Implant RealitiesAchieving success in implant dentistry

issue I • 2002

3

Planning for Esthetics Part 1: Single Tooth Implant RestorationsWill Martin, Dean Morton, Jim RuskinThe University of Florida, Center for Implant Dentistry

Feature Articles

6Early Loading with the ITI SLA Surface as a Predictable, Routine ProcedureJeffrey Ganeles, DMD, FACD

8The Immediate Load Full Maxilla Utilizing synOcta®: From Teeth to Fixed Implant Supported BridgeRobert A. Jaffin, DMD, Jorge Barrios, DDS, Akshay Kumar, DMD

16Clinical Procedures for the Conversion of a Denture to Implant Retained Utilizing the ITI Anchor Abutment and Gold MatrixTerry Charters

18Transforming Treatment with Guided Bone Regeneration Part 1:Managing the Soft TissuePaul A. Fugazzotto, DDS

12

Practical Implant Pearls: Provisional Crown Fabrication for Solid AbutmentsScott Keith, DDS, MS

14

Emergence Profile and Implant DepthsBobby Butler, DDS

In Every IssueEditor’s Note 1

Practice Growth Considerations 2

Feature Articles 3

Literature Review 21

Upcoming Events 22

Senior Editor: Paul A. Fugazzotto, DDSPlease feel free to contact me with any questions, comments or submission at progressiveperio@aol.com.

Surgical Editor: Jay Beagle, DDS, MSWhile the basic protocols for insertion of osseo integrating implants are well established, the field is now character-ized by many exciting and innovative modifications of proven techniques. We will explore newer therapies, offerappropriate and helpful clinical “pearls” and remain on the cutting edge.

Please contact me with any questions or submissions at jbeagledds@aol.com.

Restorative Editor: Frank Higginbottom, DDSThe restorative portion of this publication will address common problems, concerns and interests of users of the ITI®

DENTAL IMPLANT SYSTEM. Both conventional and complex issues will be addressed. This section of the publicationis hosted by the North American ITI members and other serious implant users, and will serve as a venue for interest-ing case presentations, as well as a sounding board for questions and answers to actual clinical quandaries.

Please feel free to contact us with any concerns you may have at any time. In addition, if you feel you have valuableinformation to submit for consideration for publication, please e-mail me at bottom@dallasesthetics.com or phone meat 247/827-1150.

Editorial Board: David Cochran, DDS, PHDJeffrey Ganeles, DMD, FACDRobert A. Jaffin, DMDH.P. Weber, DMDTom Wilson, DDS

The opinions expressed in articles signed by the authors are not necessarily those of the publisheror the editors.

Welcome to Implant Realities

The goal of this publication is to address the concerns and challenges faced

in clinical practice. Its contents are provided by experts from all areas of

implant dentistry and reviewed by an editorial board comprised of practicing

clinicians.

Implant Realities will explore all phases of implant dentistry, from treatment

planning of simple and complex cases, through proven augmentation and

implant insertion therapies, to predictable restorative options. Advances in

implant design, surgical innovations and restorative techniques will be

discussed in depth. Laboratory considerations and innovations critical to the

delivery of predictable ideal therapy will play an integral part in our content.

Finally, the review of the pertinent dental literature, and highlighting of

upcoming courses, will serve to ensure a flow of updated information that is

applicable to clinical practice.

We welcome contributions and

comments from all clinicians,

scientists and laboratory

technicians.

Sincerely,

Paul A. Fugazzotto, DDS

Senior Editor, Implant Realities

Implant Realities 2

Practice GrowthC o n s i d e r a t i o n s

Twenty thousand years ago,fifteen thousand distinctlanguages were spoken onearth. Today, humans speaksix thousand separate lan-guages, 28% of which arespoken by fewer than 1,000people. Twenty four hun-dred of the remaining lan-guages are consideredendangered. Only five peo-ple are fluent in Osaga, aNorth American Indian lan-guage.

A parallel may be drawn tomodern dentistry. Asimplant therapy has becomemore predictable and adapt-able to a variety of clinicalsituations, we have begun tolose the language of surgi-cal treatment modalitiessuch as comprehensive fur-cation therapy, includingroot resection. The impactof implant therapy has beenfelt in the restorative fieldas well, as the use ofMaryland bridge appliancesdwindles, and single toothreplacement is rightfullymore often carried outthrough the use of animplant and crown asopposed to a three unitfixed bridge. Dental spe-cialties themselves haverecently been challenged, asone implant company hasbegun to tout implants as“an alternative to root canaltherapy.”

While all conscientiousclinicians would agree thatclinical advances in implantand regenerative therapieshave forever altered thedental landscape, noresponsible therapist would

contend that such treatmentis the ideal choice in allclinical situations.

Unfortunately, an argumentcould also be made that theone true language of thedental community is beingattenuated and evenreplaced by a number ofindividual languages.

Discussions focusing uponmaterial costs; ease of exe-cution; exciting, sexiertechniques; and the numberof various therapies per-formed dominate the land-scape at many professionalmeetings. Products are tout-ed because they are “cheap-er and just as good.” Newertherapies are promoted atthe expense of proven, pre-dictable treatment modali-ties in all situations.Clinicians enumerate howmany implants, “sinus lifts”or crowns they have per-formed in the last year.Courses promise to providea blueprint for increasedpractice growth and patientacceptance of complexcases for greater “profitabil-ity.”

These discussions obscure abasic fact. The true lan-guage of dentistry isgrounded in how best tocare for an individualpatient and meet his or herneeds and desires. A patientmissing a maxillary centralincisor does not ‘want animplant.’ This patientdesires a fixed toothreplacement. It is our dutyto determine by whichmeans this desire is best

met for this individualpatient.

The number of implants Iplace is meaningless. Thenumber of patients whoseproblems I help to solvewith my co-therapists, inthe most ideal manner foreach specific patient, ishighly meaningful.

There is no doubt that giventwo treatment materials ormodalities of equal pre-dictability in a given situa-tion, I will choose toemploy the easiest of thetwo methods. However,such ease of execution cannever replace predictability,regardless of the “slight”difference in success rate. IfI am presented with twotreatment options or materi-als of equal predictabilityand equal ease of use, I willnaturally choose the lessexpensive approach andmaterial. Once again, thisdecision can never be madeat the expense of pre-dictability for a givenpatient.

The solution to practicegrowth, patient volume andincome concerns lies inremaining true to the onedental language. Patientscome to us expecting to betreated kindly, professional-ly and appropriately.Patients seek a maximiza-tion of comfort, functionand esthetics, regardless ofthe means utilized to reachthese goals. Dentists workwith each other if they areable to foster a relationshipof trust and reliability.

If you are a periodontist ororal surgeon, and you wishto increase patient referrals,make it clear to potentialreferring dentists that thepatient’s welfare is alwaysuppermost in your mind;that treatment decisions arenever made based uponpotential income; and thatthe referring dentist mayalways depend on you forhonest, trustworthy answersand support.

If you are a restorative den-tist seeking to increasepatient flow, patient caseacceptance and patientreferral from other patientsand dental specialists, thesame rules apply. If patientstruly believe you alwayshave their welfare as yourutmost concern, and thatyou will always treat themfairly, your practice willgrow beyond imaginablelimits and patient accept-ance of complex cases willbecome the rule rather thanthe exception.

In subsequent columns vari-ous authors will describemeans by which to ensureappropriate long-term prac-tice growth, and to facilitatethe running of a busy prac-tice. However, none ofthese suggestions orapproaches we will offerare useful unless spoken inthe context of the true den-tal language.

- Paul A. Fugazzotto, DDS

issue I • 2002 3

Part 1: Single Tooth Implant RestorationsPlanning for Esthetics

Osseointegrated dentalimplants have proven suc-cessful when supportingrestorations treating allforms of edentulism. Withthis in mind, it remains dif-ficult to clearly defineparameters that lead to thesuccessful planning andexecution of treatment inthe esthetic zone. In mostinstances this difficulty iscaused by a continuingnotion that patients seekimplants – when in realitythey seek replacements formissing teeth. While suc-cessful osseointegrationremains a key to success,viewing the implant as acomponent of the prosthesis

both hard and soft tissues.The purpose is to determinethe necessity for tissue aug-mentation, the goal ofwhich is ideal placement ofan implant capable of sup-porting and retaining anesthetic and functionalrestoration.

Hard tissue evaluationshould include a two-dimensional radiographicevaluation of bone heightand mesio-distal width.Radiographs should includean evaluation of the heightof the bone crests on teethadjacent to edentulousspans (Fig. 2-a,b). Ingeneral, all treatmentshould be planned to pre-serve the vertical height ofthese crests because of theirintimate relationship to thepresence of gingival papil-lae. Clinical evaluation ofhard tissues should alsodetermine the facial-palataldimension of the bone site,and relate this to the pro-posed restoration (Fig. 3-a,b). It should be noted thatresidual ridge anatomy isunreliable as an indicator ofbone dimension, and clini-cal procedures (e.g. sound-ing) should be employed toaccurately map the osseouscontour. The volume ofbone must enable restora-tion-driven implant place-ment into a site conducive

sity for detailed evaluationof the patient and appropri-ate planning for each indi-vidual site.

Diagnosis and treatmentplanning for the proposedimplant site is multifactori-al. The definitive restorationplanned for the spaceshould be the driving forcein both data collection andsite evaluation (Fig. 1). Thisinformation can be readilytransferred between teammembers with appropriatetemplate fabrication, (theprocess of which will bedetailed in a subsequentarticle). Restoration-specificsite evaluation will include

rather than pre-prostheticsurgery will improve diag-nostic and data collectionprocedures with consequentimprovements in the esthet-ic outcome.

Clearly, improvements inclinical technique (includ-ing single-stage implantplacement and acceleratedloading protocols) in con-junction with implant devel-opment (ESTHETIC PLUSimplant line, SLA surface,and immediate loadimplants) have improvedthe esthetic predictability ofimplant-based restorations.These advances do not,however, reduce the neces-

Fig. 1 Pre-operative planning: diagnostic wax-up

Implant Realities 4

to predictable healing andvolume maintenance. Ofparticular importance is thedimension of bone on thefacial aspect of the implantwith every effort made tomaintain a minimum of1mm horizontal width inthis area. This can assist inpreventing resorption ofbone and subsequent loss ofsoft tissues.

The soft tissue evaluationshould also be related to theplanned restoration. Becausewe are able to placeimplants with predictable

gence of at least 1mm whilemaintaining a total biologicwidth dimension of 3mm. Assessment of proposedimplant sites requires care-ful attention to adjacentstructures, particularlyteeth. The horizontal dis-tance between implants andteeth (Fig. 5-a,b) shouldapproximate 1.5mm. Thisdimension will help preventsignificant resorption of thebone crests during healing.In addition, adequate sup-port for the gingival tissuescan be developed throughemergence profile provi-sional restorations aiding inthe maturation of gingivalpapillae.

Lastly, to further enhancethe development of gingivalpapillae, the plannedrestoration should be relat-ed to the anatomy of eachindividual site. Every effortshould be made to plan forimplant placement whichallows for the contact pointsbetween the teeth to beplaced within 5-6 mm ofthe bone crests (Fig. 5-c,d).

In summary, the implantsite should allow for posi-tioning of the implantrestorative margin 1-2mm

sulcular epithelium, is at itsminimum in this region andplanning should assumeminimal margin for error.The planned restoration andimplant choice shouldtherefore be mindful of thisdimension (approximately 3mm) and capable of pre-serving it in the long term.

Bone responds readily tothe position of micro-gapsbetween components andthe position of junctionsbetween rough and smoothimplant surfaces. Micro-gapposition is a dominant fac-tor associated with boneheight subsequent toimplant restoration. Bone is unable to predictablyremain with approximately2mm of any gaps. Becausethe micro-gap between the restoration and anESTHETIC PLUS implantis maintained at 1.8mm, thebone height remains pre-dictable in the long-term.Choice of an ESTHETICPLUS implant will alsoplace the junction of thepolished collar and SLAsurface 1.8mm from themicro-gap. Additionally,Esthetic Plus implants allowfor the planning of a sub-gingival restoration emer-

survival and fabricateesthetic crowns routinelywith modern ceramic mate-rials, the true esthetic suc-cess of restorations is oftenrelated to the gingival con-tours - particularly the pres-ence of papillae. Soft tissueevaluation begins with theproposed gingival zenith forthe planned restoration (Fig.4-a,b). The zenith for indi-vidual teeth may be definedfor simplicity as the mostapical visible point of tooth,and will vary in horizontaland vertical positiondependent on the specificsite being restored.

Once established, the posi-tion of gingival zenith willpermit the comprehensiveassessment of soft tissues.The thickness and morphol-ogy of the gingival tissuesis critical as conventionalimplant shape brings therestorative margin of theimplant closest to the freegingival margin in theregion of the zenith. Thebiologic width (being thedistance from the free gin-gival margin to the bone),being comprised of connec-tive tissue, junctional and

Fig. 2 Pre-operative planning:radiographic assessment

Fig. 3 Pre-operative planning: horizontal width and proposed emer-gence

Fig. 4 Pre-operative planning: gingival zenith and papilla

issue I • 2002 5

apical to the proposed posi-tion of the gingival zenith,while preserving distancesfrom adjacent tooth struc-tures and proposed contactpoints. Because the restora-tive margin for theESTHETIC PLUS implantrepresents a micro-gap,bone will reposition a fur-ther 2mm apical to thisjunction. For improved pre-dictability the implantshould also place the junc-tion between rough and

Citations

Buser et al. Influence of surface characteristics on bone formation around titanium implants. A histomorphometric study in minia-ture pigs. J Biomed Mater Res 1991a; 25: 889-902

Buser et al. Soft tissue reactions to non-submerged unloaded titanium implants in beagle dogs. J Periodontol 1992a; 63: 226-236

Buser et al. Long-term evaluation of non-submerged ITI implants. Clin Oral Implant Res 1997; 8: 161-172

Cochran DL et al. Biologic width around titanium implants. A histometric analysis of the implant to-gingival junction aroundunloaded and loaded non-submerged implants in the canine mandible. J Periodontol 1997; 68: 186-198

Cochran DL. A comparison of endosseous dental implant surfaces. J Periodontol 1999; 70: 1523-1539

Hermann JS et al. Crestal bone changes around titanium implants. A radiographic evaluation of unloaded non-submerged andsubmerged implants in the canine mandible. J Periodontol 1997; 68: 1117-1130

Higginbottom F., Wilson T. Three-Dimensional Templates for Placement of Root-Form Dental Implants: A Technical Note JOMIVol.11 No.6 1996

Tarnow DP. Inter-proximal contact points and evidence of black spaces. J Perio 1992

Fig. 5 Planning implant placement

Fig. 6 Final restoration (six months) Fig. 7 Periapical radiograph(six months)

smooth surfaces 2mm fromthe gap, as is the case withthe ESTHETIC PLUSimplant. This implant posi-tion must be accuratelydescribed by a series of sur-gical templates provided tothe surgeon if predictableesthetic results are to beachieved. An inability toplace the implant accordingto the plan dictated by theproposed restoration is anindication for site enhance-ment as the reliability of

esthetic restorations fabri-cated on implants posi-tioned less than ideally isquestionable at best.

- W. MartinD. MortonJ. RuskinThe University of FloridaCenter for Implant Dentistry

Implant Realities 6

Early Loading with the ITISLA Surface as a Predictable,Routine Procedure

Treatment planning perma-nent tooth replacement withdental implant supportedrestorations often competeswith conventional prostheticprocedures for a number ofreasons. Historically,patients were often discour-aged at the prospect of mul-tiple surgical procedures,long delays between initiat-ing and completing treat-ment and questionable pre-dictability of implant proce-dures as compared to fixedpartial dentures. Similarly,

general dentists who makethe majority of the treat-ment planning recommen-dations express similar con-cerns combined with cum-bersome, unfamiliar pros-thetic procedures, potential-ly uncontrolled laboratoryfees and reduced profitabili-ty.

Implant dentistry hasadvanced tremendously toaddress the objections andchallenges of the past.Many of these improve-

ments are evidenced in con-temporary practice.However, one of the mostsignificant developments isthe routine use of reducedhealing time (42-56 days)that was recently document-ed with 4.1 mm diameterITI SLA surface implants.Published in the April, 2002Clinical Oral ImplantResearch, Cochran, Buseret al. summarized theresults of their prospectiveclinical trials from 6 centersin 4 countries. In types I, II

and III bone, implants wereallowed to heal for 42-56days (mean 49 days), andwere then subject to abut-ment placement at 35 Ncmwithout counter-torque.Prosthetic restoration wascompleted on 307 implants.The success rate at abut-ment placement was 99.3%.Life table analysis of thelongitudinal data demon-strated an implant successrate of 99.1% at 1 and 2years.

Fig. 1 Healed day 42 Fig. 2 Abutment connection at day 42

issue I • 2002 7

The clinical implication ofthis study is that patientsand dentists do not need towait for months to completetreatment. Further, the pre-dictability of the implant-supported restorations canbe shown to compete withor exceed that of fixed par-tial dentures in light of thepotential complications ofbridge fabrication, endo-dontic involvement of abut-ments and recurrent caries.

In the case illustratedbelow, a healthy, 67 year-old male presents with ahistory of bruxism, and alower right fixed partialdenture which failed due torecurrent caries and fractureof the anterior abutment.His fixed therapeutic alter-natives included a fixed

bridge extending from tooth#27-28-X-X-31 or singlecrowns on #28, 29 (I) and30 (I). The patient indicat-ed a preference for single-tooth restorations to a fixedprosthesis, so other bridgeoptions were eliminated.After endodontic therapywas performed on theremaining bicuspid, peri-odontal crown lengthening(clinical crown extension)was performed. During thesame procedure, 2 ITI SLA12mm implants were placedinto moderately dense (typeII/III) bone in ideal posi-tions. 42 days followingperiodontal and implantsurgery, solid abutmentswere torqued to 35 Ncmand the patient was referredback to his general dentistfor final impressions. Three

weeks later, 3 single crownswere cemented restoringoptimal hygiene and func-tion.

Success was optimized asfollows: Implant positionwas properly anticipatedand communicated so cor-rect placement was assuredand unexpected restorativecomplications and laborato-ry expenses were avoided.The surgeon positioned theimplants properly andreturned integrated, healedteeth and implants withhealthy surrounding tissues.Finally, the laboratory tech-nician was completelyfamiliar with the implantrestorations to insure seam-less, predictable results.

This case illustrated how

optimal prosthetic resultscan be obtained using evi-dence-based principlescombined with sound surgi-cal, endodontic, restorativeand laboratory techniques.Ideal results were obtainedfor this patient in less than10 weeks including ade-quate healing time for allprocedures and laboratorytime.

- Jeffrey Ganeles,DMD, FACD,Diplomat American Board

of Periodontology

The author would like to acknowledgethe meticulous restorative dentistry of:

Dr. Norman Lurie, Boca Raton, FLandMichael Hahn, MDT, DAS Dentalabor,Boca Raton, FL

Fig. 3 Final restorations Fig. 4 One year post-restoration

Implant Realities 8

The Immediate Load Full MaxillaUtilizing synOcta®

From Teeth to Fixed Implant Supported Bridge

Recently, immediate load-ing of dental implants hasbecome accepted and widespread. Many authors havepublished impressive resultswhich have validated theconcept. Researchers havedemonstrated not only suc-cessful integration withimmediate load, but alsogreater bone to implantcontact compared tounloaded delayed healingimplants.

The keys to a successfulcase include comprehensivepresurgical evaluationinvolving an interactiveCAT scan (Simplant), awaxed-up case mounted onan articulator and commu-nication between the sur-geon, restorative dentist,laboratory and the patient.The restorative dentist mustmake accurate casts, mountthem and wax-up the finaltooth position. The toothposition can be replicated ina surgical template which

ed for evaluation. He hadbeen told that his remainingmaxillary dentition washopeless and that he wouldneed to wear a full denturebefore implants could beplaced (fig 1).

Radiographic analysis of afull series of periapicalsrevealed that adequate bonewas present for implants inthe area of the bicuspidsand anteriors (fig 2 &3).The concept of immediateloading of implants wasexplained and that an inter-active CAT scan would benecessary to determinebone quality and volume. Scan assessment revealedample bone volume presentat sites 4, 5, 7, 10, 12, 13 toplace implants of 10-12mm(fig 4). The density at thesesites was sufficient forimmediate load (fig 5).Evaluation of the implantpositions showed that paral-lelism of the six implantswould not be achievable

lel from one side to theother and the anteriorimplants will flare labially.As a result, immediate load-ing of the full maxillabecomes more difficult withregard to splinting theimplants, abutment selec-tion and provisional fabrica-tion. The ideal way tosolve this dilemma is byindexing the implants andconstructing a master cast.Abutment selection to par-allel the implants couldthen be performed with theprovisional fabricated onthe model and then deliv-ered to the patient.

The following case reportwill demonstrate how apatient with a hopelessmaxillary dentition will beconverted into a fixedimplant supported bridgeutilizing indexed immedi-ately loaded ITI implants.

The patient, an 82 year oldhealthy white male, present-

may be radio-opaque if nec-essary for the CAT scan.

The CAT scan evaluationentails many factors. Bonedensity is the most impor-tant determinant sincemicromotion (movement >150 microns) will lead toimplant loss. The secondrequirement is adequatevolume to place theimplant. Finally, the inter-active CT can show how theimplants will relate to eachother. This will help therestorative dentist select theappropriate abutment beforeimplant surgery.

The normal anatomy andresorptive pattern in theedentulous mandible per-mits implants to be placedparallel to each other.However, in the edentulousmaxillary arch, the boneresorbs apically and palatal-ly. This produces a situationwhere the posteriorimplants may not be paral-

Fig. 1 Patient at presentation

Fig. 2 Full mouth initial radiographs

issue I • 2002 9

Fig. 4 CT preview showing location,position and size of implants

Fig. 3 Maxillary initial radiographs

Fig. 6 CT showing 3-D image of implant positionrelative to each other

Fig. 5 CT showing density of posterior implants

(fig 6). Therefore, index-ing the implants afterplacement would be neces-sary.

The prosthodontist dis-cussed the various treat-ment options with thepatient. Since no teethcould be used for supportfor an interim fixed pros-thesis, treatment optionswere a full denture or afixed immediate loadimplant bridge. The patientopted for the latter.

Due to the resorptive pat-tern of the maxilla, select-ing abutments to parallelthe implants in the edentu-lous jaw would be difficult.Furthermore, a fair amountof chair time would be necessary to fabricate theprovisional restoration.Therefore, it was decidedto impression the implantspost-surgically. A modelwith the indexed implantswould afford the prostho-dontist the ability to selectabutments and constructthe temporary.

At the next visit, teeth 6and 11 were prepped and

implants and the patientwas discharged (fig 11).

Analogs were attached tothe impression (fig 12) anda master model with a softtissue cast was poured in alow expansion die stone.Appropriate abutments uti-lizing the synOcta® plasticplanning kit were chosen.A 5.5mm solid abutmentwas utilized at 4 and 12,while at site 5, a 7mm solidabutment was used.synOcta® 15°, type A abut-ments were selected for 7,10 and 12 (fig 13). Apalatal jig was made toduplicate the positions ofthe angled abutments in themouth. The acrylic shellwas placed over the cast tocheck for clearance. Themetal abutments wereplaced on the model and theshell seated on 6 and 11.The provisional acrylic wasadded and the shell convert-

to achieve parallelism. Theosteotomies were widenedto the appropriate diameter(fig 8), tapped and theimplants installed (fig 9).All sites were then checkedto be certain that an impres-sion coping could besnapped onto the collar ofthe implant. If bone inter-fered with the coping, theosseous overhang wasremoved with a chisel. Thesoft tissue was recontouredaround the implant shoul-ders. The impression cop-ings were then snappedonto the implant shoulderswith the synOcta® position-ing cylinder placed (fig 10).The flaps were then looselycoapted with 4-0 silksuture. A polyvinyl impres-sion of the maxilla wastaken with the impressioncopings and positioningcylinders attached to theimplants. Cover screwswere then placed over the

temped. These teeth wouldserve as a positive seat forthe provisional. Impressionsof the maxilla and mandiblewere taken. The casts werepoured and mounted. Themaxillary teeth waxed tothe desired tooth position.An acrylic shell was fabri-cated which would be usedas a fixed provisional rest-ing on 6 and 11. Once thebridge was in place they(6&11) would be removed.

On the day of surgery, thepatient was premedicatedwith 1 gram of Amoxicillin.The mucoperiosteal tissuesof the maxilla were infiltrat-ed with 2% lidocaine with1:100,000 epinephrine. Theposterior bridge wasremoved. Teeth 7-10, 12and 15 were extracted (fig7). Six and 11 were main-tained to serve as an aide inaligning the implants at 5, 710 and 12 as well as provid-ing stops for the provision-al. The initial osteotomiesat 7 and 10 were drilled at2.2mm to proper M-D andB-L position. Subsequently,sites 5 and 4, followed by12 and 13 were developedto 2.2mm, with an attempt

Implant Realities 10

Fig. 7 Extraction Fig. 8 Directional indicators showing lackof parallelism

Fig. 9 Implant installation

Fig. 10 Impression cylinders and indexingindicator in place

Fig. 12 Impression with analogs in place Fig. 13 Master cast

ed to a well contoured, pol-ished provisional.

The patient returned to theprosthodontist 72 hoursafter surgery. The cuspidswere extracted and thecover screws removed. Thesolid abutments were placedat 4, 5 and 12. The jig wasintroduced onto the palateand the 15° abutments wereappropriately positioned.All posts were hand tight-ened. The access holes ofthe angled abutments wereblocked out with cotton pel-lets and composite (fig 14).The provisional was relinedagain in the mouth to insure

twelve weeks to verify inte-gration. The provisionalbridge was removed for thefi rst time since cementation(fig 16). The temporarycement was present in eachretainer, validating the passiv-ity of the provisional bridge.The abutments were torquedto 35Ncm. The patient expe-rienced no sensation or move-ment of the implants.Radiographs were taken. Theimplants were deemed asintegrated and the patientwent back to the prosthodon-tist for final restoration (figs17, 18, 19).

This case is of interest for

shoulder with the aid of ananalog. The provisionalwas tried-in and ovoid pon-tics developed for 6, 8, 9and 11. The occlusion wasadjusted with centric con-tacts on the center of theimplants. The provisionalwas polished again andsealed with Palaseal. Finaltemporary cement was uti-lized to secure the provi-sional (fig 15). At twoweeks, the sutures wereremoved and the occlusionwas checked again. Thepatient was not seen againfor ten weeks.

The patient returned at

accurate fit. The provisionalwas removed and impres-sion caps were placed onthe implants to maintainretraction of the soft tissue. The coronal half of theimpression cap was modi-fied to fit over the angledabutment. Excess acrylicwas trimmed. With analogsin the temporary, additionalacrylic was painted aroundthe gingival margins tomimic the proper emer-gence from the soft tissue.This would create a naturalprofile for the final restora-tion. The provisional wastrimmed and polished to theexact edge of the implant

Fig. 14 Abutments placed at 72hours

Fig. 11Post-op radiographs

issue I • 2002 11

Fig. 15 Provisional in place Fig. 16 Abutments and tissue at 12 weeks

Fig. 17 Radiographs of final restoration

Fig. 18 Buccal view of final restorationFig. 19 Palatal view of final restoration

many reasons. It demon-strates how important pre-operative treatment plan-ning and communicationare so that a complex casemay be precisely executed,with all variables taken intoconsideration. As a result,the implants could success-fully and easily be loaded at

installation.

Utilizing indexed implants,a master model was createdthe day the implants wereinstalled. From this cast,abutments which were par-allel were selected andplaced and a precise provi-sional fabricated. It was

delivered with few adjust-ments within 72 hours.This technique thereforediminished the number ofhours that the patient spentin the dental chair.

This case report exhibitshow patients with a failingdentition may successfully

be converted to an implantsupported prostheses withminimal chair time and agreat deal of expertise.

- Robert A. Jaffin, DMDJorge Barrios, DDSAkshay Kumar, DMD

Implant Realities 12

Practical Implant Pearls:Provisional Crown Fabrication for Solid AbutmentsIt is just another busy dayin the life of your practice.You wrap up a new patientconsultation and immedi-ately head for the hygienepatient waiting to bechecked in the next operato-ry. Without missing a beat,you pick up the stack ofphone messages piling upon your desk and glance atthe schedule. Mrs. Jones iscoming in today for you torestore her ITI implant. Itseems like she just had thatimplant placed the otherday, but you refer to theprogress notes in her chartand realize it has alreadybeen 6 weeks since her sur-gery. As you wonder wherethe time goes, your officemanager alerts you to anunscheduled emergencypatient being worked intoyour already hectic after-noon schedule. It is dayslike this that call for a sim-

plified method to help youfabricate a provisionalcrown on an ITI solid abut-ment. This practicalimplant pearl will helpdemonstrate the techniqueto create an accurately fit-ting provisional restoration.In addition to covering andprotecting the implant abut-ment, your provisionalcrown will begin to load theimplant, support and shapethe gingival tissues, andprovide your patient with anesthetic and durable tempo-rary tooth replacement.

In this particular situationwe are restoring thepatient’s missing lowerright first molar (#30)which was lost following afailed endodontic treatment.An ITI wide neck implantwas placed in the edentu-lous site with the aid of asurgical template and the

patient was allowed to healfor 6 weeks. Upon removalof the healing cap with anSCS screwdriver, a 4mmWNI solid abutment is car-ried to the implant andscrewed into place with fin-ger pressure (Fig. 1). Atthis point it is wise to con-fi rm that the abutmentheight selected allows foradequate occlusal clearance.Once you select and placethe appropriate sized solidabutment, you must firmlyaffix it within the Morsetaper of the implant body.This is accomplished bytightening the abutmentusing 35Ncm of force withthe Straumann torquewrench. A pick-up impres-sion coping can then besnapped onto the implantshoulder, and the matchingpositioning cylinder isaligned and pressed intoplace over the solid abut-

ment (Fig. 2). At this pointyou will make your finalimpression using the elas-tomeric impression materialof your choice. Most stan-dard crown and bridge typepoly-vinyl siloxanes worknicely (Fig. 3).

If everything goes accord-ing to plan, your abutmentconnection and finalimpression will requireabout 15 minutes of chairtime…much less time thanis required for a conven-tional crown preparation.Often times, these implantrestorative procedures donot require the use of anes-thetic! With only a fewprecious minutes of timeremaining before your nextemergency patient is seated,you must somehow make aprovisional crown over theimplant. Although youhave the option of cement-

Fig. 1 4mm WNI solid abutment Fig. 2 Impression transfer Fig. 3 Final impression

Fig. 4 Color-coded restorative components Fig. 5 Acrylic resin applied to implantanalog

Fig. 6 Completed provisional “cap”

issue I • 2002 13

ing a prefabricated protec-tive cap over the implantabutment, you will learn itis not difficult to create aprovisional crown with asmall amount of effort.More and more patients aredemanding higher qualityservice and are expecting ahigh value in return fortheir hard-earned money.In an effort to exceed thisdemand, today’s topimplant clinicians will beexpected to provide implantprovisional crowns as theywould for any preparedtooth.

In order for this process tobe most efficient with yourchair-side time, it willrequire you to do someadvance preparation. Takethe color-codedimplant/abutment analogfrom your impression kit(Fig. 4) and paint a layer ofpetroleum jelly on the ana-log as a separating medium.Mix together an acrylicresin provisional materialand apply it to the abutmentsurface area (Fig. 5). Allconventional methyl-methacrylate (power-liquidcombination resins) workwell for this process. These

materials allow you to addto the same material andwill adhere chemically to apreviously set mix. Allowthe material to cover theabutment and run down tothe implant margin. It isimportant to ensure that theacrylic completely coversthe implant shoulder/mar-gin. If extra material runsover the margin it can betrimmed back after it hasfinished setting. Once theresin has cured, gentlyremove it from the analogwith a hemostat (Fig. 6).These “prefabricated” pro-visional copings can bemade up for all sizes of thestandard ITI implant solidabutments (4mm, 5.5mm,and 7mm) and the wideneck implant solid abut-ments (4mm and 5.5mm).Often, this process is com-pleted well in advance ofthe patient’s arrival in theoffice and extra copings arekept in the implant prosthet-ic organizer along with var-ious other implant compo-nents.

Now that you have madeyour impression, retrieve anacrylic coping for the 4mmWNI solid abutment. Take

this coping to the mouth,place it over the abutment,and press it into place(Figure 7). Because youhave already captured themargin of your provisionalimplant restoration, the pre-formed acrylic resin capwill displace soft tissue inany areas that are sub-gingi-val. At this point you willfill a clear, vacu-formedcoping with a new mix ofacrylic resin and seat it overthe resin cap and the adja-cent teeth (Fig. 8). It isnoteworthy to mention thatbis-acryl resin provisionalmaterials that are dispensedfrom automix cartridges donot work as well for thistechnique. The simple rea-son is that the oxygen-inhibited layer that formson the surface of the resinprevents bonding of thesame material and you willnot successfully “pick-up”the acrylic coping in thevacu-formed shell.Flowable composite resinshave been suggested to addto these materials but areoften messy and expensive.The simplest method is touse a resin (such as amethyl-methacrylate) thatallows you to add an addi-

tional mix that will chemi-cally adhere. As with anyprovisional restoration, takecare not to lock the acrylicinto adjacent tooth under-cuts. Check occlusal con-tacts with articulating filmand adjust accordingly. Theprovisional restoration isthen polished and cementedinto place with a smallamount of temporarycement (Fig. 9). Carefullyremove any excess setcement beyond the marginand instruct your patient inhome care as you would forany provisional restoration.

As you dismiss the patient,she turns and thanks youfor her new implant tooth.She smiles and remarks thatit feels like a real tooth andshe can’t believe it was thateasy and painless. Youreturn a smile of your ownand enjoy the moment…it’sjust another busy day in thelife of your implant prac-tice.

- Scott E. Keith, DDS, MS

- Scott E. Keith, DDS, MS

Fig. 7 Acrylic “cap” seated over abutment Fig. 8 Vacu-form coping to pick-up resin Fig. 9 Completed provisional restoration

Implant Realities 14

The ITI® implant systemoffers the most research ofany “one stage” implantdesign.2,4,5 With this designin posterior sites, placementdepth is routine. However,altering placement depthwith the ITI® system allowsfor flexibility and optimalesthetics in the anteriorregion.1 The standardplacement depth calls forthe SLA surface to be sub-osseous and the machinedsurface to serve as thetransmucosal portion. TheITI ® implant has a 1.8mmor 2.8mm machined collar,to accommodate differentsoft tissue thickness. TheESTHETIC PLUS solidscrew implant was designedfor anterior sites with the1.8mm machined collar.Ideally, an interproximal

The mesial distal diameterof the tooth being replacedis a critical aspect to con-sider. The ultimate estheticresult is dependent upon thesoft tissue form being wellsupported by the implantand restoration emergingfrom a subgingival location.Such a transition cannotoccur over a distance of0.5-1mm. Therefore, theimplant neck must beplaced deeper subgingivallyto develop the gingival andpapillary form. Most cen-tral incisors are >9mm inwidth. If the incisor is 10-11mm wide, the 4.8mmimplant neck must beplaced deeper than in thecase of a 9mm wide incisor.

The gingival thickness as athin scalloped biotype is

surface does not promoteosseointegration and shouldbe limited when possible.4

Two stage systems pre-dictably demonstrate crestalosseous “cupping” (i.e.bone loss) to the firstimplant thread after abut-ment attachment due theclose proximity of themicrogap.6,7,8 The ITI® sys-tem may have to be some-what countersunk due toesthetic concerns but doesnot require placement asdeep as many two stageimplant designs. This isdue to the flare from theimplant body to 4.8mm atthe implant neck. Howdeeply should you counter-sink the implant to attainappropriate esthetics, with-out causing subsequentbone loss?

scallop of the SLA implantsurface would be present toenhance preservation of theosseous profile. Such adesign is not yet availableclinically. Different collarheights alone cannotaccommodate for the sharpscallop of the osseousarchitecture in the estheticzone. The soft tissue thick-ness, anatomical interproxi-mal osseous scallop andosseous thickness all affectthe depth of placement foran optimal cosmetic result.

In order for the facial aspectof the implant bevel to beplaced subgingivally, theinterproximal aspect of theimplant must often beplaced subcrestally. Sub-crestal placement of asmooth machined titanium

Emergence Profile and Implant Depth

Fig. 1 The side mesio distal width of the tooth to be replaced (11mm) requires the implant to be countersunkmore deeply. The central incisor was restored using an octa abutment, a UCLA type gold coping with acemented porcelain fused to metal crown.

issue I • 2002 15

also a factor in depth. Ifthe width of the tooth to bereplaced is <9mm, theimplant neck may be placedcloser to the facial gingivalmargin. Such placementallows utilization of acemented restoration, withmargins 1-1.5mm subgingi-val facially and 2-3mm sub-gingival interproximally.When a pronounced scallopis present, or the mesial –distal width to be consid-ered is >9mm, the implantis often countersunk 1mmcoronal to the facial osseouscrest. The interproximalneck of the implant is nowoften 1-1.5mm subcrestal.The emergence profile maybe developed smoothly, andthere is room for an appro-priate transition of porce-lain color and form.

The type of restoration tobe utilized is a factor whenconsidering the depth of

angulation and depth ofplacement, as these are crit-ical aspects of success.Familiarity with the systemand the discussed guide-lines will make placing andrestoring ITI® implants rou-tine in esthetic sites.

- Bobby Butler, DDS

ESTHETIC PLUS implant.

The use of the ITI® systemin the esthetic zone offersthe combination of a provenimplant design, a pre-dictable, well-researchedSLA surface, and a widerange of abutments andrestorative options. Implantplacement with any systemmust be well planned, withattention paid to implant

implant placement. A solidabutment with a cementedcrown may not be appropri-ate, as the interproximalmargin could be as much as4-7mm subgingival. Thepotential for retained sub-gingival cement in such asituation is very high.9 TheITI ® system offers greatflexibility with other abut-ment options. Use of asynOcta® or octa abutmentallows fabrication of ascrew retained restoration,or a cemented restorationwith a customized cementmargin level. A transversescrew restoration is also anoption, although it is prima-rily designed for use withmaxillary central incisors.

Use of a synOcta® or octaabutment with a cementedrestoration is simple, versa-tile and highly esthetic. Acast-on gold, machinedabutment is used to fabri-cate a UCLA type of abut-ment. A ceramic restorationwith a customized finishline is now cemented on theabutment. Such anapproach may be used inmaxillary central or caninesites, where the implant iscountersunk more deeply.Lateral incisors are oftenrestored with solid abut-ments as the reduced diam-eter of the tooth usuallydoes not require as muchdepth. If the diameter ofthe lateral incisor to bereplaced is very narrow, anarrow neck implant isused, and countersunk asnecessary, often to a depthof 1-1.8mm coronal to thefacial osseous crest, asdescribed previously for the

Fig. 2 A radiograph one yearafter placement of thefinal restoration.

References

1. Belser UC, Buser D, HessD, Schmid B, Bernard JP,Lang NP. Aestheticimplant restorations inpartially edentulouspatients–a critical apprais-al. Periodontol 20001998;17:132-150.

2. Buser D, Mericske-Stern R,Bernard JP, et al. Longtermevaluation of non-sub-merged ITI implants. I.An 8-year life table analy-sis of a prospective multi-center study with 2359implants. Clin OralImplants Res 1997;8:161-172.

3 Cochran DL, Hermann JS,Schenk RK, HigginbottomFL, Buser D. Biologicwidth around titaniumimplants. A histometricanalysis of the implant-gingival junction aroundunloaded and loaded non-submerged implants in thecanine mandible. JPeriodontol 1997;68:186-198.

4. Cochran DL. Endosseousdental implant surfaces inhuman clinical trials. Acomparison using meta-analysis. J Periodontol1999;70:1523-1539.

5. Fiorellini JP, Martuscelli G,Weber H-P. Longitudinalstudies of implant systems.

Periodontol 20001998;17:125-131.

6. Hermann JS, Cochran DL,Nummikoski PV, Buser D.Crestal bone changesaround titanium implants.A radiographic evaluationof unloaded nonsub-merged and submergedimplants in the caninemandible. J Periodontol1997;68:1117-1130.

7. Hermann JS, SchoolfieldJD, Schenk RK, Buser D,Cochran DL. Influence ofthe size of the microgap oncrestal bone changesaround titanium implants.A histometric evaluationof unloaded non-sub-merged implants in thecanine mandible. JPeriodontol 2001Oct;72(10):1372-83.

8. Oh TJ, Yoon J, Misch CE,Wang HL. The causes ofearly implant bone loss:myth or science? JPeriodontol. 2002Mar;73(3):322-33.

9. Pauletto N, Lahiffe BJ,Walton JN. Complicationsassociated with excesscement around crowns onosseointegrated implants:a clinical report. Int J OralMaxillofac Implants. 1999Nov-Dec;14(6):865-8.

issue I • 2002 S Implant Realities 16

On many occasions,patients require greaterretention to stabilize theirdentures than conventionaltreatment modalities allow.The lack of financialresources to completelyremake their prosthesisoften further complicatesthe situation. One treatmentplan to deal with such aproblem is the utilization oftwo or more implants withretentive anchor abutments,and the addition of retentiveelements for increased sta-bility and retention. Toreduce laboratory expenseand time, the simplest wayto accomplish this end is toretrofit the existing dentureintra orally in the office.

A classic example is illus-trated below: The patientpresents with a relativelynew prosthesis (Figs. 1 &2). One of the easiest andmost affordable abutmentsto use is the RetentiveAnchor Abutment (Fig. 3).An abutment driver is avail-

able which fits the torquecontrol device (Fig. 4), andis used to place the abut-ment in the implant. Thehealing caps are removedwith the SCS screwdriver(Fig. 5). The internal aspectof the implant is evident(Fig. 6). The retentiveanchor abutments are placedwith the Torque ControlDevice adjusted to 35Ncm(Fig. 8). An indicating medium isused to locate the positionof the implants and abut-ments in the denture. Thedenture is relieved in thearea of the implants to allowcomplete seating of the den-ture with the abutments inplace (Fig. 11). The pre-ferred method of relief is to

Clinical Procedures for the Conversionof a Denture to Implant Retained

Utilizing the ITI Retentive AnchorAbutment and Gold Matrix

1 2

3

4

5

6

7

issue I • 2002 17

create a complete windowover the implant to improveaccess to the attachment.The abutment must now beblocked out so that the self-curing resin cannot migrateunder the abutment orimplant margin, utilizing“rope wax” or “ortho wax “(Fig. 8). It is placed overthe abutment and implantand molded into shape (Fig.9). Utilization of the waxmakes paralleling theattachments easier, andreduces the possibility ofthe attachments changingposition. Once the wax is inplace, the gold matrix ispressed into position andparalleled by eye (Fig. 10).

The denture is tried in andchecked for any impinge-ment of the attachment onthe denture base (Fig. 12).If there is contact betweenthe acrylic and the attach-

ment, more relief is needed.With the denture in place,self-curing resin is appliedto the attachments and thedenture base (Fig. 13). Theresin is allowed to fully cure(usually about 5 minutes)(Fig.14). When the resin ishard to the touch, it is“unsnapped out” and theinternal adaptation of theacrylic is checked (Fig. 15).If no voids are noted theexterior of the denture ispolished. The case is com-plete. This procedure takesno more than an hour to per-form. Most patients noticean immediate sense of sta-bility and comfort.

Instruments are available toincrease or decrease thedegree of retention to thedesired level.

- Terry Charters

8

9

10

11

12

13

14

15

Implant Realities 18

The advent of simple, pre-dictable Guided BoneRegeneration (GBR) therapyhas significantly altered boththe treatment planning andtherapeutic phases of every-day clinical dentistry. Oncethought of as a complextreatment modality necessi-tating multiple surgical sitesand the procurement of oraland/or extra oral autogenousbone, GBR therapy is nowrecognized as a straightfor-ward procedure which doesnot require the use of an ofautogenous bone graft toeffect ideal treatment results.The literature has demon-strated the ability to pre-dictably regenerate largequantities of lost alveolarbone through the utilizationof appropriate surgicaldesigns, particulate materialsand membranes.

Nowhere is the impact ofGBR therapy upon treatmentplanning and subsequenttherapy more evident than inthe transformation of toothextraction into a reconstruc-tive event.

mucogingival junction.Palatal releasing inci-sions are placed a dis-tance of at least onetooth mesial and distalfrom the site to beregenerated.

B. Horizontal extensions ofthe buccal and lingualreleasing incisions areutilized as necessary toincrease flap mobility.While commonly 3-4mm in length, thesehorizontal extensionsmay reach up to 8-10mm in length.

C. Full thickness flap reflec-tion is carried out,including reflection ofthe “triangle” borderedby the vertical releasingincisions, its horizontalextension, and thehypotenuse connectingthese two incisions.

D. The above releasing inci-sions are adequate forattainment and mainte-nance of passive soft tis-sue primary closure in

tection through mem-brane placement.

V. Selection of an appro-priate membrane toensure precise recre-ation of the desiredmorphology of the boneto regenerated.

VI. Membrane stabilization.

VII. Control of overlyingpostoperative forces.

While performing GBRtherapy, the attainment andmaintenance of primary softtissue closure throughout thecourse of regeneration isrecognized as one of thegreatest challenges facingthe treating clinician.

This challenge is predictablymet through the utilizationof proven flap designs:A. Buccal and lingual

releasing incisions areutilized on the mesialand distal extents of themucoperiosteal flap tobe reflected, whichextend well beyond the

Rather than hoping for man-ageable post tooth extractionridge atrophy and subse-quent soft tissue collapse,the clinician may now utilizethe tooth extraction visit asan opportunity to performappropriate regenerativetherapy and significantlyenhance the subsequent hardand soft tissue morphology(Figs. 1-4).

The prerequisites for themaximization of GBR thera-peutic outcomes have beenwell elucidated in a numberof publications, and include:I. Appropriate flap design

and suturing to ensureattainment and mainte-nance of passive pri-mary closure throughoutthe course of hard tissueregeneration.

II. Complete debridementof the site to augmented.

III. Decortication of theregenerative site ifappropriate.

IV. Clot isolation and pro-

Part 1 Managing the Soft TissueTransforming Treatment with Guided Bone Regeneration

Fig. 1 Fig. 2 Fig. 3 Fig. 4

A significant osseous defect ispresent following extraction of amaxillary cuspid.

Note regenerated bone in thecuspid site, compared to the lat-eral incisor area of prior extrac-tion.

A severe osseous defect is evi-dent following extraction of thecentral incisor.

Guided bone regeneration isperformed without the use ofautogenous bone grafting.

issue I • 2002 19

the post tuberositymucosa (Fig. 10).

C. A palatal pedicle flap isnow rotated from thepalatal aspect of the softtissue which overlaid themaxillary tuberosity.This palatal pedicle nowcovers the buccal portionof the tuberosity regionwhich has been leftdenuded through themesial rotation of thebuccal flap (Fig. 11).

D. Appropriate suturing isnow carried out.

There are only three reasonsnot to perform the appropri-ate regenerative therapy atthe time of tooth extraction:

I. The inability to attainand maintain passivesoft tissue primary clo-sure: The aforemen-tioned flap designs willensure the maintenanceof such closure. A pre-vious publication docu-ments maintenance of

and maintenance of passiveprimary closure in almost allclinical situations.

When faced with extractionof a maxillary second molar,in the presence of a signifi-cant palatal hard tissue toruswhich does not allow rota-tion of a palatal pedicle flap,a further flap modificationmay be employed:A. The initial incision

designs are as previouslydescribed, with theexception that the distalincision extends into themucosa distal to themaxillary tuberosity(Fig. 9).

B. Following tooth extrac-tion, and performance ofappropriate regenerativetherapy, the portion ofthe buccal flap whichoverlay the tuberositydistal to the extractedsecond molar is rotatedmesially, so that it over-lays the extraction sock-et area. Such mesialrotation is easily accom-plished through theappropriate extension ofthe distal incisions into

tioned internal hori-zontal incision (Fig.7).

4. The dissected inter-nal aspect of thepalatal flap is reflect-ed coronally and out-wardly, thus increas-ing the apico occlusaldimension of the pal-atal flap (Fig. 8).

When employing such a flapdesign, it is imperative thatthe patient be placed in anappropriate supine positionto allow adequate visualiza-tion. In addition, the place-ment of palatal releasingincisions at a distance of atleast one tooth mesial anddistal from the area wherethe palatal pedicle will beperformed is crucial forappropriate visualization.Finally, the clinician mustrealize that this palatal pedi-cle flap does need to berotated 180°. The amount ofrotation required is that nec-essary for placement of thisrotated palatal pedicle overthe area to be augmented.

The above outlined flapdesigns ensure attainment

the vast majority of situ-ations. However, whensignificant maxillaryaugmentation therapy isto be performed, the rel-ative immobility of thepalatal flap may man-date additional flapmodification to ensurepassive soft tissue pri-mary closure. In such asituation, a rotatedpalatal pedicle flap isemployed.1. A full thickness

palatal flap is reflect-ed with appropriatereleasing incisions aspreviously described(Fig. 5).

2. An incision is madealong the internalaspect of the palatalflap approximately3mm coronal to thebase of the flap (Fig.6).

3. Utilizing a 15 bladeand a 1 2 tissue for-cep, the internalaspect of the palatalflap is split in a coro-nal direction, begin-ning at the aforemen-

Fig. 5 Fig. 6 Fig. 7 Fig. 8

A full thickness palatal flap isreflected.

An internal incision is made 3-4mm from the base of the palatalflap.

The palatal flap is dissected inapical coronal direction.

The dissected internal aspect ofthe palatal flap is reflected coro-nally and outwardly, extendingthe length of the palatal flap.

Implant Realities 20

primary closure for aminimum of six monthsfollowing regenerativetherapy in 96.1% of thetreated cases. This per-centage of success isnow much higher, fol-lowing the developmentof the additional flapdesign modification fortreatment of maxillarysecond molar areas.

II. The lack of appropriatetreatment planning andcoordination of therapybetween the restorativedentist and the treatingperiodontist/oral sur-geon: Such a lack ofcoordination is inexcus-able.

References

Fugazzotto PA, Shanaman R, Manos T, Shectman R.Guided bone regeneration in implant therapy: Successand failure rates in 1503 sites. Int J Periodont & RestorDent, 1997;7:293-99.

Fugazzotto PA. Tooth Extraction as a ReconstructiveEvent. J Mass Dent Soc 1998;47:23-30.

Fugazzotto PA. Report of 302 consecutive ridge aug-mentation procedures: Technical considerations andclinical results. Int J Oral & Maxillofac Impl,1998:13:358-68.

Fugazzotto PA. Maintaining of soft tissue closure fol-lowing guided bone regeneration: Technical considera-tions and report of 723 cases. J Perio 1999; 70:1085-97

III. The unwillingness orinability of the peri-odontist/oral surgeon tosee a patient requiringtooth extraction aug-mentation immediately:This inflexibility on thepart of the treating clini-cian is inexcusable. Ourpatients deserve better.

Use of GBR therapy at thetime of tooth extraction isnot a luxury. Such a treat-ment approach is a necessi-ty, if we are to truly regener-ate the hard tissue scaffoldof the soft tissue drape ofesthetics.

- Paul A. Fugazzotto, DDS

Fig. 9 Fig. 10

Fig. 11

Releasing incisions extend into the mucosa distal to themaxillary.

Following performance of regenerative therapy the buc-cal flap is rotated mesially from the distal wedge area.

A pedicle flap is rotated from the internal aspect of thepalatal flap in the area of the tuberosity to cover thebone denuded by the mesial rotation of the buccal flap.

issue I • 2002 21

“Clinical and Radiographic Evaluation of the Papilla LevelAdjacent to Single-Tooth Dental Implants. A RetrospectiveStudy in the Maxillary Anterior Region”- Vincent Choquet, Marc Hermans, Philippe Adriaenssens, Philippe Daelemans,

Dennis P. Tarnow, and Chantal Malevez; Journal of Periodontology 2001: 72: 1364-1371.

Literature Review

One of the greatest chal-lenges facing dentistry ismaintenance of interdentalpapilla in the maxillaryanterior region – the esthet-ic zone. A number ofauthors including DennisTarnow published articlesregarding requirements forthe maintenance of inter-dental papillae around natu-ral teeth. In the October2001 issue of The Journalof Periodontology a studyauthored by VincentChoquet et al. reportedrecent findings on interden-tal papillae around singletooth dental implants in themaxillary anterior region.The group investigated twospecific hypotheses:whether the distancebetween the contact pointand crest of bone correlateswith the presence orabsence of interproximal

papillae adjacent to single-tooth implants; and if sec-ond stage surgical techniqueinfluences the outcome.The retrospective studyevaluated the papilla levelaround 27 single toothimplants and their adjacentteeth in 26 patients. A totalof 52 papillae were evaluat-ed radiographically andclinically. Six months afterimplant placement, twotechniques were used toexpose the fixtures: a con-ventional approach (17 fix-tures) and a techniquedesigned to develop papillaaround dental implants (10fixtures).

The study demonstratedseveral key points. Whenthe distance between thecrest of bone and contactpoint was 5mm or less,papillae was present nearly

100% of the time.However, when the distancebetween contact point andcrestal bone was ≥6mm,papillae were present lessthan 50% of the time.These findings are similarto those described byTarnow in 1992 regardingpapillae around naturalteeth.

There was little clinical andradiographic difference(less than 0.25mm) betweenthe two second stage sur-gery techniques. Such adiscrepancy is not clinicallysignificant.

Achieving anterior estheticsoften proves elusive.Tarnow’s earlier work pro-vided clinicians with amethod of quantifying thedistance from crestal boneto contact point required to

predictably generate inter-dental papillae around teeth.Choquet’s group providesclinicians with similarinformation around dentalimplants. The key to gener-ating and maintaining inter-dental papillae around den-tal implants appears to belimiting the distance fromthe crestal bone to the con-tact point to 5mm.

Frederic J. Norkin, DMD

Implant Realities 22

Upcoming EventsSpecial Events

ITI World Symposium • October 24-26, 2002 • San Diego, CA • www.iti.ch

Congresses

AAP Annual Meeting • September 25-28, 2002 • New Orleans, LA

AAOMS Annual Meeting • October 2-5, 2002 • Chicago, IL

AAID • October 2-6, 2002 • Los Angeles, CA

ADA Annual Meeting • October 19-23, 2002 • New Orleans, LA

AAMP • November 3-6, 2002 • Orlando, FL

ACP • November 6-9, 2002 • Orlando, FL

AAOMS Specialty Meeting • December 6-7, 2002 • Chicago, IL

Courses

Esthetics and Implant DentistrySeptember 13-14, 2002 • November 22-23, 2002Presented by Drs. James Ruskin, Dean Morton, Will Martin

Clinical Realities of Ridge Augmentation, Sinus Augmentation, PRP: A Live Surgical CourseSeptember 18, 2002 • October 16, 2002 • November 6, 2002 • December 4, 2002Presented by Dr. Paul A. Fugazzotto • Phone 617/696-7257

Strategies for Success with the ITI® DENTAL IMPLANT SYSTEMOctober 4, 2002 • Presented by Dr. Scott Keith

ITI® DENTAL IMPLANT SYSTEM Lab Certification CourseOctober 4-5, 2002 • Presented by Mr. Terry Charters

Predictable Esthetics in Implant DentistryOctober 11, 2002 • Presented by Dr. Robert Vogel

Sustained Practice Growth in a Changing Environment: A Proven ApproachNovember 8, 2002 • April 4, 2003 • Presented by Drs. Neal H. Fleisher, DMD and Paul A. Fugazzotto, DDS

Comprehensive Implant Prosthetics and Predictable Anterior EstheticsNovember 8, 2002 • Presented by Dr. Robert Vogel

For more information about these courses, please call Kathy Bowler at 781/890-0001 ore-mail education.us@straumann.com

Implant Realities

© 2002Printed in USA