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Despite ≤significant advances in dental therapeutics, there are patients for whom no reasonable treatmentis available that will reliably restore or maintain their existing dentition. The causes for future edentulisminclude untreatable periodontal disease, advanced caries, failing root canal therapy, inadequate numbers ofteeth to support a fixed prosthesis, or a history of failed previous rehabilitations. For these patients, dentalimplants supporting a fixed prosthesis provide a more predictable function and esthetics than retention oftheir remaining teeth.

A transitional fixed prosthesis specifically designed for a patient with terminal dentition offers the advantage

of maintenance and development of proper gingival esthetics with improved function. Prior to implant place-

ment, the gingival frame is established, enhancing the overall appearance of the final, full–arch implant reha-

bilitation. The specific prosthodontic, surgical, and laboratory techniques required for successful treatment of

these patients are presented.

THE THE INTERDICIPLINARINTERDICIPLINARYYAPPROACHAPPROACH

TO THE RESTORATO THE RESTORATION OF THE TERMINAL DENTITION PTION OF THE TERMINAL DENTITION PAATIENTTIENT

WITH AN IMPLANTWITH AN IMPLANT-SUPPOR-SUPPORTED FIXED PROSTHESISTED FIXED PROSTHESIS

Richard P. Kinsel, D.D.S., Daniele Capoferri, CDT, Foster City California

Keywords: dental implants, ovate pontics, immediately–loaded implants, gingival morphology,implant–supported dental prosthesis, transitional prostheses, interdisciplinary treatment,Sinfony™

Introduction

Although there have been significant advances in periodontics and prosthodontics, somepatients have severely debilitated dentitions that cannot be successfully rehabilitated. Previously,conventional removable dentures were the only available treatment. With the success of osseoin-tegrated dental implants, an alternative exists for predictable restoration with a fixed prosthesis.However, the patient’s expectation that their implant–supported restorations precisely duplicate

the appearance of natural dentition continuesto challenge the implant treatment team.Today, success can no longer be judged bywhether or not the implant simply osseointe-grates. Although the skilled dental technicianmay be able to create a restoration that emu-lates a natural tooth in every respect, thisresult may be an esthetic failure if optimal gin-gival profile and underlying supportingosseous structures are absent.

The patient with a terminal dentitionoffers a unique opportunity to maintain or fur-ther improve gingival profiles prior to implantplacement. An integral part of proposed treat-ment includes the concept of immediatelyloaded implants, which appears to be success-ful as reported by several clinicians. 1–7

Following tooth extraction, the facialbone and the interproximal osseous alveolarcrest that supports the papillae will resorb.Retention of sufficient teeth to support a tran-sitional fixed prosthesis with ovate pontics canbe used to maintain, enhance, or transform theexisting gingival contours. Once the gingivalframe has been successfully established, a sur-gical technique that eliminates the convention-al full thickness reflected flap is used to placethe implants. Next, the remaining abutmentteeth can be removed and the provisional pros-thesis converted to one that is solely implantsupported.

The use of ovate pontics to supportfacial and interproximal tissues thus resulting ina more natural appearance is not a new con-cept. Many clinicians 8–13 have reported on thisprosthetic technique to enhance desired gingi-val contours of the edentulous ridge. Spear12described the concept and protocol for main-taining papillary height and form followinganterior tooth removal. The consensus of thesereports validates the opinion that optimalesthetics using ovate pontics can be achievedwithout a deleterious effect upon the surround-ing hard and soft tissues.

Restoration of the terminal dentitionpatient requires interdisciplinary collaborationamong the prosthodontist, laboratory techni-cian, and implant surgeon during all phases ofpatient care. In addition to the normal informa-tion gathering, diagnostic casts mounted withfacebow, interocclusal records, and analysis of

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digital photographs of the teeth relative to cer-tain esthetic parameters must be reviewedprior to initiating treatment.

Collaborative Esthetic Evaluation andTreatment Planning

The patient chosen to demonstrate thistechnique was a 56–year–old female in generalgood health with advanced periodontal dis-ease of the maxillary arch (Figs. 1a to 1f).

Figs. 1a to 1f: A 56–year–old female presented in general

good health with advanced periodontal disease of the maxil-

lary arch. The existing problems included a retrognathic

mandibular occlusion, a missing left lateral incisor, a midline

discrepancy, the super–eruption with left inclination of the

maxillary anterior teeth, an uneven occlusal plane, and a

deep bite. Conventional periodontal therapy did not offer a

predictable long–term prognosis. Note that the gingival dis-

play of the canines and right central incisor is favorable (a).

The midline coincides with the desired position of the inter-

dental papilla (f). (for fig. 1c-1f, see page 422)

1a

1b

Initial evaluation demonstrated a retrognathicmandibular deficiency; a missing left lateralincisor, a midline discrepancy, and thesuper–eruption with left inclination of themaxillary anterior teeth, an uneven occlusalplane, and a deep bite. The remaining maxil-lary dentition was determined by the patient’speriodontist to be either hopeless or severelycompromised if conventional osseous resec-tion therapy were instituted. Therefore, themost predictable treatment option for achiev-ing the patient’s goals was maxillary dentalimplants placed to support a fixed prosthesis.

It is important to note that the estheticparameters regarding the gingival contoursand maxillary midline (Fig. 1a) were favorablefor the anticipated definitive prosthesis. Thefacial gingiva adjacent to the canines and rightcentral incisor was in proper horizontal posi-tion and the midline coincided with thedesired position of the interdental papilla (Fig.1f). The major esthetic deficiency was theimproper present positions of the gingivalcontours to the desired definitive prosthetic

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teeth. The major esthetic deficiency was theimproper present positions of the gingival con-tours to the desired definitive prosthetic teeth.The diagnostic casts were mounted with thefacebow parallel to the horizon while thepatient’s head was perpendicular and with thecentric relation position interarch record (Fig.2a and 2b). The occlusal view of the maxillarycast (Fig. 3a) clearly shows the midline dis-crepancy, missing left lateral incisor tooth, andconstricted arch form.

The diagnostic wax–up is crucial for properarrangement of teeth in the vertical, horizon-tal, and sagittal planes. From this information,the correction of the midline, occlusal, esthet-ic, and arch form problems were addressed byremoving the first premolars. The increase inspacing allowed the technician to place thecanine and incisor teeth into a more pleasingposition (Figs. 3b to 3d). The facial portion ofthe cast has also been contoured to simulatethe typical root prominence surrounding nat-ural teeth (Fig. 3c). The excessive vertical dis-play of the maxillary anterior teeth, unevenocclusal plane, and deep bite have also beencorrected (Fig. 3d).

1c 1d

1e 1f

Figs. 3a to 3d: Comparison of the diagnostic cast and the wax–up using reference markers (dotted lines). Removal of the firstpremolars provided adequate space to improve arch form and to replace the missing left lateral incisor tooth (b). The secondpremolars served as interim abutments for the provisional fixed bridge. The placement of the facial gingival contours was basedupon the proper tooth height once the incisal position had been determined (c). The midline, the lateral and sagittal inclinations,the excessive vertical display, the uneven occlusal plane, and the deep bite have been corrected (d)

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Figs. 2a and 2b: The diagnostic casts were mounted on the articulator using the facebow, which is positioned parallel to thehorizon when the patient’s head is perpendicular, and the centric relation interarch record

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3c 3d

PA) to improve bonding14–16 and then this isveneered with Sinfony™ (ESPE America, Inc,Norristown, PA); a light–cured composite resin.The composite resin gives the dental techni-cian precise control of the color, translucency,and surface characterization (Figs. 5a to 5c).Metal wire reinforcement of the provisionalfixed prosthesis minimized flexure and possi-ble fracture.

A properly designed provisional fixedprosthesis has a profound influence on the gin-gival facial and interproximal contours prior toimplant placement. The transitional restorationwith ovate pontics can be placed immediatelyfollowing tooth extraction, thereby modifyingthe soft tissue surrounding the extractionsockets. Initial treatment planning requireddetermination of those extraction sites that aremost favorable for dental implants. Relevantconsiderations included optimal biomechanicalstability of the prosthesis, bone quantity, andanatomic restrictions. Finally, the minimal num-bers of abutment teeth required to support aninterim acrylic resin fixed provisional prosthe-sis, during the typical four months of healingfollowing tooth removal, were chosen. Often,the interim prosthesis is far more effective indeveloping optimal soft tissue contours with-out requiring additional gingival surgery by theperiodontist. Unfortunately, the implant teamfrequently overlooks the importance of theprovisional restoration.

Fabrication of the Provisional Fixed Prosthesis

To fabricate the interim fixed restoration, themaxillary wax–up cast was duplicated using alaboratory polysiloxane (Lab–Putty, Coltène,Mahwah, New Jersey, USA) impression materi-al (Fig. 4a and 4b). This impression also servesas a matrix for the acrylic resin core of theprovisional restoration. The teeth scheduledfor initial extraction are removed from thestone duplicate of the wax–up cast and sock-ets made to extend at least 3 mm apical fromthe gingival margin (Fig. 4c to 4f). This willform the shape of the gingival portion of theovate pontics and ultimately the soft tissueprofile. The interim abutment teeth, which inthis case included the second premolars, werereduced approximately 2 mm on the cast (Fig.4d to 4e).

The casts of the prepared teeth werelubricated with a separating medium. Aself–curing acrylic resin (SR Ivocron, IvoclarAG, Schaan, Liechtenstein) was placed into thematrix and seated on the cast. The acrylicresin was cured in warm water under 20 psi.The acrylic core was reduced on the facial andincisal surfaces approximately 1 to 1.5 mm toallow sufficient room for the composite resinveneering material. The acrylic was treatedwith Rocatec (ESPE America, Inc, Norristown,

Figs. 4a to 4c: The diagnostic wax–up was duplicated in diestone (a,b) with a polyvinylsiloxane laboratory putty impres-sion. The first molars and anterior teeth were removed andsockets deepened at least 3 mm apical from the gingivalmargin (c).

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4a

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4c

Figs. 4d to 4f: During the processing of the provisional pros-thesis, the ovate pontics will conform to this depression,which will support and shape the facial and proximal gingiva.The second premolars were reduced approximately 2 mm onthe cast and served as the interim abutments (d–f).

Figs. 5a to 5c: The acrylic core of the provisional fixedrestoration has been veneered with Sinfony™ composite resin.The gingival aspects of the pontics simulate the proximaldimension of the analogous root and have narrow gingivalembrasures that facilitate the formation of interdental papil-lae.

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Prosthodontic Gingival Tissue Enhancement

The second premolars were prepared in themouth prior to tooth removal. Following theextractions of the selected teeth, the provi-sional fixed prosthesis was relined withself–curing acrylic resin and cemented with atemporary luting agent. Note the clinicalappearance immediately following cementa-tion of the provisional restoration (Fig. 6a).The extraction sockets of the former caninesand right central incisor are indicated by theyellow arrows. Although these extraction sitesdid not coincide with the desired locations ofthe definitive prosthetic teeth, the ponticsformed interdental papillae and favorablefacial gingival contours (Fig. 6b to 6d).

Following four months of healing, theimplants were placed using a tissue–punchsurgical technique17 that does not require thereflection of a full thickness flap or sutures(Fig. 7a and 7b). Precise location of theimplant within the confines of the crown abut-ment is crucial. A surgical guide facilitatedcorrect placement of each implant. The guidewas fabricated by duplication of the existingprovisional prosthesis in clear acrylic resin.Parallel holes of 2.5 mm in diameter wereplaced into the guide at the center of theprospective implant sites. Engaging the abut-ment teeth ensured stability of the surgicalguide.

Once the implants were placed, theremaining teeth were extracted and the solid4.0 mm abutments were connected to theimplants and tightened (Fig. 7c). The standardtechnique of the ITI™ implant system forimpression and transfer of the implant abut-ment position was utilized to reline the exist-ing interim prosthesis (Fig. 7d). The cast con-taining the laboratory analogs was mountedusing facebow and centric relation records.The vertical dimension of occlusion wasrecorded using a gingival margin reference onthe cast of the provisional bridge and thismeasurement transferred to the same positionon the implant analog cast. (Fig. 7e). Theprovisional prosthesis was modified to incor-porate the implant abutments into the formerpontics and the remaining teeth on the castwere extracted and converted into ovate pon-tics. Special attention was given to the devel-

Figs. 6a to 6d: The teeth have been extracted with theexception of the second premolars. The provisional fixedprosthesis was relined with self–curing acrylic resin andcemented with a temporary luting agent. The extractionsockets of the former canines and right central incisor areindicated by the yellow arrows (a). After approximately threemonths, the provisional fixed bridge has shaped the tissue (bto d).

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opment of a definite cementoenamel junctionand root form analogous to natural dentitionto enhance the facial and proximal gingivalprofiles. The provisional restoration wascemented onto the solid abutments with GCFuji Plus (GC Corporation, Tokyo, Japan) andthe excess cement thoroughly removed (Fig7i). The advantages of an extraoral laboratoryreline are simplification of the procedure, gin-gival margin integrity, and the curing of theacrylic resin under pressure to reduce voidsand improve density. The immediate restora-tion of the implants is necessary for continuedsupport of the soft tissue profile during theosseointegration period.

Following successful osseointegrationof the maxillary arch implants, the provisionalwas removed and the solid abutments were

Figs. 7a and 7b: Four months after the teeth have beenextracted, the implants were placed using a tissue–punchsurgical technique into the locations of the first molars,canine, and central incisor teeth. The surgical guide engagesthe abutment teeth prior to extraction and facilitates correctimplant placement (a,b).

Figs. 7c to 7e: Once the implants have been placed, the solid4.0 mm abutments were inserted into the implants and tight-ened (c). The standard technique of the ITI™ implant systemfor impression and transfer of the implant solid abutmentposition is utilized to reline the existing interim prosthesis (d).The technician adjusts the laboratory analogs to correct anyangulation problem (e).

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Figs. 7f and 7i: The facial matrix, previously taken of the provisional bridge in situ, is used to properly index the provisional bridgeon the implant analog cast. A lingual metal reinforcement is needed to ensure rigidity of the provisional bridge and reduce the riskof fracture (g). The reline is completed using a self–curing acrylic resin under 20 psi (h). The restoration is cemented onto theimplant abutments with a glass ionomer luting agent (i).

7f 7g

7h 7i

tightened to the recommended torque of 35Ncm. The impressions for casts, facebowtransfer, and centric relation records weremade. A cast of the provisional prosthesis inplace served as a template for the frameworkdesign and porcelain application. The appear-ance of the soft tissue profile, following seat-ing of the final porcelain fused to metal fixedprosthesis, mirrored the facial and interproxi-mal contours typically found surroundinghealthy, natural dentition (Fig 7a to e).

Fabrication of the Definitive Restorations

Typically, the one–piece framework can beinvested and cast without requiring separationand soldering (Fig. 8a and 8b). To accurately

transfer the precise positions of the implants,a die stone with minimal expansion(ResinRock, Whip Mix Corp, Louisville,Kentucky, USA) was used to fabricate themaster cast. The framework wax–up wasinvested (GC Fujivest Super®, GC Europe NV,Leuven, Belgium) and cast in precious alloy(JP–1, Jensen Industries Incorporated, NorthHaven, CT, USA). The definitive restorationsconsisted of an upper one–piece ceramometalfixed bridge (Creation™ Klema Meiningen,Austria) supported by implants at the sites ofthe central incisors, canines and first molars.The lower arch was restored with threeimplant supported porcelain crowns for thefirst molars and left second bicuspid, and oneporcelain crown for the right second bicuspidtooth (Figs. 9a to 9d). The mandibular retrog-

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nathism prevented the establishment of ante-rior contacts in centric relation position;therefore the occlusion developed was groupfunction with broad contacts in all excursivemovements. After final delivery of the restora-tions, a mandibular occlusal guard was fabri-cated and worn every night to prevent therisk of coronal movement of the lower anteri-or segment caused by the long–term absenceof contact with the palatal surfaces of themaxillary incisor teeth. A soft tissue cast wasfabricated to transfer the contour of the softtissues for proper porcelain application(Gengisil, Techim Group, Milano, Italy). Specialattention was directed toward the contours ofthe cementoenamel junction and gingivalembrasures of the definitive prosthesis (Fig.10a to 10c). The gingival embrasure dimen-sions must be biologically acceptable; howev-er, the volume and distance from the contactpoint to the interseptal bone must also facili-tate the maintenance of interdental papillae.Appropriately designed provisional restora-tions are well tolerated by the surroundingsoft tissue structures leading to clinicallyhealthy gingiva found adjacent to natural den-tition (Figs. 11a to 11c). An optimal gingivalcontour, both facially and proximally,

Figs 8a and 8b: A dimensionally stable die stone with minimalexpansion is used to fabricate the cast with the implantanalogs. This allows the technician to cast the metal frame-work in one piece without need to separate the connectorsand solder.

Figs 9a to 9d: The definitive restorations consisted of a one–piece porcelain fused to metal maxillary fixed bridge. The lowerarch was restored with a combination of single porcelain fused to metal crowns supported by the lower ITI implants and theright second premolar tooth.

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enhances the illusion of nature (Figs 12a to12e). The most talented ceramist cannot com-pensate for missing bone or soft tissues thatarise from poor treatment planning andimproper sequencing of therapy.The stability of the height of the underlyingbone is also important, because the osseouscrest serves as the supporting scaffold for theoverlying soft tissue. Therefore, the correctpositioning of the implant and the restorativeplatform is necessary to maintain the bonecontour over time. The radiographs show the

Figs 10a to 10c: A resilient soft tissue mask, recorded from themaster cast prior to die trimming, is imperative for developingproper gingival emergence profile and embrasure form in thedefinitive prosthesis.

Figs 11a to 11c: A resilient soft tissue mask, recorded from themaster cast prior to die trimming, is imperative for develop-ing proper gingival emergence profile and embrasure form inthe definitive prosthesis.

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Figs 12a to 12e: The definitive restorations following finalcementation. The gingival frame including interdental papillaefavorably influences the illusion of individual natural teeth.

Fig. 13: The finalradiographs ofthe completedcase demonstratethe marginintegrity andbone levels thatwill remain stableand continue tosupport the over-lying soft tissueprofile.

Fig 14a and 14b: A comparison of the definitive restoration and its outline superimposed on the pretreatment photograph usingthe same gingival reference point (blue arrow). Notice the relationship of the final prosthesis and soft tissue contours relative to theprevious esthetic deficiencies.

margin integrity and location of thecrown–implant interface to the bone (Fig. 13).At least 2 mm of distance, coronal to the bone,is required to prevent alveolar bone loss. Thesignificant esthetic changes in this case are evi-dent when the outline of the definitive restora-tions are superimposed over the pretreatmentdentition (Fig 14 a and 14b).

Acknowledgment

The authors are pleased to acknowledge theconsiderable surgical skills of Robert E. Lamb,DDS, MSD in the placement of the dentalimplants.

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Contact Addresses

Daniele CapoferriSwiss Dental Design

1291 East Hillsdale BoulevardSuite 142

Foster City, California 94404tele: 650-572-9866

email: swissdd@aol.com

Richard P. Kinsel, D.D.S.Assistant Clinical Professor

Department of Restorative DentistryBuchanan Dental Center

University of California, San FranciscoPrivate Practice:

1291 East Hillsdale Boulevardfoster City, California 94404

fax: 650-573-8280email: drcycle@aol.com

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