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Implantology
Surgical Preparation and Technique
23
185
Implantology
Edward R. Schlissel DDS, MS
The Clinical Problem (Fig. 23.1) Synopsis The patient, a 20-year-old woman, suffered an injury to the anterior maxilla in a motor vehicle accident. There were no injuries to her lips or other perioral structures. ■ Emergency care was provided immediately, and reconstruction commenced 3 months later. ■ Treatment, over a period of 18 months, included two surgical procedures and dental rehabilitation, including gingival surgery. ■ Treatment was provided by a team, which included a maxillofacial surgeon, restorative dentist, and dental technical laboratory. ■
The Aesthetic Problem (Fig. 23.2) Following this injury, the patient was left with a significant dentofacial injury, which made her extremely self-conscious about her smile. She was also unable to speak clearly and could not eat satisfactorily. She believed that she could not continue with her education and that her chances for employment were diminished. These prospects made her emotionally depressed. She avoided social contacts and became withdrawn. At the time of examination, after emergency care, the following conditions were noted: • The maxillary central incisors, associated alveolar bone, and soft tissue had been avulsed. • The maxillary left lateral incisor was fractured, devitalizing the dental pulp. • Primary closure of the wound, without grafting, resulted in location of the labial frenulum at the crest of the alveolar ridge.
• There was significant deficiency in the volume of bone and soft tissue, including a lack of keratinized connective tissue. • Lacking incisor teeth, the patient was unable to make all speech sounds clearly, would not smile without hiding her face behind her hand, and was in emotional distress. A panoramic radiograph was made at the time of examination (see Fig. 23.2). Note the teeth missing at the maxillary midline and the impacted third molars. The goal of treatment was to replace the missing teeth and tissue and restore the damaged teeth to appear and function in a manner consistent with long-term health. The plan of treatment that was selected included augmentation of bone and soft tissue, placement of two dental implants, and placement of dental restorations on the four maxillary incisor teeth. The procedures selected offered the best outcome, with the least compromise to remaining dental structures. The alternative treatments were a removable partial denture or fixed partial denture. The location of the maxillary frenulum would have interfered with either type of restoration. Additionally, the patient rejected a removable prosthesis as an alternative. A fixed partial denture was not possible because of the damage to the adjacent teeth and the poor long-term prognosis in a young patient.
Surgical Preparation and Technique Treatment This reconstruction was accomplished in four stages—surgical restoration of bone and soft tissue with grafting, placement of dental implants, development of soft tissue contour for tooth replacement, and restoration of damaged and missing teeth. 185
186
CHAPTER 23 • Implantology
L
FIGURE 23.3 Panoramic radiograph made after placement of the dental implants.
FIGURE 23.1 Conditions present at the initial examination.
FIGURE 23.4 Provisional restorations, 6 weeks after placement.
L
FIGURE 23.2 Panoramic radiograph made at the time of the initial examination.
The time for healing and maturation of tissue in between stages was critical to the outcome of the procedures. Bone augmentation was accomplished by reflection of the tissue and placement of a combination autogenous bone and allograft material, protected by a resorbable membrane. The autogenous bone was obtained during the surgical removal of the impacted maxillary and mandibular third molars. The flap was advanced, and the labial frenulum was repositioned to a location suitable for dental restorations. Healing after this procedure was 6 months. After 6 months, the tissue was reflected minimally, and two dental implants were placed (Fig. 23.3). The implants, which are made of chemically pure titanium and had chemically prepared surfaces, were placed into osteotomy sites prepared with low-speed rotary instrumentation under continuous irrigation. Under these circumstances, it is predictable that the implant will be colonized by bone and will achieve osseointegration. This interface can withstand the force of occlusal function and can support gingival tissues. After 4 months, the implants were exposed, and their status was evaluated. Reverse torque testing at 35 Newton centimeter (Ncm) demonstrated that the implants were firmly integrated
FIGURE 23.5 Provisional restorations, immediately after recontouring with laser.
with the surrounding bone and were suitable for dental restoration. One week later, provisional dental restorations were made and placed on the implants. The provisional restorations were made of polyether ether ketone (PEEK) and dental composite resin. They were secured to the implants by a titanium screw, tightened to 20 Ncm. Soft tissue healing was evaluated at 6 weeks (Fig. 23.4). It was noted that contour was not aesthetically pleasing. Small modifications were made with a low-energy diode laser (2 W, 808 Ncm; Fig. 23.5). After 4 weeks, healing was reevaluated (Fig. 23.6). It was determined that tissue healing was acceptable. The socket areas surrounding the dental implants had also healed (Fig. 23.7). Note the triangular shape of the recesses, which mimic the natural shape around maxillary central incisors.
Postoperative Program
FIGURE 23.6 Provisional restorations, 4 weeks after recontouring with laser.
187
FIGURE 23.9 Titanium abutments seated on implants, before placement of crown restorations.
FIGURE 23.7 Socket areas around implants. The lateral incisors have been prepared for crown restorations.
FIGURE 23.10 Radiograph of implants, screws, abutments, and crown restorations.
FIGURE 23.8 Ceramic crown restorations before placement.
Dental restorations were made of lithium disilicate ceramic (Fig. 23.8). The shade used matches the remaining teeth, and the contours are aesthetically pleasing. Custom posts for the implants were made with computeraided design and Computer Assisted Manufacturing (CAM) technology. They are composed of commercially pure titanium, which was plated with titanium nitride. This gold-hued surface appears more natural under restorations and through translucent tissue than dark grey titanium (Fig. 23.9). The abutments were secured with gold plated titanium screws tightened to a torque level of 20 Ncm. The restorations were placed on the natural teeth and titanium abutments with dental adhesive cement. The radiograph shown in Fig. 23.10 of the area shows the implants with the abutments, screws and restorations. The patient was pleased with the outcome and had full function restored. Her aesthetic concerns were resolved, she was able to speak and chew properly and was no longer
FIGURE 23.11 Clinical condition 6 months after placement of restorations.
self-conscious about her injury. The teeth and the soft tissue contours appear natural (Fig. 23.11).
Postoperative Program The patient did not require any special posttreatment care. Routine dental visits were satisfactory.
188
CHAPTER 23 • Implantology
Complications Restoration of this defect by the team could have been complicated by any of the following errors: ■ ■
Inadequate replacement of missing hard and soft tissues Improper location of the labial frenulum Incorrect selection or location of dental implants Poor surgical technique, leading to failure of the dental implants to integrate with the surrounding bone ■ Poorly contoured provisional restorations that did not lead to the desired outcome ■ Dental restorations with poor contour or color matching, resulting in patient dissatisfaction of unacceptable function ■ ■
These complications may be avoided by using a team approach to treatment and by following accepted protocols for surgical and restorative dental procedures.
Further Reading Elian, N., Jalbout, Z., Cho, S., et al., 2003. Realities and limitations in the management of the interdental papilla between implants: Three case reports. Pract. Proced. Aesthet. Dent. 15 (10), 737–744. Tarnow, D., Elian, N., Fletcher, P., et al., 2003. Vertical distance from the crest of bone to the height of the interproximal papilla between adjacent implants. J. Periodontol. 74 (12), 1785–1788. Tarnow, D.P., Magner, A.W., Fletcher, P., 1992. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. J. Periodontol. 63 (12), 995–996.
23
185
Implantology
Edward R. Schlissel DDS, MS
The Clinical Problem (Fig. 23.1) Synopsis The patient, a 20-year-old woman, suffered an injury to the anterior maxilla in a motor vehicle accident. There were no injuries to her lips or other perioral structures. ■ Emergency care was provided immediately, and reconstruction commenced 3 months later. ■ Treatment, over a period of 18 months, included two surgical procedures and dental rehabilitation, including gingival surgery. ■ Treatment was provided by a team, which included a maxillofacial surgeon, restorative dentist, and dental technical laboratory. ■
The Aesthetic Problem (Fig. 23.2) Following this injury, the patient was left with a significant dentofacial injury, which made her extremely self-conscious about her smile. She was also unable to speak clearly and could not eat satisfactorily. She believed that she could not continue with her education and that her chances for employment were diminished. These prospects made her emotionally depressed. She avoided social contacts and became withdrawn. At the time of examination, after emergency care, the following conditions were noted: • The maxillary central incisors, associated alveolar bone, and soft tissue had been avulsed. • The maxillary left lateral incisor was fractured, devitalizing the dental pulp. • Primary closure of the wound, without grafting, resulted in location of the labial frenulum at the crest of the alveolar ridge.
• There was significant deficiency in the volume of bone and soft tissue, including a lack of keratinized connective tissue. • Lacking incisor teeth, the patient was unable to make all speech sounds clearly, would not smile without hiding her face behind her hand, and was in emotional distress. A panoramic radiograph was made at the time of examination (see Fig. 23.2). Note the teeth missing at the maxillary midline and the impacted third molars. The goal of treatment was to replace the missing teeth and tissue and restore the damaged teeth to appear and function in a manner consistent with long-term health. The plan of treatment that was selected included augmentation of bone and soft tissue, placement of two dental implants, and placement of dental restorations on the four maxillary incisor teeth. The procedures selected offered the best outcome, with the least compromise to remaining dental structures. The alternative treatments were a removable partial denture or fixed partial denture. The location of the maxillary frenulum would have interfered with either type of restoration. Additionally, the patient rejected a removable prosthesis as an alternative. A fixed partial denture was not possible because of the damage to the adjacent teeth and the poor long-term prognosis in a young patient.
Surgical Preparation and Technique Treatment This reconstruction was accomplished in four stages—surgical restoration of bone and soft tissue with grafting, placement of dental implants, development of soft tissue contour for tooth replacement, and restoration of damaged and missing teeth. 185
186
CHAPTER 23 • Implantology
L
FIGURE 23.3 Panoramic radiograph made after placement of the dental implants.
FIGURE 23.1 Conditions present at the initial examination.
FIGURE 23.4 Provisional restorations, 6 weeks after placement.
L
FIGURE 23.2 Panoramic radiograph made at the time of the initial examination.
The time for healing and maturation of tissue in between stages was critical to the outcome of the procedures. Bone augmentation was accomplished by reflection of the tissue and placement of a combination autogenous bone and allograft material, protected by a resorbable membrane. The autogenous bone was obtained during the surgical removal of the impacted maxillary and mandibular third molars. The flap was advanced, and the labial frenulum was repositioned to a location suitable for dental restorations. Healing after this procedure was 6 months. After 6 months, the tissue was reflected minimally, and two dental implants were placed (Fig. 23.3). The implants, which are made of chemically pure titanium and had chemically prepared surfaces, were placed into osteotomy sites prepared with low-speed rotary instrumentation under continuous irrigation. Under these circumstances, it is predictable that the implant will be colonized by bone and will achieve osseointegration. This interface can withstand the force of occlusal function and can support gingival tissues. After 4 months, the implants were exposed, and their status was evaluated. Reverse torque testing at 35 Newton centimeter (Ncm) demonstrated that the implants were firmly integrated
FIGURE 23.5 Provisional restorations, immediately after recontouring with laser.
with the surrounding bone and were suitable for dental restoration. One week later, provisional dental restorations were made and placed on the implants. The provisional restorations were made of polyether ether ketone (PEEK) and dental composite resin. They were secured to the implants by a titanium screw, tightened to 20 Ncm. Soft tissue healing was evaluated at 6 weeks (Fig. 23.4). It was noted that contour was not aesthetically pleasing. Small modifications were made with a low-energy diode laser (2 W, 808 Ncm; Fig. 23.5). After 4 weeks, healing was reevaluated (Fig. 23.6). It was determined that tissue healing was acceptable. The socket areas surrounding the dental implants had also healed (Fig. 23.7). Note the triangular shape of the recesses, which mimic the natural shape around maxillary central incisors.
Postoperative Program
FIGURE 23.6 Provisional restorations, 4 weeks after recontouring with laser.
187
FIGURE 23.9 Titanium abutments seated on implants, before placement of crown restorations.
FIGURE 23.7 Socket areas around implants. The lateral incisors have been prepared for crown restorations.
FIGURE 23.10 Radiograph of implants, screws, abutments, and crown restorations.
FIGURE 23.8 Ceramic crown restorations before placement.
Dental restorations were made of lithium disilicate ceramic (Fig. 23.8). The shade used matches the remaining teeth, and the contours are aesthetically pleasing. Custom posts for the implants were made with computeraided design and Computer Assisted Manufacturing (CAM) technology. They are composed of commercially pure titanium, which was plated with titanium nitride. This gold-hued surface appears more natural under restorations and through translucent tissue than dark grey titanium (Fig. 23.9). The abutments were secured with gold plated titanium screws tightened to a torque level of 20 Ncm. The restorations were placed on the natural teeth and titanium abutments with dental adhesive cement. The radiograph shown in Fig. 23.10 of the area shows the implants with the abutments, screws and restorations. The patient was pleased with the outcome and had full function restored. Her aesthetic concerns were resolved, she was able to speak and chew properly and was no longer
FIGURE 23.11 Clinical condition 6 months after placement of restorations.
self-conscious about her injury. The teeth and the soft tissue contours appear natural (Fig. 23.11).
Postoperative Program The patient did not require any special posttreatment care. Routine dental visits were satisfactory.
188
CHAPTER 23 • Implantology
Complications Restoration of this defect by the team could have been complicated by any of the following errors: ■ ■
Inadequate replacement of missing hard and soft tissues Improper location of the labial frenulum Incorrect selection or location of dental implants Poor surgical technique, leading to failure of the dental implants to integrate with the surrounding bone ■ Poorly contoured provisional restorations that did not lead to the desired outcome ■ Dental restorations with poor contour or color matching, resulting in patient dissatisfaction of unacceptable function ■ ■
These complications may be avoided by using a team approach to treatment and by following accepted protocols for surgical and restorative dental procedures.
Further Reading Elian, N., Jalbout, Z., Cho, S., et al., 2003. Realities and limitations in the management of the interdental papilla between implants: Three case reports. Pract. Proced. Aesthet. Dent. 15 (10), 737–744. Tarnow, D., Elian, N., Fletcher, P., et al., 2003. Vertical distance from the crest of bone to the height of the interproximal papilla between adjacent implants. J. Periodontol. 74 (12), 1785–1788. Tarnow, D.P., Magner, A.W., Fletcher, P., 1992. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. J. Periodontol. 63 (12), 995–996.