I case report

Fig. 1_Tooth 26, which proved

not worth preserving, after

root resection.

Fig. 2_The state of tooth 26

after extraction.

Fig. 3_Implantation

after 12 weeks.

_In the past ten years, CAD/CAM restorationshave been established as standard in implant pros-theses. The advantages of such restorations includethe chairside use of full ceramics and digital impres-sions. Owing to the introduction of ceramic blockswith prefabricated twist-proof screw channels, theworkflow for the chairside manufacture of individ-ual hybrid abutments and hybrid abutment crownscan be applied in daily practice. By means of the casesreported in this article, the indications, suitable ma-terials and attachments, and related studies are dis-cussed.

_Case reports

Case 1

In September 2013, a 35-year-old patient cameinto our practice for the first time. The general anam-nesis found no peculiarities. She complained of painin the second quadrant. The clinical and the radio-logical examination found that tooth 26 was notworth preserving (Fig. 1). The patient was subse-quently informed of the treatment options, whichwere revision of the root canal filling, and a secondroot resection and extraction with subsequent im-

Permanent implant

prosthesesChairside manufacture of a hybrid abutment crown

Authors_Dr Arzu Tuna, Dr Umut Baysal & Dr Rainer Valentin, Germany

14 I implants4_2014

Fig. 1 Fig. 3Fig. 2

plantation. Finally, tooth 26 was extracted and im-plantation followed 12 weeks later (4.3 mm × 9 mmCAMLOG implants; Figs. 2–4). We decided againstclosed healing and the implant was closed with a flatgingiva former (2 mm). With this, a further operationto expose the implant could be avoided.

Chairside workflow

Ten weeks after implantation, the prostheticrestoration was performed in one session without aphysical model. A digital impression was taken bymeans of CEREC Bluecam (Sirona Dental Systems).Since no exposure of the implants was necessary andthere were no open wound edges, we were able to usethe powder for the scanning procedure without anyconcerns (Fig. 5). After the insertion of the CAMLOGTiBase (Sirona Dental Systems; Fig. 6), which servedas the titanium adhesive abutment for the chairside-manufactured hybrid abutment crown made oflithium disilicate (IPS e.max, Ivoclar Vivadent), theappropriate scan body (Sirona Dental Systems; Fig. 7)was placed on the TiBase. Before taking the impres-sion, the placement of the TiBase was radiologicallycontrolled (Fig. 8).

The virtual construction was created by means ofCEREC Software 4.2 (Sirona Dental Systems) and wasbuilt up similar to the crown’s construction. An ad-vantage of the virtual construction is the more flex-ible control of the emergence profile. The pressure onthe gingiva can be adjusted individually, and dis-placements of about 5 mm have proven to be un-problematic.

Further parameters, such as minimum strengthand position of the screw channels, should be ad-justed and included in the construction according tothe manufacturer’s instructions. The manufacture ofthe hybrid abutment crown was achieved with theCEREC MC XL milling unit (Sirona Dental Systems;Fig. 9). After the colour determination, the lowtranslucency A2 A16 (L) ceramic block was selected.

After glazing and colouring, the crystallisation orcombination firing was done (Programat CS, IvoclarVivadent). The monolithic polished abutment crownwas then extra-orally attached (Multilink HybridAbutment, Ivoclar Vivadent) to the TiBase (Fig. 10).The hybrid abutment crown was screwed in and the

I 15implants4_2014

Fig. 4_Four weeks after

implantation.

Fig. 5_The situation before the

digital impression.

Fig. 6_CAMLOG TiBase.

Fig. 7_Preparation for the

digital impression.

Fig. 8_Radiological control

of the TiBase.

Fig. 9_The hybrid abutment

produced by the milling unit.

Fig. 10_The hybrid abutment crown

with luting composite.

Fig. 6 Fig. 7

Fig. 4 Fig. 5

Fig. 8 Fig. 10Fig. 9

Fig. 11_Intraoral view after insertion.

Fig. 12_Case 2: three months

after implantation.

Figs. 13 & 14_Try-in of the hybrid

abutment crown before

crystallisation firing.

Fig. 15 a_The hybrid abutment

crown on the firing tray before

crystallisation firing.

Figs. 15b & c_Intra-oral view of the

crown.

Figs. 16–18_Case 3: implant

restoration in regio 15.

Fig. 14 Fig. 15bFig. 15a

Fig. 11 Fig. 13Fig. 12

I case report

16 I implants4_2014

screw channel was sealed with PTFE tape (3M ESPE)and composite (IPS Empress Direct, Ivoclar Vivadent;Fig. 11).

Cases 2 and 3

Figures 12 to 18 illustrate the cases of the secondand third patients. Both patients were treated fol-lowing the same treatment plan described in the firstcase.

Case 2 demonstrates the prosthetic restoration ofan implant in region 26 (Fig. 12). Figures 13 and 14

show the try-in of the hybrid abutment crown beforecrystallisation firing. After the try-in, the polishedceramic crown was glazed, coloured and filled withauxiliary firing paste (IPS Object Fix Putty, Ivoclar Vi-vadent; Figs. 15a–c). Case 3 shows restoration in re-gion 15 (Figs. 16–18).

_Discussion

Restoration using CAD/CAM methods has beenestablished as standard in implant prostheses. Be-sides the industrial manufacture of materials and the

Fig. 15c Fig. 16

Fig. 17 Fig. 18

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consequent high quality, the individualised, tooth-coloured design of the emergence profile and flexi-bility regarding construction (angulation, dimen-sion) are further advantages. Furthermore, digitaltreatment concepts offer the possibility of chairsiderestoration and shortened treatment duration with-out compromising the healing period. Systems thatdo not require the use of powder offer the possibilityof detecting the implant position during implant in-sertion and thus the possibility of a prostheticrestoration during exposure. In this way, the designand dimensions of the superstructure can be ideallycreated without the need for individual gingiva for-mers. From an aesthetic aspect, it makes sense tohave a natural and tooth-coloured emergence pro-file. In view of possible recession, the risk of exposedmetallic elements can be avoided.

_Conclusion

As described in the cases reported, the hybridabutment and the hybrid abutment crown togetheroffer a suitable alternative to full-ceramic abut-ments made of zirconium dioxide ceramic. Contraryto zirconium dioxide abutments, the mating surfaceto the implant body is made of titanium and not ofzirconium dioxide ceramic. Since zirconium dioxideceramic is harder than titanium, the implant bodycan be affected by material abrasion, which appearsto be confirmed by recent studies. In addition, a darkdiscolouration of the surrounding gingiva can arisefrom the worn-off titanium particles, similar toamalgam tattoos. In aesthetically significant areas,such as the anterior maxillary zone, this would be aserious complication and could arise years after in-sertion. Regarding the adhesive bond between theTiBase and abutment body, the initial data is verypromising. If adhesion is performed carefully ac-cording to manufacturer’s instructions, it should notfail.

Finally, further studies are needed to clarify thebiocompatibility of adhesive gaps with the sur-rounding tissue positioned 0.4 mm from the implantshoulder and ideally also from the bone._

Dr Arzu Tuna

Dr Umut Baysal

Praxis am NordwallNordwall 257439 Attendorn, Germany

www.zahnarzt-attendorn.de

_contact implants