PUBLISHED ARTICLE

RESTORING SOFT AND HARD DENTAL TISSUES USING A REMOVABLE IMPLANT PROSTHESIS WITH DIGITAL IMAGING FOR OPTIMUM DENTAL AESTHETICS: A CLINICAL REPORT


 Edward M. Amet, DDS, MSD
     Diplomate American Board of Prosthodontics
     Diplomate American Board of Oral Implantology/Implant Dentistry


ABSTRACT


Currently most dental implants are placed in the aesthetic zone with a delayed surgical protocol. This delay can result in loss of both soft and hard oral tissues following the healing period, necessitating guided tissue regeneration, distraction osteogenesis, or bone expansion and grafting procedures either prior to or at the time of implant placement. If a delayed placement protocol is used or if grafting procedures are ineffectual, the prosthetic phase of implant dentistry must restore the missing structures artistically and functionally to integrate with the patient’s existing dentition. This article reviews a technique that provides for aesthetic restoration of soft and hard tissues with digital imaging using a unique removable implant prosthesis. A computer-assisted camera was used to record speaking, smiling, and active facial positions, with digital imaging to achieve realism for tooth position during the prosthetic phase. The captured patient images with the aesthetic set-ups were transmitted by e-mail with direct viewing by both dentist and dental technician prior to case completion. These images were viewed as references files during laboratory construction of the prosthesis to achieve the desired esthetic and functional results. 

KEY WORDS: aesthetic zone, implants placed in a delayed manner 

The aesthetics restoration of facial appearance and improved dental function with implant prosthodontics is directly related to correctly restoring missing intraoral soft and hard tissues and the aesthetics and technical abilities of the dentist and dental technician.^l The use of dental implants for oral rehabilitation has revolutionized prosthodontics over the past 3 decades. Multiple studies have proven the efficacy and excellent long-term prognosis with dental implants.^2-5 

While initial research and clinical use were directed primarily toward the edentulous patient, more recent studies have focused on the aesthetic and functional use of implants in the partially edentulous patient.6 The most challenging area of modern implant dentistry remains the “esthetic zone” in the anterior maxilla and mandible. Replacing multiple anterior teeth in the otherwise dentate patient requires careful consideration of the location and volume of residual bone, soft tissue aesthetics, and room for the implants and prosthesis. 

Most dental implants are placed in a delayed manner, after tooth extraction allowing for both hard and soft tissues to heal prior to implantation. Unfortunately, this allows for resorption of the alveolar ridge in both the buccolingual and coronoapical directions. Studies have shown that as much as 3 to 4 mm of resorption can occur during the first 6 months post extraction without the intervention of tissue grafting or regeneration techniques.^7,8 Dental implants if placed with a delayed surgical protocol, for an implant supported ceramometal reconstruction with only residual native bone may have unnatural tooth length with spaces between the root structures. 

Since facial appearance and normal speech depends on where the teeth are positioned, as well as their shape, form, surface texture and color, it is often not difficult on casual meeting to detect a person who has an implant supported overdenture or fixed partial denture. To compensate for the appearance change, small teeth are often used. The evenly set small teeth can detract from realism and interfere with speech patterns. The lips will often appear lengthened, tense or thin in an attempt to conceal anterior teeth, which may be set too far posterior in the mouth. The result is the appearance of premature aging which is caused not by age itself but by the change of facial appearance from the chin and nose to close together with the soft tissue compensating for this change in occlusal vertical dimension, or decreased facial height. The result is the lack of an aesthetic dental smile with premature aging and may result in the incorrect pronunciation of words with the f, & v sounds Fig 1 & 5. 

The most important information to be sought while the patient makes the f, & v sounds, is the relationship of the incisal edges to the lower lip. The dentist should stand along side the patient and look at the lower lip and the upper anterior teeth. If the upper anterior teeth touch the labial surface of the lower lip while these sounds are made, the upper anterior teeth are too far forward or the lower anterior teeth are too far back in the mouth. 

If the upper anterior teeth are set to far back in the mouth, they will contact the lingual side of the lower lip when f & v sounds are made. This may also may occur if the lower anterior teeth are set too far forward in relation to the lower residual ridge. Observing from the side and slightly above the patient will provide the necessary information for determining which changes should be made.

From a dental point of view, the s sound is the most important one. This is the case because its articulation is mainly influenced by the teeth and palatal part of the maxillary prosthesis. The sibilants or (sharp sounds) s, z, sh, ch, and j are alveolar sounds, because the tongue and alveolus form the controlling valve. The important observation when the s or sibilant sound is produced, is the relationship of the anterior teeth to each other. The upper and lower incisors should approach end to end but not touch. More important, a failure of the incisal edges to approach exactly end to end indicates a possible error in the amount of horizontal overlap of the anterior teeth. This test will reveal the error but will not indicate whether it is the upper teeth or the lower teeth that are incorrect labiolingually.

An implant in bone stimulates and maintains bone dimension and density in a manner similar to healthy natural teeth. As a result of implant stability and prosthetic position, the patient's facial features are complimented by support. A totally implant-supported restorations can be positioned for aesthetics, function, and speech, rather than in the "neutral zones" of soft tissue support as in a complete tissue supported removable prosthesis. 

The purpose of this clinical report is to describe a unique removable implant prosthesis for the aesthetic restoration of missing soft and hard tissues using a computer-assisted camera with digital imaging. These images are viewed as references files during laboratory construction of the prosthesis when the patient is not available, having been recorded during office visits with speaking, smiling, and active facial positions, to achieve realism in the final removable prosthesis. The patient captured images can then be transmit by e-mail with the artistic and functional results viewed by both dentist and dental technician. Finally both professionals have the ability to work together more effectively, as each can view the treatment progress and suggest improvements prior to completion.

MATERIAL AND METHOD
An intraoral dental camera (Imagin, from Imagin Co, Irvine, CA) with a computer network system
(ViperSoft Software, Carmarillo, CA) was used to record all patient treatment images. A preoperative photograph, often a picture of a much younger age or pre-operative appearance, was scanned into to the computer with the camera or a flat bed scanner to represent the patient’s original and desired appearance. The patient’s current dental prosthesis and facial appearance are then scanned into the computer with a combination of a zero and 90 degree camera lenses. The intraoral and extraoral findings are best recorded with the zero degree lens, to achieve the most desired facial appearance . All prosthesis setups are tried-in and recorded with speaking, smiling, and active facial positions with full profile and frontal views. Fricative and sibilant sounds are used to aid in determining incisal edge position and maxillary central incisor to vermilion lip border position as well as midline, buccal corridor, and occlusal plane positions. These are recorded for verification at the patient appointment and reviewed later in the laboratory prior to completion of the prosthesis

PATIENT REPORT #1

A 58-year-old white Caucasian female presented for a new removable overdenture prosthesis, after 5 years of function with a previously placed implant prosthesis. A panoramic radiograph revealed complete

edentulism of both the maxillary and mandibular arches, with 4 dental implants having been previously placed in the symphysis of the mandible. A defective implant connecting bar was present. A tentative treatment plan was developed consisting of; restoring normal occlusal vertical dimension, constructing a new implant connecting bar with a totally implant supported mandibular overdenture, a maxillary complete denture, and the use of anatomical porcelain denture teeth. Pre-operative and post-operative photographs show the difference in facial appearance and shape with the newly constructed removable prosthesis. A photograph of the patient’s appearance and smile at high school graduation was scanned into the computer as a direction for tooth replacement. The vermilion borders of the lips as the patient presented for prosthesis replacement, were thin from lack of adequate support and the reduced occlusal vertical dimension. The previous tooth arrangement consisted of small, dark, evenly set teeth, that had been positioned too far posterior in the mouth, resulting in the lack of an aesthetic dental smile with resulting premature aged appearance. The computer-assisted camera enabled a comparison between the appearance as the patient presented, the original high school photograph recorded in the computer, and the new prosthesis during its construction phase in the laboratory, and resulted in the new prosthesis and aesthetic facial appearance.

PATIENT REPORT #2

A 36-year-old white Caucasian male presented after implant placement for ceramometal 

Fig 7. Pre-operative photograph of patient needing implant prosthetic reconstruction.

reconstruction. The implants as placed were in residual native bone resulting in an excessive opposing tooth to ridge defect. A traditional implant ceramometal reconstruction would result in teeth of unnatural length with spaces between the root structures or the need for porcelain gingivae. The management of patient aesthetics in compromised implant position with a high lip line involves; traditional fixed prosthodontics, which may result in hypertrophied tooth length with spaces between the roots or need for tissue colored porcelain with hygiene maintenance difficulties 
and a retrievable prosthesis. Deficient areas with previously placed implants can also be corrected by implant removal, grafting or distraction osteogenesis, and then implant replacement and ceramometal prosthesis. Removable prosthodontics however, can manage implant position as 

Fig 8. Profile view displaying a high lip line, excessive tooth height to restore without replacing soft tissue, posterior crossbite, and a class III mandible.

placed with correction of soft or hard tissue deficiencies. The removable implant partial prosthesis gains stability from the prosthesis guides of the implant connecting bar and metal retention clips. 

Pre-prosthetic photographs of the patient displayed a high lip line with excessive tooth height to restore without replacing soft tissue, a posterior crossbite, and a class III mandible. Four dental implants had been previously placed in the partially edentulous premaxilla. A tentative treatment plan was developed consisting of; restoring normal facial aesthetics using an implant connecting bar with a totally implant supported maxillary removable partial denture, and the use of personalized plastic denture teeth. Pre-operative and post-operative photographs show the difference in facial appearance and restoration of the missing hard and soft tissues with the newly constructed removable prosthesis. A photograph of the patient’s appearance and smile at high school graduation was scanned into the computer as a direction for tooth replacement. The vermilion border of the maxillary lip as the patient presented for prosthesis replacement, was thin from lack of adequate support. The original natural tooth arrangement consisted of teeth, that had been positioned in a class III jaw relationship, resulting in an aesthetic dental smile. The computer-assisted camera enabled a comparison between the appearance as the patient presented, the original high school photograph recorded in the computer, and the new prosthesis during its construction phase in the laboratory, and resulted in the aesthetic facial appearance.

The laboratory phase of the reconstruction consisted of a series of steps using the master cast to construct the implant connecting bar and removable prosthesis as shown in figs 9-16. Every attempt was made to create an illusion as well as realism in the prosthesis, resulting in patient satisfaction.

                                                                                        Fig 9. Wax-up for implant connecting bar with prosthesis guides in red wax.
                                                                                        Fig 10. Frontal view of cast and polished bar with prosthesis guides.
                                                                                        Fig 11. Occlusal view of cast and polished bar with prosthesis guides.
                                                                                        Fig 12. Occlusal view of cast with implant connecting bar waxed out for duplication.

                                                                                     Fig 13. Master cast with bar and clips waxed out for duplication and framework construction.
                                                                                     Fig 14. Master cast with removable implant partial denture framework.
                                                                                     Fig 15. Master cast with removable implant partial denture completed.
                                                                                     Fig 16. Tissue surface of completed removable implant partial denture.

Fig 17. Completed removable implant partial denture

                                                                  Fig 18. Profile view displaying a high lip line, excessive tooth height to restore without replacing soft tissue, posterior crossbite, and a class III mandible.
                                                                  Fig 19. Completed removable implant partial denture.
                                                                  Fig 20. Prosthesis integrated with existing dental and facial structures.
                                                                  Fig 21. Profile view displaying a high lip line, with excessive tooth height restored with soft tissue replacement.

PATIENT REPORT #3

A 78-year-old white Caucasian female presented for restoration of previously placed posterior implants. A panoramic radiograph revealed partial edentulism of the maxillary arch, with five dental implants having been previously placed in the posterior area of the maxilla.   

                                                         Fig 20. Radiographic view displaying excessive tooth height and soft tissue to restore, posterior crossbite, and a tilted plane of occlusion.
                                                         Fig 21. Completed implant connecting bars for removable partial denture prosthesis.
                                                         Fig 22. Completed removable partial denture prosthesis with O-ring retention.
                                                         Fig 23. Occlusal view with prosthesis integrated with existing dental and facial structures with excessive tooth height and soft tissue restored.


A series of short implants were present with 5mm healing abutments. A tentative treatment plan was developed consisting of; restoring existing occlusal vertical dimension, constructing bilateral implant connecting bars, and a totally implant supported maxillary removable partial denture with the use of anatomical plastic denture teeth. Pre-operative and post-operative photographs show the difference in occlusal view with the newly constructed and retentive removable implant prosthesis with O-ring retention.

CONCLUSION 
If dental implants are placed with a delayed surgical protocol it can result in loss of both soft and hard oral tissues during the healing period, necessitating guide tissue regeneration, distraction osteogenesis, or a bone grafting procedure either prior to or at the time of implant placement. If a delayed placement protocol is used or if grafting procedures are ineffectual, the prosthetic phase of implant dentistry must restore the missing structures artistically and functionally to integrate with the patient’s existing dentition. This article reviewed a technique that provided for aesthetic restoration of soft and hard tissues with a unique removable implant prosthesis. A computer-assisted camera with digital imaging was used to record speaking, smiling, and active facial positions, to achieve realism during the implant prosthesis construction. The captured patient images, and the artistic endeavor were transmit by e-mail with direct viewing by both dentist and dental technician to achieve the desired aesthetic and functional result prior to completion. 

REFERENCES 
1. Zarb G, Bolender C, Carlsson, G, Boucher’s Prosthodontic Treatment for Edentulous Patients, Eleventh Edition. St. Louis, The C. V. Mosby Company; 1997.
2. Adell R, Lekholm U, Rockler B, Branemark P-I. A 15-year study of osseointergrated implants in the treatment of edentulous jaw. Int J Oral Surg 1981;10(6):387-416. 
3. Branemark P-I., Zarb GA, Alberktsson T (eds). Tissue-Intergrated Prostheses. Osseointergration in Clinical Dentistry. Carol Stream, Il; Quintessence, 1985.Linquist LW,
4. Carlsson GE, Glantz PO. Rehabilation of the edentulous mandible with a tissue- intergrated fixed prothesis: A 6-year longitudinal study. Quintessence Int 1987; 18:89-96
5. Laney WR, Tolman D, Keller EE, Desjard RP, Van Roekel NB, Branemark P-I. Dental implants; Tissue-intergrated prosthesis utilizing the osseointergration concept. Mayo Clin Proc 1986;61(2):91-97.
6. Chiche GJ, Block MS, Pinault A. Implant surgical template for partially edentulous patients. Int J Oral Maxillofac Implants 1989;4:289-292.
7. Atwood DA, Coyt DA. Clinical, cephalometric and densitometric study of reduction of residual ridges. J Prosthet Dent 1971;26:280-293
8. Johnson K. A study of the dimensional changes occurring in the maxilla after tooth extraction. Part I: Normal healing. Aust Dent J 1963;8:428-433.

CAPTIONS

Fig 1. Thin vermilion lip borders present with lack of prosthesis support and inadequate occlusal vertical dimension.

Fig 2. Normal red vermilion lip border appearance present with adequate lip support from the prosthesis and restored occlusal vertical dimension.

Fig 3. Small dark evenly set teeth positioned too far posterior in the mouth. 

Fig 4. Normal tooth size and positioned according to a recorded patient’s picture at an earlier age with natural teeth.

Fig 5. Thin vermilion lip borders present with lack of prosthesis support and inadequate occlusal vertical dimension.

Fig 6. Normal red vermilion lip border appearance present with adequate lip support from the prosthesis and restored occlusal vertical dimension.

Fig 7. Pre-operative photograph of patient needing implant prosthodontic reconstruction.

Fig 8. Profile view displaying a high lip line, excessive tooth height to restore without replacing soft tissue, posterior crossbite, and a class III mandible.

Fig 9. Wax-up for implant connecting bar with prosthesis guides in red wax.

Fig 10. Frontal view of cast and polished bar with prosthesis guides.

Fig 11. Occlusal view of cast and polished bar with prosthesis guides.

Fig 12. Occlusal view of cast with implant connecting bar waxed out for duplication.

Fig 13. Master cast with bar and clips waxed out for duplication and framework construction.

Fig 14. Master cast with removable implant partial denture framework.

Fig 15. Master cast with removable implant partial denture completed.

Fig 16. Tissue surface of completed removable implant partial denture.

Fig 17. Completed removable implant partial denture.

Fig 18. Profile view displaying a high lip line, excessive tooth height to restore without replacing soft tissue, posterior crossbite, and a class III mandible.

Fig 19. Completed removable implant partial denture.


Fig 20. Prosthesis integrated with existing dental and facial structures.

Fig 21. Profile view displaying a high lip line, with excessive tooth height restored with soft tissue replacement.

Fig 22. Radiographic view displaying excessive tooth height and soft tissue to restore, posterior crossbite, and a tilted plane of occlusion.

Fig 23. Completed implant connecting bars for removable partial denture prosthesis.

Fig 24. Completed removable partial denture prosthesis with O-ring retention.

Fig 25. Occlusal view with prosthesis integrated with existing dental and facial structures with excessive tooth height and soft tissue restored.


Author’s C.V.


Edward M. Amet, BS, DDS, MSD, a 1965 graduate of the University of Puget Sound, a 1969 graduate of Northwestern University Dental School and a 1974 prosthodontic graduate from the University of Missouri, Kansas City, a Diplomate of the American Board of Prosthodontics and a Diplomate of the American Board of Oral Implantology/Implant Dentistry. He practices in Overland Park, Kansas as the director of the Reconstructive & Implant Dental Center and is the owner of the Reconstructive & Implant Dental Laboratory.

Joseph P Milana a dental technician with 18 years of experience, and advance training and skills in the field of dental technology.

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