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Stage I indexing to replace a failed implant in an edentulous arch: a clinical report
Stage I indexing to replace a failed implant in an edentulous arch: A clinical report Peter Glavas, DDS,a and Mark S. Moses, DDSb College of Dentistry, New York University, New York, N.Y.; New York Harbor Health Care System, New York, N.Y. Implant failure may complicate and lengthen a planned treatment. This article describes a modified stage I indexing technique for registering the position of an implant and replacing a failed implant, allowing prosthesis fabrication time and healing time to be coincidental. The clinician can proceed as originally planned with a minimal increase in overall treatment time. (J Prosthet Dent 2003;89:533-5.)
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tage I indexing has been presented as a method of expediting the completion of implant restorations in partially edentulous arches. The technique uses an acrylic resin index fabricated on a diagnostic cast. The implant position is registered at time of placement with the adjacent teeth used as reference positions. The cast is then altered by use of this index to fabricate a master working cast.1-4 This clinical report presents the use of stage I indexing to register the position of a replacement implant by use of previously osseointegrated implants in an otherwise edentulous arch.
CLINICAL REPORT A 55-year-old male patient of the Department Of Veteran Affairs, N.Y. Harbor Health Care System, presented after placement of 8 threaded, root-form implants (Osseotite; 3i, Palm Beach Gardens, Fla.) in his maxilla 6 months earlier (Fig. 1). He was symptom free with no significant medical history. The patient was wearing a complete maxillary denture and cast mandibular removable partial denture as interim prostheses. The maxilla was treatment planned for a cement-retained 12-unit metal-ceramic fixed partial denture supported by 8 implants. At stage II surgery, clinical mobility was noted in the maxillary right distal implant that necessitated removal. The area was degranulated, and the remaining implants received healing abutments (EP One-Piece Healing Abutments; 3i). The treatment dilemma was to restore the existing 7 integrated implants or replace the failed implant and wait for osseointegration. In an effort to maximize anterior-posterior force distribution and also reduce treatment time, the decision was made to replace the implant through a modified stage I indexing approach. a
Attending Prosthodontist, Staten Island University Hospital, Staten Island, N.Y.; Clinical Assistant Professor, New York University, College of Dentistry, New York, N.Y.; and Private Practice, Staten Island and Queens, N.Y. b Director of Oral and Maxillofacial Surgery, Department of Veteran Affairs, New York Harbor Health Care System, Manhattan, N.Y. and Private Practice, Manhattan, N.Y. JUNE 2003
Fig. 1. Presentation of patient with failing maxillary right distal implant.
After a 2-week period, the healing abutments were removed and an implant level impression was made of the remaining 7 implants. A soft tissue master cast was fabricated. An acrylic resin index (Pattern Resin; GC America Inc, Alsip, Ill.) was made on the master cast with 2 neighboring analogs (Lab Analogs; 3i). Two implant-level impression copings (Twist Lock Transfer Type; 3i). were airborne particle abraded with 50-m aluminum oxide particles (Microetcher; Danville Engineering Inc, San Ramon, Calif.) and luted together with acrylic resin (Pattern Resin; GC America Inc) to form the reference portion. A third impression coping was precoated with resin (Pattern Resin; GC America Inc) to form the index portion (Fig. 2, A). A surgical template fabricated by duplicating the existing denture was used to guide implant placement. A 10-mm threaded, root-form implant was placed (Osseotite; 3i). Primary stability of the implant at stage I surgery is critical for successful registration of its position in the indexing technique. Noted mobility may be a contraindication for indexing and for implant placement.5 Although the site was open, the 2 components of the index were seated and their fit was verified by a radioTHE JOURNAL OF PROSTHETIC DENTISTRY 533
THE JOURNAL OF PROSTHETIC DENTISTRY
GLAVAS AND MOSES
Fig. 3. Compatible analog placed on distal impression coping.
Fig. 2. A, Index fabricated with adjacent implants, acrylic resin, and implant level impression copings to register implant position at time of placement. B, Index jig luted intraorally with acrylic resin.
tioning was verified by a radiograph (Fig. 5). The abutment was stabilized by pliers (K.Y., GC America Inc) to limit stress to the implant. The abutment screw was torqued to 32 Ncm. A solder index was completed, and the metal framework was sent to the laboratory for porcelain application. The complete denture was converted to a provisional fixed partial denture and luted over the custom abutments with provisional cement (Temp-Bond; Kerr Corp, Orange, Calif.). Eliminating centric occlusion and excursive contacts on the replaced implant minimized the risk of early loading. Cross-arch stability was achieved by joining all implants, helping to minimize unfavorable stresses.6
DISCUSSION graph. The components were luted together with acrylic resin (Pattern Resin; GC America Inc) and removed as a single unit (Fig. 2, B). The cover screw was placed and the site was closed. A compatible analog was placed on the distal impression coping (Fig. 3). An access hole was prepared in the master cast and the indexing jig was seated. The analog was placed free of any contact with the stone. Type III dental stone (Quickstone; Whip Mix Corp, Louisville, Ky.) was placed to fix the analog and create an altered master cast (Fig. 4). Maxillomandibular records were made and the casts were sent to the laboratory with gold UCLA cylinders (3i). Custom abutments and metal copings were requested. Two weeks later, the custom abutments were positioned. Their fit was verified with radiographs, and they were retained with abutment screws (Gold-Tite; 3i) torqued to 32 Ncm. The replaced implant was surgically exposed, the cover screw was removed, and the custom abutment was placed instead of a healing abutment. The abutment screw was hand tightened, and proper posi534
The implant-abutment connection should be considered when this technique is used. In the patient presented, the implants were externally hexed, and all the impression copings were compatibly hexed. A hex height of 0.7 mm allowed enough freedom for indexing. With external hex implants, multiple nonhexed reference copings can be used but should be hexed for single reference copings. The index coping should always remain hexed for proper orientation of the implant. The longer internal connections of other implant systems may only allow reference of 1 neighboring implant. The technique may not be able to tolerate a great convergence or divergence of implant position regardless of the implant connection used. The clinician should take care when the technique is used in the anterior portion of the mouth. Soft tissue manipulation may result in an unfavorable esthetic result.
SUMMARY A modified stage I indexing technique was presented for use in registering the position of a replacement for a VOLUME 89 NUMBER 6
GLAVAS AND MOSES
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 5. Proper positioning of custom abutment verified by radiograph.
level impression copings to register the implant position at time of placement. The index was then used to alter the master cast. The technique helps minimize the delay of replacing a failed implant before fabrication of the restoration, because prosthesis fabrication and healing occur concurrently with negligible increase in overall treatment time. REFERENCES 1. Hochwald DA. Surgical template impression during stage I surgery for fabrication of a provisional restoration to be placed at stage II surgery. J Prosthet Dent 1991;66:796-8. 2. Prestipino V, Ingber A. Implant fixture position registration at the time of fixture placement surgery. Pract Periodontics Aesthet Dent 1992;4:23-7. 3. Rosenlicht JL. Advanced surgical techniques in implant dentistry: contemporary applications of early techniques. J Dent Symp 1993;1:16-9. 4. Drago C. Stage I surgical indexing: clinical and laboratory procedures. J Dent Technol 2000;17:16-21. 5. Meredith N. Assessment of implant stability as a prognostic determinant. Int J Prosthodont 1998;11:491-501. 6. Corso M, Sirota C, Fiorellini J, Rasool F, Szmukler-Moncler S, Weber HP. Clinical and radiographic evaluation of early loaded free-standing dental implants with various coatings in beagle dogs. J Prosthet Dent 1999;82: 428-35.
Fig. 4. A and B, Analog placed free of any contact with master cast and luted in position. C, Altered master cast.
failed implant in an edentulous arch. An index was fabricated with adjacent implants, acrylic resin, and implant
JUNE 2003
Reprint requests to: DR PETER GLAVAS 45-22 LITTLE NECK PKWY LITTLE NECK, NY 11362 TEL: (718) 224-4040 E-MAIL: [email protected] Copyright © 2003 by The Editorial Council of The Journal of Prosthetic Dentistry. 0022-3913/2003/$30.00 ⫹ 0 doi:10.1016/S0022-3913(03)00172-0
535
S
tage I indexing has been presented as a method of expediting the completion of implant restorations in partially edentulous arches. The technique uses an acrylic resin index fabricated on a diagnostic cast. The implant position is registered at time of placement with the adjacent teeth used as reference positions. The cast is then altered by use of this index to fabricate a master working cast.1-4 This clinical report presents the use of stage I indexing to register the position of a replacement implant by use of previously osseointegrated implants in an otherwise edentulous arch.
CLINICAL REPORT A 55-year-old male patient of the Department Of Veteran Affairs, N.Y. Harbor Health Care System, presented after placement of 8 threaded, root-form implants (Osseotite; 3i, Palm Beach Gardens, Fla.) in his maxilla 6 months earlier (Fig. 1). He was symptom free with no significant medical history. The patient was wearing a complete maxillary denture and cast mandibular removable partial denture as interim prostheses. The maxilla was treatment planned for a cement-retained 12-unit metal-ceramic fixed partial denture supported by 8 implants. At stage II surgery, clinical mobility was noted in the maxillary right distal implant that necessitated removal. The area was degranulated, and the remaining implants received healing abutments (EP One-Piece Healing Abutments; 3i). The treatment dilemma was to restore the existing 7 integrated implants or replace the failed implant and wait for osseointegration. In an effort to maximize anterior-posterior force distribution and also reduce treatment time, the decision was made to replace the implant through a modified stage I indexing approach. a
Attending Prosthodontist, Staten Island University Hospital, Staten Island, N.Y.; Clinical Assistant Professor, New York University, College of Dentistry, New York, N.Y.; and Private Practice, Staten Island and Queens, N.Y. b Director of Oral and Maxillofacial Surgery, Department of Veteran Affairs, New York Harbor Health Care System, Manhattan, N.Y. and Private Practice, Manhattan, N.Y. JUNE 2003
Fig. 1. Presentation of patient with failing maxillary right distal implant.
After a 2-week period, the healing abutments were removed and an implant level impression was made of the remaining 7 implants. A soft tissue master cast was fabricated. An acrylic resin index (Pattern Resin; GC America Inc, Alsip, Ill.) was made on the master cast with 2 neighboring analogs (Lab Analogs; 3i). Two implant-level impression copings (Twist Lock Transfer Type; 3i). were airborne particle abraded with 50-m aluminum oxide particles (Microetcher; Danville Engineering Inc, San Ramon, Calif.) and luted together with acrylic resin (Pattern Resin; GC America Inc) to form the reference portion. A third impression coping was precoated with resin (Pattern Resin; GC America Inc) to form the index portion (Fig. 2, A). A surgical template fabricated by duplicating the existing denture was used to guide implant placement. A 10-mm threaded, root-form implant was placed (Osseotite; 3i). Primary stability of the implant at stage I surgery is critical for successful registration of its position in the indexing technique. Noted mobility may be a contraindication for indexing and for implant placement.5 Although the site was open, the 2 components of the index were seated and their fit was verified by a radioTHE JOURNAL OF PROSTHETIC DENTISTRY 533
THE JOURNAL OF PROSTHETIC DENTISTRY
GLAVAS AND MOSES
Fig. 3. Compatible analog placed on distal impression coping.
Fig. 2. A, Index fabricated with adjacent implants, acrylic resin, and implant level impression copings to register implant position at time of placement. B, Index jig luted intraorally with acrylic resin.
tioning was verified by a radiograph (Fig. 5). The abutment was stabilized by pliers (K.Y., GC America Inc) to limit stress to the implant. The abutment screw was torqued to 32 Ncm. A solder index was completed, and the metal framework was sent to the laboratory for porcelain application. The complete denture was converted to a provisional fixed partial denture and luted over the custom abutments with provisional cement (Temp-Bond; Kerr Corp, Orange, Calif.). Eliminating centric occlusion and excursive contacts on the replaced implant minimized the risk of early loading. Cross-arch stability was achieved by joining all implants, helping to minimize unfavorable stresses.6
DISCUSSION graph. The components were luted together with acrylic resin (Pattern Resin; GC America Inc) and removed as a single unit (Fig. 2, B). The cover screw was placed and the site was closed. A compatible analog was placed on the distal impression coping (Fig. 3). An access hole was prepared in the master cast and the indexing jig was seated. The analog was placed free of any contact with the stone. Type III dental stone (Quickstone; Whip Mix Corp, Louisville, Ky.) was placed to fix the analog and create an altered master cast (Fig. 4). Maxillomandibular records were made and the casts were sent to the laboratory with gold UCLA cylinders (3i). Custom abutments and metal copings were requested. Two weeks later, the custom abutments were positioned. Their fit was verified with radiographs, and they were retained with abutment screws (Gold-Tite; 3i) torqued to 32 Ncm. The replaced implant was surgically exposed, the cover screw was removed, and the custom abutment was placed instead of a healing abutment. The abutment screw was hand tightened, and proper posi534
The implant-abutment connection should be considered when this technique is used. In the patient presented, the implants were externally hexed, and all the impression copings were compatibly hexed. A hex height of 0.7 mm allowed enough freedom for indexing. With external hex implants, multiple nonhexed reference copings can be used but should be hexed for single reference copings. The index coping should always remain hexed for proper orientation of the implant. The longer internal connections of other implant systems may only allow reference of 1 neighboring implant. The technique may not be able to tolerate a great convergence or divergence of implant position regardless of the implant connection used. The clinician should take care when the technique is used in the anterior portion of the mouth. Soft tissue manipulation may result in an unfavorable esthetic result.
SUMMARY A modified stage I indexing technique was presented for use in registering the position of a replacement for a VOLUME 89 NUMBER 6
GLAVAS AND MOSES
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 5. Proper positioning of custom abutment verified by radiograph.
level impression copings to register the implant position at time of placement. The index was then used to alter the master cast. The technique helps minimize the delay of replacing a failed implant before fabrication of the restoration, because prosthesis fabrication and healing occur concurrently with negligible increase in overall treatment time. REFERENCES 1. Hochwald DA. Surgical template impression during stage I surgery for fabrication of a provisional restoration to be placed at stage II surgery. J Prosthet Dent 1991;66:796-8. 2. Prestipino V, Ingber A. Implant fixture position registration at the time of fixture placement surgery. Pract Periodontics Aesthet Dent 1992;4:23-7. 3. Rosenlicht JL. Advanced surgical techniques in implant dentistry: contemporary applications of early techniques. J Dent Symp 1993;1:16-9. 4. Drago C. Stage I surgical indexing: clinical and laboratory procedures. J Dent Technol 2000;17:16-21. 5. Meredith N. Assessment of implant stability as a prognostic determinant. Int J Prosthodont 1998;11:491-501. 6. Corso M, Sirota C, Fiorellini J, Rasool F, Szmukler-Moncler S, Weber HP. Clinical and radiographic evaluation of early loaded free-standing dental implants with various coatings in beagle dogs. J Prosthet Dent 1999;82: 428-35.
Fig. 4. A and B, Analog placed free of any contact with master cast and luted in position. C, Altered master cast.
failed implant in an edentulous arch. An index was fabricated with adjacent implants, acrylic resin, and implant
JUNE 2003
Reprint requests to: DR PETER GLAVAS 45-22 LITTLE NECK PKWY LITTLE NECK, NY 11362 TEL: (718) 224-4040 E-MAIL: [email protected] Copyright © 2003 by The Editorial Council of The Journal of Prosthetic Dentistry. 0022-3913/2003/$30.00 ⫹ 0 doi:10.1016/S0022-3913(03)00172-0
535