Combining a Single Implant and a Veneer Restoration in the Esthetic Zone

CLINICAL RESEARCH

Combining a single implant and a veneer restoration in the esthetic zone

Jose Villalobos-Tinoco, DDS Department of Restorative Dentistry, Autonomous University of Queretaro School of Dentistry, Queretaro, Mexico

Nicholas G. Fischer, BS Minnesota Dental Research Center for Biomaterials and Biomechanics, University of Minnesota School of Dentistry, Minneapolis, Minnesota, USA

Carlos Alberto Jurado, DDS, MS Clinical Digital Dentistry, A.T. Still University Arizona School of Dentistry & Oral Health, Mesa, Arizona, USA

Mohammed Edrees Sayed, BDS, MDS, PhD Department of Prosthetic Dental Sciences, Jazan University College of Dentistry, Jazan, Saudi Arabia

Manuel Feregrino-Mendez, DDS Periodontal Private Practice, Queretaro, Mexico

Oriol de la Mata y Garcia, CDT Dental Technician, Private Practice, Puebla, Mexico

Akimasa Tsujimoto, DDS, PhD Department of Operative Dentistry, Nihon University School of Dentistry, Tokyo, Japan

Correspondence to: Nicholas G. Fischer Minnesota Dental Research Center for Biomaterials and Biomechanics, University of Minnesota School of Dentistry, 515 Delaware Street SE, Minneapolis, Minnesota 55455, USA; Tel: +1 612 625 0950; Email: [email protected]

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Abstract and the soft tissue contouring was started for an immediate provisional restoration. A suturing technique Objective: The combination of partial edentulism was executed that aimed at maintaining an interproxi- and a worn anterior tooth in the esthetic zone can mal papilla. Conservative veneer preparation was per- be a challenge for the dentist. This clinical situation formed on tooth 21 in order to bond the restoration requires extensive knowledge of soft and hard tissue to the enamel structure. Final restorations included a management, surgical planning and execution for custom abutment with a lithium disilicate fused to zir- implant therapy, and conservative tooth preparation conia crown for the implant on site 11 and a lithium with ideal bonding protocols for the tooth-supported disilicate veneer on tooth 21. prosthesis. Moreover, an optimal selection of the final Conclusions: A well-planned single implant and a ce- restorative materials is imperative to manage occlusal ramic veneer restoration was able to fulfill the patient’s forces and fulfill the patient’s esthetic demands. esthetic expectations. The selection of materials for Materials and methods: The patient presented with the final restoration was crucial to manage the occlu- partial edentulism on site 11, a worn incisal edge, and sal forces and to mimic the shade and shape of the facial defects on tooth 21. Minimally invasive implant adjacent teeth. therapy for site 11 was performed with a papilla-sparing flap design that only included the edentulous site, (Int J Esthet Dent 2020;15:2–11)

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Introduction texture, and various other aspects of the implant-associated soft tissue need to look Anterior tooth loss presents a major esthet- similar to the surrounding soft tissue to max- ic challenge to dentists because any small imize the esthetic outcomes.19,20 To achieve defect is projected in the patient’s smile.1 this, provisional implant prostheses help to Partial edentulism can be managed with create and form the ideal peri-implant tis- conventional dentistry and implant pros- sue.21 The timing of the placement of pro- thodontic therapy, but both require proper visional implant restorations (immediate as planning to achieve ideal esthetic results.2-4 opposed to 6 months, for example) is in- Tooth-supported ﬁxed restorations function formed by many factors such as the implant well, but esthetic and oral hygiene may be stability and the amount of graft applied.22,23 compromised if the design of the soft tis- Ceramic veneers are a conservative sue and pontic is not properly achieved.5 treatment option for teeth presenting with On the other hand, while partial remov- defects, fractures, etc. These bonded ce- able prostheses may meet esthetic require- ramic veneers have shown successful long- ments, the lack of stability could interfere term results.24,25 The long-term success of with other functions such as mastication.6 ceramic veneer restorations is dependent For both treatment options, conventional on components such as restoration de- restorations can detrimentally affect the re- sign26 and adhesive methods,27 among oth- tention and/or support of the neighboring er factors.28 While the reduction of tooth teeth. structure is usually needed for the place- Implant therapy is the standard treatment of veneers, excessive or overzealous ment provided by most clinicians as it pre- tooth preparation can expose the dentin serves the adjacent teeth and provides a and detrimentally affect the bonding of predictable long-term solution.7,8 Several veneers.29 Recent advances in technology studies have shown fairly similar success have made it possible to produce ultrathin rates for implants placed in the maxillary ceramic veneers with a thickness of only esthetic zone compared with those placed 0.5 mm, which bond to the tooth structure in posterior sites.9-11 While implant survival with little hard tissue removal.30 There are is obviously crucial and many studies have many dental ceramic options and formu- focused on it, fewer have evaluated the es- lations currently available31,32 that produce thetic outcome of implants placed in the acceptable esthetic results and bond dura- maxillary esthetic zone, despite this being bility.33 Minimal tooth reduction can provide crucial to many patients.12-14 positive fracture characteristics when res- Maxillary alveolar ridge (anterior) thick- in-based cements are used to bond ceram- ness can compromise esthetic expectations ic veneers to the underlying tooth,34,35 with for implant therapy. In these situations, hard good survival rates.36 The aim of this report and soft tissue grafting may be required.15 is to show a clinical protocol combining a This complexity could increase when pa- single implant and a veneer restoration in tients present thin gingival phenotypes or the esthetic zone. limited mesiodistal space.16 The tradition- al approach for implant therapy in the es- Clinical report thetic zone might include the extraction of a non-restorable tooth and a bone graft- A 40-year-old female patient presented at ing procedure, followed by a healing time our dental clinic with the chief complaint of about 3 to 4 months.17,18 The thickness, of having lost an anterior tooth. Her wish

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Fig 1 Patient’s initial smile. Fig 2a and b Initial smile and intraoral situation.

was for an implant to replace the lost tooth decided to place an immediate implant on (Fig 1). The patient stated that her tooth (11) edentulous site 11. Implant placement with had been fractured in a car accident and she immediate provisional restorations was had undergone an emergency extraction of planned, as it is a common procedure to es- it 3 months prior to her fi rst visit. She was tablish an ideal emergence profi le in order also concerned about the incisal wear and to provide maximum tissue volume, pre- facial defects on tooth 21 (Fig 2). After the serve the midfacial gingiva, and ensure pa- initial clinical evaluation, the patient was in- tient comfort and treatment acceptance.37,38 formed of the need for a diagnostic wax- A customized, anatomical, screw-retained up to evaluate the tentative position and provisional restoration was selected to contours of the restoration as well as for manage the emergence profi le. The shape a CBCT evaluation to evaluate the residual of the provisional restoration is key to bone in the edentulous site. She approved achieving good esthetics. The plan was to the treatment plan. fabricate the fi nal crown out of lithium disil- Diagnostic casts were made and a diag- icate, which provides excellent strength and nostic wax-up (GEO Classic; Renfert) was toughness compared with other materials.39 fabricated to take the patient’s wishes into At the surgical appointment, local anes- account and provide her with a harmonious thesia was applied by infi ltration with 1.8 ml smile. After presenting the patient with the of 4% articaine hydrochloride with epineph- diagnostic wax-up, a diagnostic mock-up rine 1:100,000 (Septocaine), and infraorbital was performed with temporary bis-acrylic blocks of 3.6 ml of 0.5% bupivacaine hydro- material (Structur Premium; Voco). She was chloride with 1:100,000 epinephrine (Mar- pleased with the initial result and consented caine). A papilla-sparing fl ap was designed to the treatment. and elevated,40 with the aim of exposing the After the CBCT evaluation and treat- area of the edentulous site and preventing ment plan discussion between the patient, gingival recession in the adjacent teeth. An periodontist, and restorative dentist, it was implant (Neobiotech) of 4 × 13 mm was

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Fig 3a and b Implant placement.

Fig 4 Provisional restoration fabrication.

Fig 5 Immediate implant provisional restoration.

then placed at site 11 following the manu- A titanium custom abutment was de- facturer’s specifications (Fig 3). The pa- signed and fabricated on implant 11, and tient presented a thick periodontal pheno- a conservative veneer restoration was pro- type.41,42 Suturing was performed with 5-0 vided for tooth 21 (Fig 8). A final crown of chromic gut sutures (PolySyn FA; Surgical lithium disilicate fused to a zirconia core Specialties), and a coronally repositioned for implant 11 and a pressed lithium disil- vertical mattress suture was used to achieve icate veneer for tooth 21 were fabricated primary soft tissue closure. An immediate (Fig 9). Periodic radiographs were taken af- provisional restoration (Fig 4) in self-curing ter the impression (Fig 10a), the abutment acrylic resin (Jet Tooth Shade; Lang Dental) placement (Fig 10b), and the final crown was then placed. The provisional restoration placement (Fig 10c). The crown was ce- contoured the soft tissue until it had a simi- mented using a resin-modified glass-ion- lar appearance to the adjacent teeth (Figs 5 omer cement (RelyX Luting Plus Cement; and 6). This provisional stage requires mod- 3M ESPE), and the lithium disilicate res- ification of the prosthesis until the peri-im- toration was bonded with a resin cement plant soft tissue mimics the soft tissue of the (Panavia V5; Kuraray Noritake Dental) fol- adjacent teeth. A final impression was made lowing the protocols recommended by with a closed tray technique, and a titanium the manufacturers (Figs 11 and 12). The custom abutment was planned (Fig 7) for patient was provided with a night guard placement after approximately 6 months. to protect her dentition and restorations. Postoperative instructions were given to the A CBCT was taken at the 2-year follow-up patient, along with a prescription for chlor- (Fig 13). The patient was still satisfied with hexidine gluconate twice a day, and ibupro- the restoration at the 3-year follow-up fen (600 mg) three times a day for 1 week. (Fig 14).

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Fig 6 Soft tissue contouring with the provisional restoration. Fig 7 Closed tray impression.

Fig 8 Custom abutment and veneer preparation. Fig 9 Fabrication of the ﬁnal restorations.

Fig 10 Radiographs following the impression (a), abutment placement (b), and ﬁnal crown abc placement (c).

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Fig 11a and b Final restorations.

Fig 12 Patient’s smile at the end of the treatment.

Discussion planning.43,44 The patient’s pretreatment implant evaluation included a consultation Esthetic risk assessment needs to be per- to establish a solid diagnosis and progno- formed prior to starting treatment. Achiev- sis. Her restorative and periodontal needs ing a long-term esthetic outcome de- were considered, together with her esthet- pends on a restorative-driven approach, ic expectations. Diagnostic casts, radio- and starts with comprehensive presurgical graphs, and CBCT are needed to enhance

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Fig 13a to c CBCT a c scans at 2-year follow-up.

Fig 14 Three-year follow-up.

presurgical planning and preparation.45,46 The diagnostic wax-up provided impor- Another factor that should be considered is tant information concerning the tentative po- to inform patients that alveolar growth can sition of the future implant and the contours occur and might require intervention later of the ceramic veneer. Three-dimensional on in life.47 In this case, the 3-year follow-up planning for implant therapy is key to evalu- showed a very stable outcome and contin- ate the amount of alveolar ridge that is avail- ued patient satisfaction. able for implant placement. The outcome

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of this evaluation might dictate the need cause recession to occur on the adjacent for hard and soft tissue grafting procedures. teeth. This 3D evaluation also allows the clinician The choice of cemented or screw-re- to consider different brands and implant tained restorations is controversial. Both dia meters. The diagnostic wax-up can also types of single implant crowns have their be used to fabricate tooth reduction guides advantages and disadvantages.55 Cemented for veneer preparation. Ridge preservation restorations are thought to be more esthet- or socket conversion procedures are crucial ic due to the lack of a visible screw access.56 at the time of tooth extraction to minimize The implant trajectory will only determine the natural resorption that occurs in the the type of retention method, either ce- presence of a thin buccal plate.48 In general, mented or screw-retained; however, both narrow-diameter implants provide the de- can achieve the same esthetic results. The sired buccal bone thickness of 2 to 3 mm. implant trajectory in this case followed the On the other hand, wider-diameter implants incisal edge. This was the main reason for can lead to marginal gingival recession.49,50 the decision to fabricate cement-retained Less bone loss occurs around bone-level restorations.57 Despite the use of a custom implants placed in naturally thick mucosal or stock abutment, the absence of residual tissue compared with thin phenotypes.51 excess cement cannot be guaranteed.58 For this patient, a 4-mm–diameter implant There is no universal agreement about the was used after measuring the mesiodistal type of luting cement to use for cement-re- space available at the edentulous site and tained implant restorations. Usually cements the alveolar ridge thickness using the CBCT. are chosen arbitrarily, and clinicians tend to It has been reported that a flapless implant select familiar techniques used for natural placement approach minimizes the possi- teeth.59 Studies demonstrate that excess res- bility of peri-implant tissue loss postoper- in cement is very difficult to remove and pro- atively and hence reduces the challenges motes substantially higher bacterial biofilm of soft tissue management after implant growth compared with other cements such placement in patients with sufficient kerati- as glass-ionomer or zinc phosphate.60 In this nized gingival tissue.52 Other benefits of the case, a resin cement was used, and the ce- flapless approach are that it saves surgery mentation procedure was performed using time, promotes postsurgical healing, and an extraoral pre-extrusion step before ce- is generally more comfortable for the pa- mentation. The excess cement was removed tient.53 The disadvantage of this approach is extraorally from the crown using a copy the limited view of the surgical site; the un- abutment and then cemented intraorally. derlying bone cannot be observed, which A titanium custom abutment was used in might cause unwanted perforation that can this case due to cost considerations. Despite lead to adverse biologic and esthetic com- titanium being a gold standard abutment plications.54 The limited clinical view could material, it has demonstrated more bleed- also cause thermal trauma to the underlying on probing compared with zirconia. ing bone due to the lack of external irriga- Moreover, zirconia has similar blood flow tion, so that it does not reach the full depth to natural teeth, which might suggest that of the osteotomy during site preservation. it is also a suitable abutment material.61,62 The present implant therapy was performed Furthermore, in vitro evidence suggests that with a papilla-sparing flap design. This is gingival fibroblasts, which are key to the very conservative because the flap is only creation of an epithelial layer during reepi- released on the implant site, which does not thelization to ensure implant survival and

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favorable esthetics, are not negatively influ- Conclusion enced by titanium abutment materials.63-65 In recent years, dental implant therapies For many reasons, the combination of im- have become a predictable treatment for plant placement and a veneer restoration single-tooth replacement, but mindful treat- in the esthetic zone might be challenging ment planning is fundamental to meet the for the dentist. Significant knowledge of im- esthetic challenges of the anterior esthetic plant planning and placement, flap design, zone. The role of the provisional prosthesis suturing techniques, provisional restoration is critical to form a ‘scallop’ with the soft tis- soft tissue contouring, and ideal material sue in order to make it similar to the gingival selection for the final restorations is fun- margin of the natural tooth.66 Contour man- damental to achieve good esthetic results. agement of provisional restorations and sur- Conservative tooth preparation to maintain rounding soft tissue is equally important, as the enamel structure is crucial for the long- has recently been noted.67 The high esthet- term success of bonded ceramic veneers. ic demand for partial edentulous areas and The material chosen for these types of res- facial defects in adjacent teeth can be met torations needs to withstand the occlusal by the clinician through careful attention. demands as well as satisfy the patient from The simultaneous fabrication of the veneer an esthetic point of view. The presented and implant restoration allowed the dental case report successfully combined a lithium technician the opportunity to match identi- disilicate fused to zirconia restoration for cal shapes and shades in order to create a the implant on site 11, and a lithium disilicate more natural-looking result. veneer for tooth 21.

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