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Restoring a Long-Edentulous Maxillary Ridge Segment with Adjacent Implants
Abstract: Using dental implants for restoration of long-edentulous sites on the maxilla in the esthetic zone can be a challenge with regard to soft-tissue architecture. This article discusses a case report in which natural gingival contours were achieved at a decades-old edentulous site on the maxilla through proper treatment planning along with the use of an appropriately selected implant system, custom abutment design, and restorative material.
Restoring long-edentulous sites on the maxilla in the esthetic zone with dental implants can be cosmetically challenging in terms of soft-tissue architecture. The notorious peri-implant tissue discrepancies that often occur between adjacent implants due to the bone loss associated with this type of situation and its concomitant lack of papillary support can make these cases even more difficult.1,2 Immediate protocols can give the clinician the luxury of having an established osseous scaffolding to preserve that, which will maintain natural gingival contours in such cases.3,4 However, this article presents a case in which such contours were achieved at a decades-old edentulous site on the maxilla by proper treatment planning along with the use of an appropriately selected implant system, custom abutment design, and restorative material.
The patient was a 49-year-old male of Middle Eastern descent with a non-contributory medical history. He presented to the author’s practice complaining chiefly of edentulism on the maxilla. He had lost teeth Nos. 5 and 6 as a teenager and became increasingly conscious of this esthetic condition the longer he lived in western society. Subsequent to receiving a review of all tooth replacement options, the patient decided on dental implants and was referred to an oral surgeon for surgical consultation. After accepting this proposed rehabilitation, treatment planning began.
Several limitations to treatment planning were imposed upon this case due to the patient’s restricted finances. Among them was the decision that despite significant resorption of the alveolar bone at the projected implant site (Figure 1), grafting to augment bone would not be done. While this constraint would be challenging, the author concluded that satisfactory gingival esthetics could be achieved using the proper materials. This limitation would have a considerable influence on the implant system chosen for the case, as conservation of the existing bone and the development of an associated soft-tissue profile were major issues under these circumstances. Moreover, because orientation and angulation were also key concerns for the same reasons, range and flexibility of abutment design would also be critical. Last, the indications for the restorative material would not only need to take into account optimal esthetic results, but also promote maintenance of healthy peri-implant soft tissues. Based on the author’s experience with the material armamentarium at his disposal, a diagnosis was made that satisfactory esthetics could be achieved in this case with the absence of any bone grafting.
The implant system (Ankylos®, DENTSPLY Implants, www.dentsplyimplants.com) that was chosen was selected for several reasons, including its well-documented hard- and soft-tissue promoting attributes5,6; because it is an FDA-approved system that claims hard- and soft-tissue growth around the implants; and because of its Morse taper abutment that has shown to virtually eliminate micromovement.7 Additionally, it is reported to create an environment free of the harmful bacteria known to cause hard- and soft-tissue loss in the peri-implant zone,8 and it was also compatible with the abutment system that was used (Atlantis™, DENTSPLY Implants). The Atlantis system was chosen because of its ability to meet various applications9 and because custom abutment design would be crucial to the esthetic outcome that could otherwise be compromised by a less-than-optimal angulation of implant placement.
After these decisions were made, the logistics of the case proceeded. An iCAT® scan (Imaging Sciences International, LLC, www.i-cat.com) of the patient was completed, and a surgical stent was created before the surgical date was set. Twelve weeks after the single-stage surgery, osseointegration of the implants was confirmed by the oral surgeon. Subsequently, the patient presented to the author’s office to begin the restorative process (Figure 2).
Upon removal of the sulcus formers of the implant system, well-formed and healed sulci were revealed along with emergent interdental papillae development (Figure 3). Moreover, the author’s laboratory indicated that the predictability of sulcus formation in this case precluded the need for soft-tissue training through interim fixed or removable prostheses in order to ensure proper margin placement of definitive restorations.
One of the clinical benefits associated with the implant system used in this case is its ability to promote soft-tissue development when the appropriate healing abutment (known as a sulcus former in this system) is chosen. Appropriate selection with regard to the size of the implant used will promote hard- and soft-tissue development, resulting in natural gingival contours.10 The author’s laboratory has also described this development as routinely resulting in a gingival level showing approximately 1 mm of the superior portion of the sulcus former. This can allow for the predictable determination of the position of the tissue level in the mouth to match the soft-tissue model from which the abutment and restoration are delivered. In turn, this can minimize the need for any dubious surgical correction or a costly remake.
In addition, the abutment system’s patient-specific GoldHue™ abutment provided excellent soft-tissue transition esthetics because of the yellow-red color created by its titanium-nitride coating (Figure 4). This, in conjunction with the definitive Captek™ restorations (The Argen Corporation, www.captek.com) placed over the abutments, provided an optimal level of metal-supported esthetics and biocompatibility while delivering the strength required of a case that presented with particularly notable occlusal issues due to its anterior group function guidance, which included the canine.
After sulcus former removal, a transfer and opposing impression were taken (Figure 5), as were a maximum intercuspation record and a shade reading. Captek was chosen as the definitive restorative material based on reports that it promotes soft-tissue health11 and offers superior esthetic properties compared to porcelain-fused-to-metal systems, and because it also rivals all-ceramic restorations12 or even surpasses them in terms of gingival esthetics.13
Try-In and Follow-Up
The case returned from the laboratory on a soft-tissue model (Figure 4) generated from the transfer impression. The abutments were first hand-tightened in the mouth (Figure 6), after which the Captek restorations were tried in. After occlusion, interproximal contacts, and marginal integrity were verified, the patient was asked to approve the esthetics of the definitive restorations. After patient approval was given, the abutments were torqued in and the restorations were luted into place (Figure 7). Follow-up visits at 2 weeks, 5 weeks, and 12 weeks, respectively, revealed progressive maturation of the peri-implant soft tissues to a more natural gingival form (Figure 8 through Figure 10).
This case illustrates that, even with certain limitations on pre-prosthetic treatment, satisfactory results can be achieved in cases where a long-edentulous ridge segment in the maxillary esthetic zone is restored with adjacent implants. Careful selection from among the restorative and surgical doctors’ armamentaria, along with appropriate treatment planning and meticulous laboratory and clinical implementation, can lead even a difficult case to a successful conclusion, as demonstrated in this case.
The author would like to thank Daniel De Tolla, DDS, MD, for his expertise in dental implant surgery with this case, David Avery, CDT, AAS, for his help in the preparation of this manuscript, and his talented team of technicians at Drake Dental Laboratory (Charlotte, North Carolina) for the Captek restorations shown.
The author has no affiliation with any of the products mentioned in this article.
ABOUT THE AUTHOR
Barry F. McArdle, DMD
Private Practice, Portsmouth, New Hampshire; Cofounder, Seacoast Esthetic Dentistry Association, and Founder, Seacoast Dental Seminars, Portsmouth, New Hampshire
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