Prosthodontic Considerations in the Implant-Supported All-Ceramic

Restoration of Congenitally Missing Maxillary Lateral Incisor:

A Clinical Report
Francisco Martı́nez-Rus, DDS, PhD,1 Begoña Rivera, DDS, PhD,2 Mutlu Özcan, Prof Dr med dent, PhD,3
& Guillermo Pradı́es, DDS, PhD1
1
Department of Buccofacial Prostheses, University Complutense of Madrid, Madrid, Spain
2
Department of Dentistry, University Rey Juan Carlos, Madrid, Spain
3
Clinic for Fixed and Removable Prosthodontics and Dental Materials Science, University of Zürich, Zürich, Switzerland

Keywords Abstract
Custom abutment; feldspathic porcelain;
fractography; osseointegrated implant; tooth
The congenitally missing maxillary lateral incisor is the most common agenesis in the
agenesis; zirconia. anterior region. There are several treatment options for this anomaly, which causes
severe deficiencies: orthodontic space closure, tooth-supported restoration, or single-
Correspondence tooth implant. Each of these solutions has a high degree of success if used in the
Francisco Martı́nez-Rus, University correct situation. An implant-supported restoration with an interdisciplinary approach
Complutense of Madrid—Buccofacial provides a predictable outcome. This article describes the treatment of a patient with
Prosthesis, Faculty of Odontology, Plaza agenesis of the maxillary left lateral incisor. After orthodontic space management, it
Ramón y Cajal 28040, Madrid 28040, Spain. was decided to restore the tooth with an all-ceramic crown cemented on a zirconia
E-mail: [email protected] custom abutment, which fractured after only 6 weeks of service. Fractographic analysis
revealed that the failure was due to over-reduction of the buccal wall to correct the
The authors deny any conflicts of interest. labial emergence of the implant. Zirconia abutments should be designed with even
Accepted May 9, 2013
wall thicknesses of at least 0.8 mm to avoid areas that may compromise functional
success.
doi: 10.1111/jopr.12096

The most common congenitally missing anterior tooth is the and bulk microstructural defects, may lead to crack formation
maxillary lateral incisor, which affects about 1% to 2% of and jeopardize the overall stability of the material.11,12
the world’s population.1 Today, multiple treatment options for This article describes the multidisciplinary treatment of a
the replacement of congenitally missing lateral incisors ex- young female patient with agenesis of the maxillary left lateral
ist, including orthodontic repositioning of canines to close incisor, in which there was a fracture of the zirconia custom
the edentulous space, tooth-supported restorations, and single- abutment after only 6 weeks of service.
tooth implants. The advantages and disadvantages of each of
these solutions have been widely discussed in the literature.2-4 Clinical report
An implant-supported restoration with an interdisciplinary ap-
proach provides a predictable outcome.4-7 The patient was in good general health, and the medical and
Especially in the anterior zone, the success of single-implant dental histories were noncontributory. The initial clinical situa-
therapy depends on the harmony of the crown-implant complex tion showed narrow dental arches, a congenitally missing max-
in terms of color and form with the mucosa and the neighboring illary left lateral incisor with the canine located in the lateral
teeth.8 In that respect, the use of customized emergence profiles incisor position, and the deciduous primary canine still located
and abutments is critical to imitate the appearance of natural in its original position (Fig 1). The patient was classified as
teeth. The high mechanical properties and good biological com- American College of Prosthodontists Prosthodontic Diagnostic
patibility of zirconia have led to its increased use as an abutment Index (ACP PDI) class I patient. Treatment planning involved
material. The results from a recent clinical study demonstrated a multidisciplinary interaction among restorative dentistry, or-
that zirconia abutments for implant-supported crowns per- thodontics, and implantology to achieve satisfactory esthetics
formed well over a follow-up period of up to 5 years.9 Fractures and functional results.
of zirconia abutments have been rarely reported to date.10 Nev- The deciduous maxillary left canine was extracted, and
ertheless, in vitro studies have demonstrated that the reduction a fixed orthodontic appliance was used to correct the mal-
in zirconia’s bulk thickness, as well as the existence of surface occlusion and redistribute the interdental spaces to create

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All-Ceramic Implant Restoration of Maxillary Lateral Incisor Martı́nez-Rus et al

Figure 1 Pretreatment intraoral views showing esthetic and functional deficiencies due to canine location and presence of primary tooth.

Figure 2 Before removing the orthodontic appliance, a panoramic radio-

graph was taken to confirm the ideal root position and adequate spacing Figure 5 Intraoral view of the new zirconia implant abutment, which was
for future implant placement. designed with less palatal tilting to avoid areas that might compromise
functional success.

Figure 6 Clinical follow-up after 8 months.

Figure 3 Intraoral view of the zirconia implant abutment.

appropriate spacing for the implant rehabilitation. Before

debonding the maxillary brackets, a panoramic radiograph was
taken to confirm the adequate root position of the maxillary
left central incisor and canine for future implant placement
(Fig 2). After orthodontic treatment was finalized, a removable
retainer (DENTSPLY Raintree Essix Glenroe, Sarasota, FL)
with a prosthetic tooth was used to replace the missing tooth as
well as to ensure postorthodontic retention.
The surgical phase was initiated at 20 years of age with clin-
ical and radiographic examination of the maxillary left lateral
incisor site. The bone height and mesiodistal width were ade-
quate for implant placement; however, computerized tomogra-
phy revealed a slight alveolar process buccal undercut, which
Figure 4 SEM image of clinically failed zirconia abutment. Note that the the authors desired to correct by bone augmentation procedure.
critical crack was located at the internal surface of the labial axial wall The patient refused bone grafting at the site. Therefore, an al-
(70×). ternative possibility was proposed, placing the implant with

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Martı́nez-Rus et al All-Ceramic Implant Restoration of Maxillary Lateral Incisor

a more labial inclination. A screw implant of 13 mm length tate future implant placement; however, success of single-tooth
and 3.75 mm diameter (MG-Osseous; Mozo-Grau, Valladolid, implants is no longer defined solely by the survival of the im-
Spain) was placed following the manufacturer’s osteotomy pro- plant. Maintenance of a harmonious soft- and hard-tissue archi-
tocol. The implant shoulder was positioned about 1 mm apical tecture, and achievement of undetectable implant restorations
to the cemento-enamel junction (CEJ) of the contralateral tooth, are among the challenges of modern implant dentistry.
with the extended long axis directed slightly labial to the incisal In the anterior maxilla, implant placement in an ideal restora-
edge of the planned restoration. tive tooth position is often not possible because of the lack of
Following a 3-month healing period, a minimally invasive sufficient bone, vertically and/or horizontally. Deficient alve-
surgical procedure was performed to expose the implant. An olar crest width and/or facial bone atrophy require a bone
implant-level impression was made using a tapered transfer augmentation procedure so the implant can be positioned in
coping and vinylpolysiloxane (VPS) (Virtual; Ivoclar Vivadent, a correct position. Such patients should be informed of the im-
Schaan, Liechtenstein) to produce the first working cast. A portance of proper site development for implant placement. The
diagnostic wax set-up revealed the need to fabricate a cement- quality and quantity of alveolar bone and gingival tissues in a
retained crown on a custom ceramic abutment to compensate potential implant recipient site are major determinants of the
for the labial emergence of the implant. CAD/CAM technol- long-term prognosis of implant treatment.13 In this case, the
ogy was used to create an individualized zirconia abutment implant shoulder was positioned mesiodistally and apicocoro-
(NobelProcera Abutment Zirconia; Nobel Biocare, Zürich, nally in the comfort zones; however, in the orofacial dimension,
Switzerland) according to the prospective dimensions of the the implant shoulder was slightly labial to the point of emer-
definitive restoration and respecting the minimum wall thick- gence of the adjacent teeth, because the patient was interested
ness of 0.9 mm up to a height of 3 mm above the implant level, in implant-retained rehabilitation without bone augmentation
as recommended by the manufacturer. To ensure the ideal space procedure.
for the core and veneering material, it was designed angled so Several authors have concluded that angulated abutments
the screw-access opening emerged through the buccal surface. may be considered a suitable restorative option when implants
The abutment was torqued to 35 Ncm according to the are not placed in ideal axial positions.14,15 In the present case, a
manufacturer’s recommendation using a torque control system zirconia custom abutment was fabricated to improve the emer-
(no. 29165; Nobel Biocare) (Fig 3). After the screw hole gence profile of the definitive restoration and imitate the ap-
was filled with polytetrafluoroethylene tape and restorative pearance of natural teeth. All-ceramic abutments made from
material (Tetric Evoceram; Ivoclar Vivadent), a provisional zirconia have some esthetic advantages over titanium abut-
crown was cemented with zinc-oxide eugenol (TempBond; ments; however, the material itself is not the exclusive deter-
Kerr Corporation, Orange, CA) to stabilize the gingival tissue minant for clinical success. Despite their attractive mechani-
surrounding restoration. cal properties, zirconia abutments are less stable than titanium
The fabrication of the final implant-supported crown was ini- abutments from a biomechanical point of view. In vitro stud-
tiated after 6 weeks of soft tissue maturation; however, when ies have shown that fracture resistance of crowns on titanium
removing the interim prosthesis, a catastrophic abutment frac- abutments was higher than for zirconia abutments.16-19 Proper
ture was observed in the mesiobuccal area (Fig 4). Therefore, design and careful handling are key for successful implementa-
a new zirconia abutment was fabricated with a more conser- tion of zirconia-based materials.20 Zirconia abutments should
vative design to provide adequate and even wall thickness and be ideally designed to imitate a natural abutment tooth pre-
to avoid the screw-access opening in an unfavorable location pared for a complete crown. In this case, the zirconia abutment
(Fig 5). Following another 6 weeks of soft tissue stabilization fractured after only 6 weeks of service. Fractographic analysis
around the new interim prosthesis, the zirconia abutment was revealed that the failure was due to excessive tilting of the abut-
treated like a natural abutment tooth to obtain a final impression ment to correct the labial emergence of the implant. Scanning
using one gingival retraction cord (Ultrapack #000; Ultradent electron microscopic (SEM) examination showed overreduc-
Products, South Jordan, UT) and a VPS (Virtual) one-step, tion of the buccal wall, resulting in a thin cross section at the
double-mix impression technique. The final implant-supported site of fracture (441 µm) (Fig 4). To ensure long-term stability,
crown was fabricated entirely from feldspathic porcelain (SiO2 - a minimum wall thickness of 0.8 mm is required in the entire
Al2 O3 -Na2 O-K2 O) (Creation CC; Creation Willi Geller, Baar, structure of the zirconia abutment.21 Below this value, the use
Switzerland), without high-strength core, using the refractory of a titanium abutment may be more advantageous.10 In the
die technique. The crown was tried in to check the marginal present case, the new zirconia abutment was designed signifi-
adaptation, emergence profile, and interproximal contacts. An cantly less angulated (more straight) to provide increased wall
adhesive resin cement (Multilink Implant; Ivoclar Vivadent) thickness and thus to gain full potential of its high strength.
was used for final insertion of the restoration. Figure 6 shows Additionally, unexpected failure of zirconia abutments could
the final result after 8 months. be related to other causes, such as over-torquing, defects in the
fabrication process, sintering prestresses, or handling errors.10
Discussion Moreover, not only the implant abutment but also the im-
plant restoration material should be considered during pros-
Multidisciplinary treatment planning is necessary for esthetic thetic treatment planning of congenitally missing maxillary
and functional success of implant replacement of congenitally lateral incisors. Different studies have proposed the use of all-
missing maxillary lateral incisors. The orthodontic treatment ceramic restorations for esthetic rehabilitation of single-tooth
must provide the coronal and apical spacing necessary to facili- implants.22-25 At present, there is an abundance of all-ceramic

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C 2013 by the American College of Prosthodontists 3
All-Ceramic Implant Restoration of Maxillary Lateral Incisor Martı́nez-Rus et al

systems available for fabrication of an implant-supported sin- follow-up study. Clin Oral Implants Res 2011;22:1308-
gle crown. In this case, because of the limited labial space for 1314
ceramic material and to maintain the labial profile in harmony 10. Aboushelib MN, Salameh Z: Zirconia implant abutment fracture:
with adjacent teeth, the new zirconia abutment was restored clinical case reports and precautions for use. Int J Prosthodont
with a feldspathic porcelain all-ceramic crown. This ceramic 2009;22:616-619
11. Wang H, Aboushelib MN, Feilzer AJ: Strength influencing
material allows the fabrication of esthetic restorations with a
variables on CAD/CAM zirconia frameworks. Dent Mater
reduced thickness due to its high light transmission; however, 2008;24:633-638
all-ceramic crown core-veneer systems tend to be more opaque 12. Aboushelib MN, Feilzer AJ, Kleverlaan CJ: Bridging the gap
and pose a challenge when trying to match natural tooth color between clinical failure and laboratory fracture strength tests
in areas with limited space. The success of the feldspathic using a fractographic approach. Dent Mater 2009;25:383-391
porcelain restorations is greatly determined by the strength and 13. Buser D, Martin W, Belser UC: Optimizing esthetics for implant
durability of the bond to the substrate. Therefore, adhesive restorations in the anterior maxilla: anatomic and surgical
luting is mandatory to enhance their fracture resistance and considerations. Int J Oral Maxillofac Implants
longevity.26 Unfortunately, no clinical data on the effective- 2004;19(Suppl):43-61
ness of feldspathic all-ceramic crowns adhesively cemented on 14. Eger DE, Gunsolley JC, Feldman S: Comparison of angled and
standard abutments and their effect on clinical outcomes: a
zirconia abutments are available.
preliminary report. Int J Oral Maxillofac Implants
2000;15:819-823
15. Sethi A, Kaus T, Sochor P, et al: Evolution of the concept of
Acknowledgments angulated abutments in implant dentistry: 14-year clinical data.
The authors would like to thank Dr. Antonio H. de Aza (Depart- Implant Dent 2002;11:41-51
ment of Ceramics, Institute of Ceramic and Glass, Spanish Re- 16. Cho HW, Dong JK, Jin TH, et al: A study on the fracture
strength of implant-supported restorations using milled ceramic
search Council, Madrid, Spain) for his assistance with the frac-
abutments and all-ceramic crowns. Int J Prosthodont
tographic analysis. Furthermore, they gratefully acknowledge 2002;15:9-13
Mr. Pedro Horna (Horna Dental Laboratory, Madrid, Spain) for 17. Att W, Kurun S, Gerds T, et al: Fracture resistance of
the fabrication of the abutments and restorations. single-tooth implant-supported all-ceramic restorations after
exposure to the artificial mouth. J Oral Rehabil 2006;33:380-386
18. Att W, Kurun S, Gerds T, et al: Fracture resistance of
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