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Solutions For Implants Placed With Prosthetic Inconvenience
Solutions For Implants Placed With Prosthetic Inconvenience
Graeme Bryce
The popularity of implant-supported The importance of this implant-tissue outcome and long-term maintenance
restorations has led to the development of association has led to the development issues.9 Conversely, superficial fixture
increasingly innovative clinical techniques of ‘prosthetically driven’ surgical placement (<2 mm) can also lead to
to provide successful and aesthetic tooth protocols, where the optimal prosthetic aesthetic complications as it may create
replacements. Successful implant outcomes tooth position2 is used to determine the a more acutely angled emergence profile
are underpinned by positioning the fixture correct spatial position for the implant of the prosthetic restoration and risk
at the optimal vertical and horizontal fixture. exposure of the abutment and possibly
position within the alveolar bone, Failure to achieve the the fixture10 (Figure 2).
encouraging the development of a healthy ideal horizontal and vertical spatial Comprehensive patient
peri-implant soft tissue collar1 and reducing relationships can lead to problems. assessment and treatment planning,
the risks of peri-mucosal complications.2 Horizontal misalignment within the in combination with a good surgical
buccal plane may increase the risk technique, can normally mitigate against
Graeme Bryce, BDS, MSc, MEndoRCS, of alveolar bone loss3,4 and mucosal the risk of implant malposition. A
MRD RCPSG, FDS(Rest), Consultant in recession2,5,6 (Figure 1). In contrast, diagnostic wax-up of the final prosthetic
Restorative Dentistry, Defence Primary palatal placement risks an inferior restoration can help determine not
Health Care Centre for Restorative emergence profile of the prosthetic only the ideal shape of the restoration,
Dentistry (email: graemebryce001@ crown.7 Inappropriate mesial-distal but also optimally guide the implant
hotmail.com), Nicholas Diessner, MSc, implant position may also affect the position. However, despite meticulous
Dental Technician, Defence Primary Health shape and size of the interproximal planning, the ideal fixture position may
Care Centre for Restorative Dentistry, Ken papilla,8 with failure to achieve a be inherently compromised by the
Hemmings, BDS, MSc, DRD RCS, FDS RCS, 1.5−2 mm peripheral bone margin, presence of adverse anatomical features
ILTM, FHEA, Consultant in Restorative resulting in loss of the papilla height, (neurovascular bundles, maxillary
Dentistry, Eastman Dental Hospital, 256 reduced thickness of the gingival collar sinus, adjacent teeth alignment) or
Gray's Inn Road, London WC1X 8LD and and an undesirable embrasure form and alveolar bone and soft tissue defects,
Neil MacBeth, BDS, MSc, FFGDP, MGDS, emergence profile. resulting in a challenging prosthetic
MFGDP, MFDS, FDS(Rest), Consultant in With regards to vertical reconstruction. The early identification
Restorative Dentistry, Defence Primary
apical-coronal malpositioning, deep of cases, where the prosthetically-driven
Health Care Centre for Restorative
implants (>2 mm) can result in an protocol cannot be followed, allows
Dentistry, Evelyn Woods Road, Aldershot,
increased risk of bone resorption, tissue for investigation of different prosthetic
GU11 2LS, UK.
shrinkage, a compromised aesthetic solutions. Close liaison with the dental
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RestorativeDentistry
a a
b
Figure 6. Case 1: The final outcome shows
b improved peri-implant soft tissue health
associated with the increased width of KM
around the implant-retained bridge. However,
the limitations of the buccal angulation of the
implants with metal show at the neck of the UR3.
Definitive restoration
The definitive implant restoration can
be manufactured as either a one-piece
screw-retained structure starting at the
implant level, or in two components,
using an angulated or custom abutment
Figure 9. Case 2: The 2-year review shows a thick and cemented crown. Although both
soft tissue collar around the crowns, masking Figure 12. Case 3: The shallow placement of the techniques are successful, the use of
the underlying implants. However, the custom implant has challenged the emergence profile as an angulated abutment allows the
abutments were unable to disguise the poor illustrated by the dimensional disparity between clinician to use a variety of abutment
positioning of the implants, with the emergence the ‘red’ line of the emergence profile and ‘black’ orientations to support the prosthetic
of the crowns lying apical to the gingival zenith line of the ideal crown shape. structure. Influencing factors include:
of the adjacent central incisors. Alternative
the type of implant (bone level or
treatment options would have been explantation a
with block bone grafting to facilitate improved
trans-mucosal designs), the implant
positioning. configuration (internal or external
hex), divergent implant direction, the
a available restorative space, aesthetic
demands and desired prosthetic
outcome.
a a a
b b b
c Figure 27. (a, b) Case 5: Use of mucosal-coloured Figure 29. (a, b) Case 6: The implants were
porcelain to disguise loss of inter-dental papilla. explanted using 3i BioMet® (Palm Beach, Fl, USA)
Implant Removal Kit and a further two implants
placed.
Deep (>5 mm peri-implant Deep uncleansible periodontal Increased abutment length Manufacturing a tapered
pocket) pocket Risk of abutment exposure abutment to achieve a natural
Soft tissue recession emergence profile.
Peri-implantitis Gauging the correct amount
of pressure that the abutment/
restoration can apply to the
soft tissue (biotype is difficult to
determine from models).
A removable soft tissue
model is required.
Table 1. Overview of implant orientation and potential clinical and laboratory challenges.
with a technician to ensure that the situations of abutment screw fracture or was obtained from all individual
substructure design is: cleansable, damaged fixture head. participants included in the article.
provides support for the overlying
materials to enable replication of the Conclusion (Table 1) References
gingival form and that sufficient intra- 1. Garber D. The esthetic dental
Implant treatment is a complex
arch distance space remains to allow implant: letting restoration be the
procedure with multiple factors
placement of suitably sized teeth. guide. J Oral Impl 1996; 22: 45−50.
associated with a successful functional
2. Mezzomo LA, Shinkai RS, Mardas
and aesthetic outcome for the
N, Donos N. Alveolar ridge
Explantation patient. Implant placement using
preservation after dental extraction
Historically, removal of unrestorable an ideal prosthetic protocol is not
and before implant placement: a
dental implants was challenging, often always feasible and, in particular, may literature review. Revista Odonto
involving significant bony trauma. present challenges to the creation Ciênc 2011; 26: 77−83.
The introduction of implant removal of an abutment that is in harmony 3. Belser U, Buser D, Higginbottom
kits has simplified explantation and with the soft tissues. Meticulous F. Consensus statements and
allows removal of fixtures with minimal treatment planning and close liaison recommended clinical procedures
destruction to the surrounding bone with laboratory technicians can ensure regarding esthetics in implant
tissues. In cases (Case Six) where that successful outcomes can still be dentistry. Int J Oral Max Impl 2004;
sub-optimal implant placement has achieved in sub-optimally positioned 19: 73−74.
compromised the immediate or dental implants. 4. Nevins M, Camelo M, De Paoli S,
longer-term outcomes (Figure 28), Friedland B, Schenk RK, Parma-
explantation (Figures 29 and 30) and Compliance with Ethical Standards Benfenati S et al. A study of the
placement of new implants may be Conflict of Interest: The authors declare fate of the buccal wall of extraction
a preferable solution (Figure 31). that they have no conflict of interest. sockets of teeth with prominent
However, these kits cannot be used in Informed Consent: Informed consent roots. Int J Perio Rest Dent 2006; 26:
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