Ceramic abutments--a new era in achieving optimal esthetics in implant dentistry.

In the visible dental region in particular, implant-prosthetic restorations filling single-tooth gaps make exacting demands on function and esthetics. One crucial factor influencing the esthetic outcome is the emergence profile of the restoration. The introduction of aluminum oxide or zirconium oxide abutments, which can be milled to meet individual requirements, provides new opportunities for reconstruction adapted to anatomic findings. Tooth-matched coloring combined with customized preparation and dimensioning make for optimal mucogingival esthetics in implant-supported single-tooth restorations. The aim of the present article is to give a general survey and to illustrate the use of ceramic abutments with clinical case reports.

Maxillary sinus augmentation prior to placement of endosseous implants: A histomorphometric analysis.

The aim of this prospective study was to histomorphometrically evaluate at various time intervals the mineralization stage and process of an allogeneic-xenogeneic bone graft used in sinus augmentation procedures. One biopsy was taken from 20 patients at either 6, 8, 10, or 12 months after sinus augmentation. Immediately following the biopsy, an endosseous implant was placed into the biopsy site. This protocol provided 4 groups of 5 patients each, based on healing time following sinus augmentation. Using backscattered electron image analysis, the specimens were histomorphometrically analyzed to determine the volume fractions of residual cancellous bone, newly formed bone, soft tissue, bovine hydroxyapatite, and "remineralized" freeze-dried demineralized bone allograft (rDFDBA). "Remineralization" of DFDBA particles was observed in a few areas in all specimens. Polarized light microscopy showed that only the 12-month biopsies had a predominance of lamellar bone formation. The area within the biopsies that represented the residual alveolar ridge consisted of 32.6% +/- 8.6% (mean +/- SD) of bone. In the grafted area of the biopsies the volume fraction of newly formed bone at 12 months (20.7% +/- 8.3%) was significantly higher (P < .05, analysis of variance) than at 6 months (8.1% +/- 3.0%). There was no statistically significant difference between newly formed bone in the inferior, central, and superior grafted areas in all 4 time intervals. This prospective study indicates that the mineralization process of an allogeneic-xenogeneic sinus graft is incomplete 6 months after the sinus augmentation procedure. New bone formation increased up to 12 months postaugmentation; however, it remained lower than the volume of residual bone.

Bone formation and reosseointegration in peri-implantitis defects following surgical implantation of rhBMP-2.

This study was designed to evaluate bone formation and reosseointegration following surgical implantation of recombinant human bone morphogenetic protein-2 (rhBMP-2) in peri-implantitis defects. Hydroxyapatite-coated dental implants were placed bilaterally in the mandibular and maxillary premolar area in four rhesus monkeys and were allowed to osseointegrate for 1 year. Cotton ligatures were then placed around the healing abutments, and plaque was allowed to accumulate for 11 months. Resulting circumferential peri-implantitis defects exhibited a large intrabony and horizontal component. At reconstructive surgery, peri-implantitis defects in contralateral jaw quadrants were randomly assigned to receive rhBMP-2 (0.43 mg/mL implant volume) in an absorbable collagen sponge carrier or a carrier control. The animals were sacrificed 4 months postsurgery, and block sections were prepared for histometric analysis. Summary statistics included means calculated per animal. Paired t tests were used to evaluate differences between experimental conditions (n = 4). Defect depth amounted to 3.4 +/- 0.9 mm and 3.2 +/- 0.9 mm for rhBMP-2 and control defects, respectively. Vertical bone gain in rhBMP-2 defects (2.6 +/- 1.2 mm) was significantly greater than in controls (0.8 +/- 0.8 mm; P < .01). Reosseointegration within the confines of the defect for rhBMP-2 defects (29.0 +/- 10.5%) differed significantly from that in the control (3.5 +/- 2.5%; P < .01). Reosseointegration within the extent of newly formed bone averaged 40.0 +/- 11.0% in rhBMP-2 defects as compared to 8.9 +/- 7.8% in the control (P < .01). Osseointegration in resident bone amounted to 69.5 +/- 6.9% and 72.6 +/- 8.0% for rhBMP-2 and control defects, respectively. There is significant evidence that rhBMP-2 has potential to promote bone formation and reosseointegration in advanced peri-implantitis defects in a demanding nonhuman primate model.

Endosseous implant placement in conjunction with inferior alveolar nerve transposition: an evaluation of neurosensory disturbance.

This retrospective study evaluated neurosensory dysfunction and the implant success rate associated with 64 implants placed in 15 patients following transposition of the inferior alveolar nerve. A total of 21 inferior alveolar nerve mobilization surgeries were performed. The mean postoperative follow-up time was 41.3 months, with a range of 10 to 67 months. The effects of surgical technique and implant surface geometry on neurosensory dysfunction were evaluated by using light touch, brush stroke direction, and two-point discrimination. The implant success rate was 93.8% (60/64). The surgical technique that involved detaching the mental foramen resulted in a significantly greater incidence of neurosensory disturbance (77.8%, 7/9) than did the technique that left the bony foramen intact (33.3%, 4/12). The overall incidence of neurosensory disturbance was 52.4% (11/21).

Experimental peri-implant tissue breakdown around hydroxyapatite-coated implants.

This study monitored experimental peri-implant tissue breakdown around hydroxyapatite (HA)-coated titanium dental implants. Thirty-two HA-coated cylindrical implants, in groups of two, were bilaterally inserted in the posterior maxilla and mandible in 4 Macaca mulatta monkeys. Two months after healing-abutment connection, a 2-month plaque control program was initiated. Clinical and radiographic recordings and peri-implant submucosal microbial samples were then obtained (baseline). Cotton ligatures were next placed around the healing-abutments and plaque control measures were abandoned. Clinical and radiographic recordings were repeated at 5 and 10 months post-baseline. Microbial samples were repeated at 10 months post-baseline, and ligatures were removed. Clinical, radiographic, and microbial examinations were again repeated at 11 months post-baseline. Mean modified plaque index (mPI; P < 0.01), gingival index (G]; P < 0.01), and bleeding on probing (BOP; P < 0.05) scores increased over the plaque accumulation period. The mPI, and GI scores decreased after ligature removal (P < 0.001). Mean probing depth (PD) and clinical attachment level (AL) increased between baseline and the 5- and 10-month examinations (delta PD 3.0 mm; delta AL 2.7 mm; P < 0.05). PD values were reduced following ligature removal (P < 0.05). AL values and BP scores remained unchanged. A significant negative correlation was found between induced defect depth and width of keratinized mucosa at baseline (P = 0.03). At baseline, the submucosal microbiota was dominated by coccoid cells. Following ligature placement, the microbiota included a large proportion of Gram-negative anaerobic rods, predominantly Porphyromonas gingivalis, Bacteroides forsythus, and Fusobacterium species as well as beta-hemolytic streptococci. Ligature removal had a limited effect on the composition of the submucosal microbiota. This non-human primate study indicates that ligature-enhanced plaque accumulation is a precursor of progressive peri-implant tissue breakdown around HA-coated implants. The associated microbiota resembles that of peri-implantitis and destructive periodontal disease in humans. This preclinical model may be useful to study modalities aimed at arresting peri-implant tissue breakdown and at regeneration of bone in peri-implantitis defects.

Bone formation and osseointegration stimulated by rhBMP-2 following subantral augmentation procedures in nonhuman primates.

The purpose of this study was to evaluate bone formation and osseointegration using titanium dental implants in the subantral space following surgical implantation of recombinant human bone morphogenetic protein-2 (rhBMP-2). In each of four cynomolgus monkeys, one subantral site was treated with rhBMP-2 (0.19 mg per implant) in an absorbable collagen sponge (ACS). The contralateral site was treated with vehicle in ACS (control). Three months later, two screw-type titanium dental implants were placed into each augmented sinus, and one additional implant was placed immediately anterior to the sinus. Thus, each animal had three experimental sites: rhBMP-2, control, and nonsinus. Animals were sacrificed after an additional 3 months, and block sections were harvested and prepared for histometric analysis. Analysis of variance and t tests were used to evaluate differences between experimental conditions. Mean (+/- SD) vertical bone gain was significantly greater in rhBMP-2 than in control sites (6.0 +/- 0.3 versus 2.6 +/- 0.3 mm; P < .002). Bone density in rhBMP-2 sites averaged 14.4 +/- 2.9% versus 13.9 +/- 4.6% and 14.1 +/- 3.6% for control and nonsinus sites, respectively, without significant differences between experimental conditions. Bone-implant contact in rhBMP-2 sites (41.4 +/- 7.7%) was not significantly different from that in control (38.9 +/- 12.4%) and nonsinus sites (46.8 +/- 10.6%). The present study provides evidence for considerable vertical bone gain in the subantral space following surgical implantation of rhBMP-2, thus allowing placement of dental implants. The newly formed bone appears to be of similar quality and to be as suitable for osseointegration as the residual bone in this nonhuman primate model. Thus, surgical implantation of rhBMP-2 appears to have clinical utility and may provide a realistic alternative to autogenous bone grafts for subantral augmentation procedures.

Simultaneous hard and soft tissue augmentation for implant-supported single-tooth restorations.

The replication of nature in the rehabilitation of a single missing anterior tooth is primarily a surgical challenge, as hard and soft tissue deficiencies compromise the achievement of functional and aesthetic implant-supported restorations. Bone defects can be treated using guided bone regeneration (GBR), with or without bone graft materials. The successful application of the GBR technique has been documented in several experimental and clinical studies; the primary challenge associated with single tooth replacement is the creation of an adequate soft tissue recipient site. However, the increased morbidity and prolonged healing period involved in performing hard and soft tissue grafting procedures in two consecutive appointments do not achieve patient expectations. The learning objective of this article is to master a single-tooth replacement technique that allows surgical treatment of bony and soft tissue deficiencies in a single procedure, during either an immediate or delayed implant placement.