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30 ◊Page 28 RESTORATIVE Dental Tribune Middle East & Africa Edition | 2/2017 Fig 13: Finalized E-max abutment wax up with Ti base abutment Fig 14: E-max abutment wax-up with sprue for press- ing protocol Fig 15: E-max veneer with custom E-max Abutment and sandblasted Ti-base abutment Fig 16: Customized E-max abutment with pressed veneer ed on etched IPS e.max framework and then the restoration was deliv- ered with a fi nal torque of 35 Ncm. The Technical Protocol for Custom- ized IPS e.max Abutment: Pressed ceramics (IPS e.max, Lithium Disilicate) have proved to be an ex- tremely successful and reliable mode of fabricating esthetic and accurate restorations for implants. Creating a durable bond with Titanium base abutments using luting compos- ites opens new opportunities such as customized IPS e.max abutment concept, wherein the ability to lute extraorally and deliver a screw re- tained restoration intraorally proves to be a distinct advantage. Once the customized coping impres- sion is processed with a soft tissue cast fabrication, a Ti base abutment is selected and a wax-up to fi nal con- tour is done based on the gingival ar- chitecture created by the provisional (Fig 10). A putty index of this situa- tion is made. The wax up is then cutback from the facial surface using the putty in- dex as a guide for reduction (Fig 11). We welcome you to meet us on Stand SR623 at AEEDC Dubai 7–9 February 2017 Fig 17: Final Result with excellent tissue response Fig 18: Post-operative X ray The Finalization of Esthetic Resto- ration: At the prosthetic phase after 16 weeks, the provisional crown was removed to fi nd the gingival archi- tecture sculpted by its shape (Fig 7). During fi nal impressions a custom- ized impression coping (Fig 8) is used to capture the already perfected soft tissue emergence profi le and a stone cast is fabricated with ideal soft tis- sue contours (Fig 9). A Ti-base abutment is used from the implant manufacturer on which a customized IPS e.max framework is fabricated. This IPS e.max frame- work is designed to receive an IPS e.max veneer on the labial aspect. In this case the screw access hole of the implant emerged favourably from the cingulum of 12. Although it was possible to fi re veneering ceramic di- rectly to the core abutment, we pre- ferred to make multiple thin veneers of differing values on the underlying core and hence chose this method of fabrication where the veneer of IPS e.max is bonded to the underly- ing customized IPS e.max core extra orally before delivering the restora- tion. After trial the veneer was bond- Dental Institute Discover our range of high-quality, high-intensity postgraduate courses Study: MClinDent/MSc/Diploma • Full-time, part-time, on-campus and online • Online study includes residential blocks of training on-campus • Range of 19 courses including restorative specialty training Research: MPhil/MRes/PhD Four multidisciplinary science divisions • Craniofacial Development & Stem Cell Biology • Mucosal & Salivary Biology • Population & Patient Health • Tissue Engineering & Biophotonics RANKED NUMBER ONE IN THE UK FOR DENTISTRY QS WORLD UNIVERSITY RANKINGS 2016 GLOBAL TOP 10 FOR CLINICAL, PRE-CLINICAL AND HEALTH (INCLUDING DENTISTRY) TIMES HIGHER EDUCATION WORLD UNIVERSITY RANKINGS 2015-16 RANKED NUMBER FOUR IN THE WORLD FOR DENTISTRY QS WORLD UNIVERSITY RANKINGS 2016 Find out more: visit www.kcl.ac.uk/dentistry email dental-postgraduate@kcl.ac.uk The cutback is made in a manner to mimic a veneer preparation as the fi nal design for the IPS e.max abut- ment, with the implant access hole favourably placed on the palatal side (Fig 12, 13). This way we have maxi- mum strength for the abutment design as well as a good stump shade which can be customised with IPS e.max stains and suffi cient space for an IPS e.max veneer. Two veneers of slightly differing value are fabricated for crucial cases in esthetic zone, to identify the value that matches best intraorally. The abutment is then invested and pressed using a MO ingot (Fig 14). Af- ter carefully divesting, the abutment is then checked for fi t to the Ti base. The abutment is checked for suffi - cient space on the facial surface for an IPS e.max veneer. Palatal contacts are fi ne tuned to provide a good oc- clusal contact with the lowers teeth. The customized IPS e.max abutment is then stained and characterized as required. This allows the colours to be built-in from within, as found in natural teeth. The surface of the abutment that is in contact with the soft tissue is fi nished to a high glaze. Using the putty index as a guide the veneer is then waxed up and pressed to fi nal contour. Once the veneer fi t is verifi ed, it is cut back facially on the incisal 1/3 to create space for micro layering of ceramics and create internal charac- terizations using the wide range of IPS e.max Ceram incisal effects, and essence powders. In this case we fab- ricated two veneers, one veneer with standard IPS e.max Ceram Incisal ef- fects and the 2nd veneer was done with the new IPS e.max power incisal to increase the brightness level (Fig 15, 16). A try in is done at chairside to check for fi t and form of the restoration to provide a good emergence profi le. Thereafter the veneer is stained and characterised and polished. The IPS e.max Abutment is then ce- mented to the Ti-base. The Ti base is screwed onto a spare Implant replica. The surface of the Ti base in contact with the soft tissue and the screw ac- cess hole of the Ti base is protected with wax. The area of the Ti base that is to receive the IPS e.max abutment is gently sandblasted to achieve a surface that is matt grey and its sur- face conditioned to receive the IPS e.max abutment. The wax is then steam cleaned from the abutment. Monobond Plus is ap- plied to the cleaned Ti base surface for 60 sec and the surplus is dried with air that is water and oil free. The internal surface of the IPS e.max abutment is then treated with an etching gel for 20 sec only. The etch- ant is then removed and cleaned. Monobond Plus is applied to the in- ternal surface of the IPS e.max abut- ment for 60 secs and the surplus is dried with air that is water and oil free. Multilink Implant is used to bond the IPS e.max abutment to the Ti base. A glycerine gel is used at the cervical joint between the IPS e.max abutment and Ti base to prevent the formation of an inhibition layer and this is then cured in a light curing unit. The abutment is then fi nished with silicone polishers to achieve a smooth surface and remove any ce- ment residue. The IPS e.max abutment is now ready to receive the pressed veneer for bonding. The facial surface of the IPS e.max abutment is etched and so is the internal surface of the IPS e.max ve- neer for 20 seconds each. The fact that there can be such predictable bonding on IPS e.max abutments is a distinct advantage over Zirconia abutments. Monobond plus is applied to both the bonding areas on the IPS e.max abutment as well as the IPS e.max veneer. Variolink 2 is used to lute the IPS e.max veneer to the IPS e.max abut- ment. Excess luting material is re- moved and the veneer margins are covered with a glycerine gel and then light cured for fi nal polymerization. Thereafter, the IPS e.max abutment and veneer margin junction is fi n- ished with silicone polishers. The restoration is then delivered by torqueing the abutment screw to 30 Ncm intraorally. The palatal cin- gulum access hole is fi nished with a light cured composite material, and fi nished to a high polish using sili- cone intraoral polishers. The fi nal result showed excellent healing of the soft tissues around the implant (Fig 17). The post-operative radiograph revealed a well-integrat- ed restoration and implant (Fig 18) Discussion The greatest advantage of T1 protocol is that only one surgical procedure is needed and the overall treatment time is reduced. There is no doubt that in certain cases this protocol renders excellent short term results especially if all the six clinical assess- ment factors mentioned above are favourable. However caution has to be exercised by clinicians as there are several pitfalls of T1 protocol like challenges with irregular Socket Morphology and increased risk of mucosal recession especially in thin- ner biotypes. Adjunct soft tissue surgeries such as a connective tissue graft may be necessary for a success- ful esthetic outcome. Using an IPS e.max Customized abutment provides several advan- tages; such as ability to etch and bond the fi nal restoration thereby providing a stable long term result, and with better colour & translucen- cy, the customized IPS e.max abut- ment will provide a better substrate for the fi nal esthetic restoration and a scaffold for excellent gingival heal- ing due to its outstanding biocom- patibility. Conclusion Optimization of tissue support with customized lithium disilicate abut- ments is a viable treatment option for single and short span Implant restorations in the anterior zone. With the suffi cient strength and better translucency that it offers over zirconia abutments, it makes a strong case to be chosen as the fi rst line of restorative options in cases with high demand from implant res- torations in the esthetic zone. References available from the pub- lisher.