Prosthodontics. Periodontics. Endodontics. Research. Laboratory Considerations
VOLUME 4 No 2 MARCH 2002
.Aesthetic RestorativeOptions and Implant Site Enhancement Using Orthodontic Extrusion .Immediate Implant PlacementWith Immediate Provisional Crown Placement \ .Multidisciplinary Approach for Achieving Aesthetics in a Cleft lip and Palate Patient
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A Montage'Media, Publication MONTAGE MEDIA CORPORATION IS AN ADA CERP RECOGNIZED PROVIDER
Practical Procedures & AESTHETICDENTISTRY
Figure 2. The metal try-in of multiple single units. It is difficult to distinguish between implants and natural tooth abutments.
Figure 1. The implant site consists of the surrounding socket walls of an extracted tooth, the shape of the root, and the continuity of form emerging from the implant leading to the proposed restoration.
W hile the treatment of hopeless, fractured, or miss- ing teeth has traditionally presented difficulties
within the anterior region, one of the primary consid- Figure 3. Size 30 endodontic files with rubber erations in deciding on tooth replacement procedures stops were used to measure the interproximal has been a lack of predictability in constructing an aes- peak of bone on the adjacent sites and their distance from the final contact points. thetic restoration, particularly following implant therapy.
Most clinicians have limited guidance in the evaluation
and then selection of the appropriate restorative options
in the "aesthetic zone." Recent investigations have
focused on the diagnostic evaluation of a site prior to
selecting a particular restorative option for tooth replace-
ment (Tablel. This selection criteria is based upon a
thorough evaluation of the alveolar bone surrounding
the site, particularly the interproximal bone, which sig- Figure 4. Radiographic measurements display the impor- nifiCantly influences individual tooth form and aesthet- tance of the measurement of the adjacent sites in predicting ics (Figures 1 through 41. anticipated soft tissue position interproximally between implants, natural teeth, and pontics. One of the primary reasons for failure in this region
has been ineffective or missing "diagnostic indicators"
that cause aesthetic tooth replacement sele<;;tion of a sounding .of the interproximal peaks must be performed,
site to be unpredictable. If) an attempt to simplify the and the laI:Jial plate must be located prior to selection of
diagnostic process, the authors defined future restora- the appropriate restoration (Figures 5 and 6). As described
tive sites as: 1) existing edentulous spans (ie, delayed by Tarnow and Kois, as well as Salama et al, the loca-
sites), and 2) hopeless teeth prior to planned extrac- tion of the interproximal peak of bone will allow deter-
tions (eg, immediate sites). During the treatment of a mination of the an!icipated quality of the interproximal
previously extracted tooth in an edentulous ,5pan, bone soft tissues around the restorations."3 The interproximal \
126 Vol. 14, No.2 Salama
Figure 5. An ovate pontic preparation was Figure 6. Labial plate and interproximal bone performed prior to delayed implant placement. sounding is required prior to implant placement.
Figure 7. The fractured left central incisor was Figure 8. Bone sounding was performed prior radiographically observed and a poor prognosis to extraction on the mesial and distal aspects of was determined. the hopeless tooth. Adequate bone support for interdental soft tissue response was indicated.
peak of bone has been indirectly utilized in the middle of bone on the adjacent teeth, implants, or pontic areas of the contact area to suggest the predictability of papilla should, therefore, facilitate appropriate selection of a around dental implants.4 Probing of the site adjacent to proposed restoration. Based upon a variety of clinical the proposed implant has also demonstrated efficacy in data (Table!, the preoperative bone sounding measure-
predicting the postoperative location of the interproxi- ments should facilitate the selection of an optimal restora-
mal soft tissue levels.3 Probing of the interproximal peaks tive option that corresponds to the surrounding bony
PPAD 127 Practical Procedures & AESTHETiC DENTISTRY
Figure 9. Preoperative facial view Figure 10. Orthodontic extrusion and Figure II. Immediate implant place- demonstrates the presence of a sub- occlusal adjustment was performed ment was performed following atrau- gingival fracture on the maxillary left to enhance the bone and soft tissue matic extraction utilizing a tapered central incisor within the lip perimeter dimensions 8 to 12 weeks prior to implant, approximately 5.5 mm in and the oesthetic zone. extraction. diameter, to replace the extracted central incisor.
Figure 12. A healing abutment was Figure 13. Postoperative facial view Figure 14. Periotomes are ideal for used for vertical support of the soft demonstrates enhanced aesthetics atraumatic extraction following ortho- tissues. Note the added dimension and surrounding soft tissue health. dontic extrusion, as they place no of soft tissue provided by the ortho- added pressure on the surrounding dontic treatment. bony walls.
anatomy of the individual patient.5 Since many post- a vertical direction and thereby relocate the bone and
operative complications are developed due to poor soft tissues coronally to extraction (Figure 10). This tech-
diagnosis and not from lack of technical expertise, this nique generally requires approximately 8 to 1 2 weeks of
information will significantly influence the development orthodontic extrusion followed by 4 to 6 weeks of stabili-
of an aesthetic result. zation. The levels of orthodontic forces applied are light
Bone sounding is an important aspect of the diagnos-
tic phase during the treatment of teeth that are scheduled
for extraction (eg, immediate sites) (Figures 7 and 8).
The site can then be evaluated and orthodontically altered
if it is determined to be inadequate:6 Orthodontic tooth
movement will allow for a simplified nonsurgical approach
to enhancing areas with poor soft tissue levels, recession,
or missing papillae with inadequate interproximal peaks
of bone prior to extraction and immediate implant place-
ment (Figure 9).
The orthodontic augmentation technique utilizes the
remaining attachment apparatus around the hopeless Figure 15. Selection of the implont diameters is based tooth by providing orthodontic tension on the periodon- upon the anticipated location of the head of the fixture in tal ligament to manipulate the attachment apparatus in relqtion to the mesial distal diameter of the root anatomy.
128 Vol. 14, No.2 Solomo
Figure 16. Following extraction with Figure 17. Utilizing a temporary Figure 18. Five months postoperative the periotomes, the implant site is cylinder, a healing abutment was healing and maturotion of the soft internally and externally reevaluated customized to reestablish the proper tissue. Note the health and contour of with a probe. subgingival contours and support the soft tissue that was formed utiliz- the interdental papillae and labial ing a customized healing abutment. gingiva.
Figure ]9. A permanent abutment Figure 20. The all-ceramic cerabase Figure 21. The all-ceramic abutment sleeve was placed to facilitate the use abutment was placed on the labora- was placed on the soft tissue model of an all-ceramic (cerabase) abutment. tory model. prior to preparation of the final Screw access was palatal to the adja- abutment chamfer line. cent incisal edges.
(approximately 80g to 120g 1and the teeth should demon- cases without the need for raising a flap -and avoids
strate no sign of inflammation or periodontal or periapical stripping of the periosteum and compromising the vas-
pathology. Following stabilization, extraction and imme- cularity of the buccal plate. Utilization of this technique
diate implant placement are suggested (Figure 111.7 can provide the practitioner with a shorter, simplified,
To account for potential recession and shrinkage of and more efficient approach to management of tooth
the hard and soft tissues following surgery, the authors replacement procedures in the anterior region. Clinicians
recommend approximately 20% to 25% overcorrec- have been utilizing this technique since 1996 with the
tion of the site prior to extraction and immediate implant results comparable to traditional single-stage implant tech-
placement (Figure 121. Following atraumatic extraction, niques (Figure 13). it is necessary to once again reevaluate the site utilizing Once orthodontic treatment has optimized the site
the aforementioned bone sounding techniques. Selection and overcorrected the hard and soft tissue dimensions
of the appropriate implant diameters, shape, and thread vertically, the teeth are extracted with periotdmes in an
design then becomes paramount in managing the implant atraumati~ method. The periodontal ligament spaces
site. A tapered implant system with different anatomic should be engaged in an apical direction to slowly tear
diameters may allow for a true anatomic reconstruction those fibers and release the tooth without destruction or
beginning at the neck of the implant and may allow for pressure of standard elevators to the surrounding socket
an enhanced engagement of the tapered implant to the and bony walls (Figure 14). Once the tooth is extracted,
tapered extraction site. As with other implant systems, the extraction site is internally and externally evaluated
this allows for atraumatic surgical placement- in many via bone sounding (Figures 15 and 16). In the absence
PPAD 129 Practical Procedures & AESTHETiCDENTISTRY
challenging. The authors suggest that preoperative
diagnostic evaluation of the site utilizing bone sounding
and radiographic evaluation will enable selection of
the most appropriate restorative procedure for a pre-
dictable aesthetic result. When evaluating a deficient
site prior to extraction, utilization of adjunctive orthodontic
extrusion will facilitate manipulation of the surrounding
attachment apparatus prior to extraction and implant
Figure 22. Following porcelain application, placement. This technique allows for utilization of the the subgingival area was minimized to avoid patient's own bone and soft tissue in a nonsurgical excessive apical placement of the implant- crown interface. approach that enhances the implant site vertically and
provides for an atraumatic extraction with immediate
implant placement. Treatment can be achieved in a sin-
gle surgical phase (in many instances) and can be man-
aged without the reflection of a surgical flap to facilitate
expeditious healing and predictable soft tissue support
and contours for the final restorative phase. In addition, .. this nontraumatic implant placement technique allows for
maintenance of the vascularity to the critical labial plate
of bone and minimizes the potential for postoperative Figure 23. Postoperative view following place- soft tissue recession. ment of the single-tooth implant restoration demonstrates enhanced aesthetics, soft tissue scallop, height of interdental papilla, and overall soft tissue health. Acknowledgment The authors declare no financial interest in any of the
of fenestrations, an appropriate anatomic diameter implant products cited herein. is selected to engage the mesiodistal walls of the socket
based on the mesiodistal diameter of the extraction References
socket. Custom anatomically shaped healing abutments 1 Tarnaw DP, Magner AW, Fletcher P The effect of the distance from the contact point to the crest of bone on the presence or can be fabricated chairside with acrylic or composite absence of the interproximal dental papilla J Periodontal 1992;63112)995-996 resin when necessary to maintain or condition the soft 2 KoisJ Altering gingivallevels- The restorative connection Part I Biologic variables J Esthet Dent 1994;63-9 tissue during the osseointegration phase of healing 3- Salama H, Salama MA, Garber DA, Adar P The interproximal ( Figures 17 and 18).8 Careful attention should be tqken height of bone A guidepost to predictable aesthetic strategies and soft tissue contours in anterior tooth replacement Pract to ensure that the implant is placed slightly to the palatal Periodont Aesthet Dent 1998; 101911131-1141 4 Tarnow DP The effect of inter-implant distance on the height of aspect in order to avoid trauma to the buccal plate and inter-implant bone crest J Periodontol 2000;71 (4)546-549 5 Salama H, Garber DA, Salama MA The periodontal issues in allow for a screw access that promotes the utilization of smile design Presented at the Academy of Periodontology Annual aesthetic ceramic abutment systems or opacious porce- Meeting; September 17, 2000; Honolulu, H I 6 Sal0ma H, Salama MA- The role of orthodontic extrusive remodel- lains that conceal the metallic substructure of the implant ing i" the enhancement of soft and hard tissue profiles prior to implant placemenr A systematic approach to the manage- components (Figures 19 through 23). ment of extraction site defects Int J Periodont Rest Dent 1993; 1314)312-333 7 Wohrle PS Single-tooth replacement in the aesthetic zone with Conclusion immediate provisionalization Fourteen consecutive case reports Pract Periodont Aesthet Dent 1998;10191-11 07-1114 When planning for tooth replacement in the aesthetic zone, 8 Wheeler S, Vogel R, Casellini R Tissue preservation and main- tenance of optimum esthetics- A clinical report Int J Oral selection of an appropriate restoration is exceptionally Maxillofac Impl2000;1512r265-271
130 Vol. 14, No.2 ~~~(A"OHr;-E
To submit your CE Exercise answers, please use the answer sheet found within the CE Editorial Section of this issue and complete as follows: 1) Identify the article; 2) Place an X in the appropriate box for each question of each exercise; 3) Clip answer sheet from the page and mail it to the CE Department at Montage Media Corporation. For further instructions, please refer to the CE Editorial Section.
The 10 multiple-choice questions for this Continuing Education exercise are based on the article "Guidelines for aesthetic restorative options and implant site enhancement: The utilization of orthodontic extrusion" by Maurice A. Salama, DMD, Henry Salama, DMD, and David A. Garber, DMD. This article is on Pages 125-130.
Learning Objectives: This article presents the utilization of orthodontic extrusion in combination with atraumatic extraction and immediate implant replacemenl utilizing a tapered implant system. Upon reading this article and completing this exercise, the reader should: .Demonstrate an awareness of the anatomical and biological considerations during immediate extraction and implant placement. .Understand the diagnostic indicators of orthodontic extrusion.
1. The selection of the oppropriate tooth replacement 6. To account for potential recession ond shrinkQge of technique should b:Etaided by, prediagnostic: the hQrdand soft tissues following immediate implant q, Sub$jn$iyp!~y!rure7 placement, the Quthors recommend approximately what " cb.l; "t "f """ "CJ" ' 1;.J,," "c"key~ q,~r!qo<;!1;nta:U)seose, " ~~entOge of ov~rcorrection of the site? ' 061 '9 ""j,,\\ gcl yjotQ15%:, 9 teeth\"j"" \jj\:"j"""\C" "~r,,'\ :,,\:\"\: \'\,,\\\ L50%io55% 2. The area of bone sounding that helps to predict the future soft tissue papilla levels is found on what aspect? , 7. What ImplQntshape was recommended by the Quthor Q.Pi;Jiatal. immediately extracted teeth? L(;':,~; I [k o.!acti;J" ?cc" cccc~ L'I'"""' "c?CC c "c.cSuo'fngua'!cc?kcI
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9. CustOmandtO~ically shaped healing abutments placed 4. Orthodontic augmentation techniques work by Utilizing , at the time of i~medidteim plant placement hel ps to: what anatomical and biological rationale? bjid(#6fize osseofnfegratlorij! Q.PRP. !\'y7.~j ~T"::c'! ; :Yj Y Y Y Y "dBMPL;' "" " " "C"
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pp 131