In 2006, I received a copy of the ITI Treatment Guide Volume 1: Implant therapy in the aesthetic zone (TGV1), free of charge as a member of the ITI.
I was not particularly aware of the fact that I would be receiving this book and didn’t realise how it would change my practising life. This became a resource that I would use in years to come and as I flick through the book now it is a well-used old friend in implant dentistry.
This book has become my guide to the treatment of patients with implants in the aesthetic zone and how to achieve predictable results in these cases and to explain to patients when they cannot be achieved. It has enabled me to discuss with patients issues such as risks that the patients bring with them to the treatment and taught me not to beat myself up when I cannot achieve an exceptional aesthetic result.
This ability to assess patients appropriately prior to treatment has removed much of the stress of my implant practice in the aesthetic zone and allowed me to talk honestly and openly to patients about what kind of results I can actually achieve. Further to this, in patients who have ideal conditions, I can explain how I know we can provide an exceptional result and show them examples of the results we have already provided.
The TGV1 begins (as all the treatment guides do) with the statements from the consensus document recommending clinical procedures regarding aesthetics in implant dentistry. It discusses treatment planning of patients in the aesthetic zone and uses wonderful schematics to demonstrate the points raised. The clinical photography is simply superb and the description of surgical procedures in aesthetic cases is the best I have ever seen.
Following the surgical section, the restorative elements of treatment of patients in the aesthetic zone is simply second to none. This is the area that particularly changed my practising career as I am an oral surgeon with limited expertise in implant restorative care and this allowed me to provide some wonderful results in cases where aesthetics were of high demand. In particular, the description of the custom impression technique allowed me to provide results as shown.
For those who are unaware of the technique, it involves the use of a provisional or adjustable crown following exposure of the implant. This takes for granted the fact that the implant will have been placed using an appropriate aesthetic protocol and achieving primary closure at all times. Once the provisional, adjustable crown is in place it is possible to leave the area to mature and to adjust the crown appropriately to achieve the best possible gingival aesthetics. Once both the patient and clinician are satisfied that the result is optimised, it is possible to take a custom impression of the provisional restoration and to send this to the laboratory to allow the technician to fabricate a crown with the ideal emergence profile to retain excellent gingival aesthetics. Following a thorough description of how this can be achieved in ideal cases, there is an excellent chapter on aesthetic complications and their causes, which explains why optimal aesthetics are not achieved in many cases.
The following cases demonstrate how the techniques and explanations in the volume were used in my practice to improve the outcomes for patients.
This was the first patient I treated using the knowledge I had gained from TGV1. A lady in her mid thirties with a missing UR2 for approximately six months was seeking a fixed restoration.
After careful assessment and discussion, a dental implant prosthesis was prescribed with a staged block bone graft approach.
Figure 1 shows the clinical situation following block bone grafting and placement of a Straumann 10mm RN 4.1mm SP implant. Note the space is slightly larger than a normal lateral incisor space.
Figure 2 shows the design of the provisional restoration that is a composite crown constructed on a Straumann temporary abutment (screw retained). This allows easy removal of the provisional crown for adjustment with addition of composite or trimming to achieve the best possible emergence profile of the final crown.
Figure 3 demonstrates the situation following adjustment of that crown and tissue maturation.
Once the optimum situation for the case is achieved, it is possible to take a custom impression to copy the emergence profile for the laboratory technician to allow the final crown to be made with the ideal emergence to support the soft tissue (see later cases for demonstration of this).
Figures 4 and 5 show the final crown at cementation and in function.
This all assumes that the implant has been placed in the ideal three-dimensional position. A full description of the ideal placement with superb schematics and clinical cases is published in the book to assist the clinician.
It may be helpful to explain at this point that this was the first such restoration undertaken by an oral surgeon with no formal restorative training and allowed me the chance to provide and excellent result.
A female patient in her early 20s presented on referral from her GDP complaining of pain and a draining sinus from UR1 (Figure 6).
This tooth had been post crowned and root filled with a previous apicectomy procedure carried out (Figure 7).
An implant restoration was planned following extraction of the diseased tooth (Figure 8) and a period of healing of six weeks, during which time the patient was able to wear a temporary adhesive bridge (Figure 9).
A Straumann Bone Level implant (BLRC 12mm) was placed at six weeks with associated GBR and healing for 10 weeks was uneventful followed by exposure and placement of a provisional crown, which was allowed to mature (Figure 10).
Once the optimum aesthetic result had been achieved and an excellent emergence profile created (Figure 11 and 12), a custom impression technique was used to copy the emergence by removing the provisional crown and placing it on a lab analogue.
This was then embedded in impression material, the crown removed and the space occupied by the emergence of the crown filled up with pattern resin (Figure 13 and 14).
This allowed the standard impression post to be customised to support the soft tissue emergence (Figure 15).
A close up view of the impression taken (Figure 16) shows how much pattern resin is required to support the soft tissues in the required position and hence how much material would be missing in a standard impression technique.
The final crown was then constructed and the appearance is pleasing despite the slight shade discrepancy (Figure 17 and 18).
A female patient in her late twenties presented with a fractured UL1 following an incident in which her dog had accidentally hit her in the face. Her tooth was extracted and left to heal for six weeks, after which time a Straumann dental implant was placed (BLRC 12mm) with associated GBR and healing was uneventful up to 12 weeks when the implant was uncovered. A provisional crown was placed and a period of adjustment and maturation was undertaken until the area was deemed suitable for construction of a final prosthesis. A custom impression was made, this time by placing a stock impression post and injecting flowable composite into the emergence space and once more the bulk of material in the impression signifies the importance of the technique. A final crown was fitted to provide and excellent aesthetic result with a further photograph taken at two weeks showing full closure of the papillary space. A final radiograph is demonstrated in figure 25.
This was a 19-year-old female who was struck in the face by hockey ball and received her remedial care at a local A&E department. (Her lower incisors have been treated by her GDP). The patient attended to see me some days later and I was able to use the aesthetic risk assessment from TGV1 to ascertain if a good aesthetic result was possible. Having decided it was possible; I was able to proceed to treatment to provide a good final result.
TGV1 is still available to purchase through Quintessence Publishing and I believe it is an essential tool for dentists providing implant dentistry to have in their armoury. Without a shadow of a doubt, it changed my practising career and allowed me to move the quality of my practice to a level higher than it had been. I believe it is one of the many benefits of being an ITI member, along with the sharing of information and expertise that makes everyone better and allows us to treat our patients in the best way possible.
For more information about the ITI please visit: www.iti.org.
Colin is a GDC-registered specialist in oral surgery who qualified from the University of Glasgow in 1994. Colin has worked in oral and maxillofacial surgery units in Glasgow, Nottingham and Derby before entering practice as a vocational trainee and then becoming a vocational trainer. He secured one of the first waves of PDS oral surgery contracts in 1999 and has provided Primary Care Trust oral surgery for more than 10 years. Colin became involved in implant dentistry as a clinician in 1998 and began lecturing in 2000. He was awarded fellowship of the International Team for Implantology in 2006 and is the communications officer for the UK and Ireland section, sitting on the leadership team of the organisation. He is the clinical director at Campbell and Peace Specialist Practice in Nottingham and also the clinical drector of Refine Specialist Dental Care in Derbyshire.