All-On-4TM Success Rates with Different Implant Systems€¦ · All-On-4TM Success Rates with Different Implant Systems. ... allows precision of osteotomy site preparation and less

The Journal of Implant & Advanced Clinical Dentistry

Volume 7, No. 5 may/JuNe 2015

Gunshot Wound Reconstruction with Iliac Crest Graft

All-On-4TM Success Rates with Different Implant Systems

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The Journal of Implant & Advanced Clinical Dentistry • 3

The Journal of Implant & Advanced Clinical DentistryVolume 7, No. 5 • may/JuNe 2015

Table of Contents

11 A Retrospective Analysis of Patients Treated with the All-On-4 Treatment Concept using a Variety of Different Dental Implant Systems Dan Holtzclaw, Nicholas Toscano, Joseph Yang

21 Mandibular Reconstruction and Full Arch Rehabilitation with Dental Implants Following a Gunshot Injury: A Clinical Report Luis Roberto Sanchez Garza, Brayann Oscar Aleman, Francisco José Carrillo Morales, Luis Roberto Sanchez Ramirez

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Table of Contents

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47 Current CAD/CAM Materials and Systems for All Ceramic Restorations: A Review of the Literature Christian Brenes, Ibrahim Duqum, Gustavo Mendoza, Lyndon Cooper

61 Biophysical Factors Affecting Bacterial Adhesion to Dental Implant Surfaces: A Focused Review Charles M. Cobb, Keerthana M. Satheesh, Mabel L. Salas, Simon R. MacNeill

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Tara Aghaloo, DDS, MDFaizan Alawi, DDSMichael Apa, DDSAlan M. Atlas, DMDCharles Babbush, DMD, MSThomas Balshi, DDSBarry Bartee, DDS, MDLorin Berland, DDSPeter Bertrand, DDSMichael Block, DMDChris Bonacci, DDS, MDHugo Bonilla, DDS, MSGary F. Bouloux, MD, DDSRonald Brown, DDS, MSBobby Butler, DDSNicholas Caplanis, DMD, MSDaniele Cardaropoli, DDSGiuseppe Cardaropoli DDS, PhDJohn Cavallaro, DDSJennifer Cha, DMD, MSLeon Chen, DMD, MSStepehn Chu, DMD, MSD David Clark, DDSCharles Cobb, DDS, PhDSpyridon Condos, DDSSally Cram, DDSTomell DeBose, DDSMassimo Del Fabbro, PhDDouglas Deporter, DDS, PhDAlex Ehrlich, DDS, MSNicolas Elian, DDSPaul Fugazzotto, DDSDavid Garber, DMDArun K. Garg, DMDRonald Goldstein, DDSDavid Guichet, DDSKenneth Hamlett, DDSIstvan Hargitai, DDS, MS

Michael Herndon, DDSRobert Horowitz, DDSMichael Huber, DDSRichard Hughes, DDSMiguel Angel Iglesia, DDSMian Iqbal, DMD, MSJames Jacobs, DMDZiad N. Jalbout, DDSJohn Johnson, DDS, MSSascha Jovanovic, DDS, MSJohn Kois, DMD, MSDJack T Krauser, DMDGregori Kurtzman, DDSBurton Langer, DMDAldo Leopardi, DDS, MSEdward Lowe, DMDMiles Madison, DDSLanka Mahesh, BDSCarlo Maiorana, MD, DDSJay Malmquist, DMDLouis Mandel, DDSMichael Martin, DDS, PhDZiv Mazor, DMDDale Miles, DDS, MSRobert Miller, DDSJohn Minichetti, DMDUwe Mohr, MDTDwight Moss, DMD, MSPeter K. Moy, DMDMel Mupparapu, DMDRoss Nash, DDSGregory Naylor, DDSMarcel Noujeim, DDS, MSSammy Noumbissi, DDS, MSCharles Orth, DDSAdriano Piattelli, MD, DDSMichael Pikos, DDSGeorge Priest, DMDGiulio Rasperini, DDS

Michele Ravenel, DMD, MSTerry Rees, DDSLaurence Rifkin, DDSGeorgios E. Romanos, DDS, PhDPaul Rosen, DMD, MSJoel Rosenlicht, DMDLarry Rosenthal, DDSSteven Roser, DMD, MDSalvatore Ruggiero, DMD, MDHenry Salama, DMDMaurice Salama, DMDAnthony Sclar, DMDFrank Setzer, DDSMaurizio Silvestri, DDS, MDDennis Smiler, DDS, MScDDong-Seok Sohn, DDS, PhDMuna Soltan, DDSMichael Sonick, DMDAhmad Soolari, DMDNeil L. Starr, DDSEric Stoopler, DMDScott Synnott, DMDHaim Tal, DMD, PhDGregory Tarantola, DDSDennis Tarnow, DDSGeza Terezhalmy, DDS, MATiziano Testori, MD, DDSMichael Tischler, DDSTolga Tozum, DDS, PhDLeonardo Trombelli, DDS, PhDIlser Turkyilmaz, DDS, PhDDean Vafiadis, DDSEmil Verban, DDSHom-Lay Wang, DDS, PhDBenjamin O. Watkins, III, DDSAlan Winter, DDSGlenn Wolfinger, DDSRichard K. Yoon, DDS

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Founder, Co-Editor in ChiefDan Holtzclaw, DDS, MS

Co-Editor in ChiefNick Huang, MD


Holtzclaw et al

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Holtzclaw et al

Introduction: To date, no study has com-pared success rates between different dental implant systems when utilized for the All-On-4 treatment concept. The aim of this retrospec-tive analysis is to evaluate the outcomes of patients treated with the All-On-4 concept using a variety of dental implant systems.

Materials and Methods: A retrospective chart review encompassing the dates July 2009 to January 2015 was performed in three private peri-odontal offices to assess the results of patients treated with the All-On-4 treatment concept.

Discussion: A total of 384 arches were treated, utilizing 1,704 dental implants from 4 different dental implant systems in 289 patients. Cumu-lative dental implant survival rate was 99.00% with an overall prosthetic survival rate of 100%.

Conclusion: The All-On-4 treatment con-cept allows for predictable immediate full arch function and can be accomplished with a variety of dental implant systems.

A Retrospective Analysis of Patients Treated with the All-On-4 Treatment Concept using a Variety of Different Dental Implant Systems

Dan Holtzclaw, DDS, MS1 • Nicholas Toscano, DDS, MS2 Joseph Yang, DDS, MS3

1. Consultant Faculty at US Navy Postgraduate Dental School, Department of Periodontics, Bethesda, Maryland, USA. Private Practice, Round Rock, Texas, USA.

2. Private Practice, New York, New York, USA.

3. Private Practice, San Diego, California, USA

Abstract

KEY WORDS: Dental implants, all-on-4, survival rate, immediate load


12 • Vol. 7, No. 5 • May/June 2015

INTRODUCTIONThe All-on-4 treatment concept involves restor-ing an arch with at least 4 dental implants, the distal of which are tilted up to 45 degrees, and immediately loading the transitional prosthesis.1 This concept was originally documented over 10 years ago as an immediately loaded treat-ment option for resorbed mandibles that could not be treated in the traditional manner.2 Biome-chanically, tilting the posterior dental implants offers a number of benefits over axially inclined implants including increased anterior-poste-rior spread, reduction of prosthetic cantilever length, and increased bone-to-implant contact.3

Anatomically, benefits of tilted implants include avoidance of the inferior alveolar nerve and mental foramen bundle,4 elimination of the need for maxillary sinus augmentation,5 elimination of bone grafting procedures,6 and improved implant anchorage in dense anterior alveolar bone.6,7 A number of articles have documented the success of the All-on-4 treatment concept and full-arch immediately loaded implant con-cepts in both the mandible and the maxilla using a variety of dental implant systems includ-ing Astra Tech,8 Biohorizons,9 Straumann,10

and BioMet 3i.11-14 Most studies document-ing the success of the All-On-4 treatment con-cept, however, have focused on Nobel Biocare dental implant systems.1,2,4-7,15-23 Each dental implant system has specific design features that may or may not make them ideally suited for the unique idiosyncrasies associated with the All-On-4 treatment concept. Addition-ally, the restorative components associated with these dental implant systems differ sig-nificantly. To date, there is no known study that compares different dental implant sys-

tems for use with the All-On-4 treatment con-cept. The goal of retrospective observational study, therefore, is to document success rates and ease of restoration for the All-on-4 treat-ment concept in both the mandible and maxilla when utilizing a variety of dental implant sys-tems in the hands of experienced clinicians.

MATERIALS AND METHODSA retrospective chart review was performed for all patients treated in private periodontal practices (DH in Texas, NT in New York, and JY in California) between July 2009 and Janu-ary 2015 with the All-On-4 treatment concept. As this was a retrospective chart review, there were no exclusion criteria. All patients in each practice were treated in a similar fashion. Prior to surgery, medical histories were obtained and clinical/radiographic examinations were performed. One day prior to surgery, patients were instructed to begin antibiotic treatment with Amoxicillin 500mg three times per day, which would then continue for an additional nine days after surgery. On the day of sur-gery, patients were consented for treatment and then received local anesthesia in the con-ventional fashion in addition to intravenous sedation unless medically contraindicated. Full thickness flaps were elevated in the standard fashion. If dentate, all teeth were extracted and extractions sockets degranulated. Bone reduction was then performed with a high speed surgical drill (Osteomed, Addison, Texas) under irrigation. The amount of bone reduc-tion was determined by utilization of clear sur-gical stents or bone reduction rulers to create at least 12mm or vertical restorative space.

The surgical phase of treatment was similar

Holtzclaw et al


for both the maxilla and mandible. In the max-illa, minor access to the maxillary sinus was obtained through the lateral sinus wall and a periodontal probe was inserted to locate the mesial extent of the sinus cavity. Care was taken to avoid perforation of the Schneiderian membrane. After locating the anterior wall of the maxillary sinus, posterior dental implant osteotomies were performed with all sites being underprepared and angled to accom-modate the anterior sinus wall. Osteotomy underpreparation was performed to improve the chance of obtaining higher torque val-ues during dental implant placement. Tilted posterior dental implant placement typically occurred in the location of the first or second premolar. The mesial angulation of the poste-rior tilted dental implants usually resulted in subcrestal submergence of the distal aspect of the implant platform. Accordingly, high speed hand pieces and hand instruments were used to reshape this bone to allow full access to the dental implant platform. Anteriorly located dental implants were then placed in an axial

fashion, typically in the area of the lateral inci-sor with care being taken to avoid perforation of the nasal cavity. Dental implants placed in the maxilla routinely achieved torque values of 32-75 Ncm. In select cases with individual dental implant torque values less than 32 Ncm, additional dental implants were placed adjacent to the low torque implant. Following the place-ment of all maxillary dental implants, straight or angulated multi-unit abutments were secured to each dental implant according to manufac-turer’s directions, typically with torque values of 15 Ncm. When placing multi-unit abutments, transitional prostheses with restorative access windows were placed to evaluate transitional coping access points. Screw access holes were always placed palatally to the teeth in the anterior region and in the occlusal surface or slightly palatal in the posterior region. Follow-ing the placement of multiunit abutments with proper angulation, healing caps were secured to the abutments and the mucogingival flaps were recontoured with scalpels and biopsy punches to reduce bulk and allow for better tis-

Figure 1: Maxillary All-On-4 patient prior to treatment. Figure 2: Maxillary All-On-4 patient with transitional restoration.

Holtzclaw et al

14 • Vol. 7, No. 5 • May/June 2015

sue adaptation around the multi-unit abutments. Prior to flap replacement and suturing with resorbable 4-0 chromic gut suture, exposed dental implant threads and residual extraction sockets were grafted with a combination of mineralized/demineralized bone allograft (Maxx-eus, Community Tissue Services, Dayton OH).

Surgical treatment in the mandible was sim-ilar to that of the maxilla with a few minor differ-ences. In the mandible, the mental foramen was visually identified and dental implants were placed at a 45° angle posteriorly. As in the maxilla, all dental implants were placed to achieve torque values of at least 32 Ncm. Mucogingival tissue recontouring in the mandible was typically less involved than that of the maxilla due to the fact that mandibular mucogingival tissue is less bulky and less keratinized than its maxillary counterpart.

Upon completion of all surgeries, immedi-ate chairside conversion of provisional pros-theses was achieved (Figs. 1, 2). Healing caps were removed and multi-unit transitional posts were hand tightened on the multi-unit abutments. Custom premade conventional dentures were adjusted to allow the multi-unit transitional posts to cleanly exit in occlusal or lingual positions. Rubber dam material was placed around all tran-sitional posts and hand mixed acrylic was injected between the restorations and the posts. Once the acrylic was set to a hard consistency, the tran-sitional restoration was removed by unscrewing the transitional posts. Healing caps were then replaced onto the multi-unit abutments and the transitional restoration was refined to completion, typically within two hours. All transitional restora-tions were torqued onto the multi-unit abutments at 15 Ncm and screw access holes were filled with Teflon tape and sealed with light cured flow-

able composite. Occlusion was verified with bilat-eral balanced posterior contacts and light anterior contacts prior to the dismissal of each patient.

Post-surgically, patients were provided with ibuprofen 800mg and tramadol 50mg for pain control. Patients also continued their antibiotic therapy in addition to taking a methylpredniso-lone dose pack. Follow-up visits were typically performed at 7, 14, 42, and 90 days after surgery. Between 3 to 4 months after the initial surgery, patients began the final prosthetic phase of treat-ment. The transitional prostheses were removed and all multi-unit abutments were retorqued to 15 Ncm. In the event that multi-unit abutment plat-forms were obscured with excess gingival tis-sue, a diode laser (Biolase, Irvine, California) was utilized to fully expose the platform edges. Final restorations (Fig. 3) were then fabricated with either hybrid milled titanium frames wrapped in acrylic or full zirconia and were delivered, on average, between 6 to 7 months after the ini-tial surgery. Following final prosthesis delivery, patients were seen yearly for clinical exams, pros-thesis prophylaxis, and radiographic evaluation.

Dental implant survival was graded accord-ing to the Malo Clinic survival criteria1: 1) the implant fulfilled its purported function as sup-port for reconstruction; 2) the implant was sta-ble when individually and manually tested; 3) no signs of infection were observed around the implant; 4) no radiolucent areas were observed around the implant; 5) the implant demon-strated good esthetic outcome of rehabilitation; 6) the implant allowed for construction of the implant supported fixed prosthesis, which pro-vided patient comfort and good hygiene main-tenance. Dental implants that were removed for any reason at any time were considered failures.

Holtzclaw et al


DISCUSSIONTwo hundred eighty nine patients (167 females and 122 males) with a mean age of 63.53 years (range 31-87) were included in this retrospective observational study which had follow up times ranging from 12-39 months in function. A total of 1,704 dental implants were utilized to restore 222 maxillae and 182 mandibles with 327 arches being dentate and 77 edentulous. A total of 17 dental implants failed producing a cumulative den-tal implant survival rate of 99.00%. All implant failures occurred in the transitional prosthesis phase of treatment and none compromised the final restoration resulting in a prostheses sur-vival rate of 100%. The most common complica-tion encountered during treatment was fracture of the transitional restoration which occurred in 33 arches. The various dental implant systems utilized in this retrospective observational study and their respective performances are listed in Table 1. Of the patients included in this study, 93.08% were treated with Nobel Biocare (Yorba Linda, California) dental implants, 3.81% were treated with MIS (Fair Lawn, New Jersey) den-

tal implants, 2.08% were treated with Zimmer (Carlsbad, California) dental implants, and 1.03% were treated with Biomet 3i (Palm Beach Gar-dens, Florida) dental implants. Of the 17 dental implant failures reported in this study, all occurred with Nobel Biocare dental implants. Although no failures were seen with MIS, Biomet 3i, and Zimmer implants, the number of these implants used in this study was very small compared to the number of Nobel Biocare implants. Addi-tionally, Nobel Biocare dental implants were uti-lized in much more challenging cases than the other implant systems. Overall dental implant survival rates were comparable between systems with Nobel Biocare achieving a 98.95% survival rate and all other brands achieving a 100% suc-cess rate. If comparable numbers of implants were used for all brands mentioned in this study, it is likely that all would produce similar results.

While all brands of dental implants used in this study produced comparable statistical results, a number of intangible factors should be men-tioned. First and foremost, each dental implant system used in this study has uniquely different

Table 1: Implant Systems Data

# Patients # Arches # Implants # Implants # Prosthesis Implant System Treated Treated Placed Failures Failures

Nobel Biocare 269 384 1,624 17 0

MIS 11 11 44 0 0

Zimmer 6 6 24 0 0

Biomet-3i 3 3 12 0 0

Total 289 404 1,704 17 0

Holtzclaw et al

16 • Vol. 7, No. 5 • May/June 2015

Figure 3: Maxillary All-On-4 patient with final restoration. Figure 4: Multi-unit abutments with screwed long handle metal attachments.

properties. Concerning treating patients with the All-On-4 treatment concept, certain dental implant design characteristics proved to be very important. Average torque values achieved in this study were 53.67 Ncm which is substantially higher than that reported in many other dental implant studies.24,25 To achieve such high torque values, the authors routinely underprepared den-tal implant osteotomy sites. In such instances, the use of aggressive, self-tapping, end cutting den-tal implants was extremely beneficial. Particular dental implant systems proved to be more reli-able and easier to use in this regard compared to other implant systems. In fact, the lack of aggres-sive end cutting ability with some implant systems resulted in some implants failing to achieve full placement depth. In such cases, the implant oste-otomy sites had to be widened with larger drills causing a loss in placement torque. Such a loss in torque had the potential to compromise the ability to immediately load the transitional pros-thesis, although this did not happen with any of the cases in this study. A second important factor found to differ between systems was the angled

multi-unit abutments, with some being much eas-ier to use than others. The multi-unit abutments for one particular dental implant system came with a long metallic handle that is screwed into place (Fig. 4) while a different system utilized a shorter metallic handle which was also screwed in place (Fig. 5). Conversely, the multi-unit abutments for another system utilized plastic handles that were snapped onto the abutment (Fig. 6). In addition to providing ease of handling, the multi-unit abut-ment handles are a valuable tool for determining path of insertion for screw access. The authors found that the longer, screwed, metallic handles were much easier to use and more reliable than other types of multi-unit abutment handles. A third and final factor that differed between sys-tems was the multi-unit abutment temporary heal-ing caps, with some systems using plastic caps (Fig. 7) while others utilized metallic caps (Fig. 8). When recontouring gingival tissue prior to final primary closure, the authors frequently used biopsy punches to quickly and accurately trim around abutments. In cases where the metal healing caps were utilized, the biopsy punches

Holtzclaw et al


Figure 5: Multi-unit abutments with screwed short handle metal attachments.

Figure 6: Multi-unit abutment with plastic snap on attachment.

Figure 7: White healing caps secured to multi-unit abutments following suture closure.

Figure 8: Metal healing caps secured to multi-unit abutments following suture closure.

would quickly dull due to friction between the metal components and often had to be replaced.

CONCLUSIONThis is the first known study to compare the results of different dental implant systems for the All-On-4 treatment concept. Within the limita-tions of this study, it can be concluded that the All-On-4 treatment concept produces high suc-cess rates for both dental implants and pros-theses no matter what brand of dental implant

is used. While all dental implant systems pro-duced comparable results, some systems and their respective components proved easier to use than others for the clinicians in this study. ●

Correspondence and reprint requestsDan Holtzclaw, DDS, MS4010 Sandy Brook Dr., Suite 204Round Rock, TX 78665Tele: 512-375-0050 e-mail: [email protected]

Holtzclaw et al

18 • Vol. 7, No. 5 • May/June 2015

Disclosure:The authors claim to have no financial interests, either directly or indirectly, in the products or information listed in this article.

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13. Testori T, Del Fabbro M, Capelli M, et al. Imme-diate occlusal loading and tilted implants for the rehabilitation of the atrophic edentulous maxilla: 1-year interim results of a multicenter prospective study. Clin Oral Implants Res 2008;19:227-32.

14. Boyse B, Sullivan S. Implant placement and im-mediate provisional restoration of edentulous arches: A case presentation. J Implant Recon-struc Dent 2011;2:1-5.

15. Pomares C. A retrospective clinical study of edentulous patients rehabilitated according to the ‘all on four’ or the ‘all on six’ immediate func-tion concept. Eur J Oral Implantol 2009;2:55-60.

16. Agliardi E, Clericò M, Ciancio P, Massironi D. Immediate loading of full-arch fixed prostheses supported by axial and tilted implants for the treatment of edentulous atrophic mandibles. Quintessence Int 2010;41:285-93.

17. Babbush CA, Kutsko GT, Brokloff J. The all-on-four immediate function treatment concept with NobelActive implants: a retrospective study. J Oral Implantol 2011;37:431-45.

18. Malo P, de Araújo Nobre M, Lopes A, et al. A lon-gitudinal study of the survival of All-on-4 implants in the mandible with up to 10 years of follow-up. J Am Dent Assoc 2011;142:310-20.

19. Maló P, de Araújo Nobre M, Lopes A, et al. “All-on-4” immediate-function concept for completely edentulous maxillae: a clinical report on the me-dium (3 years) and long-term (5 years) outcomes. Clin Implant Dent Relat Res 2012;14:139-50.

20. Maló P, de Araújo Nobre M. Partial rehabilitation of the posterior edentulous maxilla using axial and tilted implants in immediate function to avoid bone grafting. Compend Contin Educ Dent 2011;32:136-45.

21. Maló P, Nobre MD, Lopes A. The rehabilitation of completely edentulous maxillae with different de-grees of resorption with four or more immediately loaded implants: a 5-year retrospective study and a new classification. Eur J Oral Implantol 2011;4:227-43.

22. Malo P, Nobre Mde A, Lopes A. Immediate reha-bilitation of completely edentulous arches with a four-implant prosthesis concept in difficult condi-tions: an open cohort study with a mean follow-up of 2 years. Int J Oral Maxillofac Implants 2012;27:1177-90.

23. Agliardi E, Panigatti S, Clericò M, Villa C, Malò P. Immediate rehabilitation of the edentulous jaws with full fixed prostheses supported by four implants: interim results of a single co-hort prospective study. Clin Oral Implants Res 2010;21:459-65.

24. Salimov F, Tatli U, Kürkçü M, et al. Evaluation of relationship between preoperative bone density values derived from cone beam computed tomog-raphy and implant stability parameters: a clinical study. Clin Oral Implants Res 2014;25:1016-21.

25. Tadi DP, Pinisetti S, Gujjalapudi M, et al. Evalu-ation of initial stability and crestal bone loss in immediate implant placement: An in vivo study. J Int Soc Prev Community Dent 2014;4:139-44.

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The Journal of Implant & Advanced Clinical Dentistry • XX

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Background: Management of gunshot inju-ries to the face led in many ways to the development of modern maxillofacial sur-gery, and it remains a cornerstone of the specialty of oral and maxillofacial surgery.Bone grafts are frequently required in the man-agement of Gunshot wounds to the face, whether for replacement of true loss of bone or in cases in which comminuted and misplaced fragments need to be replaced or reinforced. Insertion of osseointegrated dental implants several months after mandibular reconstruc-tion using bone grafts has proved to be a suc-cessful method to achieve mastication and complete oral rehabilitation. The successful restoration of patients with dental implants can result in a change in dental function and health.

Methods: This paper presents a 43-year-old female who suffered gunshot wound to the

anterior mandible, with reconstruction of the resultant bony defect with Iliac Crest Bone Graft and Implant-supported fixed prosthesis.

Results: Reparative, reconstructive and reha-bilitation procedures have achieved in a high amount and quantity, the stability and sym-metry of facial soft tissues, phonetics, swal-lowing and chewing of the patient, therefore, psychological health, allowing to the patient get back to her social and occupational activities with much more self-confidence.

Conclusion: Improvement in the management of gunshot wounds to the face has paralleled the advancement of oral and maxillofacial surgery.Oral implantology is the treatment of choice not only for the restoration of missing teeth, other-wise the return of functional and aesthetic param-eters allowing patients to their social reintegration.

Mandibular Reconstruction and Full Arch Rehabilitation with Dental Implants Following a

Gunshot Injury: A Clinical Report

Luis Roberto Sanchez Garza, MCD1 Brayann Oscar Aleman, CD2 • Francisco José Carrillo Morales, CD3

Luis Roberto Sanchez Ramirez, DDS4

1. Oral and Maxillofacial Surgeon, Department of Oral and Maxillofacial Surgery ISSSTE Monterrey, Nuevo León, México; Private Practice Monterrey, Nuevo León, Mexico

2. Private Practice Monterrey



Abstract

KEY WORDS: Gun shot wound, dental implants, iliac crest, prosthodontics, oral surgery


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INTRODUCTIONThe potential problems of a wound caused by a projectile can be better anticipated if one has some knowledge of the weapon and projec-tile type that caused the wound. Gugala and Lindsey suggested a civilian gunshot injury clas-sification scheme. It takes into account energy (high or low), involvement of vital structures (neural and vascular), wound type (non- pen-etrating, penetrating, perforating), fracture (intra-articular and extra-articular), and con-tamination.1 Gunshot wounds involving the face may be associated with an entrance or exit wound in the neck, which is divided into three zones originally described by Monson and colleagues from Cook County Hospital.1,2

Zone I is most commonly defined as the area from the clavicles to the cricoid cartilage. It contains the inferior aspect of the trachea and esophagus along with the major vessels of the thoracic inlet: the common carotid arteries, thy-rocervical trunk, internal jugular veins, brachio-cephalic trunk, subclavian arteries and veins, thoracic duct, thyroid gland, and spinal cord. Zone II represents the area from the cricoid car-tilage to the angle of the mandible. It contains the common carotid arteries, internal and exter-nal carotid arteries, internal jugular veins, larynx, hypopharynx, and cranial nerves X, XI, and XII. It is the largest area and therefore the most com-monly involved zone in penetrating neck trauma.

Zone III spans the region from the skull base to the angle of the mandible. It contains the carotid arteries, the internal jugular veins, and the pharynx along with multiple cranial nerves exit-ing the skull base. It should be appreciated that gunshot wounds that involve mandibular frac-tures are accompanied by injuries to Zone III.

The development of rigid fixation tech-niques and their application to GSWs was an important advance. By allowing the early sta-bilization of bone segments, percolation of contaminated oral fluids was prevented, pri-mary bone healing was made possible, and the effects of scar contracture were minimized.1

The surgeon facing a gunshot injury should consider the concept introduced by Manson for evaluation of four compo-nents: soft tissue injury, bone injury, soft tis-sues loss (true avulsion), and bone loss.3,1

Teeth should be maintained if possible to aid in restoration of occlusion and proper jaw relations. Earlier repair leads to improved out-comes with less scar contracture and resul-tant deformity. Bone grafts at the time of initial surgery may be indicated in the midface1

Advocates of delayed repair point to a higher incidence of infection and to benefits of closed treatment, whereas those advocating more aggressive management report improved func-tional and aesthetic outcomes.4,5,1 The main disadvantage of open reduction is infection, which primarily affects the mandible.6,1 Bone grafts are frequently required in the manage-ment of GSWs to the face, whether for replace-ment of true loss of bone (avulsive injuries) or in cases in which comminuted.These are frac-tures that exhibit multiple fragmentation of the bone at one fracture site. These are usually the result of greater forces than would normally be encountered in simple fractures.and misplaced fragments need to be replaced or reinforced.1,9 Gruss and colleagues have published exten-sively on their success with early bone graft-ing to stabilize and support soft tissues, and to decrease scar contracture and distortion.7,1


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Most agree, however, that delayed grafting of discontinuity defects of the mandible is still indi-cated because of the high risk of exposure and loss of bone grafts in this site, and that immedi-ate grafting in the mandible should be avoided.8,4,1 Maintenance of mandibular segments with rigid reconstruction plates combined with delayed grafting or free flap reconstruction offers a pre-dictable result, and in most cases primary graft-ing of the mandible is not indicated. Delayed bone reconstructions frequently suffer from a scarred hypovascular environment that does not support the graft. Vascularized bone grafts can support osseointegrated implants to complete the reconstruction.1 The goals of therapy9 are: 1) Obtain stable occlusion; 2) Restore interincisal opening and mandibular excursive movements; 3) Establish a full range of mandibular excursive movements; 4) Minimize deviation of the man-dible; 5) Produce a pain-free articular appara-tus at rest and during function; 6) Avoid internal derangement of the temporomandibular joint on the injured or the contralateral side; 7) Avoid the long-term complication of growth disturbance.

The goals of reconstruction under the afore-mentioned conditions are to provide morphology and position of the bone in relation to its opposing jaw, provide adequate height and width of bone, restore continuity of the mandible and maxilla, and provide facial contour and support for soft tissue structures.10, 11,12 The body of the mandible is probably the most complex area of the mandible to reconstruct for several reasons. It has a complex curved shape that makes reconstruction difficult, it is along the lever of the mandible and has the highest loads placed on it, it contains a sensory nerve that is prone to injury, and it is the site of attachment of a complex array of muscles.10,11,12,13

The first step in reconstruction is to classify the defect determined by its size, location, and functional or cosmetic impairment.10,14,15 The use of osseointegrated dental implants is an impor-tant technique for the oral rehabilitation of these patients. Osseointegrated implants provide the most rigid prosthetic stabilization available to withstand masticatory forces.16 Branemark & Lindstrom used implants with free bone grafts. Riediger was the first to place them in an iliac crest flap.16 The incorporation of osseointe-grated implantology in the oromandibular reha-bilitation of oncological head and neck patients has improved aesthetic and functional results spectacularly.16,17,18,19 When deciding if reha-bilitation should include a fixed prosthesis or a removable prosthesis, a series of factors should be analyzed: 1) Number and position of implants; 2) Occlusal space; 3) Antagonist arch; 4) TMJ function; 5) Labial or lingual hypoesthe-sia; 6) Patient’s attitude to prosthetic hygiene.

METHODSA 43 year old female patient presented with a reference sheet to the Department of Oral and Maxillofacial Surgery, Hospital Clinic ISSSTE Monterrey, Nuevo Leon, for the assessment of the gunshot wound. The reference sheet indicated that the patient was taken by the paramedics to the emergency department approximately 2 hours after the shooting, where ATLS protocol was applied, the patient was admitted to the intensive care for 15 days and a maxillomandibular fixa-tion with Erich Arch Bars was made for the stabi-lization of the bone segments. When the patient was stabilized, she revealed that the gun was a revolver which was shot at a distance of about 10cm with the projectile entry into the mouth

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symphysis region and exit on the left subman-dibular region. In the clinical extraoral evaluation, the object of the observation is the scar gunshot wound in zone II associated with mandibular frac-ture as rated by Monson and colleagues, with the presence of deformity of the lower lip, ecchymo-sis, submental edema. Intraorally loss of multiple dental organs, trismus, generalized chronic peri-odontitis, tooth mobility grade II and III is being obseved, as well as pain and crepitus on palpa-tion in the left mandibular. AP cervical radiogra-phy and chest rule out the presence of foreign bodies. Is important to point out that, once the missiles were introduced into the tissues, they rarely follow a straight path. In the panoramic radiograph the comminuted fracture covering symphysis region, parasymphyseal and left man-dibular body is observed (figure 1). Surgical pro-tocol studies were required, which are evaluated by determining internal medicine patient ASA I.

TREATMENT PLANOpen reduction and fixation of viable bone fragments with titanium plates and screws; placement of reconstruction plate; removal of nonviable bone fragments.

● Deferred mandibular bone reconstruction with corticocancellous graft anterior iliac crest

● Removal of dental organs with poor prognosis and placement of the endosseous biphasic dental implants.

● Discovery of the placement of dental implants and placement of healing abutments.

● Oral Rehabilitation with endosseous dental implants and implant-supported fixed pros-thesis of precious-porcelain metal.

Phase 1 - Bone Reduction and Fixation of Bone FragmentsPatient is placed under general anesthesia with balanced nasotracheal intubation, prior asep-tic surgical bed with 10% povidone-iodine supine; anesthetic lidocaine 2% with epineph-rine 1:100,000 in submental and submandibular left region; an incision of about 8 cm in length is performed with a Nº 15 scalpel blade with sub-sequent dissection planes (figures 2-6). Once addressed, nonviable fragments are removed from the fracture zone, and the bone is modeled for better consolidation of the bone segments, viable fragments are reduced with 2 straight tita-nium mini-plates of 2mm system which are fixed with Monocortical titanium screws of 2.0 x 7mm. Once fragments are reduced, a 10 hole recon-struction bar is preformed and molded, and attached to the bone fragments with titanium bicortical screws of the 2.7mm x 11 mm system. Mouth floor muscles are sutured to the locking bar using simple nylon 1-0 points to prevent muscle breakdown with its subsequent closure plans. Intradermal closure is performed with 4-0 Vicryl maximizing the aesthetics of the wound closure. Semi-rigid inter-maxillary fixation is placed with 4 screws of inter-maxillary fixation of 2.0 x 9mm

Figure 1: Pre-op panoramic radiograph.


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system, two located in the buccal apical region to the upper lateral incisors and two in the symphy-sis apical area to the remaining teeth, anchored with wire. It was decided to preserve the inter-maxillary fixation with Erich Arch Bars to preserve existing occlusion parameters (figures 7-20). The postoperative OPG shows a stable occlusion, appropriate reduction of mandibular bone frag-

ments, and a correct relationship of temporo-mandibular complex (figure 21). After 21 days inter-maxillary fixation is removed and a stable presence of trismus occlusion is observed, so soft diet, physical therapy, exercises of mouth open-ing and oral hygiene techniques are indicated. 24 hours after the removal of the FIM, the patient’s occlusion is evaluated, showing good stability.

Figure 2: Pre-op submandibular view. Figure 3: Submandibular incision from midline to the posterior aspect of the gonial area, 2 cm below the inferior mandibular edge.

Figure 4: Blunt dissection minimizing risk of vascular injury.

Figure 5: Facial artery ligated.

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Phase 2 - Deferred Mandibular Bone Reconstruction with Anterior Iliac Crest Corticocancellous GraftFive months after the reduction of mandibu-lar bone fragments, we proceed to the recon-struction of the bone defect by the anterior corticocancellous graft anterior iliac crest, so

that once established such graft would be fea-sible for the rehabilitation of the oral cavity to return functional and aesthetic parameters.

Autologous grafts of anterior iliac crest, offer a greater volume of bone progenitor cells, capa-ble of creating a more favorable environment for the consolidation of the new bone. Mandibu-

Figure 6: Bone segments located and bony fragments removal.

Figure 7: Bone reduction with titanium straight 2.0mm miniplates and 2.0 x 7mm monocortical screws.




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lar reconstruction is performed simultaneously by the trauma and maxillofacial surgery team, wherein the first addresses the ilium obtaining the bone graft, and the second addresses the mandibular region affected for its reconstruc-tion. After obtaining the graft, maxillofacial sur-gery team models, adapts, and sets the graft to

the reconstruction plate with bicortical screws of 2.7 x 13mm system. Autologous fibrin clot and bovine bone Geistlich Bio-Oss® (Pharma AG CH-6110 Wolhusen Suiza) of slow rese-ption are placed to accelerate the bone heal-ing (figures 22-50). Drenovac (Dimeja S.A. de C.V.®, Tepatitlán de Morelos, Jalisco) is a system




Figure 13: Presentation and fixation of locking reconstruction plate with bicortical screws.

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used for postoperative drainage, followed by suture closure plans and intradermal 4-0 Vicryl suture (figures 51-52). Semi-rigid inter-maxil-lary fixation is placed with 4 screws of intermax-illary fixation of 2.0 x 9mm system, two located in the buccal apical region to the upper lateral incisors and two in the symphysis apical area to

the remaining teeth, anchored with wire. After 10 days of control a satisfactory observa-tion is being observed, the wound is aes-thetically acceptable, inter-maxillary fixation is removed and it was decided to wait for the consolidation of the graft through a course of six months (figures 53-58).


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Figure 18: Placement of four inter-maxillary fixation screws (2.0 x 9mm system), two in the upper jaw and two in the lower jaw anchored with osteosynthesis wire.



Figure 21: Post-Op panoramic radiograph.

Phase 3- Removal of Dental Organs with Poor Prognosis and Placement of the Endosseous Biphasic Dental ImplantsIt is essential to do the CBCT study for the implant position planning. With the radiographic guide in the position and visualization software 3D of the images, we evaluated the fol-

lowing essential aspects of implant place-ment: 1) Quantity of the bone; 2) Quality of the bone; 3) Number of implants; 4) Position of the implants in the arch; 5) Diam-eter of the implants; 6) Depth of the implants

Once these data were done and analyzed, we found quality and suitable bone quantity so

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Figure 22: Cortico-cancellous bone graft harvested from the ilium.

Figure 23: Ilium aspect after bone graft harvest.

Figure 24: Submandibular incision in the same place done before for the mandibular fracture reduction.

Figure 25: Sharp dissection of the skin layer and blunt dissection of the deepest layers.

it was decided to perform the placement of six dental implants Certain (Biomet Inc. Warsaw, Indiana) biphasic endorsements to complete the rehabilitation of the lower arch in the areas of dental bodies (FDI Tooth Numbering Sys-tem) 46 of 4 x 10mm, O.D 44 x 13mm, 4, OD 42 4 x 13mm, OD 32 4 x 13mm, OD 34 4 x 13mm and OD 36 4 x 11mm (figures 59-65).

Under local anesthesia with 2% mepivacaine and epinephrine 1: 100,000, incision was made on alveolar ridge, rising mucoperiostic flap, pre-fabricated surgical guide is positioned and oste-otomies are made to indicate the position of the implants; deep osteotomies was made and par-allel pin and periapical radiographs are taken to evaluate their position. Once the desired par-


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Figure 26: Exposition of the bone defect taking care no perforate the intraoral mucosa.

Figure 27: Preparation of the mandibular bone edges, drilling small holes encouraging bone bleeding.

Figure 28: Preparation of the mandibular bone edges, drilling small holes encouraging bone bleeding.

Figure 29: Preformation of bone graft with a low-speed handpiece and constant irrigation.

allelism was obtained, we continued with the sequential osteotomies according to manufac-turer’s indications to the diameter of 4mm in the corresponding area, getting the implant place-ment with an adequate insertion torque and settle-ment to achieve primary stability. Wound closure with single point interrupted 3-0 silk sutures.

Ten days after the surgery, the clinical out-

come is satisfactory, so suture material is removed and the control appointment was made one week after showing complete closure of the wound.

Once the total wound healing was achieved, removable prosthesis is posi-tioned to return it to the possible, the peri-oral tissue support and as well as the phonetic and masticatory functionality (figure 66).

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Figure 30: Appearance of the bone graft in the defect, showing good fitting and continuity with smooth edges.




Phase 4 - Discovery of the dental Implants and Placement of Healing AbutmentsThree months after placement, implants located in the area of 42 and 32 were observed, so it was not necessary to perform any surgi-cal maneuver in these areas, however, in implants remaining total gingival epithelial keratinized tissue coverage so infiltrative sur-

gical procedure under local anesthesia was performed. The position of the implants are located and incisions are made, rising full thick-ness flap, and healing abutments placed.

Simple interrupted suture points were place with 3/0 silk retiring them 10 days after the event with good performance and satisfactory insertion of peri-implant keratinized tissue. (photo 67-70)


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Figure 38: Bone graft fixation to the reconstruction plate with bicortical screws.




Oral Rehabilitation with Implant-Supported Fixed ProsthesisThree weeks after the discovery of den-tal implants, we decided to start with the rehabilitation treatment.

Impression posts are placed with a base of 4mm and 5mm on emergence profiles, and total and passive seating is verified by

periapical radiographs. Impression is taken with type A silicone of the brand Hydrox-treme (Coltene® Feldwiesenstrasse Switzer-land) heavy and light body by drag technique, obtaining working model for the production of a PFM fixed prosthesis implant-supported.

Due to extensive restoration, was decided to conduct two separate structures, which


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Figure 42 : Bone graft fixation to the reconstruction plate with bicortical screws.




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Figure 46: Placement of PRGF in the interphase of bone graft and mandibular bone.




range from the situation of the organ 3.6 to 3.1 and the other from the organ 4.1 to 4.6. Cus-tom temporary abutments are manufactured from GingiHue® Abutment (Biomet Inc. War-saw, Indiana) designed with the emergence profile dimensions that allow a more natural appearance of the final restoration (photo 71-73).

A design wax-up of the fixed prosthesis is created, which will give the base for the restora-tion, these are tested before and after the metal is created and it is finalized over the abutments.

Once a tight seal and a liability settlement of the structures are done, porcelain layering tech-nique is applied to improve aesthetics of the final


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Figure 51: Suture of the wound by layers with Vycril 4/0.

Figure 52: Final suture by intradermal technique, allowing a better scar appearance in the future and Drenovac placement to reduce the post-op edema.

Figure 53: Post-op panoramic radiograph were we evaluate the bone graft position.

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Figure 54: 10 days post-op extraoral photos, showing a little edema, nice scar and healing evolution.




result (figures 74-75). When the manufacture or the restauration are completed , we take them to the mouth to verify the stability, occlusion and esthetic appearance, ones all of these is verified we cement the restorations with Glass Ionomer

(figures 76-80). The control panoramic radio-graph after oral rehabilitation shows bone stability in the peri-implant area and fracture lines as well as continuity and sustainability of cortico-travecu-lar bone block graft of the iliac crest (figure 81).


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Figure 58: 10 days post-op intraoral photo, that indicate nice occlusion, in this day we decide to remove inter-maxillary fixation, allowing to the patient start with physiotherapy.

Figure 59: Panoramic radiograph taken with the surgical guide with barium sulphate teeth, showing the right position where the implants should be placed.

Figure 60: Meticulous evaluation of the CBCT, measuring the quantity and quality of the bone, distance to the alveolar nerve, planning thus the position, profundity, angulation and quantity of the dental implants to be placed.


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Figure 66: Panoramic radiograph after the dental implants placement, showing a good disposition and parallelism.

Figure 67: Appearance of second phase healing screws after three weeks of their uncover, exhibiting adequate keratinized tissue.



RESULTSReparative, reconstructive and rehabilitation pro-cedures have achieved in a high amount and quantity, the stability and symmetry of de facial soft tissues, phonetics, swallowing and chewing of the patient, therefore, psychological health, allowing

to the patient get back to her social and occupa-tional activities with much more self-confidence. The patient is going annually to maintenance appointments where prophylaxis, periodontal and dental assessment usually are performed. Assessment of the durability of dental implants,

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Figure 71: Aspect of the abutments with nice passive settlement and parallelism.



soft and hard periimplant tissue, as well as the implant-supported restorations and the stabil-ity of the Iliac crest bone graft are performed, evidencing an uneventfully excellent evolution.

DISCUSSIONWhen procedures in which there is substan-

tial loss of bone tissue are performed, mouth floor muscles tend to collapse obstructing the airways, making swallowing, breathing, pho-netics, chewing, more difficult even impos-sible. The ilium is the most preferred donor site for bone grafting. It contains the great-est absolute cancellous bone volume and has


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Figure 74: Final prosthesis divided in two structures. Figure 75: Final prosthesis divided in two structures.

Figure 76: Cementation of the prosthesis with Glass Ionomer and adjustment of the occlusion.

Figure 77: Cementation of the prosthesis with Glass Ionomer and adjustment of the occlusion.

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Figure 78: Final appearance of the prosthesis. Figure 79: Final appearance of the prosthesis.

Figure 80: Blunt dissection minimizing risk of vascular injury.

Figure 81: Final panoramic radiograph after the rehabilitation.

the highest cancellous-to-cortical bone ratio.The fixed prosthesis requires a larger num-

ber of implants, occlusal adjustment is more complex and maintaining hygiene is more dif-ficult. Treatment is more costly, but it pro-vides greater satisfaction for the patient in comparison with the removable prosthesis.

CONCLUSIONImprovement in the management of GSWs to the face has paralleled the advancement of oral and maxillofacial surgery. Techniques and skills devel-oped by oral and maxillofacial surgeons in the management of these injuries translated directly to other areas such as bone grafting, and promoted


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the growth and expanding scope of the specialty. The successful restoration of the patient with den-tal implants can result in a change in dental func-tion and health, with a happy patient. The basis for the use of dental implants is initiated by the normal sequence of wound healing, the transla-tion of surface engineering to implant design, and evidence-based trials that verify and confirm effi-cacy of treatment methods. Therefore, we would like to stress the real possibility that we have of offering mandibulectomized patients that have been reconstructed with bony grafts and dental rehabilitation with an implant-supported pros-thesis and/or implant-retained prosthesis that will improve facial harmony and quality of life. ●

Correspondence:Dr. Luis Roberto Sanchez GarzaGómez Morín 2003 L-9Col. CarrizalejoSan Pedro Garza GarcíaZip Code: 66254Phone: 044-818-280-8992Office: 83032636 email: [email protected].

DisclosureThe authors report no conflicts of interest with anything mentioned in this article.

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9. Principles of Oral and Maxillofacial Surgery, Principles of Management of Mandibular Fractures, Guillermo E. Chacon, DDS Peter E. Larsen, DDS, pg 401- 433

10. Principles of Oral and Maxillofacial Surgery, Bony Reconstruction of the Jaws, Randall M. Wilk, DDS, PhD, MD

11. Ahlmann E, Patzakis M, Roidis N, et al. Comparison of anterior and posterior iliac crest bone harvest in terms of harvest site morbid-ity and functional outcomes. J Bone Joint Surg 2002;84:716–20.

12. Callan DP, Salkeld SL, Scarborough N. Histologic analysis of implant sites after grafting with demineralized bone matrix putty and sheets. Implant Dent 2000;9:36–44.

13. Lekholm U, Wannfors K, Isaksson S, Adielsson B. Oral implants in combi-nation with bone grafts. Int J Oral Maxillofac Surg. 1999;28:181–187.

14. Stoler A, Hill T. Part 1. Reconstruction after total mandibulectomy with free cranial and micro-vascular iliac crest grafts as prepa-ration for implants. J Oral Implantol. 1992;18:36–44.

15. Keller EF, Van Rockel NB, Desjardins RP, Tolman DE. Prosthetic-surgical reconstruction of the severely resorbed maxilla with iliac bone grafting and tissue-integrated prosthesis. Int J Maxillofac Implants. 1987;2:155–156.

16. Rehabilitación implantosoportada en el colgajo libre de peroné C. Navarro Cuéllar1, S. Ochandiano Caicoya, F. Riba Garcia1, F.J. Lopez de Atalaya, J. Acero Sanz2, M. Cuesta Gil, C. Navarro Vila.

17. Cuesta Gil M, Ochandiano S, Barrios JM, Navarro Vila C. Rehabilitación oral con implantes osteointegrados en pacientes oncológicos. Rev Esp Cirug Oral Maxilof 2001;23:171-82.

18. Marx R, Morales MJ. The use of implants in the reconstruction of oral cancer patients. Dent Clin North Am 1998;42:177-201.

19. Frodel JL, Funk GF, Capper DT, Fridrich KL, Blumer JR, Haller JR, Hoffman HT. Osseointegrated implants: a comparative study of bne thick-ness in four vascularized bone flaps. Plast Reconstr Surg 1993;92:449-55.

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Introduction: A literature review was done to review the evolution, properties, charac-teristics, and marginal fit of current CAD/CAM materials and fabrications systems for all-ceramic restorations. Methods: A data search of peer-reviewed articles through PUBMED search, annual publications and a hand search of textbooks and journals on CAD/CAM all-ceramic materials was sought. The last search was conducted on July 2014.

Results: The current literature shows that multiple materials and systems are currently available for clinical use and there is not a uni-versal material or system for all clinical situations.

Conclusion: Within the scope of this litera-ture review, there is a lack of evidence to sup-port the universal application of a single system or ceramic material for all clinical situations; careful consideration of the material choice should be done as part of the treatment plan.

Current CAD/CAM Materials and Systems for All Ceramic Restorations:

A Review of the Literature

Christian Brenes, DDS, MS1 • Ibrahim Duqum, DDS, MS2 Gustavo Mendoza, DDS, MS, PhD3 • Lyndon Cooper, DDS, PhD4

1. Prosthodontist, Private Practice. Houston, Texas

2. Clinical Assistant Professor, Director of the Oral Health Innovation Center, Department of Prosthodontics at the University of North Carolina at Chapel Hill

3. Clinical Associate Professor, Department of Biologic and Materials Sciences, Division of Prosthodontics, University of Michigan School of Dentistry

4. Director of Prosthodontics Graduate Program, Distinguished Professor of Dentistry of the Department of Prosthodontics at the University of North Carolina at Chapel Hill

Abstract

KEY WORDS: CAD/CAM, Glass Ceramics, Alumina Ceramics, Lithium Disilicate, Zirconia, All ceramic


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INTRODUCTIONDental crowns have been used for decades to restore compromised, heavily restored teeth, and for esthetic improvements. New CAD/CAM (Com-puter Aided Design/Computer Aided Manufactur-ing) materials and systems have been developed and evolved in the last decade for fabrication of all-ceramic restorations. Dental CAD/CAM tech-nology is gaining popularity because of its bene-fits in terms of time consuming, materials savings, standardization of the fabrication process, and predictability of the restorations. The number of steps required for the fabrication of a restoration is less compared to traditional methods (Fig. 1). Another benefit of CAD/CAM dentistry include the use of new materials and data acquisition; which represents a non-destructive method of saving impressions, restorations and informa-

tion that is saved in a computer and constitutes a extraordinary communication tool for evaluation.

The incorporation of dental technology has not only brought a new range of manufactur-ing methods and material options but also some concerns about the processes involving restora-tions fit, quality, accuracy, short and long-term prognosis.1 The purpose of this document is to provide a review of the literature regarding the dif-ferent materials and systems available until June 2014. In addition marginal fit of CAD/CAM res-torations is included for clinical considerations.

CAD/CAM MATERIALSGLASS CERAMICSThe first in office ceramic material was Vitablock Mark I (Vident), it was a feldspathic based ceramic compressed into a block that was milled into a dental restoration. After the invention of the Mark I block the next generation of materials for CAD/CAM milling fabrication of all-ceramic restora-tions were Vita Mark II (Vident) and Celay, which replaced the original Mark I in 1987 for fine feld-spathic porcelains primarily composed of silica oxide and aluminum oxide.2 3 Mark II blocks are fabricated from feldspathic porcelain particles embedded in a glass matrix and used for single unit restorations available in polychromatic blanks nowadays. On the other hand, Celay ceramic inlays have been considered clinically acceptable by traditional criteria for marginal fit evaluation.4

Dicor-MGC was a glass ceramic material composed of 70% tetrasilicic fluormica crys-tals precipitated in a glass matrix; but this mate-rial is no longer available in the market.5 Studies from Isenberg, et al. suggested that inlays of this type of ceramics were judge as clini-cally successful in a range from 3 to 5 years of

Figure 1: Digital and Conventional Workflow for All-Ceramic Crown Fabrication.


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clinical service.6-8 In 1997, Paradigma MZ100 blocks (3M ESPE) were introduced as a highly filled ultrafine silica ceramic particles embed-ded in a resin matrix; the main advantage of this material is that it can be use as a milled dense composite that was free of polymeriza-tion shrinkage but can not be sintered or glazed.9

In early 1998 IPS ProCAD (Ivoclar Vivadent) was introduced as a leucite reinforced ceramic similar to IPS Empress but with a finer particle size; this material was designed to be use with the CEREC system (Sirona Dental, Germany) and was available in different shades.2 More recently the introduction of IPS Empress CAD (Ivoclar) and Paradigm C that according to the manufac-turer 3M ESPE it is a 30%-45% Leucite rein-forced glass ceramic with a fine particle size.10

To overcome esthetic problems of most CAD/CAM blocks having a monochromatic res-toration; a different version was developed as a multicolored ceramic block which was called Vita TriLuxe (Vident) and also IPS Empress CAD Multiblock; the base of the block is a dark opaque layer, while the outer layer is more trans-lucent; the CAD software allows the clinician to position or align the restoration into the block for the desire outcome of the restoration.11 12

In 2014 the Enamic (VITA) material was released as a ceramic network infiltrated with a reinforcing polymer network that has the benefits of a ceramic and resin in one material but no clinical data is available.13

ALUMINA BASED CERAMICS Alumina blocks (Vitablocs In-Ceram Alumina, VITA) are available for milling with the CEREC system (Sirona Dental) and now compatible with other milling machines as well. Due to the opacity

of alumina based ceramic materials the In-Ceram Spinell (VITA) blocks were developed as an alter-native for anterior esthetic restorations; it is a mix-ture of alumina and magnesia. Its flexural strength is less than In-Ceram Alumina, but veneering with feldspathic porcelain for a more esthetic result could follow it after the milling process.14 15

Nobel Biocare developed Procera mate-rial; for its fabrication high purity aluminum oxide is compacted onto an enlarged die that is fabri-cated from the scanned data.16 The enlarged fabricated core shrinks to the dimensions of the working die when sintered at 1550o C; this mate-rial offers a very high strength core for all-ceramic restorations; the crown is finished with the appli-cation of feldspathic porcelian.17 More recently In-Coris AL (Sirona Dental) has been intro-duced as a high strength aluminum oxide block with similar mechanical properties as Procera.18

LITHIUM DISILICATE Lithium disilicate is composed of quartz, lithium dioxide, phosphor oxide, alumina, potassium oxide and other components. According to Saint-Jean (2014) the crystallization of lithium disilicate is heterogenous and can be achieved through a two or three stage process depending if the glass ceramic is intended to be used as a mill block (e-max CAD) or as a press ingot (e-max press).

Lithium disilicate blocks (blue blocks) are partially sintered and relatively soft; they are easier to mill and form to the desired restora-tion compared to fully sintered blocks; after this process the material is usually heated to 850°C for 20-30 minutes to precipitate the final phase. This sintering step is usually associ-ated with a 0.2% shrinkage accounted for the designing software.19 Nowadays, blocks of lith-

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ium disilicate are available for both in-office and in-laboratory fabrication of all-ceramic restora-tions; monolithic blocks require layering or stain-ing to achieve good esthetic results.8 Different in vitro studies that evaluate marginal accuracy of milled lithium disilicate reveal that these restora-tions could be as accurate as 56-63 microns.20

According to the manufacturer specifica-tions the designing principles for E-max lithium disilicate are produced by default in the design-ing software, but in full all-ceramic crowns structures the minimum thickness must be applied in the preparation design (Table 1).

During the crystallization process the ceramic is converted from a lithium metasilicate crys-tal phase to lithium disilicate. Some commercial types of ceramics are Empress CAD (Ivoclar) and IPS E-max. The first one is a leucite based glass ceramic with a composition similar to Empress ceramic. IPS E-max was introduced in 2006 as a material with a flexural strength of 360 to 400MPa (two to three times stronger than glass ceramics); the blocks are blue in the partially crys-tallized state but it achieves the final shade after it is submitted to the firing process in a porcelain oven for 20 to 25 minutes to complete the crystal-lization; the final result is a glass-ceramic with a

fine grain size of approximately 1.5 μm and 70% crystal volume incorporated in a glass matrix.21

In 2014 Vident company released Suprin-ity; the first glass ceramic reinforced with zirconia (10% weight); this material is a zirco-nia reinforced lithium silicate ceramic (ZLS) available in a precrystallized or fully crys-talized (Suprinity FC) state indicated for all kind of single all-ceramic restorations.

ZIRCONIA Zirconia has been used in dentistry as a bioma-terial for crown and bridge fabrication since 2004; it has been useful in the most posterior areas of the mouth were high occlusal forces are applied and there is limited inter-occlusal space.22

Zirconia is a polymorphic material that can have three different forms depending on the tem-perature: monoclinic at room temperature, tetrag-onal above 1170 °C, and cubic beyond 2370° Centigrade. According to Piconi (1999) “the phase transitions are reversible and free crys-tals are associated with volume expansion”. Dif-ferent authors state that when zirconia is heated to a temperature between 1470°C and 2010°C and cooled a volume shrinkage of 25 to 35% can occur that could affect marginal fit or pas-

Table 1: Recommended Dimensions for E-max CAD by Ivoclar Vivadent

Material Thickness Anterior Premolar Molar Veneers

Staining Technique 1.2 1.5 1.5 0.6

Cut-back Technique 1.2 1.5 1.5 0.6

Layering Technique 0.8 0.8 — —


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siveness of the restorations.22 This feature lim-ited the use of pure zirconia until 1970 when Rieth and Gupta developed the yttria-tetragonal zirconia polycrystal (Y-TZP) containing 2-3% mol-yttria in the intent to minimize this effect.10

One of the most interesting properties of zir-conia is transformation toughening; Kelly (2008) describes it as: “A phenomenon that happens when a fracture takes place by the extension of al already existing defect in the material struc-ture, with the tetragonal grain size and stabi-lizer, the stress concentration at the tip of the crack constitutes an energy source able to trig-ger the transformation of tetragonal lattice into the monoclinic phase.” This process dissipates part of the elastic energy that promotes progres-sion of cracks in the restoration; there is a local-ized expansion of around 3.5% that increases the energy that opposes the crack propagation.23

Zirconia restorations can be fabricated from fully sintered zirconium oxide or partially sintered zirconium oxide blanks (green-state). Proponent of milling fully sintered zirconia claim that fitness of restorations is better because it avoid volumetric changes during the fabrication process. On the other hand, the green state is easier and faster to mill and proponents of milling partially sintered blanks claim that micro cracks can be induced to the restoration during the milling process and it also requires more time and intensive milling pro-cesses; this micro defects or surface flaws can affect the final strength of the final restoration and could potentially chip the marginal areas; how-ever further research is needed about this topic.10

One of the first systems that used zirconia was In-Ceram Zirconia (Vident), which is a modi-fication of the In-Ceram Alumina but with the addition of partially stabilized zirconia oxide to

the composition. Recently many companies have integrated zirconia into their CAD/CAM work-flow due to its mechanical properties, which are attractive for restorative dentistry; some of this properties are: high mechanical strength, frac-ture toughness, radiopacity for marginal integ-rity evaluation, and relatively high esthetics.24

Different systems in the market are using zir-conia as one of their main matrials such as: Cera-mill Zolid (Amann Girbach), Prettau (Zirkonzahn), Cercon (Dentsply), BruxZir (Glidewell Labora-tories), IPS ZirCAD (Ivoclar Vivadent), Zenostar (Ivoclar Vivadent), inCoris ZI (Sirona Dental), VITA In-Ceram YZ (Vident), among others. Com-panies have introduced materials that are in combination with zirconia to improve its prop-erties in different clinical situations. Lava Plus for example is a combination of Zirconia and a nano-ceramic. Table 2 describes some of the CAD/CAM materials used by dental clinicians and laboratories for all-ceramic restorations and its restorative indications by the manufacturers.

CAD/CAM SYSTEMS A number of different manufacturers are providing CAD/CAM systems which generally consist of a scanner, design computer and a milling machines or 3D printers. Laboratories are able to receive digital impression files from dentists or use a scanner to create digital models that are use for restorations designing or CAD. Dental scanners vary in speed and accuracy. Milling machines vary in size, speed, axes, and also in which restor-ative materials can be milled; in this category milling machines could be classified as wet or dry depending if the materials require irrigation.

The development of dental CAD/CAM sys-tems occurred around 1980 with the introduc-

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Table 2: Most Used CAD/CAM Materials for all Ceramic Restorations Available for 2014

Material Composition Company Indications

ArgenZ Zirconia Argen Crowns, abutments, onlays.

BruxZir Zirconia Glidwell Copings, multiunit, crowns, inlays/onlays

Ceramill Zolid Zirconia Amann Girbach Crowns, inlays, onlays, multiunit.

Cercon ht Zirconia Dentsply Copings, multiunit, crowns, veneers.

DC Zirkon Zirconia DCS Dental/Vita Crowns, copings.

Empress CAD Leucite reinforced Ivoclar Crowns, inlays, onlays.

Enamic Ceramic resin Ivoclar Vivadent Crowns, inlays/onlays.

InCoris AL Alumina oxide Sirona Copings, multiunit.

InCoris ZI Zirconia Sirona Multiunit, crowns, inlays/onlays.

IPS E-max Lithium Disilicate Ivoclar Crowns, inlays, onlays.

IPS Zircad Zirconia Ivoclar Copings, multiunits.

Lava Ultimate Ceramic resin 3M ESPE Crowns, inlays, onlays.

Paradigm C Leucite reinforced glass ceramic 3M ESPE Crowns, inlays, onlays.

Prettau Full contour zirconia Zirkonzahn Copings, multiunit, crowns, inlays/onlays

VITA Alumina Sintered Aluminum Oxide Vident Crowns, inlays, onlays, veneers.

Vita InCeram YZ Zirconia Vident Crowns, inlays, onlays, multiunit, veneers, abutments.

VITA Mark II Feldpathic porcelain Vident Crowns, inlays, onlays, veneers.

VITA Spinell Aluminum oxide glass infiltration Vident Anterior crowns, veneers.

Vita TriLux Felspathic ceramic Vident Crowns, veneers, onlays, inlays.

Zenostar Zirconia Ivoclar Vivadent Copings, multiunit, crowns, veneers.


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tion of the Sopha system developed by Dr. Duret. Few years after that event Dr. Mormann and the electrical engineer Marco Brandestini developed the CEREC-1 system in 1983, the first full digital dental system created to allow dentist to design and fabricate in office resto-rations. Since then the continuous evolution of systems dedicated to this field has continue and has exponentially increased in the last decade.14

Cerec systems has evolved into CEREC Bluecam scanner; accuracies as close as 17 microns for a single tooth have been reported by authors using this system. Recently CEREC Omnicam was introduced offering true color digital impressions without the need of a con-trast medium. In a recent study by Neves, et al (2013) about marginal fit of CAD/CAM resto-rations fabricated with CEREC Bluecam; they compared lithium disilicate single unit restora-tions to heat-pressed restorations and 83.8% of the specimens had measurements of ver-tical gap with less or at least 75 microns.25

The Cerec InLab CAD software (Sirona Den-tal) was designed for dental laboratories for a wide range of dental capabilities that can be combined with third party systems. With this soft-ware the dental technician is able to scan their own models using Sirona inEos X5 (Sirona Den-tal) scanner and design the restoration; once this process is completed the file can be send to a remote milling machine or a milling cen-ter for fabrication in a wide range of materials.

The Procera system introduced in 1994 was the first system to provide fabrication of a res-toration using a network connection. Accord-ing to research data the average ranges of marginal fit of this restorations are from 54 to 64 microns.20 A computer integrated crown

reconstruction system (CICERO) introduced by Denison et al. in 1999 included a rapid custom fabrication of high strength alumina coping and semi finished crowns to be delivered to dental laboratories for porcelain layering and finishing.26

Another system that was developed years ago was the Celay system, which fabricated feld-pathic restorations through a copy-milling pro-cess. The system duplicated an acrylic resin pattern replica of a restoration. Zirkonzahn com-pany developed a similar system called the Zirk-ograph in 2003 which was able to copy-mill zirconia prosthesis and restorations out a replica of the restoration. Some years after Cercon sys-tem (Dentsply Ceramvo) was able to design and mill zirconia restorations out of a wax pattern.24

Almost at the same time that these compa-nies develop this first copy mill prototypes Lava (3M ESPE) introduced in 2002 the fabrication of yttria-tetragonal zirconia polycrystal (Y-TZP) cores and frameworks for all ceramic restorations. With the Lava system the die is scanned by a optical process, the CAD software designs and enlarge the restoration or framework that is milled from a pre-sintered blank. Studies on marginal adap-tation suggest that Lava restorations have a marginal fit that can be as low as 21 microns.27 Some other systems that were able to mill zirco-nia were DCS Zirkon(DCS Dental) and Denzir.28

In the last decade companies have decided to differentiate their products by having a full CAD/CAM platform or by focusing on specific areas of expertise like CAD software and intraoral scan-ners; this companies claim to be open platform because their systems allow to export universal files such as STL. or OBJ. to be used with the majority of nesting softwares and milling machines in the market that are able to import them. Defend-

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Table 3: Most used Dental CAD Systems Available for 2014

CAD System Manufacturer File output

3Shape 3Shape Propietary/STL

ARTI / Modelliere Zirkonzahn STL

CeraMill Amann Girbach STL

Cercon Eye/Art Dentsply Propietary

Cerec Sirona Propietary

Delcam Delcam STL

Dental Wings Dental Wings STL

E4D Planmeca Propietary/STL

Exocad Exocad STL

InLab Sirona Propietary/STL

Procera Nobel Biocare Propietary/STL

ers of close platforms claim that the integration of different CAD and CAM systems does not allow for a good integration between parts and probably lead to the incorporation of fabrication errors; at this point no research about systems integration is available. Table 3 shows some of the systems used for dental CAD with their file output; Table 4 shows some of the most used CAM systems with their material recommendations and capabilities.

MARGINAL FIT Marginal fit evaluation is considered an essential factor for clinical success. Christensen (1966) reported that clinically detectable subgingival mar-gins are in a range of 34-119 microns and 2-51 microns for supragingival margins. McLean (1971) suggested that 120 microns should be the limit

for clinically acceptable marginal discrepancies.29

Poor marginal adaptation can result in disso-lution of cement; increase plaque accumulation, periodontal inflammation, and secondary caries.14

Holmes, et al. (1989) did a research study measuring the marginal fit of restorations and defined absolute marginal discrepancy for the first time. This concept states that marginal fit should be considered as the angular com-bination of the vertical and horizontal error.30

Some of the main concerns from clinicians about all-ceramic CAD/CAM restorations accu-racy of fit are: scanning resolution, software designing limitations, and milling hardware limi-tations of accuracy. Clinicians’ and technicians’ experience with the CAM/CAM system inte-gration is also a key factor for fabricating good


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Table 4: Most used Dental CAM Systems Available for 2014

CAM System Manufacturer Type Milling materials

BruxZir Mill Glidewell Dry Zirconia, wax, PMMA

CARES Straumann Wet/Dry Zirconia, Glass ceramic, ceramic resins, Lithium Disilicate, Chrome Cobalt, PMMA, wax, titanium.

CeraMill Motion 2 Amann Girbach Wet/Dry Zirconia, Glass ceramic, ceramic resins, Lithium Disilicate, Chrome Cobalt, PMMA, wax, titanium.

Datron D5 Datron Wet/Dry Zirconia, Glass ceramic, ceramic resins, Lithium Disilicate, Chrome Cobalt, PMMA, wax, titanium.

Denzir Ivoclar Dry Zirconia

E4D PlanMill 40 Planmeca Wet Lithium disilicate, ceramic resin

InLab MC XL Sirona Wet/Dry Zirconia, Glass ceramic, ceramic resins, Lithium Disilicate, Chrome Cobalt, PMMA, wax, titanium.

LAVA 3M ESPE Dry Zirconia, wax, glass ceramic

M1/M5 Zirkonzahn Wet/Dry Zirconia, Glass ceramic, ceramic resins, Lithium Disilicate, Chrome Cobalt, PMMA, wax, titanium.

Procera Nobel Biocare Wet Aluminum oxide

Zenotec Ivoclar Dry Zirconia, Wax, PMMA

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Table 5: Summary of Research Studies Including Marginal Adaptation of all Ceramic Restorations

Study Material and System Type of Study Mean Marginal Gap

Att, et al. Zirconia/DCS In vitro 86

Baig, et al. Cercon/Zirconia In votro 66.4

Bindl, et al. In Ceram/CEREC In vitro 43 Procera 17

Boeining, et al. Procera In vivo 90-118

Colpani, et al. In ceram/CEREC In vitro 28.5

De Vico, et al. Zirconia/3shape In vitro 78.8

Denissen, et al. Mark II/ CEREC 2 In vivo 85 Procera 68 CICERO 74

Grenade, et al. Procera In vitro 51 Ceramill/zirconia 81

Hmaidouch et al. In Ceram YZ/ CEREC In vitro 81.6

In-sung, et al. In Ceram/Celay In vitro 83

Lee, et al. Alumina/Procera In vitro 89.5 Mark II/CEREC 94.4

Martinez, et al. In Ceram 12.3 Cercon 13.1 Procera 8.7

Matta, et al. Zirconia/Lava In vitro 51 Zirconia/Zenotec 82

May, et al. Procera In vitro 56-63

Neves, et al. Lithium disilicate/CEREC In vitro 39.2 Lithium disilicate/E4d 66.9

Pelekanos et al. In ceram Al/CEREC In vitro 55

Reich, et al. In Ceram/CEREC In vivo 77 Lava 80

Souza, et al. Leucite reinforced In vitro 28-99 ceramic/ CEREC

Syrek, et al. Lava In vitro 49

Tinschert, et al. DC Zirkon/Precident In vitro 60-71


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restoration; the computer software per se will not allow an inexperience operator to create an excellent dental restoration from scratch.31

The clinical evaluation of the restorations is a process that is done routinely at delivery and is usually evaluated by the use of instruments like sharp dental explorers. In an article by Hickel (2007) different recommendations regarding clini-cal evaluation of restorations were proposed. The use of explorers with blunt tips of 150 and 250 microns are recommended as the development of secondary caries has only been correlated to gaps >250 microns. It has been stated in differ-ent studies evaluating restorations made with conventional or digital impressions that marginal gaps that are not clinically detectable represent a harmonious continuation of the junction tooth/restoration. According to Hickel (2007) “gaps that deviate from ideal but could be adjusted to ideal by polishing are between 50 and 150 microns; gaps with leakage and discoloration lim-ited to the borders of the restorations are easily perceptible with explorers and are not consid-ered to have a long-term negative impact if they are between 150 and 250; gaps larger than 250 microns should be replaced to prevent sec-ondary caries or large fractures at the margins”.

Although in clinical practice the previous meth-ods in addition to radiographs are used to deter-mine marginal fit; several authors using different methods have investigated the fit of CAD/CAM restorations using different materials and systems.

DISCUSSION Several advantages can be drawn from including CAD/CAM dental technology, 3D scanning and the use of mill materials for all-ceramic restora-tions. Even though clinical studies have shown

that marginal fit of CAD/CAM restorations is compared to conventional restorations the fabri-cation of dental restorations still a complex task that requires experience, knowledge and skills.

The incorporation of new systems and mate-rials bring a lot of concerns regarding system implementation, capabilities and mechanical properties of the different materials. One of the biggest problems that still remain in CAD/CAM dental systems is the accuracy of each step in the CAD/CAM chain, from digital impres-sion to the milling step. Using computer aided manufacturing is dependent on the calibration of hardware with software in the workflow. Fur-thermore, the virtual configuration of the die spacer between the tooth and the restorations is essential for the accuracy of the marginal adap-tation and has to be calibrated for each one of the systems. Weittstein et al. demonstrated that the difference of fit between CAD/CAM resto-rations is directly related to the gap parameters from the computer design and also related to the intrinsic properties of the CAD/CAM system.32

On the other hand, analysis of the publica-tions demonstrates that there is a wide diversity of methodologies used to assess the level of adap-tation of restorations fabricated with CAD/CAM technology; standardization and reliability of meth-ods should be use to guide investigations on this field. Some of the methods that were used were: 1) Marginal fit evaluation using microphotography or light microscopy; 2) Microscope measurements with sectioned silicone replicas of the restorations and abutments; 3) Measurements with electro-microscopy of cemented restorations after sec-tioning; 4) Micro-CT technology with and without cement; 5) Triple scan method and reconstruction using 3D scanners to visualize the internal space.

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CONCLUSIONThis review of current and past literature regard-ing the evolution, characteristics, and marginal fit of milled CAD/CAM all-ceramic restorations materials and systems show that it is possible to fabricate restorations with the same marginal fit expected from conventional methods and within the range of clinically accepted restora-tions. When comparing both methods the advan-tage of using CAD/CAM technology is not to obtain the most precise level of fit, but rather to obtain a high level of reliability in a large number of restorations; especially when high produc-

tion levels are expected. However, there is lim-ited number of clinical studies and the diversity of the results between systems and protocols does not allow giving a definitive conclusion. ●

Correspondence:Dr. Christian Brenes4548 Bissonnet St. Bellaire, TX. 77401. Phone: (919) 627-3749 Fax: (713) 664-1140. E-mail: [email protected]

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DisclosureThe authors report no conflicts of interest with any-thing mentioned in this article.

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13. Baig, M. Tan, K. Nicholls, J. Evaluation of marginal fit of zirconia ceramic computer aided machined (CAM) crown system. J of Prosth Dent. 2010 : 216-227.

14. Bindl A, Mormann WH. Marginal and internal fit of all-ceramic CAD/CAM crown- copings on chamfer preparations. J Oral Rehabil 2005;32:441-7.

15. Bindl A, Mormann WH. Survival rate of mono-ceramic and ceramic-core CAD/ CAM-generated anterior crowns over 2-5 years. Eur J Oral Sci 2004.

16. Denissen H, Dozic A, van der Zel J, van Waas M. Marginal fit and short-term clinical performance of porcelain-veneered CICERO, CEREC, and Procera onlays. J Prosthet Dent 2000;84:506-13.

17. Fradeani M, D’Amelio M, Redemagni M, Corrado M. Five-year follow-up with Procera all-ceramic crowns. Quintessence Int 2005.

18. Esquivel-Upshaw JF, Chai J, Sansano S, Shonberg D. Resistance to staining, flexural strength, and chemical solubility of core porcelains for all-ceramic crowns. Int J Prosthodont 2001.

19. Reich SM, Peltz I, Wichmann M, Estafan D. A comparative study of two CEREC software systems in evaluating manufacturing time and accuracy of restorations. Gen Dent 2005

20. May, K. Russell, M. Razzoog, M. Lang, B. Precision of fit: The Procera AllCeram crown. J Prosthet Dent. 1998: 394-404.

21. Schwartz N, Whitsett L, Berry T, Steward J. Unserviceable crowns and fixed partial dentures: Life span and causes for loss of serviceability. J Am Dent Assoc 1970; 81:1395–1401.

22. Anusavice, K. Phillips’ Science of Dental Materials. 12edition. In: Saunders. Elsevier; 2014.

23. Kosmac T, Oblak C, Jevnikar P, Funduk N, Marion L. The effect of surface grinding and sandblasting on flexural strength and reliability of Y-TZP zirconia ceramic. Dent Mater 1999

24. Raigrodski AJ. Contemporary all-ceramic fixed partial dentures: a review. Dent Clin North Am 2004.

25. Neves F, Prado C, Prudente M, Carneiro T, Zancope K, Davi L, Mendonçe G, Cooper L, Soares C. Marginal fit evaluation with micro CT of lithium disilicate crowns fabricated by chairside CAD/CAM systems and the heat-pressing technique. J Prosthet Dent. 2014.

26. Tinschert J, Natt G, Mautsch W, Spie- kermann H, Anusavice KJ. Marginal fit of alumina-and zirconia based fixed partial dentures produced by a CAD/CAM system. Oper Dent 2001

27. Hertlein G. Kramer M, Sprengart T, et al. Milling time vs marginal fit of CAD/CAM manufactured zirconia restorations. J. Dent Res 2003; 82:194.

28. Guazzato M, Proos K, Quach L, Swain MV. Strength reliability and mode of fracture of bilayered porcelain/zirconia (Y-TZP) dental ceramics. Biomaterials 2004.

29. McLean JW, von Fraunhofer JA. The estimation of cement film thickness by an in vivo technique. Br Dent J 1971:107–111.

30. Holmes JR, Sulik WD, Holland GA, Bayne SC. Marginal fit of castable ceramic restorations. J Prosthet Dent 1992;67:594.

31. Martin N, Jedynakiewicz NM. Interface dimensions of CEREC-2 MOD inlays. Dent Mater 2000.

32. Syrek, A. Reich, G. Ranftl, D., Klein, C. Cerny, B. Brodesser, J. Clinical evaluation of all-ceramic crowns fabricated from intraoral digital impressions based on the principle of active wavefront sampling. Journal of Dentistry 2010.

33. Att W, Komine F, Gerds T, Strub JR. Marginal adaptation of three different zirconium dioxide three-unit fixed dental prostheses. J Prosthet Dent. 2009; 101:239–247.

34. Boening KW, Wolf BH, Schmidt AE, Kastner K, Walter MH. Clinical fit of Procera AllCeram crowns. J Prosthet Dent 2000;84:419-24.

35. Colpani JT, Borba M, Della Bona A. Evaluation of marginal and internal fit of ceramic crown copings. Dent Mater. 2013;29:174–180.

36. Da Costa JB, Pelogia F, Hagedorn B, Ferracane JL. Evaluation of different methods of optical impression making on the marginal gap of onlays created with CEREC 3D. Oper Dent 2010; 35:324-9.

37. De Vico G, Ottria L, Bollero P, Bonino M, Cialone M, Barlattani A Jr. et al. Aesthetic and functionality in fixed prosthodontic: experimental and clinical analysis of the CAD- CAM systematic 3Shape. Oral Implantol. 2008; 1:104–115.

38. Gehrt, M. Wolfart, S. Rafai, N., Reich, S. Edelhoff, D. Clinical results of lithium-disilicate crowns after up to 9 years of service. Clinical Oral Investigations17(1), 275–84.

39. Gupta TK, Bechtold JH, Kuznickie RC, Cadoff LH, Rossing BR. Stabilization of tetragonal phase in polycrystalline zirconia. J Mater Sci 1978;13:1464.

40. Hamza TA, Ezzat HA, El-Hossary MM, Katamish HA, Shokry TE, Rosenstiel SF Accuracy of ceramic restorations made with two CAD/CAM systems. J Prosthet Dent 2013;109:83-7.

41. Hmaidouch R, Neumann P, Mueller W-D. Influence of preparation form, luting space setting and cement type on the marginal and internal fit of CAD/CAM crown copings. Int J Comput Dent. 2011;14:219–226.

42. Keshvad A, Hooshmand T, Asefzadeh F, Khalilinejad F, Alihemmati M, Van Noort R. Marginal gap, internal fit, and fracture load of leucite reinforced ceramic inlays fabricated by CEREC inLab and hot-pressed techniques. J Prosthodont 2011;20:535-40.

43. Lee, K. Park, C. Kim, K. Kwon, T. Marginal and internal fit of all ceramic crowns fabricated with two different CAD/CAM systems. Dent Materials J. 2008; 27(3): 422-426

44. Martinez, F. Suarez, M. Rivera, B. Pradies, G. Evaluation of the absolute marginal discrepancy of zirconia based ceramic copings. J of Prosth Dent. 2011 :108-114.

45. Matta RE, Schmitt J, Wichmann M, Holst S. Circumferential fit assessment of CAD/CAM single crowns–a pilot investigation on a new virtual analytical protocol. Quintessence Int. 2012; 43:801–809.

46. Pelekanos S, Koumanou M, Koutayas S, Zinelis S, Eliades G. Micro-CT evaluation of the marginal fit of different In-Ceram alumina copings. Eur J Esthet Dent. 2009; 4:278–292.

47. Piconi C, Maccauro G. Zirconia as a ceramic biomaterial. Biomaterials 1999; 20:1–25.

48. Pjetursson, B. Sailer, I., Zwahlen, M. Hämmerle, C. A systematic review of the survival and complication rates of all-ceramic and metal-ceramic reconstructions after an observation period of at least 3 years. Part I: Single crowns. Clinical Oral Implants Research, 18 Suppl 3, 73–85.

49. Schaefer, O. Schmidt, M. Goebel, R. Kuepper, H. Qualitative and quantitative three-dimensional accuracy of a single tooth captured by elastomeric impression materials: An in vitro study. J Prosthet Dent. 2012: 108(3), 165-172.

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Background: Increased placement of dental implants will lead to an increase in the prevalence of peri-implant disease. Peri-implant inflammatory lesions are initiated by the host response to the presence of a microbial biofilms. How microbes attach themselves to implant surfaces involves the interaction of several biophysical factors. This limited review discusses the role of several inter-related biophysical factors that directly impact microbial adhesion to dental implant surfaces. Methods: An electronic search of MEDLINE was conducted of studies published between 1995 through 2014. Subject specific articles that predated 1995 were also considered. The following terms were used in the search: dental implants, surface roughness, topog-raphy, surface free energy, wettability, hydro-philicity, hydrophobicity, microbial adhesion,

bacterial adhesion, and biofilms. Both in vitro and in vivo studies were considered in the review.

Results: Surface roughness, surface free energy, hydrophilicity, and adsorption of pro-tein-carbohydrate complexes derived from saliva and gingival crevicular fluid all interact in a complex manner in the attraction and adhe-sion of supragingival and subgingival bacteria.

Conclusions: It has proven difficult to differen-tiate the effects of individual biophysical implant surface attributes. Once bacteria begin to colo-nize a surface and are allowed to increase in mass without disturbance the biophysical char-acter of the surface becomes less important. From the clinicians view, this latter observation reinforces the need for exquisite oral hygiene to maintain a healthy peri-implant environment.

Biophysical Factors Affecting Bacterial Adhesion to Dental Implant Surfaces:

A Focused Review

Charles M. Cobb, DDS, MS, PhD1 • Keerthana M. Satheesh, DDS, MS1

Mabel L. Salas, DDS, MS1 • Simon R. MacNeill, BDS, DDS1

1. Department of Periodontics, University of Missouri Kansas City School of Dentistry

Abstract

KEY WORDS: Dental implants, bacteria, bacteria adhesion, biofilm, review


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INTRODUCTIONThe increased placement of dental implants will lead to an increase in the prevalence of peri-implant disease.1 Mombelli et al. 2 in a recent review reported that 10% of implants and 20% of patients exhibit clinical signs of peri-implantitis. Other authors have reported prev-alence rates for peri-implantitis ranging from 31% to 53% of patients and 22% to 38% of implants.3-5 Peri-implant mucositis and peri-implantitis represent inflammatory lesions initi-ated by the host response to the presence of a microbial biofilm.6 How microbes attach them-selves to an implant surface involves the inter-action of several biophysical factors among which surface roughness has been viewed as the dominant factor.6-8 However, the texture of a surface, i.e., surface roughness, brings into play other biophysical factors that are sig-nificant to the biology of cellular and bacte-rial adhesion to substrates. This attenuated review will summarize a relatively large body

of literature and focus on the role of several interrelated biophysical factors that influence microbial adhesion to dental implant surfaces.

MATERIALS AND METHODSAn electronic search of MEDLINE was con-ducted of studies published between 1995 through 2014. Subject specific articles pub-lished prior to 1995 were also considered. The following terms were used in the search: dental implants, surface roughness, topog-raphy, surface free energy, wettability, hydro-philicity, hydrophobicity, microbial adhesion, bacterial adhesion, and biofilms. The empha-sis was on in vivo studies but significant in vitro were also considered in the review.

RESULTSSurface RoughnessAdhesion of bacteria to a solid substrate, such as a dental implant, is considered to be dependenton several interrelated factors, such as surface

Figure 1: Profile view showing surface topography of a Straumann SLA® dental implant. Original magnification of 2,500x with bar = 10 μm.

Figure 2: Profile view showing surface roughness of a Steri-Oss HA® dental implant. Original magnification of 2,500x with bar = 10 μm.


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roughness, free energy, net charge, chemis-try, hydrophilicity, and the presence of salivary and gingival crevicular fluid (GCF) derived pel-licles.9 It is notable that, with the exception of the salivary and GCF derived pellicles, all the listed factors are controlled by implant sur-face chemistry and/or biomechanical design.

Implant surfaces with varying degrees of roughness and with sophisticated biomechani-cal designs are intended to enhance the osseo-integration (Figs. 1-3). Indeed, some degree of surface roughness is considered essential to osseointegration.10 There is considerable evi-dence correlating surface roughness to increased bone-to-implant contact, osteoblastic differentia-tion and osseointegration.10-14 Likewise, it would seem obvious that increasing surface roughness should equate to increased microbial adherence and, therefore, more aggressive colonization of the surface.15-18 Indeed, the early literature in this area repeatedly notes the interaction of surface rough-ness and surface free energy in the attraction and

adhesion of bacteria and the maturation of bio-films on implant substrata.7, 8, 15, 16 However, this may not always be the case as recent research lit-erature is conflicted regarding the role of implant surface roughness and microbial adhesion.18-24

As early as 1996, Bollen et al.18 reported little difference in the number of colony form-ing units, both supra- and subgingival aerobic and anaerobic microbes, as surface roughness of implant abutments decreased to a rough-ness average (Ra) of 0.2 μm. Indeed, at least two papers have noted that polished surfaces do not reduce oral microbial colonization and (Fig. 4), in fact, polishing a surface to mini-mize bacterial adhesion may be more miscon-ception than reality.19, 20 Recent studies have noted that although surface roughness does not appear to impact colonization of bacterial species,21-23 it may reduce treatment efficacy when compared to smoother surfaces.24 This is particularly true in the treatment of peri-implan-titis when it becomes necessary to decon-

Figure 3: Profile view showing surface roughness of a Nobel Replace Groovy® implant. Original magnification of 2,500x with bar = 10 μm

Figure 4: Bacterial colonization of smooth surfaced implant collar and abutment. Original magnification of 20x with bar = 1 mm.

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taminate an implant surface that was designed to facilitate osseointegration (Figs. 5 & 6).

Surface Free EnergySurface free energy (SFE) has been defined by as the difference between the energies of molecules located on the surface and within the mass of a material. Molecules embedded within the mass of a material experience no net forces whereas environmental factors may act on the outermost molecules. Because of exposure to the environment the surface mol-ecules are in a higher energy state than those located internally. The net difference in energy between internal and surface molecules is expressed as surface tension, i.e., SFE.25 SFE can also be thought of as a function of liquid surface tension and the solid-liquid interfacial free energy, i.e., wettability of the surface.25

The SFE of an implant has been implicated in the promotion of plaque adherence; spe-cifically, those surfaces with higher energies

and, therefore, greater hydrophobicity, have been shown to favor the adherence of bio-films.26, 27 In addition, research indicates that the amount of absorbed protein is greater on hydrophobic surfaces and that the absorbed protein layer influences initial bacterial coloni-zation. The latter process is mediated through the protein-cell interface, with the absorbed protein functioning as a ‘bridge’ between the implant surface and the bacterium.27-29 This phenomenon is confirmed by the adherence of bacteria to saliva and GCF derived pellicles that coat the implant substrata which, in turn, are directly influenced by the material’s SFE.

Numerous studies have recognized the bio-physical interactions of surface roughness, SFE, and hydrophobicity. In consideration of these relationships, Quirynen and Bollen7 contend that the influence of surface roughness is domi-nant over SFE in facilitating microbial adhesion to an implant surface. However, Subramani et al.30 have noted that the aforementioned domi-

Figure 5: SteriOss HA® surface being colonized by various morphotypes of bacteria, e.g., cocci, rods, fusiforms and spirohetes. Original magnification of 5,000x with bar = 5 μm.

Figure 6: Surface of mature biofilm associated with peri-implantitis comprised predominantly of rods of various lengths and diameters, fusiforms and treponemes. Original magnification of 5,000x with bar = 5 μm.


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nance of surface roughness on accumulation of biofilms is largely based on descriptive lit-erature which is difficult to reliably quantify.

Several studies, both in vitro and in vivo, have indirectly evaluated the impact of SFE on bacterial adhesion with varying results.31-34 Collectively, these in vitro stud-ies establish a tenuous hierarchy of implant surfaces that, in a given time period, attract the least numbers of bacteria to those that attract the most: gold-platinum alloy, tita-nium nitride surfaces, zirconium, titanium alloy, commercially pure titanium surfaces.31-34

A more recent study by Salihoğlu et al.23 reported no significant differences in DNA copy numbers for Porphyromonas gingiva-lis (P.g.), Aggregatibacter actinomycemcomi-tans (A.a.) and total bacteria both for titanium and zirconium oxide abutments and biopsies taken from adjacent buccal gingiva. The differ-ence between the SFEs of the abutments, zir-conium oxide being appreciably smoother, had no influence on the microbiologic findings. This conclusion, as regards SFE impact on bacte-rial adhesion, is supported by Burgers, et al.35

as they reported that initial adhesion of bacte-ria to differently textured titanium surfaces was influenced by the roughness average value (Ra) and that SFE was of minor importance.

Hydrophilicity Surface roughness can be viewed in terms of hydrophilicity (a.k.a. wettability). Hydrophilic-ity refers to a decrease in surface tension that allows a liquid to spread, thereby “wetting” the surface.36 In terms of implant surfaces it is interesting to note that both hydrophobicity and hydrophilicity are determined, in major part, by

surface composition and surface roughness.37,

38 In addition, the degree of hydrophobicity of an implant surface is influenced by surface free energy (SFE).37 Ultimately, the degree of hydrophobicity will, in part, dictate the interac-tion between an implant surface and the proxi-mate biologic environment. Implant surfaces exhibiting hydrophilicity are reported to have a “wicking” effect on tissue fluids, including blood and likely other fluids, such as saliva and GCF. This, in turn, leads to absorption of proteins that may aid in binding of host cells (such as fibro-nectin in blood) and bacteria to the implant surface.39 Further, surface hydrophilicity and SFE have been shown, in vitro, to promote cell attachment, cell spreading, and osseointegra-tion.12, 38-42 For these reasons most research concerning implant surface hydrophilicity has been focused on the interactions of host cells during the osseointegration of implants by increasing SFE and wettability.37, 43

There are relatively few studies address-ing the role of hydrophilicity in microbial adhe-sion to implant surfaces. Schmidlin et al.17 reported that surface roughness had a moder-ate influence on in vitro biofilm formation while hydrophilicity appeared to exhibit little effect.

In apparent contradiction, Almaguer-Flores et al.44 concluded that initial in vitro biofilm for-mation was significantly influenced by the micro-topography and hydrophilicity of the substrate surface. Not surprisingly, regardless of surface topography, all implant specimens exhibited higher numbers of attached bacteria when incu-bated in an enriched Mycoplasma broth-media compared to those cultured in human saliva. Of greater interest, however, was the observa-tion that surface topography and the culture

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medium appeared to dictate the proportions of bacterial species in the early stage biofilm. For example, the numbers of Actinomyces israelii and Porphyromonas gingivalis were depressed when the biofilm was grown on an SLA or modi-fied SLA surface in the presence of saliva. This observation is likely related to the presence of anti-bacterial components found in whole saliva.

Substrata, Protein Adsorption and Bacterial AdhesionSaliva contains multiple components such as mucins, acidic proline-rich proteins, histatins, statherin, cystatins, agglutinins, amylase, secre-tory IgA, lysozyme, and lactoferrin.45,46 When saliva is mixed with GCF, a transudate con-sisting of serum glycoproteins, albumin and heme, the result is a carbohydrate-protein complex the coats all exposed soft and hard tissue surfaces in the oral cavity.47 This com-plex is referred to as the acquired pellicle.

The pellicle composition dictates the kinds of bacteria that initially adhere to a specific intraoral surface. The initial bacterial adhe-sion involves recognition of oligosaccharide receptors by protein adhesions, in lectin-like reactions, protein-protein interactions, and ionic or hydrophobic or hydrophilic associa-tions between microbial surface components and the adhesion substrate. The compo-nents of a microbial biofilm (i.e., microbial community) found at different sites within the oral cavity can exhibit considerable variabil-ity. Basically, the bacteria that first adhere to a site do so because of the biological prop-erties and number of available receptors. The forces that mediate adsorption of salivary and GCF derived proteins to dental materials

substrates, to include implant surfaces, have been identified and include Van der Waals forces, electrostatic interactions, and acid-base bonding.48 Together these forces cre-ate a distance-dependent energy field that can attract and bind proteins salivary and GCF derived proteins and eventually bacteria. Once bacteria begin to attach to an implant surface the biophysical differences between various substrata become academic, particu-larly if bacterial accumulation remains undis-turbed and progress to a mature biofilm.49, 50

CONCLUSIONThe research literature shows that microbial adhe-sion can occur on any implant surface, regard-less of the degree of surface roughness. Initial biofilm formation and composition can be influ-enced by the interrelated biophysical character-istics of surface roughness, surface free energy, and degree of hydrophilicity. It has proven dif-ficult to differentiate between the effects of the individual biophysical attributes. However, once bacteria begin to colonize a surface and are allowed to increase in mass without distur-bance, e.g., shear forces, the biophysical charac-ter of the surface becomes less important. From the clinicians view, this latter observation rein-forces the necessity for exquisite oral hygiene to maintain a healthy peri-implant environment. ●

Correspondence:Dr. Charles M. Cobb424 West 67th TerraceKansas City, MO 64113Phone: 816-444-3167E-mail: [email protected]


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DisclosureThe authors report no conflicts of interest with anything mentioned in this article.

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