Protocol for Implementing Aesthetic Implant Restorations

Beneficial to patients and providing unparalleled results, dental implants are more frequently being provided to patients.¹ Whether completing the procedure for themselves or referring to a specialist, it behooves dentists to offer implants as a treatment option (when indicated) to provide the patient with the best in function, longevity, and aesthetics. Innovative implant technologies—combined with advanced diagnostics, a team-oriented approach, and proper case selection—have made implants a more viable option than ever in the general dental practice.¹

IMPLEMENTING DENTAL IMPLANTS
Although implants can be completed in the general dental practice, implementation is incumbent upon having the proper systems in place, including specific team member roles, diagnosis and treatment planning protocols, and diagnostic and restorative material technology.¹ Additionally, proper case and treatment selection is necessary when providing implants, specifically whether treatment will involve a single tooth, a partially edentulous or fully edentulous patient, or placing fixed and removable restorations.²

Figure 1. Preoperative close-up view of the patient’s anterior teeth Nos.7 to 10.	Figure 2. Close-up view of tooth No. 7; a primary tooth to be extracted and replaced with an implant.
Figure 3. Close-up view of tooth No. 10; a primary tooth to be extracted and replaced with an implant.	Figure 4. View of the preoperative cone beam computed tomography scan used during implant treatment planning.
Figure 5. Facial view of the SimPlant (Materialise Dental) plan developed for treatment planning purposes.	Figure 6. Occlusal view of the SimPlant surgical plan.
Figure 7. The surgical guide in position for implant placement.	Figure 8. Radiographic view of the standard abutment immediate provisional for tooth No. 7.
Figure 9. Radiographic view of the zirconia abutment immediate provisional for tooth No. 10.	Figure 10. View of tooth No. 10 with the extracted tooth used as a provisional.

Team Members
Placing implants requires a team approach that involves the surgeon, the laboratory, and the patient in order to decide and plan the ultimate outcome and how it will appear.^3,4 By combining the knowledge, experience, and talents of each dental specialty, the highest quality of care can be provided to the patient, while communicating openly with other dental team members ensures the best aesthetic, functional, and long-lasting results can be achieved.^3,4

Diagnosis and Treatment Planning
To ensure the most predictable and ideal result for the patient, the diagnostic and treatment planning protocol used is of utmost importance. Diagnostic models, digital radiography, and computed tomography (CT) scans should be incorporated to plan implant placement, ensuring that sufficient, stable bone exists and that where the implant is placed will promote optimal retention.^5,6
In general, the key to successful implant placement is starting with the end result in mind. This is incumbent upon the incorporation of proper diagnostic tools and protocols, along with comprehensive treatment planning.^1,5,6 Planning first begins by envisioning the completed implant case. Once the restoration is envisioned, the case should be sent to the laboratory for completion of a diagnostic wax-up to confirm that the anticipated results can be achieved. After confirming the case with the laboratory, provisionals can be fabricated to “test-drive” the restorations and evaluate the overall function and aesthetics.^1,5,6

Diagnostic and Restorative Materials
Many innovative diagnostic and restorative materials and tools are available for use to provide predictable and excellent clinical results. For example, panoramic radiography (such as Panorex) and digital radiography allow us to capture many measurements; however, they are only 2-dimensional and there is a 20% to 25% distortion rate with the panoramic technology. When completing precise measurements for implants, this distortion is a cause for concern.^7,8
Therefore, an additional diagnostic technology should be used in conjunction with digital radiography.^7,8 Innovative and advanced, cone beam (CB) CT demonstrates zero distortion, enabling dentists to measure the exact width and depth of hard tissues.^7,8 Providing a 3-dimensional (3-D) image, CBs allow dentists to view cross sections and all other aspects before starting treatment.^7,8
Innovative diagnostic software programs have also become available, which allow dentists to take diagnostic information and place it into the software program to virtually plan the case.9 Furthermore, these programs allow the dentist to pull through a library and choose the exact implant size required.⁹ With the ability to rotate the case 3-dimensionally, the entire case can be viewed and the final result confirmed. Overall, these programs provide invaluable information during treatment planning.⁹

CASE REPORT
Diagnosis and Treatment Planing
A 33-year-old male presented with retained primary upper left and right lateral incisors, which functioned well up to the time of treatment, when they were failing (Figures 1 to 3). In cases of congenitally missing teeth, it is often necessary to extract the affected dentition and place implants. This was the treatment selected in this case, and the teeth would be atraumatically removed and implants placed. A technique to immediately provisionalize the implant was also chosen to reduce the amount of time the patient would be without some type of restoration in the affected areas.

Figure 11. An Essix (DENTSPLY Raintree Essix) provisional appliance with composite.	Figure 12. View of the standard abutment at tooth No. 7 at 4 months postoperative.
Figure 13. View of the zirconia abutment at tooth No. 10 at 4 months postoperative.	Figure 14. Impression transfer copings for a fixture level impression.
Figure 15. The final impression (Aquasil Ultra [DENTSPLY Caulk]) and analogs.	Figure 16. The lab-fabricated custom zirconia abutment on the model.
Figure 17. Note the healthy tissue response surrounding the ANKYLOS C?X (DENTSPLY Friadent) implant following 4 months of healing.	Figure 18. The completed all-ceramic (Cercon [DENTSPLY Ceramco]) (over implants) restorations for teeth Nos. 7 and 10.
Figure 19. Postoperative view of tooth No. 7.	Figure 20. Postoperative view of tooth No. 10.

A panoramic radiograph was taken first, which provided some information on the case. A CB scan was also taken (KODAK 9000D [Carestream Dental]) (Figure 4) to provide a clearer view of the patient’s dentition and bone structure. Additionally, with the assistance of iMagDent (iMagDent)/SimPlant (Materialise Dental), a 3-D software system, a digital mock-up was created that could be shown to the patient to allow him to see what treatment would be done, why it would be done, and what was required to complete this procedure (Figures 5 and 6).
Using the information from the diagnostic tools, it was then necessary to determine the ideal position for the implants, thinking restoratively first. This allowed proper planning and placement of the implants in the ideal position, knowing definitively that there was sufficient bone and soft tissue to retain the implant. As with any restorative case, all diagnostic work for implants should be completed first, prior to any restorative work.
When undertaking an implant case that requires immediate provisionalization, there are several key factors essential to successful treatment. The first step is often, as it was in this case, an atraumatic extraction that requires removal of the tooth root without breaking the buccal plate. Tools that prove useful during this procedure are periotomes, special atraumatic forceps (Global Dental Solutions), or tooth sectioning.

Osteotomy
To begin the osteotomy of the extraction site at tooth No.7, the CT scan was used to first develop a surgical guide Materialise (Materialise Dental) (Figure 7), which provided the exact position and angle needed to place the implant in the ideal position. The ANKYLOS system (DENTSPLY Tulsa Dental Specialties) enables the implant to be placed subcrestally. This was decided upon since, in the anterior region, placing the implant subcrestally allowed creation of the emergence profile in a shorter time and with a more aesthetic result overall. The surgical area was then irrigated and a CO2 laser (Deka Lasers) was used to decontaminate and ensure that no tissue remained that would impinge the implant placement.

Implant Placement
Since the implants would undergo immediate provisionalization, at least 3 mm of bone apical to apex of the root for primary stability was required. Additionally, in the upper anterior region of the oral cavity, the implants would be placed a little more toward the palate instead of placing them midcrestally. This provided more palatal bone, as well as more palatal and apical stability, contributing to the success of the final restorations. Through the resistance experienced at this point in the procedure, it was clear that implant placements were very successful and solid. The next stage of treatment involved abutment selection.

Abutment Placement
Standard Titanium Abutment: Tooth No. 7—Initially, try-in abutments were utilized to select the proper abutment for immediate provisionalization. Ultimately, a standard abutment with 1.5-mm tissue height with a 6-mm abutment height was chosen.
Zirconia Abutment: Tooth No. 10—Another option used in this case was a zirconia abutment on the implant for tooth No. 10. Prior to the surgical procedure, a zirconia abutment was fabricated from the study models of the case and designed to rest slightly below the tissue. Ideal in the aesthetic area, the zirconia abutment was used because of the thin biotype tissue at the No. 10 site.

Immediate Load Provisionalization
When immediately loading an implant, there are many advantages. Among them, the patient can leave the same day with a restoration in place. However, the most noteworthy benefit is the ability to maintain the papilla, which is the key to achieving optimal dental aesthetics. Studies have shown that although immediate provisionalization will cause a 1.0 mm loss of tissue apically, a 0.37 to 5.4 mm gain can be expected in the papilla area.^10-12 By maintaining the interproximal bone, the interproximal tissue would be maintained as long as the proper protocol were followed.¹³

Provisionalization Techniques
Many different options for immediate provisionalization are available. In this case, provisionalization choices were based on required strength and aesthetics.
Composite Provisional—For standard titanium abutments, a chairside fabricated composite provisional could be used for immediate loading. The first step is to complete a diagnostic wax-up of the case. Once completed, a putty matrix is then made from the wax-up. A provisional restoration is then fabricated from a bis-GMA temporary acrylic resin (Integrity [DENTSPLY Caulk]). To trim the composite provisional, the analog is used, which is an exact replica of the abutment. This enables all trimming and polishing to be completed outside the surgical area and reduces the risk of contamination (Figure 8).
Laboratory-Fabricated Provisional—For the zirconia abutment on tooth No. 10, a laboratory fabricated provisional was chosen. The dental laboratory team fabricated the temporary for abutment No. 10 using a provisional and diagnostic resin (Radica [DENTSPLY Prosthetics]).
The laboratory-fabricated restoration was first tried-in to ensure proper fit and function. A sterile piece of cotton was then placed over the screw access, and the provisional was lined with a bis-GMA composite material.
After trimming back the provisional to the desired margin, the temporary restoration was fully seated on abutment No. 10 (Figure 9). The provisional was then checked very carefully to ensure that the contours were correct in order to maintain the papilla, as well as to ensure the absence of occlusal interferences. The implant and provisional were then checked for lateral forces in excursive movements. Upon completion of the provisional work, the patient would be given a nightguard to ensure that no lateral forces would be placed on the implant and provisional during this stage in treatment. The laboratory-fabricated material proved to be extremely adaptable, strong, biocompatible, and aesthetically pleasing.
Extracted Tooth Provisional—Another provisionalization option for immediate loading was using the extracted tooth or teeth. This technique is favorable in many situations because the patient can walk out with the same tooth/teeth that the patient entered the office with, only now more aesthetically pleasing (Figure 10).
Provisionalization When Immediate Loading is Not Possible—A provisional technique that may be used in implant dentistry when immediate loading is not possible is an Essix retainer (DENTSPLY Raintree Essix). Using the preoperative study model, a restoration is fabricated inside a retainer and placed in the patient’s mouth. This type of provisional restoration is extremely useful in cases that cannot hold an immediate load. Restorations placed in an Essix retainer function well and allow the patient to leave the office without being concerned about not having a tooth. Additionally, if only the extraction is completed without placing the implant, composite could be added to the pontic to make it an ovate pontic; this would allow shaping of the papilla from the time of extraction, without the implant in place (Figure 11).
Extracted Tooth—The extracted tooth or teeth may also be used in cases that cannot support immediate provisionalization. To complete this procedure, the extracted tooth would be modified as necessary and then bonded to the adjacent teeth. It is recommended to make a lingual matrix before extracting the tooth to aid in the bonding process.

Cementation
After the provisional materials had been selected and the restorations fabricated, they were then cemented on the abutments. A piece of sterile cotton and some composite were first placed to close the access hole on the zirconia abutment. The provisional was cemented and then lifted back up to ensure that there was not an exorbitant amount of excess cement, then reseated.
When seating the Radica provisional, the cement was allowed to set for 2 minutes prior to removing any excess. The small hole in the back of the restoration was designed as a vent for the extrusion of excess cement. Excess cement was removed through flossing, using an explorer, and blowing with air. Utilizing a radiograph, care was taken to ensure that no cement remained in the sulcus area. This is very important for the health of the tissue, since cement is caustic and the tissue will retract to pull itself away from it. Because the reason for immediate provisionalization is to maintain and start developing the papilla, excess cement must be thoroughly removed from the sulcus. Using a high magnification with a light source like the cordless Freedom by Orascoptic (Sybron Dental), a final inspection is performed to confirm that all the excess cement has been removed.
Four months after the implant procedure, the patient returned for placement of the definitive restorations. Soft-tissue biology and morphology were ideal. With no micromovement, the connection was very strong and no bone remodeling occurred. Additionally, the strong connection prevented any bacterial contamination of the implant site (Figures 12 and 13). It was necessary to discuss and plan the best restorative treatment options to provide the longevity, function, and aesthetics the patient desired. Aesthetic restorative material options on zirconia abutments include all-ceramic choices such as lithium dislicate, zirconia, and others. In this case the abutment and crown were Cercon (DENTSPLY Ceramco) zirconia.

Impression Procedure
Impression Preparation—The provisional restorations were removed from site Nos. 7 and 10. The standard abutment on No. 7 and the zirconia abutment on No. 10 were removed. Fixture level transfer copings were placed (Figure 14).
Impression Taking—Two different impression techniques can be used: a fixture level coping that is a closed tray or an open tray technique. Utilizing the open-tray technique, an access hole was made in the impression so it could be removed from the tray. The selected impression material for this technique was a vinyl polysiloxane material (Aquasil Ultra [DENTSPLY Caulk]). A low-viscosity material (Aquasil Ultra) was used for the light body while the dental assistant mixed the rigid material (Aquasil Ultra), and the procedure was completed similar to impression techniques for crown and bridge. Using the syringe, the material was placed around the abutment area, ensuring the material could be screwed through.
Regular set material was used in this case for extended working time. Once the material had set, the screw access hole was located and the screw was loosened. With the screw completely loose, the impression tray was removed (Figure 15).
After repositioning the impression posts, the analogs were put together and placed back into the impressions. With the impressions complete, the laboratory then was able to pour a soft-tissue model and a stone cast from the impressions. The definitive restorations would ultimately be fabricated from these models.

Delivery
The patient returned to the office after delivery of the laboratory-fabricated restorations. Using the contours of the soft-tissue model, the lab fabricated the customized zirconia abutments for implants Nos. 7 and 10 (Figure 16). Using a lab-fabricated jig placed in the mouth, all that remained was placing the definitive abutments and restorations intraorally.
Customized Abutment Placement—After removing the temporary restorations, the provisional abutments were removed. Upon removal, it was clear that the tissue remained very healthy and there was no bacterial contamination. There was no odor or bleeding (Figure 17). The customized zirconia abutment were then placed utilizing the placement jigs.
Crown Seating—With the abutments in place, the definitive restoration for tooth No. 10 was placed on the abutment and contacts checked with dental floss, along with occlusion. Following occlusal adjustments, the restoration was checked for lateral forces. With no lateral forces present and the fit verified, the jig was placed back on the restoration.
This was completed to ensure that the crown was in the proper position. After verifying the position, the restoration was torqued down to 15 Newton centimeters. A benefit of the ANKYLOS C/X (DENTSPLY Friadent) system, the torque is built into the wrench, making the procedure simple. The same procedure was performed for tooth No. 7.
Cementation—There were several materials to choose from when cementing the definitive crown on zirconia abutments, including permanent cement, bonded resin cement, and provisional cement. In this case, noneugenol provisional cement (ImplaTemp [Osseous Technologies of America]) was decided upon since it would allow the restoration to be removed if any changes needed to be made, and retention was ensured through the customization of the zirconia abutment. The end result was a highly aesthetic zirconia restoration with lifelike shading and vitality.
The final result was very rewarding for the patient and the dental team. After years with retained primary teeth that were barely hanging on, the patient finally had teeth that would function extremely well with restorations that appeared natural. At the end of the case, it was nearly impossible to differentiate his natural teeth from the implants and their respective restorations.
By visualizing the end result first and using advanced diagnostic technologies, the dental team maintained the interproximal bone and health of the papilla. This type of restoration was the most aesthetic that could be chosen for implants, since there was no metal show-through. Overall, the all-ceramic zirconia restorations (Cercon) provided great biocompatibility and aesthetics, and a great result for the patient (Figures 18 to 20).

CONCLUSION
Implants in the general dental practice offer unmatched service to patients, as demonstrated by the case illustrated. Proper planning, a team approach, and case selection are of the utmost importance for ensuring the predictability and success of these dental restorations.^2-4 Using innovative diagnostic and material options such as the ANKYLOS system, implants have become more viable than ever in the general practice setting.¹ By the tissue care connection providing long-term hard and soft-tissue stability, along with a tighter fit to minimize micromovement and bacterial contamination, healthy and stable implant restorations can be achieved.^14,15

Acknowledgment
The author wishes to thank the contribution made by Troy P. Apparicio, CDT.

References

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Dr. Little received his dental training at the University of Texas Health Science Center at San Antonio and maintains a private practice in San Antonio, Tex. An accomplished international speaker, professor, and author, he is also a respected clinical researcher focusing on implants, laser surgery, and dental materials, as well as a consultant on emerging restorative techniques and materials. Dr. Little’s leadership and experience in team motivation and vision are recognized worldwide. He can be reached at (210) 648-4411 or at dlittledds@aol.com.

Disclosure: Dr. Little reports no disclosures.