Clinical or Case Report

IMPLANTOLOGY. December 2020. 212-218
https://doi.org/10.32542/implantology.202019

ABSTRACT


MAIN

  • Ⅰ. Introduction

  • Ⅱ. Case Report

  • Ⅲ. Discussion

  • Ⅳ. Conclusion

Ⅰ. Introduction

Rehabilitation with an implant is a predictable treatment option for a single missing tooth area.1 However, treatment with implants in the anterior maxillary region should be approached with care because of the aesthetic demands.2 Moreover, the anatomical condition is unfavorable due to the relatively narrow width of the ridge, thin gingival biotype, and the need for maximizing placement in all three dimensions.3

It has been reported that immediate placement and provisionalization can positively influence the creation and adequacy of the emergence profile, enhancing the formation of the papilla, guiding the morphological development of the peri-implant mucosa, and controlling the design of the final restoration.4,5 In case of implant placement in the maxillary anterior regions, occlusal forces are directed obliquely rather than axially, which may cause loosening of abutment screws and fracture of provisional restoration. A prosthesis designed to avoid an unintended occlusal force can reduce this complication.6

Recently, a simple and straightforward method for recording dynamic occlusion data using an intraoral scanner has been introduced. Along with the static scan data obtained with the intraoral scanner, it became possible to design and fabricate a prosthesis considering mandibular movement through computer-aided design/computer-aided manufacturing (CAD/CAM) technology. This report describes the successful application of an intraoral scanner-based mandibular movement scanning in a case requiring rehabilitation with a single implant in the maxillary anterior tooth region.

Ⅱ. Case Report

A 55-year-old female patient presented to the Department of Prosthodontics at Yonsei University Dental Hospital to receive treatment for a mobile maxillary right lateral incisor. The tooth was diagnosed as a horizontal root fracture with a hopeless prognosis (Fig. 1).

/media/sites/kaomi/2020-024-04/N0880240404/images/kaomi_24_04_04_F1.jpg
Fig. 1

Pre-operative evaluation. (A) Intraoral frontal view. (B) Periapical radiograph exhibiting a horizontal root fracture of the maxillary right lateral incisor (marked with yellow arrow).

Hence, it was decided that the tooth be extracted and rehabilitated with a single implant. The tooth was extracted atraumatically without flap reflection, followed by immediate implant placement (Straumann BLT, Institut Straumann AG; 3.3 × 10 mm) to preserve the papilla, with bone graft procedures in the buccal gap defect with bovine-derived xenograft materials (Bio-Oss collagen; Geistlich Pharma AG) (Fig. 2). The implant was placed along the palatal wall of the extraction socket, at the center of the extraction region in the mesio-distal aspect and 3 mm apical to free gingival margin.

/media/sites/kaomi/2020-024-04/N0880240404/images/kaomi_24_04_04_F2.jpg
Fig. 2

Occlusal view immediately after the completion of surgical procedure.

As the primary stability of the implant was 30 N·cm, immediate provisionalization procedures proceeded as planned. A scan body (Geo Scanbody; GeoMedi) was connected to the implant, and digital impression was obtained with an intraoral scanner (TRIOS 3; 3Shape A/S). Subsequently, dynamic occlusion records (Patient Specific Motion; 3Shape A/S) were additionally obtained using the same intraoral scanner (Video 1). The obtained information was imported into the CAD software (Dental System; 3Shape A/S), and a screw-type immediate provisional restoration was designed. Any interferences observed were visualized and removed in the software using the dynamic occlusion records obtained during the intraoral scanning phase (Fig. 3).

/media/sites/kaomi/2020-024-04/N0880240404/images/kaomi_24_04_04_F3.jpg
Fig. 3

Design of an implant provisional restoration in the computer-aided design software (Dental System). (A) Frontal view of implant provisional restoration at centric occlusion. (B) Frontal view of implant provisional restoration at edge-to-edge occlusion. (C) Occlusal view showing the path of mandibular movements (marked with blue color).

The restoration was fabricated with a polymethylmethacrylate resin block (VIPI Block Trilux; Dental VIPI Ltda) and a milling machine (M4 Wet Heavy Metal Milling Unit; Zirkonzahn), and cemented to a titanium link abutment (Geo Multibase Abutment; GeoMedi) with a resin cement (Multilink N; Ivoclar Vivadent). This screw-retained provisional restoration was placed on the same day of implant surgery. Occlusion was evaluated to verify that there was no contact with the antagonists (Fig. 4).

/media/sites/kaomi/2020-024-04/N0880240404/images/kaomi_24_04_04_F4.jpg
Fig. 4

Immediate placement of the implant provisional restoration. (A) A screw-retained immediate provisional restoration that enables access to the abutment screw. (B) Intraoral frontal view exhibiting the immediate rehabilitation of the maxillary right lateral incisor.

Following periodic check-ups, final impressions were made through a digital approach at 3 months after the implant surgery. A titanium custom abutment and a monolithic zirconia definitive prosthesis reflecting the scan data of the provisional restoration were fabricated and placed with a resin-modified glass ionomer cement (RelyX Luting 2 Cement; 3M ESPE). Both esthetic and functional outcomes were satisfactory (Fig. 5).

/media/sites/kaomi/2020-024-04/N0880240404/images/kaomi_24_04_04_F5.jpg
Fig. 5

Placement of the definitive prosthesis. (A) Intraoral frontal view. (B) Periapical radiograph.

Ⅲ. Discussion

The present method of designing a prosthesis that reflects the movement of the mandible is effective in fabricating prostheses that do not receive unintended loading. In the past, movement of the mandible was recorded using a functionally generated path technique.7 Recently, several workflows have been proposed to implement this technique using a digital approach. However, the procedure is not intuitive and requires additional clinical and laboratory steps.8,9 Jaw motion analyzers are another tool to record mandibular kinematics. However, they are bulky, require an additional learning curve, and are expensive.10,11

In contrast, the present workflow is straightforward as it uses built-in software within the intraoral scanner and is compatible with a CAD software program. The anatomical structure formed by dental technicians can be preserved as much as possible. Moreover, simplifying the procedure and reducing the time for adjustment are advantageous in delivering screw-retained provisional restorations. If the intraoral scan data were obtained at the first visit, the time for prosthesis design on the surgery day could be further reduced.

As implant healing accelerates due to surface modification of the dental implants, immediate implant placement and loading have been attempted recently.12 An immediately placed implant and immediate provisionalization reduces the period of edentulous time, thereby reducing esthetic discomfort to the patient. In addition, a study has recently reported that immediately placed implants and provisionalization show better volume preservation than those without provisionalization.13

This case corresponds to Type 1A classification in which implant placement and loading are performed immediately after extraction.14 An immediately placed implant and immediate provisionalization can reduce the period of edentulous time, thereby reducing esthetic discomfort to the patient, and showed better volume preservation than cases that did not perform immediate provisionalization13 Atraumatic extraction, flapless technique, and a bone graft procedure were performed to achieve this goal.15,16

In color-coded maps that superimposed the scan data of within 3 weeks post-surgery scan data over the pre-operative scan data, the red colored area appeared, indicating some distinct volumetric difference among the scan datasets (Fig. 6A-6C). However, these were considered to be a difference due to post-operative edema. From the timepoint of 2 months post-surgery and after the placement of the definitive restoration, soft tissue change was minimal compared to the pre-operative scan data (Fig. 6D-6F). The color-coded maps on the soft tissue areas were expressed with only plus sign values, and a creation of cross-sectional views aided in determining the direction of the surface changes.

/media/sites/kaomi/2020-024-04/N0880240404/images/kaomi_24_04_04_F6.jpg
Fig. 6

Dimensional changes shown as a color-coded map using the built-in software (TRIOS Patient Monitoring; 3Shape A/S). All scan datasets were superimposed over the initial (pre-operative) scan dataset, and the tolerance level was set as 0.30 mm. (A) Initial versus post-surgery. (B) Initial versus 10 days post-surgery. (C) Initial versus 3 weeks post-surgery (D) Initial versus 2 months post-surgery (E) Initial versus 3 months post-surgery (F) Initial versus 4 months post-surgery.

The present report described successful application of the intraoral scanner-based mandibular movement data for the rehabilitation of a single-tooth implant prosthesis. Further controlled clinical studies are necessary to evaluate long-term prognosis, and to extend its application to multiple-tooth implant prostheses.

Ⅳ. Conclusion

A maxillary anterior missing tooth region was successfully rehabilitated with a single implant. The provisional restoration was placed immediately after the surgery with minimal adjustment by recording dynamic mandibular movement with the intraoral scanner. The patient was satisfied with esthetic and functional outcomes of both the provisional and definitive prostheses.

Supplementary Material

Video 1

Mandibular movement recorded with a specific tool (Patient Specific Motion) using an intraoral scanner (TRIOS 3). (http://implantology.or.kr)

References

1
Wittneben JG, Buser D, Salvi GE, Bürgin W, Hicklin S, Brägger U. Complication and failure rates with implant-supported fixed dental prostheses and single crowns: a 10-year retrospective study. Clin Implant Dent Relat Res 2014;16:356-64. 10.1111/cid.1206623551688
2
Chappuis V, Engel O, Reyes M, Shahim K, Nolte LP, Buser D. Ridge alterations post-extraction in the esthetic zone: a 3D analysis with CBCT. J Dent Res 2013;92:195S-201S. 10.1177/002203451350671324158340PMC3860068
3
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;19:43-61.
4
Délben JA, Goiato MC, Gennari-Filho H, Gonçalves Assunção W, dos Santos DM. Esthetics in implant-supported prostheses: a literature review. J Oral Implantol 2012;38:718-22. 10.1563/AAID-JOI-D-11-0008622066512
5
Kan JY, Rungcharassaeng K, Lozada JL. Immediate implant placement and provisionalization of maxillary anterior single implants. Periodontol 2000 2018;77:197-212. 10.1111/prd.1221229478284
6
Levin BP, Wilk BL. Immediate provisionalization of immediate implants in the esthetic zone: a prospective case series evaluating implant survival, esthetics, and bone maintenance. Compend Contin Educ Dent 2013;34:352-61.
7
Meyer FS. The generated path technique in reconstruction dentistry: Part II. Fixed partial dentures. J Prosthet Dent 1959;9:432-40. 10.1016/0022-3913(59)90075-7
8
Park S-g, Kim M, Yoo J-j, Yoon J-H. Application of the functionally generated path technique in designing an implant-supported fixed prosthesis with CAD-CAM technology: a dental technique. J Prosthet Dent 2020;123:667-70. 10.1016/j.prosdent.2019.05.02531590977
9
Kim S-H, Lee J, Choi Y-S. Fixed prosthodontic rehabilitation of maxillary posterior teeth using functionally generated path technique and intraoral digital scan: Case report. J Korean Acad Prosthodont 2020;58:228-38. 10.4047/jkap.2020.58.3.228
10
Mapelli A, Machado BCZ, Garcia DM, Rodrigues Da Silva MAM, Sforza C, de Felício CM. Threedimensional analysis of jaw kinematic alterations in patients with chronic TMD - disc displacement with reduction. J Oral Rehabil 2016;43:824-32. 10.1111/joor.1242427545052
11
Sójka A, Huber J, Kaczmarek E, Hędzelek W. Evaluation of Mandibular Movement Functions Using Instrumental Ultrasound System. J Prosthodont 2017;26:123-8. 10.1111/jopr.1238926488230
12
Buser D, Broggini N, Wieland M, Schenk RK, Denzer AJ, Cochran DL, et al. Enhanced bone apposition to a chemically modified SLA titanium surface. J Dent Res 2004;83:529-33. 10.1177/15440591040830070415218041
13
Wang IC, Chan HL, Kinney J, Wang HL. Volumetric facial contour changes of immediately placed implants with and without immediate provisionalization. J Periodontol 2020;91:906-16. 10.1002/JPER.19-030831846073
14
Gallucci GO, Hamilton A, Zhou W, Buser D, Chen S. Implant placement and loading protocols in partially edentulous patients: a systematic review. Clin Oral Implants Res 2018;29:106-34. 10.1111/clr.1327630328194
15
Botticelli D, Berglundh T, Lindhe J. Hard-tissue alterations following immediate implant placement in extraction sites. J Clin Periodontol 2004;31:820-8. 10.1111/j.1600-051X.2004.00565.x15367183
16
Crespi R, Capparé P, Gherlone E, Romanos GE. Immediate versus delayed loading of dental implants placed in fresh extraction sockets in the maxillary esthetic zone: a clinical comparative study. Int J Oral Maxillofac Implants 2008;23:753-8.
페이지 상단으로 이동하기