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Dental Tribune Middle East & Africa Edition No.2, 2016

Fig.1.Pretreatment clinicalview.(Photos/ProvidedbyDr.PaulS.Petrungaro) Fig.3.Ovatepontic typedefect created Fig.4.DentatusANEWimplant seatedminimallyinvasiveprotocol Fig.2.Preoperativeperiapicalradiograph. Dental Tribune Middle East & Africa Edition | 2/2016 10 mCME Long-term clinical success in the management of compromised intertooth spaces utilizing small-diameter implants mCMEarticlesinDentalTribunehavebeenapprovedby: HAADashavingeducationalcontentfor2CMECreditHours DHAawardedthisprogramfor2CPDCreditPoints CAPP designates this activity for 2 CE Credits. ByPaulS.Petrungaro,DDS,MS Management of edentulous sites in the oral cavity with dental implants has been well documented in den- tal literature during the past 25-plus years.1-3 Patients seeking tooth re- placementforpartialortotallyeden- tulous situations have been able to enjoy natural appearing and func- tioningprosthesesthatarefixed,sta- ble and, in some cases, so natural it’s difficulttoascertainadentalimplant restorationfromatoothrestoration. Using dental implants to replace the natural tooth system in the es- thetic zone has also seen an increase in restorative treatment plans and, with the advent and perfection of immediate restoration protocols initially reported in the literature,4-7 achieving natural soft-tissue esthet- ics around dental implants can be predictable and successful. How- ever, certain clinical situations can complicate or negate the procedure altogether. One of these complications is insuf- ficient intertooth spacing between natural teeth and, most commonly, with congenitally missing lateral incisors following orthodontic treat- ment.8 Oftenasasolutiontothis,the dentist chooses a removable partial denture or some type of resin-bond- ed bridge, both of which may not be appealing to younger individuals. In extreme cases, the dentist may elect toproceedwithafixedbridge,which would cause excessive destruction to the natural teeth serving as abut- ments and, for a young individual, this could be devastating to these teeth during a 40-50 year period, if notsooner.8 To properly form an ovate pontic type emergence profile in the soft tissue, which is required for a fixed bridge to have a natural clinical ap- pearance, consideration must be given to the intertooth edentulous space.9-12 This is also very important when choosing dental implants for natural tooth replacement. Wallace, MischandSalama,etal,9-11 statedthat for a normal two-piece implant, the implant should be placed at least 1.5 mmfromtheadjacentteeth. As a result, using a 3.5 mm diameter implant, the minimum inter-tooth spacetosupportinterproximalbone andnaturalsoft-tissuepapillarycon- tours should be 6.5 mm, and with a 3.0 mm diameter implant, 6.0 mm for the edentulous space. Often, the intertooth space in these types of casesissmallerthan6.0mm. Taking these parameters into ac- count, small-diameter implants (3.0 mmisthesmallestfrommostdental implant manufacturers) should not be used in cases with less than 6.0 mm of inter-tooth space, to prevent potential tooth root damage, crestal bone loss and unnatural-appearing gingivaltissuesandpapillae. Small-diameter, or mini, implants were developed more than 20 years ago and, initially, the recommended use was to support temporary re- movable prostheses during the heal- ing phase for advanced bone-graft- ing procedures and/or conventional implantplacement.12-13 Their use was later expanded into immediate conversion of full den- tures into implant-supported den- tures, support for partially eden- tulous cases and for anchorage of single tooth implant restorations in compromisedintertoothspaces.14-15 Implants are available from 1.8 mm diameter to 2.8 mm diameter and offer a fixed permanent tooth re- placement option for patients who otherwise would not be able to have implants placed and restored. Their ease of use and atraumatic place- ment utilizing a flapless approach, with only one coring procedure, as well as simplistic abutment transfer and provisional construction make the use of these implants in the aforementioned sites a must for the dentalimplantpractice. The following case report will dem- onstrate the use of the Dentatus ANEW (Dentatus USA, Ltd, New York, N.Y.) implant for the management of the compromised, congenitally missing lateral space in a 17-year-old youngwomanwitha10-yearclinical followup. Casereport A 17-year-old, non-smoking female presented for tooth replacement in the congenitally missing maxillary left lateral incisor site (Fig. 1). The pa- tient had recently completed ortho- dontic therapy, and the orthodontist and general practitioner had agreed thiswasthefinalobtainableresultin regard to the remaining intertooth spacebetweenthemaxillaryleftcen- tral incisor and maxillary left canine (Fig.2). The resultant intertooth space was less than 5.0 mm, and conventional two-stage implants with abutment options were ruled out. The patient and her parents ruled out conven- tional tooth-replacement options and chose the minimally invasive procedure: a small-diameter im- plant, 1.8 mm in diameter, which would allow for natural papillary contourstobedeveloped. After administration of an appro- priate local anesthetic, an ovate pontic contour was created utiliz- ing a football-shaped diamond in the attached, keratinized tissue of the edentulous site (Fig. 3). This scal- loped-type tissue contour helps in thecreationofthenatural-appearing papillarycontours. The small-diameter implant chosen, a 1.8 mm x 14 mm Dentatus ANEW Implant was then placed after a single coring of the site with a 1.4 mm needlepoint CePo to full depth, within the sculpted tissue emer- gence profile previously created (Fig. 4). Conversion to an esthetic provi- sional restoration was completed by placing an abutment coping with a delrin retention screw (Dentatus USA,NewYork,N.Y.). An ion shell provisional crown was then hollowed out and retrofitted to the abutment coping with flow- able composite. The margins of the provisional were corrected and pro- visionalcontouredoutofthemouth. The restoration was polished and seated with the set screw from the palatal. The immediate postopera- tive clinical view is seen in Fig. 5. The immediate postoperative periapical viewisseeninFig.6. The patient then went through the three-month healing and observa- tion phase prior to construction of a lab-processed provisional restora- tion (Fig. 7). One year later, the pa- tient underwent final restoration fabrication at the left lateral incisor site. A 10-year postoperative clini- cal image can be seen in Fig. 8 and a 10-year postoperative CT scan of the implantinFig.9. Please note the beautiful soft-tissue esthetic result obtained and excel- lent maintenance of the crestal and lateralcontours. Conclusion The management of compromised intertooth spaces presents a chal- lenge for the contemporary dental implant team. These spaces have limits on how they are handled and require implants 3.0 mm wide or less, as was demonstrated in the text of this article. Availability of smaller- diameter implants allows patients who normally would have to pro- ceed with a fixed bridge, or resin- bonded bridge, the luxury of dental implants with no preparation and/ or reduction to the adjacent natural dentition. Proper placement procedures and restorative techniques can lead to very esthetic results, allowing for natural tissue contours and emer- genceprofileformation,reminiscent ofthenaturaltooth. Acknowledgement Originally published in Inside Den- tistry. © 2014 to AEGIS Publications, LLC.Allrightsreserved. Reprinted with permission from the publishers. References 1)BranemarkP-I,ZarbGA,Albrektson T, eds. Tissue-Integrated Prosthesis: Osseointegration in Clinical Den- tistry. Carol Stream, IL: Quintessence Publishing:1985:11-81 2) Adell R, Lekholm U, Rockler B, et al. A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg. 1981; 10(6):387-416. 3) Babbush CA. Dental Implants: The ArtandScience.Philadelphia,PA:WB SaundersCo.2001:201-216. 4) Kan JY, Rungcharassaeng K. Im- mediate placement and provision- alization of maxillary anterior single implants: A surgical and prosthetic rationale. Pract Periodontics Aesthet ÿPage11

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