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Team-Driven Planning Resulting in Predictable Implant Therapy
Successfully co-existing metal ceramics, esthetics, and function
In this age of esthetically driven, digitally fabricated restorations, dental professionals tend to overestimate the functional ability of the numerous metal-free options available today. When implant therapy is selected for the restoration of a single maxillary canine, close consideration of the occlusal scheme is critical to the long-term success of the restoration. The implant is encased in bone and, therefore, in a static relationship compared to a natural tooth cushioned by an active periodontal ligament. This phenomenon exerts significantly more stress on the restoration, especially under the constant lateral load of a canine in anterior group function.
The treatment described in this article addresses this situation in a functionally esthetic way at the abutment and restoration levels. The patient presented with missing teeth Nos. 5 and 6. The sites had been edentulous for an extensive period of time. This left a less than ideal quantity of buccal bone, but due to financial limitations, the patient refused the ideal augmentation procedure (Figure 1).
The ANKYLOS® implant system (DENTSPLY Implants, www.dentsplyimplants.com) was chosen for its well-documented hard- and soft-tissue promoting attributes, and it is the only system that has been cleared by the FDA to make claims of hard- and soft-tissue growth around its implants (Figure 2). The clinical stability of its recommended subcrestal placement along with its true Morse taper abutment connection (Osteo-Ti, www.oseteo-ti.com) helps to eliminate micro-movement, which in turn, helps to minimize the harmful bacteria known to cause hard- and soft-tissue loss in the peri-implant zone.
At the impression appointment, removal of the ANKYLOS sulcus formers revealed well formed and healed sulci with emergent interdental papillae development (Figure 3). The author’s experience of predictability of sulcus formation with this system precludes the need for soft-tissue training through interim fixed or removable prostheses in order to ensure predictable margin placement of definitive restorations.
It is extremely critical that the appropriate sulcus former is used, as it is vital to the promotion of an ovate receptor site. Appropriate selection correlates to soft-tissue depth, with an ideal result showing approximately 1 mm of the superior portion of the sulcus former.
When the system’s sulcus formers are correctly used, the position of the tissue level in the mouth as the abutment and restoration are being delivered will predictably match the soft-tissue model, eliminating the need for unpredictable surgical correction or a costly remake. After sulcus former removal, the clinician captured a transfer and opposing impression along with an occlusal registration. The appropriate shade was selected and digital images were taken for optimum laboratory communication. Upon receipt of the case in the laboratory, a soft-tissue cast was developed and articulated with the opposing cast.
The choice of the custom abutments in this case would be crucial to its esthetic outcome due to the location within the esthetic zone. Thus the patient-specific ATLANTIS™ Abutment, GoldHue (DENTSPLY Implants) was chosen for its excellent soft-tissue transition esthetics owing to the warm yellow-red color created by its titanium nitride coating.
The master cast was scanned and the file with the digital prescription for fabrication was sent for the design and production of the ATLANTIS Abutments (Figure 5). The ATLANTIS Abutments were received 2 days later, they were then seated on the cast and reviewed for proper support of the intended crowns (Figure 6).
Captek™ copings (Precious Chemicals USA, Inc., www.captek.com) were fabricated with additional marginal ridge porcelain support on tooth No. 5 and a metal lingual on tooth No. 6 due to limited occlusal clearance (Figure 7). This gold surface also limited the possibility of opposing enamel abrasion and contributed additional strength (Figure 8). Veneering ceramics were then applied and fired matching the prescribed shade and natural morphology of the teeth restored (Figure 9 and Figure 10).
With the combination of high-strength Captek restorations over the ATLANTIS Abutment, GoldHue, abutments exhibited the best metal-supported esthetics and biocompatibility while delivering the strength required of a case that presented with particular occlusal load concerns due to its anterior group function guidance that included the canine.
The case was returned to the clinician for delivery. The ATLANTIS Abutments were first hand tightened in the mouth 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. With the patient having done so, the ATLANTIS Abutments were then torqued in and the Captek restorations were luted into place (Figure 11). The patient’s follow-up appointments at 2 (Figure 12) and 5 (Figure 13) weeks revealed further maturation of the peri-implant soft tissues to a more natural gingival form.
This case illustrates that, even with certain limitations on pre-prosthetic treatment, satisfactory results can be achieved in the maxillary esthetic zone using ANKYLOS implants placed adjacent to each other. Appropriate consideration of the restorative materials from a functional as well as an esthetic perspective combined with restoratively driven treatment planning can lead to a successful conclusion. Meticulous laboratory and clinical communication from the surgical planning stage to completion are of the utmost importance to ensure a predictable outcome.
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Disclaimer: The preceding material was provided by the manufacturer. The statements and opinions contained therein are solely those of the manufacturer and not of the editors, publisher, or the Editorial Board of Inside Dental Technology.
About the Author
David Avery, CDT, AAS, is the director of professional services at Drake Dental Laboratory.