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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 2  |  Issue : 1  |  Page : 8-12

Immediate implant and customized abutments: Esthetic peri-implant preservation alternative without immediate loading esthetic customized abutment


Pos-graduation of Implant Dentistry, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil

Date of Web Publication22-Apr-2019

Correspondence Address:
Dr. Priscila Ladeira Casado
Mario Santos Braga Street, 28 Centro, Niterói, Rio de Janeiro - 24020-140
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/GFSC.GFSC_5_19

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  Abstract 


The aim of this case report was to describe an alternative treatment for the healing and maintenance of peri-implant mucosa in esthetical region. Managing the peri-implant soft tissue is one of the most challenging tasks in anterior implant esthetics, especially when replacing a failing tooth. However, not all patients underwent extraction, and immediate implant placement can receive loading, conducting to uncertain predictability. This is a case report that describes an alternative treatment for the healing and maintenance of the peri-implant mucosa in an esthetically significant region, through the use of a customized abutment to obtain an emergency profile when there is insufficient torque for immediate implant loading. The present technique was able to ensure not only healthy peri-implant soft and hard tissues, but also esthetic maintenance of the anterior region for immediate implant placement. This clinical case demonstrates a different manipulation technique from the peri-implant soft tissues in immediate implants of the esthetic region favoring the peri-implant health and clinical results, promoting treatment success, and patient satisfaction.

Keywords: Immediate implant, implant esthetic, peri-implant mucosa


How to cite this article:
Machado A, Goncalves R, Pinheiro AD, Filho CC, Rangel BC, Alto RM, Casado PL. Immediate implant and customized abutments: Esthetic peri-implant preservation alternative without immediate loading esthetic customized abutment. Int J Growth Factors Stem Cells Dent 2019;2:8-12

How to cite this URL:
Machado A, Goncalves R, Pinheiro AD, Filho CC, Rangel BC, Alto RM, Casado PL. Immediate implant and customized abutments: Esthetic peri-implant preservation alternative without immediate loading esthetic customized abutment. Int J Growth Factors Stem Cells Dent [serial online] 2019 [cited 2019 Jul 22];2:8-12. Available from: http://www.cellsindentistry.org/text.asp?2019/2/1/8/256789




  Introduction Top


The longevity and functionality of dental implants depend on both, osseointegration around the implant and the establishment of a soft-tissue barrier which protects the underlying hard tissue structures and the implant itself.[1]

The healing of soft tissues around the transmucosal portion of an implant after surgery starts with the formation of a blood clot and the induction of an inflammatory process which leads to tissue formation and remodeling.[2]

Taking into account that mucosae healing, in an oral environment, is challenging due to the consistent exposure to microorganisms, the rapid formation of an efficient soft-tissue seal is, therefore, crucial for the establishment and maintenance of peri-implant tissue health status.[3]

In the case of implants in the anterior region, the esthetics of the implant prosthesis becomes critical to the acceptance of the implant treatment; therefore, soft-tissue control is absolutely fundamental.[1] In this context, in cases of indication of extraction of anterior teeth, the insertion of immediate implants has become a clinical routine for the implant dentist. When the parameters for implant placement into fresh alveoli are respected, the esthetic results are extremely satisfactory, reducing consultation time, promoting a positive psychological impact on the patient and the maintenance of peri-implant mucosa.[4]

Furthermore, immediate loading can achieve primary stability by using the implant insertion torque of at least 40 Ncm.[5] This technique has a failure rate similar to conventional implants[6] with less alveolar bone crest loss.[7] To achieve these results, the alveolar bone must be intact in a site with thick gingival biotype and adequate three-dimensional positioning of the implant in the alveolus.[7]

Immediate loading directly influences the soft-tissue framework around the implant. The maintenance of the peri-implant tissue through the manipulation of the temporary implant is quite important for gingival health and esthetics of the region where the implant was inserted.[8]

However, the needs of patients are diverse, and esthetics is an increasingly important demand. In clinical practice, not all patients can be submitted to extraction with immediate implant placement and loading. In cases of uncertain predictability, when the placement of a temporary implant jeopardizes the success of the immediate implant, how should one proceed to maintain the gingival structure?

This is a case report that describes an alternative treatment for the healing and maintenance of the peri-implant mucosa in an esthetically significant region, through the use of a customized abutment to obtain an emergency profile when there is insufficient torque for immediate implant loading.


  Case Report Top


A 40-year-old female patient sought the Implant Dentistry Teaching Program at the Fluminense Federal University seeking to improve the esthetics of her smile. The consent form was obtained from the patient. Her main complaint was the different color shades of her anterior teeth. After clinical evaluation, the following examinations were required: extraoral panoramic radiography, complete periapical radiography, and computed tomography of the anterior maxillary region. The tomographic evaluation revealed an intraradicular nucleus and a fracture in the right upper lateral incisor, which had been previously endodontically treated [Figure 1].
Figure 1: Cone beam computed tomography

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After analyzing the risks and benefits of the treatment options, the patient consented to the extraction of the fractured tooth, insertion of an osseointegrated implant immediately after dental extraction and placement of an immediately loaded temporary composite resin implant.

Before implant surgery, a temporary light-curing resin was fabricated for esthetic reasons and adaptation of marginal peri-implant mucosa. After local anesthesia, exodontia was performed atraumatically using periotomes (Quinelato®, Rio Claro, SP, Brazil) to remove dentogingival fibers, with minimal damage to the alveolar bone and without mucosal flap [Figure 2].
Figure 2: Periotome for atraumatic extraction

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The site was then debrided and irrigated with 0.9% saline solution. The integrity of the vestibular face of the alveolus was verified using a millimeter periodontal probe [Figure 3]. Sequential osteotomies for implant placement were performed with the adapted surgical guide, followed by the placement of a morse cone implant measuring 3.5 mm in diameter and 13.0 mm in height (SIN®, São Paulo, SP, Brazil) [Figure 4].
Figure 3: Periodontal probe for the evaluation of bone integrity

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Figure 4: Surgical guide – onset of bone perforation

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In the apical-coronal direction, the implant was placed 3 mm apical to the vestibular gingival margin. In the mesiodistal direction, the implant was placed in the center of the interdental space, leaving at least 2 mm between the adjacent tooth and implant. In the vestibular-palatine direction, the implant was placed in the alveolar palatine bone to achieve primary stability. However, torque for primary stability was 20 Ncm.

Considering that torque of 20 Ncm is not enough to withstand immediate loading of the temporary implant, requiring a minimum torque of 40 Ncm insertion for immediate loading, an alternative treatment was chosen to preserve the alveolar bone and the stability of the peri-implant mucosal structure.

A temporary connection (SIN®, São Paulo, SP, Brazil) was cut at the level of the gingival margin and fixed to the implant platform. A fluid composite resin (Nova DFL®, Rio de Janeiro, RJ, Brazil) was adapted around the healing screw, considering a concave profile, to support the nature of the healing mucosa [Figure 5].
Figure 5: Healing personalized trough customized abutment

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The micro-filled composites were highly polished to improve contour and emergence profile and to keep plaque accumulation to a minimum. An adhesive prosthesis was made to esthetically fill the region of the extracted tooth without any contact with the healing screw. The immediate postoperative result was favorable, with no sign of local inflammation, adequate conditioning of gingival tissues around the customized healing screw and immediate esthetics.

Adequate antibiotic and analgesic therapy was prescribed. The patient was instructed to use 0.12% chlorhexidine gluconate oral rinse twice a day for 14 days.

Fifteen days after surgery, tissue healing did not present an exacerbated inflammatory reaction, with optimal healing of the interproximal tissues [Figure 6].
Figure 6: Peri-implant mucosae aspect 15 days after healing

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The impression was performed to fabricate the temporary implant-supported resin prosthesis after 4 months of maintenance of the peri-implant structure. The customized abutment was only definitively removed when the temporary prosthesis was adapted to the implant platform, thus exerting its function of keeping the gingival tissues in perfect conditions, including the interproximal papillae [Figure 7] and [Figure 8].
Figure 7: Provisional implant supported prosthesis

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Figure 8: Submucosa adaptation of temporary prosthesis keeping the peri-implant mucosae aesthetic

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After 6 months, an implant-supported all-ceramic crown was fabricated. Twelve-month following implant surgery, the papilla and the emergence profile presented healthy peri-implant and esthetic appearance [Figure 9].
Figure 9: Twelve months after final prosthesis adaptation

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  Discussion Top


It is clear in the current literature that the balance of pink and white esthetics results in a treatment with a higher success rate. Immediate implants in the anterior area require more careful planning due to the need to maintain the papilla and the peri-implant structure. However, it is not always possible to insert a temporary implant-supported prosthesis immediately after implant placement to improve the esthetic result. Therefore, this case report aimed to describe an alternative treatment for the maintenance of the peri-implant mucosa within an esthetic area without immediate loading. Immediate and long-term results have shown excellent patient acceptance, formation of mucosal seals and maintenance of the peri-implant soft-tissue structure, including the absence of retraction of the interdental papilla and satisfactory esthetics.

In anterior teeth, esthetics is a higher priority; therefore, natural gingival anatomy and a healthy color are prerequisite properties for a satisfactory treatment result.[1] It is desirable to be able to predict the amount of mucosal recession; therefore, it is important that the mid-buccal margin is located more than 2 mm above the implant superstructure[1] to prevent predictable annual recession of 0.6 mm.[9]

It is imperative to consider that during implant placement in the anterior region, the interproximal papilla is related to the bone levels and insertion of the adjacent tooth. This is because the level of the implant platform is positioned according to the buccal bone level, being apical to the interproximal bone.[10] To achieve satisfactory results, the tooth to be extracted must be healthy, without evidence of pathologies, infection or any inflammatory reactions that could damage the protective periodontium, culminating in instability of the marginal gingiva. In addition, other factors such as the location of the palatine implant, abutment shape, and gingival biotype are important for mucosa maintenance.[1]

In the present case report, these prerequisites were respected throughout planning and implant placement, and the risks for possible gingival retraction were assessed, which contributed to the maintenance of the immediate gingival structure after the insertion of the prosthesis.

Another important factor to consider was the concave profile of the customized abutment, adapted immediately after implant placement. This profile was able to maintain the structure of the soft-tissue framework, making it difficult to retract due to the convexity located in the region in contact with the implant platform, which possibly limited apical tissue migration. Considering that contraction of the circular fibers present in the peri-implant mucosa occurs predominantly in the horizontal direction during the healing period, adaptation of the mucosal seal becomes much more predictable on the concavity of the personalized abutment.[11] Perhaps, that is why, in this report, retraction of the peri-implant mucosa has not been observed.

Numerous prospective studies have shown significant alterations in the level of peri-implant soft tissue during early healing stages after single implant placement.[12] We believe that a strict protocol, with maximal hard and soft tissue preservation and immediate soft-tissue support, will certainly guide the uneventful early healing, preventing disruption of the pink anatomy.

Papilla reduction, midfacial recession, and alveolar resorption were prevented by the described technique. One of the benefits of this technique was that there was no gingival inflammation, which may be related, among other factors, to the use of fluid resin. No signs of inflammation, such as redness, bleeding, or itching, have been observed in any postoperative follow-ups when using this technique. At 12 months, pink esthetics was comparable with the preoperative status, and as such, esthetics could be preserved. However, future randomized clinical trials using the same technique, with a greater number of cases, should be performed to confirm our findings.

To the best of our knowledge, no previous studies have discussed the exact technique described in this case report. Gowda et al.[13] described, in a clinical case, the use of customized abutments to achieve contour around immediate implants, presenting satisfactory results that include better esthetics and emergency profile in anterior restorations. However, the authors used customized abutments during a second surgical procedure, not immediately after implant placement, followed by the immediate impression for the preparation of temporary resin prosthesis.

The present findings highlight a technique able to ensure not only healthy peri-implant soft and hard tissues, but also esthetic maintenance of the anterior region for immediate implant placement.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Atsuta I, Ayukawa Y, Kondo R, Oshiro W, Matsuura Y, Furuhashi A, et al. Soft tissue sealing around dental implants based on histological interpretation. J Prosthodont Res 2016;60:3-11.  Back to cited text no. 1
    
2.
Berglundh T, Abrahamsson I, Welander M, Lang NP, Lindhe J. Morphogenesis of the peri-implant mucosa: An experimental study in dogs. Clin Oral Implants Res 2007;18:1-8.  Back to cited text no. 2
    
3.
Tomasi C, Tessarolo F, Caola I, Piccoli F, Wennström JL, Nollo G, et al. Early healing of peri-implant mucosa in man. J Clin Periodontol 2016;43:816-24.  Back to cited text no. 3
    
4.
Chrcanovic BR, Albrektsson T, Wennerberg A. Dental implants inserted in fresh extraction sockets versus healed sites: A systematic review and meta-analysis. J Dent 2015;43:16-41.  Back to cited text no. 4
    
5.
Balaji P, Balaji SM, Ugandhar P. Immediate implant in single rooted teeth – Study on primary stability and bone formation. Indian J Dent Res 2015;26:421-6.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Ioannidou E, Doufexi A. Does loading time affect implant survival? A meta-analysis of 1,266 implants. J Periodontol 2005;76:1252-8.  Back to cited text no. 6
    
7.
Trisi P, Rao W, Rebaudi A. A histometric comparison of smooth and rough titanium implants in human low-density jawbone. Int J Oral Maxillofac Implants 1999;14:689-98.  Back to cited text no. 7
    
8.
Soares NP, Pimentel AC, Cançado RM, Manzi MR, Brozoski M, Camino Junior R, et al. Determining factors for formation and/or maintenance of peri-implant papilla: Literature review. Dent Press Implantol 2013;7:73-80.  Back to cited text no. 8
    
9.
Grunder U. Stability of the mucosal topography around single-tooth implants and adjacent teeth: 1-year results. Int J Periodontics Restor Dent 2000;20:11-7.  Back to cited text no. 9
    
10.
Kan JY, Shiotsu G, Rungcharassaeng K, Lozada JL. Maintaining and attenuating periodontal tissues for aesthetic implant placement. J Oral Implantol 2000;26:35-41.  Back to cited text no. 10
    
11.
Iorio-Siciliano V, Marzo G, Blasi A, Cafiero C, Mignogna M, Nicolò M, et al. Soft and hard tissue modifications at immediate transmucosal implants (with laser-lok microtextured collar) placed into fresh extraction sites: A 6-month prospective study with surgical reentry. Int J Periodontics Restorative Dent 2014;34:541-9.  Back to cited text no. 11
    
12.
Cosyn J, De Bruyn H, Cleymaet R. Soft tissue preservation and pink aesthetics around single immediate implant restorations: A 1-year prospective study. Clin Implant Dent Relat Res 2013;15:847-57.  Back to cited text no. 12
    
13.
Gowda VS, Anand D, Sundar MK, Reveredo AM, Shetty S. Custom anatomic healing abutments. J Indian Prosthodont Soc 2016;16:386-9.  Back to cited text no. 13
[PUBMED]  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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