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Esthetic maxillary arch vertical location for the osseointegrated cylinder implant
_____________________J ! * » A _____________________ C L I N I C A L
T E C H N I Q U E S
Esthetic maxillary arch vertical location for the osseointegrated cylinder implant
O le T . Jen sen , DDS, MS C arl B row nd, DDS, MS Ja c q u e s d eL o rim ier, DDS, MS
T he single tooth edentulous space can be treated w ith an o sseo in teg ra ted im p la n t if presurgical prosthetic p la n ning is specific and accurate. To establish accurate placement o f the im plant, the position o f the m andibular incisor m ust be studied in relation to the exit poin t o f the im p la n t in the m a xilla ry arch. A sufficient space for placing the im plant a b u tm e n t co m ponents, as w ell as fo r the crown, m ust be provided.
sth etic re sto ra tio n of a sin g le tooth in the m axillary anterior dentition with an osseointegrated im plant requires presurgical planning. If the im plant declination is greater than 5° off the vertical axis, even a class A site may become difficult, if not im pos sible, to restore. If the im plant is placed too far p alatally or buccally, esth etic and phonetic treatm ent results may be compromised.1-3 One plane that has not been addressed adequately in the literature is the vertical
E
placem ent dimension. T he question of how deep to place the im plant is directly related to the esthetic success of maxillary anterior restoration. T h is is especially im portant if there are only a few abutm ent lengths to choose from as in intram obile cy lin d e r tw o-stage o sseo in teg rated im p lan t system (IMZ system, Interpore Inti). Currently, the 3.3-mm IMZ im plant is limited to 1- and 2-mm length abut ments. If the conventional intram obile element is used, only one vertical place m ent p o sitio n is possible, a ssu m in g g in g iv al d im en sio n al change is m in imal.4'6 T he preferred depth of im plant place m ent is established p resu rg ic ally by constructing a splint that is indexed to the ad jacen t teeth w ith gu id e holes centered in relation to the edentulous sites to receive im p lan ts. A p in w ith a ru b b er d ep th m arker a ttac h ed to it (analogous to an endodontic file depth m arker) goes th ro u g h the g u id e hole to engage the su rg ical g u id e in an a rtic u la to r-m o u n ted study cast w ork up used in presurgical treatm ent p la n ning. T he locator pin also helps to
establish entry p o in t and axial d e cli n a tio n , as w ell as the fin al vertical position of the im plant (Fig 1). W hen the surgical flap is reflected, the osseous pilot hole is drilled directly th ro u g h the guide hole in the s p lin t to a depth corresponding to the rubber marker on the locator pin. T his engages the splint at the exact angle and depth of the p lac em en t of the p re p a ra tio n . When the im plant is placed, the emer gence point of the im plant (through the alveolus) is established exactly to the vertical dim ension desired. With this
Fig 1 ■ T he final vertical position of the im plant is shown clinically above as determined by the locator pin in the surgical guide splint.
JADA, Vol. 119, December 1989 ■ 735
CLINICAL
TECHNIQUES
Fig 3 ■ Smile of an 18-year-old female patient with congenitally missing maxillary right and left lateral incisors.
m ended for su b g in g iv a l viscoelastic fu n c tio n (A. K irsch, DDS, personal communication, March 10, 1988). Figure 2 shows an anterior restoration plan and measurements associated with having a slight ridge lap and still having an intram obile element ju st above g in gival tissue level. Figures 3-5 show an 18-year-old female w ith c o n g e n ita lly m issin g m a x illa ry lateral incisors treated with 3.3-mm IMZ implants placed according to the vertical locator pin technique as described. The technique can be used for establishing vertical position in any type of cylindrical im plant system.
Summary Fig 2 ■ T h e anterior restoration p lan for a m axillary incisor where the vertical dimension of the im plant components is described for the 3.3mm IMZ im plant in relation to the incisal edge of the m an d ib u lar tooth. Note: a slight ridge lap is used to obscure the transgingival shadow of the im plant body and because the intramobile element is placed in a supragingival position.
technique, im plants of any length can be placed accurately. T h e low er in ciso r edge p o sitio n in rela tio n to the m ax illary arch is also im p o rta n t to observe in p resu rg ical planning. T he m andibular incisors may be supereru p ted an d should be e q u il ibrated if occluding on p alatal tissue. T he lower incisor edge and the im plant cy linder ex it p o in t at the m ax illary alveolar crest when the teeth are occluded should be spaced a m inim um of 6 mm ap art (5 m m if the 1-mm abutm ent is used). T h is distance will accommodate the 2-m m a b u tm e n t an d in tra m o b ile element (2.5 mm), as well as the casting and occlusal fastening screw (about 1.5 mm). If the cylinder is placed far enough subgingivally to allow room for m an d ib u la r in ciso r fu n ctio n , gross e q u il ibration of m andibular incisors will not be required. R esto rativ e esth etic a p p e a ra n ce is com prom ised at the gingival aspect of the crown if the im plant is not placed subgingivally enough. Alternatively, if the im p la n t is placed too deep, gingivoplasty may be required. T he in tra mobile element is currently not recom-
736 ■ JADA, Vol. 119, December 1989
Fig 4 ■ T he patient’s smile (Fig 3) after restora tion with single tooth im plants replacing the maxillary right and left lateral incisors.
Dental restoration of the anterior m ax illary dentition with an osseointegrated im p la n t req u ires specific presu rg ical prosthetic p la n n in g to ensure esthetic and functional results. T o help accom plish this, a surgical splint with vertical depth marker capability is suggested.
J'ADA
Dr. Jensen is an oral and maxillofacial surgeon, 1633 Fillmore St, suite 5, Denver, 80206; Dr. Brownd is a maxillofacial prosthodontist in private practice in Denver; Dr. deL orim ier is a prostho d o n tist in private practice in Boulder, CO. Address requests for reprints to Dr. Jensen.
Fig 5 ■ Final restoration of the congenitally missing teeth in a patient (Fig 3) who had never required a dental restoration. Single unit im plants provided the advantage of avoiding cutting down adjacent teeth to construct fixed partial dentures p ro v id in g there is enough in tercisal space available.
1. Branemark PI, Zarb GA, Albrektsson T. Tissue integrated prosthesis: osseointegration in clinical dentistry. Chicago: Quintessence, 1985. 2. Jensen OT. A new classification for evaluating m ax illary alveolar a tro p h y [A bstract]. Second In ternational Congress on P reprosthetic Surgery. S Calif Soc Oral Maxillofac Surg, 1987. 3. Jensen OT. Site classification for the osseoin tegrated implant. J Prosthet Dent 1989;61:228-34. 4. Lewis SG, Beumer J, Perri GR, H ornburg WP. Single tooth im p lan t su p p o rt restoratio n s. In t J Oral Maxillofac Im plants 1988;3:25-30. 5. Je m p t T . M odified sin g le an d sh o rt sp an restorations supported by osseointegrated fixtures in the p artially edentulous jaw . J P ro sth et Dent 1986;55:243-7. 6. Babbash CA, Kirsch A, M entag P J, H ill B. Intramobile cylinder (IMZ) two-stage osseointegrated im plant system with the intramobile element (IME): its ra tio n a le an d pro ced u re for use. In t J O ral Maxillofac Im plants 1987;4:204-5.
T E C H N I Q U E S
Esthetic maxillary arch vertical location for the osseointegrated cylinder implant
O le T . Jen sen , DDS, MS C arl B row nd, DDS, MS Ja c q u e s d eL o rim ier, DDS, MS
T he single tooth edentulous space can be treated w ith an o sseo in teg ra ted im p la n t if presurgical prosthetic p la n ning is specific and accurate. To establish accurate placement o f the im plant, the position o f the m andibular incisor m ust be studied in relation to the exit poin t o f the im p la n t in the m a xilla ry arch. A sufficient space for placing the im plant a b u tm e n t co m ponents, as w ell as fo r the crown, m ust be provided.
sth etic re sto ra tio n of a sin g le tooth in the m axillary anterior dentition with an osseointegrated im plant requires presurgical planning. If the im plant declination is greater than 5° off the vertical axis, even a class A site may become difficult, if not im pos sible, to restore. If the im plant is placed too far p alatally or buccally, esth etic and phonetic treatm ent results may be compromised.1-3 One plane that has not been addressed adequately in the literature is the vertical
E
placem ent dimension. T he question of how deep to place the im plant is directly related to the esthetic success of maxillary anterior restoration. T h is is especially im portant if there are only a few abutm ent lengths to choose from as in intram obile cy lin d e r tw o-stage o sseo in teg rated im p lan t system (IMZ system, Interpore Inti). Currently, the 3.3-mm IMZ im plant is limited to 1- and 2-mm length abut ments. If the conventional intram obile element is used, only one vertical place m ent p o sitio n is possible, a ssu m in g g in g iv al d im en sio n al change is m in imal.4'6 T he preferred depth of im plant place m ent is established p resu rg ic ally by constructing a splint that is indexed to the ad jacen t teeth w ith gu id e holes centered in relation to the edentulous sites to receive im p lan ts. A p in w ith a ru b b er d ep th m arker a ttac h ed to it (analogous to an endodontic file depth m arker) goes th ro u g h the g u id e hole to engage the su rg ical g u id e in an a rtic u la to r-m o u n ted study cast w ork up used in presurgical treatm ent p la n ning. T he locator pin also helps to
establish entry p o in t and axial d e cli n a tio n , as w ell as the fin al vertical position of the im plant (Fig 1). W hen the surgical flap is reflected, the osseous pilot hole is drilled directly th ro u g h the guide hole in the s p lin t to a depth corresponding to the rubber marker on the locator pin. T his engages the splint at the exact angle and depth of the p lac em en t of the p re p a ra tio n . When the im plant is placed, the emer gence point of the im plant (through the alveolus) is established exactly to the vertical dim ension desired. With this
Fig 1 ■ T he final vertical position of the im plant is shown clinically above as determined by the locator pin in the surgical guide splint.
JADA, Vol. 119, December 1989 ■ 735
CLINICAL
TECHNIQUES
Fig 3 ■ Smile of an 18-year-old female patient with congenitally missing maxillary right and left lateral incisors.
m ended for su b g in g iv a l viscoelastic fu n c tio n (A. K irsch, DDS, personal communication, March 10, 1988). Figure 2 shows an anterior restoration plan and measurements associated with having a slight ridge lap and still having an intram obile element ju st above g in gival tissue level. Figures 3-5 show an 18-year-old female w ith c o n g e n ita lly m issin g m a x illa ry lateral incisors treated with 3.3-mm IMZ implants placed according to the vertical locator pin technique as described. The technique can be used for establishing vertical position in any type of cylindrical im plant system.
Summary Fig 2 ■ T h e anterior restoration p lan for a m axillary incisor where the vertical dimension of the im plant components is described for the 3.3mm IMZ im plant in relation to the incisal edge of the m an d ib u lar tooth. Note: a slight ridge lap is used to obscure the transgingival shadow of the im plant body and because the intramobile element is placed in a supragingival position.
technique, im plants of any length can be placed accurately. T h e low er in ciso r edge p o sitio n in rela tio n to the m ax illary arch is also im p o rta n t to observe in p resu rg ical planning. T he m andibular incisors may be supereru p ted an d should be e q u il ibrated if occluding on p alatal tissue. T he lower incisor edge and the im plant cy linder ex it p o in t at the m ax illary alveolar crest when the teeth are occluded should be spaced a m inim um of 6 mm ap art (5 m m if the 1-mm abutm ent is used). T h is distance will accommodate the 2-m m a b u tm e n t an d in tra m o b ile element (2.5 mm), as well as the casting and occlusal fastening screw (about 1.5 mm). If the cylinder is placed far enough subgingivally to allow room for m an d ib u la r in ciso r fu n ctio n , gross e q u il ibration of m andibular incisors will not be required. R esto rativ e esth etic a p p e a ra n ce is com prom ised at the gingival aspect of the crown if the im plant is not placed subgingivally enough. Alternatively, if the im p la n t is placed too deep, gingivoplasty may be required. T he in tra mobile element is currently not recom-
736 ■ JADA, Vol. 119, December 1989
Fig 4 ■ T he patient’s smile (Fig 3) after restora tion with single tooth im plants replacing the maxillary right and left lateral incisors.
Dental restoration of the anterior m ax illary dentition with an osseointegrated im p la n t req u ires specific presu rg ical prosthetic p la n n in g to ensure esthetic and functional results. T o help accom plish this, a surgical splint with vertical depth marker capability is suggested.
J'ADA
Dr. Jensen is an oral and maxillofacial surgeon, 1633 Fillmore St, suite 5, Denver, 80206; Dr. Brownd is a maxillofacial prosthodontist in private practice in Denver; Dr. deL orim ier is a prostho d o n tist in private practice in Boulder, CO. Address requests for reprints to Dr. Jensen.
Fig 5 ■ Final restoration of the congenitally missing teeth in a patient (Fig 3) who had never required a dental restoration. Single unit im plants provided the advantage of avoiding cutting down adjacent teeth to construct fixed partial dentures p ro v id in g there is enough in tercisal space available.
1. Branemark PI, Zarb GA, Albrektsson T. Tissue integrated prosthesis: osseointegration in clinical dentistry. Chicago: Quintessence, 1985. 2. Jensen OT. A new classification for evaluating m ax illary alveolar a tro p h y [A bstract]. Second In ternational Congress on P reprosthetic Surgery. S Calif Soc Oral Maxillofac Surg, 1987. 3. Jensen OT. Site classification for the osseoin tegrated implant. J Prosthet Dent 1989;61:228-34. 4. Lewis SG, Beumer J, Perri GR, H ornburg WP. Single tooth im p lan t su p p o rt restoratio n s. In t J Oral Maxillofac Im plants 1988;3:25-30. 5. Je m p t T . M odified sin g le an d sh o rt sp an restorations supported by osseointegrated fixtures in the p artially edentulous jaw . J P ro sth et Dent 1986;55:243-7. 6. Babbash CA, Kirsch A, M entag P J, H ill B. Intramobile cylinder (IMZ) two-stage osseointegrated im plant system with the intramobile element (IME): its ra tio n a le an d pro ced u re for use. In t J O ral Maxillofac Im plants 1987;4:204-5.