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Dental Tribune Middle East & Africa No. 6, 2016

Dental Tribune Middle East & Africa Edition | 6/2016 11 The delivery appointment was un- eventful. The lab provided a seating jig that simplified the positioning of the customized abutment (Fig. 15). The abutment was torqued to man- ufacturer’sspecification(Figs.16,17). The crown was tried in and adjust- ments were made to proximal contacts and to occlusion. A dental laboratorytechnicianwasenlistedto providecustomchairsidestainingto perfectthecolormatch.Bothpatient and clinician were satisfied with the resultantrestoration(Fig.18).Thepa- tency of the abutment screw chan- nel was protected with compacted siliconetape,andtherestorationwas seated with implant cement (Pre- mierImplantCement,Premier). Great care was taken to avoid excess cement and to protect the sulcus from any incursion of residual ce- ment extrusion from margins.8 A crown-seating jig was provided by the laboratory to be used for remov- al of excess cement prior to seating ofthecrown. Patient was rescheduled at a two- week interval for a final evaluation and photography. She was extreme- ly satisfied with both the esthetics and comfort of the definitive resto- ration.Clinically,therestorationmet the criteria for an inconspicuous res- toration(Figs.19,20). Conclusion Understanding of the soft-tissue interface with implant-supported restorations is critical, fundamental knowledge. All practitioners whose goal is to deliver inconspicuous res- torations should practice these con- cepts. This case study revealed the stark contrast between tissue-man- agement protocols. There is no place in contemporary implant dentistry for ridgelap crowns assuming ap- propriate pretreatment parameters aremet. The esthetic zone must be evalu- ated prior to implant placement and any modification of the ridge form should be taken into consideration well in advance of implant place- ment surgery.9-11 Surgery should be driven by prosthetic requirements. Once surgery is accomplished, it is imperative that restorative clini- ciansunderstandhowtomanipulate theperi-implantsofttissues. All of this tissue management is critically important. However, then comes fabrication of the final resto- ration. The abutment must be de- signed in such a way as to conceal the crown/abutment interface. Fur- thermore,itmustallowforadequate crown thickness to have appropriate strength to withstand mastication forces and still remain retentive. The final contours of the crown must be managed in such a way as to blend intotheexistingdentition. This patient did not have a symmet- rical arch form. The lateral incisiors were not bilaterally symmetrical nor were the incisal edges consistent. Finally, the color match of the res- toration, especially a central incisor, must be as identical as possible to the existing dentition. None of these parameters can be accomplished withoutprecisecommunicationand excellentlaboratoryworkflow. This case was a success based upon all previously described parameters. The gingival contour was essentially mirror image identical to the adja- cent central incisor. Papillae were intact.12 The laboratory was skilled at modification of the abutment so that the margins were concealed within the sulcus. The axial and in- cisal contours of the abutment pro- vided adequate clearance so that a proper thickness crown could be developed. This is critical for both esthetics and for long term strength and stabil- ity of the definitive restoration. The technician selected the appropriate ingot of ceramic material to serve as substrateforthesubsequentapplica- tion of modifying porcelain and sur- face staining. Final color matching could not have been accomplished without skilled hands and eyes of a technicianatchairside. Close communication and strong laboratory relationships, along with appropriate clinical understanding of soft-tissue management, leads to success. The inconspicuous final result of this case could never have been accomplished without strong supportfromthedentallaboratory. Note: Dr. Holt would like to extend thanks to the exceptional team at Drake Precision Laboratories for pro- viding all laboratory support for this case. References 1. Kois JC. Predictable single tooth peri-implant esthetics: five diagnos- tickeys.CompendContinEducDent. 2004;25(11):895-900. 2. Lorenzana ER. Soft-tissue risk as- sessment in esthetic restorative and implant dentistry: smile analysis, gingival esthetics, and dental im- plant report. Functional Esthetics & RestorativeDentistry.2008;2(3):8-18. 3. Saadoun et al. Selection and ideal tri-dimensional implant position for soft tissue aesthetics. Prac Perio Aes- thetDent1999;11:1063–1072. 4. Kinsel, Lamb. Tissue-directed placement of dental implants in the esthetic zone for long-term biologic synergy: A clinical report. Int J Oral MaxillofacImpl2005;20(6):913-922. 5. Lee, Fu, and Wang. Soft Tissue Bio- typeAffects Implant Success. Implant Dentistry Volume20•Number3 38-44. 6. Priest. Esthetic Potential of Single- Implant Provisional Restorations: Selection Criteria of Available Al- ternatives. JERD Vol. 18, Number 6, 2006326-338 7.BelserUC.Estheticchecklistforthe fixed prosthesis. Part II: Biscuit bake tryin.InScharerP,RinnLA,KoppFR (Eds). Esthetic guidelines for restora- tive dentistry. pp 188–192. Chicago: Quintessence,1982. 8. Wadhwani C, Piñeyro A. Tech- nique for controlling the cement for an implant crown. J Prosthet Dent. 2009;102(1):57-58 9. Buser D, Martin W, Belser UC. Optimizing esthetics for implant restorations in the anterior maxilla: anatomic and surgical considera- tions. Int J Oral Maxillofac Implants. 2004;19(suppl):43-61. 10. Martin WC, Morton D, Buser D. Pre-operative analysis and pros- thetictreatmentplanninginesthetic implant dentistry. In: Buser D, Belser U, Wismeijer D, eds. ITI Treatment Guide, I: Implant Therapy in the Esthetic Zone: Single Tooth Replace- ments. Quintessence Publishing; 2007:9-24. 11. Jivraj S, Chee W. Treatment plan- ning of implants in the aesthetic zone. BrDentJ.2006Jul22;201(2):77- 89. 12. Tarnow D P, Magner A W, Fletcher P. The effect of distance from the contact point to the crest of bone on the presence or absence of the inter- proximal dental papilla. J Periodon- tol1992;63:886–995. mCMESELFINSTRUCTIONPROGRAM CAPPmea together with Dental Tribune provides the opportunity with its mCME - Self Instruction Program a quick and simple way to meet your continuingeducationneeds.mCMEoffersyoutheflexibilitytoworkatyour own pace through the material from any location at any time. The content is international, drawn from the upper echelon of dental medicine, but also presentsaregionaloutlookintermsofperspectiveandsubjectmatter. Membership YearlymembershipsubscriptionformCME:1,100AED OneTimearticlenewspapersubscription:250AEDperissue.Afterthe payment,youwillreceiveyourmembershipnumberandallowingyouto starttheprogram. CompletionofmCME • mCMEparticipantsarerequiredtoreadthecontinuingmedical education(CME)articlespublishedineachissue. • Eacharticleoffers2CMECreditandarefollowedbyaquiz Questionnaireonline,whichisavailableonwww.cappmea.com/ mCME/questionnaires.html. • Eachquizhastobereturnedtoevents@cappmea.comorfaxedto: +97143686883inthreemonthsfromthepublicationdate. • Aminimumpassingscoreof80%mustbeachievedinordertoclaim credit. • Nomorethantwoansweredquestionscanbesubmittedatthesame time • Validityofthearticle–3months • Validityofthesubscription–1year • CollectionofCredithours:Youwillreceivethesummaryreport withCertificate,maximumonemonthaftertheexpirydateofyour membership.Forsinglesubscriptioncertificatesandsummary reportswillbesentonemonthafterthepublicationofthearticle. Theanswersandcritiquespublishedhereinhavebeencheckedcarefully andrepresentauthoritativeopinionsaboutthequestionsconcerned. Articlesareavailableonwww.cappmea.comafterthepublication. Formoreinformationpleasecontactevents@cappmea.comor +97143616174 FORINTERACTIONWITHTHEAUTHORSFINDTHECONTACTDETAILSAT THEENDOFEACHARTICLE. Fig.11.Ankylosimpressioncopingplaced. Fig.13.Abutment withsoft tissuemoulage. Fig.15.Seatingjig. Fig.17.Abutment torquedandreadyforcrownseat. Fig.19.Finalrestorationat twoweeks. Fig.12.Finalimpression. Fig.14.eMaxcrownonabutment. Fig.16.Placingabutment withseatingjig. Fig.18.Seatingcrown. Fig.20.Patient postoperativesmile. LarryR.Holt,DDS, FICD,graduatedfrom theUNCSchoolof Dentistryin1978.He wasinprivatepractice from1978-2008. Since2008,hehas been thedirectorofclinicaleducation andresearchat DrakePrecisionDental LaboratoriesinCharlotte,N.C. ◊Page10 mcme Dental Tribune Middle East & Africa Edition | 6/201611

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