Novel Approach for Predictably Matching a Veneer to an Implant Crown QUINTESSENCE OF DENTAL TECHNOLOGY 2019

Editorial New Horizons for Digital Technology in Dental Education Digital technology in dentistry is a fact that can no longer go unnoticed by academic institutions Of all the dental laboratory technology programs in the United States that are accredited by CODA (Commission on Dental Accreditation), only a few currently include dedicated courses in digital technology as an integral part of their programs Similarly, dental schools have yet to fully embrace digital technologies as an integral part of their curriculum It is clear that the logistics of implementation is challenging the eagerness for its application Fortunately, several positive attempts have been made to introduce digital technology to the dental curriculum Just a few weeks ago, the American Dental Education Association (ADEA) organized a conference where deans and invited leadership of all American and Canadian dental schools gathered to discuss digital technologies in dental education and in health care The American College of Prosthodontists (ACP) has also worked very hard to promote a digital curriculum for dental schools CODA recognizes the importance of digital technology and has recently included standards focusing on new technologies with which educational institutions must comply For Dental Laboratory Technology programs, CODA emphasizes that students need to be exposed to as many new technologies as possible—including digital scanning and digital design (Dental Laboratory Technology CODA Standards 2-19 and 2-20) For Predoctoral Dental Education programs, CODA accreditation standards require that students must be able to evaluate, assess, and apply current and emerging science and technology (CODA Standard 2-24); dental schools must show evidence of the use of technology in didactic and clinical components of the curriculum (CODA Standard 3-2); and that patient care must be evidence-based, and dental schools should use evidence to evaluate new technology and products as well as to guide diagnosis and treatment decisions (CODA Standard 5-2) Our experience with the Digital Technology Curriculum at the University of Southern California has been amazingly positive Students’ engagement and eagerness to learn has increased, as has the overall quality of their work, since digital technology allows students to become more critical of their own work Digital technology should be expanded beyond methods of fabrication of single-unit crowns to include minimally invasive adhesive restorations (inlays, onlays, veneers), digitally guided implant-supported treatment (treatment planning, surgical guides, and restorations), removable prosthodontics (digital design and 3D printing), and, of course, crown and bridge restorations It is time to fully embrace digital technologies in education Implementation of digital technology into dental curricula should be made as early as possible in the student’s education, and not as a “selective” or isolated course at the end of a student’s educational program The next generation of practitioners (dentists and dental technicians) should be exposed to all the possibilities, advantages, as well as limitations that digital technology brings to the field The way in which restorative dentistry has been practiced is changing rapidly Education should follow a similar path by making preservation of dental tissues through minimally invasive adhesive dentistry and digital technology a priority in future dental technicians’ and dentists’ curricula Please join me in appreciating the collection of superb clinical and scientific works in this edition of Quintessence of Dental Technology, where the fusion of digital technology, adhesion, dental materials, artistry, and implant therapy are challenged to promote esthetic and functional outcomes Sillas Duarte, Jr, DDS, MS, PhD sillas.duarte@usc.edu © 2019 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER Copyright of Quintessence of Dental Technology (QDT) is the property of Quintessence Publishing Company Inc and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission However, users may print, download, or email articles for individual use MASTERPIECE © 2019 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER Novel Approach for Predictably Matching a Veneer to an Implant Crown Iñaki Gamborena, DMD, MSD, FID1 Yoshihiro Sasaki, CDT2 Markus B Blatz, DMD, PhD3 Adjunct Professor, Department of Preventive and Restorative Sciences, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania, USA; and Private Practice, San Sebastián, Spain Private Practice, San Sebastián, Spain Professor of Restorative Dentistry and Chairman, Department of Preventive and Restorative Sciences, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania, USA Correspondence to: Dr Iđaki Gamborena, C/ resurrección M Azkue #6 -4, 20018 San Sebastián, Guipúzcoa, Spain Email: Gambmila@telefonica.net, www.Drgamborena.com I n recent years, single anterior implants have become a predictable treatment option when a tooth is missing or in need for extraction The situation becomes more challenging when a veneer restoration has to be fabricated next to an anterior implant crown Blending the color and especially the translucency of a veneer restoration with an adjacent crown is always difficult To match both restorations in a simple manner, a screw-retained implant crown is the restoration of choice to allow shade matching of the zirconia abutment to the color of the prepared veneer abutment tooth When the shade of the zirconia abutment is the same as the shade of the abutment tooth, the dental technician can build up both restorations in the same manner and create an optimal result Key details are explained and depicted with two select clinical cases QDT 2019 © 2019 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER GAMBORENA ET AL CASE years postoperative Preoperative Slim healing abutment Connective tissue graft from tuberosity • Final result years after delivery of a single-tooth screw-retained implant restoration A 3.0-mm NobelActive implant (Nobel Biocare) was placed in the area of the maxillary right central incisor and a feldspathic veneer on the left central incisor • Initial situation reveals a vertical and horizontal ridge defect in the area of the right central incisor • Implant placement with a Slim healing abutment in a one-stage surgery • Subepithelial connective tissue graft (CTG) was harvested from the tuberosity and sutured crestally on the ridge to minimize the tissue defect QDT 2019 © 2019 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER Novel Approach for Predictably Matching a Veneer to an Implant Crown Provisional implant restoration with a flat tissue scallop allows for shaping of the ideal scallop with gingivectomy Zirconia abutment selection and shade communication Final implant impression was made to design and fabricate the zirconia implant abutment before the veneer preparation Gingival recontouring through gingivectomy to recreate ideal gingival scallop and align gingival levels Intracrevicular margin location for optimal tissue volume support and scallop Try-in of the zirconia abutment: Light-cure stain was applied to accurately communicate abutment shade to the technician Abutment shade was reproduced in the laboratory with corresponding chroma and value Second try-in of the zirconia abutment to verify base shade of preparations before final delivery of the restorations The two veneers were layered and completed at the same time and in the exact same manner The veneer on the natural tooth was tried in before cementation with glycerin gel to assess shade, value, and color match of the two restorations The feldspathic veneer was then acid etched, silanated, and bonded to the abutment tooth Bonding only one veneer next to the implant restoration decreases bonding difficulty QDT 2019 © 2019 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER GAMBORENA ET AL The zirconia abutment was bonded to a titanium post with resin cement due to the lack of metal connection for the NobelActive 3.0 implant Palatal view of both restorations with splinted teeth (with fibers) adjacent to the implant restoration to avoid extrusion years Initial years Restorations: Screw-retained implant restoration to replace maxillary right central incisor and porcelain laminate veneer on left central incisor Materials used: Maxillary right central incisor—white color ZR NobelProcera, bonded with HO0 Multilink Hybrid abutment (Ivoclar Vivadent) to titanium abutment, engaging Maxillary left central incisor—laminate veneer bonded with translucent resin cement G-CEM LinkAce (GC) Creation ZI-CT porcelain used for both restorations 10 QDT 2019 © 2019 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER Novel Approach for Predictably Matching a Veneer to an Implant Crown CASE 2 years Initial Final Initial QDT 2019 11 © 2019 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER GAMBORENA ET AL 12 Provisional restoration on maxillary left central incisor and composite resin restoration on right central incisor were made to adequately support the soft tissues Two weeks after tooth extraction, immediate implant placement with NobelActive × 13 mm and CTG Situation months after surgery indicates ideal tissue contour and support Final impression was made with a customized impression coping to support emergence profile in the same manner as the provisional restoration Design and fabrication of the screwretained final zirconia abutment restoration with angulated screw channel (ASC, Nobel Biocare) Veneer preparation and ASC zirconia abutment in situ Shade communication of the zirconia on day of veneer preparation with light curing (Optiglaze, GC) Base color abutment is fired on top of the zirconia to match the shade of the natural abutment tooth Second try-in of the zirconia abutment is necessary after adjustment to verify color match of both abutments Porcelain veneering is completed in the same manner for both restorations Laminate veneer on the natural tooth is bonded first to ensure accurate adaptation, followed by the screw-retained implant restoration to control interproximal contact areas Final restorations on the master cast with the same veneer layering QDT 2019 © 2019 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER COPY, RESTORE, REDEFINE: Degrees of Creativity with Bonded Lithium Disilicate Restorations 12l 12m 12n Fig 12l Stages of ceramic build-up, glazed restorations, try-in Fig 12m Glazed restorations Fig 12n Try-in Individual dies were used to wax up the restoration bases (anterior teeth) and the full anatomical restorations (posterior teeth) All wax-ups were then invested, burned out, and pressed with lithium disilicate ingots Anterior bases were pressed using low-translucancy (LT) A2 shade, while the posterior teeth were pressed using hightranslucancy (HT) A2 shade Following adjustments and fitting on a solid cast (second pour of the original impression), further cutback of the incisal edge and facial surface was performed and then layered with feldspathic porcelain The restorations presented appropriate blending (anterior and posterior) and were similar in shape to the wax-up/mock-up (Figs 12l to 12n) Following minor adjustments for proper insertion and surface conditioning (etching, silane, adhesive resin wetting), restorations were delivered onto the air-abraded/ etched preparation surfaces with Variolink II (Ivoclar Vivadent) QDT 2019 219 © 2019 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER RODRÍGUEZ-IVICH ET AL 12o 12p 12q 12r 12s 12t 12v Figs 12o to 12s Occlusion adjustment, canine guidance confirmed Figs 12t to 12v Final result and panoramic radiograph 220 QDT 2019 12u © 2019 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER COPY, RESTORE, REDEFINE: Degrees of Creativity with Bonded Lithium Disilicate Restorations The occlusion was fine-tuned in centric occlusion since the occlusal scheme was modified Each tooth was confirmed to have at least one contact.18 Knowing that bruxism negatively affects the success rate of any type of restoration (not only of veneers), even more so when teeth are nonvital,19 an anterior bite plane20 was provided to protect the restoration from occlusal overload.21 No additional endodontic procedures were performed (Figs 12o to 12v) CONCLUSION Based on solid knowledge of dental morphology combined with an adequate diagnosis, it is possible to optimize the esthetic outcome of restorations with minimally invasive treatment The success of esthetic and functional rehabilitations will require various degrees of creativity and skill by the dentist and dental technician Clinical situations have been presented to illustrate the range of possibilities that are available with adhesive dentistry—from simple composite resin additions, to more challenging unilateral indirect cases, to full-mouth rehabilitation ACKNOWLEDGMENTS To my parents Manuel Rodríguez, Paty Ivich, and my brother Haziel Rodríguez To my mentors Antônio Carlos Cardoso, Luiz N Baratieri, and Roberto Da Silva To my friends Alberto Sierra, Juan Felipe Dumes, Joaquin Lopez, Blanca Nieves, Mehrdad Razaghy, and Victor Manuel Andrade REFERENCES Magne P A new approach to the learning of dental morphology, function, and esthetics: The “2D-3D-4D” concept Int J Esthet Dent 2015;10:32–47 Baratieri LN, Araujo E, Monteiro S Jr Color in natural teeth and direct resin composite restorations: Essential aspects Eur J Esthet Dent 2007;2:172–186 Lussi A, Schlueter N, Rakhmatullina E, Ganss C Dental erosion—An overview with emphasis on chemical and histopathological aspects Caries Res 2011;45(suppl 1):s2–s12 Layton DM, Walton TR The up to 21-year clinical outcome and survival of feldspathic porcelain veneers: Accounting for clustering Int J Prosthodont 2012;25:604–612 Gurel G, Sesma N, Calamita MA, Coachman C, Morimoto S Influence of enamel preservation on failure rates of porcelain laminate veneers Int J Periodontics Restorative Dent 2013;33:31–39 Magne P, Hanna J, Magne M The case for moderate “guided prep” indirect porcelain veneers in the anterior dentition The pendulum of porcelain veneer preparations: From almost no-prep to over-prep to no-prep Eur J Esthet Dent 2013;8:376–388 Dumfahrt H, Schäffer H Porcelain laminate veneers A retrospective evaluation after to 10 years of service: Part II—Clinical results Int J Prosthodont 2000;13:9–18 Rodriguez-Ivich EJ, Prado AM, Cardoso AC, Ferreira CF Lithium disilicate versatility for veneers, crown, and implant restoration: A clinical report J Tenn Dent Assoc 2017;97:43–46 Edelhoff D, Sorensen JA Tooth structure removal associated with various preparation designs for anterior teeth J Prosthet Dent 2002; 87:503–509 10 Magne P, Magne M Use of additive waxup and direct intraoral mockup for enamel preservation with porcelain laminate veneers Eur J Esthet Dent 2006;1:10–19 11 Pahlevan A, Mirzaee M, Yassine E, et al Enamel thickness after preparation of tooth for porcelain laminate J Dent (Tehran) 2014;11:428– 432 12 Ferrari M, Patroni S, Balleri P Measurement of enamel thickness in relation to reduction for etched laminate veneers Int J Periodontics Restorative Dent 1992;12:407–413 13 Cortellini D, Canale A Bonding lithium disilicate ceramic to featheredge tooth preparations: A minimally invasive treatment concept J Adhes Dent 2012;14:7–10 14 Magne P IDS: Immediate Dentin Sealing (IDS) for tooth preparations J Adhes Dent 2014;16:594 15 Chandra S, Singh A, Gupta KK, Chandra C, Arora V Effect of gingival displacement cord and cordless systems on the closure, displacement, and inflammation of the gingival crevice J Prosthet Dent 2016; 115:177–182 16 Moretti LA, Barros RR, Costa PP, et al The influence of restorations and prosthetic crowns finishing lines on inflammatory levels after non-surgical periodontal therapy J Int Acad Periodontol 2011;13:65– 72 17 Magne P, Belser UC (eds) Bonded Porcelain Restorations in the Anterior Dentition: A Biomimetic Approach Chicago: Quintessence Publishing, 2002 18 Wiskott HW, Belser UC A rationale for a simplified occlusal design in restorative dentistry: Historical review and clinical guidelines J Prosthet Dent 1995;73:169–183 19 Beier US, Kapferer I, Burtscher D, Dumfahrt H Clinical performance of porcelain laminate veneers for up to 20 years Int J Prosthodont 2012;25:79–85 20 Carlsson GE Critical review of some dogmas in prosthodontics J Prosthodont Res 2009;53:3–10 21 Cardoso AC, Pereira Neto AR, Ferreira CF, Myers SL In reality is there occlusal trauma without bruxism? Int J Stomatol Occlusion Med 2012;5:97–98 QDT 2019 221 © 2019 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER Copyright of Quintessence of Dental Technology (QDT) is the property of Quintessence Publishing Company Inc and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission However, users may print, download, or email articles for individual use The Use of Dual- or Co-Axis Macro-Designed Implants to Enhance Screw-Retained Restorations in the Esthetic Zone Adam J Mieleszko, CDT1 Hanae Saito, DDS, MS, CCRC2 Stephen J Chu, DMD, MSD, CDT3 I mplant placement into postextraction sockets with a provisional restoration in nonfunctional occlusion (immediate tooth replacement therapy) in the maxillary anterior region has increased in use and clinical relevance since its introduction in the late 1990s.1 Treatment procedures are condensed into fewer patient appointments, reducing overall treatment time and increasing patient comfort.2–4 Survival rates reported for immediate implant protocols are comparable to those for delayed procedures with or without provisional restoration and bone grafting.5,6 In addition, positive esthetic outcomes have been reported regarding ridge collapse, midfacial recession, and tissue discoloration depending on implant position, immediate provisional restoration, and bone grafting.3,7–11 The dual-zone (tissue and bone zones) therapeutic concept, in which a hard tissue graft material is intentionally placed not only adjacent to the labial bone plate but also into the soft tissues, was introduced in 2012.2,3,10–13 The utilization of this technique has led to enhanced and consistent esthetic outcomes without employing supplemental connective tissue grafting QDT 2019 © 2019 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER 223 MIELESZKO ET AL 1a 1b Figs 1a and 1b Pretreatment extraoral smile and labial views of the maxillary right central incisor The patient exhibits a high smile line A 20-year-old porcelain-fused-to-metal crown and gingiva show discoloration due to a dark root after root canal treatment Fig Pretreatment periapical radiograph and CBCT shows a thin labial plate, narrow socket dimension, and bone apical and palatal to the tooth root In addition, the use of macro changes in implant design, specifically angle correction or Co-Axis implants (Southern Implants), may minimize the need for custom abutments and cement-retained definitive restorations.14 It has been documented that remaining cement remnants in the soft tissues and surrounding the implant-abutment platform can lead to inflammation and resultant attachment loss.15 The following case illustrates the use of these techniques and implant macro design elements to minimize changes in ridge dimension, gingival recession, and tissue color while ensuring screw retention of the restoration associated with immediate tooth replacement therapy in the esthetic zone CASE PRESENTATION A 41-year-old Asian woman presented for treatment of the maxillary right central incisor (tooth 11) following traumatic insult (Figs 1a and 1b) The tooth had been previously treated endodontically due to trauma and restored with a full-coverage restoration A cone beam computed tomography (CBCT) scan was taken preoperatively, and all findings, treatment options, and risks were reviewed (Fig 2) The patient consented to immediate tooth replacement therapy (ITRT) using the dual-zone technique Informed consent was obtained based on the Helsinki Declaration of 1975 An irreversible hydrocolloid impression material (Jeltrate Alginate, Dentsply Caulk) was made, and an acrylic “eggshell” was fabricated using the powder-liquid (Nealon) technique.16 Excess material was trimmed to create the final tooth form shell prior to relining it with a prefabricated gingival former device (i-Shell, Vulcan Custom Dental), which replicates the shape and dimensions of the extracted root at the cervical area and properly supports the subgingival mucosal tissues.17 After the administration of local anesthesia, the crown was removed, with sharp dissection of the supracrestal gingival fibers performed by means of a 15c scalpel blade The tooth was extracted atraumatically with fine-tipped forceps (Fig 3) The labial soft tissue measured at mm from free gingival margin (FGM) with rounded-end springless calipers (Iwanson Spring Caliper, Henry Schein) revealed a thickness of 0.5 mm (Figs 4a and 4b) After socket debridement with a surgical excavator, an intact buccal plate and soft tissue or type socket was con- 224 QDT 2019 © 2019 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER The Use of Dual- or Co-Axis Macro-Designed Implants to Enhance Screw-Retained Restorations in the Esthetic Zone 4a 4b Fig Extraction was performed in an atraumatic manner without flap elevation An intact buccal plate was confirmed Figs 4a and 4b Buccal soft tissue thickness 2.0 mm below the free gingival margin was measured with an Iwanson rounded-end springless caliper Thin buccal soft tissue of 0.5 mm was noted Fig Osteotomy was done according to the manufacturer’s recommendation, and the angulation of the implant followed the incisal edges of the adjacent teeth Fig Implant driver showed an implant platform angle correction of 12 degrees, which enabled positioning of a screwaccess hole at the cingulum area by macro implant design alone Fig The angle correction or co-axis implant was placed approximately to mm below the buccal free gingival margin Note that the external hex platform was now positioned at the cingulum firmed, and the site was prepared to receive an endosseous implant.18 The drilling protocol is consistent with cement-retained restorations, where the path of angulation is coincident with the incisal edge position of the adjacent teeth (Fig 5) The implant site preparation was consistent with the manufacturer’s recommendations A 5.0-mm-diameter textured and threaded implant design with variable platform switching and a 12-degree angle correction feature (Co-Axis, Southern Implants) was used and placed with 65 Ncm of insertion torque value (Fig 6) The implant position was set at approximately 3.0 to 4.0 mm in depth from the midfacial FGM, and leaving a “labial gap” to be filled with biomaterial (Fig 7) A screw-retained custom provisional restoration was fabricated using a preformed subgingival former acrylic shell or sleeve filled and connected to a polyether-ether-ketone polymer (PEEK) temporary cylinder with autopolymerizing resin (Super T, American Consolidation Manufacturing Co) (Figs to 13) The provisional restoration was intentionally positioned in labioversion to ensure nonocclusal loading during the healing phase Prior to insertion of the custom provisional restoration, the subgingival surface of the abutment was steam cleaned for 20 seconds (Touchsteam, Kerr) to allow the provisional restoration to serve as a platform for initial peri-implant soft tissue healing.19 A tall and slender titanium healing abutment was placed to protect the prosthetic screw hole while small-particle (250 to 500 micron) corticocancellous bone allograft (Puros, Zimmer Biomet) was packed against the abutment into the buccal gap with an amalgam condenser (Fig 14a) The bone graft material occupied the bone zone as well as the tissue zone to the height of the FGM (Fig 14b) The healing abutment was subsequently removed, and the fabricated provisional restoration replaced and secured with a retaining screw that was hand tightened (Figs 15 to 17) The excess bone graft was removed The patient was placed on a postsurgical broad-spectrum antibiotic and analgesic, as needed, and she was seen for follow-up at week QDT 2019 225 © 2019 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER MIELESZKO ET AL 8a 8b 10a 10b 11 Figs 8a and 8b Prefabricated polymethyl methacrylate (PMMA) shell device was placed into the socket over the implant Fig PMMA temporary abutment placed onto the implant The platform angle correction enabled optimal angulation of the prosthetic abutment relative to the extraction socket Figs 10a and 10b Palatal aspect of prefabricated shell device was modified to facilitate the temporary screw-retained cylinder Fig 11 Space between the temporary abutment and shell device was filled with autopolymerizing resin Fig 12 The preoperative impression was used to form an “egg shell” in a powder-liquid (Nealon) technique and connected to the subgingival structure of the provisional restoration 12 Figs 13a and 13b Removed provisional restoration before and after the custom characterization using Optiglaze color (GC America) 13a 13b 226 QDT 2019 © 2019 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER The Use of Dual- or Co-Axis Macro-Designed Implants to Enhance Screw-Retained Restorations in the Esthetic Zone 14a 14b 15 16a 16b 18 19 17 Figs 14a and 14b Healing abutment was placed into the implant to protect the screw access hole, and cancellous particulate allograft was placed up to the free gingival margin Fig 15 Provisional restoration was placed and excess bone graft was removed Figs 16a and 16b Buccal and occlusal views after the immediate tooth replacement therapy Fig 17 CBCT taken right after the immediate tooth replacement therapy showed platform angle correction and avoidance of apical perforation of the extraction socket with the co-axis implant design Fig 18 Five months after the ITRT, coronal migration of the facial mucosal margin was noted Fig 19 Bleeding, due to torn soft tissue fiber attachment from the peri-implant sulcus yet healthy, was noted at the first disconnection of the provisional restoration After months of undisturbed healing, the custom provisional crown was removed (disconnection) for the first time to make an implant-level impression for fabrication of the definitive restoration (Fig 18) A 2.0-mm increase in buccal peri-implant soft tissue thickness was measured (Fig 19) The patient demonstrated good oral hygiene (eg, plaque-free score higher than 90%) Pattern resin (Pattern Resin LS, GC America) was used to capture the subgingival soft tissue profile, and implant-level transfer copings were attached for an open-tray impression The impression was made with a dual-viscosity (light syringe and heavy tray) monophase polyvinyl siloxane material (Flexitime, Kulzer) QDT 2019 227 © 2019 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER MIELESZKO ET AL 20a 20b 21a 21b 22 21c 23 Figs 20a and 20b Shade selection using the shade tabs with regular and polarized photography Figs 21a to 21c Laboratory fabrication of the prosthetic screw-retained abutment/crown (a) Soft tissue model, (b) which showed increase of buccal peri-implant soft tissue of 2.0 mm (net of 2.5 mm) from the initial thickness of 0.5 mm, and (c) metal prosthetic framework Fig 22 Incisal third of the restoration contains some grayish-violet to create the illusion of depth, and the gingival third has a more chromatic hue profile Fig 23 Segmental lateral buildup: Incisal third with grayish-violet to create the illusion of depth and gingival third with chromatic profile It is recommended that color matching be performed prior to impression-making to prevent false shades associated with tooth dehydration Multiple shade guides and tabs (Vitapan 3D Master, VITA North America) are used in the shade communication photographs, which helps determine the variations in color, chroma, and value (Fig 20a) Polarized digital photography eliminates surface reflections and visually exposes internal characteristics, such as mamelons, deep translucencies, or craze lines, while providing 228 QDT 2019 easier determination of color saturation when used with shade guides (Fig 20b) The laboratory made a soft tissue cast that allowed fabrication of a screw-retained noble metal alloy restoration (Argedent 52SF Special, Argen) (Figs 21a to 21c) The framework was opaqued to create the base for color and fluorescence The incisal third of the restoration required a slight grayish-violet tone to create the illusion of depth, while the gingival third contained a more saturated © 2019 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER The Use of Dual- or Co-Axis Macro-Designed Implants to Enhance Screw-Retained Restorations in the Esthetic Zone 24 25 26 27a 27b 27c 27d Fig 24 Shade was verified using a polarized filter and the same shade tabs used for shade selection Fig 25 Gold powder applied to verify the texture and luster of the restoration independent of the shade Fig 26 Try-in of the final restoration Modifications to the distal contour, chroma, and surface texture were required Figs 27a to 27d Fine tuning of the crown, fabricated of porcelain fused to gold-ceramic alloy, with additional texture, incisal transparency, and contour chromatic base color profile (Fig 22) A segmental lateral buildup technique using feldspathic ceramic powders (HeraCeram, Kulzer Dental US) was performed to achieve proper hue and translucency characteristics (Fig 23) Morphology of the restoration, including texture and surface luster, was achieved to create a lifelike definitive restoration The final shade was verified using polarized filter photography and the same shade guide tabs that were used for clinical shade selection (Fig 24) Gold powder (Benzer Dental AG) was applied to verify the surface texture and luster (Figs 25 to 27) The screw-retained crown, fabricated of porcelain fused to gold-ceramic alloy, was delivered with 35 Ncm approximately months after final impression-making (Figs 28 and 29) The definitive restoration months after delivery is shown in Figs 30a to 30e QDT 2019 229 © 2019 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER MIELESZKO ET AL 28a 28b 28c 29 Figs 28a to 28c Screw-retained final restoration placed (a) Labial view, (b) distal papilla, and (c) smile view The patient was pleased with the result Fig 29 Periapical radiograph of the final restoration placed months after the placement of a dental implant 230 QDT 2019 © 2019 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER The Use of Dual- or Co-Axis Macro-Designed Implants to Enhance Screw-Retained Restorations in the Esthetic Zone 30a 30b 30c 30d 30e Figs 30a to 30e (a) Occlusal, (b) smile, (c) distal papilla, (d) profile, and (e) polarized image views taken months after the delivery of final restoration Note maintained buccolingual ridge width and midfacial soft tissue height compared to contralateral tooth (maxillary left central incisor) QDT 2019 231 © 2019 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER MIELESZKO ET AL CONCLUSION To achieve predictable esthetic success with ITRT, the critical clinical and laboratory steps outlined in this case report must be respected These steps are helpful to limit the amount of buccal ridge dimensional change as well as midfacial peri-implant soft tissue recession of the implant and potentially enhance the thickness of the peri-implant soft tissues coronal to the implant-abutment interface as well as offering a screw-retained definitive restoration with a co-axis macro implant design ACKNOWLEDGMENTS The authors would like to thank Dr Dennis P Tarnow for the skillful work REFERENCES Wöhrle PS Single-tooth replacement in the aesthetic zone with immediate provisionalization: Fourteen consecutive case reports Pract Periodontics Aesthet Dent 1998;10:1107–1114; quiz 1116 Tarnow DP, Chu SJ, Salama MA, et al Flapless postextraction socket implant placement in the esthetic zone: Part The effect of bone grafting and/or provisional restoration on facial-palatal ridge dimensional change-a retrospective cohort study Int J Periodontics Restorative Dent 2014;34:323–331 Chu SJ, Salama MA, Garber DA, et al Flapless postextraction socket implant placement, part 2: The effects of bone grafting and provisional restoration on peri-implant soft tissue height and thickness—a retrospective study Int J Periodontics Restorative Dent 2015;35: 803–809 Kan JY, Rungcharassaeng K, Lozada JL, Zimmerman G Facial gingival tissue stability following immediate placement and provisionalization of maxillary anterior single implants: A 2- to 8-year follow-up Int J Oral Maxillofac Implants 2011;26:179–187 Cooper LF Objective criteria: Guiding and evaluating dental implant esthetics J Esthet Restor Dent 2008;20:195–205 232 QDT 2019 Raes S, Cosyn J, Noyelle A, Raes F, De Bruyn H Clinical outcome after to 10 years of immediately restored single implants placed in extraction sockets and healed ridges Int J Periodontics Restorative Dent 2018;38:337–345 Crespi R, Capparè P, Gastaldi G, Gherlone EF Buccal-lingual bone remodeling in immediately loaded fresh socket implants: A cone beam computed tomography study Int J Periodontics Restorative Dent 2018;35:43–49 Cosyn J, Eghbali A, De Bruyn H, Collys K, Cleymaet R, De Rouck T Immediate single-tooth implants in the anterior maxilla: 3-year results of a case series on hard and soft tissue response and aesthetics J Clin Periodontol 2011;38:746–753 Tarnow D, Chu SJ, Salama MA, et al Flapless postextraction socket implant placement in the esthetic zone: Part The effect of bone grafting and/or provisional restoration on facial-palatal ridge dimensional change—a retrospective cohort study Int J Periodontics Restorative Dent 2014;34:323–331 10 Chu SJ, Saito H, Salama MA, et al Flapless postextraction socket implant placement, part 3: The effects of bone grafting and provisional restoration on soft tissue color change—a retrospective pilot study Int J Periodontics Restorative Dent 2018;38:509–516 11 Saito H, Chu SJ, Zamzok J, et al Flapless postextraction socket implant placement: The effects of a platform switch-designed implant on peri-implant soft tissue thickness-a prospective study Int J Periodontics Restorative Dent 2018;38(suppl):s9–s15 12 Chu SJ, Salama MA, Salama H, et al The dual-zone therapeutic concept of managing immediate implant placement and provisional restoration in anterior extraction sockets Compend Contin Educ Dent 2012;33:524–532, 534 13 Saito H, Chu SJ, Reynolds MA, Tarnow DP Provisional restorations used in immediate implant placement provide a platform to promote peri-implant soft tissue healing: A pilot study Int J Periodontics Restorative Dent 2015;36:47–52 14 Howes D Angled implant design to accommodate screw-retained implant-supported prostheses The Compend Contin Educ Dent 2017; 38:458–463; quiz 464 15 Wadhwani C, Piñeyro A Technique for controlling the cement for an implant crown J Prosthet Dent 2009;102:57–58 16 Nealon FH Acrylic restorations by the operative nonpressure procedure J Prosthet Dent 1952;2:513–527 17 Chu SJ, Hochman MN, Tan-Chu JH, Mieleszko AJ, Tarnow DP A novel prosthetic device and method for guided tissue preservation of immediate postextraction socket implants Int J Periodontics Restorative Dent 2014;34(suppl):s9–s17 18 Deas DE, Moritz AJ, McDonnell HT, Powell CA, Mealey BL Osseous surgery for crown lengthening: A 6-month clinical study J Periodontol 2004;75:1288–1294 19 Saito H, Hsia RC, Tarnow DP, Reynolds MA Cell adhesion to acrylic custom provisional abutment placed on an immediate implant: A case report Compend Contin Educ Dent 2017;38:114–119 © 2019 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER Copyright of Quintessence of Dental Technology (QDT) is the property of Quintessence Publishing Company Inc and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission However, users may print, download, or email articles for individual use ... create an optimal result Key details are explained and depicted with two select clinical cases QDT 2019 © 2019 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL... harvested from the tuberosity and sutured crestally on the ridge to minimize the tissue defect QDT 2019 © 2019 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL... tooth Bonding only one veneer next to the implant restoration decreases bonding difficulty QDT 2019 © 2019 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL