Conversion of an existing metal ceramic crown to an interim restoration and nonfunctional loading of a single implant in the maxillary esthetic

zone: A clinical report

Konstantinos Michalakis, DDS, MSc, PhD,a Christos D. R. Kalpidis, DDS, DSc,b and Hiroshi Hirayama, DDS, DMD, MSc Tufts University School of Dental Medicine, Boston, Mass; Aristotle University School of Dentistry, Thessaloniki, Greece
Implant placement and immediate placement of an interim restoration can be a safe therapeutic approach with high survival rates. The technique is often used in the anterior esthetic area because of the better preservation of the periimplant soft tissue contours. Traditionally this procedure involves the fabrication of an acrylic resin implant-supported interim restoration. This clinical report describes the modication of an existing metal ceramic crown to be used as an implant-supported interim restoration for immediate nonfunctional loading to achieve an improved esthetic result and optimal support of the adjacent soft tissues. (J Prosthet Dent 2014;111:6-10) Dental implants present a valid treatment modality for completely1-4 and partially edentulous patients.5-8 Additionally, dental implants provide an excellent solution for patients who have lost a single tooth.9-12 Nevertheless, one of the biggest disadvantages of implant therapy is the lengthy treatment time (the original protocol of PI Brnemark requires an undisturbed healing period of 4 to 6 months3) and the need for an interim prosthesis. The disadvantages of most interim restorations are associated with the uneven healing of the soft tissue and underlying bone or even the loss of the interdental papillae,13 thereby compromising the esthetic result. A recent study suggested that implant placement and immediate loading of an interim restoration can be a safe therapeutic approach with high survival rates.14 Preliminary clinical data suggest that the soft tissue periimplant contours can be preserved with careful immediate implant placement and the use of an interim restoration.15-17
a

A recent prospective clinical study by Block et al18 demonstrated that support of the gingival margin with an interim restoration at the time of the tooth extraction and implant placement preserved 1 mm more facial gingival margin position than delayed implant placement. In clinical studies and patient reports, immediate nonfunctional loading has

been provided with custom-made acrylic resin interim restorations.19-21 Traditionally, this procedure involves shade selection, diagnostic waxing, acrylic resin processing, and nishing procedures. However, the denitive esthetic outcome may sometimes be disappointing because of the inherent inability of acrylic resin to simulate the optical properties of the adjacent natural teeth. An improved

1 Maxillary right central incisor with marginal inammation and coronal migration.

Adjunct Associate Professor, Division of Graduate and Postgraduate Prosthodontics, Department of Prosthodontics and Operative Dentistry, Tufts University School of Dental Medicine; and Assistant Professor, Department of Prosthodontics and Clinical Director, Graduate Prosthodontics, Aristotle University School of Dentistry. b Private practice, Thessaloniki, Greece. c Professor, Division Head of Postgraduate Prosthodontics; Director, Graduate and Postgraduate Prosthodontics; Director, Advanced Education in Esthetic Dentistry; and Director, Advanced Dental Technology and Research Program, Tufts University School of Dental Medicine.

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2 Preoperative periapical radiograph revealing apical radiolucency. esthetic result may sometimes be obtained if composite resins are used for the same purpose. Besides color, other parameters such as surface texture and contour are important for a successful result. Correct contour is also essential for proper support of the adjacent soft tissues.22 The mesial and distal papillae should be supported but not compressed with the crown form.22,23 In addition, the cervical third should be anatomically correct to avoid gingival margin recession.18 These parameters, which are important for the denitive esthetic result, are usually satised by a properly fabricated metal ceramic restoration. This clinical report describes the modication of an existing metal ceramic crown to be used as an implantsupported interim restoration for immediate nonfunctional loading.

3 Extracted root of right central incisor. affected tooth, inammation at the gingival margin, and 2 mobility. Additionally, the tooth seemed to have migrated to a more coronal position (Fig. 1). The radiographic examination revealed that the tooth had been treated with apicoectomy and presented an apical radiolucency (Fig. 2). After consultation with an endodontist and periodontist, different treatment plans were presented to the patient: surgical retreatment of the affected area, extraction of the tooth and placement of an implant, with delayed or immediate loading, and placement

4 Retrieved cast post and core and metal ceramic crown. of a resin-bonded or conventional partial xed dental prosthesis. The patient consented to an implant-supported restoration replacing the failing tooth. On the basis of the collected clinical and radiographic ndings, and because of the esthetic component, the patient was categorized as an American College of Prosthodontists Prosthodontic Diagnostic Index class II completely dentate patient.24 Preliminary impressions were made with irreversible hydrocolloid impression material (Blueprint Cremix; Dentsply DeTrey GmbH). Diagnostic casts for

CLINICAL REPORT
A 40-year-old woman presented complaining of a dull pain, slight swelling, and mobility of the maxillary right central incisor, which had been restored with a metal ceramic crown 10 years previously. The clinical examination revealed the presence of a stula in the apical third of the root of the

5 Extraction site with defect at apical part of buccal plate. Extra care has been taken for osseous ridge preservation in coronal part of buccal plate.

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both the maxillary and mandibular arches were fabricated with Type III dental stone (Moldano; Heraeus Kulzer) and were mounted in maximal intercuspal position on a semiadjustable articulator (Denar Mark II; Whip Mix Corp) after a facebow transfer. An autopolymerizing polymethyl methacrylate acrylic resin (Pattern Resin; GC Corp) index was fabricated to assist in the proper positioning of the interim restoration on the day of the surgery. A surgical template was then fabricated with clear autopolymerizing polymethyl methacrylate resin (Orthoplast; Vertex Dental BV). The tooths cingulum area was marked, and an access channel was opened with a laboratory tungsten carbide bur (261E-023; Brasseler USA). On the day of the implant surgery, local anesthesia with 4% articaine (1:100 000 epinephrine) (Ubistesin Forte; 3M ESPE) was delivered, and a full-thickness ap was raised. Thin elevators and a periotome were used for atraumatic extraction of the tooth (Fig. 3). Extra care was taken not to fracture the metal ceramic restoration (Fig. 4) and to preserve the buccal plate (Fig. 5). A surgical curette was used to debride the socket of all granulation tissue. The metal ceramic restoration with the cast post and core was removed from the root of the tooth. The cast post and core was then removed with a high-speed handpiece (625C Super Torque; Kavo GmbH) and a tungsten carbide metal cutting bur (CB 37R.314012; DrendelZweiling Diamant GmbH). A round diamond rotary cutting instrument (801G.314-018; DrendelZweiling Diamant GmbH) with a tungsten carbide metal cutting bur were used to open a palatal access at the metal ceramic crown. Multiple undercuts were created on the intaglio surface of the crown by using the above-mentioned tungsten carbide bur. In addition, the intaglio surface of the crown was airborne particle abraded with 50 mm Al2O3 under 0.4 MPa pressure. The osteotomy started with a round bur, which was placed into the channel

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6 External hexagon Osseotite implant 7 Modied metal ceramic crown (413 mm) was placed in extraction connected with temporary cylinder. socket.

8 Interim restoration fastened on implant. of the surgical template previously described and continued with the 2.3-mm twist drill, the pilot drill, and the 3.2513 mm shaping drill at 500 rpm, with the drill torque test set at 50 Ncm. The clinician was careful to engage the palatal wall of the extraction socket with the drills. The osteotomy was performed under copious saline irrigation. A 413 mm external hexagon implant (Osseotite; Biomet 3i) was placed by using 20 rpm at 40 Ncm torque. The platform of the implant was placed 2 mm apically to the cementoenamel junction of the right maxillary central incisor (Fig. 6).25-27 A temporary metal cylinder (Biomet 3i) was fastened on the implant with a titanium screw and marked so that it could be reduced to the proper length. It was then removed, fastened to an implant replica, and cut with a diamond separating disk (340 00280; Bredent). It was further reduced and shaped with diamond rotary instruments. The nal length and shape of the temporary cylinder were evaluated intraorally with the metal ceramic restoration in place. Furthermore, the clearance between the temporary cylinder and the metal ceramic restoration was veried. The metal ceramic restoration was then

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aligned with the left central incisor both apicocoronally and buccolingually and stabilized in that position with the index previously fabricated in the laboratory. Autopolymerizing polymethyl methacrylate acrylic resin (Jet; Lang Dental Mfg Co) was then added intraorally between the interim restoration and the temporary cylinder with the bead-brush technique. After the polymerization was completed, the interim restoration/ temporary cylinder complex was removed and fastened on an implant replica. More autopolymerizing polymethyl methacrylate acrylic resin was added to achieve a smooth transition from the neck of the temporary abutment cylinder to the margins of the metal ceramic crown. The restoration was placed in a pressure pot (Aqua Press; Lang Dental Mfg Co) containing warm water. It was then shaped with laboratory tungsten carbide burs and polished with abrasive rubber points and pumice (Fig. 7). The interim restoration was fastened on the implant with a torque driver (Anthogyr) with a 20 Ncm torque (Fig. 8). The palatal access hole was closed with gutta percha and acrylic resin. The occlusion was evaluated and any centric and eccentric contacts were eliminated. The acrylic resin was further polished with abrasive points. A remaining buccal bone deciency was lled with bovine-derived bone xenograft (Bio-Oss; Geistlich Pharma AG) and covered with a guided tissue regeneration membrane (Bio-Gide; Geistlich Pharma AG) (Fig. 9).28,29 The ap was sutured in place (Fig. 10). Postoperatively, the patient was prescribed 1 g of amoxicillin/clavulanate potassium (Augmentin; GlaxoSmithKline) per day for 6 days and the nonsteroidal analgesic nimesulide (Mesulid; Boehringer Ingelheim GmbH, Ingelheim, Germany) (100 mg twice a day for 6 days). A 0.12% chlorhexidine (Peridex; Procter & Gamble) rinse was also prescribed, and the patient was instructed to use it 3 times a day for 14 days. The sutures were removed after 10 days. The patient was placed on a soft food diet for 6 weeks in order to promote uneventful healing (Fig. 11).

9 Bone deciency lled with bovine-derived bone xenograft and covered with guided tissue regeneration membrane.

10 Flap sutured in place.

11 Interim existing metal ceramic restoration 6 weeks after implant placement.

SUMMARY
A metal ceramic crown that had been in function for almost 10 years was modied and used as an interim implant-supported restoration and was

immediately nonfunctionally loaded. The advantages of this approach are the enhanced esthetic result provided by the optical properties, the improved contour and surface texture of the metal ceramic crown, and the

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continued support of the adjacent soft tissues.
11. Ekfeldt A, Carlsson GE, Brjesson G. Clinical evaluation of single-tooth restorations supported by osseointegrated implants: a retrospective study. Int J Oral Maxillofac Implants 1994;9:179-83. 12. Enquist B, Nilson H, Astrand P. Single-tooth replacement by osseointegrated Brnemark implants. A retrospective study on 82 implants. Clin Oral Impl Res 1995;6:238-45. 13. Salama H, Salama M, Garber D, Adar P. The interproximal height of bone: a guidepost to predictable aesthetic strategies and soft tissue contours in anterior tooth replacement. Pract Periodont Aesthet Dent 1998;10:1131-41. 14. Schnitman P, Whrle PS, Rubenstein JE. Immediate xed interim prostheses supported by two-stage threaded implants: methodology and results. J Oral Implantol 1990;2: 96-105. 15. Lazzara RJ. Immediate implant placement into extraction sites: surgical and restorative advantages. Int J Periodontics Restorative Dent 1989;9:332-43. 16. Garber DA, Salama MA, Salama H. Immediate total tooth replacement. Compend Contin Educ Dent 2001;22:210-6, 218. 17. Chen ST, Wilson TG Jr, Hmmerle CH. Immediate or early placement of implants following tooth extraction: review of biologic basis, clinical procedures, and outcomes. Int J Oral Maxillofac Implants 2004;19(suppl): 12-25. 18. Block MS, Mercante DE, Lirette D, Mohamed W, Ryser M, Castellon P. Prospective evaluation of immediate and delayed provisional single tooth restorations. J Oral Maxillofac Surg 2009;67:89-107. 19. Hui E, Chow J, Li D, Liu J, Wat P, Law H. Immediate provisional for single-tooth implant replacement with Brnemark system: preliminary report. Clin Implant Dent Relat Res 2001;3:79-86. 20. Lorenzoni M, Pertl C, Zhang K, Wimmer G, Wegscheider W. Immediate loading of single-tooth implants in the anterior maxilla. Preliminary results after one year. Clin Oral Implants Res 2003;14:180-7. 21. Degidi M, Piattelli A, Felice P, Carinci F. Immediate functional loading of edentulous maxilla: a 5-year retrospective study of 388 titanium implants. J Periodontol 2005;76: 1016-24.

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22. Choquet V, Hermans M, Adriaenssens P, Daelemans P, Tarnow DP, Malevez C. Clinical and radiographical evaluation of the papilla level adjacent to single-tooth dental implans. A retrospective study in the maxillary anterior region. J Periodontol 2001;72: 1364-71. 23. Belcer UC, Bernard JP, Buser D. Implantsupported restorations in the anterior region: prosthetic considerations. Pract Periodontics Aesthet Dent 1996;8:875-83. 24. McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, et al. Classication of the completely dentate patient. J Prosthodont 2004;13:73-82. 25. Chiche FA, Leriche MA. Multidisciplinary implant dentistry for improved esthetics and function. Pract Periodont Aesthet Dent 1998;10:177-88. 26. Saadoun AP, Le Gall MG, Touati B. Selection and ideal tridimensional implant position for soft tissue aesthetics. Pract Periodont Aesthet Dent 1999;11:1063-72. 27. Buser D, Martin W, Belser UC. Optimizing esthetics for implant restorations in the anterior maxilla: anatomic and surgical considerations. Int J Oral Maxillofac Implants 2004;19(Suppl):43-61. 28. Sclar AG. Preserving alveolar ridge anatomy following tooth removal in conjunction with immediate implant placement. The Bio-Col technique. Atlas Oral Maxillofac Surg Clin North Am 1999;7:39-59. 29. Vasilic N, Henderson R, Jorgenson T, Sutherland E, Carson R. The use of bovine porous bone mineral in combination with collagen membrane or autologous brinogen/bronectin system for ridge preservation following tooth extraction. J Okla Dent Assoc 2003;93:33-8. Corresponding author: Dr Konstantinos Michalakis 3 Gregoriou Palama str Thessaloniki 54622 GREECE E-mail: kmichalakis@the.forthnet.gr Copyright 2014 by the Editorial Council for The Journal of Prosthetic Dentistry.

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