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12 mCME Dental Tribune Middle East & Africa Edition | 3/2018 Long-term clinical success in the management of compromised intertooth spaces utilizing small-diameter implants mCME articles in Dental Tribune have been approved by: HAAD as having educational content for 1 CME Credit Hour DHA awarded this program for 1 CPD Credit Point CAPP designates this activity for 1 CE Credit By Paul S. 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- placement for partial or totally eden- tulous situations have been able to enjoy natural appearing and func- tioning prostheses that are fi xed, sta- ble and, in some cases, so natural it’s diffi cult to ascertain a dental implant restoration from a tooth restoration. 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- fi cient intertooth spacing between natural teeth and, most commonly, with congenitally missing lateral incisors following orthodontic treat- ment.8 Often as a solution to this, 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 to proceed with a fi xed bridge, 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 not sooner.8 To properly form an ovate pontic type emergence profi le in the soft tissue, which is required for a fi xed 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, Misch and Salama, et al,9-11 stated that for a normal two-piece implant, the implant should be placed at least 1.5 mm from the adjacent teeth. As a result, using a 3.5 mm diameter implant, the minimum inter-tooth space to support interproximal bone and natural soft-tissue papillary con- 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 cases is smaller than 6.0 mm. Taking these parameters into ac- count, small-diameter implants (3.0 mm is the smallest from most dental 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 gingival tissues and papillae. 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 implant placement.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 compromised intertooth spaces.14-15 Implants are available from 1.8 mm diameter to 2.8 mm diameter and offer a fi xed 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 fl apless 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 dental implant practice. The following case report will dem- onstrate the use of the Dentatus ANEW (Dentatus USA, Ltd, New York, Fig. 1. Pretreatment clinical view. (Photos/Provided by Dr. Paul S. Petrungaro) Fig. 2. Preoperative periapical radiograph. N.Y.) implant for the management of the compromised, congenitally missing lateral space in a 17-year-old young woman with a 10-year clinical follow up. Case report 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 this was the fi nal obtainable result in regard to the remaining intertooth space between the maxillary left cen- 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 contours to be developed. 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 the creation of the natural-appearing papillary contours. 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 profi le 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, New York, N.Y.). An ion shell provisional crown was then hollowed out and retrofi tted to the abutment coping with fl ow- able composite. The margins of the provisional were corrected and pro- visional contoured out of the mouth. 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 view is seen in Fig. 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 fi nal 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 implant in Fig. 9. Please note the beautiful soft-tissue esthetic result obtained and excel- lent maintenance of the crestal and lateral contours. 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 fi xed 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- gence profi le formation, reminiscent of the natural tooth. Acknowledgement Originally published in Inside Den- tistry. © 2014 to AEGIS Publications, LLC. All rights reserved. Reprinted with permission from the publishers. References 1) Branemark P-I, Zarb GA, 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 Art and Science. Philadelphia, PA: WB Saunders Co. 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 Fig. 3. Ovate pontic type defect created Fig. 4. Dentatus ANEW implant seated minimally invasive protocol ÿPage 13