Vol. 2, No. 1, 2006 Advanced Esthetics & Interdisciplinary Dentistry 17

Comprehensive ReconstructionUsing Sequential Extraction andImplant Placement

Greggory A. Kinzer, DDS, MSDAffiliate Assistant Professor

University of Washington Schoolof Dentistry

Seattle, Washington

Private Practice,Seattle, Washington

Abstract: Several restorative options are available for managing the debilitated dentition when multi-ple teeth will need to be extracted. Generally, the teeth can be replaced using a removable prosthesis orsome type of fixed restoration. The fixed restoration can either be supported by the remaining teeth,if the number and location of the remaining teeth are amendable, or by the use of osseointegratedimplants. For patients who do not want a removable appliance as the final restoration, implants arethe treatment of choice.

Figures 1A, 1B, and 1C—Initial presentation reveals an extensively restored dentition with generalized moderate-severe caries at the crown margins.Generalized moderate gingival inflammation was present with probing depths ranging from 5-9 mm.

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Traditionally, if an implant-supportedrestoration was desired, the required

extractions were made and the patientwas transitioned to the final restorationby the placement of an immediate fullor partial denture. If immediate implantplacement did not occur, the implantswere placed after an initial healingperiod. The implants were then allowedto remain undisturbed for a period of4 months in the mandible and 6months in the maxilla to allow forosseointegration.1-3

To bypass the need for a transitionalremovable appliance, studies have beenconducted to assess the osseointegrationof immediately loaded implants.4-7

Although immediate loading protocolswere first applied to the restoration ofthe edentulous mandible, it has also beenshown to be effective in the restorationof the edentulous maxilla.8-11 Whenimmediate implant loading is associatedwith fully edentulous arches, implantsplinting that achieves cross-arch stabi-lization is needed to control the trans-verse forces and limit micro-movement

at the implant-bone interface. The pre-dictability of the protocol drops if pri-mary stabilization of the implants is notachieved. The main benefits of immedi-ate implant loading in the full arch arethat it can bypass the need for aninterim removable appliance and it canhelp support and maintain the positionof the soft tissues in the esthetic zone.However, this technique can be extremelydifficult in situations where significanthard/soft tissue augmentation is required.

As an alternative to the above-men-tioned protocols, there is one othertechnique that alleviates the need of atransitional removable appliance, main-tains and supports the soft tissue, allowsaugmentation where needed, and elimi-nates problems with osseointegrationowing to early occlusal loading. Thisapproach involves the selective extrac-tion of some teeth followed by immedi-ate implant placement. The remainingteeth are temporarily maintained tosupport a fixed provisional while thefirst set of implants is integrating. Onceosseointegration of the implants is

achieved, abutments can be placed onthe implants and the provisional relinedso that it is the implants that supportthe provisional. This will then allow theremaining teeth to be extracted and thesecond set of immediate implants tobe placed. Following integration, thesecond set of implants can be used tosupport the provisional before definitiverestoration with an implant-supportedprosthesis. Although there are manyadvantages to this protocol, the maindisadvantage is the extended treatmenttime that is required with two separatestages of implant placement.

This case will demonstrate the treat-ment sequencing that is necessary forsequential extraction and implant place-ment in a debilitated dentition. In addi-tion it will describe a technique that canbe used to transfer the emergence profileof the provisional and the resultantposition of the soft tissues around theimplants to the technician for fabrica-tion of the definitive restoration.

Case ReportA 66-year-old man presented with

extensive restorations in the entiremaxillary and mandibular posteriorarch, which had been in place approx-imately 30 years (Figures 1A through1C). Clinical and radiographic exami-nation revealed generalized moderate-severe recurrent caries at the existingcrown margins as well as around areasthat had been secondarily patched. Inaddition, generalized moderate-severebone loss was diagnosed in the maxil-lary and mandibular posterior. The onlyteeth not previously restored were themandibular anteriors. Aside from thepresence of moderate incisal attrition,no caries or bone loss was present onthese teeth.

Given the severity of the caries andthe localized advanced bone loss, thetreatment plan was to extract all of themaxillary teeth, with the exception ofteeth Nos. 9 and 10, as well as theremaining mandibular molars. Sincethe patient requested not to have anytype of removable appliance, implantswere used to replace the missing teeth.Sequential extraction and implant place-ment were planned to allow a sinus liftin the area of of tooth No. 3; augment(ridge-split) in the areas of teeth Nos.

5-6 and 11-12; preserve the soft tissuearchitecture in the area of teeth Nos.6-7; and forgo the use of an interimpartial denture. After the mounting ofstudy models and subsequent diagnos-tic waxing to incorporate the desiredesthetic and functional changes, all ofthe existing restorations on the maxil-lary arch were removed (Figure 2Aand Figure 2B).

First Treatment StageTo leave as many strategic abut-

ments as possible and maximize theedentulous spaces already present, itwas decided that teeth Nos. 8, 13, and14 would be extracted during the firststage of treatment and implants placed

Figure 2A—The extent of the caries can bevisualized upon removal of the existing restora-tions. Teeth Nos. 9 and 10 are the only teeth onthe maxillary arch that will not require extraction.

Figure 2B—To maximize the number and dis-bursement of the abutment teeth and utilizethe existing edentulous areas, only teeth Nos.8, 13 and 14 were to be extracted in the firstphase of treatment. Note that No. 7 was tem-porarily built up to help support the provisional.

Figure 5—When the second phase of implantswere integrated, temporary abutments wereplaced and the existing maxillary provisionalrelined. At the same appointment the lowerarch was also prepared and provisionalized.

Figure 3—The first stage of treatment includeda ridge split in the Nos 5-6 and 11-12 areas aswell as placement of implants in the Nos. 5, 6,8, 11, and 13 sites. Following implant place-ment, the provisional, solely supported by theremaining abutment teeth, was recemented.

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Figure 4—After 6 months of integration, tem-porary abutments were attached to theimplants. The provisional was then relined toallow the implants to support the occlusal load.

Figures 6A and 6B—To fabricate customizedimpression copings to transfer more accuratelythe soft tissue profile, the provisionals andtemporary abutments are removed from themouth. After attaching fixture replicas to theabutments, the provisionals are mounted infast set mounting stone.

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Figures 7A and 7B—A fast-setting siliconeis injected around the provisional restorationincluding the ovate pontic. The silicone willcapture the external contours in the gingivalthird of the provisional.

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18 Advanced Esthetics & Interdisciplinary Dentistry Vol. 2, No. 1, 2006

in the Nos. 5, 6, 8, 11, and 13 sites.Caries control was performed on theabutment teeth that would be main-tained, and a one-piece splinted provi-sional restoration (Protemp™ 3Garant™, 3M ESPE, St Paul, Min-nesota) was fabricated and temporarilycemented (TempBond®, Kerr Corpo-ration, Orange, California). The fol-lowing day the patient was seen by thesurgeon to extract teeth Nos. 8, 13,and 14, increase the width of the ridgein the Nos. 5-6, 11-12 areas with aridge split, and place implants in theNos. 5, 6, 8, 11, and 13 sites. In addi-tion, a sinus lift was completed in thearea of Nos. 3-4. At the completion ofthe surgical treatment, the provisionalwas recemented with long-term tem-porary cement (Fynal®, DentsplyCaulk, Milford, Delaware) (Figure 3).

Second Treatment StageAfter 6 months of integration, the

second stage of extraction and implant

placement was initiated. The provi-sional restoration was removed andabutments were placed on the implants(Figure 4). The provisional was thenrelined over the implant abutments totransfer the load from the remainingabutment teeth to the implants them-selves. The patient was then seen bythe surgeon to extract teeth Nos. 4, 7,and 12 and place implants in the Nos.3, 4, 12, and 14 sites. The secondmolars were to remain in place to helpsupport the provisional until the sec-ond phase of implants were ready tobe loaded, at which point they were tobe extracted. Abutments were placedon the second phase of implants after6 months and the provisionals relined.At this point, specific attention wasgiven to the subgingival contours ofthe provisional to support the softtissues. In addition to finalizing theprovisionals on the maxillary arch, thelower arch was also prepared and pro-visionalized (Figure 5).

Final Impressions After verifying the esthetics and

occlusion of the provisionals, the finalimpressions were taken. The purposeof the final impression is not only totransfer the position of the implant fix-tures and the prepared teeth to thetechnician but also to transfer accu-rately the position of the soft tissuearchitecture and the ovate ponticreceptor site in the area of No. 7. Theposition of the soft tissue architecturehad been created by the subgingivalemergence profile of the provisionalrestorations. Customized impressioncopings were fabricated to ensure collec-tion of all the necessary information.

To fabricate the customized impres-sion copings, the provisional restora-tion and temporary abutments are firstremoved from the mouth. The tempo-rary abutments are attached to fixturereplicas and mounted in fast setmounting stone (Figure 6A and Figure6B). A fast-setting silicone (Mach-2®,Parkell Inc, Edgewood, New York) isthen injected around the provisionalrestoration to capture the externalcontours of the gingival third of theprovisional (Figure 7A and Figure 7B).Once the material has set, the provi-sional and temporary abutments are

removed and “open tray” impressioncopings can be attached to the fixturereplicas (Figure 8A and Figure 8B). Alight-cured composite is then flowedaround the impression copings andinto the ovate pontic site and cured(Figure 9). The impression copingscan then be attached in the mouth.Since the subgingival contour of thecustomized impression coping exactlymatches the contour of the provisionalrestoration, the soft tissues are sup-ported throughout the entire impres-sion-making process (Figure 10A andFigure 10B).

The remaining abutment teeth andimpression copings were picked up inthe final impression (Aquasil Ultra,Dentsply Caulk, Milford, Delaware)(Figure 11). The customized impres-sion copings were only fabricated forthe anterior implants given the differ-ence in depth of the anterior implantscompared with the posterior implants

20 Advanced Esthetics & Interdisciplinary Dentistry Vol. 2, No. 1, 2006

Figures 8A and 8B—When the silicone hasset, the provisionals are removed revealing theexact contour of the provisional that is sup-porting the soft tissues in the mouth. To usethese contours, pick-up impression copings areattached to the implant analogs.

Figure 9—When the impression copings are inplace, light-cured composite resin or auto-cured acrylic resin can be flowed into the spacebetween the impression copings and the sili-cone. The composite is also carried into theovate pontic site and left attached to the mate-rial around the implant for support.

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Figures 10A and 10B—With the customizedimpression copings seated in the mouth, opti-mum support of the soft tissues is achieved andmaintained throughout the impression-makingprocess. Given the flat gingival architecture andthe shallower implant placement, conventionalimpression copings are used in the posterior.

Figure 11—When the impression is removedfrom the mouth, the subgingival portion of thecustomized impression copings can be seen. Asoft tissue replicating material and die stone canbe placed directly against these surfaces totransfer the contours of the soft tissue to themaster model.

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as well as the difference in gingivalarchitecture in the front of the mouthcompared with the back. Before pour-ing the master cast, soft tissue replica-tion material (Gingitech™, IvoclarVivadent Inc, Amherst, New York)was used to represent the gingival tis-sues. The direct benefit of using thecustomized impression copings is thatthe technician can then fabricate theimplant abutments and final restora-tions without having to adjust the tis-sue on the master model (Figure 12).The restorations will support the tis-sues just like the provisionals in themouth as long as they are designed tointimately contact the contours of thesoft tissue as captured by the cus-tomized impression copings. The finalrestorations consisted of customizedzirconia implant abutments and all-ceramic crowns and bridges (Lava™, 3MESPE, St Paul, Minnesota) (Figure 13).

Final RestorationsUpon removal of the provisional

restorations, the zirconia implant abut-ments were seated in the mouth. Thefit of the abutments was verified clini-cally and radiographically. Once veri-fied, the abutments were torqued to35 Ncm. The final restorations wereseated on the abutments and the estheticsand occlusion evaluated and adjusted

as needed. A mutually protected occlu-sion was designed. The final restora-tions were cemented, making sure toremove all remnants of subgingivalcement (Figures 14A through Figure14C). A temporary cement (Temp-Bond® Clear, Kerr Corporation,Orange, California) was chosen toallow removal of the restorations if anabutment screw were to come loosesometime in the future.

ConclusionSequencing the extraction of teeth

and placement of implants can be verybeneficial. In addition to easing thetransition to a fully implant-supportedrestoration without the need for aremovable appliance, it does so withoutthe increased risk of prematurely over-loading the fixtures before osseo-integration. In addition, it can also allowfor augmentation in areas that requireimplant site development. With regardto esthetics, using a fixed provisionalrestoration throughout the course oftreatment allows continual support ofthe soft tissue architecture. Being ableto maintain the soft tissue scallop andtransfer the information to the techni-cian helps alleviate many potential prob-lems and can increase the predictabilityof the final restorative result.

AcknowledgmentThe author would like to thank

Bobby L. Butler, DDS, for the surgicalplacement of the implants depictedherein.

References1. Branemark P-I, Hansson BO, Adell R, et al.

Osseointegrated implants in the treatmentof the edentulous jaw. Experiences from a10-year period. Scand J Plast Reconstr SurgSuppl. 1977;16:1-132.

2. Albrektsson T, Zarb G, Worthington P, Eriks-son AR. The long-term efficacy of currentlyused dental implants: A review and pro-posed criteria for success. Int J Oral Maxillo-fac Impl. 1986;1(1):11-25.

3. Garber DA, Salama MA, Salama H. Immedi-ate total tooth replacement. Compend Con-tin Educ Dent. 2001;22(3):210-216.

4. Sagara M, Akagawa Y, Nikai H, Tsuru H. Theeffects of early occlusal loading on one-stagetitanium alloy implants in beagle dogs:A pilot study. J Prosthet Dent. 1993;69(3):281-288.

5. Piattelli A, Corigliano M, Scarano A, et al.Immediate loading of titanium plasma-sprayed implants: An histologic analsis inmonkeys. J Periodontol. 1998;69(3):321-327.

6. Balshi TJ, Wolfinger GJ. Immediate loadingof Branemark implants in edentulousmandibles: A preliminary report. ImplantDent. 1997;6(2):83-88.

7. Cooper LF, Rahman A, Moriarty J, et al.Immediate mandibular rehabilitation withendosseous implants: Simultaneous extrac-tion, implant placement and loading. IntJ Oral Maxillofac Implants. 2002;17(4):517-525.

8. Tarnow DP, Emtiaz S, Classi A. Immediateloading of threaded implants at stage 1 sur-gery in edentulous arches. Ten consecutivecase reports with 1- to 5-year data. Int J OralMaxillofac Implants. 1997;12(3):319-324.

9. Bocklage R. Rehabilitation of the edentulousmaxilla and mandible with fixed implant-supported restorations applying immediatefunctional loading: A treatment concept.Implant Dent. 2002;11(2):154-158.

10. Olsson M, Urde G, Andersen JB, Sennerby L.Early loading of maxillary fixed cross-archdental prostheses supported by six or eightoxidized titanium implants: Results after1 year of loading. Clin Implant Dent RelatRes. 2003;5 Suppl 1:81-87.

11. Balshi TJ, Wolfinger GJ. Immediate loadingof dental implants in edentulous maxilla:Case study of a unique protocol. Int J Perio-dontics Restorative Dent. 2003;23(1):37-45.

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Figure 12—The master model shows the pre-pared teeth as well as customized zirconia abut-ments that have been fabricated to support acement retained implant restoration. Note thecontours of the soft tissues in the implant andovate pontic site that was transferred by thecustomized impression copings.

Figure 13—The final restorations consisted ofcustomized zirconia abutments with Lava™ all-ceramic restorations. Other than two three-unitbridges, all restorations were kept as singleunits.

Figures 14A, 14B, and 14C—The final case as seen at a post-insertion follow-up. The esthetic, functional, and structural goals set forth in the treatmentplan have been attained.

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