamoto I, Funaki K, Yamauchi K, Kodama T, geometry placed into extraction sockets in the mineral with and without a bioresorbable Takahashi T. Alveolar ridge reconstruction with maxilla. Clin Oral Impl Res. 2010;21:13-21. collagen membrane. Int J Periodontics titanium mesh and autogenous particulate bone6. Araujo MG, Liljenberg B, Lindhe J. B-tricalcium Restorative Dent 2012;32:459-465. graft: Computed tomography-based evaluations phosphate in the early phase of socket healing: of augmented bone quality and quantity. Clin an experimental study in the dog. Clin Oral Impl 17. S cheyer ET, Schupbach P, McGuire MK. Impl Dent Rel Res 2012;14:304-311. Res. 2010;21:445-454. A histologic and clinical evaluation of7. Iasella JM, Greenwell H, Miller RL, Hill M, Drisko ridge-preservation following grafting with 26. Coachman C, Calamita M. The reconstruction C, Bohra AA, Scheetz JP. Ridge preservation demineralized bone matrix, cancellous bone of pink and white esthetics. Int Dent SA, with freezed-dried bone allograft and a collagen chips, and resorbable extracellular matrix 2010;12(3):88-93. membrane compared to extraction alone for implant membrane. Int J Periodontics Restorative Dent site development: A clinical and histologic study in 2012;32:543-552. 27. Coachman C, Salama M, Garber DA, Calamita humans. J Periodontol. 2003;74:990-999. M, Salama H, Cabral G. Prosthetic gingival8. V on Arx T, Buser D. Horizontal ridge 18. B oyan BD, Ranly DM, Schwartz Z. Use of reconstruction in a fixed partial restoration. augmentation using autogenous block grafts and growth factors to modify osteoinductivity of Part 1: Introduction to artificial gingival as an the guided bone regeneration technique with demineralized bone allografts: Lessons for alternative therapy. Int. J. Periodontics & Restor. collagen membranes: a clinical study with 42 tissue engineering of bone. Dent Clinics N Dent. 2009;29:471-477. patients. Clin Oral Impl Res. 2006;17:359-366. America 2006;50:217-228.9. M isch CM, Misch CE. The repair of localized 28. Salama M, Coachman C, Garber DA, Calamita severe ridge defects for implant placement 19. C ochran DL, Jones AA, Lilly LC, Fiorellini M, Salama H, Cabral G. Prosthetic gingival using mandibular bone grafts. Implant Dent. JP, Howell H. Evaluation of recombinant reconstruction in a fixed partial restoration. Part 1995;4:261-267. human bone morphogenetic protein-2 in oral 2: Diagnosis and treatment planning. Int. J.10. N evins M, Al Hezaimi K, Schupbach P, Karimbux applications including the use of endosseous Periodontics & Restor. Dent. 2009;29:573-581. implants: 3-year results of a pilot study in N, Kim DM. Vertical ridge augmentation using humans. J Periodontol 2000;71:1241-1257. 29. Coachman C, Salama M, Garber DA, Calamita an equine bone and collagen block infused M, Salama H, Cabral G. Prosthetic gingival with recombinant human platelet-derived 20. F iorellini JP, Howell TH, Cochran D, Malmquist reconstruction in a fixed partial restoration. Part growth factor-BB: A randomized single-masked J, Lilly LC, Spagnoli D, Toljanic J, Jones A, 3: Laboratory procedures and maintenance. Int. histologic study in non-human primates. J Nevins M. Randomized study evaluating J. Periodontics & Restor. Dent. 2010;30:19-29. Periodontol 2012;83:878-884. recombinant human bone morphogenetic protein-2 for extraction socket augmentation. J 30. Priest GF, Lindke L. Gingival-colored Periodontol 2005;76:605-613. porcelain for implant-supported prostheses in the aesthetic zone. Practical Periodontic & Aesthetic Dentistry 1998;10:1231-1240. The Journal of Implant & Advanced Clinical Dentistry • 27

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Management of Soft Tissue with an Wilcko et alEmergence Profile Pontic Design for MaxillaryImplant-Supported RestorationsYvan Fortin, DMD1 • Burton Langer DMD2 • Richard M. Sullivan DDS3 AbstractBackground: Currently the two most prev- labial to palatal results. To avoid disrupt-alent pontic designs for anterior esthetics ing the pontic/soft tissue interface, patientsare the modified ridge lap and ovate types. are instructed not to floss. Instead they needThis article describes a new, mildly compres- only brush the teeth for routine oral hygiene, asive design that follows the contours of the regime that most patients can easily maintain.residual osseous ridge crest and displacesmore of the soft tissue into the labial, pala- Results: The authors have documented long-termtal, and interproximal areas, better repro- (up to 15 years) maintenance of the soft-tissueducing a natural tooth-emergence profile. health under Emergence Profile Pontics (EPPs).Methods: As the actively directed soft tis- Conclusion: When sufficient residual soft tis-sue flows into the proximal areas and circum- sue volume is available, this design can be rec-ferentially over the pontic line angle borders, ommended for pontics supported by both naturala lack of through-and-through access from tooth and implant abutments in esthetic areas.KEY WORDS: Dental implants, prosthetics, pontic design, papilla, esthetics, emergence profile 1. Private Practice, Montreal, Quebec 2. Private Practice, New York, New York3. Vice President, Clinical Technologies, Nobel Biocare Americas The Journal of Implant & Advanced Clinical Dentistry • 29

Fortin et alFigure 1a: Saddle pontics can be esthetic but have largely been abandoned due to the oral hygiene compromises theyrequire. Figure 1b: Ridge-lap pontics require a significant patient commitment to oral hygiene maintenance.Figure 1c: Although ovate pontics initially create the appearance of a true emergence form the pontic site, they do not addto the vertical papillary height. Figure 1d: T he Emergence Profile Pontic design uniformly compresses the tissue, parallelingthe residual osseous ridge crest and displacing soft tissue over the pontic line angle borders. In this illustration, the gray areasrepresent labial and palatal tissue displaced by compression. Introduction implant crowns and any intervening pontics is not harmonious, both the esthetic outcome and long-In the history of pontic development and tissue term hygienic maintenance may be compromised.management associated with crown-and-bridgerehabilitation, a longstanding objective has been The types of pontics used in fixed partialto avoid any compression of the soft tissue that dentures have evolved gradually over the years.might result in blanching, blood-supply com- Early pontic were sanitary, allowing easy accesspromise, and necrosis of the compressed tis- for brushing, but they had little esthetic appeal.sues. Another concern has been to allow dental Saddle pontics (Figure 1a) that approximatedhygiene access for periodontal health.1,2 Esthetic the ridge crest were able to give the illusion ofresults can be challenging to achieve with pontics a tooth emerging from the ridge but have largelybecause tooth extraction often is associated with been abandoned due to the oral hygiene com-hard- and soft-tissue site resorption. The reduced promise associated with their design. To meetresidual tissue volume can make it difficult or growing demand for a more esthetic alternative,impossible to reproduce the ideal gingival con- ridge-lap pontics were developed that extendedtours associated with the cervical-labial area of the the cervical margins labially (Figure 1b). Thistooth or teeth being replaced.3,4 Even if implant allowed the host tissue to be visible interproxi-placement has been optimal and the optical mally, resembling a papilla. Although more visu-properties and other characteristics of the pros- ally appealing, ridge-lap pontics required thethetic restoration are excellent, if the relationship use of floss or other adjunctive measures tobetween the soft-tissue interface relative to both thoroughly clean under the bridge. Recently30 • Vol. 5, No. 9 • September 2013

Fortin et alFigure 1e: Animation showing gingival tissue recontouring with the use of an Emergence Profile Pontic.Kim, Cascione, and Knezevic described using a of ovate pontics14 that could as well apply toridge-lap pontic design that compresses tissue pontics in general. These objectives include:circumferentially with the strategy of displace-ment to develop “pseudo” interdental papillae.5 ● Achieving a natural look that is unde- tectable as a dental restoration. Ovate pontics represent another attemptto produce natural looking pontic emer- ● C reating the most natural emergence profilegence.6-13 The tissue-contacting surface of possible. The bridge pontic should lookthis design is convex relative to the soft tis- like it is growing out of the gingiva, withsue (Figure 1c), compressing it against the the gingiva and crown(s) in alignment.ridge crest. Soft tissue outside the area undercompression is displaced away from the pon- ● Bridge pontics should nottic. Although this creates a true initial emer- retain pieces of food.gence from the pontic site, it does not add to The aim of this article is to present an alter-vertical papilla height. Luc and Patrick Rut- native pontic design that was developedten have listed primary objectives for the use over a 15 year period for maxillary screw- retained dental-implant-supported resto- rations. This design includes not only the The Journal of Implant & Advanced Clinical Dentistry • 31

Fortin et alFigure 2: The Emergence Profile Pontic design emergence profile, while maintaining tissuesimultaneously directs tissue from the midcrestal position health (Figure 1e) . Achieving this requires atoward the interproximal, labial, and palatal areas by more complex topography than that embod-selective compression of available soft tissue. The labial- ied in earlier pontic designs. As Figure 2 illus-palatal contours are concave in the center and convex as trates, the labial-to-palatal (or labial-to-lingual)they approach the labial and lingual, roughly mirroring contours of the pontic body (illustrated by thethe contours of the osseous ridge crest. The plane from green lines) are concave in the center andmesial to distal (red) is convex throughout the tissue- convex as they approach the labial and lin-contacting surface of the pontic body. The proximal gual, roughly mirroring the contours of theconnections (black) are convex to effectively direct the flow osseous ridge crest. This shape is intended toof the compressed tissue toward the labial and the palatal compress the soft tissue uniformly against theproximal areas in the shape of a papilla. residual bone crest. Typically the height of the soft tissue between the pontic and the bonepontics themselves but also all intervening crest is reduced by 1.5mm; under no circum-connections to redistribute the entire three- stances should the compression reduce thedimensional soft-tissue volume dynamically tissue height by more than half. The compres-and esthetically, without compromising the sion displaces the soft tissue toward the entireoral hygiene or causing tissue inflammation. pontic periphery – labial, palatal, and proximal. The Emergence Profile The mesial-to-distal contours of the EPP, Pontic illustrated by the red lines, are convex through- out the tissue-contacting surface of the pon-The Emergence Profile Pontic (EPP) (Fig- tic body. This convexity echoes the facialure 1d) was developed to apply pressure in a appearance of a natural tooth as it emergesselective and strategic manner to the underly- from the soft tissue (longer in the mid-cervi-ing soft tissue, directing the compressed tis- cal area and shorter at the interproximal junc-sue to flow into the surrounding areas in such tions). But it differs significantly from thea way as to reproduce a natural looking tooth- mesial-to-distal convexity of the ridge-lap pon- tic depicted in Figure 1b; that mesial-to-distal convexity only involves the portion of the pon- tic covering the labial aspect of the ridge. The third important element of the EPP design is the shape of the labial-to-palatal junction between the pontic and the ele- ments adjoining, either other pontics or implant-supported crowns (illustrated by the black lines in Figure 2). Unlike the centrally concave labial-to-palatal pontic body con-32 • Vol. 5, No. 9 • September 2013

Fortin et alFigure 3a: The restoration framework is designed either Figure 3b: After the framework is produced in zirconia,virtually or by scanning an acrylic design. The EPP contours porcelain is added to the tissue-contacting surface. Theare designed with proper emergence to the solid cast. final contours are refined with a disc.tours, the junctional contour is uniformly con- resume, and capillary remodeling occurs, lead-vex, with the contour peaking in the middle ing to vascular remodeling.15 Depending onof the connection. This shape creates addi- the situation, harmonious vascular remodel-tional space on the labial and palatal sides of ing and reorganization of the tissue mass maythe pontic into which the compressed soft tis- require successive phases of compression andsue can flow, while applying some additional relaxation until the pontic is in its final posi-compression to direct the soft- tissue volume tion, and the tissues are properly vascularizedto the labial and palatal in the papilla area. through newly formed shunts.16,17 When this occurs, the color of the compressed tissue To achieve optimal results, it is helpful will again match that of the surrounding tissue.to understand the cross-sectional anatomyof the edentulous site receiving an EPP, as The following section describes the stepswell as the dynamics of blood flow as tissue necessary to create a maxillary screw-retainedis compressed and redirected. When gingi- porcelain-to-zirconia bridge incorporating EPPs.val tissue is compressed, it does not simplydisappear. Instead, tissues are displaced by Clinical Preparation of the Patientthe source of compression, gradually adapt- It is recommended that impressions be per-ing to it as long as adequate vasculariza- formed only when the soft tissue is stable,tion is maintained. Should vascularization be whether following delivery of a provisional res-inhibited by compression for too long, varying toration or healing abutments. The impres-degrees of tissue necrosis will ensue. In con- sion may be made at the implant or abutmenttrast, when compression is minimal and con- level, following the principles for precise-trolled, local circulation and tissue oxygenation fitting screw-retained implant restorations. The Journal of Implant & Advanced Clinical Dentistry • 33

Fortin et alFigure 4a: Porcelain to zirconia implant-level restoration Figure 4b: Soft tissue immediately upon removal ofmarked to show tissue compression strategy. Green porcelain to zirconia restoration adjacent to naturaldemonstrates pontic concavity, red pontic convexity, and teeth. The bridge has been in place for 3 months and wasblack connection convexity to tissue surface. removed for photographic demonstration purposes only. No oral hygiene other than toothbrush has been used, as access under bridge is impeded by soft tissue. Continued growth of interproximal tissue resembling a papilla can be expected to improve over time.Figure 4c: Emergence profile pontic design with labial and Dental Laboratory Procedureinterproximal displacement of tissue. Compressed depth to The first pour of the impression with appro-half the distance to the residual ridge crest with observant priate implant or abutment replicas attacheddelivery will maintain vitality of the soft tissue and bone is for production of a scanning model to bewhile redistributing soft tissue where directed by the used in the framework-production process.pontic contours. This is made with impression plaster, follow- ing the manufacturer’s directions. A secondThe authors’ experience has been limited pour of the impression with new replicas isto open-tray impressions with splinted non- then made with the possibility for removableengaging impression copings or non-engag- soft tissue to be incorporated into the modeling titanium cylinders. The impression is for mounting and overall framework design.made over the luted cylinders or impres- A third pour of the impression with replicas ission copings and is removed as one unit. then made, with the edentulous areas that will receive the pontics reproduced in solid stone. The restoration framework is then designed, either virtually on a computer or as a resin pro-34 • Vol. 5, No. 9 • September 2013

Fortin et altotype to be scanned (Figure 3a). The soft-tis- tance of the typically convex alveolar crest bysue-contacting areas of the pontics are refined paralleling it with the concave pontic surface.to create optimal emergence profiles from theridge crest for the intended restorations (which The process then continues with porcelainat this point resemble saddle pontics or the added in lesser amounts on either side of theunderside of denture teeth). The tissue-con- central compressive area (similar in concept totacting area should roughly follow the curvature the development of “blunted” triangular ridges onof the residual ridge crest, as produced on the maxillary premolar cusps). This introduces bothsolid stone model. The connections of the pon- a labial and palatal convexity to the pontic under-tics either to other pontics or to the implant- or side, with both planes sloping toward each otherabutment-retained elements are designed as to produce a concavity that continues to paral-described above with the convex contour peak- lel the ridge. Again, this serves to concentrateing in the middle of the connection. The apex the compression in the center of the pontic, withof this convex contour should extend as far lesser amounts of compression applied to the softtoward the ridge crest as the emergence-profile tissue as it is directed toward the proximal con-contours of the restoration design will allow. nections. The simultaneous compression of the sloping pontic interface and the apical convex- The framework is now ready for fabrication ity of the connections redirects tissue toward thein zirconia. When the completed framework is relieved open areas, thus forming papillae. Tissuereturned to the laboratory, the patient is sched- also flows circumferentially over the pontic bor-uled for try-in. Because there is no compres- der, submerging it within a soft tissue cuff. Thesion at this time, the framework should seat fact that the soft tissue is moved to now overlapfully, with radiographic confirmation. Once both pontic borders and connections creates afull seating has been established, long guide situation in which traditional oral hygiene usingpins are substituted for prosthetic screws. an implement is no longer possible because ofThe framework is then picked up in an open the lack of direct through-and-through access.tray impression to produce a new cast relat-ing the framework to the soft tissue. This new At this point, the framework will no longer seatcast aids in precise addition and contour- on the solid cast, so a cast with removable softing of porcelain relative to the soft tissue. tissue must be used for further mounting proce- dures. After firing, the pontic area is contoured The technician then applies the normal with a wheel (Figure 3b) to refine the mesial/dis-esthetic veneering and adds porcelain to the tal convexity that will direct the flow of the soft tis-pontic compression areas. In adding the por- sue toward the entire periphery – interproximallycelain, it should be kept in mind that tissue will as well as labially and palatally (Figures 4 a-c).be directed from the area of most compressiontoward the areas of relief. Although the center Clinical Procedureof the pontic will compress the most, within Because the EPP Pontic is overextended api-that central area, the intention is to uniformly cally relative to the current soft-tissue crest,compress the soft tissue against the resis- it cannot be expected to seat fully on the first The Journal of Implant & Advanced Clinical Dentistry • 35

Fortin et alFigure 5a: Flat tissue topography before initial Figure 5b: Initially, the bridge cannot be fully seated, withplacement of a screw-retained porcelain-to- zirconia obvious blanching due to the tissue compression. Therestoration with EPPs. bridge is loosened to allow blood to repenetrate and then seated again. This process is repeated until full seating on implants occurs.Figure 5c: Approximately one hour after initial bridge Figure 5d: Six months later, the EPPs have created adelivery, the bridge has been fully seated with minimal highly natural soft-tissue appearance around the bridge,blanching, and the patient can be discharged. Papilla fill which has not been removed since the initial delivery.will occur over the next several months. The patient willmaintain oral hygiene with brushing only.Figure 5e: Facial view of the soft tissue after removal of Figure 5f: The occlusal view of the soft tissue six monthsthe bridge (for photographic purposes only) six months after delivery of the bridge with EPPs compares strikinglyafter delivery. with the appearance of the tissue in Figure 5a.36 • Vol. 5, No. 9 • September 2013

Fortin et alattempt. After initial placement of the bridge tics during compression, it is advisable to ori-and gentle fastening against the resistant soft ent the displacement toward zones that requiretissue, blanching typically occurs. After 10 min- additional tissue. The design of the EPPutes, the bridge is loosened for two to three described in this article results (Figures 8a, 8b)minutes to allow blood to re-penetrate the com- in relatively significant displacement of tissuespressed area. This sequence is then repeated directed toward the labial and proximal areas ofthree to four times. The blanching should grad- the pontic crown. To enhance the illusion thatually lessen, indicating progressive adaptation these tissues are framing a real tooth that hasof the soft tissue to the pontic, with normal gin- grown naturally into place, rather than a syn-gival color returning by the end of the visit (Fig- thetic substitute, it is important that the facialures 5 a-f). In the event of blanching continuing surface of the pontic be oriented along thefor an extended period (more than an hour), the same axis as the natural tooth being replaced.clinician may choose between three alternatives: To accomplish this, a defined line angle is cre- ated between the pontic underside and the 1. Modify the bone underlying the pontic site. labial surface that is less than 90 degrees. An 2. Modify the underside of the pontic. equivalent or very similar angle is created at 3. Insert a needle into the blanched area to the junction of the palatal surface to the pon- tic underside. Through clinical and/or empirical stimulate new blood sup- observation, it has been found that this angle ply through angiogenesis.18-20 encourages—or at least does not interfere with— To avoid over-compression, the return tissue adaptation and restructuring over theseof blood flow after the blanching process line angles of the pontic itself in addition to tis-must be observed before the patient is dis- sue volume directed to the interproximal areas.charged.21-23 The patient leaves with instruc-tions that only a toothbrush (manual or The observed response shows that pro-electronic) is to be used for oral hygiene. The vided the vascularity of residual attached softgingiva will continue adapting to the pontic tissue is not compromised, the position of thecontours throughout the ensuing year, with tis- residual tissue will move in response to direc-sue directed to the labial, palatal, and inter- tion while rapidly developing new blood supplyproximal areas. The authors have documented to compensate for the compromise introducedlong-term (up to 15 years) maintenance of the by the compression. Keeping in mind the mor-soft-tissue health under EPPs, in the absence phology of teeth, ever efficient at reposition-of specific hygiene measures directed at ing food during mastication away from thethis junction (Figures 6a-i, Figures 7 a-d). stamping cusps through sluiceways created by triangular ridges and embrasures, the pon- Discussion tic underside similarly nudges the tissue along a similar path. That this repositioning is main-Tooth extraction in the esthetic zone often leads tained is not surprising, since highly scallopedto a soft-tissue deficit affecting both the labial soft tissues underneath pontics have beentissue volume and papillae adjoining any ponticteeth. Given that tissues are displaced by pon- The Journal of Implant & Advanced Clinical Dentistry • 37

Fortin et alFigures 6a-6c: Ten-year follow-up of Emergence Profile Figure 6bPontic design. Porcelain-fused-to-gold was previously usedbefore zirconia. The restoration, which was removed forinvestigative and photographic purposes only, had been inplace for 10 years and was maintained with toothbrush only. Figure 6d: EPP design with computer graphics superimposes to accentuate the contours, including the interproximal connection concavities (in black).Figure 6c undersides of framework pontics and support- ing abutments, at the present and proposedobserved for decades when fixed partial den- soft-tissue interface, demand as much consid-tures supported by teeth have been removed eration in design and finishing as the occlu-either for replacement or dental extraction. sal surface relative to the opposing dentition.These observations have included many pon-tic sites of high tissue health that have not had Multiple adjacent pontics (i.e., side-by-sidea history of routine oral hygiene maintenance. replacements of two or more missing teeth)These findings demonstrate that the restorative38 • Vol. 5, No. 9 • September 2013

Fortin et alFigures 6e and 6f: Soft-tissue topography after no oralhygiene measures other than routine tooth brushing. Figure 6fFigure 6g: Upper left quadrant, photographed beforerestoration was re-seated. Figure 6h: Restoration suspended before final seating to show interproximal adaptation of soft tissue.Figure 6i: Restoration re-seated before screw access-holeclosure. The Journal of Implant & Advanced Clinical Dentistry • 39

Fortin et alFigure 7a Figure 7bFigure 7c Figure 7dFigures 7a-d: Implant restoration with EPPs at 15-year follow-up. Note the appearance of the soft tissue immediatelyafter bridge removal (for photographic purposes only). This restoration had been in place for eight years since the previousremoval. No cleaning of the restoration or soft tissue has been performed.have an additional requirement, namely that ments with dental hygienists to avoid any dis-the junction zone between the two pontics be ruption of the intimate pontic/gingival interface.designed to permit the formation of a papilla.The complex contours of the EPP’s tissue- This methodology has allowed predictablecontacting surface direct the displaced tissue reproduction of ideal pontic features accord-toward formation of an esthetic papilla at the ing to the Rutten criteria.14 The EPP initiallylabial surface. To preserve the newly formed was used for conventional cemented tooth-sup-papilla, patients are instructed to use nor- ported bridges. However, in that application,mal brushing methods for oral hygiene and to it was difficult to verify the three-dimensionalstimulate the gingival tissue but to avoid pass- condition of the soft tissue beneath the pon-ing dental floss underneath the bridge. This tic over time. Using the EPP in conjunctionregime is also followed at maintenance appoint- with dental implants, particularly with screw- retained restorations, facilitates such verifica-40 • Vol. 5, No. 9 • September 2013

Fortin et alFigures 8a, 8b: Close-up of pontic design. With the residual maxillary ridge providing resistance, the soft tissue is directedover the pontic periphery. This not only gives the appearance of a sulcus, but this tissue repositioning also blocks access fororal hygiene implements.tion. First, it allows for controlled compression not guarantee ideal results in every situation.during try-in, enabling a gradual tissue compres- When restoring patients who have little com-sion and decompression as needed to maintain pressible tissue, clinicians have less latitude,proper circulation. Second, it enables removal and there is greater risk of tissue necrosis. Itof the bridge at any time after try-in to check the is thus important to assess whether the tis-condition of the underlying tissues. The pontic sue volume is sufficient to achieve the desiredalso can be modified by removing and/or adding post-compression results. Preparatory workmaterial as required. This has allowed for more such as a bone contouring, bone augmentation,objective validation of the results of using EPPs. and/or connective tissue grafts may be advis- able to increase the soft-tissue volume.4,24,25 For the past five years, the emphasis hasbeen on porcelain to zirconia restoration with Conclusionframeworks produced by industrial manufactur-ing. Zirconia frameworks have provided supe- The use of screw-retained, implant-supported,rior fit, and have the added benefit of more partial- or full-arch restorations that can besimplified porcelain modification or repair. This removed for direct observation of soft-tissuetechnique originally began with porcelain-to- response has allowed for verification thatgold screw-retained restorations with good active engagement of the residual soft-tissueresults, and the technique described could crest through pontic compression can be ben-be modified for these materials. Because of eficial. Contour requirements for single andknife-edged ridges and minimal amounts of multiple pontic restorations have been identi-attached gingiva, evaluation of suitable tech- fied, and a method to reproduce the criticalniques for the lower anterior jaw continues. design elements has been developed. The ability of the Emergence Profile Pontic design It should be noted that use of the EPP can- The Journal of Implant & Advanced Clinical Dentistry • 41

Fortin et alto locally reposition soft tissue that remains Disclosurevital over time has been demonstrated. Ben- The authors report no conflicts of interest with anything mentioned in this article.efits include increases in labial tissue volumeand papilla space soft-tissue fill. At the same Referencestime, this design simplifies hygiene mainte- 1. B ecker C, Kaldahl W. Current theories of crown contour, margin placementnance, requiring use of a toothbrush only. and pontic design. J Pros Dent 2005; 93: 112-14, reprinted from J Prosthet The Emergence Profile Pontic design can Dent 1981; 45: 268-77.be recommended for maxillary pontics sup- 2. B ehrend DA. The design of multiple pontics. J Prosthet Dent 1981; 46(6):ported by both natural tooth and implant abut- 634-8.ments in esthetic areas, with more favorable 3. A brams H, Kopczyk RA, Kaplan AL. Incidence of anterior ridge deformities inresults being achieved when sufficient residual partially edentulous patients. J Prosthet Dent 1987; 57(2): 191-94.soft tissue volume is available. Current designs 4. S tuder S, Lehner C, Bucher A, Schärer P. Soft tissue correction of a single-use zirconia frameworks with the apical pontic tooth pontic space: a comparative quantitative volume assessment. J Prosthetdesign computer-milled to precise specifica- Dent 2000; 83(4): 402-11.tions. Further studies should ideally include 5. K im T, Cascione D, Knezevic A. Simulated tissue using a unique pontic design:histological analysis to determine whether epi- A clinical report. J Prosthet Dent 2009; 102: 205-10.thelial attachment to biomaterials such as zirco- 6. N allaswamy D. Textbook of Prosthodontics. New Delhi: Jaypee Brothersnia and porcelain occurs when those materials Publishers 1996: 510.are incorporated in EPPs. Optimal designs 7. S pear F. The use of implants and ovate pontics in the esthetic zone.for lower jaws also await investigation. ● Compendium 2008; 29(2); 72-4, 76-80; quiz 81, 94. 8. E delhoff D. A review of esthetic pontic design options. Quintessence Int 2002; Correspondence: 33(10): 736-46. 9. M itrani R, Phillips K, Kois J. An implant-supported, screw-retained, provisional Dr. Richard Sullivan fixed partial denture for pontic site enhancement. Pract Proced Aesthet Dent 2005; 17(10): A-F. 22715 Savi Ranch Parkway 10. D ylina, TJ. Contour determination for ovate pontics. J Prosthetic Dent 1999; Yorba Linda, California 92887 82(2): 136-42. 11. Z itzmann NU, Marinello C, Berglundh T. The ovate pontic design: a histologic Phone: 714/282-4820 observation in humans. J Prosthet Dent 2002; 88(4): 375-80. Fax: 714/998-9236 12. A l-harbi S. Nonsurgical management of interdental papilla associated with E-mail: [email protected] multiple maxillary anterior implants: A clinical report. J Prosthet Dent 2005; 93(3): 212-16. 13. L iu C. Use of a modified ovate pontic in areas of ridge defects: a report of two cases. J Esthet Restor Dent 2004; 16(5): 273-81; discussion 282-3. 14. R utten L, Rutten P. Crown -- Bridge & Implants -- The Art of Harmony. Fuchstal, Germany: Teamwork Media GmbH; 2006: 230-31. 15. Orsini G, Murmura G, Artese L, Piattelli A, Piccirilli M, Caputi S. Tissue healing under provisional restorations with ovate pontics: a pilot human histological study. J Prosthet Dent 2006; 96(4): 252-7. 16. K erdvongbundit V. Microcirculation and micromorphology of healthy and inflamed gingivae. Odontology 2003; 91(1): 19-25. 17. K ocabalkan E, Turgut M. Variation in blood flow of supporting tissue during use of mandibular complete dentures with hard acrylic resin base and soft relining: a preliminary study. Int J Prosthodont 2005; 18(3): 210-3. 18. Retzepi M. Comparison of gingival blood flow during healing of simplified papilla preservation and modified Widman flap surgery: a clinical trial using laser Doppler flowmetry. J Clin Periodontol 2007; 34(10): 903-11. 19. H olderfield MT, Hughes CC. Crosstalk between vascular endothelial growth factor, notch, and transforming growth factor-beta in vascular morphogenesis. Circ Res 2008; 102(6): 637-52. 20. O hno M. Fluid shear stress induces endothelial transforming growth factor beta-1 transcription and production. Modulation by potassium channel blockade. J Clin Invest 1995; 95(3): 1363-9. 21. P atiño-Marín N, Martínez F, Loyola-Rodríguez JP, Tenorio-Govea E, Brito- Orta MD, Rodríguez-Martínez M. A novel procedure for evaluating gingival perfusion status using laser-Doppler flowmetry. J Clin Periodontol 2005; 32(3): 231-7. 22. B ouquot JE. Ischemic osteonecrosis under fixed partial denture pontics: radiographic and microscopic features in 38 patients with chronic pain. J Prosthet Dent 1999; 81(2): 148-58. 23. Kaidar-Person O. Compression anastomosis: history and clinical considerations. Am J Surg 2008; 195(6): 818-26. 24. Calesini G. Edentulous site enhancement: a regenerative approach for the management of edentulous areas. Part 1. Pontic areas. Int J Periodontics Restorative Dent 2008; 28(5): 517-23. 25. A zzi R, Etienne D, Takei H, Fenech P. Surgical thickening of the existing gingiva and reconstruction of interdental papillae around implant-supported restorations Int J Periodontics Restor Dent 2002; 22(1): 71-7.42 • Vol. 5, No. 9 • September 2013

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Subperiosteal Twin Implant Maxillary Wilcko et alTuberosity-Bound to Increase StabilityAntonio T. Di Giulio1 • Giancarlo Di Giulio1 • Enrico Gallucci2 AbstractBackground: For patients with severe resorbed detail. A stereolithographic model of the max-maxillae who do not want to wear a traditional illa was constructed upon which a subperi-denture, subperiosteal implants can be an alter- osteal twin implant was then constructed.native. In some patients, however, the sever- This was made by two implants, one fittingity of bone loss in the maxilla precludes even the palatal part and the other the vestibularthe placement of subperiosteal implants. This part, plus an implant shaped to hold the max-report describes a modification of the traditional illary tuberosity connected to the abutmentmaxillary subperiosteal implant to provide such of implant body by a metal crown in order topatients with a new modified implant referred increase the stability of the whole implant.to as subperiosteal twin implant maxillarytuberosity-bound (subperiosteal twin implant). Conclusion: This implant is considered a further evolution of the subperiosteal den-Material and methods: All patients who tal implant and its success, up to now, relieswere candidates for subperiosteal twin implant on the opportunity to take advantage of themaxillary tuberosity-bound underwent com- maxillary tuberosity, so as to become the siteputed tomography (CT) scans to reproduce of anchorage to confer an additional stabil-the exact maxilla bone crest in maximum ity to the whole body of subperiosteal implant.KEY WORDS: Subperiosteal dental implant, maxillary tuberosity, stereolithography 1. San Babila Day Hospital, via Stoppani 36-Milano, Italy2. Farmaco-Biologico Department, Università degli Studi di Bari Aldo Moro, Italy The Journal of Implant & Advanced Clinical Dentistry • 45

Di Giulio et al Introduction The subperiosteal implant has been used since 1940 when Dahl4 first installed it, thenIn daily clinical practice, one often encounters Goldberg and Gershkoff,5 and finally Linkow.6maxillae and /or mandibles with severe atrophy In a previous published paper by DiGuilio et al.,7in height and width. The reasons for this are long term survival rates of subperiosteal dentalmultifactorial, but periodontitis plays an impor- implants were reported with good results. In atant role. Although the best advice by clini- subsequent paper,8 a modification of the previ-cians is stressing the prevention of periodontal ous implant was described, taking advantage ofdisease, we still face ruinous situations due to some characteristics of such as bone undercuts.tooth and bone loss in many patients. Denturesand/or overdentures are not always accepted This goal of this report is to describeby patients, and in such cases, implants with the use of a subperiosteal body implantfixed prostheses may be the best option. In with an extension shaped as to tie crestalsome patients, however, the morphology of the tuberosity, which by connecting the dis-atrophic bone, the posterior maxilla in particu- tal abutment of the implant body, firmlylar, poses serious challenges to implant therapy locks it, resulting in increased stability.and prothesis rehabilitation. The augmenta-tion of alveolar bone defects in these areas, if MATERIALS AND METHODSpossible, is an essential step for successfuldental implants. Currently, many possibilities Subperiosteal dental implants placed by theare devoted to this aim including autogenous authors from 2008 to 2012 examined 120grafts, allografts, and growth factors such as patients. A total of 65 female patients (meanFC1 ,PRP, cPRP, PRGF, PRF,2 or rhBMP-2.3 age of 51.5 ± 11.0 years) and 55 males (mean age of 49.3 ± 12.0 years) were evaluated. Bone and soft tissue grafting have reached All patients treated in this study were com-a level that can often meet the patients’ and pletely edentulous and typically presented withdoctors’ best satisfaction. Additionally, the severely resorbed maxilla. Furthermore, smok-advent of bone allografts has reached a point ers and those suffering from chronic systemicwhere, in many cases, autogenous bone graft- conditions such as diabetes, cardiovascular dis-ing is no longer required to facilitate the place- ease, severe osteoporosis, or those undergo-ment of dental implants. The use of allografts ing chemo/radiation therapies were excluded.is often more accepted by patients due to Candidates for subperiosteal implant therapyreduced morbidity and the elimination of sec- received panoramic radiographs and computedondary surgical sites. In some cases, however, tomography (CT) scans with 64 multislicesbone loss is so extreme that neither allograft (General Electric Co, USA) to reproduce osse-nor autogenous grafting techniques can pro- ous structures in maximum detail. Such pre-vide enough bone for the placement of dental treatment analysis allowed us to become familiarimplants. As this problem still persists in cer- with the patient’s three-dimensional (3D) bonytain patients, the use of subperiosteal dental architecture and critical anatomical struc-implants offers a solution for these patients. tures so as to plan the subperiosteal implant.46 • Vol. 5, No. 9 • September 2013

Di Giulio et alFigure 1: Components of the twin implant partially Figure 2: Components of the twin implant assembled onassembled on the stereolithographic model, with exclusion the stereolithographic model.of the two extensions of crestal tuberosity visible on theright. This analysis allowed for fabrication of max- Initially intravenous dose of midazolamillary stereolithographic models used in con- 0.05 mg/kg for sedation and a maintainingstructing custom fabricated subperiosteal dose of 0.03 mg/kg was given every 15 min.dental implants. The exacting detail of the mod- At this concentration midazolam does notels allowed for fixtures that intimately adapted inhibit cough and breathing reflex. To reduceto the patients’ osseous anatomy before any psycoemotional component during the inter-surgical procedure was ever undertaken. The vention patients were treated with diazepamstructure of the maxillary subperiosteal dental (initial dose of 5-10 mg and maintenance doseimplant, constructed of titanium, has a palatal of 2.5mg every 15min). Articaine cloridratebar connected to the vestibular bars simulat- (0.01mg as plexical anaesthesia, Ketorolacing roots of the molars. This can be considered (30mg) for management of pain, and desa-the basic structure at which, as an integra- metasone (4mg) and ranitidine (30mg) alsotion, a subperiosteal implant extension to the were used. ECG, arterial pressure and SpO2crestal tuberosity which is inserted with a cap were continuously monitored during surgery.on the abutment of basic implant, has beenadded. The advantages of this subperiosteal An incision was made on the alveolarimplant integration abutment are an increase crest and mucoperiosteal flaps were elevatedin the surface of contact of the implant struc- to facilitate fixture delivery. Before sutur-ture with the bone and pulling the basic struc- ing the gingiva, the implant was covered withture so firmly as to block the whole implant. hydroxyapatite or demineralized bone allo- graft. Patients underwent panoramic radiog- The Journal of Implant & Advanced Clinical Dentistry • 47