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CONTINUING EDUC ATION 12

,PROSTHETIC PROCEDURES FOR

OPTIMAL AESTHETICS IN SINGLE-TOOTH

IMPLANT RESTORATIONS: A CASE REPORT Avi Donitza, DMD*

Restoration of a single-tooth implant in the anterior max­

illa requires a multidisciplinary approach throughout the

treatment and proper communication between the clini­

cian and laboratory technician. Although surgical pro­

cedures have an important role in the manipulation of

the soft tissues, it is often necessary to perform final con­

touring of the soft tissue through the provisionalization

stage. Unless the soft tissue contour supports the defini­

tive restoration, the treatment is considered a failure. This

article reviews various prosthetic procedures that influ­

ence the soft tissue contour and establish aesthetics for

implant-supported restorations.

Key Words: implant, analog, coping, soft tissue, impression

The restoration of a single implant in the anterior max­

illa is a complex task. It requires a multidisciplinary

approach to diagnosis and treatment planning as well

as the surgical, prosthetic, and laboratory procedures in

order to achieve on aesthetic and functional restoration

that is harmonious with the adjacent teeth. Since it cre­

ates a frame around the restoration, the soft tissue contour

that surrounds the implant is on inseparable component

of the final aesthetic result.

The optimal level of the soft tissues (specifically the

interdental papilla) con be restored by several surgical

procedures. In many patients, however, surgical means

*Adjunct Assistant Professor, Advanced Prosthodontics, UCLA School of Dentistry, Los Angeles, California; private practice, Beverly Hills, California.

Avi Donitza, DMD

152 S. Lasky Dr. #204

Beverly Hills, CA 90212

Tel: 310-276-7028Fax: 310-276-7990E-mail: avidonitza@gmail.com

Pract Periodont Aesthet Dent 2000;12(4):347-352

must be supplemented by additional treatment to estab­

lish the correct gingivol contour and to create and main­

tain the papilla around implant-supported restorations.

When surgical procedures alone ore insufficient, guided

soft tissue healing with a provisional restoration is nec­

essary to achieve on aesthetic soft tissue contour around

the provisional and definitive restorotions. 1·3 Once the soft

tissue has healed around the provisional restoration, its

exact contour must be accurately transferred to the lab­

oratory technician. This allows the fabrication of a defin­

itive restoration that properly supports the soft tissue and

provides an anatomically stable and aesthetic result.4

Since the tissues that surround the implant ore tri­

angular or oval, cylindrical impression copings ore often

unable to accurately transfer the anatomically healed

tissue contour to the laboratory. Contemporary abutment

systems (eg, Bio-Esthetic, Nobel Biocore, Yorba Linda,

CA) have specific healing abutments that ore used in the

anterior maxilla and premolar regions; these abutments

allow the soft tissue to heal in the desired contour. The

Figure 1 A. Preoperative radiograph exhibits sufficient bone volume. 1 B. Radiograph of implant at second-stage surgery.

347

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Practical Periodontics & ArsrnEnc DENTISTRY

heoling obutments ore subsequently reploced with finol

obutments thot hove the some size ond shope subgin-

givolly. These obutments, however, ore composed of tito-

nium, ond their use is llmited in instonces where the soft

tissue is thin. They connot be custom{obricoted to spe-

cific requirements. The use of contoured heoling obut-

ments is odvontogeous in the nonsubmerged implont

plocement technique, which ollows the soft tissues to heol

for six months oround the heoling obutment. This orticle

emphosizes the significonce of guided soft tissue heol-

ing with o provisionol reslorotion. lt olso demonstrotes

on efficient monner to tronsfer the exoct finol coniour of

the soft tissue oround the implont to the technicion.

Csse Fresenfofion

A 2[yeor-old femole potient presented for the restoro-

tion of o congenitolly missing loterol incisor. The potient

hod previously completed orthodontic theropy ond hod

worn o provisionol retoiner with on ocrylic denture

iooth to restore the onterior spoce. Clinicol ond rodio-

grophic exominotion reveoled sufficient bone volume for

implont plocement in the horizontol ond verticol dimen-

sions (Figure 1A). The interdentol spoce beiween the

incisor ond the conine ollowed the fobricotion of o pros-

thetic tooth with dimensions thot corresponded to the con-

troloterol tooth. Soft tissue meosurements indicoted the

presence of sufficient verticol ond horizontol levels, which

- olthough flot in shope - required no ougmentotion.

Figure 2. Fociol view of o stondord impression coping (3i, polm BeochGordens, F[} connected to the implont. Note the initiol heoling of thesoft fissues.

Figure 3. Once on impression is mode, o temporory custom obutmentis ploced to focilitote the provisionol resforotion.

Figure 4. ln order to prevent troumo tro the surrounding gingivoltissues, the initiol provisiono! reslorotion is undercontoured inevery dimension.

At this phose, o decision wos mode to restore teeth

#7112lrthrough #9,'21) simultoneously with rhe implont

ot site #10(22). The controloterol incisor hod been

restored with on unoesthetic porceloin{used-to-metol

crown restorotion, tooth #B(ll) hod been keoted with

endodontic theropy, ond on overcontoured composite

restorotion wos removed from the left centrol incisor.

lmploni Plocement

A stondord diometer implont (3.75 mm A, 3i, Polm Beoch

Gordens, FL) wos inserted occording to o preformed sur-

gicol templote. As described in severol recent reports,s.z

this precise plocement considered the onotomy of the

onticipoted restorotion ond the surrounding structures in

348 Vol. 12, No. 4

Figure 5. ln order to focilitote odequote heoling of the verticolincision, the buccol emergence profile of the provisiono! crownrestorotion remoins Ievel.

Figure 6. Progressive gingivol heoling with the correct emergenceprofile of the provisionol restorotion is evident 2 months followingsecond-stoge surgery.

order to develop on oesthetic emergence profile. ln the

verticol plone, the heod of the implont wos 2.5 mm

opicol to the onticipoted buccogingivol morgin.6

Plocement olso oddressed the biologic width oround the

implont ond the I mm of bone resorption thot wos

expected following one yeor of looding.6'8 e Upon ploce-

ment, the implont's position in the olveolor bone olso sot-

isfied criterio thot would ollow creotion ond mointenonce

of the popillor0 while simultoneously minimizing resorp-

tion ond exposure of the restorotion's morgins.6'8

Second-stoge surgery wos performed 6 months post-

implontotion (Figure 1B). lncisions were performed mesio-

distolly on the polotol ospect of the ridge, ond o short

verticol incision divlded the flop into two ports thot were

Donitzo

sutured on both sides of the implont. ln this monner, oddi-

tionol soft tissue wos ovoiloble for the creotion of the

popillo. The preliminory impression wos recorded I week

following second-stoge surgery, ond o stondord impres-

sion coping (3i, Polm Beoch Gordens, FL)wos connected

to the implont (Flgure 2). The impression wos poured in

stone, ond o provisionol custom obutment (3i, Polm Beoch

Gordens, FL) wos prepored in the loborotory ond seoted

introorolly (Figure 3).

Provisionolization

The provisionol restorotion wos ploced 2 weeks following

second-stoge surgery (Figure 4). This restorotion opplied

continuous pressure to the soft tissue ond mointoined the

proper scollop of the gingivo, which would hove other-

wise collopsed ond lost its shope.'"''2 In order to prevent

troumo to the heoling tissues, the iniiiol restorotion wos

undercontoured in oll dimensions. One month following

second-stoge surgery (ofter on odditionol two weeks),

the provisionol crown wos removed to permit the oddi-

tion of self-cured composite resin to the proximol sub-

gingivol oreos. When the provisionol restorotion wos

recemented, it estoblished slight pressure on the soft tissues,

which were forced to heol coronolly ond creote o popillo.

The buccol emergence proflle of the provisionol crown

wos left flot to prevent buccol pressure ond to ollow the

verticol incision to properly heol (Figure 5). Following

one odditionol month, heollng hod progressed, ond the

popillo wos evident oround the implont (Figure 6).

Figure 7. The divergent lissue contour thot surrounds the provisionolresforotion necessitotes the use of o custom obutment.

P P ',.r i'l 349

Practical Periodontics & AESTHETIC DENTISTRY

Restorative Phase

Four months after second-stage surgery, complete healing

was noted, and the final prosthetic stage was initiated.

A custom abutment was fabricated for the implant­

supported restoration. Since the width and the divergence

of the tissue contour around the provisional restoration

were greater than available abutments (Figure 7), an alu­

minum oxide abutment (CerAdapt, Nobel Biocare, Yorba

Linda, CA) was selected for optimal aesthetics. This abut­

ment would be modified by the laboratory technician and

layered to proper contour with the appropriate shade

of porcelain.

In order to transfer the exact tissue contour to the

laboratory technician, it was necessary to duplicate it

and fabricate a model that included the position of the

implant in relation to the adjacent teeth. Since a custom

impression coping was necessary, the provisional restora­

tion was detached, and a laboratory analog was con­

nected to the existing abutment (Figure 8). To prevent the

collapse of the soft tissue around the implant while the

provisional crown was removed, a light-body polyvinyl­

siloxane impression material (Extrude, Kerr/Sybron,

Orange, CA) was injected into the soft tissue socket. The

analog was embedded halfway in quick-setting plaster,

and polyvinylsiloxane material was injected around the

site. As the analog is stable in the stone, accuracy was

maintained, and the impression material precisely dupli­

cated the exact contour of the provisional restoration

(Figure 9A).

A traditional impression coping was connected to

the analog (Figure 98), and self-curing acrylic resin was

injected around it (Figure l 0). A standard pick-up-type

impression was made with polyvinylsiloxane, poured in

stone, and the soft tissue contour around the implant was

reproduced in silicone. On the custom aluminum oxide

abutment, shaded porcelain was added to the subgin­

gival region to match the transferred contour. The gingi­

val margin of the anticipated restoration was established

0.5 mm below the free gingival margin (Figure l l ).

The custom abutment was seated on the implant with a

resin template to ensure the correct positioning of the

implant (Figure 12). Once the contour and the position

of the gingival margin were evaluated, the abutment was

tightened to the manufacturer's specifications (Figure 13).

350 Vol. 12, No. 4

Figure 8. A laboratory analog is connected to the temporary custom abutment and the provisional restoration.

Figure 9A. An impression material is used to duplicate tissue contour around the implant. 98. Self-curing acrylic resin is injected around the impression coping.

Figure 10. Facial view demonstrates placement of the final custom impression coping.

Donitzo

Figure I lA. Porceloin is odded to the subgingivol morgin to replicotethe honsferred contoun 1 I B. Correct shode ond contour ore providedby the oluminum oxide obutment (CerAdopt, Nobel Biocore, YorboLindo, CAl.

Figure I2. A resin stent is utilized to ensure correcl positioning ofthe cuslrom obutment within the moxillory orch.

Figure I3. Following evoluotion of contour ond gingivol morginposilion, the obutmenl is secured in ploce.

The finol impression of the obutment ond the remoining

onterior teeth wos obtoined with polyvinylsiloxone mote-

riol. All-ceromic crown restorotions (Procero AllCerom,

Nobel Biocore, Yorbo Lindo, CA) were fixed with resin

cement (Voriolink ll, lvoclor Vivodent, Amherst, NY). The

definitive full-coveroge crown restorotions were hormo-

niously integroted with the heoled soft tissues (Figures 14

through 16).

ffiiceaJ*s&mffi

During implont plocement, it is criticol to position the

fixture occording to defined three-dimensionol criterio.

The distonce between the contoct points of the restored

implont ond the teeth odiocent to the interproximol bone

crest should be o moximum of 5 mm in order to estoblish

ond mointoin o popillo.'0 ln the horizontol plone, o dis-

tonce of .l.5

mm to 2 mm should be respected between

the implont ond the odiocent teeth. ln the sogittol plone,

2 mm of buccol bone is required in order to minimize

resorption ond exposure of the restorotion's morgins.6'8

The length of the provisionolizotion process ond the

period required for the complete heoling of the soft tis-

sue depend on severol voriobles thot include the thick-

ness of the connective tissue, the extent of the surgicol

site, ond orol hygiene. These considerotions vary in eoch

individuol, ond the provisionol restorotion must be core-

fully monitored during tissue heoling. Four to six months

ore generolly required to ochieve o stoble tissue level.''

Severol cose reports hove described meons to pro-

duce o custom impression coping. Two identicol provi-

sionol restorotions - one forworded directly to the

loborotory In o pick-up impression - moy be used

occordingly.ra Bite registrotion poste (Regisil, Dentsply,/

Coulk, AAilford, DE) hos olso been utilized to duplicote

the provisionol restorotion ond subsequently fobricote

o custom impression coping.rs Vorious other moteriols

(self-cured resin, pottern resin) hove been iniected oround

o troditionol impression coping while it is connected to

the implont to ochieve o similor result.'''2 The oforemen-

tioned technique is olso useful in situotions where the

implont is ploced in o less-thon-optimol position. The

custom impression coping oids in the fobricotion of o

definitive restorotion with contour thot will mointoin the

soft tissue oestheticolly.rs

F p,A ij 351

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Practical Periodontics & ArsrHEnc DENTISTRY

Figure 14. Postroperolive occlusol view of the definitive reslorolionploced in the moxillory orch demonsholes oesthetic ond hormoniousintegrotion wirhin the moxillory orch.

Figure l5A. Rodiogroph demonskotes seoted custom impressioncoping. l5B. Rodiogroph of implont-supported restorotion 18 monthspostoperotively.

Figure 16. Fociolview of the definitive restorotion 6 months foltowingcementotion demonstrotes oesthetic plocement ond conloun

352 Vol. 12, No.4

(oncXusion

This orticle hos described the importonce of the prosthetic

ond provisionol phoses in the oesthetic restorotion of o

single implonFsupported crown restorotion. The success

of the treotment wos ottributed to thorough treotment plon-

ning ond coordinotion between the members of the restoro-

tive teom. The provisionol restorotion wos on inseporoble

component of the reconstruction process ond served on

importont role in the molding, contouring, ond heoling

of the soft tissues. The oforementioned indirect method

wos time efficient, occurote, ond did not risk the compro

mise of the sott tissues. This method olso estoblished proper

communicotion between the clinicion ond the loborotory

technicion, which ollowed the fobricotion of o precise,

noturol, ond duroble restorotion.

AcknowledgmentThe outhor mentions his grotitude to Joseph P. Cooney,

BDS, MS, Director of Advonced Prosthodontics, UCIA

School of Denfistry, ond Dentech lnf., for their ossisfonce

in the preporotion of this article. The outhor declares no

financiol interests in the products ciled herein.

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