Prd 34 S Chu 2129 02.Pdf

The International Journal of Periodontics & Restorative Dentistry

A Novel Prosthetic Device and Method for Guided Tissue Preservation of Immediate Postextraction Socket Implants

Stephen J. Chu, DMD, MSD, CDT1 Mark N. Hochman, DDS2 Jocelyn Hui-Ping Tan-Chu, DDS3 Adam J. Mieleszko, CDT3 Dennis P. Tarnow, DDS4

Preservation of the surrounding hard and soft tissues associated with an Placement of implants into anterior immediate postextraction socket implant to replace a nonrestorable tooth in postextraction sockets has gained the esthetic zone is one of the greatest challenges facing the dental team. popularity since the introduction Several studies have documented the biologic and esthetic benefits of bone of this approach in 1989.1,2 It con- graft containment with either a custom healing abutment or provisional restoration. Use of a prefabricated shell that replicates the extracted tooth denses treatment procedures at at the cervical region can help achieve guided tissue preservation and the time of tooth removal, decreas- sustainable esthetic outcomes in an easy, simple, consistent, and less time- ing the overall treatment period consuming way. The following case report of a hopeless maxillary right central and enhancing the total patient ex- incisor in a female patient possessing adjacent teeth with a thin periodontal perience. When immediate postex- phenotype illustrates this new treatment device, method, and concept. (Int J traction implant placement (with Periodontics Restorative Dent 2014;34(suppl):s9–s17. doi: 10.11607/prd.2129) or without provisional restoration) was compared to delayed proto- cols, equivalent survival rates were reported.3–9 The esthetic ramifica- tions of immediate implants, especially for single anterior teeth in the esthetic zone, are therefore of increasing significance. The thickness of peri-implant mucosal tissues af- fects abutment materials selection, all of which must be in balance to achieve a predictable and sustainable esthetic outcome.10–15 1Clinical Associate Professor, Director of Esthetic Education, Columbia University College of Dental Medicine, New York, New York, USA. Several clinical obstacles may 2Former Associate Clinical Professor, NYU College of Dentistry; Private Practice of complicate fabrication of an im- Periodontics and Orthodontics, New York, New York, USA. plant-supported provisional resto- 3Private practice, New York, New York, USA. 4Clinical Professor, Director of Implant Education, Columbia University College of ration following tooth removal. The Dental Medicine, New York, New York, USA. peri-implant mucosal tissues often immediately collapse after tooth Correspondence to: Dr Stephen J. Chu, 150 East 58th Street, Suite 3200, New York, extraction, socket debridement, NY 10155, USA; fax: 212-754-6753; email: [email protected]. and implant placement, compli- ©2014 by Quintessence Publishing Co Inc. cating the task of capturing the

Volume 34, Supplement, 2014

© 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. s10 subgingival contours and preex- provisional restorations have a dis- existing screw-retained provisional traction state of the tooth cervix tinct advantage in that they only implant component (eg, PreFor- relative to eccentric spatial im- possess one subgingival connec- mance Temporary Cylinder, Biomet plant positioning. Any bone graft tion: the implant-abutment inter- 3i), thereby capturing the subgin- material also must be adequately face. In contrast, cement-retained gival profile of the mucosal tissues contained by the provisional res- restorations have two, with the ad- independent of the implant posi- toration or custom healing abut- ditional subgingival connection be- tioning. As Trimpou has stated24: ment.16–22 ing the crown-abutment interface. “Simulation of the exact dimension Blood contaminants caught An IIPR should embody several of the lost tooth, especially on the within the body of the provisional key essential design elements to cervical part of the new provisional restorative material (acrylic resin, allow for simple, easy, quick, pre- restoration, is expected to pre- bis-acryl, or composite) can later dictable, and repeatable fabrica- serve all relevant information and oxidize, causing discoloration and tion: (1) The subgingival contours allows the design of a natural look- weakening of the parent material. and shape of the cervical root area ing emergence profile.” A device that controlled bleeding of the removed tooth should be The following case report il- within the extraction socket would replicated in their preextraction lustrates the use of this device and be beneficial and advantageous state. (2) The subgingival shape method for fabricating an immedi- during this process. Current meth- should be captured in the IIPR in- ate provisional restoration of an im- ods such as the Nealon technique, dependent of the implant position. plant placed immediately after tooth in which a liquid-powder method Current knowledge suggests that extraction in the esthetic zone. is used to paint the material into implant placement should be at the socket around a provisional least 3 to 4 mm in depth from the implant abutment component, or midfacial free gingival margin and Case report injection of a mixed material may 2 mm palatally from the facial os- be insufficient to accurately du- seous crest,7 ie, placement should A 26-year-old woman with a den- plicate the subgingival profile of be spatially eccentric, by default or tal history of trauma to the maxil- the mucosal tissues.23 Use of an error. (3) Placement of a bone graft lary right central incisor presented existing (autogenous) extracted material into the gap to the level of with evidence of internal resorp- tooth to create an immediate pro- the free gingival margin, followed tion (Fig 1a). The midfacial gingi- visional restoration on an immedi- by containment, protection, and val margin was slightly higher than ate postextraction implant also has maintenance, with the IIPR func- that of the contralateral tooth due been suggested.24,25 Steigmann tioning as a prosthetic socket-seal to prior incisal edge fracture with and Wang reported esthetic out- device,24,25 is critical for the esthetic compensatory tooth eruption (Fig comes in regard to retaining the in- outcome. 1b). Periodontal probing enabled terdental tissues as well as patient To meet these goals, a prefab- assessment of the periodontal satisfaction using the extracted ricated polymethyl methacrylate phenotype; although all the adja- tooth as a provisional restoration.26 (PMMA) shell device was devel- cent tooth sites were thin, the tis- Generally, an immediate im- oped to replicate the shape and sue surrounding the central incisor plant provisional restoration (IIPR) dimensions of the extracted root was characterized as thick.28 An ir- should be screw retained to avoid at the cervical area and properly reversible hydrocolloid (alginate) problems associated with inade- support the subgingival mucosal impression (Jeltrate, Dentsply) quate cement removal—so-called tissues. Both analog (physical) and was made of the incisor, and a iatrogenic peri-implantitis.27 From digital (stereolithography, STL) file provisional crown was fabricated a biologic perspective, screw- forms were developed. The ana- from autopolymerizing acrylic resin retained versus cement-retained log version can be joined to any (Super-T, American Consolidated).

The International Journal of Periodontics & Restorative Dentistry

Fig 1a The patient presented with an internal resorption lesion of the maxillary right central incisor; note the Class IV distal incisal edge fracture repaired with a composite resin restoration.

Fig 1b The gingival zenith of the hopeless tooth needed correction in the definitive estoration.r

Fig 1c After tooth extraction, socket debridement, and implant placement, the mucosal tissues immediately collapsed.

a b c

Fig 2 A medium-sized shell was used for the maxillary right central incisor. Three views are shown: (a) facial, (b) facio-occlusal, and (c) occlusal.

a b c

Fig 3 (a) The fit of the shell was verified in the extraction socket and seated to the level of the free gingival margin prior to luting to the provisional implant cylinder. (b) The mesial aspect of the shell is by design slightly more incisal, indicative of the mesial papilla. (c) The shell supports the mucosal tissues, replicating the preextraction state of the tooth root cervix as well as controlling the volume of blood in the socket. a b c

An intrasulcular incision was made point, the peri-implant mucosal tis- ported the mucosal tissues before with a 15c scalpel blade to sepa- sues had already notably collapsed. the provisional screw-retained poly- rate the supracrestal gingival fibers An analog maxillary right cen- etheretherkeytone (PEEK) implant from the root surface prior to atrau- tral incisor prefabricated shell was component (PreFormance Tempo- matic tooth extraction. After socket selected; each shell is tooth-specific rary Cylinder, Biomet 3i) was seated debridement, a 4-mm-diameter im- (Fig 2). The fit was verified within (Fig 4a) and luted with acrylic resin plant (3i T3, Biomet 3i) was placed the socket (Figs 3a to 3c), making (Fig 4b). Placement of the implant with a palatal bias (Fig 1c). At this sure that the shell properly sup- into the extraction socket helps to

Volume 34, Supplement, 2014

Fig 4 (a) PreFormance Temporary Cylinder was seated and (b) acrylic resin was added using the Nealon technique to secure the two independent components. (c) The pre fabricated provisional crown was adapted over the shell using autopolymerizing acrylic resin to create a full provisional restoration. a b c

Centric Palatal Labial

Fig 5 The provisional restora- Fig 6 When using a prefabricated device, the subgingival contours of the provisional restoration tion was removed from the have the correct shape irrespective of the implant position. With palatal positioning of the implant, mouth and placed onto a labo- the shell creates a proper full facial contour. A flat contour may result if the implant location is ratory replica to enable removal excessive to the labial aspect. of the excess acrylic, along with trimming, finishing, polishing, and cleaning, prior to reinser- tion in the patient’s mouth.

control bleeding, and the shell as- that duplicate the preextraction placed toward the labial), since the sists in this process. The provisional state, just as the use of prefabri- IIPR is engaged to the provisional crown was relieved internally and cated sheetrock in wall construction implant cylinder independent of the readapted over the provisional im- has replaced the archaic and time- implant position (Fig 6). After the plant cylinder to create a full-con- consuming process of hand-plaster- occlusion of the IIPR has been re- toured provisional crown (Fig 4c). ing, making present-day fabrication duced and its surface has been fin- After polymerization of the acrylic easier, faster, and less variable. The ished, polished, and cleaned, bone resin, the screw-retained provisional restorative clinician can now focus graft material can be placed. restoration was removed and con- on refining the contours of the IIPR The IIPR was removed from nected to a laboratory analog prior (Fig 5). Use of a prefabricated shell the implant, and a flat-contoured to trimming the excess acrylic. The ensures that the provisional crown healing abutment was seated. This advantage of using a prefabricated contours will be correct irrespective allowed clear access to the gap device is that it simplifies the chal- of the implant position29 (ie, convex between the labial bone plate and lenging and time-consuming work if the implant is placed toward the the implant surface. Bone graft ma- of creating subgingival contours palatal aspect and concave if it is terial was then placed and packed

The International Journal of Periodontics & Restorative Dentistry

Fig 7 The provisional restoration was removed, and a tall, flat-profile healing abutment was seated to allow access for placement of bone graft material into the gap between the facial plate and the implant surface. A sterile amalgam carrier and plugger were used to place and condense the bone graft material. The graft material was placed to the height of the free gingival margin, and then the healing abutment was carefully removed to allow reseating of the provisional crown.

Fig 8 The provisional restoration was Fig 9 Five months later, the gingival mar- Fig 10 At the first provisional estorationr reinserted, acting as a prosthetic socket- gin was still slightly lower than that of the disconnection, the increased width and sealing device to contain, protect, and adjacent tooth, but the tissue was healthy. shape of the implant ridge were evident, maintain the bone allograft material dur- compared to those of the adjacent tooth. ing the 5-month healing period. Using a Bone grafting along with use of a provisional periodontal scaler, excess bone allograft restoration that compensated for eccentric material was removed to the level of the implant positioning and supported the pre- free gingival margin. extraction state of the mucosal tissues were critical elements for achieving sustainable esthetics of the ridge shape and peri- implant mucosal tissues.

with a sterile amalgam carrier and visional restoration was cleaned ment (Fig 9), the IIPR was dis- plugger to the level of the midfacial and replaced.32 It then served as a connected for the first time. The free gingival margin (Fig 7).30 The prosthetic socket seal (Fig 8). The excellent ridge and peri-implant particles may not be biologically preextraction state of the cervical mucosal tissue contours can be reactive and can be incorporated region of the tooth was duplicated, seen in Fig 10. into the mucosal tissues, poten- and with the addition of the bone During impression making, tially increasing their thickness.31 graft material, the ridge profile can the mucosal tissues tend to spon- The graft material acts as a scaf- theoretically be increased. taneously collapse after removal fold to counteract bone modeling/ Postoperative follow-up was of the provisional restoration or remodeling, maintaining the shape performed 1 week after surgery, custom healing abutment. Several and contour of the facial ridge, and the site was allowed to heal authors have published techniques and minimizing collapse. The heal- for an additional 19 weeks, during to counteract this problem, one of ing abutment was then carefully which the patient elected to have which is to make a custom impres- removed, leaving the bone graft her remaining dentition whitened. sion coping of the provisional res- particles undisturbed, and the pro- Five months after implant place- toration contours.33 However, when

Volume 34, Supplement, 2014

a b c Fig 11 (a) A prefabricated shell can also be used in conjunction with a BellaTek Encode (digitally coded) healing abutment to be scanned intraorally or recorded with a (b) tissue-level impression. (c) The shell and abutment must be at least 1 mm above the free gingival margin to be read accurately on the stone cast.

Fig 12 The digital file of the shell being replaced, in this instance the central incisor, can be combined with the scanned location of the implant head. (a) The CAD/CAM design is seamless and less time consuming than traditional planning techniques since the file can be selected automatically with the predetermined shape and merged. (b) The occlusal outline form of the CAD/CAM abutment is provided by the scanned shell, which should protrude from the free gingival margin by at least 1 mm. The technician can merge the tooth-specific file to the implant connection spatial location. a b

using a prefabricated shell, another implant-level impression coping crown35 with a custom-fabricated tooth-specific component can be (Fig 13) and a definitive impression metal-alloy abutment (Figs 15a luted to a digitally coded healing was made with a medium/light- and 15b). The custom abutment abutment (BellaTek Encode Heal- body one-step technique using a was gold plated and cleaned prior ing Abutment, Biomet 3i), using polyvinyl siloxane material (Flexi- to connection to the implant. A du- pattern resin (Pattern Resin LS, GC time Xtreme, Heraeus). A working plicate die (Luxatemp Ultra, DMG America) to precisely retain the po- cast was fabricated in the labora- America) indirect cementing tech- sition and shape of the mucosal tis- tory with gypsum stone. Again, a nique36 was used to provisionally sues (Fig 11a). It is important that comparable prefabricated shell for cement the definitive crown and the shell and abutment extend at the maxillary right central incisor avoid any risk of leaving excess ce- least 1 mm above the margin of the made in pattern resin can be used ment that could irritate the tissue. mucosa so it can be properly visu- in the wax-up process of a custom- The definitive restoration inte- alized (Fig 11b). A tissue-level im- fabricated abutment (Fig 14a). Fur- grated well with the pink and white pression can then be made, a stone ther labial contour was created in esthetics of the surrounding den- cast poured (Fig 11c) and scanned, the laboratory to move the mid- tition (Fig 16) and periodontium and a computer-aided design/ facial gingival zenith slightly more (Fig 17). At the 1-year posttreatment computer-assisted manufacture apical34 to match that of the maxil- recall, the facial contour of the max- custom abutment designed (Figs lary left central incisor (Fig 14b). illary right central incisor compared 12a and 12b). In the present case, The definitive restoration was favorably with the silhouette of the an equivalent shell was luted to an a cement-retained metal-ceramic contralateral natural tooth (Fig 18).

The International Journal of Periodontics & Restorative Dentistry

a b Fig 13 An identical shell component can Fig 14 The shell is duplicated in pattern resin in the fabrication of the final be used for the implant-level impression- custom abutment. (a) The shell conforms to the mucosal shape without adjust- making procedure. The device prevents ment. (b) Additional contour was added with pattern resin to the abutment during collapse of the mucosal tissues during this fabrication to stretch the soft tissues to a gingival zenith position matching that of process and can be luted to the implant the contralateral central incisor. impression coping with pattern resin to secure its position.

a b Fig 15 A metal-ceramic full crown restoration was made on Fig 16 The definitive metal-ceramic crown was provisionally the metal alloy custom abutment. (a) The ceramic powders were cemented onto the custom alloy abutment intraorally. Integration layered, fired, and shaped; surface texture and luster were created; of white and pink esthetics has been achieved. and (b) the definitive restoration was glazed and polished.

Fig 17 The facial view confirms the concept of predictable, Fig 18 At 1 year, the intraoral labio-occlusal view shows the sustainable esthetics from provisional restoration fabrication to contours of the treated site in comparison with the contralateral definitive abutment design in an easy, simple, predictable, and natural tooth. repeatable workflow.

Volume 34, Supplement, 2014

Conclusions References 11. Ishikawa-Nagai S, DaSilva JD, Weber HP, Park SE. Optical phenomenon of peri-implant soft tissue. Part II. Preferred Use of a prefabricated shell that 1. Lazzara RJ. Immediate implant place- implant neck color to improve soft tissue conforms to the subgingival con- ment into extraction sites: Surgical and esthetics. Clin Oral Implants Res 2007;18: restorative advantages. Int J Periodon- 575–580. tours of the mucosal tissues is of tics Restorative Dent 1989;9:332–343. 12. Jung RE, Sailer I, Hammerle CH, Attin T, clinical relevance and importance 2. Wohrle PS. Single-tooth replacement in Schmidlin P. In vitro color changes of soft the esthetic zone with immediate pro- for hard and soft tissue preserva- tissues caused by restorative materials. visionalization: Fourteen consecutive Int J Periodontics Restorative Dent 2007; tion. It compensates for several case reports. 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