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Dental Tribune Middle East & Africa No. 6, 2016

Dental Tribune Middle East & Africa Edition | 6/2016 10 mcme Inconspicuous anterior implant-supported restorations: Combining clinical and laboratory expertise mCMEarticlesinDentalTribunehavebeenapprovedby: Haadashavingeducationalcontentfor2cmecreditHours dHaawardedthisprogramfor2cpdcreditpoints CAPP designates this activity for 2 CE Credits ByDr.LarryR.Holt,USA The ultimate goal of tooth replace- ment in the esthetic zone is an in- conspicuous transition from dental restoration to the patient’s natural, biologic tissues.1 This transition is evaluated at many levels.2 Color and contour of gingiva at the interface must mimic the natural contours and color of adjacent and contralat- eralteeth. The dental restoration must match contour and blend seamlessly into the existing dentition. Color match- ingoffinalcrownmustbeconsistent withexistingdentition.(hue,chroma and value). This case study explores the management and correction of a previously treated implant-retained maxillarycentralincisor. The patient presented as a healthy, 48-year old female with no con- tributory health history to prohibit dental treatment. Recent dental his- tory revealed an Ankylos implant to replace tooth #9 had been placed approximately five months prior to this visit. The implant had been un- covered and a temporary abutment wasplaced. A ridge lap provisional restoration was fabricated to fit the coronal por- tion of the abutment. The resultant provisional was not only unesthetic but also was the source of consider- able tissue inflammation and pa- tient discomfort (Figs. 1-3). Patient reported dissatisfaction with the provisional treatment and was seek- ingamoredesirablesolution. Clinical evaluation revealed a well- placed implant with acceptable posi- tion both facio-lingually and mesio- distally.3 Additionally, there was good volume of soft tissue and ridge form was ideal.4 Surgeon reported that the implant was well-integrated in bone. There was a poorly adapted provisional restoration over an in- adequately contoured provisional abutment. Radiograph revealed ex- cess acrylic that extended well into the dental sulcus all the way to the implant platform (Fig. 4). This acrylic did not provide any emergence pro- filesupportoftransmucosaltissue. The provisional restoration was poorly adapted to both the abut- ment and to the ridge crest soft tis- sue. Intaglio surface was rough and madeinsuchamannerastocreatea ridgelapprofile.Thefacialandproxi- mal surfaces of the provisional were fitted over soft-tissue crest. There had been no attempt to modify gin- gival tissue emergence profile or to create the environment for incon- spicuous transition from restoration tobiologictissues. Techniques for managing emer- gence profile are well-documented in the literature. Interproximal tis- sues will point and form papillae when appropriate lateral pressure is applied with a temporary abutment whennaturalteethareoneitherside of the implant. The adjacent bone heightwilldictatethelevelofthepa- pillae assuming the restoration and its associated abutment properly support them.5 Facial contour can be manipulated to create appropriate gingival zenith height by increasing or decreasing facial emergence pro- file. Increasing the profile will move the gingival zenith apically and re- duction of contour will move the crestincisally.6 Treatmentplanconsistedofremoval of temporary abutment/provisional crown, fabrication of a temporary partial denture (Figs. 5,6) and place- ment of an appropriate temporary abutmentthatdidnotretainaprovi- sionalcrown(Ankylossulcusformer) (Fig.7). This sulcus former, as its name implies, would provide soft-tissue emergence profile support. The par- tialdenturewastobeplacedtoavoid interference with the sulcus former whenfullyseated(Fig.8).Patientwas to be recalled in one-week intervals toevaluatetheresponsetothistreat- ment. Once healed, a final, custom- ized abutment and cementable all- ceramiccrownwouldbedelivered. The plan was followed per previ- ous description. Postoperative visits were uneventful. Patient comfort was immediate. Tissue health and emergence profile were deemed ap- propriate at the second week recall visit(Figs.9,10). At a subsequent appointment, the sulcusforming abutment was re- moved,aclosedtrayimpressioncop- ing was placed and an impression (Identium,Kettenbach)wastakenfor fabrication of final restoration (Figs. 11,12). Appropriate opposing model, bite registrations and facebow ac- companied the case to the laborato- ry. A careful shade map and clinical photographywereincluded. Clinically,itwasdeterminedthatthis would be a difficult shade because of surface characteristics and mav- erick colors of the adjacent central incisor. Arrangements were made to have a laboratory technician avail- able at the delivery appointment. Sulcus former and temporary par- tial were reinserted and patient was dismissed and scheduled or delivery appointment. All model work was accomplished. The laboratory was given the option of fabricating a custom abutment or customizing a stock abutment. This decision was to be based on the trajectory of the abutment relative to the position of the implant. The placement of the implant was ideal and the use of a lab-modified, stock abutment was selected (0 degree Cercon Balance Abutment, Dentsply Implant). The contour correlation between the sulcus former and the emergence profile of the stock abutment com- plement one another. The margins were placed 1 mm subgingivally on facial, mesial and distal. The lingual marginwasplacedat.5mm. Once the abutment was perfected, an all-ceramic crown was fabricated (eMax, Ivoclar). This crown was waxed to full contour, and then the facial was cut back to provide a field into which a customized facial sur- face could be developed from added porcelain. The wax pattern was in- vested and pressed. The resultant crown was then modified with ad- ditional application of porcelain and was left preglazed in anticipation of chairsidestaining7 (Figs.13,14). Fig.1.Initialappearance.(Photos/ProvidedbyDr.LarryR.Holt) Fig.2.Provisionalremoved. Fig.3.Provisionallateralintaglio. Fig.6.Temporarypartial. Fig.9.Tissuehealedandemergenceprofileestablishedat twoweeks. Fig.10.Sulcusformerremoved. Fig.7.Ankylossulcusformer. Fig.8.Temporarypartialplaced. Fig.5.Impressionfor temporarypartial. Fig.4.Provisionalabutment andcrown. ÿPage 11

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