Combining a single implant and a veneer restoration in the ...428_Tinoco.indd 433 15.10.20 17:32...

428 | The International Journal of Esthetic Dentistry | Volume 15 | Number 4 | Winter 2020

CLINICAL RESEARCH

Combining a single implant

and a veneer restoration

in the esthetic zone

Jose Villalobos-Tinoco, DDS

Department of Restorative Dentistry, Autonomous University of Queretaro School of

Dentistry, Queretaro, Mexico

Nicholas G. Fischer, BS

Minnesota Dental Research Center for Biomaterials and Biomechanics, University of

Minnesota School of Dentistry, Minneapolis, Minnesota, USA

Carlos Alberto Jurado, DDS, MS

Clinical Digital Dentistry, A.T. Still University Arizona School of Dentistry & Oral Health,

Mesa, Arizona, USA

Mohammed Edrees Sayed, BDS, MDS, PhD

Department of Prosthetic Dental Sciences, Jazan University College of Dentistry, Jazan,

Saudi Arabia

Manuel Feregrino-Mendez, DDS

Periodontal Private Practice, Queretaro, Mexico

Oriol de la Mata y Garcia, CDT

Dental Technician, Private Practice, Puebla, Mexico

Akimasa Tsujimoto, DDS, PhD

Department of Operative Dentistry, Nihon University School of Dentistry, Tokyo, Japan

Correspondence to: Nicholas G. Fischer

Minnesota Dental Research Center for Biomaterials and Biomechanics, University of Minnesota School of Dentistry,

515 Delaware Street SE, Minneapolis, Minnesota 55455, USA; Tel: +1 612 625 0950; Email: [email protected]

428_Tinoco.indd 428 15.10.20 17:32

VILLALOBOS-TINOCO ET AL

429The International Journal of Esthetic Dentistry | Volume 15 | Number 4 | Winter 2020 | 429The International Journal of Esthetic Dentistry | Volume 15 | Number 4 | Winter 2020 |

Abstract

Objective: The combination of partial edentulism

and a worn anterior tooth in the esthetic zone can

be a challenge for the dentist. This clinical situation

requires extensive knowledge of soft and hard tissue

management, surgical planning and execution for

implant therapy, and conservative tooth preparation

with ideal bonding protocols for the tooth-supported

prosthesis. Moreover, an optimal selection of the final

restorative materials is imperative to manage occlusal

forces and fulfill the patient’s esthetic demands.

Materials and methods: The patient presented with

partial edentulism on site 11, a worn incisal edge, and

facial defects on tooth 21. Minimally invasive implant

therapy for site 11 was performed with a papilla-spar-

ing flap design that only included the edentulous site,

and the soft tissue contouring was started for an im-

mediate provisional restoration. A suturing technique

was executed that aimed at maintaining an interproxi-

mal papilla. Conservative veneer preparation was per-

formed on tooth 21 in order to bond the restoration

to the enamel structure. Final restorations included a

custom abutment with a lithium disilicate fused to zir-

conia crown for the implant on site 11 and a lithium

disilicate veneer on tooth 21.

Conclusions: A well-planned single implant and a ce-

ramic veneer restoration was able to fulfill the patient’s

esthetic expectations. The selection of materials for

the final restoration was crucial to manage the occlu-

sal forces and to mimic the shade and shape of the

adjacent teeth.

(Int J Esthet Dent 2020;15:2–11)

429

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CLINICAL RESEARCH


texture, and various other aspects of the

implant-associated soft tissue need to look

similar to the surrounding soft tissue to max-

imize the esthetic outcomes.19,20 To achieve

this, provisional implant prostheses help to

create and form the ideal peri-implant tis-

sue.21 The timing of the placement of pro-

visional implant restorations (immediate as

opposed to 6 months, for example) is in-

formed by many factors such as the implant

stability and the amount of graft applied.22,23

Ceramic veneers are a conservative

treatment option for teeth presenting with

defects, fractures, etc. These bonded ce-

ramic veneers have shown successful long-

term results.24,25 The long-term success of

ceramic veneer restorations is dependent

on components such as restoration de-

sign26 and adhesive methods,27 among oth-

er factors.28 While the reduction of tooth

structure is usually needed for the place-

ment of veneers, excessive or overzealous

tooth preparation can expose the dentin

and detrimentally affect the bonding of

veneers.29 Recent advances in technology

have made it possible to produce ultrathin

ceramic veneers with a thickness of only

0.5 mm, which bond to the tooth structure

with little hard tissue removal.30 There are

many dental ceramic options and formu-

lations currently available31,32 that produce

acceptable esthetic results and bond dura-

bility.33 Minimal tooth reduction can provide

positive fracture characteristics when res-

in-based cements are used to bond ceram-

ic veneers to the underlying tooth,34,35 with

good survival rates.36 The aim of this report

is to show a clinical protocol combining a

single implant and a veneer restoration in

the esthetic zone.

Clinical report

A 40-year-old female patient presented at

our dental clinic with the chief complaint

of having lost an anterior tooth. Her wish

Introduction

Anterior tooth loss presents a major esthet-

ic challenge to dentists because any small

defect is projected in the patient’s smile.1

Partial edentulism can be managed with

conventional dentistry and implant pros-

thodontic therapy, but both require proper

planning to achieve ideal esthetic results.2-4

Tooth-supported fixed restorations function

well, but esthetic and oral hygiene may be

compromised if the design of the soft tis-

sue and pontic is not properly achieved.5

On the other hand, while partial remov-

able prostheses may meet esthetic require-

ments, the lack of stability could interfere

with other functions such as mastication.6

For both treatment options, conventional

restorations can detrimentally affect the re-

tention and/or support of the neighboring

teeth.

Implant therapy is the standard treat-

ment provided by most clinicians as it pre-

serves the adjacent teeth and provides a

predictable long-term solution.7,8 Several

studies have shown fairly similar success

rates for implants placed in the maxillary

esthetic zone compared with those placed

in posterior sites.9-11 While implant survival

is obviously crucial and many studies have

focused on it, fewer have evaluated the es-

thetic outcome of implants placed in the

maxillary esthetic zone, despite this being

crucial to many patients.12-14

Maxillary alveolar ridge (anterior) thick-

ness can compromise esthetic expectations

for implant therapy. In these situations, hard

and soft tissue grafting may be required.15

This complexity could increase when pa-

tients present thin gingival phenotypes or

limited mesiodistal space.16 The tradition-

al approach for implant therapy in the es-

thetic zone might include the extraction of

a non-restorable tooth and a bone graft-

ing procedure, followed by a healing time

of about 3 to 4 months.17,18 The thickness,

428_Tinoco.indd 430 15.10.20 17:32


431The International Journal of Esthetic Dentistry | Volume 15 | Number 4 | Winter 2020 |

decided to place an immediate implant on

edentulous site 11. Implant placement with

immediate provisional restorations was

planned, as it is a common procedure to es-

tablish an ideal emergence profi le in order

to provide maximum tissue volume, pre-

serve the midfacial gingiva, and ensure pa-

tient comfort and treatment acceptance.37,38

A customized, anatomical, screw-retained

provisional restoration was selected to

manage the emergence profi le. The shape

of the provisional restoration is key to

achieving good esthetics. The plan was to

fabricate the fi nal crown out of lithium disil-

icate, which provides excellent strength and

toughness compared with other materials.39

At the surgical appointment, local anes-

thesia was applied by infi ltration with 1.8 ml

of 4% articaine hydrochloride with epineph-

rine 1:100,000 (Septocaine), and infraorbital

blocks of 3.6 ml of 0.5% bupivacaine hydro-

chloride with 1:100,000 epinephrine (Mar-

caine). A papilla-sparing fl ap was designed

and elevated,40 with the aim of exposing the

area of the edentulous site and preventing

gingival recession in the adjacent teeth. An

implant (Neobiotech) of 4 × 13 mm was

was for an implant to replace the lost tooth

(Fig 1). The patient stated that her tooth (11)

had been fractured in a car accident and she

had undergone an emergency extraction of

it 3 months prior to her fi rst visit. She was

also concerned about the incisal wear and

facial defects on tooth 21 (Fig 2). After the

initial clinical evaluation, the patient was in-

formed of the need for a diagnostic wax-

up to evaluate the tentative position and

contours of the restoration as well as for

a CBCT evaluation to evaluate the residual

bone in the edentulous site. She approved

the treatment plan.

Diagnostic casts were made and a diag-

nostic wax-up (GEO Classic; Renfert) was

fabricated to take the patient’s wishes into

account and provide her with a harmonious

smile. After presenting the patient with the

diagnostic wax-up, a diagnostic mock-up

was performed with temporary bis-acrylic

material (Structur Premium; Voco). She was

pleased with the initial result and consented

to the treatment.

After the CBCT evaluation and treat-

ment plan discussion between the patient,

periodontist, and restorative dentist, it was

Fig 1 Patient’s initial smile. Fig 2a and b Initial smile and intraoral situation.

a

b

428_Tinoco.indd 431 15.10.20 17:32

CLINICAL RESEARCH


A titanium custom abutment was de-

signed and fabricated on implant 11, and

a conservative veneer restoration was pro-

vided for tooth 21 (Fig 8). A final crown of

lithium disilicate fused to a zirconia core

for implant 11 and a pressed lithium disil-

icate veneer for tooth 21 were fabricated

(Fig 9). Periodic radiographs were taken af-

ter the impression (Fig 10a), the abutment

placement (Fig 10b), and the final crown

placement (Fig 10c). The crown was ce-

mented using a resin-modified glass-ion-

omer cement (RelyX Luting Plus Cement;

3M ESPE), and the lithium disilicate res-

toration was bonded with a resin cement

(Panavia V5; Kuraray Noritake Dental) fol-

lowing the protocols recommended by

the manufacturers (Figs 11 and 12). The

patient was provided with a night guard

to protect her dentition and restorations.

A CBCT was taken at the 2-year follow-up

(Fig 13). The patient was still satisfied with

the restoration at the 3-year follow-up

(Fig 14).

then placed at site 11 following the manu-

facturer’s specifications (Fig 3). The pa-

tient presented a thick periodontal pheno-

type.41,42 Suturing was performed with 5-0

chromic gut sutures (PolySyn FA; Surgical

Specialties), and a coronally repositioned

vertical mattress suture was used to achieve

primary soft tissue closure. An immediate

provisional restoration (Fig 4) in self-curing

acrylic resin (Jet Tooth Shade; Lang Dental)

was then placed. The provisional restoration

contoured the soft tissue until it had a simi-

lar appearance to the adjacent teeth (Figs 5

and 6). This provisional stage requires mod-

ification of the prosthesis until the peri-im-

plant soft tissue mimics the soft tissue of the

adjacent teeth. A final impression was made

with a closed tray technique, and a titanium

custom abutment was planned (Fig 7) for

placement after approximately 6 months.

Postoperative instructions were given to the

patient, along with a prescription for chlor-

hexidine gluconate twice a day, and ibupro-

fen (600 mg) three times a day for 1 week.

Fig 4 Provisional

restoration fabrica-

tion.

Fig 3a and b

Implant placement.

Fig 5 Immediate

implant provisional

restoration.

a b

428_Tinoco.indd 432 15.10.20 17:32



Fig 6 Soft tissue contouring with the provisional restoration. Fig 7 Closed tray impression.

Fig 8 Custom abutment and veneer preparation. Fig 9 Fabrication of the final restorations.

Fig 10 Radiographs following

the impression (a), abutment

placement (b), and final crown

placement (c).a b c

428_Tinoco.indd 433 15.10.20 17:32

CLINICAL RESEARCH


planning.43,44 The patient’s pretreatment

implant evaluation included a consultation

to establish a solid diagnosis and progno-

sis. Her restorative and periodontal needs

were considered, together with her esthet-

ic expectations. Diagnostic casts, radio-

graphs, and CBCT are needed to enhance

Discussion

Esthetic risk assessment needs to be per-

formed prior to starting treatment. Achiev-

ing a long-term esthetic outcome de-

pends on a restorative-driven approach,

and starts with comprehensive presurgical

Fig 11a and b Final restorations.

Fig 12 Patient’s smile at the end of the treatment.

a

b

428_Tinoco.indd 434 15.10.20 17:32



The diagnostic wax-up provided impor-

tant information concerning the tentative po-

sition of the future implant and the contours

of the ceramic veneer. Three-dimensional

planning for implant therapy is key to evalu-

ate the amount of alveolar ridge that is avail-

able for implant placement. The outcome

presurgical planning and preparation.45,46

Another factor that should be considered is

to inform patients that alveolar growth can

occur and might require intervention later

on in life.47 In this case, the 3-year follow-up

showed a very stable outcome and contin-

ued patient satisfaction.

Fig 13a to c CBCT

scans at 2-year

follow-up.a

b

c

Fig 14 Three-year

follow-up.

428_Tinoco.indd 435 15.10.20 17:32

CLINICAL RESEARCH


cause recession to occur on the adjacent

teeth.

The choice of cemented or screw-re-

tained restorations is controversial. Both

types of single implant crowns have their

advantages and disadvantages.55 Cemented

restorations are thought to be more esthet-

ic due to the lack of a visible screw access.56

The implant trajectory will only determine

the type of retention method, either ce-

mented or screw-retained; however, both

can achieve the same esthetic results. The

implant trajectory in this case followed the

incisal edge. This was the main reason for

the decision to fabricate cement-retained

restorations.57 Despite the use of a custom

or stock abutment, the absence of residual

excess cement cannot be guaranteed.58

There is no universal agreement about the

type of luting cement to use for cement-re-

tained implant restorations. Usually cements

are chosen arbitrarily, and clinicians tend to

select familiar techniques used for natural

teeth.59 Studies demonstrate that excess res-

in cement is very difficult to remove and pro-

motes substantially higher bacterial biofilm

growth compared with other cements such

as glass-ionomer or zinc phosphate.60 In this

case, a resin cement was used, and the ce-

mentation procedure was performed using

an extraoral pre-extrusion step before ce-

mentation. The excess cement was removed

extraorally from the crown using a copy

abutment and then cemented intraorally.

A titanium custom abutment was used in

this case due to cost considerations. Despite

titanium being a gold standard abutment

material, it has demonstrated more bleed-

ing on probing compared with zirconia.

Moreover, zirconia has similar blood flow

to natural teeth, which might suggest that

it is also a suitable abutment material.61,62

Furthermore, in vitro evidence suggests that

gingival fibroblasts, which are key to the

creation of an epithelial layer during reepi-

thelization to ensure implant survival and

of this evaluation might dictate the need

for hard and soft tissue grafting procedures.

This 3D evaluation also allows the clinician

to consider different brands and implant

dia meters. The diagnostic wax-up can also

be used to fabricate tooth reduction guides

for veneer preparation. Ridge preservation

or socket conversion procedures are crucial

at the time of tooth extraction to minimize

the natural resorption that occurs in the

presence of a thin buccal plate.48 In general,

narrow-diameter implants provide the de-

sired buccal bone thickness of 2 to 3 mm.

On the other hand, wider-diameter implants

can lead to marginal gingival recession.49,50

Less bone loss occurs around bone-level

implants placed in naturally thick mucosal

tissue compared with thin phenotypes.51

For this patient, a 4-mm–diameter implant

was used after measuring the mesiodistal

space available at the edentulous site and

the alveolar ridge thickness using the CBCT.

It has been reported that a flapless implant

placement approach minimizes the possi-

bility of peri-implant tissue loss postoper-

atively and hence reduces the challenges

of soft tissue management after implant

placement in patients with sufficient kerati-

nized gingival tissue.52 Other benefits of the

flapless approach are that it saves surgery

time, promotes postsurgical healing, and

is generally more comfortable for the pa-

tient.53 The disadvantage of this approach is

the limited view of the surgical site; the un-

derlying bone cannot be observed, which

might cause unwanted perforation that can

lead to adverse biologic and esthetic com-

plications.54 The limited clinical view could

also cause thermal trauma to the underly-

ing bone due to the lack of external irriga-

tion, so that it does not reach the full depth

of the osteotomy during site preservation.

The present implant therapy was performed

with a papilla-sparing flap design. This is

very conservative because the flap is only

released on the implant site, which does not

428_Tinoco.indd 436 15.10.20 17:32



Conclusion

For many reasons, the combination of im-

plant placement and a veneer restoration

in the esthetic zone might be challenging

for the dentist. Significant knowledge of im-

plant planning and placement, flap design,

suturing techniques, provisional restoration

soft tissue contouring, and ideal material

selection for the final restorations is fun-

damental to achieve good esthetic results.

Conservative tooth preparation to maintain

the enamel structure is crucial for the long-

term success of bonded ceramic veneers.

The material chosen for these types of res-

torations needs to withstand the occlusal

demands as well as satisfy the patient from

an esthetic point of view. The presented

case report successfully combined a lithium

disilicate fused to zirconia restoration for

the implant on site 11, and a lithium disilicate

veneer for tooth 21.

favorable esthetics, are not negatively influ-

enced by titanium abutment materials.63-65

In recent years, dental implant therapies

have become a predictable treatment for

single-tooth replacement, but mindful treat-

ment planning is fundamental to meet the

esthetic challenges of the anterior esthetic

zone. The role of the provisional prosthesis

is critical to form a ‘scallop’ with the soft tis-

sue in order to make it similar to the gingival

margin of the natural tooth.66 Contour man-

agement of provisional restorations and sur-

rounding soft tissue is equally important, as

has recently been noted.67 The high esthet-

ic demand for partial edentulous areas and

facial defects in adjacent teeth can be met

by the clinician through careful attention.

The simultaneous fabrication of the veneer

and implant restoration allowed the dental

technician the opportunity to match identi-

cal shapes and shades in order to create a

more natural-looking result.

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