Journal of Implant and Advanced Clinical Dentistry August 2014

Volume 6, No. 5 August 2014 The Journal of Implant & Advanced Clinical Dentistry Clinical Performance of Short Dental Implants CAD/CAM Customized Abutment for Soft Tissue

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The Journal of Implant & Advanced Clinical Dentistry Volume 6, No. 5 • August 2014Table of Contents5 C ase Report : The Tripod 29 R ehabilitation of the Anterior Configuration for Implant Maxilla with Guide Bone Retained Overdentures Offers Regeneration and a Dental More Flexibility with GPSTM Implant Supported Prosthesis: Abutments A Case Report Dr. Alessandro Onesti Dr. Manesh Lahori, Dr. Lanka Mahesh, Dr. Rahul Nagrath, D. Dipta12 A n Invitation to Enter a New 37 C linical and Radiological Field of Dental Implant Surface Performance of Short Dental Modifications: A Review Implants (6.5mm): 2 years Follow Up Dr. Preeti Pachauri, Dr. Lakshmana Rao Bathala, Dr. Rajashek-Ar Sangur, Jean-Nicolas Hasson, Jacques Hassid, Dr. Tanu Mahajan Dominique Aubazac, Paul Zeman21 T he use of Milled CAD/CAM Customized Abutments to Control Soft Tissues in the Aesthetic Zone: A Case Study Dr. Tim Doswell, Steve Campbell The Journal of Implant & Advanced Clinical Dentistry • 1

The Journal of Implant & Advanced Clinical Dentistry Volume 6, No. 5 • August 2014Publisher Copyright © 2014 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 1-888-923-0002.2 • Vol. 6, No. 5 • August 2014

The Journal of Implant & Advanced Clinical DentistryFounder, Co-Editor in Chief Co-Editor in Chief Founder, Co-Editor in ChiefDan Holtzclaw, DDS, MS Nick Huang, MD 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 • 3

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Case Report : The Tripod Configuration for Wilcko et alImplant Retained Overdentures Offers More Flexibility with GPSTM AbutmentsDr Alessandro Onesti, DDS1 AbstractBACKGROUND: The patient presented with as well as in a lower rate of wear of the retain-compromised residual elements of the lower ing components. However this configuration canarch and a poorly adapting removable par- be challenging if using conventional ball attach-tial denture. Extractions were performed and ments, in reason of their lack of compliance toa temporary complete lower denture was eventual implant disparallelism (max 10 deg)placed and relined with soft material. 3 monthslater the patient was ready for implant treat- RESULTS/CONCLUSION: The GPS implantment. Treatment goals included improve- attachments offer a better compliance to an even-ment of lower denture stability, with hygienic tual disparallelism: 20 deg for the internal malesand easy to maintain intra-oral components. and up to 40 deg when using external males. This features make this kind of attachment veryMETHOD/TREATMENT PLAN: implant retained useful when managing more than 2 implants.overdenture, supported by 3 implants, positioned In addition, single attachments are far easierin a tripod configuration, each of them provided to maintain intraorally and offers a much bet-with a single attachment. Advantages of this tri- ter accessibility to domiciliary oral-hygienepod configuration included elimination of the procedures compared to a bar mesostruc-antero-posterior rolling movement compared to a ture. This aspect is crucial when deal-conventional 2-attachment implant-retained over- ing with aged patients with limited ability todenture, resulting in a better functional comfort access and clean intra-oral components.KEY WORDS: Tripod Configuration, Overdenture, Retention, Implant-Supported Prosthesis, Anterior Guidance1. Adent Cliniques Dentaires, Switzerland The Journal of Implant & Advanced Clinical Dentistry • 5

Onesti CASE REPORT Systems similar to Locator®, such as the GPSTM abutments from Implant Direct offer sig-The reason for the practice visit is the patient’s nificantly more freedom and potential for success.desire for a quick solution to his problem. In most In addition, the individually adaptable retentioncases, however, various process steps first need rate is highly praised by many patients becauseto be carried out beforehand and this was also the of the individually adjustable retention sheathscase here. Before the lower jaw could be sup- made from plastics of different hardness levels.plied with a new, implant-supported prosthesis, Such characteristics make this retention mecha-the prerequisites for function and adaptation of nism valuable for treatments with more than twothe removable dental prosthesis in the lower jaw implants. In addition, other advantages of theneeded to be transferred to a stable state and oral GPSTM abutment include the simple cleaning ofhygiene needed to be improved. For this, teeth the retention components and the even simplerwere extracted and the lower jaw was supplied positionability – in particular for older and dis-with a temporary prosthesis that was underlaid abled patients. Three months later at the begin-with soft material for the transitional period. The ning of June this year, the implantation was able topreoperative panorama image (photo 1) shows be performed. We performed the treatment withthe initial situation. A lateral cephalometric radio- three SwishPlusTM implants (Implant Direct). Thegraph was helpful here in order to get a good selected size: 4.1 mm in diameter × 14.0 mm inpicture of the bone dimension in the anterior jaw length. The self-tapering SwishPlusTM implant isarea (photo 2). Our treatment objective was to compatible with both the Standard and Standardprevent the dreaded anterior/posterior rocking Plus implantation systems from Straumann®. Theeffect using an implant construction in order to SwishPlusTM implant represents a further devel-improve comfort and to avoid bone atrophy. This opment in certain key areas. For example, theruled out a telescoping prosthesis supported by SwishPlusTM has a neck section made with bothonly two implants as a treatment concept. At a polished shoulder and a microrough shoulderthe end of the planning phase, it was determined each measuring 1 mm as well as microgroovesthat the best possible option was a prosthesis that minimize the pressure on the crestal bone.supported by three implants in a tripod configu- This microrough surface offers me the option ofration. Here, each implant has its own retention placing the implant either in a sub- or transgin-element. The desired effect: function, comfort gival position. The insertion posts and the duoand the least possible wear and tear rate of the grip cover screw supplied with the product areretention elements. Thus, ball head or Locator® compatible with all insertion instruments, ratch-systems are possible options. However, please ets and screwdrivers from Straumann.® The self-be aware that this kind of tripod configuration is tapering thread has proven itself in my practice,extremely challenging if a conventional ball head since, together with the conically tapered apexis to be used as a retention element. Ultimately, of the implant, it offers the desired primary sta-only implant axes/insertion divergences of 10° bility. The ideal implant position is marked beforeare permissible, which, however, is something the minimally invasive flap is designed (photo 3).that bony structures often do not readily allow.6 • Vol. 6, No. 5 • August 2014

OnestiFigure 1: Preoperative panorama image.In order to protect the bone from unnecessary thetic integration becomes apparent in photo 12.destruction and overheating, the final drill is used Thanks to the tripod configuration the ante-at an extremely low speed (approximately 85 rpm)(photo 4). The first implant serves as the angle rior/posterior rocking effect, which is typi-set value for the subsequent steps. Using the cal for a ball head retention system on twoinsertion posts for easier orientation has proven implants, is practically neutralized. Anterioruseful for achieving the desired implant parallel- guidance is made possible; there is no need forism (photo 5 and photo 6). Photo 7 shows the a bilateral balanced occlusion (photo 13). ●implants with locking screw and extender. Forwound closure, the mucous membrane is posi- Disclosuretioned around the locking screw and extender. The author reports no conflicts of interest with anything mentioned in this article.The transmucosal healing allows for a very goodmaturation of the peri-implant soft tissue (photo Correspondence8). The post-operative panorama image shows Dr Alessandro Onesti, DDSthe positioning of the implant body (photo 9). Adent Cliniques DentairesAfter six weeks, the adjustment of the prosthe- Martigny: Avenue de Fully 53sis was carried out (photo 10). The appropri- CH 1920 Martigny - Switzerlandate GPSTM abutment was selected from among Tél: +41(0)273993000 Fax:four possible length options. The abutment +41(0)273993005housing could then be easily placed in the pros- Lausanne: R.te du Chatelard 54bthesis (dental lab: E. Samson, Martigny, Swit- CH 1018 Lausanne - Switzerlandzerland). Photo 11 shows the placement of the Phone: +41(0)216442000GPSTM abutments and the excellent healing Fax: +41(0)216442005of the transmucosa. The very convincing, aes- Mobile: +41(0)767088186 The Journal of Implant & Advanced Clinical Dentistry • 7

OnestiFigure 2: Lateral cephalometric radiograph to assess the Figure 3: Marking the ideal implant position.bone dimension.Figure 4: The drill is used at an extremely low speed. Figure 5: Insertion posts simplify the orientation.8 • Vol. 6, No. 5 • August 2014

OnestiFigure 6: Insertion posts simplify the orientation Figure 7: Implants with locking ring and extender.(secondary view).Figure 8: Wound closure. The Journal of Implant & Advanced Clinical Dentistry • 9

OnestiFigure 9: Post-operative panorama image. Figure 11: The placement of the GPSTM abutments.Figure 10: Adjustment of the prosthesis.10 • Vol. 6, No. 5 • August 2014

OnestiFigure 12: The aesthetically convincing final result. Figure 13: Anterior guidance is made possible. The Journal of Implant & Advanced Clinical Dentistry • 11

An Invitation to Enter a New Field of Wilcko et alDental Implant Surface Modifications: A ReviewDr. Preeti Pachauri1 • Dr. Lakshmana Rao Bathala2 Dr. Rajashek-Ar Sangur3 • Dr. Tanu Mahajan3 AbstractBackground: Titanium dental implants have performed for articles published betweenbeen used successfully used for centuries December, 1987 to January, 2012. Search wasbut they have serious shortcomings related to conducted in Medline, PubMed and Googletheir osseointegration and the fact that their scholar. The search was supplemented bymechanical properties do not match those of handsearch in selected journals and by exami-bone. Current trends in dental implant therapy nation of bibliographies of the identified articles.include use of endosseous dental implant sur-faces embellished with nanoscale topographies. Conclusion: Modification of dental osse-The objective of this review article is to summa- ous implants at nanoscale level can alterrize the role of nanoscale surface modifications biological responses that may improve osseo-of titanium dental implants for the purpose of integration and dental implant procedures.improving osseointegration, along with mer-its and demerits of surface modifications and Significance: Accomplishment of cell spe-various techniques that can impart nanoscale cific function is better understood by meanstopographic features to dental implants. of Nanotechnology. The ultimate goal is to search materials that will bring special-Methods: An electronic search of English lan- ized technology to the bedside and improveguage peer-reviewed dental literature was quality of life and current standard of care.KEY WORDS: Dental implants, engineered surfaces, intelligent surfaces, sputtering, superhydrophillic, chemical vapor deposition, osseointegration 1. Postgraduate student, Department of Prosthodontics, Rama Dental College, Kanpur, India 2. Professor and Department Head, Department of Prosthodontics, Rama Dental College, Kanpur, India 3. Professor, Department of Prosthodontics, Rama Dental College, Kanpur, India12 • Vol. 6, No. 5 • August 2014

INTRODUCTION nium implant. The second type of bone response is related to direct bone–implant contact with-Nanotechnology has been around since the out an overriding connective tissue layer. This isancient times. The inspiration for the field of nano- known as osseointegration. Surface propertiestechnology was provided by American Physicist like surface composition, hydrophilicity and sur-and Nobel Laureate Dr. Richard Phillips Feynmaan face roughness determines the rate and quality ofin 1959. The term “Nanotechnology” was first osseointegration in titanium implants.3 Cochrancoined by Norio Taniguchi in 1974. Nanomaterials, and colleagues4 did a histometric study in caninewith basic structural units, grains, particles, fibers mandible and demonstrated that the surfaceor other constituent components smaller than roughness of titanium implants affects the rate of100nm in at least one dimension, have induced osseointegration and biomechanical fixation. Wen-an enormous amount of attention for improving nberg et al5 in their histomorphometric evalua-disease prevention, diagnosis and treatment.1 tion of screw shaped implants concluded that the amount of bone in contact to the implant surface DISCUSSION is dependent on the surface roughness. Increase in surface roughness makes greater specific sur-Chemical composition and electrical charge on face area that give rise to more available surfacethe dental implant surface which is important for active sites for reactions by higher thermodynamicprotein adsorption and cell attachment are deter- reaction potential.6 Depending on the scale fea-mined by bulk composition and surface treatment. tures, surface roughness can be divided intoMost endosseous dental implants are made from three levels: a) Macro level topography, b) Micrograde 4 commercially pure titanium (cpTi) as it level topography and c) Nano level topography.is stronger than other grades. Titanium alloys are Macro and Micro level surface features demon-mainly composed of Ti6Al4V (grade 5 titanium strated to be efficient in enhancing in vitro and inalloy) with superior yield strength and fatigue vivo7 biological events but now it is documentedproperties than pure titanium. Chemical composi- that material-host tissue interactions are princi-tion of dental implant influences hydrophilicity of pally governed by nanometric surface modifica-the implant surface. Highly hydrophilic surfaces tions. As an outcome macro and micron-scaleseem more advantageous than hydrophobic features can only at best have an indirect influ-ones in view of their interactions with biological ence on cellular activity and thereby has inherentlyfluids, cells and tissues.2 The clinical success of limited activity and achievement. Therefore, thereoral implants is associated with early osseointe- is a necessity for surface features that can givegration which depends on geometry and surface rise a direct and rapid outcome. Various strate-topography. Two types of responses occur after gies have been formulated and enforced to nan-implantation. The first type involves the formationof a fibrous soft tissue capsule around the tita- The Journal of Implant & Advanced Clinical Dentistry • 13

Pachauri et alotextured surfaces that can directly regulate the removal of surface contaminants and improve-biological functionalities of implantable metals.8 ment of wear and corrosion resistance.11 Nanotopography can determine the process Mechanical Methodsof cell migration, proliferation and differentia- The main objective of mechanical surface modifi-tion by modulating cell behavior. These surfaces cation is to obtain specific surface topographies,hasten the wound healing process as related to roughness, removal of surface contamination andprotein adsorption and cell adhesion following to modify the adhesion in subsequent bondingimplant placement thus enhancing the process steps. Mechanical methods include: i) Machin-of osseointegration. Nanotopography modifica- ing; ii) Grinding; iii) Polishing; iv) Blasting. Thesetions are described as surface nanoroughness methods results in rough or smooth surfaces whichthat means adding nano features to the implant can increase the adhesion, proliferation and differ-surface. A nanostructure is an object of interme- entiation of cells. First of all, material is cut accord-diate size between molecular and micrometre- ing to required size. Afterwards grinding is requiredsized structures and often defined between 1 for surface treatment to remove hard abrasive par-and 100 nm. Dalby MJ and co-workers9 revealed ticles from the implant surface. The finest polish-that nanoscale topography also influences cell ing grade can exercise to change the surface toadhesion and osteoblastic differentiation. Oh an extremely smooth, mirror-like surface. The grind-SH et al10 illustrated that nanotechnology can ing and polishing procedures are mainly used tointerpolate the implant surface at an atomic convert the surface to a preferred surface topog-level and may determine the chemical composi- raphy. Therefore grinding and polishing methodstion of these surfaces. Nanorough titanium can for implant surface treatment are contemplated asenhance osteoblast adhesion and differentia- an intermediate step prior to chemical treatment.tion when equated to their nano smooth control. Blasting is a method that leads to the manu- METHODS OF IMPLANT facturing of a porous surface accomplished SURFACE MODIFICATIONS through the collision with microscopic scales. The thickness of the porous layer is regulated bySurface morphology appreciably affects osteo- the granulometry of the particles. Grit blastinggenic cell activities, its phenotypes and so the technique is practiced by bombarding surfacespeed and quality of peri-implant osteogen- with hard particles at high velocity for clean-esis. This will ultimately leads to the establish- ing gross surface contamination, finishing andment and upholding of bone implant integration. ameliorating the surface roughness. Alumina isImplant surface chemistry, morphology and struc- one of the commonly used materials for blast-ture can be altered by three ways: Mechani- ing but use of alumina could compromise osseo-cal methods, Chemical methods, Physical integration like particles detachment during themethods. Principal function of these techniques healing process and progressive absorption byis to modify the bio-mechanical characteris- the surrounding tissues. TiO2 is another alter-tics of the implant surfaces such as stimulation native as a blasting material showing interest-of bone formation to improve osseointegration,14 • Vol. 6, No. 5 • August 2014

Pachauri et aling results in experimental studies. Ivanoff CJ & like nanostructures with tunable sizes as well ashis collegues12 evaluated histomorphometrically, to deposit a range of 10 mm-long titania nano-demonstrated that TiO2 blasted implants were tubes through a porous alumina mask. Nano-associated to a significantly higher bone implant structured layers on various metallic surfacescontact when compared with machined surfaces. have been similarly made using electrophoreticThe blasted particles are used to change the sur- deposition. For example nanocrystalline hydroxy-face chemical composition and to remove the apatite (nano-HA) coatings (crystals size in theparticulate contaminations. Although simple and 15–25 nm range) and multi-walled carbon nano-partially appropriate, these alterations are too tubes have been laid down on titanium-basedcoarse to directly influence events on the spa- metals resulting in an enhanced bioactivity.16tial scale at which cells function. It is increasinglyaccepted that interactions between biomateri- Acid treatment operates to remove the sur-als and host tissues are regulated by nanoscale face oxide and contamination which leads to afeatures. In addition adsorbed proteins and their clean and homogenous implant surface. The acidsaggregates are a few nanometers in dimension. commonly used are hydrochloric acid, sulfuric acid, hydrofluoric acid and nitric acid. It results inChemical Methods uniform roughness with micro pits ranging fromChemical modification is one of the most common 0.5- 2 μm, increase in surface area and enhancesand pliable method to modify metallic surfaces bone to implant contact. Takeuchi M et al17 evalu-on the nanoscale. It is based on chemical reac- ated the decontamination efficiency of three acidstions occurring at the interface between titanium Na2S2O8, H2SO4 and HCl to Ti surfaces as pre-and its surrounding solution. Chemical methodw treatment of surface modifications and proposedinclude: i) Anodic oxidation; ii) Acid Treatment; that HCl treatment was as an excellent decon-iii) Alkali Treatment; iv) hydrogen peroxide treat- tamination method. A combinations of strongment; v) sol-gel treatment; vi) Chemical vapor acids (or bases) and oxidants has been shown todeposition.13 According to Bagno A and Di efficiently creates networks of nanopits (pit diam-Bello C14 surface roughness, composition and eter ranging from 20 to 100 nm) on Ti, Ti6Al4V,enhancement of surface wettability are altered CrCoMo alloys and Ta.18 Surface topography canby chemical surface modification of titanium. be meticulously controlled by adjusting the length of exposure, temperature and composition of the Anodic oxidation has been successfully used etching solutions. Variation in the nature of theto alter smooth Ti implant surfaces into nanotu- etching solution makes possible to incorporatebular structures with diameters less than 100 selected elements e.g. fluorine, which has antibac-nm.15 By adjusting factors such as the chem- terial effects and contributes to bone formation.istry of the electrolyte, voltage and currentdensity one can accurately transform physico- Alkali treatment involves immersion of thechemical properties of surfaces, diameter and titanium implants in either sodium or potassiumthe spacing between nanotubes. On Ti sur- hydroxide followed by heat treatment by rins-faces, anodization also permits to create pillar- ing in distilled water. This results in the devel- opment of a bioactive, nanostructured sodium The Journal of Implant & Advanced Clinical Dentistry • 15

Pachauri et altitanate layer on the implant surface. The surface of sintering temperature, chemical pretreatmentacts as a site for the subsequent in vitro nucle- and surface roughness. Bajgai MP & his associ-ation of calcium phosphates when dipped in ates21 studied bioactivity of titanium coating andsimulated body fluid (SBF). This includes an ini- observed that apatite growing faster in titaniatial formation of Ti-OH by release of sodium ions containing gel while substrate is dipped in SBFfrom the sodium titanate layer by the route of ion for 1 to 15 days. Nishimura and colleagues22exchange. This is followed by development of cal- demonstrated a directed approach to assemblecium titanate as a result of reaction with the cal- CaPO4 nanofeatures on dual acid-etched cp Tita-cium ions from the fluid. Being negatively charged, nium implant surfaces. The deposition of discreteTi-OH groups react precisely with the positively 20–40 nm nanoparticles on an acid-etched tita-charged calcium ions in the SBF to form cal- nium surface led to increased mechanical inter-cium titanate. Phosphate and calcium ions get locking with bone and the early healing of bone atincorporated into this calcium titanate and get the implant surface in a rat model. Gutwein andchange into apatite which can facilitate favorable Webster23 equated the relationship of particleconditions for bone marrow cell differentiation. size and cell viability and proliferation compared to micron-particles and evaluated that nanopar- Hydrogen peroxide treatment results in ticles of titania and alumina had less negativechemical dissolution and oxidation of the tita- impact in cell viability and proliferation. There maynium implant surface. When titanium surfaces be an improvement by nanoscale modificationreact with hydrogen peroxide, Ti-peroxy gels are of surfaces using sol–gel coating methods. Theproduced. The thickness of titania layer formed quantum interaction of high electron density atcan be controlled by calibrating the treatment the atomic level can enforce high bond strengthtime. Tavares MG & his coworkers19 demon- between the substrate and nanoscale coating.strated that thicker layers of titania gel are moreadvantageous for the deposition of apatite when Chemical vapor deposition involves chemicalimmersed in simulated body fluid (SBF). A com- reactions between chemicals in the gas phasebination of NaOH and hydrothermal treatments and the surface of the substrate which leads tohas also been practiced to Ti to generate an the deposition of a non-volatile compound on theextensive variety of bioactive nanostructures substrate. Popescu S & coworkers24 did compar-such as nanoleaves, nanoneedles, nanorods, ative study and concluded that the properties ofnanotubes and multiscale octahedral whiskers20. metallic surfaces can also be altered at the nano- metric level by chemical vapor deposition (CVD). The sol-gel process used to lay down TiO2,CaP, TiO2-CaP composite and silica-based coat- Physical Methodsings on the titanium implant surface. It includes The physical methods of surface modi-controlled hydrolysis and condensation of a sol- fication includes: i) Plasma spray-uble pioneer to form a sol, a homogeneous sus- ing; ii) Sputtering; iii) Ion deposition.pension of submicroscopic solid oxide particlesin liquid. Adhesion of TiO2 sol-gel coatings on The plasma deposition method is able to gen-titanium substrate are perceived as a function erate an engineered-surface nanostructure with16 • Vol. 6, No. 5 • August 2014

Pachauri et alfeatures usually less than 100 nm. First of all a ing response when implanted into the trabecularvacuum is used to eliminate all contaminants bone of the goat. The main drawback of this tech-then kinetic energy guides the charged metal- nique is that the deposition rate is very low andlic ions or plasma to the implant surface. The the process itself is very slow. The deposition rateprocess permits a wide range of materials (e.g. is modified by using a magnetically enhanced vari-Ag, Au, Ti etc.) to be coated onto an extensive ant of diode sputtering known as radio frequencyrange of underlying materials (e.g. metals, poly- magnetron sputtering.28 Radio frequency sput-mers and ceramics). In dental implants, titanium tering (RF) is used to deposit thin films of stan-particles deposit on the implant surface with a dardized CaP coatings on titanium implants. Theuniform pattern. This process is most commonly benefit of this technique is that the coating showsused for deposition of calcium phosphate coat- strong adhesion to the titanium, the Ca:P ratioings such as HA onto implant materials to improve and crystallinity of the deposited coating can betheir bioactivity. It increases the osteoblast den- changed easily. Magnetron sputtering is a via-sity on the implant surface. According to De ble thin-film technique as it allows the mechani-Groot K and collegues25 HA-coated implants cal properties of titanium to be preserved whilehave higher percentage of bone- implant contact. maintaining the bioactivity of the coated HA.Regardless of clinical success plasma-spraying Coatings were deposited in a custom-built sput-method has several disadvantages including ter deposition chamber at room temperature.reduced long-term adherence of the coating to This method shows strong HA titanium bond-the substrate material, uneven thickness of the ing associated with outward diffusion of titaniumdeposited layer, variations in crystallinity and com- into the HA layer forming TiO2 at the interface.29position of the coating that can affect the stabilityof the implants as well as pose a health hazard.26 The Ion Deposition method includes atomic rearrangements. This technique allows the fine Sputtering is a method in which atoms or control of the concentration and depth distribu-molecules of a material are ejected in a vacuum tion of the implanted elements. The potential cre-chamber by bombardment of high-energy ions. ation of superficial stresses and modification ofThis process is useful for the deposition of bioc- preexisting surface nanometric features musteramic thin films (based on Ca–P systems) due be carefully considered when using this highlyto the ability of the technique to provide greater energetic process.30,31 Approach based on thiscontrol on the coating’s properties and improved technology offer the possibility to insert selectedadhesion between the substrate and the coat- biologically effective ions (i.e. Ca2+, F-, Na+).ing. Properties like biocompatibility, biologicalactivity and mechanical properties such as wear LATEST ADVANCES TO MODIFYresistance and corrosion resistance are improved DENTAL IMPLANT SURFACESby sputtering. Vercaigne S & his associates27 didhistological evaluation using TiO2 grit blasted and The effect of laser procedure, pico to nanometersputtered CaP implants, the sputtered CaP coat- thin TiO2 coatings and synergistic effect of micro-ings showed improved initial fixation and heal- nano hybrid topography on titanium surface with UltraViolet (UV) Photo functionalization are recent The Journal of Implant & Advanced Clinical Dentistry • 17

Pachauri et aladvances that will enhance the surface chemis- ita Y et al34 directed the possibility of picotry of titanium implant without altering their bio- to nanometer-thin TiO2 coatings on micrologically proven surface morphology/ topography. roughened titanium surfaces and suggested that establishment of a super-thin TiO2 coat-Laser modified nano-structured dental ing ranging from pico-to-nanometer thicknessimplant surface accelerating the biological properties of theLaser is used as a micromachining tool to pro- proven micro roughened titanium surfacesduce a 3-D structure at micrometer and nanome-ter level. This technique generates short pulses Synergistic Effect of Nanotopography withof light of single wavelength providing energy Ultra violet (UV) photofunctionalizationfocused on one spot. It is rapid, extremely clean The effect of micro-nano hybrid topography onand suitable for the selective modification of titanium surface with UV photofunctionaliza-surfaces and allows the generation of complex tion is synergistic. UV Photofunctionalizationmicrostructures/features with high resolution. is intended to be a new approach of surfaceIts advantages are associated with precise, tar- enhancement as compared to conventionalgeted and guided surface roughening.32 These surface modification methods It cleans theadvantages make the technique interesting for implant surfaces by removing the contaminantsgeometrically complex dental implant. Thoms- of hydrocarbon via TiO2-mediated photocataly-son & Esposito33 performed retrospective case sis and direct decomposition by ultra violet35.series and developed laser micromachining pro- Tsukimura N & his co-workers36 addressed thecess to create micro and nano structured surface synergistic effects of UV photofunctionaliza-roughness in only the inner part of the thread. The tion and identified regulatory surface fac-inner part of the thread is considered to be more tors determining these synergistic effects,suitable for bone formation than the outer part. the micropits with 300-nm nodules show- ing the highest bioactivity after UV treatment.Picometer to Nanometer thin TiO2 coatingsA TiO2 coating of a thickness ranging from CONCLUSION300 pm to 6.3 nm was effectively appliedusing a slow-rate sputter deposition of molten Nanoscale surface modification techniquesTiO2 nanoparticles to augment the surface oxy- are likely to promote reflective changes in thegen components without changing the exist- ways dental implants are designed and manu-ing microscale architecture and roughness factured. Therefore any procedure that canof the substrates. These biological effects enhance the performance of dental implants willwere exponentially correlated with the thick- have a major impact on the quality of life andness of TiO2 and oxygen percentage on the result in major economic benefits to society.surface suggesting that even a TiO2 coating Progression in metallurgical, surface-engineer-as thin as a picometer is effective in enhanc- ing techniques and “intelligent surfaces” assureing the biological capability of titanium. Sug- a new generation of improved dental implant devices with exclusive bioactive surfaces. ●18 • Vol. 6, No. 5 • August 2014

Pachauri et alCorrespondence: 10. Oh SH, Finones RR, Daraio C, Chen LH, Jin 24. P opescu S, Demetrescu I, Sarantopoulos C, S. Growth of nano-scale hydroxyapatite using Gleizes AN, Iordachescu D. The biocompatibilityDr. Pretti Pachauri chemically treated titanium oxide nanotubes. of titanium in a buffer solution: compared effects Biomaterials. 2005;26:4938–4943. of a thin film of TiO2 deposited by MOCVD andRoom no. 5, of collagen deposited from a gel. J Mater Sci 11. Milinkovi I, Rudolf R, Raic KT, Aleksic Z, Lazic Mater Med. 2007;18:2075-2083.Staff accommodation, V, Todorovic A, Stamenkovic D. Aspects of titanium-implant surface modification at the 25. D e Groot K, Geesink R, Klein CP, Serekian, P.Rama dental college, Kanpur. micro and nano levels. Materials and technology. Plasma sprayed coatings of hydroxyapatite. J 2012;46: 251–256. Biomed Mater Res. 1987; 21: 1375-1381.Telephone No: 12. Ivanoff CJ, Hallgren C, Widmark G, Sennerby L, 26. B allo AM, Omar O, Xia W and Palmquist A.+919838573886 Wennerberg A. Histologic evaluation of the bone Dental Implant Surfaces – Physicochemical integration of TiO2 blasted and turned titanium Properties, Biological Performance, and Trends.E-mail: microimplants in humans. Clin. Oral Implants [Cited 2011 Aug29]. Available at: http://www.in- Res. 2001; 12: 128–134. techopen.com/books/[email protected] evolving-practice/dental-implant-surfaces-phys- 13. Ercan B, Webster TJ. The effect of biphasic icochemical-properties-biological-performanceDisclosure electrical stimulation on osteoblast function at and-trends. Accessed August 29, 2011.The authors report no conflicts of interest with anodized nanotubular titanium surfaces. Bioma-anything mentioned in this article. terials. 2010;31:3684-3693. 27. V ercaigne S, Wolke JGC, Naert I, Jansen JA. A histological evaluation of TiO2- gritblasted andReferences 14. Bagno A, Di Bello C. 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J Biomed Mater Res in the canine mandible. J Biomed Mater Res. 24:1821-1827. B. 2010 ;93:581-591. 1998;40:1–11.5. Wennerberg A, Hallgren C, Johansson C, 18. Variola F, Lauria A, Nanci A, Rose F. Influence of 31. H anawa T, Kamiura Y, Yamamoto S, Kohgo T, Danelli S. A histomorphometric evaluation of treatment conditions on the chemical oxidative Amemiya A, Ukai H, Murakami K, Asaoka K. screw-shaped implants each prepared with two activity of H2SO4/H202 Mixtures for modulating Early bone formation around calcium-ion-implant- surface roughnesses. Clin Oral Implants Res. the topography. Advanced Engineering Materi- ed titanium inserted into rat tibia J Biomed Mater 1998;9:11–19. als. 2009;12:227-234. Res. 1997;36:131-136.6. Hussain MM, Gao W. How is the Surface Treat- ments Influence on the Roughness of Biocompat- 19. Tavares MG, De Oliveira PT, Nanci A, Haw- 32. A .Y. Fasasi, S. Mwenifumbo, N. Rahbar, J. Chen, ibility? Trends Biomater. Artif. Organs. 2008; 22: thorne AC, Rosa AL, Xavier SP. Treatment of a M. Li, A. C. Beye, C. B. Arnold, W. O. Soboyejo, 144-157. commercial, machined surface titanium implant Nano-second UV laser processed micro-grooves7. C elletti R, Marinho VC, Traini T, Orsini G, Brac- with H2SO4/H2O2 enhances contact osteo- on Ti6Al4V for biomedical applications. Materials chetti G, Perrotti V, Piattelli A. Bone contact genesis. Clinical oral implants research. 2007; Science and Engineering C. 2009;29:5–13. around osseointegrated implants: a histologic 18: 452-458. study of acid-etched and machined surfaces. J 33. T homsson M, Esposito M. A retrospective case Long Term Eff Med Implants. 2006;16:131-143. 20. Divya Rani VV, Manzoor K, Menon D, Selvamuru- series evaluating Branemark BioHelix implants8. Khang D, Lu J, Yao C, Haberstroh KM, Webster gan N, Nair SV. The design of novel nanostruc- placed in a specialist private practice following TJ. The role of nanometer and sub-micron surface tures on titanium by solution chemistry for an ‘conventional’ procedures. One-year results after features on vascular and bone cell adhesion on improved osteoblast response. Nanotechnology. placement. Eur J Oral Implantol. 2008;1:229-234. titanium. Biomaterials. 2008;29:970-983. 2009;20:195.9. D alby M.J, Andar A, Nag, A, Affrossman S, Tare R, 34. S ugita Y, Ishizaki K, Iwasa F, Ueno T, Minami- McFarlane S, Oreffo RO. Genomic expression of 21. Bajgai MP, Parajuli DC, Park SJ, Chu KH, Kang kawa H, Yamada M, Suzuki T, Ogawa T. Effects mesenchymal stem cells to altered nanoscale to- HS, Kim HY. In vitro bioactivity of sol-gel derived of pico-to-nanometer-thin TiO2 coating on the pographies. Journal of the Royal Society, Interface hydroxyapetite particulate nanofiber modified biological properties of microroughened tita- / the Royal Society. 2008;5:1055-1065. titanium. J Mater Sci Mater Med. 2010;21:685- nium. 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The Journal of Implant & Advanced Clinical Dentistry ATTENTION PROSPECTIVE AUTHORSJIACD wants to publish your article! For complete details regarding publication in JIACD,please refer to our author guidelines at the following link: http://www.jiacd.com/authorinfo/ author-guidelines.pdf or email us at: [email protected]

The use of Milled CAD/CAM Customized Wilcko et alAbutments to Control Soft Tissues in the Aesthetic Zone: A Case StudyDr. Tim Doswell1 • Steve Campbell, RDT2 AbstractThe restoration of implants in the aesthetic until a satisfactory soft tissue level has been zone remains one of the great challenges achieved. By default though, this means that the in restorative dentistry. The central incisor provisional crown, and the permanent succes-is a particular challenge, with mismatches in sym- sor, may have a deeper cement margin. There ismetry usually being very obvious to the patient increasing evidence that this may increase theand observer. The symmetry of a central incisor risk of peri-implant diseases such as peri-implantis not only defined by the colour characteristics mucositis and peri-implantitis because of the riskand shape of the restoration, but also by the soft of incomplete removal of the cement during fit-tissue architecture of the peri-implant tissues. In ting of the restoration which may go undetected.addition to this, the loss of the interdental papil-lae may also compromise the final aesthetic result. This article discusses the merits of using milledOne of the traditional methods for controlling the CAD/CAM customised abutments in the aestheticsoft tissues in the aesthetic zone is to fit a provi- zone and a technique to control the healing of thesional crown to a modified pre-formed abutment, soft tissues around them so that the use of a mod-and adjust the emergence profile of this crown ified preformed abutment fitted with provisional crowns to control the soft tissues may be avoided.KEY WORDS: Dental implants, prosthetics, CAD/CAM, abutments, temporization 1. Private practice, Practice in Knaresborough in North Yorkshire 2. Managing Director of Ambridge Ceramics Ltd The Journal of Implant & Advanced Clinical Dentistry • 21

Doswell et al INTRODUCTION She was a regular attender of the practice and did not smoke. Her presenting complaint was ofThe restoration of implants in the aesthetic zone a post retained crown at 8 which regularly failed.remains one of the great challenges in restor-ative dentistry. The central incisor is a particular On examination, there was very little coro-challenge, with mismatches in symmetry usually nal ferrule evident and evidence of a crackedbeing very obvious to the patient and observer. root. The diagnosis of vertical root fracture was made and the tooth was deemed unrestorable. The symmetry of a central incisor is not onlydefined by the colour characteristics and shape The patient had a medium-high smile lineof the restoration, but also by the soft tissue but a relatively thick biotype. Apart from somearchitecture of the peri-implant tissues. In addi- minor oral hygiene issues, the patient had ation to this, the loss of the interdental papillae healthy mouth and no obvious periodontal dis-may also compromise the final aesthetic result. ease. There was no obvious evidence of occlu- sal problems and no history of parafunction. One of the traditional methods for control-ling the soft tissues in the aesthetic zone is to The various options of filling the gap at 8fit a provisional crown to a modified pre-formed were discussed with the patient, such as aabutment, and adjust the emergence profile removable denture, Maryland Bridge or toothof this crown until a satisfactory soft tissue supported bridge. The patient did not wantlevel has been achieved.1 By default though, a removable denture as a long term solu-this means that the provisional crown, and tion or the potential unreliability of a Mary-the permanent successor, may have a deeper land bridge. A conventional tooth supportedcement margin. There is increasing evidence bridge would have been far too destructivethat this may increase the risk of peri-implant of the unrestored 8 and 9. Written consentdiseases such as peri-implant mucositis and was therefore obtained for the implant option.peri-implantitis because of the risk of incom-plete removal of the cement during fitting of Initial treatmentthe restoration which may go undetected.2 At the initial appointment, an impression using addition cured silicone putty was taken in order This article discusses the merits of using to make an immediate Maryland bridge. Atmilled CAD/CAM customised abutments in the following appointment, the offending postthe aesthetic zone and a technique to con- crown at 11 was extracted as atraumaticallytrol the healing of the soft tissues around as possible under local anaesthetic (2% Ligno-them so that the use of a modified preformed caine and 1/8000 adrenaline, buccal and pala-abutment fitted with provisional crowns to tal infiltrations) using periotomes and luxators.control the soft tissues may be avoided. Post extraction socket mapping confirmed that the buccal plate had been preserved. METHODS The space at 8 was temporar-Patient selection and History ily filled with an immediate MarylandThe patient used in this study was a 48 year old bridge, with lingual retainers on 8 and 9.female patient with no relevant medical history.22 • Vol. 6, No. 5 • August 2014

Doswell et alFigure 1: Healed site at 8 weeks. Figure 2: Flap designed with a remote crestal incision and oblique releasing incisions at 7-9. Open tray pick-up coping in situ.Figure 3: Soft tissue wax-up of anticipated soft tissue Figure 4: A Soft tissue model was then cast andhealing. emergence profile sculpted using pre-op photograph to determine position of gingival zenith.Surgical PhaseAn “Early placement” protocol, as described also given a pre-op mouth rinse with Cor-by Buser et al.3, was planned so the sodyl immediately pre-op. Local anaestheticimplant placement was scheduled for 8 using 2% lignocaine and 1/80000 adrena-weeks post-extraction. Consent for the line was administered buccally and palatally.likely use of a bovine bone filler and por- Aseptic conditions were observed through-cine collagen membrane were obtained. out. The implant was placed using the stan- dard Astratech surgical protocol. Figures A prophylactic dose of 3g Amoxicillin was 1 and 2 show the stages of the surgery.administered 1 hour pre-op. The patient was The Journal of Implant & Advanced Clinical Dentistry • 23

Doswell et alFigure 5: VAD software images. Figure 6: Atlantis Gold-hue and Duplicate abutment.Figure 7: Gold hue abutment fitted to implant (torqued Figure 8: The position of the soft tissues was satisfactorydown to 25NCM). The screw access hole was sealed with a around the provisional.pledget of cotton wool and composite. Preliminary Laboratory ProceduresFigure 9: Final result - Emax crown cemented to The preliminary model was cast from theabutment. impression taken at first stage surgery upon which the technician did a wax up of the antici-24 • Vol. 6, No. 5 • August 2014 pated soft tissue healing (Fig 3). A pre-sur- gical photograph was used by the technician to determine the correct levels of the soft tis- sues in the edentulous space as well as the adjacent teeth as these references are obvi- ously lost by raising the flap during surgery. A Soft tissue model was then cast and emergence profile sculpted using

Doswell et alFigure 10: Peri-apical radiograph above which was taken Figure 11: Long term Peri-apical radiograph of restoredimmediately after cementation. implant.pre-op photograph to determine posi- Restorative Phasetion of gingival zenith at UR1 (Fig 4). A period of 3 months was allowed before car- rying out second stage surgery. As the impres- At this point the model was then scanned sion had been taken during first stage surgery,and sent to Atlantis to be programmed into their this allowed either the Atlantis abutment or theVirtual Abutment Design (VAD) software (Fig Duplicate abutment, along with the provisional5). A Gold-Hue Atlantis abutment and Duplicate crown, to be fitted as a customised healingabutment were ordered (Fig 6). As the emer- abutment at second stage surgery rather thangence profile was being dictated by the soft using a traditional healing abutment. A periodtissue model sculpted by the technician, a pre- of 8 weeks soft tissue maturation was thenscription of “no tissue displacement” was made. allowed to pass at which point the patient wasA provisional acrylic crown was also ordered. reviewed. The results are shown in figure 7. The Journal of Implant & Advanced Clinical Dentistry • 25

Doswell et al RESULTS profile with the crown, often leaves them with a reduced surface area for bonding. This meansThe following image (fig 8) was taken 8 weeks that the crowns are far more likely to debond andafter the Atlantis abutment and provisional will be troublesome to recement as the soft tis-crown had been fitted at second stage. The sues will rapidly collapse onto the exposed abut-final shape of the provisional was refined using ment. This in itself compromises the peri-implantcomposite and an alginate matrix was taken tissues as there is a risk of the implant crownto convey the desired shape to the labora- not being fully re-seated during re-cementation.tory. As the position of the soft tissues wassatisfactory around the provisional, it was NOT These risks are substantially reduced withnecessary to take a further impression of the the type of milled CAD/CAM customised abut-abutment. The technician simply made the final ment used in this case study because the cementcrown on the Duplicate abutment mounted margin is usually far less subgingival (fig 11).on the working model. An Emax crown wasordered to the desired shading and charac- This particular abutment system uses the prin-teristics. The final result is shown in Figure 9. ciple of reverse treatment planning during the manufacture and is generated from a Virtual ide- DISCUSSION alised wax-up of the final restoration. Because this virtual wax up determines the position of theThe Practice of using a modified pre-formed cement margin of the final crown, it is the custom-Abutment and a Provisional crown to control ised abutment that dictates the emergence profile,the soft tissues in the aesthetic zone is widely rather than the crown. The additional benefit of thisaccepted and used in implant dentistry, and method of design is that these abutments balancewithout question, can achieve some excellent allowing sufficient space for material for techni-results.1 But this technique comes with a bio- cian to deliver an aesthetic restoration with maxi-logical compromise in that by default, the cement mum surface area for bonding of the restoration.margin will be more subgingival and in somecases can be right next to the crestal bone. But the biological benefits of a custom- ised abutment aside, until now there was no This point is illustrated by the peri-apical radio- way of controlling the soft tissues with a cus-graph above (fig 10) which was taken immedi- tomised abutment, without remaking the abut-ately after cementation. Although the radiograph ment with a different emergence profile. Withdoesn’t show any retained cement interdentally, this technique, the huge benefit of taking theit is impossible to determine whether it has been impression during first stage surgery is that theremoved thoroughly, buccally and palatally. When Atlantis abutment can be used as a custom-the cement margin is particularly deep, it can also ised healing abutment. If after a period of softbe very difficult to determine retained cement by tissue healing there is no change and thereclinical examination, even in the hands of expe- is a desirable aesthetic result, the technicianrienced clinicians. From a more practical point can manufacture the final crown on the Dupli-of view, the modification of the pre-formed abut- cate abutment without the dentist having toments in order to allow the correct emergence remove the Atlantis abutment from the patient’s26 • Vol. 6, No. 5 • August 2014

Doswell et almouth. Evidence suggests that this is biologi- having a recession defect. Any Class III of IVcally advantageous as any epithelial attachment bone defects (Cawood and Howell classifica-to the abutment will not be disturbed and the tion)5 left untreated will result in a compromisedimplant interface will not get re-contaminated.4 aesthetic result regardless of technique used. If however there has been a little soft tissue The use of the Duplicate abutment is costchange such that the cement margin is slightly effective for the surgeon and costs roughlyexposed, the Atlantis abutment can be modified the same as a new healing abutment. It mustso that the cement margin is finished slightly however be ordered at the same time assubgingival and then returned to the technician the Atlantis abutment. The Duplicate abut-for the final crown to made. The Duplicate Abut- ment is available in the Titanium and Goldment can then be placed in the patient’s mouth Hue versions of the Atlantis abutment system.to support the provisional crown thus main-taining the same soft tissue emergence that CONCLUSIONShas been created. Without the Duplicate abut-ment, a standard healing abutment would have The use of this technique allows the surgeon toto be placed which would change the soft tis- use an abutment system whereby the abutmentsue emergence that had been created which is generated from an idealised virtual wax-up.could be detrimental to the final aesthetic result. This ensures that the abutment has a maximum surface area for bonding but still with enough In the event that there is too much soft tis- space for the technician to manufacture an aes-sue and some recession is desired, the dentist thetic crown and a cement margin which is onlystill has the option to request that the buc- just subgingival. This allows easier cementa-cal aspect of the Atlantis Abutment is finished tion of the restoration and reduces the risk ofslightly more subgingival so that the crown peri-implant mucosal problems such as peri-can be designed to place some pressure on implant mucosistis and peri-implantitis. The usethe buccal tissues to induce some recession. of the Atlantis and Duplicate abutments andObviously the surgeon must then take great all the biological advantages they bring, allowscare during the cementation of the crown to the surgeon some control of the soft tissuesensure that no cement is left subgingivally. in the aesthetic zone so that the use of a modi- fied pre-formed abutment and provisional crown In the cases we have done using this tech- with a deep cement margin can be avoided. ●nique so far, our experience is that there hasonly been very slight recession defects which Correspondence:have not been detrimental to the final aesthetic Dr Tim Doswellresult. The greatest care has been taken during BChD Dip.Imp.Dent.RCSthe planning of these cases to ensure that any http://www.raglansuite.co.ukbuccal deficiencies in the bony ridge have beenidentified and treated accordingly (usually usingGuided Bone Regenaration)3 prior to or duringimplant placement so that there was no risk of The Journal of Implant & Advanced Clinical Dentistry • 27

Doswell et alDisclosure 2. Wilson TG Jr. The positive relationship between 4. D o Nascimento C et al. Influence of repeatedThe authors report no conflicts of interest with excess cement and peri-implant disease:A screw tightening on bacterial leakage along theanything mentioned in this article. prospective clinical endoscopic study. J implant-abutment interface. Clin Oral Implants Periodontol. 2009 Sep;80(9):1388-92. Res. 2009 Dec;20(12):1394-7.References1. G anddini MR et al. Technique for fabricating a 3. Buser D et al. Early implant placement following 5. C awood JI, Howell RA. A classification of the single-tooth extraction in the esthetic zone: edentulous jaws. Int J Oral Maxillofac Surg. 1988 cement-retained single-unit implant-supported biologic rationale and surgical procedures. Aug;17(4):232-6. provisional restoration in the esthetic zone. J Int J Periodontics Restorative Dent. 2008 Prosthet Dent. 2005 Sep;94(3):296-8. Oct;28(5):441-51. The Journal of Implant & Advanced Clinical Dentistry ATTENTION PROSPECTIVE AUTHORS JIACD wants to publish your article! For complete details regarding publication in JIACD, please refer to our author guidelines at the following link: http://www.jiacd.com/authorinfo/author-guidelines.pdf or email us at: [email protected] • Vol. 6, No. 5 • August 2014

Rehabilitation of the Anterior Maxilla with GuideWilcko et al Bone Regeneration and a Dental Implant Supported Prosthesis: A Case Report Dr. Manesh Lahori, MDS1 • Dr. Lanka Mahesh, BDS, MBA2 Dr. Rahul Nagrath, BDS3 • D. Dipta, BDS3 AbstractWith the increased popularity of implants peri-implant bone that supports and maintains and focus on esthetics, there is great gingival contours. Here we present a case with emphasis on idealized bone foun- alveolar ridge deficiency in the maxillary ante-dation and soft tissue contours. The goal of rior region and the surgical procedure done toreconstructive procedures is to provide ideal achieve final platform for implant placement.KEY WORDS: Dental implants, ridge augmentation, reconstructive procedure, bone graft 1. Professor, Department of Prosthodontics, KDDC, Mathura, India 2. Private Practice, New Delhi, India 3. Post Graduate Student, Department of Prosthodontics, KDDC, Mathura, India The Journal of Implant & Advanced Clinical Dentistry • 29

Lahori et alFigure 1a: Initial presentation (facial view). Figure 1b: Initial presentation (occlusal view).Figure 2: Mucoperiosteal flap reflection showing Figure 3: Dental implant osteotomies.edentulous ridge. INTRODUCTION establishing idealized bone foundation and soft tissue contours for optimal esthetic results.Clinical management of missing teeth with Specifically for dental implants in the estheticdental implants has become common and well zone, intact papillae with ideal facial gingivalaccepted. With current techniques and pro- contours that are indistinguishable from adja-tocols, success of dental implants is more cent natural teeth are the goals of therapy andthan 90 percent in both the maxilla and man- demands of patients. The goal of hard tissuedible, with even higher success in the ante- augmentation is to provide a foundation forrior regions.(1, 2) With the increased popularity ideal implant placement that not only allows forof dental implants and a paradigm shift from biomechanically sound implant positioning, butrestoring function to restoring form and func- also supports soft tissue for optimal esthetics.tion, there has been a greater emphasis on30 • Vol. 6, No. 5 • August 2014

Lahori et alFigure 4a: Clinical view of dental implant placement.Figure 5: Xenograft placed for guided bone regeneration. Figure 4b: Radiographic view of dental implantFigure 6: Trimmed guided bone regeneration barrier. placement. CASE REPORT AN 18-year-old male reported to the outpatient dental department of K.D. Dental College & Hospi- tal Mathura, with missing upper right and left cen- tral incisors, and upper left lateral incisor (Figures 1a, 1b). The patient gave a history of trauma due to a car accident which resulted in loss of some anterior teeth. On clinical examination, deficiency in the anterior residual alveolar ridge with loss of buccal cortical plate was noted. The patient was otherwise in good general health and was a non- smoker. The patient presented with his natural dentition in good condition. On examination there were no clinical signs of periodontitis or dental caries. The clinical findings were confirmed in the radiographic examination. After thorough exami- nation, oral prophylaxis was done then diagnostic impressions were made with irreversible hydrocol- The Journal of Implant & Advanced Clinical Dentistry • 31

Lahori et alFigure 7: Guided bone regeneration barrier placed at Figure 8: Primary surgical closure.surgical site.Figure 9a: Radiograph at 4 months healing. Figure 9b: Clinical view (facial) at 4 months healing.Figure 9c: Clinical view (occlusal) at 4 months healing. Figure 10: Soft tissue sculpting from dental implant abutments.32 • Vol. 6, No. 5 • August 2014

Lahori et alFigure 11a: Closed tray impression copings in place. Figure 11b: Closed tray impression of dental implants.Figure 12a: Facial view of prosthesis. Figure 12b: Palatal view of prosthesis.loid. The upper right and left central incisor, and prosthesis. Further, the anticipated long-termupper left lateral incisor were missing and the result and alternative treatment options were dis-edentulous ridge in this region was insufficient in cussed. After having evaluated the options, itboth width and height for 3rd implant placement. was decided that a ridge augmentation pro-The remaining teeth were vital and in good health. cedure including guided bone regeneration (GBR) should be performed with subsequent TREATMENT PLANNING implant placement and prosthetic reconstruction.The patient was informed about the lack of suf- TREATMENT: Initial therapyficient bone in the upper front teeth region. Thedifferent treatment modalities that were available This treatment included patient infor-were described. These included bone augmen-tation, implant placement and implant supported mation, oral hygiene instruction and professional tooth debridement. The Journal of Implant & Advanced Clinical Dentistry • 33

Lahori et alFigure 13a: Final restoration (facial view). Figure 13b: Final restoration (palatal view).Ridge Augmentation with Simultaneous with a 0.12-0.2% solution of chlorhexidine glu-Implant Placement: conate. The patient is subsequently coveredA full thickness mucoperiosteal flap was ele- with sterile sheets to minimize bacterial con-vated both buccally and palatally and extended tamination from extraoral sites. The surgical pro-from tooth 6 to tooth 11 (Figure 2). Osteoto- cedure is in most cases performed on a lightlymies were done (Figure 3) with the placement sedated patient and under local anesthesia.of implants (Figures 4a, 4b). Bone graft (AlphaBIOs) was selected and was mixed with saline A full thickness crestal incision is placedand placed on the ridge in the bony defect and within the keratinized mucosa of the edentulouswas well adapted so that full concavity was ridge. In a partially dentate patient the crestalrestored (Figure 5). A guided bone regenera- incision is extended into an intrasulcular inci-tion (resorbable collagen membrane) membrane sion, mesially and/or distally, to involve one or(Figure 6) was adapted and fixed to the eden- two adjacent teeth. Vertical releasing incisionstulous bone crest (Figure 7). Releasing inci- are made at the mesial and distal ends of thesions were placed in the periosteum to reduce crestal incision. In order to get proper accessthe tension and the flaps were closed with hori- to the surgical site the releasing incisions arezontal mattress and interrupted sutures (Figure frequently made in buccal as well as in lingual8). The sutures were removed after 2 weeks. (palatal) direction. Once exposed, the cortical bone at the recipient site is curetted with a DISCUSSION chisel to remove all remnants of granulation tissue and portions of adherent periosteum. Ridge augmentation procedures shouldbe performed in a proper surgical set-up Guied Bone regeneration in membrane pro-and in patients with a dentition free of signs tected defects, heal in a sequence of stepsof destructive periodontitis. Before the surgi- that stimulate bone formation after tooth extrac-cal session, the perioral skin should be cleaned tion. After blood clot formation, bone regen-with the use of a disinfectant and the patient eration is initiated by the formation of wovenshould rinse his or her mouth for 2 minutes bone initially along new blood vasculature at the periphery of the defect. Membranes have34 • Vol. 6, No. 5 • August 2014

Lahori et albeen manufactured from biocompatible materi- CONCLUSIONals that are both nonresorbable and resorbable. This case describes the different phases A barrier membrane frequently used in included in the surgical reconstruction of a siteridge augmentation procedures is made of which included three missing maxillary teeth.expanded polytetrafluoroethylene (e-PTFE; In this particular case the esthetic outcomeGore-Tex, W.L. Gore Ass., Flagstaff, AZ, was of great importance. Therefore, a numberUS) and often the titanium reinforced of different procedures were required to recon-variety of the e-PTFE membrane (TR struct both the hard and the soft tissues. ●GTAM; Gore-Tex, W.L. Gore Ass. Flag-staff, AZ, USA) is placed to obtain optimal Referencesstability of the wound in the recipient site. 1. M oy PK, Medina D, et al, Dental implant failure rates and associated risk factors. Xenograft material was used in this patient Int J Oral Maxillofac Implants 20(4):569-77, 2005.(Alpha bios graft-Germany). Bone graft mate-rials have been used to facilitate bone forma- 2. C reugers NH, Kreulen CM, et al, A systematic review of single-tooth restorationstion within a given space by occupying that supported by implants. J Dent 28(4):209-17, 2000.space and allowing the subsequent bonegrowth. Natural bovine bone is a highly reli-able and dimensionally stable, purified graft-ing material. The mineral composition, threedimensional structure and the physico-chem-ical and biological properties of natural bovinebone are similar to those of human bone. Theunique manufacturing process for this xeno-graft involves high-temperature heating. Theprocess removes all organic components andeliminates all potential immunological reactions. The patient was recalled for follow-up after1 month, 3 months, 4 months, and 6 months(Figures 9a-c). After 6 months healing abut-ments were placed for 3 weeks to achieve thesoft tissue profile (Figure 10). After 3 weeks, aclosed tray impression (Figure 11a) was madewith rubber base impression material (Figure11b). The impression was sent to the labora-tory for the final prosthesis (Figures 12a, 12b).The final implant prosthesis placed six monthsafter implant placement (Figures 13a, 13b). The Journal of Implant & Advanced Clinical Dentistry • 35

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Wilcko et al Clinical and Radiological Performance ofShort Dental Implants (6.5mm): 2 years Follow UpJean-Nicolas Hasson DDS1 • Jacques Hassid DDS2 Dominique Aubazac DDS3 • Paul Zeman, PhD4AbstractBackground: Reconstruction of missing Results: 56 patients have received 77 short Tita-teeth in posterior areas has been always ham- nium implants. Radiographic evaluation of thepered by the limited bone availability and insuf- peri-implant bone height confirmed the remarkablyficient bone quality. The aim this paper was stable bone level related to the use of the implantto assess the clinical and radiological perfor- line. The peri-implant bone level stabilized at 0.9mance of short (6.5mm) implants inserted in ± 0.5 mm (mean ± standard deviation) beneaththe premolar and molar regions of the max- the microgap i. e. implant-abutment connection.illa. Implants were restored as single crowns or A case is included that documents the favorablefixed span bridges and followed up for 2 years. clinical outcome obtained with short implants.Methods: Reported are the results of a pro- Conclusions: Within the limitations of this casespective case series. Included patients had series, the reliable and predictable use of shortto show a vertical bone height 6.5 - 8.0mm implants for up to 2 years was confirmed. Theas well as a minimal bone width of 6.0 mm. results obtained in a multi-center setting con-Implant stability was assessed by tactile inves- firmed the positive observations reported by othertigation. Periapical X-ray’s were evaluated 6 authors. Minimal periapical bone loss (<1mm) hasmonths and 2 years after implant placement. been found radiographically. Long term studies are still needed to reveal if there are any specific risk factors pertinent to the use of short implants.KEY WORDS: Dental implants, short dental implants, success rates 1 Private practice, France 2 Private practice, France 3 Private practice, France4 Private practice, Switzerland The Journal of Implant & Advanced Clinical Dentistry • 37

Hasson et al BACKGROUND sis (FEA) indicate clearly that the distribution of horizontal and vertical loading forces is similar toThe reconstruction of missing teeth in posterior longer implants.9,10,11,12 Other calculations haveareas has been always hampered by the limited also shown that bone stress should be virtuallybone availability and insufficient bone quality typi- independent from implant length; a more impor-cally found in the posterior regions due to post tant role was assigned to implant diameter.6,13,14extraction bone atrophy both apico-occlusally and More recent reports1,14 indicated that it is possi-bucco-palatally, pneumatized sinus etc. Additional ble to achieve highly acceptable implant survivalfactors such as significant functional forces in the rates with the current short implants. Stellingsmaposterior segments of the maxilla increase the fail- et al. have shown survival rates of 88 to 100% inure risk of implant placement.1 Similar anatomical atrophied mandible.13 A survival rate of 96% waslimitations are mentioned in the recent review by reported for short implants in severely atrophicEstefanous et al.2 The restoration of implants in maxilla.15 Esposito et al. in a randomized, paral-posterior areas is more complex if e. g. permanent lel group study compared the 3 year post load-teeth were lost at young age, due to weak bone ing outcome of short and long (with guided bonequality (D3 and D4), enhanced bone resorption regeneration) implants.16 They have concludeddue to mucous stimuli and the presence of ana- that in cases with limited residual bone of 7 - 8mmtomic structures such as sinus cavity or inferior over the mandibular canal short implants are analveolar nerve, etc.3 Particularly in the maxilla the interesting alternative to vertical augmentation.use of short implants i. e. < 7mm long (endosse- The treatment is faster, cheaper and related toous part), is advantageous to avoid the need for less morbidity. It is to be noted that implant inser-sinus floor augmentation (sinus lift). Several bone tion into pristine bone was compared to implantsaugmenting techniques have been developed with placed after preliminary sinus lift elevation.17 In thisthe goal of increasing the bone volume before prospective study that included 393 implants andimplant placement thereby allowing the use of 155 patients treated in two groups, the implantslonger and wider diameter implants. The surgical placed in augmented sinuses had a lower survivalproblems and potential failures of such techniques rate compared to implants placed in pristine bone.have been clinically extensively documented.4 Theplacement of shorter implants has the potential to Excessive crown-implant ratios have beenavoid the need for such techniques. This would discussed to be detrimental to long term with-be beneficial for the patients both in terms of less drawal. For obvious reasons this ratio needs par-morbidity as well as economically. Despite the ticular attention when using short implants. Birdifact that early papers on short implants reported et al. determined the crown-implant ratios of 309higher implant loss rates,5,6,7,8 recent systematic single tooth implant supported restorations onliterature reviews stated that initial survival rates short implants.18 The mean follow up time waswere comparable to longer implants and thus con- 21 months. The mean crown - implant ratio wasstitute a viable alternative to additional augmenta- 2.0 i. e. quite unfavorable for a tooth. No statis-tion procedures. This correlates well with the fact tically significant relationship was found betweenthat model calculations by Finite Element Analy- the crown-implant ratio and neither implant suc-38 • Vol. 6, No. 5 • August 2014

Hasson et alcess nor the mesial or distal periapical bone level. man et al. from their systematic literature review De Santis et al. have studied short implants of survival rate of 2611 short implants that were installed in partially edentulous patients.24 Nev-(≤8.5mm) placed in posterior edentulous areas, ertheless the authors have found an increase inpredominantly in the mandible, that were affected implant survival (from 93.1% to 98.6%) that wasby high bone resorption. After 1 - 3 years follow associated with increasing implant length (fromup they have found a survival rate of 98.1% i. e. 5.0mm to 9.5mm). The authors believe that thereonly 2 of 107 implants have been lost, and a suc- is fair evidence that short implants can be placedcess rate of 96.3% i. e. only 4 of 107 implants in the partially edentulous patient, although withfailed the predefined success criteria.3 The a tendency towards an increasing survival rateresults of this study are therefore also in favor of per implant length and a better prognosis in theusing short implants in posterior areas with highly mandible of non-smokers. Morand and Irinakis inresorbed bone. In this context it is important to their earlier literature review also concluded thatbe aware that the implant length used by Bråne- “... although (short implants) are commonly usedmark et al. in their original protocol was estab- in the areas of the mouth under increased stresslished empirically.19 The implants at that time had (posterior region), their success rate mimic thosemachined (smooth) endosseal surface. Currently of longer implants when careful case selection cri-used implants with microstructured endosseal teria have been used”25. Last but not least Anni-surfaces are characterized by improved osseointe- bali et al.26 concluded their systematic reviewgration and increased amount of bone-to-implant on short implants that “The provision of shortcontacts. Together with optimized geometry, con- implant-supported prostheses in patients withtemporary implants are superior in maintaining atrophic alveolar ridges appears to be a suc-implant stability.3 This in turn should allow the use cessful treatment option in the short-term; how-of shorter implants. Short implants are typically ever more evidence is needed for the long term”.described as <10 mm long,20 but Hagi et al.21have described short implants as <7.0mm long. The aim this paper is to assess the clinicalThis is more practicable as implants >8.0mm and radiological performance of short (6.5mm)were commonly used for a long time without implants inserted in the premolar and molarany particular problem related to their length.22 regions of the maxilla. The residual bone vol- ume showed a bone height was at least 6.5mm In a recent review on meta-analysis of short and bone width at least 6mm. They wereimplant survival studies,20 it was concluded that restored as single crowns or fixed span bridges“the majority of studies obtain a CSR similar and followed up for 2 years after insertion.to that of longer implants (92.5% - 98.42% formachined and rough surface implants, respec- METHODStively)” and “... rehabilitations with short implantsare a reliable treatment”.23 This conclusion is to be Patientsunderstood within the limitations of a meta-anal- This prospective case series included 56 con-ysis and the lack of well designed, randomized secutive patients (35 females / 21 males) referredtrials. A similar conclusion was drawn by Telle- for dental implantation to three different practices The Journal of Implant & Advanced Clinical Dentistry • 39

Hasson et al(JNH, JH, DA). Patients were entered into the explained and signed prior to any intervention.study consecutively i. e. with no specific selec-tion criteria apart from the routine assessment Surgical procedureof their suitability to undergo implant surgery. Standard surgical one stage procedure was per-Patients with good overall physical status (ASA formed under local anesthesia. Patients receivedPS1 or PS2), had at least one missing tooth in antibiotic premedication one hour before sur-positions 15 - 17, 25 - 27, 35 - 37, or 44 - 47. gery (2gr amoxicillin or 600mg clindamycin ifAt the implant site they had to show a vertical allergic to penicillin) and rinsed for 1 min withbone height between 6.5mm and 8mm as well 0.15% chlorhexidine mouth wash. Drilling proto-as a minimal bone width of 6 mm, assessed by col was performed according to manufacturer’svirtual implant placement using Simplant® soft- recommendations. Bone quality (D1-D4; Mischware (Materialise, France). This is based on a classification) was recorded in patient’s chart.native image obtained by cone beam computed The insertion depth of the implant was driven bytomography (CBCT). Particular attention was the anatomy of the surrounding bone: particu-given to keep a 2mm safety zone from the men- lar attention was given to avoid any rough sur-tal nerve to avoid any trauma during the surgery face to be in contact with soft tissue. Implantsdue to an initial radiographic error. Moreover, placed were 6.5mm long titanium implants withpatients they had to present with a normal occlu- a 1 mm polished collar, platform diameters 4.0,sion (no open bite) including an opposing arch 4.5, 5.0 or 6.0mm and hydrophilic, moderatelyoffering adequate occlusal support. Care was rough enossal surface.1 At the end of the sur-taken not to insert the implants in heavy smok- gery, patients were instructed to use standarders ( >5 cigarettes per day), patients with heavy mouth hygiene procedures including chlorhexi-bruxism, untreated periodontal disease, poor dine mouth wash immediately after implanta-plaque control or a position where an implant tion. Paracetamol 1gr every 6 hours was givenwas lost previously. Implants were inserted into for 48 hours. No antibiotic nor antiinflamatoryhealed bone i. e. the tooth extraction had to be medication were prescribed after implant place-done at least 3 months before implant insertion. ment. Sutures were removed after one week.No crestal bone augmentation was performed. Restoration The patients were informed about all avail- Implants were occlusaly loaded with resin tem-able alternative therapeutic options. They were porary crowns between 8 and 12 weeks postincluded only if they chose short implants treat- surgery. For permanent prosthetics, patientsment. The participating patients were therefore were referred back to their dentist at least 2not exposed to any additional risk and this case months later. As a result, some of the restora-series was therefore not qualified as research. In tions were still provisional by the final examination.compliance with valid ethical requirements (Dec-laration of Helsinki, current edition), the patients 1 ELEMENT INICELL (Thommen Medicalwere instructed about the details of their par- AG, Waldenburg, Switzerland).ticipation and a written Informed Consent was40 • Vol. 6, No. 5 • August 2014

Hasson et alImplant stability cular disease. Two patients underwent simultane-Implant stability was assessed by tactile inves- ous bone augmentation with deproteinized bovinetigation. The implants were considered to be bone mineral (DBBM) and autogenous bonestable in the absence of any signs of mobil- as filling material. 43 (56%) implants have beenity, pocketing and in the absence of bleed- placed in the maxilla (FDI 15-17, 25 - 27) and 34ing on probing or pain during the investigation. (44%) in the mandible (FDI 35-37, 45-47). From the 77 inserted 6.5mm long implants, 16 (21%)Follow up had platform diameter 4.0mm, 37 (48%) 4.5mm,The patients were followed up 2 months after 17 (22%) 5.0mm and 7 (9%) a platform diam-loading and following visits were scheduled eter of 6.0mm. In two of the three participatingat least once per year. Routine follow up pro- centers (DA, JH) the maximal insertion torque2gram eventually included oral hygiene rein- was recorded (40 implants). 16 implants (40%)forcement, scaling and X-rays (when needed). were inserted at 20 Ncm, 22 implants (55%) at 30 Ncm and 2 implants (5%) at 35 Ncm, sug-Radiographic marginal bone level gesting good bone healing at inserted sites. Thisassessment corresponded well with the fact that no implantRoutine periapical X-rays were deemed to be not was lost i.e. apparent 100% implant survival rate.necessary therefore they were taken at 6 monthsand 2 years post surgery to check uneventful The radiographic evaluation of the peri-implantosseointegration. Care was taken to use the paral- bone height confirmed the remarkably stablelel-perpendicular technique i. e. the sensor holder bone level related to the use of this implant linewas placed parallel and the X-ray tube perpendic- (Figure 1).27, 28, 29 The peri-implant bone level sta-ular to the implant axis to ensure optimal projec- bilized at 0.9 ± 0.5 mm (mean ± standard devia-tion for each patient. Particular attention was given tions) beneath the microgap i. e. implant-abutmentto obtain an X-ray that would show the apex of connection. The used implants have a 1mm highthe implant and the occlusal aspect of the crown machined collar therefore also in this patient pop-in order to evaluate the clinical root/crown ratio. ulation the bone level has stabilized at the inter-Along with the clinical check the X-rays have been face to the moderately rough enossal surface.used for quantitative bone level evaluation. Thiswas done by a single evaluator (PZ) using ImageJ One patient, a 74 year old female of the cohort(NIH, USA, current version). The images were reported above, presented with partially edentu-scaled using the known implant thread height.27 lous right posterior mandible. The teeth had been extracted more than 3 months ago i.e. three ELE- RESULTS MENT RC INICELL implants have been placed into healed sites. Due to the limited distance56 patients have received 77 short implants in of the nerve channel i. e. to avoid the risk of itsthis report. The average patient age at implanta- injury, “short” implants were inserted in replace-tion was 59 (34 - 77) years. One patient was on ment of the second premolar and first molaranticoagulant therapy and one had a cardiovas- 2 MONO torque ratchet (Thommen Medi- cal AG, Waldenburg, Switzerland). The Journal of Implant & Advanced Clinical Dentistry • 41

Hasson et alFigure 1: Peri-implant (mesial and distal) bone level around short implants 6 months (0.5years) and 2 years after implantinsertion. The implant shoulder is included to visualize the peri-apical bone level also in relation to the implant geometry.teeth (positions 45 and 46, respectively). The DISCUSSIONimplants were covered with healing abutments.After 2 months of uneventful trans-gingival Recently, short dental implants have proved(non-submerged) healing, the healing abut- to be as successful as longer implants. Thisments were removed (Figure 2). This picture improvement30 can be explained by more exactalso documents that the soft tissue around the indications and consequently improved initialimplants was fully conditioned. A periapical diagnosis resulting from the widespread use ofX-ray was taken that confirmed the absence of CBCT that is available since the turn of the cen-any pathological signs (not shown). An open- tury, improved implant design and our ability totray impression was taken. The framework was identify risk factors related to periimplantitis.31,screw-attached to ensure that passive fit was 32 The availability of more accurate diagnosticachieved, the occlusion checked and the per- tools that enable more widespread manufac-manent restoration (Fig. 3) completed and turing of (precise) surgical guides have con-screw attached within two weeks after removal tributed to the increased survival and successof the healing abutments. An intraoral picture of short implants. This improvement in hard tis-taken after 2 years of function documents the sue management was accompanied by morevery favorable and predictable outcome (Fig. 4). precise soft tissue diagnosis (thin biotype) management which in turn may have also con- tributed to the improved survival and success42 • Vol. 6, No. 5 • August 2014

Hasson et alFigure 2: Three implants placed in the right mandible. The healing abutments were removed after 2 months of trans-gingivalhealing.rates observed in more recent publications. non-splinted crowns has been published quite Studies using finite element analysis tend recently.33 In this clinical investigation 221 short (6-9mm; diameters 3.7-5.6mm) implantsto show that highest strains are only exerted on placed and restored on 168 patients have beenthe crestal part of the dental implant, whereas followed for 27 months. The survival rate inlittle forces are transmitted to the apical part. the maxilla was 88.6% whereas it was 96.0%Following this rule longer implant thus should in the mandible. Cigarette smoking, diabetesnot show any mechanical advantage, if only mellitus and bone augmentation proceduresthis aspect would be considered. This par- were not associated with (early) implant fail-ticular point is supported by the results of the ure rate. The authors have concluded that thepresented case series. We have demonstrated survival rate of short implants restored as sin-that success of short implants is similar to long gle crowns over an average of 37 months wasones. Moreover, the implant/crown ratio < 2 favorable and comparable with longer implants.does not seem to have any importance, leav-ing open the question of the need to splint The attached case documents the high pre-short to long implants. It supports the feasi- dictability of the selected treatment protocolbility of treating single missing teeth by short (Figs. 2 - 4.) Without the availability of shortimplants. The results of the assessment of implants a much more invasive surgical protocolshort dental implants restored as single unit would have been needed. Consequently a signif- The Journal of Implant & Advanced Clinical Dentistry • 43

Hasson et alFigure 3: Permanent bridge (porcelain-fused to metal) Figure 4: Buccal view of the permanent bridge 2 years afterbefore insertion. implant placement.icant clinical risk was avoided and the treatment found radiographically. Long term studies arewas also more advantageous economically. still needed to reveal if there are any specific risk factors pertinent to the use of short implants. ● The eventual development of peri-implan-titis remains a major problem. Two factors are Correspondence:to be considered: the ability to provide an opti- Dr. Jean-Nicholas Hassonmal plaque control which may be difficult due 5, rue du Werkhofto the posterior location of these implants and F-68100 Mulhousethe adequate periodontal support. This aspect Franceshould be addressed by appropriate hard and +33 (3) 89 45 89 84soft tissue management i.e. ensuring suffi- +33 (3) 89 56 31 12cient surrounding bone on facial and lingual/ [email protected] aspects and optimal soft tissue biotype. CONCLUSIONSWithin the limitations of this case series, thereliable and predictable use of short implantsfor up to 2 years was confirmed. The resultsobtained in a multi-center setting confirmed thepositive observations reported by other authors.Minimal periapical bone loss (<1mm) has been44 • Vol. 6, No. 5 • August 2014

Hasson et alDisclosure 12. Gentile MA, Chuang SK, Dodson TB. Survival 24. T elleman G, Raghoebar GM, Vissink A, denThe authors report no conflicts of interest with estimates and risk factors for failure with 6- x Hartog L, Huddleston Slater JJR, Meijer HJA.anything mentioned in this article. 5.7-mm implants. Int J Oral Maxillofacial Implants A Systematic Review of the Prognosis of Short 2005; 20: 930-937. (<10 mm) Dental Implants Placed in the PartiallyReferences Edentulous Patient. J Clin Periodontol 2011;1. Fugazzotto P, Beagle J, Ganeles J, Jaffin R, Vlas- 13. Stellingsma C, Vissink A, Meijer HJ, Kuiper C, 38(7): 667-676. Raghoebar GM. Implantology in the severely sis J, and Kumar A. Case Series Success and resorbed edentulous mandible. Crit Rev Oral 25. M orand M, Irinakis T. The Challenge of Implant Failure Rates of 9 Mm or Shorter Implants in the Biol Med 2004;15: 240-248. 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