c r use of patient’s own natural teeth as part of the...

Use of Patient’s Own Natural Teeth as Part of the InterimProsthesis on Immediately Placed Single Implants in aStaged Surgical Approach: A Clinical ReportSarah A. Bukhari, BDS1*Abdulaziz AlHelal, BDS, MS2

Periklis Proussaefs, DDS, MS3

Antoanela Garbacea, DDS, MSD1,3

Mathew T. Kattadiyil, BDS, MDS, MS1

A technique is described where the tooth’s natural crown is used as part of the interim implant supported prosthesis in clinical situations

where a tooth with poor prognosis is extracted and an implant is placed immediately after tooth extraction. A preliminary impression is

made before tooth extraction, and the exact tooth positioning is assessed in the laboratory as part of the treatment plan. An acrylic resin

repositioning jig is fabricated that will guide the clinician in seating and orienting the crown intraorally after implant placement is

completed. After the natural tooth is extracted and an implant is immediately placed via guided approach, the extracted natural crown is

hollowed and placed on top of an interim abutment. The natural crown is positioned intraorally by using the acrylic resin repositioning jig.

The crown is then internally relined and placed as part of the interim implant supported prosthesis. After osseointegration has been

confirmed, a definitive prosthesis is placed.

Key Words: IIPP, IPP, immediate placement and provisionalization, immediate provisionals, natural teeth provisional, provisionals

INTRODUCTION

Demands for harmony between the peri-implant

gingiva and adjacent dentition especially in the

esthetic zone are increasing.1 In situations where an

immediate implant is immediately loaded, it is

essential to provide the patient with an adequate provisional

crown.2–17 Gingival recession has been associated with

immediate implant placement and temporization (IIPT).3,7,13,15

that can be attributed, among other factors, to compression of

the peri-implant soft tissue caused by an over-contoured

restoration at the cervical area.17,18

A duplication of the exact contours of the extracted tooth,

especially at the cervical part of the interim prosthesis, is

expected to preserve the soft tissue morphology and allow the

creation of a naturally looking emergence profile. A near-

natural dimensioned seal of the gingival soft tissue collar may

initiate a tissue-maintaining healing process.19–21 Most authors

has suggested fabricating an interim implant supported crown

made of autopolymerized acrylic resin after implant surgery3 or

using a prefabricated interim crown that can be relined with

autopolymerized acrylic resin chair side after implant surgery

has been completed.4,7,8 However, the use of patient’s natural

tooth as part of the interim prosthesis can simulate a

replantation in the dentogingival complex.21 Natural tooth also

represents a biocompatible structure, which is favored over the

surface topography of any long-term interim crown material

due to the potential for development of a good soft tissue

attachment.21 The use of the patient’s natural crown as part of

the interim prosthesis has been described by fabricating an

interim abutment and modifying the natural crown to fit the

abutment.21

The purpose of the presented technique is to demonstrate

the application of IIPT protocol for restoring single implants in

the aesthetic zone by using the patient’s natural dental crown

and focusing on the maintenance of the hard and soft tissues in

the region in a staged surgical approach. A guide was

developed to reposition the natural tooth crown after implant

surgery so that the interim prosthesis is fabricated as a

duplicate of the diagnostic treatment plan.

CLINICAL REPORT

A 65-year-old female presented at the Center for Prosthodon-

tics and Implant Dentistry at Loma Linda University School of

Dentistry for prosthodontic evaluation and treatment. Upon

1 Advanced Specialty Education Program in Prosthodontics, Loma LindaUniversity School of Dentistry, Loma Linda, Calif.2 Department of Prosthetic Dental Sciences, College of Dentistry, KingSaud University, Riyadh, Saudi Arabia.3 Advanced Specialty Education Program in Implant Dentistry, LomaLinda University School of Dentistry, Loma Linda, Calif, and privateprosthodontic practice, Ventura, Calif.

* Corresponding author, e-mail: [email protected]

DOI: 10.1563/aaid-joi-D-17-00292

Journal of Oral Implantology 351

CASE REPORT

clinical examination, the 4 maxillary anterior teeth exhibited

grade II tooth mobility (Figure 1a). Radiographic examination

revealed very short roots (Figure 1b). After discussing different

treatment options with the patient, a decision was made to

extract the 4 maxillary incisors and immediately place 2 root

form dental implants at the area of maxillary lateral incisors. The

restorative plan included restoring the 2 implants with implant-

supported fixed partial denture (ISFPD).

The presurgical data collection consisted of clinical

diagnostic examination, impressions, occlusal records, and

radiographic examination (cone beam computerized tomogra-

phy [CBCT]). Upon CBCT evaluation the case was deemed

suitable for immediate implant placement and provisionaliza-

tion (Figure 2a and b).22 A decision was made to stage teeth

extraction.

In the first stage of the treatment, the 2 maxillary lateral

incisors were extracted and 2 root form dental implants were

placed. Implant surgery was digitally simulated to ensure

adequacy of bone around the dental implants and to fabricate

a tooth-supported surgical guide (Invivo 5; Anatomage, San

Jose, Calif).

In the laboratory, the maxillary cast was modified in order

to fabricate an acrylic resin jig to position the provisional

restorations after the placement of the implants. Existing

maxillary right lateral incisor was proclined (Figure 3a). An

orthodontic setup was made to move the right maxillary lateral

incisor palatally so it is properly aligned within the dental arch

(Figure 3b and c). Correcting the position of the right maxillary

lateral incisor to match the left lateral incisor was done to

improve the esthetic outcome. An orientation jig was

fabricated on the new maxillary cast using pattern resin

(Pattern resin; GC America Inc, Alsip, Ill) to register this relation

(Figure 3d).

On the day of surgery, extractions of the maxillary lateral

incisors were performed with minimal trauma preserving the

facial and the interproximal bone (Figure 4a). After teeth

extraction, both sockets were curetted and irrigated with

saline solution and the levels of the crestal bone were re-

evaluated. The tooth supported surgical guide was then

placed and the osteotomies were prepared (Figure 4b). A 3.3

bone level root form implants (BLT Roxolid SLActive,

Straumann, Andover, Mass) were placed at the area of the

maxillary lateral incisors and the gap between the implant and

the extraction socket was filled with xenograft bone graft

material (Bio-Oss small particle; Geistlich, Princeton, NJ)

(Figure 5).

Primary implant stability was achieved with a minimal

insertion torque of 35N-cm. Immediate restorations using the

patient’s existing natural teeth were prepared. Engaging

titanium temporary abutments (NC temporary abutment for

FIGURES 1 AND 2. FIGURE 1. (a) Intraoral frontal view of patient’s preexisting condition. (b) Preoperative periapical radiograph of teeth #s 7and 10. FIGURE 2. (a) Digital planning of implant #s 7 and 10 using Invivo 5 software. (b) Cone beam computerized tomography (CBCT)showing digital planning of implant #7. (c) CBCT showing digital planning of implant #10.

352 Vol. XLIV / No. Five / 2018

Natural Tooth Provisional for Immediate Implant Placement

crown, Straumann) were hand tightened into each implant

(Figure 6). The appropriate height of both temporary abutment

was marked and the temporary abutments were then removed

and adjusted extra-orally. The temporary abutments were then

reseated into the implants, hand tightened, and the screw

accesses were blocked. The natural teeth were then modified.

The natural teeth (Figure 7a) were trimmed leaving only the

facial surface from the cemento-enamel junction (CEJ) to the

incisal edge (Figure 7b and c). The teeth were then placed into

the acrylic resin jig that was previously fabricated. The jig was

seated in the patient’s mouth (Figure 7d) and light polymerized

composite resin (Filtek Supreme Ultra, 3M ESPE, St Paul, Minn)

was used to attach the tooth to the temporary abutment. The

provisional restoration was then removed and modified extra-

orally. The provisional crowns were replaced into the implants,

hand tightened, and the access holes were blocked with

polytetrafluoroethylene tape. A darker shade composite resin

(Filtek Supreme Ultra, 3M ESPE) was used to seal the screw

FIGURES 3 AND 4. FIGURE 3. (a) Frontal view of maxillary cast, showing proclined tooth # 7. (b) Frontal view of tooth #7 after orthodonticarrangement. (c) Occlusal view of maxillary cast after orthodontic arrangement. (d) Acrylic resin orientation jig used for fabricatingprovisional crowns FIGURE 4. (a) Intraoral occlusal view of maxillary arch after extracting teeth #s 7 and 10. (b) Intraoral occlusal view ofmaxillary arch with surgical guide.


Bukhari et al

access holes and occlusion was adjusted as needed (Figure 8a

through d).

The second-stage surgery was performed after 3 months of

healing (Figure 9). A definitive impression was made using

custom open tray impression copings.23 Heavy and light body

poly(vinyl siloxane) (PVS) impression material (Aquasil, Dents-

ply, York, Pa) was used along with a custom tray made of light

polymerized acrylic resin (Tru Tray Sheet, Dentsply). The

definitive cast was poured in type IV dental stone (Resin Rock;

Whip Mix Corp, Louisville, Ky) with a simulated soft tissue

material (GI-Mask; Coltene, Cuyahoga Falls, Ohio). The cast was

used to fabricate an interim fixed partial denture.

On the day of the second stage surgery, the maxillary

central incisors were extracted, both sockets were curetted,

irrigated with saline solution and then grafted with xenograft

bone graft material (Bio-Oss small particle; Geistlich). An interim

FIGURES 5–7. FIGURE 5. Intraoral occlusal view of maxillary arch showing particulate bone graft around implants #s 7 and 10. FIGURE 6.Intraoral occlusal view of maxillary arch with temporary cylinders on implants #s 7 and 10. FIGURE 7. (a) Extracted teeth # 7 and 10. (b) Facialsurface of modified tooth # 7. (c) Palatal surface of modified tooth # 7. (d) Intraoral occlusal view of seated acrylic resin orientation jig. (e)Intraoral occlusal view showing blocked access hole for implant # 7 and modified natural tooth seated intraorally using acrylic resinorientation jig.



ISFPD was seated and hand tightened into implants previously

place at the area of the maxillary lateral incisors. Interproximal

contact points were evaluated with the use of a shim stock 10

microns in thickness (Shim stock, Artus Co, Englewood, NJ). The

shim stock should be able to slide through the mesial and distal

contact points without getting torn. The occlusion was also

evaluated with the use of shim stock. Four layers of shim stock

were used and should be able to slide between the ISFPD and

the opposing dentition when the patient was in maximum

intercuspation position.24

Following a 6-month healing period, a definitive impression

was made. The definitive prosthesis was fabricated and seated

intraorally (Figure 10a through c). Occlusion was adjusted as

needed.

DISCUSSION

The significance of the presented technique is that it offers

some guidelines in utilizing the patient’s own natural crown as

part of the interim implant-supported prosthesis. Implant

placement and interim crown fabrication were both completed

under a guided protocol that might enhance the accuracy of

the clinical outcome. The intended crown position that was

assessed in the laboratory preoperatively was reproduced

clinically after implant surgery with the use of an orientation jig.

The clinical protocol for immediate implant placement and

provisionalization IIPP has been associated with the use of an

interim prosthesis made of autopolymerized acrylic resin.2,3

More recently, use of a milled interim implant-supported

prosthesis has been introduced in the literature25,26 in an

attempt to overcome potential problems associated with the

intraoral use and polymerization of autopolymerized acrylic

resin. Regardless of the technique, it has been assumed that

connective tissue healing is compromised when resin materials

are used.27 A seal between the soft tissue and the restorative

material may not develop.

Some authors have advocated the use of prefabricated

interim resin crowns that can be relined intraorally around a

prefabricated metal abutment.7,8 The rationale of using a

prefabricated resin shell is the enhanced mechanical properties

associated with prefabricated interim crowns. However, the

exact shape and contours of these crowns cannot be

customized. Either an overcontoured or undercontoured

FIGURES 8–10. FIGURE 8. (a) Frontal and lingual view of finished natural tooth provisional (b) Intraoral occlusal view of natural teethprovisional in place on day of surgery. (c) Intraoral frontal view of natural teeth provisional in place on day of surgery. (d) Post-operativeperiapical radiograph of implants #s 7 and 10. FIGURE 9. Intraoral frontal view of natural teeth provisional after 3 months of healing. FIGURE

10. (a) Intraoral occlusal view of maxillary arch showing emergence profile around implants #s 7 and 10 and pontic area of #s 8 and 9. (b)Intraoral frontal view of maxillary arch showing emergence profile around implants #s 7 and 10 and pontic area of #s 8 and 9. (c) Intraoralfrontal view of definitive prosthesis in place.


Bukhari et al

interim restoration will result in soft tissue contours that will

not be compatible with the definitive prosthesis.

Trimpou et al21 published a description of a technique

where the natural tooth was used as part of the interim

prosthesis. The authors suggested potential superiority of this

protocol that was attributed to the near ideal seal a natural

tooth can offer as compared to a resin crown. The described

technique offers a guided protocol for positioning the crown

intraorally. The positioning of the crown is based on the

position that was assessed in the laboratory during treatment

planning. Positioning the crown manually after implant surgery

may be associated with limited reproducibility and operator’s

error.

The healing process of the extraction socket has been

studied in animals.28,29 The process of osseous and soft tissue

healing after an extraction initiates immediately after the

extraction.28 The sharp coronal osseous edges that are present

after a tooth has been extracted round off by osseous

resorption, which results in reduction of the alveolar bony

height. While the extraction socket will eventually ossify, the

vertical height of the alveolar socket is reduced during the

healing process.

On the other hand, the healing of the extraction socket

during a replantation process follows a different pattern.19 The

assumption is that when the natural tooth is placed back in the

extraction socket, an ideal sealing may occur between the

replanted tooth and the surrounding tissue. Twenty-four hours

after tooth extraction the gingiva demonstrates no sign of

trauma.19,27 Soft and hard tissue remains intact around the

extracted tooth.19 It is inferred that a nearly ideal seal between

the external surface of an extracted tooth and the surrounding

tissue may result in osseous and soft tissue stability around the

area of the extraction socket. The assumption can be made that

using the natural crown as an interim prosthesis during the IIPT

protocol may result in a similar healing process with near ideal

sealing around the interim prosthesis that might result in

enhanced preservation of the surrounding tissues. An animal

study with histologic analysis is needed to validate this

hypothesis.

The clinician needs to be knowledgeable about the

controversies regarding the IIPT protocol. While some authors

have advocated that placing and temporizing an implant

immediately after tooth extraction may offer results similar to

the conventional two stage protocol,3,6,11,14,16 some other

authors have reported that following the 2-stage protocol by

allowing the extraction socket to heal before placing an

implant may offer superior implant success or survival rate.5,12

Patients need to be well informed on potential risks and

benefits when this procedure is contemplated.

A disadvantage of the described technique is the additional

time needed in the laboratory to reposition the natural crowns

and prepare the acrylic resin jig that would guide the operator

in positioning the natural teeth after implant surgery. In

addition, the described technique is based on the assumption

that the esthetics and contours of the existing natural teeth are

ideal. Presence of extensive carious lesions on the extracted

teeth may preclude the use of the described technique.

In conclusion, utilizing the patient’s natural tooth as part of

the interim implant-supported prosthesis may offer advantag-

es. A clinical study is needed to validate the application of this

protocol on regular clinical practice.

SUMMARY

A technique was developed to provide guided positioning of

natural teeth when they are used as part of an interim implant-

supported prosthesis in a staged surgical treatment plan.

Clinical studies are needed to validate the use of the described

technique on a routine basis.

ABBREVIATIONS

CBCT: cone beam computerized tomography

CEJ: cemento-enamel junction

IIPT: immediate implant placement and temporization

ISFPD: implant-supported fixed partial denture

PVS: poly(vinyl siloxane)

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