428 | The International Journal of Esthetic Dentistry | Volume 15 | Number 4 | Winter 2020
CLINICAL RESEARCH
Combining a single implant
and a veneer restoration
in the esthetic zone
Jose Villalobos-Tinoco, DDS
Department of Restorative Dentistry, Autonomous University of Queretaro School of
Dentistry, Queretaro, Mexico
Nicholas G. Fischer, BS
Minnesota Dental Research Center for Biomaterials and Biomechanics, University of
Minnesota School of Dentistry, Minneapolis, Minnesota, USA
Carlos Alberto Jurado, DDS, MS
Clinical Digital Dentistry, A.T. Still University Arizona School of Dentistry & Oral Health,
Mesa, Arizona, USA
Mohammed Edrees Sayed, BDS, MDS, PhD
Department of Prosthetic Dental Sciences, Jazan University College of Dentistry, Jazan,
Saudi Arabia
Manuel Feregrino-Mendez, DDS
Periodontal Private Practice, Queretaro, Mexico
Oriol de la Mata y Garcia, CDT
Dental Technician, Private Practice, Puebla, Mexico
Akimasa Tsujimoto, DDS, PhD
Department of Operative Dentistry, Nihon University School of Dentistry, Tokyo, Japan
Correspondence to: Nicholas G. Fischer
Minnesota Dental Research Center for Biomaterials and Biomechanics, University of Minnesota School of Dentistry,
515 Delaware Street SE, Minneapolis, Minnesota 55455, USA; Tel: +1 612 625 0950; Email: [email protected]
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Abstract
Objective: The combination of partial edentulism
and a worn anterior tooth in the esthetic zone can
be a challenge for the dentist. This clinical situation
requires extensive knowledge of soft and hard tissue
management, surgical planning and execution for
implant therapy, and conservative tooth preparation
with ideal bonding protocols for the tooth-supported
prosthesis. Moreover, an optimal selection of the final
restorative materials is imperative to manage occlusal
forces and fulfill the patient’s esthetic demands.
Materials and methods: The patient presented with
partial edentulism on site 11, a worn incisal edge, and
facial defects on tooth 21. Minimally invasive implant
therapy for site 11 was performed with a papilla-spar-
ing flap design that only included the edentulous site,
and the soft tissue contouring was started for an im-
mediate provisional restoration. A suturing technique
was executed that aimed at maintaining an interproxi-
mal papilla. Conservative veneer preparation was per-
formed on tooth 21 in order to bond the restoration
to the enamel structure. Final restorations included a
custom abutment with a lithium disilicate fused to zir-
conia crown for the implant on site 11 and a lithium
disilicate veneer on tooth 21.
Conclusions: A well-planned single implant and a ce-
ramic veneer restoration was able to fulfill the patient’s
esthetic expectations. The selection of materials for
the final restoration was crucial to manage the occlu-
sal forces and to mimic the shade and shape of the
adjacent teeth.
(Int J Esthet Dent 2020;15:2–11)
429
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430 | The International Journal of Esthetic Dentistry | Volume 15 | Number 4 | Winter 2020
texture, and various other aspects of the
implant-associated soft tissue need to look
similar to the surrounding soft tissue to max-
imize the esthetic outcomes.19,20 To achieve
this, provisional implant prostheses help to
create and form the ideal peri-implant tis-
sue.21 The timing of the placement of pro-
visional implant restorations (immediate as
opposed to 6 months, for example) is in-
formed by many factors such as the implant
stability and the amount of graft applied.22,23
Ceramic veneers are a conservative
treatment option for teeth presenting with
defects, fractures, etc. These bonded ce-
ramic veneers have shown successful long-
term results.24,25 The long-term success of
ceramic veneer restorations is dependent
on components such as restoration de-
sign26 and adhesive methods,27 among oth-
er factors.28 While the reduction of tooth
structure is usually needed for the place-
ment of veneers, excessive or overzealous
tooth preparation can expose the dentin
and detrimentally affect the bonding of
veneers.29 Recent advances in technology
have made it possible to produce ultrathin
ceramic veneers with a thickness of only
0.5 mm, which bond to the tooth structure
with little hard tissue removal.30 There are
many dental ceramic options and formu-
lations currently available31,32 that produce
acceptable esthetic results and bond dura-
bility.33 Minimal tooth reduction can provide
positive fracture characteristics when res-
in-based cements are used to bond ceram-
ic veneers to the underlying tooth,34,35 with
good survival rates.36 The aim of this report
is to show a clinical protocol combining a
single implant and a veneer restoration in
the esthetic zone.
Clinical report
A 40-year-old female patient presented at
our dental clinic with the chief complaint
of having lost an anterior tooth. Her wish
Introduction
Anterior tooth loss presents a major esthet-
ic challenge to dentists because any small
defect is projected in the patient’s smile.1
Partial edentulism can be managed with
conventional dentistry and implant pros-
thodontic therapy, but both require proper
planning to achieve ideal esthetic results.2-4
Tooth-supported fixed restorations function
well, but esthetic and oral hygiene may be
compromised if the design of the soft tis-
sue and pontic is not properly achieved.5
On the other hand, while partial remov-
able prostheses may meet esthetic require-
ments, the lack of stability could interfere
with other functions such as mastication.6
For both treatment options, conventional
restorations can detrimentally affect the re-
tention and/or support of the neighboring
teeth.
Implant therapy is the standard treat-
ment provided by most clinicians as it pre-
serves the adjacent teeth and provides a
predictable long-term solution.7,8 Several
studies have shown fairly similar success
rates for implants placed in the maxillary
esthetic zone compared with those placed
in posterior sites.9-11 While implant survival
is obviously crucial and many studies have
focused on it, fewer have evaluated the es-
thetic outcome of implants placed in the
maxillary esthetic zone, despite this being
crucial to many patients.12-14
Maxillary alveolar ridge (anterior) thick-
ness can compromise esthetic expectations
for implant therapy. In these situations, hard
and soft tissue grafting may be required.15
This complexity could increase when pa-
tients present thin gingival phenotypes or
limited mesiodistal space.16 The tradition-
al approach for implant therapy in the es-
thetic zone might include the extraction of
a non-restorable tooth and a bone graft-
ing procedure, followed by a healing time
of about 3 to 4 months.17,18 The thickness,
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431The International Journal of Esthetic Dentistry | Volume 15 | Number 4 | Winter 2020 |
decided to place an immediate implant on
edentulous site 11. Implant placement with
immediate provisional restorations was
planned, as it is a common procedure to es-
tablish an ideal emergence profi le in order
to provide maximum tissue volume, pre-
serve the midfacial gingiva, and ensure pa-
tient comfort and treatment acceptance.37,38
A customized, anatomical, screw-retained
provisional restoration was selected to
manage the emergence profi le. The shape
of the provisional restoration is key to
achieving good esthetics. The plan was to
fabricate the fi nal crown out of lithium disil-
icate, which provides excellent strength and
toughness compared with other materials.39
At the surgical appointment, local anes-
thesia was applied by infi ltration with 1.8 ml
of 4% articaine hydrochloride with epineph-
rine 1:100,000 (Septocaine), and infraorbital
blocks of 3.6 ml of 0.5% bupivacaine hydro-
chloride with 1:100,000 epinephrine (Mar-
caine). A papilla-sparing fl ap was designed
and elevated,40 with the aim of exposing the
area of the edentulous site and preventing
gingival recession in the adjacent teeth. An
implant (Neobiotech) of 4 × 13 mm was
was for an implant to replace the lost tooth
(Fig 1). The patient stated that her tooth (11)
had been fractured in a car accident and she
had undergone an emergency extraction of
it 3 months prior to her fi rst visit. She was
also concerned about the incisal wear and
facial defects on tooth 21 (Fig 2). After the
initial clinical evaluation, the patient was in-
formed of the need for a diagnostic wax-
up to evaluate the tentative position and
contours of the restoration as well as for
a CBCT evaluation to evaluate the residual
bone in the edentulous site. She approved
the treatment plan.
Diagnostic casts were made and a diag-
nostic wax-up (GEO Classic; Renfert) was
fabricated to take the patient’s wishes into
account and provide her with a harmonious
smile. After presenting the patient with the
diagnostic wax-up, a diagnostic mock-up
was performed with temporary bis-acrylic
material (Structur Premium; Voco). She was
pleased with the initial result and consented
to the treatment.
After the CBCT evaluation and treat-
ment plan discussion between the patient,
periodontist, and restorative dentist, it was
Fig 1 Patient’s initial smile. Fig 2a and b Initial smile and intraoral situation.
a
b
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CLINICAL RESEARCH
432 | The International Journal of Esthetic Dentistry | Volume 15 | Number 4 | Winter 2020
A titanium custom abutment was de-
signed and fabricated on implant 11, and
a conservative veneer restoration was pro-
vided for tooth 21 (Fig 8). A final crown of
lithium disilicate fused to a zirconia core
for implant 11 and a pressed lithium disil-
icate veneer for tooth 21 were fabricated
(Fig 9). Periodic radiographs were taken af-
ter the impression (Fig 10a), the abutment
placement (Fig 10b), and the final crown
placement (Fig 10c). The crown was ce-
mented using a resin-modified glass-ion-
omer cement (RelyX Luting Plus Cement;
3M ESPE), and the lithium disilicate res-
toration was bonded with a resin cement
(Panavia V5; Kuraray Noritake Dental) fol-
lowing the protocols recommended by
the manufacturers (Figs 11 and 12). The
patient was provided with a night guard
to protect her dentition and restorations.
A CBCT was taken at the 2-year follow-up
(Fig 13). The patient was still satisfied with
the restoration at the 3-year follow-up
(Fig 14).
then placed at site 11 following the manu-
facturer’s specifications (Fig 3). The pa-
tient presented a thick periodontal pheno-
type.41,42 Suturing was performed with 5-0
chromic gut sutures (PolySyn FA; Surgical
Specialties), and a coronally repositioned
vertical mattress suture was used to achieve
primary soft tissue closure. An immediate
provisional restoration (Fig 4) in self-curing
acrylic resin (Jet Tooth Shade; Lang Dental)
was then placed. The provisional restoration
contoured the soft tissue until it had a simi-
lar appearance to the adjacent teeth (Figs 5
and 6). This provisional stage requires mod-
ification of the prosthesis until the peri-im-
plant soft tissue mimics the soft tissue of the
adjacent teeth. A final impression was made
with a closed tray technique, and a titanium
custom abutment was planned (Fig 7) for
placement after approximately 6 months.
Postoperative instructions were given to the
patient, along with a prescription for chlor-
hexidine gluconate twice a day, and ibupro-
fen (600 mg) three times a day for 1 week.
Fig 4 Provisional
restoration fabrica-
tion.
Fig 3a and b
Implant placement.
Fig 5 Immediate
implant provisional
restoration.
a b
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433The International Journal of Esthetic Dentistry | Volume 15 | Number 4 | Winter 2020 |
Fig 6 Soft tissue contouring with the provisional restoration. Fig 7 Closed tray impression.
Fig 8 Custom abutment and veneer preparation. Fig 9 Fabrication of the final restorations.
Fig 10 Radiographs following
the impression (a), abutment
placement (b), and final crown
placement (c).a b c
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434 | The International Journal of Esthetic Dentistry | Volume 15 | Number 4 | Winter 2020
planning.43,44 The patient’s pretreatment
implant evaluation included a consultation
to establish a solid diagnosis and progno-
sis. Her restorative and periodontal needs
were considered, together with her esthet-
ic expectations. Diagnostic casts, radio-
graphs, and CBCT are needed to enhance
Discussion
Esthetic risk assessment needs to be per-
formed prior to starting treatment. Achiev-
ing a long-term esthetic outcome de-
pends on a restorative-driven approach,
and starts with comprehensive presurgical
Fig 11a and b Final restorations.
Fig 12 Patient’s smile at the end of the treatment.
a
b
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435The International Journal of Esthetic Dentistry | Volume 15 | Number 4 | Winter 2020 |
The diagnostic wax-up provided impor-
tant information concerning the tentative po-
sition of the future implant and the contours
of the ceramic veneer. Three-dimensional
planning for implant therapy is key to evalu-
ate the amount of alveolar ridge that is avail-
able for implant placement. The outcome
presurgical planning and preparation.45,46
Another factor that should be considered is
to inform patients that alveolar growth can
occur and might require intervention later
on in life.47 In this case, the 3-year follow-up
showed a very stable outcome and contin-
ued patient satisfaction.
Fig 13a to c CBCT
scans at 2-year
follow-up.a
b
c
Fig 14 Three-year
follow-up.
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436 | The International Journal of Esthetic Dentistry | Volume 15 | Number 4 | Winter 2020
cause recession to occur on the adjacent
teeth.
The choice of cemented or screw-re-
tained restorations is controversial. Both
types of single implant crowns have their
advantages and disadvantages.55 Cemented
restorations are thought to be more esthet-
ic due to the lack of a visible screw access.56
The implant trajectory will only determine
the type of retention method, either ce-
mented or screw-retained; however, both
can achieve the same esthetic results. The
implant trajectory in this case followed the
incisal edge. This was the main reason for
the decision to fabricate cement-retained
restorations.57 Despite the use of a custom
or stock abutment, the absence of residual
excess cement cannot be guaranteed.58
There is no universal agreement about the
type of luting cement to use for cement-re-
tained implant restorations. Usually cements
are chosen arbitrarily, and clinicians tend to
select familiar techniques used for natural
teeth.59 Studies demonstrate that excess res-
in cement is very difficult to remove and pro-
motes substantially higher bacterial biofilm
growth compared with other cements such
as glass-ionomer or zinc phosphate.60 In this
case, a resin cement was used, and the ce-
mentation procedure was performed using
an extraoral pre-extrusion step before ce-
mentation. The excess cement was removed
extraorally from the crown using a copy
abutment and then cemented intraorally.
A titanium custom abutment was used in
this case due to cost considerations. Despite
titanium being a gold standard abutment
material, it has demonstrated more bleed-
ing on probing compared with zirconia.
Moreover, zirconia has similar blood flow
to natural teeth, which might suggest that
it is also a suitable abutment material.61,62
Furthermore, in vitro evidence suggests that
gingival fibroblasts, which are key to the
creation of an epithelial layer during reepi-
thelization to ensure implant survival and
of this evaluation might dictate the need
for hard and soft tissue grafting procedures.
This 3D evaluation also allows the clinician
to consider different brands and implant
dia meters. The diagnostic wax-up can also
be used to fabricate tooth reduction guides
for veneer preparation. Ridge preservation
or socket conversion procedures are crucial
at the time of tooth extraction to minimize
the natural resorption that occurs in the
presence of a thin buccal plate.48 In general,
narrow-diameter implants provide the de-
sired buccal bone thickness of 2 to 3 mm.
On the other hand, wider-diameter implants
can lead to marginal gingival recession.49,50
Less bone loss occurs around bone-level
implants placed in naturally thick mucosal
tissue compared with thin phenotypes.51
For this patient, a 4-mm–diameter implant
was used after measuring the mesiodistal
space available at the edentulous site and
the alveolar ridge thickness using the CBCT.
It has been reported that a flapless implant
placement approach minimizes the possi-
bility of peri-implant tissue loss postoper-
atively and hence reduces the challenges
of soft tissue management after implant
placement in patients with sufficient kerati-
nized gingival tissue.52 Other benefits of the
flapless approach are that it saves surgery
time, promotes postsurgical healing, and
is generally more comfortable for the pa-
tient.53 The disadvantage of this approach is
the limited view of the surgical site; the un-
derlying bone cannot be observed, which
might cause unwanted perforation that can
lead to adverse biologic and esthetic com-
plications.54 The limited clinical view could
also cause thermal trauma to the underly-
ing bone due to the lack of external irriga-
tion, so that it does not reach the full depth
of the osteotomy during site preservation.
The present implant therapy was performed
with a papilla-sparing flap design. This is
very conservative because the flap is only
released on the implant site, which does not
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437The International Journal of Esthetic Dentistry | Volume 15 | Number 4 | Winter 2020 |
Conclusion
For many reasons, the combination of im-
plant placement and a veneer restoration
in the esthetic zone might be challenging
for the dentist. Significant knowledge of im-
plant planning and placement, flap design,
suturing techniques, provisional restoration
soft tissue contouring, and ideal material
selection for the final restorations is fun-
damental to achieve good esthetic results.
Conservative tooth preparation to maintain
the enamel structure is crucial for the long-
term success of bonded ceramic veneers.
The material chosen for these types of res-
torations needs to withstand the occlusal
demands as well as satisfy the patient from
an esthetic point of view. The presented
case report successfully combined a lithium
disilicate fused to zirconia restoration for
the implant on site 11, and a lithium disilicate
veneer for tooth 21.
favorable esthetics, are not negatively influ-
enced by titanium abutment materials.63-65
In recent years, dental implant therapies
have become a predictable treatment for
single-tooth replacement, but mindful treat-
ment planning is fundamental to meet the
esthetic challenges of the anterior esthetic
zone. The role of the provisional prosthesis
is critical to form a ‘scallop’ with the soft tis-
sue in order to make it similar to the gingival
margin of the natural tooth.66 Contour man-
agement of provisional restorations and sur-
rounding soft tissue is equally important, as
has recently been noted.67 The high esthet-
ic demand for partial edentulous areas and
facial defects in adjacent teeth can be met
by the clinician through careful attention.
The simultaneous fabrication of the veneer
and implant restoration allowed the dental
technician the opportunity to match identi-
cal shapes and shades in order to create a
more natural-looking result.
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