The Journal of Implant & Advanced Clinical Dentistry Neurofibromatosis … · The Journal of...

The Journal of Implant & Advanced Clinical Dentistry

Volume 9, No. 9 NoVember 2017

Neurofibromatosis Type 1 Rehabilitation with Dental Implants

Maxillary Anterior Implant Temporization

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Volume 8, No. 8 December 2016

Full Mouth Rehabilitation of Periodontitis Patient

Implant-Supported Milled Bar

Overdenture


Volume 8, No. 1 march 2016

Treatment of the Atrophic Maxilla with Autogenous Blocks

Modified Mandibular Implant Bar Overdenture


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Treatment of Mandibular Central Giant Cell Granuloma

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Implant Placement


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Mandibular Overdentures with Mini-Implants

Augmentation of Severe Ridge Defect with rhBMP-2

and Titanium Mesh

The Journal of Implant & Advanced Clinical DentistryVolume 9, No. 9 • NoVember 2017

Table of Contents

6 Dental Rehabilitation of a Patient with Neurofibromatosis Type 1 Robert L. Schneider, Stephen L. Fletcher, Kyle M. Stein

14 Prosthetic Implant Management of Extraction Site Following Removal of Anterior Tooth Tony Daher, Georgina El Ghoule, Vahik P. Meserkhani, Nick Caplanis

2 • Vol. 9, No. 9 • November 2017

The Journal of Implant & Advanced Clinical Dentistry • 3


Table of Contents

28 A Novel Technique to Optimize Screw-Retained Implant Restorations Dr. Ira Langsteint


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4 • Vol. 9, No. 9 • November 2017


Tara Aghaloo, DDS, MDFaizan Alawi, DDSMichael Apa, DDSAlan M. Atlas, DMDCharles Babbush, DMD, MSThomas Balshi, DDSBarry Bartee, DDS, MDLorin Berland, DDSPeter Bertrand, DDSMichael Block, DMDChris Bonacci, DDS, MDHugo Bonilla, DDS, MSGary F. Bouloux, MD, DDSRonald Brown, DDS, MSBobby Butler, DDSNicholas Caplanis, DMD, MSDaniele Cardaropoli, DDSGiuseppe Cardaropoli DDS, PhDJohn Cavallaro, DDSJennifer Cha, DMD, MSLeon Chen, DMD, MSStepehn Chu, DMD, MSD David Clark, DDSCharles Cobb, DDS, PhDSpyridon Condos, DDSSally Cram, DDSTomell DeBose, DDSMassimo Del Fabbro, PhDDouglas Deporter, DDS, PhDAlex Ehrlich, DDS, MSNicolas Elian, DDSPaul Fugazzotto, DDSDavid Garber, DMDArun K. Garg, DMDRonald Goldstein, DDSDavid Guichet, DDSKenneth Hamlett, DDSIstvan Hargitai, DDS, MS

Michael Herndon, DDSRobert Horowitz, DDSMichael Huber, DDSRichard Hughes, DDSMiguel Angel Iglesia, DDSMian Iqbal, DMD, MSJames Jacobs, DMDZiad N. Jalbout, DDSJohn Johnson, DDS, MSSascha Jovanovic, DDS, MSJohn Kois, DMD, MSDJack T Krauser, DMDGregori Kurtzman, DDSBurton Langer, DMDAldo Leopardi, DDS, MSEdward Lowe, DMDMiles Madison, DDSLanka Mahesh, BDSCarlo Maiorana, MD, DDSJay Malmquist, DMDLouis Mandel, DDSMichael Martin, DDS, PhDZiv Mazor, DMDDale Miles, DDS, MSRobert Miller, DDSJohn Minichetti, DMDUwe Mohr, MDTDwight Moss, DMD, MSPeter K. Moy, DMDMel Mupparapu, DMDRoss Nash, DDSGregory Naylor, DDSMarcel Noujeim, DDS, MSSammy Noumbissi, DDS, MSCharles Orth, DDSAdriano Piattelli, MD, DDSMichael Pikos, DDSGeorge Priest, DMDGiulio Rasperini, DDS

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Founder, Co-Editor in ChiefDan Holtzclaw, DDS, MS

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Schneider et al

Neurofibromatosis not only manifests in several physical issue but may also affect the oral cavity. Rehabilitation of

the dentition will likely involve several dental specialty disciplines in coordination with medi-cal colleagues. This case report demonstrates

the coordination of treatment of a neurofibro-matosis type I (NF1) patient to correct her dental issues along with efforts to improve her facial deformity. The oral and maxillofacial sur-gery and prosthodontic treatment is described.

Dental Rehabilitation of a Patient with Neurofibromatosis Type 1

Robert L. Schneider, DDS, MS1 • Stephen L. Fletcher, DDS2 Kyle M. Stein, DDS2

1. Professor Emeritus, University of Iowa Hospitals and Clinics, Hospital Dentistry Institute,Iowa City, Iowa, USA

2. Associate Professor, University of Iowa Hospitals and Clinics, Hospital Dentistry Institute,Iowa City, Iowa, USA

Abstract

KEY WORDS: Neurofibromatosis type I, dental implants, mandibular hypoplasia, dental extractions, occlusion, CAD/CAM, titanium milled framework

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Schneider et al


BACKGROUNDA 21 year old female was referred to our dental clinic from otolaryngology for evaluation of her dental condition. Her medical history was sig-nificant for Neurofibromatosis type I with exci-sion of multiple facial and arm fibromas. With the previous excision of facial lesions, cranial nerve VII was sacrificed so she also exhibits left hemi-facial paralysis. She is planning on having soft tis-sue de-bulking with a facial sling and other facial

Figure 1: Frontal view of the patient at initial presentation. Figure 2: Panoramic radiograph at initial presentation.

Figure 3a: Lateral intraoral view following initial extractions and healing.

Figure 3b: Maxillary occlusal view following initial extractions and healing.

Figure 3c: Mandibular occlusal view following initial extractions and healing.

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plastic surgery including facial “re-animation” fol-lowing completion of her dental rehabilitation.

Neurofibromatosis type 1 or NF-1 is an auto-somal dominant genetic disease also known as von Recklinghausen’s disease.1 Patients with NF-1 lesions are nearly always benign but they do have an increased risk of developing other tumors both benign and malignant.1 The diag-nosis is based on the patient having at least two

of the following: six or more café au lait macules > 5mm in pre-pubertal individuals or 15 mm in post-pubertal individuals, two or more neurofibro-mas of any type or one plexiform neurofibroma, freckling in the axillar or inguinal regions, optic glioma, two or more Lisch nodules (iris hamarto-mas), distinctive bony lesions (sphenoid dysplasia or thinning of long bone cortex or a first degree relative with NF 1 with the previous criteria.2-3 Several dental issues are also possibly present.4-7 Soft tissue lesions that arise from a single site along a peripheral nerve and presents as a focal mass with well-defined margins. Most are found on the skin and the head and neck region. The most common sites are the scalp, neck, cheek and oral cavity. The patient can also exhibit radio-graphic findings that can include and enlarged mandibular canal and mental foramen.8 A con-cern is also the presence of impacted, missing and displaced teeth particularly in the mandible. Additionally shortening of the ramus, notching of the inferior border of the mandible narrowing and

Figure 4: Panoramic radiograph following the initial extractions and healing.

Figure 5: Diagnostic wax-up intraoral try-in.

Figure 6: Panoramic radiograph post implant placement.

Schneider et al


rarefaction of the coronoid and articular process. Cranial and jaw bone abnormalities are fre-

quently identified in patients with NF-1 that affect the sphenoid bone causing sphenoid dysphasia, which can cause alterations resulting in hypopla-sia or resorption of the mandibular complex.8-11 Many articles have attempted to link NF-1 with

an increase rate of dental caries which is still not completely confirmed by various clinical studies.12

When the patient presented to the den-tal clinic for exam the following general evalu-ation was initially made. She presented with a significant dentoskeletal deformity on the left due to her extensive neurofibromatosis (figure 1). Her right side occlusion is fairly well interdigitated and the left side is not functional. Her oral hygiene was poor with active dental car-ies. There were multiple impacted teeth on the left side (figure 2). She would like teeth to chew with on the left side and to be able to speak more clearly with properly functional teeth. She denied any V2/V3 paresthesia on the left side but does exhibit significant hypo mobility of her hypertrophic tissue on the left side of her face.

Following prosthodontic evaluation it was decided that the noon-restorable and impacted teeth #10, 11, 11s, 12, 13, 15, 17, 18, 19, 20, 21, 22, 23, and 24 be removed in the operating room with general anesthesia. Following ade-

Figure 7a: Intraoral four month post op implant placement with custom healing abutments due to soft tissue thickness.

Figure 7b: Panoramic radiograph of four month healing with custom abutments on all implants.

Figure 8: Intraoral try in of the verification index to verify accuracy of the master cast prior to fabrication of the milled titanium framework.

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Figure 9a: Lateral view of the maxillary laboratory scan for the CAD/CAM milled framework.

Figure 9b: Occlusal view of the maxillary laboratory scan for the CAD/CAM milled framework.

quate healing further evaluation would be com-pleted to determine if alveolar grafting would be required prior to placing dental implants for res-toration of the left posterior maxilla and mandible with fixed implant restorations utilizing a screw retained titanium framework with prosthetic den-ture teeth and an acrylic wrapped prosthesis due to the significant amount of alveolar deformity.13-15

Following the extractions healing was unevent-ful with a normal postoperative course (figures 3a, 3b, 3c, 4). She also consulted with a facial-plastic surgeon and maxillofacial prosthodon-tics. It was determined that dental implants and fixed restorations would be completed so that the plastic surgeon could attempt a facial sling procedure to support the hypertrophic tissue on the left side of the patients face and con-sider an attempt at re-animation of the dam-aged facial nerve from previous lesion excisions.

Four months following the extractions her healing was satisfactory to begin her defini-tive prosthodontic treatment. At this time oral hygiene had greatly improved and remaining

carious lesions treated. Diagnostic casts were made for mounting and evaluation. The casts were utilized for diagnostic waxing and fabrica-tion of the surgical guides (figure 5). It was also determined through evaluation of the diagnostic casts and CBCT that no alveolar grafting would be required and implants could be successfully placed in predetermined locations due to sat-isfactory alveolar volume. Also following evalu-ation of the casts and CBCT it was determined by the prosthodontist that due to the malposition/impaction of teeth #25 and 28s they should be removed at time of implant placement to facili-tate development of a satisfactory occlusion.

Surgical guides were fabricated and utilized in placement of the implants in sites # 18, 20 and 22 along with the extractions. In the maxilla implants were placed in sites #11, 13 and 15. A particulate augmentation material was utilized by the surgeon in the placement of the implant in site 15 due to a slight distal osseous defect. Due to the thickness of the tissue custom milled 17mm healing caps were utilized in selected

Schneider et al


Figure 10a: Occlusal view of the definitive mandibular prosthesis.

Figure 10b: Lateral view of the definitive mandibular prosthesis.

Figure 10c: Lateral view of the definitive maxillary prosthesis.

Figure 10d: Gingival view of the definitive mandibular prosthesis showing convex pontic design to facilitate oral hygiene procedures. The same gingival design was utilized in the maxillary prosthesis.

sites as the standard 4.5 mm healing caps would have been covered with soft tissue necessitating a secondary procedure (figure 6). The surgeon determined that due to the quality of the alveo-lar hard tissue a healing time of five months was recommended prior to finalizing the restorations.

Healing was uneventful with no signs or symp-

toms of infection, good oral hygiene and good stability of the implants noted (figures 7a, 7b). At the five month healing period the soft tissue was healthy and the thickness was within normal limits so that several of the long custom abutments were removed and standard length healing abutments were placed, also preliminary irreversible alginate

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Figure 11: Delivery panoramic radiograph showing intimate fit of the frameworks and good alveolar bone levels.

Figure 12: Patient smile with prostheses providing improved oral function and support for future facial sling soft tissue surgical procedures.

impressions were made for fabrication of custom impression trays. Oral hygiene procedures were reinforced and the patient was appointed for final custom impressions, to be followed by jaw rela-tions records, tooth selection and try-in of the ver-ification index. This would be followed by a wax try-in and then delivery and post- delivery check.

The patient presented for final impres-sions five months post placement of the dental implants. The soft tissue was healthy and the implants stable. The healing caps were removed and fixture level impressions were made utilizing a custom tray and PVS impression material. The healing caps were replaced with standard length as the soft tissue had healing very well. A verifi-cation index was fabricated on the master casts for try-in prior to framework fabrication. At the jaw relations appointment the healing caps were removed and the index tried intraorally. (figure 8) It appeared to fit passively with no rocking and passed the single screw test. Interocclu-sal records were made along with a face-bow

transfer and a shade taken for the prosthetic teeth. The following appointment a wax try-in of the maxillary and mandibular prostheses was completed to verify the accuracy of the jaw rela-tion records and obtain the patient approval for aesthetics and phonetics. A significant improve-ment in her facial profile and support was noted with the prostheses and the patient gave her approval for the shade of the replacement teeth.

Following the patients approval of the wax try-in, the wax-up was returned to the dental labora-tory for finalization of the prostheses which would consist of a CAD/CAM designed and milled tita-nium screw retained framework for each arch and heat processing the acrylic resin teeth and sup-port (figures 9a, 9b).13-15 This prosthesis design was selected for the ability to easily remove and repair if there was any fracture and ease of per-forming oral hygiene procedures. There were other options available but the prosthodontic author has been utilizing this combination of materials for several years with excellent results.

Schneider et al


At the delivery appointment the screw retained abutments were placed following removal of the healing caps and torqued to the recommended levels (figures 10a, 10b, 10c, 10d, ). The pros-theses were placed with screws also torqued to the appropriate level. A panoramic radiograph was taken showing intimate fit of the framework and satisfactory alveolar bone levels (figure 11). Oral hygiene procedures for the prostheses were demonstrated and the screw access channels were closed with a provisional material for con-venient future access. The patient seemed very pleased with the outcome (figure 12). Due to the malformation and hypoplasia of the left con-dyle and ramus the occlusion was left slightly out of contact in maximum intercuspation (MI) as she exhibited the ability to clench and bring the pros-thesis into maximum contact with very little effort.

Recall appointments show healthy soft tis-sue and continued stability of the prosthe-ses. We continually reinforce oral hygiene and the patient began to slowly eat on the left side and seems pleased with the results. She con-tinues to be followed by our Hospital Den-tistry team and is also under treatment in our Otolaryngology Facial Plastic Surgery divi-sion. Results thus far are very promising. l

Correspondence:Dr. Robert L. [email protected]

AcknowledgementThanks very much to Danny Roberts, CDT, Hawkeye Dental Studio, Cedar Rapids, IA, for his expertise in design and fabrication of the definitive prostheses for this patient.

DisclosureThe authors report no conflicts of interest with anything in this paper.

References1. Nalin AS, Johny J, Johnson L, Kunjumon RM, George GB. IJSS Case Reports

& Reviews. June 2015, vol 2, issue 1, 20-23.

2. Shapiro SD, Abramovitch K, Van Dis ML, et al. Neurofibromatosis: oral and radiographic manifestations. Oral Surg Oral Med Oral Pathol 1984;58:493-8.

3. White AK, Smith RJ, Bigler CR, et al. Head and neck manifestations of neurofibromatosis. Laryngoscope 1986;96:732-7.

4. Kahn M, Ohri N. Oral manifestations of Type I neurofibromatosis in a family. J Clin Exp Dent 2011;3(5):e483-6.

5. Sigillo R, Rivera H, Nikitasis NG, Sauk JJ. Neurofibromatosis type 1: a clinicopathological study of the oral-facial manifestations in 6 pediatric patients. Pediatr Dent 2002;24:575-580.

6. Geist J, Gardner D, Stefanac S. Oral manifestations of neurofibromatosis type I and II. Oral Surg 1992;73:367-282.

7. D’Ambrosio JA, Langlais RP, Young RS. Jaw and skull changes in neurofibromatosis. Oral Surg Oral Med Oral Pathol 1988;66:391-6

8. Lee L, Yan YH, Pharoah MJ. Radiographic features of the mandible in neurofibromatosis: a report of 10 cases and a review of the literature. Oral Surg Oral Med Oral Pathol 1996;81:361-7.

9. Tsiklakia K, Nikopoulou-Karayianni A. Multiple neurofibromatosis associated with mandibular grown and facial asymmetry. Ann Dent 1990;49:14-17.

10. Adekeye EO, Abiose A, Ord RA. Neurofibromatosis of the head and neck: clinical presentation and treatment. J Maxillofac Surg 1984;12:78-85.

11. Friedrich RD, Giese M, Schmelzle R, et al. Jaw malformations plus displacement and numerical aberrations of teeth in neurofibromatosis type I: a descriptive analysis of 48 patients based on panoramic radiographs and oral findings. J cranio-maxillo-facial surg 2003;31:1-9.

12. Tucker T, Birch P, Savoy DM, Friedman JM. Increased dental caries in people with neurofibromatosis. Clin Genet 2007;72:524-27.

13. Schneider R, Fridrich, K, Funk G. Complex mandibular reconstruction of a partial mandibulectomy fibula free graft reconstruction. J Prosthet Dent 2013;110(3(:223-27.

14. Schneider R, Fridrich, K, Chang K. Complex mandibular reconstruction of a self-inflicted gunshot would: a patient report. J Prosthet Dent 2012:107(3):158-162.

15. Schneider R, Fletcher S, Stein K. Treatment of a central giant cell granuloma of the mandible. J of imp and adv clinic dent 2016;8(3):21-9.

Schneider et al

Daher et al

The Extraction Defect Sounding (EDS) clas-sification has importance in helping the cli-nician in establishing an appropriate plan

for surgical implant treatment. This classifica-tion sometimes comes up short and no detailed recommendation of the provisional stage is described before and after surgical treatment in the esthetic zone. The purpose of this paper is

to describe all possible provisional techniques available to restore a single tooth in the anterior esthetic zone and to give recommendations to the preferable techniques during site development and implant placement according to the EDS classification. It is strongly advisable to have a preplanning session for the preparation of a vac-uum heat formed template and ovate pontic(s).

Prosthetic Implant Management of Extraction Site Following Removal of Anterior Tooth

Tony Daher, DDS,MSEd1 • Georgina El Ghoule, DDS2 Vahik P. Meserkhani, DDS, MSD3 • Nick Caplanis, DDS, MSD4

1. Private Practice limited to prosthodontics, LaVerne, California, USA

2. Private Practice. Jal-El-Dib, Beirut Lebanon

3. Private Practice. Glendale and San Diego, California, USA

4. Associate Professor, LLU, periodontist

Abstract

KEY WORDS: Dental implant, extraction, prosthetics, soft tissue

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Daher et al


INTRODUCTIONWhen a compromised anterior tooth is removed and is planned to be replaced by a den-tal implant, surgical and prosthetic evalua-tion must be done for a predictable result.

Surgical EvaluationThe presentation of the alveolar socket varies from simple to more complex defects. The healing pro-cess initiates a cascade of biochemical and histolog-ical events that ends up in reduction of the alveolar bone and soft tissues.1 The remaining tissues sur-rounding the extraction defect dictates implant therapies.2 Several alveolar defect classification systems have been reported.3,4,5 All of these exist-ing classifications however, describe the condition of an already-healed edentulous site. A classifica-tion of the extraction defect immediately following tooth removal and prior to healing and remodeling which provides guidelines for implant treatment was introduced by Caplanis et al. in 2009.6 The Extrac-tion Defect Sounding (EDS) classification, simpli-fies the decision making process when planning for dental implant therapy from a surgical point of view. The EDS classification has its importance in help-ing the clinician in establishing appropriate plan for surgical implant treatment.6 This classification came short and no detailed recommendation of the provisional stage was described before and after surgical treatment for the esthetic zone (Table 1).

Prosthetic EvaluationAn ideal prosthesis design should fully enhance the esthetic features of the missing tooth or teeth. According to Cooper,7 for a set of proce-dures to ensure esthetic success for all anterior implants, the process begins with an esthetic diagnosis using objective criteria such as:

1) Determination of the adjacent connective tissue attachment;

2) Diagnostic wax-patterns with emphasis on peri-implant mucosal architecture;

3) Assessment of bone-to-prosthesis relationship (CBCT/bone sounding);

4) Possible bone and /or soft tissue augmentation to support objectively defined crown form;

5) Ideal placement of the implant relative to the planned gingival zenith;

6) Creating the ideal peri-implant mucosal using well-formed provisional crowns and abutments;

7) Selection of abutment and crown materi-als to support peri-implant mucosal health;

8) Removal of cement from the sulcus in case of cement-retained restorations.According to Tarnow,8 when the contact

point to the bone crest on standardized peri-apical radiographs using paralleling tech-nique was 5mm or less, the papillae were almost 100% present. When the distance was 6mm, 51% of the papillae were pres-ent, and when the distance was 7mm or greater only 23% of the papillae were pres-ent.8 There are other factors determining the existence of the interdental papilla includ-ing the morphology and alignment of teeth, the mesiodistal distance between adjacent teeth and the volume of the embrasure space.9

Following anterior tooth removal and the recommended surgical treatment is done, the development and the maintenance of esthetic soft tissue architecture is to follow using interim restorations such as custom healing abut-ments, fixed interim prostheses, fixed bonded ovate pontics, and removable interim pros-theses. Clinically we can make use of a pro-visional prosthesis as a template for the final

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prosthesis to induce the interdental papilla to undergo creeping papilla formation.10

The purpose of this paper is to describe and evaluate all possible provisional tech-niques available to restore a single tooth in

the anterior esthetic zone and to give rec-ommendations to the preferable techniques during site development and implant place-ment according to the EDS classification.

Table 1: Surgical & Prosthetic management of the extraction defect site. (Modified from Dr. Caplanis et al, by adding the prosthetic management after implant surgery by Dr. Tony Daher.)

Socket Distance Ideal Soft Surgical Prosthetic Defect General Walls Hard to Soft Treatment Treatment Type Assessment Affected Biotype Tissue Reference Tissue Recommendations Recommendations

EDS-1 Pristine 0 Thick 0mm 0-3mm Predictable Immediate Provisional Placement Screw Retianed (one stage) Crown or Bonded Ovate Pontic

EDS-2 Pristine 0-1 Thin or Thick 0-2mm 3-5mm Achievable Site Bonded Ovate to Slight but not Preservation Pontic then Damage Predictable or Immediate Screw Retained Implant (one Provisional or two stage) Crown

EDS-3 Moderate 1-2 Thin or Thick 3-5mm 6-8mm Slight Site Bonded Ovate Damage Compromised Preservation Pontic then then Implant Screw Retained Placement Provisional (two stage) Crown

EDS-4 Severe 2-3 Thin or Thick > 5 > 8 Compromised Site Bonded Ovate Damage Preservation Pontic then then Site Screw Retained Development then Provisional Implant Placement Crown (three stages)

Daher et al


Interim Removable Partial ProsthesisInterim removable partial prostheses are sel-dom used by the authors in the esthetic zone. It is hard to include positive rests and adequate retention in these interim restora-

tions to prevent excessive compression of the extraction defect during the augmenta-tion of soft and hard tissues. Because of its removable quality, interdental papillae could recede and get lost (Figures 1A,B).

Table 1: Surgical & Prosthetic management of the extraction defect site. (Modified from Dr. Caplanis et al, by adding the prosthetic management after implant surgery by Dr. Tony Daher.)

Socket Distance Ideal Soft Surgical Prosthetic Defect General Walls Hard to Soft Treatment Treatment Type Assessment Affected Biotype Tissue Reference Tissue Recommendations Recommendations

EDS-1 Pristine 0 Thick 0mm 0-3mm Predictable Immediate Provisional Placement Screw Retianed (one stage) Crown or Bonded Ovate Pontic

EDS-2 Pristine 0-1 Thin or Thick 0-2mm 3-5mm Achievable Site Bonded Ovate to Slight but not Preservation Pontic then Damage Predictable or Immediate Screw Retained Implant (one Provisional or two stage) Crown

EDS-3 Moderate 1-2 Thin or Thick 3-5mm 6-8mm Slight Site Bonded Ovate Damage Compromised Preservation Pontic then then Implant Screw Retained Placement Provisional (two stage) Crown

EDS-4 Severe 2-3 Thin or Thick > 5 > 8 Compromised Site Bonded Ovate Damage Preservation Pontic then then Site Screw Retained Development then Provisional Implant Placement Crown (three stages)

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Figure 1A: Showing an anterior maxillary tooth and its interdental papillae missing.

Figure 1B: The missing interdental papillae are due to the wear “on and off” of maxillary interim acrylic removable partial denture also used as an orthodontic retainer.

Figure 2A: Fig 2A) Immediate implant placement replacing a failing left maxillary central incisor.

Figure 2B: The modified existing metallo-ceramic crown of the extracted failing tooth is used as bonded interim fixed prosthesis.

Figure 2C: The cover screw is placed over the implant, then the crown is relined with composite. The gingival area of the pontic is filled with composite material to support the gingival tissue and contoured to form an ovate shape. The top of the ovate shape touches the cover screw.

Figure 2D: The ovate pontic is bonded to the adjacent teeth.

Daher et al


Figure 2E: All occlusal contacts must be removed in centric and lateral excursive movements.

Figure 2F: Final crown cemented over a custom made abutment.

Figure 2G: Final crown cemented over a custom made abutment.

Custom Made Healing AbutmentsCustom made healing abutments are used when a cement retained interim prosthesis is made. The authors do not like this procedure because it is time consuming, difficult to achieve optimum gin-gival contour, and hard to hide the cement margin.

Ovate Pontics (Figures 2A-G)Ovate pontics preserve and establish esthetic soft-tissue emergence profiles following site pres-ervation or development procedures. These pro-visional restorations with an ovate pontic design can be fabricated directly in the mouth or in the laboratory with the use of the study casts. It is tedious to fabricate a provisional restoration in the patient’s mouth. A preplanning session could be done to prepare a smooth and easy fabrication of a fixed interim restoration. The objective of the preplanning session is to prepare the pontic(s) and a vacuum heat formed template. The vacuum heat formed template is made from study casts before the removal of the teeth in question or from a duplicate cast of a cast with a wax pattern replacing the missing tooth.

Ovate pontic(s) fabrication is done in the labo-ratory as follow (Figures 3A-L): cast surgery is per-

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20 • Vol. 9, No. 9 • November 2017

Figure 3A: Vacuumed and heat formed template made on the cast before the removal of the questionable tooth.

Figure 3B: The study cast.

Figure 3C: Removal of the right maxillary incisor and ridge contoured with an acrylic bur.

Figure 3D: Vaseline is painted in the area for isolation purposes.

Figure 3E: Provisional ovate pontic is made from the formed template and cervically contoured according the cervical contour of the extracted tooth.

Daher et al


Figure 3F: Provisional ovate pontic is made from the formed template and cervically contoured according the cervical contour of the extracted tooth.

Figure 3G: Provisional ovate pontic is made from the formed template and cervically contoured according the cervical contour of the extracted tooth.

Figure 3H: Provisional ovate pontic is made from the formed template and cervically contoured according the cervical contour of the extracted tooth.

formed to remove the tooth in question, creating a concavity with 2-3mm depth, partially simulat-ing the extraction defect. A denture tooth, or the existing crown on the tooth to be extracted, or the clinical crown of the extracted tooth, all can be used to form ovate pontics. This ovate pontic will be bonded to the adjacent teeth after the removal of the tooth in question using a braided stainless steel wire (Figure 2). If the bonded ovate pontic is used without a retentive wire, the risk of de-bonding is possible. It is imperative to inform the patient when the pontic is loose, to come to the office as soon as possible to mini-mize the collapse of the surrounding soft tissues. This pontic will fill in the missed contour and apply no pressure on the gingival margin and interproximal papillae, holding the tissue from collapsing following tooth extraction. They can be incorporated within fixed as well as remov-able transitional restorations either chairside or in the laboratory using conventional acrylic or composite. In case of ridge preservation pro-

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22 • Vol. 9, No. 9 • November 2017

Figure 4A: Left maxillary central incisor is to be removed.

Figure 4B: Immediately a TSV Zimmer implant is placed to replace the removed central incisor.

Figure 4C: The implant mount is removed and replaced with temporary abutment and the final provisional crown is made with the heat and premade vacuumed formed clear template from the study cast. BIS-GNA acrylic material is used for the screw retained provisional crown.

Figure 4D: The screw retained provisional crown is finessed by adding flowable composite to the gingival shoulder of the temporary abutment.

Daher et al


cedures, the ovate portion of the pontic should make a less of 1mm depression on the membrane covering the bone graft. If the implant is placed and when the immediate loading is not indicated, the bonded ovate portion of the pontic should be in intimate contact with the implant cover screw. This will facilitate the maintenance of the gingival con-tour and later on facilitate the formation of adequate contour of the interim implant fixed restoration.

Screw retained Provisional crownWhen a dental implant is placed with a torque >35Ncm and stable, a screw retained provisional crown can be made. Care is made to leave the interim crown off the occlu-sion in centric and excursive movements. We feel that in these situations, the screw-retained provisional restorations have many advantages over the cement-retained provi-sional restorations from a practical and bio-logical point of view. If the access hole is on a labial or buccal surface, flowable com-posite will close it and make it undetectable.

Extraction Deficit is either EDS1 or EDS2When the general assessment of the extrac-tion deficit is pristine (EDS1) or slightly dam-aged (EDS2); (Figures 4A-G) the clinician has the option to place immediately the implant into the fresh extraction socket2. Clinical situations could arise either 1) the implant can be restored

Figure 4E: Provisional well contoured crown placed and left for 3 months for complete gingival healing and maturation. Caution is to be taken that no occlusal contacts are present on the provisional crown.

Figure 4F: Provisional well contoured crown placed and left for 3 months for complete gingival healing and maturation. Caution is to be taken that no occlusal contacts are present on the provisional crown.

Figure 4G: Final implant crown in patient mouth.

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24 • Vol. 9, No. 9 • November 2017

Figure 5A: Advanced periodontal lesion on the right lateral incisor.

Figure 5B: Ridge preservation using bone graft and resorbable membrane done right after tooth removal.

Figure 5C: An ovate-shaped denture tooth bonded in place using a rubber dam to optimize the bonding effect.

Figure 5D: An ovate-shaped denture tooth bonded in place using a rubber dam to optimize the bonding effect.

Figure 5E: An ovate-shaped denture tooth bonded in place using a rubber dam to optimize the bonding effect.

Daher et al


Figure 5F: Site healing after 4 months. Figure 5G: Site healing after 4 months.

Figure 5H: Implant placement and simultaneous placement of bone graft.

Figure 5I: Implant placement and simultaneous placement of bone graft.

Figure 5J: Same bonded tooth in place.

immediately with a provisional prosthesis in case adequate stability and a torque of > 35Ncm or 2) the implant cannot be restored immediately. In the situation (2), a bonded ovate pontic can be placed to maintain the tissue architecture. The apical portion of the ovate pontic should be in contact with the implant cover screw.

Extraction Deficit is EDS3When the general assessment of the extraction deficit is moderately damaged (EDS3) the cli-nician must do site preservation and then later

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26 • Vol. 9, No. 9 • November 2017

Figure 5K: Final cement retained implant crown over a custom abutment in place.

Figure 5L: Final cement retained implant crown over a custom abutment in place.

Figure 5M: Final restoration in place.

place the implant. When the site preservation is done, a bonded ovate pontic can be placed to maintain the tissue architecture and should not extend more than 1mm in the tooth socket. At a later date when the ridge preservation proce-dure is successful, the implant can be placed. This brings us to the situation of EDS1 or EDS2.

Extraction Deficit is EDS4When the general assessment of the extrac-tion deficit is severely damaged (EDS4) (Figures 5A-N) the clinician must do site preservation, then site development and then implant place-ment (3 stages). When the site preservation and site development are done, a bonded ovate pon-tic can be placed to maintain the tissue archi-tecture. During site development the pontic could be made short to allow the bone graft to have enough space for healing purposes. At later date when the ridge preservation proce-dure and the site development procedures are successful, the implant can be placed. And this brings us to the situation of EDS1 or EDS2.

Daher et al


SUMMARYExtraction sockets are often damaged so exten-sively multiple soft and hard tissues augmentation procedures are necessary to adequately develop the site with optimum hard and soft-tissue esthet-ics, and adequately manage the prosthetic situ-ations. For that purpose it is strongly advisable to have a preplanning session for the prepara-tion of a vacuum heat formed template and ovate pontic(s). The EDS classification attempts to categorize the most common extraction defect presentations and simplify the surgical and pros-thetic treatment decision-making process. l

Correspondence:Dr. Tony Daher1413 Foothill Blvd. Suite ALaVerne, CA [email protected]

DisclosureThe authors report no conflicts of interest with anything in this paper.

References1. Araujo MG, Lindhe J. Dimensional ridge alterations following tooth extractions.

An experimental study in the dog. J ClinPeriodontol 2005;32:212-8.2. Becker W. Immediate implant placement: diagnosis, treatment planning and

treatment steps for successful outcomes. J Calif Dent Assoc 2005;33(4):303-10.

3. Seibert JS. Reconstruction of deformed partially edentulous ridges, using full thickness onlay grafts. Part Technique and wound healing. CompendContinEduc Dent 1983;4:437-53.

4. Allen EP, Gainza CS, et al. Improved technique for localized ridge augmentation. A report of 21 cases. J Periodontol 1985; 56:195-9.

5. Wang HL, Al-Shammari K. HVC Ridge deficiency classification: a therapeutically oriented classification. Int J Period Rest Dent 2002;22:335- 43.

6. Caplanis N, Lozada JL, Kan JYK:Extraction Defect: Assessment, Classification and Management. Intern J of Clin Impl Dent, January-April 2009;1(1):1-11.

7. Cooper L. Master of Esthetic Dentistry Objective Criteria: Guiding and Evaluating Dental Implant Esthetics. Journal of Esthetic and Restorative Dentistry 2008; 20(3):195–205.

8. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. J Periodontol 1992;63:995-6.

9. Yu-Jen Wu, Yu-Kang Tu, Shay-Min Huang.The Influence of the Distance from the Contact Point to the Crest of Bone on the Presence of the Interproximal Dental Papilla. Chang Gung Med J 2003;26:822-8.

10. Hurzeler MB, Weng D. Functional and esthetic outcome enhancement of periodontal surgery by application of plastic surgery principles. Int J Periodontics Restorative Dent1995;15:298-310.

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Langstein

Background: This paper discusses the chal-lenges of fabricating screw-retained implant sup-ported restorations in clinical situations. Due to either non-ideal anatomy, or inadequate surgical alignment, screw holes for restorative retention often emerge out of restorations in poor position.

Methods: In the clinical case discussed below, a dental implant was placed immediately in an anterior extraction socket, and a screw-retained provisional crown was placed. After taking a digital scan of a scan flag to communi-cate the implant position and peri-implant tis-sue anatomy, a novel, angulated screw channel assembly was utilized in order to optimize the screw-hole emergence from the restoration.

Results: The final restoration satisfied both functional and aesthetic requirements, thus demonstrating the protocol and success of the angulated screw channel technology.

Conclusions: As clinicians are faced with mounting evidence of peri-implantitis associ-ated with cement restorations, screw-retained restorations are becoming more prevalent in clinical situations. There is an increasing need for technologies to assist in optimizing resto-rations where implant placement is non-ideal. The new angulated screw channel technol-ogy has provided a workable solution to sat-isfy the clinical requirements for excellence while employing screw-retained restorations.

A Novel Technique to Optimize Screw-Retained Implant Restorations

Dr. Ira Langstein1

1. Private practice, White Plains, New York, USA

Abstract

KEY WORDS: Dental implant, provisionalization, prosthetics

28 • Vol. 9, No. 9 • November 2017

Langstein


INTRODUCTIONDental implants are a longstanding, optimal treat-ment choice for the replacement of missing teeth, particularly a single tooth in the anterior maxilla.1 In order to be successful, this treat-ment must overcome multiple challenges, includ-ing, but not limited to, a high lip line, and limited osseous quality and volume, both antero-palatally and vertically. After successful osseointegra-tion, the final ceramic restoration is fixated to the implant through either cementation to an abut-ment, or by placing a retaining screw through the crown, attaching it to the implant. Recent stud-ies have demonstrated associated risks of peri-implantitis in cement-retained restorations.2 This destructive pathology can manifest itself many years after implant placement, and poses ongo-ing risks to implant survival. New restorative trends have focused on providing screw-retained solutions, particularly in clinical scenarios where implant placement is non-ideal and not lined up to provided cingulum access. The following case will demonstrate the use of an angulated screw (ASC)(Nobel Biocare, Yorba Linda, CA)., in order to redirect the prosthetic screw, and thus avoid cementation of the final implant crown.3

CASE REPORTA 40 year old female presented with an acute periapical infection on tooth #8 (Figs. 1, 2). The tooth had been recently treated with an apico-ectomy, with no resolution of her symptoms or pathology. Extraction, with subsequent dental implant treatment, was recommended. The tooth was extracted atraumatically at a local oral sur-geon, with no surgical flap, and the socket was carefully debrided. A 3.5 mm Nobel Biocare Active implant (Nobel Biocare, Yorba Linda, CA) was placed, aligning as close as possible with the cingulum of the adjacent teeth. The subsequent

Figure 1: A 40 year old female presented with an acute periapical infection on tooth #8.

Figure 2: A 40 year old female presented with an acute periapical infection on tooth #8

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30 • Vol. 9, No. 9 • November 2017

facial gap was filled with a bone graft to provide for optimal integration (Fig. 3). A healing abutment was placed on the implant and hand-tightened.

Upon returning to the restorative practice immediately after implant placement, the heal-ing screw was removed, and a PEEK provisional abutment cylinder (Nobel Biocare, Yorba Linda, CA) was seated on the implant (Figs. 4, 5). A lin-gual hole was created in a previously fabricated provisional crown shell in order to slide over the tube of the PEEK cylinder (Fig. 6). After verify-ing the position, the shell was luted to the tube with flowable resin (Revolution, Kerr, Inc., Orange, CA) and cured. The assembly was subsequently

Figure 3: Facial gap was filled with a bone graft to provide for optimal integration.

Figure 4: PEEK provisional abutment cylinder placed onto dental implant.

Figure 5: Provisional restoration placed onto PEEK cylinder.

Figure 6: A lingual hole was created in a previously fabricated provisional crown shell in order to slide over the tube of the PEEK cylinder.

Figure 7: The provisional crown demonstrated smooth contours and an undercontoured gingival margin to facilitate tissue stability.

Langstein


Figure 8: The provisional crown was then adjusted to remove all occlusal contacts.

Figure 9: Soft tissue stability and osseointegration was evident after 16 weeks.

Figure 10: Soft tissue stability and osseointegration was evident after 16 weeks.

Figure 11: Elos 3.5 mm scan flag (Elos Medtech, Gothenburg, Sweden) was fixated to the implant.

Figure 12: A digital scan, using the Trios 3Shape (3Shape, Copenhagen, Denmark) was performed, taking care to incorporate the emergence profile and adjacent tooth contours

Figure 13: As seen on the model, as constructed, the screw-hole would need to exit the incisal edge of the crown in order to be parallel with the implant.

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32 • Vol. 9, No. 9 • November 2017

refined by adding resin and recontouring until the provisional crown demonstrated smooth contours and an undercontoured gingival mar-gin to facilitate tissue stability (Fig. 7). The pro-visional crown was then adjusted to remove all occlusal contacts, and the screw access hole was sealed with Teflon tape and Fermin-N light cure (Fig. 8). Immediate loading and provi-sionalization of implants in the aesthetic zone has been established as a viable modality.4

Soft tissue stability and osseointegration

was evident after 16 weeks (Figs. 9, 10). After removal of the provisional implant crown, an Elos 3.5 mm scan flag (Elos Medtech, Gothenburg, Sweden) was fixated to the implant (Fig. 11). A digital scan, using the Trios 3Shape (3Shape, Copenhagen, Denmark) was performed, taking care to incorporate the emergence profile and adjacent tooth contours(Fig. 12).5 Multiple shade photos were taken, utilizing the Vita-Pan shade guide(Vita North America, Yorba Linda, CA) for reference. Images also included converted black and white images for value comparison, and polar-ized images to remove glare and focus on chroma and hue. The provisional restoration was again fixated to the implant as per the previous protocol.

The Dental laboratory received the STL files and initiated the restorative planning and execu-tion process. Instructions for digital models were sent to an external printer. After receiving digitally-printed models, the lab began assembly of the final restoration. As seen on the model, as constructed, the screw-hole would need to exit the incisal edge of the crown in order to be paral-lel with the implant (Fig. 13). The subsequent thin-

Figure 14: The ASC driver allows a modification of up to 25 degrees circumferentially.

Figure 15: The final restoration consists of a titanium insert, a zirconia core, and hand stacked porcelain.

Langstein


Figure 17: The angulated screw was torqued to 25 nm2 and the screw-access hole was sealed with Teflon tape and composite resin.



Figure 18 The angulated screw was torqued to 25 nm2 and the screw-access hole was sealed with Teflon tape and composite resin.

ning of the ceramic incisal edge, along with access resin in a non-ideal location would make this option undesirable. A new technology, using the Nobel Biocare Angulated Screw Channel (Nobel Biocare, Yorba Linda, CA) was utilized to provide the ability to redirect the screw, effectively permit-ting access through an idealized screw hole, and then changing direction as it stabilized the crown to the implant. The ASC driver allows a modifica-tion of up to 25 degrees circumferentially (Fig. 14).

The final restoration consists of a titanium insert, a zirconia core, and hand stacked porce-

Langstein

34 • Vol. 9, No. 9 • November 2017

lain (Fig. 15). The crown is friction fit over the titanium insert, with no cement interface. The angulated screw, when tightened, holds the crown in place. The titanium insert itself is retained by a Morse taper/connection internally in the implant. Zirconia has been demonstrated to produce a healthy soft tissue response.6 After verifying fit, both clinically and radio-graphically, the implant crown was inspected for aesthetics and contour. The angulated screw was torqued to 25 nm2 and the screw-access hole was sealed with Teflon tape and composite resin (Estelite Omega, Tokuyama North America, Encinitas, CA)(Figs. 16-19). The final occlusion was evaluated and adjusted in all excursions.7 The patient was instructed on proper home care and maintenance.

DISCUSSIONCement-retained implant restorations, while often providing optimal aesthetic results, carry with them the risk of peri-implant disease. Peri-implant disease often presents months or years after the restoration is completed. Treatment of peri-implant pathology is often complex with mixed results. Surgical and non-surgical ther-apy can leave the restoration compromised aes-thetically, with resulting osseous and soft tissue defects. Implant removal is sometimes indi-cated. Screw-retained restorations have existed since the advent of implant dentistry, but they carry with them their own set of compromises. Many implants are place off-angle by oral sur-geons and periodontist, either because of osse-ous limitations, or a lack of knowledge of the final prosthetic restoration. In addition, many implants are placed at poor angles as a result of not having utilized an implant placed guide. The

restorative dentist is thus left with designing a restoration where the screw hole may exit a cusp tip or a facial surface of a final restoration.

Redirecting the screw-access hole in den-tal implant restorations has previously been accomplished by the use of multi-unit abut-ments (MUAs) that serve as an intermediary between the implant and the restoration. The disadvantages of MUAs include the need for the screws and the additional vertical layer that the MUA adds. This may result in tita-nium being visible supragingivally, even though the implant platform alone provides adequate running room. Efforts to innovate to solve the problem of optimizing the screw-access hole have resulted in the development by Nobel Biocare of the Angulated Screw Channel. It is important to note that in this system, the inter-face between the insert and the implant is one of titanium. Previous efforts at utilizing zirconia for the abutment or implant stem have result in fractures of the insert or abrasion and wear of the internal aspect of the implant connection by the zirconia. The ASC system avoids cement altogether by employing zirconia that friction fits over the titanium insert and is the angulated screw holds the restoration to the insert. Since there is reasonable thickness to the restor-ative zirconia, the access resin that seals the screw hole is of adequate depth and picks up the shading of the neighboring zirconia. The result is improved aesthetics. An additional advantage of the ASC is more ideal access to posterior screw holes. Patients with limited jaw openings sometimes present access chal-lenges to the placement of drivers. With the 25 degree accommodation, the driver can be tilted mesially and still properly tighten the screw.

Langstein


CONCLUSIONThe current trends toward screw-retained implant restorations have presented the challenge of optimally placing dental implants that facili-tate screw placement. The novel Nobel Biocare Angulated Screw Channel has provided greater flexibility in implant placement while maintain-ing screw retention as the restorative modality of choice. The result is restorations that possess both functional and aesthetic predictability. l

Correspondence:Dr. Ira LangsteinEmail: [email protected]

DisclosureThe author reports no conflicts of interest with anything in this article.

References1. Survival and success rates of implants in maxilla and mandible. Presented at

IADR General Session; June 2012. Dr. Newton Selma, et.al.

2. Wilson, TG Jr. The Positive relationship between excess cement and peri-implant disease: a prospective clinical endoscopic study. J Periodontology. Sep;80(9). 1388-92.

3. Industry News_Nobel Biocare. It is time to look at aesthetics from a new angle. CAD/CAM,2,2014. 44-45.

4. Romanos, George, et.al. Survival Rate of Immediately vs Delayed Loaded implants: analysis of the current literature. Journal of Oral Implantologists. Vol. XXXVI/No. Four/2010. 315-324.

5. ADA Professional Product Review. Evaluation of the Accuracy of Six Intraoral scanning devices: an in-vitro investigation. September, 25, 2015. 1-13

6. Antonio de Medeiros, Rodrigo, et.al. Analysis of the Peri-Implant Soft Tissues in Contact with Zirconia Abutments: An Evidence-based Literature Review. The Journal of Contemporary Practice. May-June 2013;14(3):567-572.

7. Kinzer, Greggory. Sealing the Screw Access Hole on Screw-Retained Restorations. Spear Digest. February 26, 2014. 1-4.

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