CASE REPORT

SURGICAL PROTOCOL – OVERVIEW

The 55-year-old patient consulted our practice because

she hoped to improve the appearance of her anterior teeth

(Fig. 1). The treatment was tied to a limited budget and there-

fore had to meet the patient’s wish for predictability and

transparence relating to the expected costs.

Following a thorough examination, tooth 21 was judged not

salvageable and revisions of the root fillings were planned for

teeth 13, 12, 11 and 22 in order to treat the teeth later with post-

cores and ceramic crowns if the prognosis was good (Fig. 2).

Tooth 21 was gently removed so that only the soft tissue

volume needed to be improved. A mucosal transplant was

harvested from the palate and precisely placed (Fig. 3).

A slight volume excess of soft tissue is helpful for the im-

plant placement and for soft tissue contouring, which will

be subsequently required (Fig. 5). The laboratory-fabricated

temporary denture delivered at this visit is an important

step in the protocol (Fig. 4).

The healing process can then be awaited without imposition

of restrictions – but good material and prosthetic precision

are necessary for this. The patient gets a feel for the later

esthetics and can propose his own relevant ideas early on.

Insertion of an Ankylos C/X implant was performed three

months later. This type of implant is especially suitable for

single tooth replacement and has proved its worth excep-

tionally well in our practice routine. A clearly visible step

between implant and placement head contributes to place-

ment precision. The insertion was performed according to

the manufacturer’s instructions (Fig. 6).

The later uncovery and impression were likewise performed

in accordance with the classical protocol steps (Fig. 7). But

for several years we have been reducing the number of steps,

depending on the case, because we take an index impression

of the implants on the very day of insertion and so can deliver

a ready-to-use, anatomically correct, individual healing

abutment by the uncovery date (Fig. 8).

We believe that this change in the implant protocol is the

wave of the future. After two weeks of wearing this ceramic

gingiva former, the tissue is optimally contoured, and with

its emergence profile it provides an ideal model for the later

individual abutment (Fig. 9).

The most valuable information it provides is that every

custom-made abutment must be accompanied by an equally

individualized healing abutment. Prefabricated components

are not effective since an incorrectly contoured tissue site

hinders the delivery of the final abutment. Non-displaced

tissue can become trapped and thereby prevent correct abut-

ment seating. Such an event can introduce the risk of screw

fracture during the insertion at a preset torque.

standard versus custom-madeWhat benef its do individually fabricated abutments have?

| Rafaela Jenatschke | Carsten Fischer

1_Initial situation of the teeth to be treated: 13 to 22; tooth 21 is not salvageable.

2_Radiographic image of teeth 11 and 21

3_The alveolar cavity was carefully prepared and the inadequate tissue volume corrected with a soft tissue transplant

from the palate (socket preservation).

4_A laboratory-fabricated long-term provisional minimizes possible risks. The surrounding mucosa therefore has adequate

time for regeneration. Furthermore, esthetic expectations can be defined. The patient must not have to accept restrictions

before the delivery of the final restoration.

5_The excess soft tissue harvested is required to offset an unavoidable reduction during the healing process and also

to retain adequate tissue for proper contouring during the implant insertion.

6_The implant insertion is performed according to the manufacturer’s instructions. The picture shows the Ankylos C/X

placement heads with which the implant is guided into the correct position.

7_Status after uncovery and before the impression with open tray technique. An intraoperative impression makes it possible

to forego this additional session depending on the case.

8_Individual abutments require individual gingival contouring. An individual healing abutment in zirconium oxide is

fabricated to obtain optimal tissue deposition and correct contouring of the emergence profile. The defined emergence profile

is the ideal guide for the subsequent Custom Abutment.

9_Early delivery of the individual abutment in zirconium dioxide (Cercon) enables heretofore unprecedented rapid healing

of the surrounding tissue.

The right abutment choice is a key requirement for the long-term success of an implant-supported restoration.

Apart from the selection of angulation and shoulder/gingival height, the question of the right material –

especially in terms of esthetics – takes center stage among the factors to be considered. The major challenge

here is to avoid undesirable mucosal discolorations.

Although there is a wealth of standard components for the Xive and Ankylos systems (DENTSPLY Friadent),

current demands for manageable cementation space, a natural emergence profile and adequate retention

of the abutment cannot always be achieved through catalog items in the presence of a very irregular mucosal

line. A new type of procedure for the creation of custom-tailored abutments is described below as part

of a case report.

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Dr Rafaela Jenatschke

Lyoner Str. 44–48, 60528 Frankfurt / Germany

r.jenatschke@your-smile.biz

DT Carsten Fischer

sirius ceramics carsten fischer

Lyoner Str. 44–48, 60528 Frankfurt / Germany

info@sirius-ceramics.com

the screen. The dentist no longer marks his preferences

on a laboratory order but discusses them directly with the

dental technician. Digital data are used in joint planning and

decision-making. This is extraordinarily important, especially

in borderline cases (Fig. 15). The base portion of the Cercon

abutment must be highly polished using diamond paste.

The connection geometry in such cases is protected by an

implant analog and must not be touched. We receive an

exact copy of the virtual depiction. The fabrication of the

final restoration is performed on an optimally stable base.

The custom-made abutment follows the form of the adjacent

teeth (Figs. 16 and 17).

The delivery of the abutments is also performed according to

the manufacturer instructions (Fig. 18). The delivery functions

as easily as with standard components because of guided tis-

sue contouring. The insertion of the ceramic crown restoration

is performed with the aid of a palatal cementation key. Shortly

after the delivery the implant crown is no longer distinguish-

able from the adjacent natural teeth (Figs. 20 and 21).

Custom-fabricated abutments have already become a fixed

component of the implant-supported treatment concept in

our practice routine. They are an indispensable asset for

managing the success of oral restorations, especially in the

esthetic zone and in complex restorations combined with

high esthetic expectations by the patients. n

LABORATORY FABRICATION STEPS

The implant model is fabricated according to the conventional

techniques using a non-hardening gingival mask as saw-cut

model. The gingival mask is etched according to the planned

emergence profile.

Five different scanning cycles are performed with the Cercon

eye scanner (DeguDent, Hanau, Germany) and yield the first

digital image of the situation in the overlay. The software

proposes initial suggestions for a Custom Abutment, but all

details of these are open to refinement (Fig. 10). With a few

clicks of the mouse the virtual abutment acquires the shape

of an optimal dental stump (Fig. 12). Angulation, position of

the screw channel and the insertion direction harmonize

with the scanned-in shapes of the wax-up (Fig. 13).

The ease with which the emergence profile can be presented

and modified is particularly impressive (Fig. 11).

BENEFITS OF CUSTOM-FABRICATED INDIVIDUAL

ABUTMENTS

n Perfect industrial quality despite single unit fabrication

n Secure retention of the superstructure

n Manageable cementation space through a natural

emergence profile

n Zirconium oxide can be used also in the posterior region;

it requires a TitaniumBase

SINGLE AND TWO-PART INDIVIDUAL ABUTMENTS

Individual abutments are available in zirconium oxide and

titanium, and in both one- and two-piece type. The new

TitaniumBase (available for Xive and Ankylos) is used

as the bonding base in the two-piece design (Fig. 14). The

TitaniumBase sets the connection geometry between the

implant and the platform for the delivered Cercon abutment.

The two components are bonded together in the laboratory.

This type of individual abutment offers the best possible

reliability. Forces arising during the delivery of the abutment

are transmitted through the titanium portion so that the risk

of fracture is minimized. The zirconium oxide also permits

individual shaping and offers the highest level of esthetics

and the best tissue tolerance. Besides the capability to shape

abutments individually on the computer, dentist and dental

technician can communicate directly with each another on

18_The two-piece ceramic abutment fits completely naturally into the optimally formed tissue bed.

Thanks to the controlled molding of the tissues, there is no undesirable displacement of the surrounding tissues.

19_The individual abutment fits into its environment like the stump of a tooth. Thanks to the controlled cementing gap,

the subsequent crown can be cemented without irritation.

20_The completed ceramic crown restoration,13 to 22. Condition three weeks after cementing.

21_Harmonious and natural integration of the restoration into the oral environment.

22_The patient confirms the natural effect of the new restorations and the success of the collaboration by her smile.

10_Various scan phases are added together (matched) to form a virtual image for virtual fabrication of the individual abutment.

11_The perfect virtual fit into the contoured tissue process and the height of the mucosa are one particularly great advantage provided

by this technology. Likewise, a completely new type of communication can take place between dentist and dental technician.

12_The TitaniumBase bonding base is automatically input into the data image.

13_So, in no time at all, an individual custom-tailored abutment can be designed – optionally as a two-component unit (Cercon / TitaniumBase)

or a single-component unit (Cercon). All parameters of the abutment were able to be freely designed without a great deal of prior knowledge.

14_TitaniumBase is available in the indexed /X variant and the non-indexed C/ variant.

15_The two-piece abutment, consisting of the titanium bonding base (TitaniumBase) and the individual Cercon abutment.

16, 17_The custom-tailored abutment with its optimally scaled-down tooth. Hence, it provides the best retention, a controllable cementing

gap and the optimal support for the ceramic crown.

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