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The International Journal of

Vol 38/6 2018 • November/December

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Nuria Otero et. al:The Effect of Implant Abutment Design onLong-Term Soft Tissue Stability:A Clinical Case Report

The International Journal of Periodontics & Restorative Dentistry

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Volume 38, Number 6, 2018

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©2018 by Quintessence Publishing Co Inc.

1 Private Practice Limited to Prosthodontic and Esthetic Dentistry, Aventura Dental Arts, Miami, Florida, USA.

2 Private Practice, Centre de Odontologia Estetica e Implantes (COEI), Valencia, Venezuela.3 CDT, Mitt Laboratorio Odontoternico, Pescina, Italy.4 Adjunct OMFS Professor at Nova Southeastern University; Private Practice, Sclar Oral Surgery and Implant Dentistry, Sclar Center for Advanced Implant Dentistry Learning, Miami, Florida, USA.

5 Oral and Maxillofacial Prosthodontist, Staff Dental Service, William S. Middleton Memorial Veteran’s Hospital, Madison, Wisconsin, USA. Correspondence to: Dr Fong Wong, William S. Middleton Memorial Veteran’s Hospital, 2500 Overlook Terrace, Madison, Wisconsin 53705, USA. Email: [email protected]

The Effect of Implant Abutment Design on Long-Term Soft Tissue Stability: A Clinical Case Report

Prosthetic rehabilitation of malpositioned anterior dental implants can be challenging. Interdisciplinary treatment planning and precise execution of biologically acceptable prosthetic and surgical protocols are essential to achieve optimal esthetic results and while avoiding and managing esthetic complications. This case study focuses on the restorative aspect. Two sets of custom gold abutments were used prior to and following surgical correction of a pre-existing soft and hard tissue ridge defect surrounding maxillary central incisor implant restorations. A stable and esthetically pleasing result was documented 7 years following delivery of definitive esthetic central incisor implant restorations. Int J Periodontics Restorative Dent 2018;38:841–847. doi: 10.11607/prd.3068

The long-term esthetic outcome of anterior implant-supported crowns depends on a multitude of factors, including systemic and local disease, specific anatomy of the region, oral hygiene, and restorative design and execution.1,2 Controlled studies are impossible because no two patients are alike and few volunteers would likely be available to participate. Thus, the best way to learn is from well-documented clinical cases. Case reports of successes and fail-ures, especially taken together, may provide clues as to which restorative approaches work best. This article reports on a case that presented with an esthetically unsatisfactory restorative situation. The patient was retreated with preprosthetic surgery and subsequent restorations, and the esthetic outcome was not only significantly better but stable over a follow-up period of 7 years. It is the purpose of this article to report the clinical procedures used and discuss the rationales behind them. Specifi-cally, it reports how the combination of surgical pretreatment and con-cave restorative contouring led to an esthetic result that was stable and in harmony with the adjacent dentition.

A 30-year-old woman pre-sented with a chief complaint of an “artificial” appearance and dis-coloration of the gingival tissues around the maxillary central incisor implants (Fig 1). The periodontal

Nuria Otero, DDS, CAGS, MSc1

Javier Scarton, DDS, MSc1/Laura Lugo Pizzolante, DDS2

Stefano Inglese, CDT3/Anthony G. Sclar, DMD, OMFS4

Fong Wong, DDS, CAGS, MSC, FACP5



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probing depths were 2 to 3 mm in this area, with the exception of midfacial depths of 5 to 6 mm at the sites of the central incisors. A thin gingival biotype was noted at the marginal soft tissue around the central incisor implant sites and the adjacent lateral incisors and ca-nines. The mucosal tissues beyond the mucogingival margin were thin, discolored, and lacking support due to an underlying osseous ridge defect. Radiographic examination using periapical radiographs (RVG 5100, Carestream Health) and cone beam computed tomography im-ages (Kodak 9500, Carestream Health) revealed that the implants were well integrated in accept-able mesiodistal and apicocoronal positions (Fig 2).

Surgical Treatment Plan

The surgical treatment plan con-sisted of simultaneous hard and soft tissue augmentation using au-togenous bone, Bio-Oss (Geistlich), platelet-rich plasma (PRP), and a non-cross-linked Bio-Gide mem-brane (Geistlich) for guided bone regeneration (GBR). The goal was to eliminate the osseous ridge defect and provide proper support for the soft tissues.

The prosthetic treatment plan was to place new porcelain-fused-to-metal custom abutments and ceramic (IPS e.max, Ivoclar Vivadent) crowns on the existing implants in the sites of the maxillary central in-cisors and porcelain veneers on the adjacent lateral incisors. The

sequence of treatment steps consist-ed of the initial provisional prosthetic phase, surgical procedures, the sec-ond provisional prosthetic phase, and the final prosthetic phase.

Initial Provisional Prosthetic Phase

A preliminary set of custom abut-ments and provisional restorations for the implants at the site of the maxillary central incisors was fabri-cated using a silicone index taken from a wax-up. The provisionals were temporarily cemented to allow the soft tissues to heal and assume their final contour. The abutments had a highly polished concave design and a supragingival finish line (2 mm) for

Fig 1 (left) Preoperative status: Unesthetic implant-supported porcelain-fused-to-metal crowns on central incisors with discolored soft tissues due to thin gingival biotype.

Fig 2 (below) Central incisor implant abutments after crown removal. (a) Radiographic view. (b) Clinical view.

a b



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maximal coronal positioning of the grafts and cover flaps (Fig 3).

Surgical Procedures

A composite graft using a 1:1 ra-tio of Bio-Oss and autogenous tra-becular bone harvested from the maxillary tuberosity was used. PRP was used to stabilize and mold the composite graft over the implants and to repair the peri-implant soft tis-sue dehiscence defects. A Bio-Gide membrane was placed over the com-posite graft and secured with the application of PRP. In addition, a con-nective tissue graft was harvested from the maxillary tuberosity using a scalpel with a 15c blade to ensure that the graft thickness was approxi-

mately 2.5 mm. A curvilinear papilla augmentation flap was then released with a periosteal incision, coronally advanced over the composite graft, and secured to a prepared connec-tive tissue bed that included the adjacent marginal gingiva surround-ing the lateral incisors. This was per-formed to provide a more natural and harmonious esthetic gingival outcome despite preexisting loss of the interdental and interimplant bone crest height and the corre-sponding support for the papilla.

Second Provisional Prosthetic Phase

At 3 months after surgery, the ac-cessible intrasulcular finish lines

were located approximately 1.0 to 1.5 mm within the sulcus. The pro-visional abutments were relined, repolished, and recemented for an additional 3 months to allow matu-ration and stabilization of marginal tissue (Fig 3).

At 6 months after surgery, the lateral incisors were prepared for veneers. Provisionals were made of Bis-acrylic material (Luxatemp, DMG) for all four teeth (Fig 4). Ad-ditive wax-up was used on casts mounted in maximum intercuspa-tion on a semi-adjustable articula-tor. The emergence profiles were shaped to distalize the zenith po-sitions of the central incisors for improved esthetics. Provisional res-torations were polished and glazed to minimize plaque accumulation.

Fig 3 (right) First set of provisional crowns and custom abutments before and after surgery.

Fig 4 (below) Diagnostic wax-up (a) and mock-up (b) with Bis-acrylic of the maxillary central and lateral incisors.

a b



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Prosthetic Phase

The second set of provisionals was left in place for 3 weeks. At that time, the prepared lateral incisors were cleaned and polished and the final impression was taken. Double gingival retraction cord (Ultrapak, Ultradent) was used for the right central and lateral incisors. Two im-pression copings were placed on the central incisors. A one-step fi-nal impression was taken using a closed-tray technique with polyvi-nyl siloxane material (Exaflex, GC). The permanent custom abutments (UCLA) were cast with a high-noble porcelain alloy (88% Au, 10 % Pt)

to give the tissue a warm color. An opaque porcelain and fluorescent opaque dentin ceramic was used to camouflage the metal color to im-prove the luminosity of the restora-tion and optimize esthetics (Fig 5). A concave design was chosen to allow adequate space for the peri-implant connective tissues and minimize the risk of their apical retraction (Fig 6). A Duralay jig (Duralay pattern resin, Reliance) facilitated precise position-ing of the custom abutments (Fig 7). Crowns and porcelain laminate veneers were made of porcelain (e.max Press LY, Ivoclar Vivadent) (Fig 8). The rubber wheel was used to retouch the tooth axis and inter-

proximally to drive the healing and maturation of soft tissue more coro-nally and to enhance papilla growth. A long contact area was designed due to the preexisting short papillae to reduce the appearance of a black triangle (Fig 9).

The cementation procedure in-cluded the use of retraction cords. The inner surfaces were etched with 4.5% hydrofluoric acid (Ivoclar Viva-dent) for 20 seconds, thoroughly rinsed with water, cleaned in an ultrasonic bath with alcohol for 5 minutes, air dried, silanized (Mono-bond- S, Ivoclar Vivadent), and dried again for 60 seconds. Tooth prepa-rations were cleaned with pumice

Fig 8 IPS e.Max restorations on working cast.

Fig 5 Final concave porcelain-fused-to-metal abutments following hard and soft tissue graft.

Fig 6 IPS e.Max crown on final custom abutment (mesial view). Note the tissue-friendly concave design.

Fig 7 Duralay positioning jig fabricated to ensure proper orientation of final abutments.



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and rubber burs, enamel etched for 30 seconds with 37.5% phosphoric acid (Ultra-Etch, Ultradent), rinsed, and dried. A light polymerizing resin cement was applied to the veneers (Syntac, Ivoclar Vivadent; Variolink II, Ivoclar Vivadent) and a dual-cure resin cement (RelyX U100, 3M ESPE) was used to cement the restora-

tions. The access holes of the abut-ments (Fig 10) were covered with an opaque composite (OB2, Gradia).

Clinical and radiographic exam-inations were performed at 2 weeks, 3 months, 7 months, 1 year, 2 years, and 7 years following delivery of the definitive restorations to monitor the biologic stability (Figs 11 and 12).

Discussion

The criteria for successful osseoin-tegration of dental implants have been well documented.3–6 A mul-titude of factors determine the esthetic outcome of the soft tis-sue environment around implants and the restorations they support.

Fig 10 (right) Access holes of definitive abutments are covered with composite to mask the metal color.

Fig 11 (below) Postsurgical intraoral view at 2 years (a) and 7 years (b).

Fig 9 Implant-supported crowns, connected with concave design abutments.

a b



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The success of this case is consis-tent with a recent pilot study that found concave abutment design preceded by soft tissue shaping to be advantageous.7 The literature suggests that a concave design re-duces pressure on the margins of the cover flaps and allows for bet-ter blood circulation in this area.8–11 The concave gingival portion of the abutment can also help to guide tissue growth after hard and soft tissue augmentation surgery. The literature reports that platform switching (ie, smaller abutments al-

lowing concave profiles) promotes more robust soft tissue thickness, stability, and adhesion, resulting in a better seal.12–16

This case report discusses the rationales for the chosen design aspects and the clinical methodol-ogy of implementation. It is hardly possible to come to final conclusions regarding how similar clinical cases should be treated. However, by combining this report with others that may follow and with the read-er’s own clinical experiences, a con-sensus may eventually emerge.

Conclusions

This case report suggests con-cave abutment design and a cor-rect emergence profile of ceramic crowns have a positive and stable effect on soft tissue stability around implant-supported restorations that have undergone hard and soft tissue augmentation procedures. Further-more, successful implementation of hard and soft tissue implant site de-velopment procedures facilitate the subsequent dynamic prosthetic soft tissue shaping procedures required to achieve optimal labial marginal tissue morphology and peri-implant soft tissue stability.

After 7 years, the length of the central incisor crowns appears shorter. This could be explained as functional, biologic, and esthetic integration of the restorations. Api-calization of the soft tissue around the implants improved significantly in relation to the emergence profile design of the abutments.

Precise interdisciplinary plan-ning and execution of evidence-based and biologically acceptable surgical and prosthetic protocols were responsible for returning this patient’s beautiful smile and lost so-cial confidence. An excellent esthetic result was achieved and maintained for a 7-year observation period in this particular case.

Acknowledgments

The authors would like to thank Drs Ma’ Ann Sabino and Andre P. Mauderli for editorial assistance. The authors reported no conflicts of interest related to this study.

Fig 12 Clinical views at 2 years postdelivery of definitive central incisor implant-supported porcelain-fused-to-metal restorations and lateral incisor porcelain veneers. Note the harmonious pink and white esthetic results.



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References

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3. Heinemann F, Hasan I, Bourauel C, Biffar R, Mundt T. Bone stability around dental implants: Treatment related factors. Ann Anat 2015;199:3–8.

4. Smith DE, Zarb GA. Criteria for success of osseointegrated endosseous implants. J Prosthet Dent 1989;62:567–572.

5. Albrektsson T, Brånemark PI, Hans-son HA, Lindström J. Osseointegrated titanium implants. Requirements for ensuring a long-lasting, direct bone-to-implant anchorage in man. Acta Orthop Scand 1981;52:155–170.

6. Trindade R, Albrektsson T, Wennerberg A. Current concepts for the biological basis of dental implants: Foreign body equilibrium and osseointegration dy-namics. Oral Maxillofac Surg Clin North Am 2015;27:175–183.

7. Rompen E, Raepsaet N, Domken O, Touati B, Van Dooren E. Soft tissue sta-bility at the facial aspect of gingivally converging abutments in the esthetic zone: A pilot clinical study. J Prosthet Dent 2007;97(6 Suppl):S119–S125.

8. Sclar AG. Management of an esthetic im-plant complication. In: Cohen M. Inter-disciplinary Treatment Planning. Vol 2: Comprehensive Case Studies. Chicago: Quintessence, 2012:385–414.

9. Redemagni M, Cremonesi S, Garlini G, Maiorana C. Soft tissue stability with immediate implants and concave abut-ments. Eur J Esthet Dent 2009;4:328–337.

10. Nam J, Aranyarachkul P. Achieving the optimal peri-implant soft tissue profile by the selective pressure method via provi-sional restorations in the esthetic zone. J Esthet Restor Dent 2015;27:136–144.

11. Tetelman ED, Babbush CA. A new transi-tional abutment for immediate aesthet-ics and function. Implant Dent 2008;17: 51–58.

12. Bishti S, Strub JR, Att W. Effect of the implant-abutment interface on peri-implant tissues: A systematic review. Acta Odontol Scand 2014;72:13–25.

13. Ilhaut G, Schwarz F, Winter RR, Miha-tovic I, Stimmelmayr M, Schliephake H. Epithelial attachment and downgrowth on dental implant abutments—A com-prehensive review. J Esthet Restor Dent 2014;26:324–331.

14. Caram SJ, Huynh-Ba G, Schoolfield JD, Jones AA, Cochran DL, Belser UC. Biologic width around different implant-abutment interface configurations. A radiographic evaluation of the effect of horizontal offset and concave abutment profile in the canine mandible. Int J Oral Maxillofac Implants 2014;29:1114–1122.

15. Chrcanovic BR, Albrektsson T, Wenner-berg A. Platform switch and dental im-plants: A meta-analysis. J Dent 2015;43: 629–646.

16. Huh JB, Rheu GB, Kim YS, Jeong CM, Lee JY, Shin SW. Influence of implant transmucosal design on early peri-implant tissue responses in beagle dogs. Clin Oral Implants Res 2014;25:962–968.



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