Management of interproximal soft

tissue with a resin-bonded prosthesis

after immediate implant placement: A
clinical report
Erdem Ozdemir, DDS, PhD,a Wei-Shao Lin, DDS,b and
Selim Erkut, DDS, PhDc
School of Dentistry, Baskent University, Ankara, Turkey;
University of Louisville, School of Dentistry, Louisville, Ky
This report describes immediate implant placement after the extraction of a vertically fractured tooth. During the
healing phase, a resin-bonded prosthesis was inserted as a provisional restoration. After the creation of the optimal
emergence profile and papillae with the provisional restoration, the definitive metal ceramic crown was fabricated. (J
Prosthet Dent 2012;107:7-10)

The teeth most affected by trauma
are the maxillary incisors because of
their protruded position.1 When max-
illary incisors are lost, conventional
fixed, resin-bonded, partial-remov-
able, and implant-supported pros-
theses (immediate implant placement
in the extraction socket or delayed
implant placement at the healed site)
are treatment options.2
Clinical studies have demonstrat-
ed similarly favorable treatment out-
comes for immediate implant place-
ment in the extraction socket and
implant placement in the healed site
in terms of implant survival, marginal
bone resorption, soft tissue level, and
the incidence of complications.3-9 Key
factors associated with successful im-
mediate implant treatment include
atraumatic root extraction and facial
bone preservation.10 With simulta-
neous tooth extraction, immediate
implant placement and immediate
placement of a provisional restora-
tion, improved esthetics and patient
comfort with a fixed prosthesis can be
provided. This approach can decrease
the treatment time and the number of
surgeries for patients, therefore, po-
tentially increasing the acceptance of
dental implant treatments. This ap-
proach is contraindicated if primary
stability cannot be achieved because
of surgical trauma, inadequate bone
quality or quantity, or unfavorable
occlusion.11-13 Different insertion pre-
loads have been suggested to obtain
primary stability and immediate load-
ing of implants.3,14-16 Although several
factors can affect the primary stabil-
ity, such as implant design, diameter,
length, and surface texture, Wang et
al17 advocated a minimum torque
of 32 Ncm to 35 Ncm for immedi-
ate loading of single implants. When
immediate implant placement/im-
mediate loading cannot be achieved
in the esthetic region, other types of
provisional prostheses are needed. A
fixed prosthesis used as a provisional
restoration can increase patient satis-
faction more than a removable one.
A resin-bonded prosthesis (RBP) is an
alternative treatment option since it
provides the comfort of a fixed pros-
thesis and requires only minimal in-
tervention.18 It has been reported that
soft tissue contours can be improved
by applying well-controlled pressure
with a convex and highly polished
pontic surface.19,20 Applying pressure
to the soft tissue and maintenance
of oral hygiene and plaque can result
in thinning the epithelium and create
new soft tissue contours.21
This article describes a technique
using an RBP as an immediate pros-
thesis during osseointegration in the
anterior region. The pressure applied
by the ovate pontic design of the RBP
achieves interdental papilla forma-
tion and maintains the soft tissue
contours.
CLINICAL REPORT
A 28-year-old man presented to
the Prosthodontics department at
the University of Baskent with acute
symptoms related to the right central
maxillary incisor. The tooth present-
ed with failed endodontic treatment
and the radiographic examination
revealed a fractured root. No pathol-
ogy of the bone and adjacent teeth
was noted (Fig. 1). Treatment options
were presented to the patient, includ-
ing a conventional fixed prosthesis
and an implant-supported single
crown. The conventional fixed pros-
thesis option was declined by the pa-
tient because of the need to prepare
the adjacent teeth. The implant-sup-
ported single crown option was ac-
cepted by the patient, and informed

a
Clinical Doctor, Department of Prosthodontics, Faculty of Dentistry, Baskent University.
b
Assistant Professor, Department of Oral Health and Rehabilitation, School of Dentistry, University of Louisville.
c
Associate Professor, Department of Prosthodontics, Faculty of Dentistry, Baskent University.
Ozdemir et al
8 Volume 107 Issue 1
1 Periapical radiograph indicated root fracture of
right maxillary central incisor.
2 RBP was cemented with resin adhesive cement in place
after immediate implant placement.
3 Panoramic radiograph of dental implant and RBP.
The Journal of Prosthetic Dentistry
consent was obtained. A 4 mm 13
mm dental implant (Astra Tech AB,
Mlndal, Sweden) was placed imme-
diately after the atraumatic extraction
of the root of the right maxillary cen-
tral incisor. Because adequate primary
stability for immediate loading was
not achieved, a 2-stage surgical pro-
tocol was used. The implant was sub-
merged and allowed to integrate for 6
months. After the implant surgery, a
maxillary impression for the provision-
al RBP was made with condensation
silicone (Speedex; Coltne/Whale-
dentAG,Altsttten, Switzerland) and
the impression was poured with type
IV dental stone (Amberok; Anadolu
Dental Products, Istanbul, Turkey).
An irreversible hydrocolloid impres-
sion (Blueprint Cremix; Dentsply De-
Trey, GmbH, Konstanz, Germany) was
made of the opposing mandibular
dentition. The casts were articulated
in a semiadjustable articulator (Pro-
tar Evo 2; Kavo, Biberbach, Germany)
with facebow transfer and an interoc-
clusal centric relation record.
The pattern for the retainers and
pontic of the provisional RBP was fab-
ricated from sculpturing wax (Tho-
wax; Yeti Dental Products GmbH,
Engen, Germany). The metal frame-
work was fabricated with Ni-Cr alloy
(Wiron 99; Bego Dental, Bremen,
Germany) and adjusted intraorally.
An ovate pontic was created with low-
fusing feldspathic porcelain (Omega
900; VITA Zahnfabrik, Bad Sckingen,
Germany) according to the manufac-
turers instructions. The ovate pon-
tic, with its convex shape, contacts
a large area of soft tissue and places
pressure on that tissue. The RBP was
then adapted to the edentulous ridge
and cemented with adhesive resin ce-
ment (Panavia F 2.0; Kuraray, Tokyo,
Japan) according to the manufactur-
ers instructions (Fig. 2). The RBP was
inserted 3 days after surgery and the
patient was not provided with a provi-
sional restoration during this period.
A panoramic radiograph was made to
establish baseline information (Fig.
3). Oral hygiene instructions were
given to the patient, which included
Ozdemir et al
January 2012 9

4 RBP removed at 3-month appointment. Intaglio surface 5 Healed interproximal soft tissue was mature and demon-
of pontic adjusted to achieve proper soft tissue contour. strated adequate volume at 6-month recall appointment.

6 Definitive crown in place.

tooth brushing and daily flossing.
With the accessibility of the convex
pontic surface and the good oral hy-
giene maintained by the patient, no
plaque was observed during the re-
call examinations. At the 3-month
recall, the RBP was removed (Fig. 4),
and the intaglio surface of the pontic
adjusted to achieve proper soft tis-
sue contour. Rubber polishing discs
(OptraFine; Ivoclar, Schaan, Liechten-
stein) were used to polish the ceramic
surface after adjustment. The RBP
was recemented with adhesive resin
cement (Panavia F 2.0, Kuraray). At
the 6-month recall no complications
were noted. The RBP was removed
and the interproximal soft tissue had
healed and matured with adequate
volume (Fig. 5). The implant was ac-
cessed with a mucosal punch flapless
technique. A maxillary implant level
impression was made with addition
Ozdemir et al
silicone (Express; 3M ESPE, St Paul,
Minn.) with an open tray technique.
The RBP was recemented after the im-
pression procedure. An elastomeric
material for gingival reproduction
(Gi-Mask, Coltne/Whaledent) was
injected around the impression cop-
ing. A prefabricated abutment (Ti De-
sign 3.5/4.0; Astra Tech AB, Mlndal,
Sweden) was selected and prepared.
The metal coping for the definitive
restoration was fabricated with base
metal alloy (Wiron 99, composition
%: Ni: 65, Cr: 22.5, Mo: 9.5, Si: 1,
Nb: 1, Fe: 0.5, Ce: 0.5, C: max.0.02;
Bego Dental).22 Low fusing porce-
lain (Omega 900; VITA Zahnfabrik)
was applied to the metal coping. The
definitive crown was evaluated intra-
orally and the proper occlusion was
achieved. The definitive crown was
cemented with glass ionomer cement
(Ketac Cem; 3M ESPE) (Fig. 6).
DISCUSSION
An implant was placed in a fresh
extraction site and the loading of the
implant was delayed until osseoin-
tegration was achieved. During the
healing period, several provisional
prosthesis options were available to
provide an esthetic solution. Boff et
al2 proposed a provisional removable
prosthesis for the 6-month healing
period. As opposed to a removable
prosthesis, there are several advan-
tages of the RBP used in this report,
including the fact that it is minimally
invasive, has higher patient satisfac-
tion, achieves an immediate esthetic
result, and creates interdental papil-
lae by applying pressure. In this situ-
ation, the esthetic result of the soft
tissue was improved by applying well-
controlled pressure with the pontic.
Proper hygiene access was achieved
10
because of the convex shape of the
pontic and highly glazed ceramic sur-
face. At the end of the 6 month pe-
riod, there was no visible sign of soft
tissue inflammation. As Kim et al19
reported, the most favorable outcome
is obtained when pressure is applied
to thick soft tissue. To achieve an es-
thetic result, a minimum of 2 to 3 mm
of soft tissue thickness is required to
allow for the application of gingival
pressure.20 However, thick soft tis-
sue may prevent the restoration from
complete seating without applying
firm pressure. During placement of
the RBP, the soft tissue showed resis-
tance, and the restoration was held
in place until the cementation proce-
dure was completed.
Using RBP as a provisional pros-
thesis has some disadvantages be-
cause the laboratory phases are
technically demanding, the clinical
appointments are time consuming,
and there is an additional cost for the
patient.
SUMMARY
This article describes a technique
using an RBP as a provisional pros-
thesis during implant osseointegra-
tion. The soft tissue profile for the
definitive restoration can be devel-
oped with a properly designed convex
pontic during the healing period. With
successful application of this treat-
ment protocol, patient comfort and
esthetics can be provided during the
implant osseointegration phase, and
therefore the patients acceptance of
the prosthesis may be increased.
The Journal of Prosthetic Dentistry
REFERENCES
1. Loguercio AD, Leski G, Sossmeier D, Kraul
A, Oda M, Patzlaff RT, et al. Performance
of techniques used for re-attachment of
endodontically treated crown fractured
teeth. J Dent 2008 36:249-55.
2. Boff LL, Oderich E, Cardoso AC, Magne P.
Retrofitting a tooth-supported crown with
an implant and abutment: a clinical report.
J Prosthet Dent 2010;103:262-6.
3. Den Hartog L, Raghoebar GM, Stellingsma
K, Meijer HJ. Immediate loading and
customized restoration of a single implant
in the maxillary esthetic zone: a clinical
report. J Prosthet Dent 2009;102:211-5.
4. Cooper LF, Ellner S, Moriarty J, Felton
DA, Paquette D, Molina A, et al. Three-
year evaluation of single-tooth implants
restored 3 weeks after 1-stage surgery. Int J
Oral Maxillofac Implants 2007;22:791-800.
5. Andersen E, Haanaes HR, Knutsen BM.
Immediate loading of single-tooth ITI im-
plants in the anterior maxilla: a prospective
5-year pilot study. Clin Oral Implants Res
2002;13:281-7.
6. Hall JA, Payne AG, Purton DG, Torr B, Dun-
can WJ, De Silva RK. Immediately restored,
single-tapered implants in the anterior max-
illa: prosthodontic and aesthetic outcomes
after 1 year. Clin Implant Dent Relat Res
2007;9:34-45.
7. Al-Harbi SA, Edgin WA Preservation of soft
tissue contours with immediate screw-
retained provisional implant crown. J
Prosthet Dent 2007;98:329-32.
8. Pieri F, Aldini NN, Fini M, Corinaldesi G.
Immediate occlusal loading of immediately
placed implants supporting fixed restora-
tions in completely edentulous arches: a
1-year prospective pilot study. J Periodontol
2009;80:411-21.
9. Mijiritsky E, Mardinger O, Mazor Z,
Chaushu G. Immediate provisionalization
of single-tooth implants in fresh-extraction
sites at the maxillary esthetic zone: up
to 6 years of follow-up. Implant Dent
2009;18:326-33.
10.Evans CD, Chen ST. Esthetic outcomes of
immediate implant placements. Clin Oral
Implants Res 2008;19:73-80.
11.Kan JY, Rungcharassaeng K, Lozada J. Im-
mediate placement and provisionalization
of maxillary anterior single implants: 1-year
prospective study. Int J Oral Maxillofac
Implants 2003;18:31-9.
Ankara
12.Javed F, Romanos GE. The role of primary
stability for successful immediate loading of
dental implants. A literature review. J Dent
2010;38:612-20.
Volume 107 Issue 1
13.Romanos GE, Toh CG, Siar CH, Wicht H,
Yacoob H, Nentwig GH. Bone-implant in-
terface around titanium implants under dif-
ferent loading conditions: a histomorpho-
metrical analysis in the Macaca fascicularis
monkey. J Periodontol 2003;74:1483-90.
14.Pieri F, Aldini NN, Fini M, Corinaldesi G.
Immediate occlusal loading of immediately
placed implants supporting fixed restora-
tions in completely edentulous arches: a
1-year prospective pilot study. J Periodontol
2009;80:411-21.
15.Grandi T, Garuti G, Guazzi P, Tarabini L,
Forabosco A. Survival and success rates
of immediately and early loaded implants:
12-month results from a multicentric
randomized clinical study. Oral Implantol
2011 Apr 11 [Epub ahead of print]
16.Atieh MA, Atieh AH, Payne AGT, Duncan
WJ. Immediate loading with single implant
crowns: A systematic review and meta-anal-
yses. Int J Prosthodont 2009;22,378-87
17.Wang HL, Ormanier Z, Palti A, Perel ML,
Trisi P, Sammartino G. Consensus confer-
ence on immediate loading: the single
tooth and partial endentulous areas.
Implant Dent 2006;15:324-33
18.Tanoue N, Nagano K, Sawase T, Mat-
sumura H. A nine-year clinical case study of
a resin-bonded fixed partial denture seated
on the maxillary anterior teeth. J Prostho-
dont Res 2010;54:143-6.
19.Kim TH, Cascione D, Knezevic A, Now-
zari H. Restoration using gingiva-colored
ceramic and a ridge lap pontic with
circumferential pressure: a clinical report. J
Prosthet Dent 2010;104:71-6.
20.Kim TH, Cascione D, Knezevic A. Simulated
tissue using a unique pontic design: a clinical
report. J Prosthet Dent 2009;102:205-10.
21.Tripodakis AP, Constandtinides A. Tissue
response under hyperpressure from convex
pontics. Int J Periodontics Restorative Dent
1990;10:408-14.
22.Galiatsatos AA. An indirect repair tech-
nique for fractured metal-ceramic restora-
tions: a clinical report. J Prosthet Dent
2005;93:321-3.
Corresponding author:
Dr Erdem Ozdemir
Department of Prosthodontics, School of
Dentistry
Baskent University
Mutlukent Mahallesi 92. Sok. No: 17, mitky
TURKEY
Fax: +90-312-236-44-49
E-mail: dnterdem@gmail.com
Copyright 2012 by the Editorial Council for
The Journal of Prosthetic Dentistry.
Ozdemir et al