Esthetic outcome of an immediately placed maxillary anterior single-tooth implant restored with a custom-made zirconia-ceramic abutment and crown: a staged treatment.

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(1)Q u i n t e s s e n c e I n t e r n at i o n a l. Esthetic outcome of an immediately placed maxillary anterior single-tooth implant restored with a custom-made zirconia-ceramic abutment and crown: A staged treatment Tonino Traini, DDS, PhD1/Marzia Pettinicchio, DDS1/ Giovanna Murmura, MD, DDS, PhD1/Giuseppe Varvara, DDS, PhD1/ Nicola Di Lullo, MD, DDS1/Bruna Sinjari, DDS1/Sergio Caputi, MD, DDS1 This article describes the high esthetic value of a single-tooth implant immediately placed in the anterior region using a flapless approach and a custom-made zirconia-ceramic abutment and crown. The case reported illustrates the practical procedure involved in developing natural esthetics with a custom-made zirconia-ceramic prosthesis and abutment. The technique is relatively simple, can be used in a variety of clinical situations, and provides excellent results from an esthetic point of view, which is demonstrated by the results of pink esthetic scores (PES) (9 ± 0.2) and white esthetic scores (WES) (7 ± 0.5) after 4 years. (Quintessence Int 2011;42:103–108). Key words: esthetics, implant, implant-prosthetic dentistry, treatment planning, zirconia abutment. In the past decade, one of the biggest chal-. restorations, improving both the biologic and. lenges of implant dentistry has been the devel-. physiologic aspects. To assess the long-. opment of gingival esthetics, especially in the. term performance of the restoration from. anterior maxillary region. Implant therapy in. an esthetic point of view, the pink and. partially edentulous patients has become. white dimensions of esthetic restorations in. highly predictable.1 Nevertheless, implant. a 57-year-old woman were measured after. placement and single-tooth restoration in. 4 years using recently introduced indices.4,5. the anterior area can present some complications. Using immediate implant placement, mucosal recession was reported.2,3 Moreover, the underlying titanium abutment can. reduce. the. porcelain. Case presentation. translucency,. resulting in a darkened prosthesis. The use. A 57-year-old woman in good overall health. of zirconia in daily practice can provide har-. who smoked needed a replacement maxil-. monious gingival architecture around implant. lary right lateral incisor. After tooth extraction, a titanium dental implant (Bone System) 4.1 mm in diameter and 12 mm in length was. Section of Prosthodontics, Department of Oral Sciences, Nano,. 1. and Biotechnologies, Dental School, University of ChietiPescara, Chieti, Italy. Correspondence: Dr Tonino Traini, Via dei Vestini 31, 66100 Chieti, Italy. Email: t.traini@unich.it. inserted without flap elevation (Figs 1a to 1d). The day of reopening was set as day 0 for the study. Within 7 days, a provisional acrylic crown was inserted to initiate the. VOLUME 42 • NUMBER 2 • FEBRUARY 2011. 103. © 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER..

(2) Q u i n t e s s e n c e I n t e r n at i o n a l Tr a i n i e t a l. a. b. c. d. Fig 1 (a) Preoperative clinical condition upon presentation for treatment of a compromised maxillary right lateral incisor. (b) Preoperative radiographic evaluation. (c) Radiographic evaluation during surgery for immediate implant positioning protocol. (d) Postoperative radiograph 4 months following implant positioning. (e) Acrylic provisional restoration.. e. peri-implant soft tissue conditioning phase. ceramic crown (Figs 2g to 2i). A biscuit-bake. (Fig 1e). The provisional crown was gradu-. try-in session was carried out prior to finalizing. ally enlarged to optimize both the soft tissue. the zirconia-based all-ceramic suprastruc-. contour and the morphology of the restora-. tures (Fig 3). After 4 years, an esthetic evaluation. tion until the soft tissue healed (Fig 2a). After the soft tissue healed, an impres-. based on the pink esthetic score (PES). sion was made to prepare a custom-made. (Figs 4a to 4e) comprised five variables:. abutment (Fig 2b). Additionally, the labora-. mesial papilla, distal papilla, curvature of. tory technician was provided with an alginate. the facial mucosa, level of the facial muco-. impression of the provisional restoration to. sa, and root convexity/soft tissue color. customize the emergence profile of the trans-. and texture. A score value of 0 (absent), 1. gingival portion of the abutment by means of. (incomplete), or 2 (complete) was assigned. an overpressed ceramic layer to zirconia (Figs. to all five parameters. The scores also. 2c to 2e). At this point, a titanium milled post. identified the level of discrepancy (major,. was cemented inside the implant-zirconia. 0; minor, 1; none, 2) compared to the natu-. abutment unit (Fig 2f). Finally, a conventional. ral control tooth. A score of 10 was for the. impression was made to prepare a zirconia-. optimum conditions, while the threshold. 104. VOLUME 42 • NUMBER 2 • FEBRUARY 2011. © 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER..

(3) Q u i n t e s s e n c e I n t e r n at i o n a l Tr a i n i e t a l. a. b. c. d. e. f. g. h. i. Fig 2 (a) Conditioned peri-implant mucosa before impression. (b) The impression of the customized peri-implant soft tissue was made through the custom-made healing abutment itself to maintain the exact contour. (c) Customization of the standard zirconia core with casting wax. (d) Ceramic pressed to zirconia was used to complete both the shape and color of the transgingival portion of the definitive abutment. (e) The gingival portion of the definitive abutment in place. (f) Definitive abutment in situ. The customized portion of the abutment was made in zirconia, covered with colored ceramic, and connected to the implant body through friction. The remaining part of the abutment was titanium and cemented to the implant body as a cast post to a tooth. (g) Soft tissue displacement by a gingival cord. (h) Final impression. (i) Master cast.. VOLUME 42 • NUMBER 2 • FEBRUARY 2011. 105. © 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER..

(4) Q u i n t e s s e n c e I n t e r n at i o n a l Tr a i n i e t a l. a. b. c. d. e. f. Fig 3 (a) Colored zirconia core on the master cast. (b) Zirconia core after liner baking, which was used to improve the ceramiczirconia bonding. (c) Ceramic buildup. (d) Facial aspect of the zirconia-ceramic crown on the master cast. (e) Palatal aspect of the zirconia-ceramic crown on the master cast. (f) Final restoration during the clinical try-in procedure.. of clinical acceptability was set to 6. The. choosing. white esthetic score (WES) (Fig 4f) also. single-unit case, several factors should. an. abutment. for. an. anterior. comprised five parameters: tooth form,. be considered, including visibility of the. tooth outline and volume, color (hue and. region, biotype of the gingiva, color of the. value), surface texture, and translucency.. neighboring teeth, and esthetic expecta-. A score value of 0, 1, or 2 was assigned to. tions of the patient. In esthetically demand-. all five parameters. The parameters were. ing situations, a custom-made abutment. assigned by comparing the results with the. technique is indicated because several. natural contralateral control tooth. As with. advantages, such as enhancement of the. the PES, the optimum-condition WES was. emergence profile, the preservation and. 10, while the threshold of clinical accep-. development of full interdental papillae,. tance was set at a score of 6.. and the maintenance of natural soft tis-. The esthetic scores (mean ± SD), evalu-. sue contours. PES and WES are suitable. ated by five examiners, after 4 years of func-. parameters for reproducible evaluation of. tion were (9 ± 0.2) for PES and (7 ± 0.5) for. the soft tissue around single-tooth implant. WES (Figs 4e and 4f and Table 1).. crowns. In the present results, the analysis revealed a mean PES score of 9, which demonstrates that the use of a custommade zirconia abutment can be beneficial. Discussion. in the esthetic zone, and a mean WES score of 7, implying the importance of the. Along with good survival rates, esthetic. dental technician in the manufacturing of. factors are important for the success of. an all-ceramic suprastructure to provide. restorations in the anterior region. When. optimal esthetic results.. 106. VOLUME 42 • NUMBER 2 • FEBRUARY 2011. © 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER..

(5) Q u i n t e s s e n c e I n t e r n at i o n a l Tr a i n i e t a l. a. b. c. d. e. f. Fig 4 (a) Definitive restoration after cementing. (b) The arrow indicates a healing defect of the curvature of facial mucosa present 1 week after cementing. (c) Clinical view of the root convexity of peri-implant mucosa (arrows). (d) After 4 years, the defect of the curvature of facial mucosa has disappeared (arrow). (e) PES evaluation areas. (f) WES evaluation areas.. Table 1. Summary of PES and WES scores Examiners MG. VG. SB. DN. CS. Mean (± SD). Mesial papilla. 2. 2. 1. 2. 2. 1.8 (0.4). Distal papilla. 2. 2. 2. 2. 2. 2.0 (0.0). Curvature of facial mucosa. 1. 1. 2. 1. 2. 1.4 (0.5). Level of facial mucosa. 2. 2. 1. 2. 2. 1.8 (0.4). Root convexity/soft tissue color and texture. 2. 2. 2. 2. 2. 2.0 (0.0). PES. Total score for PES (mean ± SD). 9 ± 0.2. WES Tooth form. 1. 1. 1. 2. 1. 1.2 (0.4). Tooth volume and outline. 1. 2. 1. 1. 2. 1.4 (0.5). Color (hue and value). 2. 2. 1. 2. 2. 1.8 (0.4). Surface texture. 2. 1. 2. 1. 0. 1.2 (0.8). Translucency. 1. 2. 2. 1. 1. 1.4 (0.5). Total score for WES (mean ± SD). 7 ± 0.5. SD, significant difference.. VOLUME 42 • NUMBER 2 • FEBRUARY 2011. 107. © 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER..

(6) Q u i n t e s s e n c e I n t e r n at i o n a l Tr a i n i e t a l. Acknowledgments. 3. Buser D, Chen ST, Weber HP, Belser UC. Early implant placement following single-tooth extrac-. The authors are grateful to Luca Ciarrocchi, CDT, for carrying out the laboratory procedures.. tion in the esthetic zone: Biologic rationale and surgical procedures. Int J Periodontics Restorative Dent 2008;28:440–451. 4. Belser UC, Grütter L, Vailati F, Bornstein MM, Weber HP, Buser D. Outcome evaluation of early placed maxillary anterior single-tooth implants using. References. objective esthetic criteria: A cross-sectional, ret-. 1. Naert I, Koutsikakis G, Duyck J, Quirynen M, van Steenberghe D, Jacobs R. Biologic outcome of implant-supported restorations in the treatment of partial edentulism. Part I: A longitudinal clinical evaluation. Clin Oral Implants Res 2002;13:381–389. 2. Chen ST, Wilson TG, Hammerle CH. Immediate or early placement of implants following tooth extraction: Review of biologic basis, clinical procedures, and outcomes. Int J Oral Maxillofac Implants. rospective study in 45 patients with a 2- to 4-year follow-up using pink and white esthetic scores. J Periodontol 2009;80:140–151. 5. Buser D, Halbritter S, Hart C, et al. Early implant placement with simultaneous guided bone regeneration following single-tooth extraction in the esthetic zone: 12-month results of a prospective study with 20 consecutive patients. J Periodontol 2009;80:152–162.. 2004;19(suppl):12–25.. 108. VOLUME 42 • NUMBER 2 • FEBRUARY 2011. © 2010 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER..

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