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Titanium-Zirconium Implants: A Case Report: Immediate

Provisional and Restoration Using a Small-Diameter System
Written by Mariano A. Polack, DDS, MS, and Joseph M. Arzadon, MD, DDSThursday, 13 December 2012 19:45

The original implant protocol required an undisturbed healing period of 6 months before exposure and
loading.1 Reducing this waiting period was believed to prevent osseointegration and cause implant failure. 2 The
timing options for the placement of a provisional restoration and loading of dental implants have since
expanded.3-5 Currently, there is increased interest in immediate and accelerated loading protocols; that is,
shortening the amount of time between implant placement and rehabilitation with a provisional implant-supported
restoration. The fabrication of the definitive prosthesis is then usually delayed for 8 to 12 weeks.6Success rates of
these procedures appear to be similar to traditional ones. 7-10 In addition, this approach can reduce total treatment
time, eliminate the need for an interim removable prosthesis, and improve overall efficiency. 11

A novel implant material has been recently introduced to increase the range of treatment options with small-
diameter implants (Roxolid [Straumann USA]).12 The material is an alloy of titanium and zirconium and is
purported by the manufacturer to combine high tensile and fatigue strengths while providing faster
osseointegration.12 Although no clinical research on humans is available at this time to support these claims, the
properties of titanium-zirconium alloys seem promising. In vitro studies have shown them to have significantly
greater hardness than pure titanium or zirconium alone, with tensile strength tests showing a similar
tendency.13,14 It would be expected that biomaterials fabricated with these metals could withstand higher loads
than either material alone. These alloys appear to have high biomedical potential due to the combination of
biocompatibility15 and biomechanical properties.16 The availability of a small-diameter implant with increased
elongation and fatigue strength compared to pure titanium would be mechanically advantageous when limited
interdental space makes the placement of a regular diameter implant impractical. Faster osseointegration would
also help shorten the time between placement of the provisional prosthesis and the definitive restoration, likely
increasing the patient’s satisfaction.

This article illustrates the immediate provisional restoration of a small-diameter titanium-zirconium implant
replacing a maxillary canine and the definitive restoration with a zirconia abutment and crown at 6 weeks.

Diagnosis and Treatment Planning
A 39-year old woman, with nonremarkable medical history, presented to a private practice requesting the
aesthetic enhancement of the primary maxillary right canine (Figures 1a to 1c). The radiographic examination
revealed an unfavorable crown-to-root ratio. The treatment options discussed by the treating prosthodontist
included restoring the primary canine with a ceramic crown; or extracting the tooth and replacing it with a
removable partial denture (RPD), a tooth-supported fixed partial denture, or an implant.

The first option was deemed unpredictable since the tooth had a small clinical crown and an unfavorable crown-
to-root ratio that would be exacerbated by the anatomy of the new restoration. In addition, the patient did not
want a removable prosthesis or a restoration that would involve the adjacent teeth. Therefore, a dental implant
was considered the best option to provide a predictable and long-term aesthetic correction, thus addressing her
chief complaint. After the treatment plan and clinical procedures were explained, the patient requested to
minimize the time she would wear a provisional RPD, as well as the overall treatment time.

To avoid an aesthetic compromise due to the restricted mesiodistal space. the narrow diameter would allow a safer placement along the canine eminence in close proximity to the premolar roots. Clinical (a and b) and radiographic (c) preoperative presentation of right primary maxillary canine. In addition. At this time. the patient wanted to avoid hard. 17 The alveolar ridge was narrow buccolingually. The purported enhanced mechanical attributes of the titanium-zirconium implant alloy over titanium13 were expected to offset the apparent biomechanical compromise of using a small-diameter implant in the canine position. Clinical Treatment Protocol The initial phase of treatment involved the removal of the primary tooth. a small-diameter (3.3 mm) implant was chosen for the site.7 mm.and soft-tissue augmentation procedures to widen the residual ridge. maintaining a greater thickness of the buccal plate of bone needed to preserve gingival aesthetics. the definitive restoration would be fabricated with a slight mesial overlap. compared to an average permanent maxillary canine width of 7. The primary canine presented with gingival recession and lack of keratinized tissue. The permanent maxillary right canine had been removed more than 20 years earlier because of impaction. or reduce. which was not ankylosed. . the anatomy of the ridge was assessed clinically with direct visualization and an interim RPD was placed. further increasing the challenge of placing a regular diameter implant. while the minimal manipulation would facilitate synchronous soft-tissue maturation and osseointegration. In addition. This timing protocol addressed the patient’s goals of short treatment time without augmentation procedures. The mesiodistal space was limited at 6. For these reasons. and followed basic biologic principles in healing. the need for gingival grafting or flap advancement over the exposed buccal socket gap. with a buccal undercut. In addition. Figures 1a to 1c. The denture tooth (SR Phonares [Ivoclar Vivadent]) in the prosthesis was shaped as an ovate pontic to contour the gingiva while awaiting implant placement (Figure 2). this would decrease variations in the final position of the gingival margin.6 mm. This gain in soft tissue would eliminate. A 2-week delayed implant placement approach was planned to allow keratinized gingiva to migrate over the socket.

Immediately after implant placement. respectively. During the osteotomy. the healing cover was removed and a polymer provisional abutment (NC Temporary Abutment [Straumann USA]) was connected to the implant. making 3-dimensional imaging of the site unnecessary. This implant is purported by the manufacturer to be made of an alloy of titanium and zirconium and has a hydrophilic. the small primary canine socket was covered with keratinized gingiva. Occlusal contacts in maximum intercuspation. and excellent peri-implant gingival health was evident (Figures 4a and 4b). airborne-particle abraded and acid-etched surface. then seated over the prepared diagnostic cast and allowed to polymerize. The anatomy of the ridge was reassessed with sounding and palpation. The abutment was prepared intraorally using an electric handpiece (NuTorque Electric System [DentalEZ Group]) (Figure 3). The socket contours were followed to help preserve the original canine eminence. a buccal bone fenestration was created apical to the socket of the primary tooth.x 12-mm implant (SLActive Roxolid Bone Level NC [Straumann USA]) was placed with primary stability using the handpiece set at 40 Ncm. the shell was seated over the implant provisional abutment intraorally and allowed to polymerize to fabricate a screw-retained restoration. thus avoiding any aesthetic compromise. The provisional crown was polished to a high shine with medium and fine grade flour of pumice (Whip Mix). and connected to the implant with an abutment screw torqued to 15 Ncm. 3. the fenestration was grafted through the osteotomy with a bovine bone graft replacement material (Bio-Oss [Ostheohealth]). Copious water irrigation was used to prevent the heat of polymerization from affecting the implant. and protrusive excursions were eliminated. A flapless osteotomy through the newly formed keratinized gingiva was made in Type III bone with cooled saline irrigation. Next. A small amount of acrylic resin (Jet Acrylic [Lang Dental]) was placed in the corresponding area inside the impression. screw-retained interim restoration. Then. To fabricate a provisional crown shell. and the maxillary canine was prepared on the diagnostic cast before the surgery.3. The screw access hole was sealed with a light-polymerizing semi-rigid composite resin (Fermit [Ivoclar Vivadent]). Two weeks later. The preoperative group function occlusal scheme on the right side and the incisal length of the incisors allowed premolars and anterior teeth to provide lateral and anterior guidance. Its location and size were determined using depth gauges (Depth Gauge [Straumann USA]) and a curette (Lucas Surgical Curette [Hu-Friedy]). An impression was taken of the wax-up with vinyl polysiloxane (Exafast [GC America]). Removal of interim Figure 3. replicating the occlusal scheme of the deciduous canine. This approach was preferred over raising a flap. Provisional shell to be gingival scalloping supported by relined with acrylic resin to fabricate ovate pontic. and hand torqued to the final position. The patient was recalled at one week. No complications were observed. and the patient returned on the same day to the prosthodontist’s office for immediate placement of a provisional restoration. a diagnostic cast was made. The provisional crown was adjusted only on the lingual side. A surgical stent was utilized to guide implant placement. . Figure 2. which could result in gingival recession. A small-diameter. A healing cover (Straumann USA) was placed. After completion of the drilling sequence. Provisional abutment after removable partial denture reveals preparation. followed by a full-contour diagnostic wax-up of the maxillary right canine. a thin mix of acrylic resin was placed inside the shell. A small perforation was made with a 557 carbide bur (DENTSPLY Caulk) on the lingual side of the provisional restoration to remove the cotton and to gain access to the abutment screw. lateral. until the insertion of the definitive restoration. The implant-abutment connection is platform-switched. The attending dentists believed this provided sufficient information for implant placement. Cotton was placed inside the access hole of the abutment to avoid acrylic resin from blocking access to the retaining screw.

Good shade match and characterization were achieved. aesthetics. and function. the provisional restoration was removed. Then. Immediate (a) and one-week (b) presentation after insertion of provisional restoration. Six weeks after implant placement. Notes and photographs of the desired shade. Figures 5a to 5c. which was veneered with a compatible porcelain (Creation ZI-F [Jensen Industries]) to obtain proper anatomy. Zirconia abutment and crown with final prosthetic screw (a). the definitive cast was scanned (Etkon Es 1 Scanner [Straumann USA]) and specially devised software (Etkon visual 5. resistance. the access hole sealed with gutta-percha (Autofit [SybronEndo]) and composite resin (Esthet·X [DENTSPLY Caulk]). The zirconia abutment was torqued to 35 Ncm. and surface texture were forwarded to the dental laboratory team. . Gingival health is evident with no sign of recent surgery. a closed-tray impression post (NC Impression Post [Straumann USA]) was connected to the implant and an impression was made with heavy and medium body vinyl polysiloxane (Exafast [GC America]). optimal retention. In the dental laboratory. the definitive restoration was inserted after all necessary adjustments were made. The abutment was then scanned to fabricate a zirconia coping (Lava CAD/CAM system [3M ESPE]). and clinical situation immediately after insertion of definitive abutment (b) and crown (c). Note slight mesial overlap allowing proper mesiodistal width of restoration. Approximately 4 weeks after implant placement. Figures 4a and 4b. the zirconia crown was adhesively cemented with a resin cement (Multilink [Ivoclar Vivadent]) (Figures 5a to 5c).0 CAD/CAM Software [Straumann USA]) was used to design a custom-milled zirconia abutment (CAD/CAM abutment [Straumann USA]) with the desired emergence profile. contours. and support.

and the use of implants with a platform-switched connection. a recent animal study showed similar or improved bone tissue responses for this implant at 4 weeks compared to the commercially pure titanium control.10.12 However.20 This is purported to help preserve crestal bone levels and to provide better support for the soft tissue. primary stability is necessary. a screw-retained provisional crown eliminates the possibility of inadequate cement removal. It would seem valuable to compare the properties of this material to other titanium alloys used as alternatives to commercially pure titanium.5 In addition. believed to keep micromovement below 150 µm. although functional forces can be applied during mastication via the bolus. as stated earlier. the implant is theoretically protected from overload by eliminating occlusal contact on the interim restoration. The patient was recalled at one week. In addition. Bone levels to the top of the implant were maintained. In single immediate implant-supported provisional prosthesis.4. no clinical trial to date has compared the effect of different levels of stability on implant survival.18 Greater mobility is assumed to compromise the healing of the bone and its intergrowth into the implant.13 potentially making it useful in sites with high mechanical stress. DISCUSSION To allow for the immediate placement of a provisional restoration or immediate loading. and 6 months. These recommendations were followed for the patient treatment described herein.5 This is usually linked to an implant insertion torque greater than 35 Ncm. This material has better elongation and fatigue strength than pure titanium. Six-month postoperative visit (a and b) and radiographic evaluation (c). Although the scientific validity of this claim remains unclear. or in situations where augmentation procedures are infeasible. Accelerated protocols require that special attention be made to the prosthesis design. The definitive restoration shared a group function occlusal scheme with the maxillary premolars. there are no human studies available at this time. 2 months. the manufacturer purports that this implant achieves enhances osseointegration. Natural and aesthetic soft tissue surrounds the inconspicuous restoration. Figures 6a to 6c. which could result in bone loss.3 Some authors advise a soft diet during the healing stages. .19 The latter refers to an interface between the abutment and the implant that occupies a medial position between a wide implant platform and a comparatively narrow abutment. The implant used for this patient consisted of an alloy of titanium with 13% to 17% zirconium (Roxolid [Straumann USA]).12 This implant could also be helpful in areas with limited interdental space where a wider implant would be preferable but impractical. However. and displayed excellent gingival health and natural aesthetics (Figures 6a to 6c).

2009. LLC.(1):CD003878. Albrektsson T. Requirements for ensuring a long-lasting. Cangini F. Hansson HA. 1981. providing additional comfort and abbreviating total treatment time. Primary stability allowed for immediate insertion of the provisional restoration despite the reduced bone volume. Clin Implant Dent Relat 2-year clinical and radiographic study.(3):30-33.7 mm narrower than a conventional 4. 10. Acta Orthop Scand. 2005. with reduction of primary stability. Starget. Calandriello R.23:37-45. Interventions for replacing missing teeth: different times for loading dental implants. Wolfinger GJ. Wöhrle PS. 1992. thus benefiting accelerated protocols by further shortening the total treatment time. Zarb GA. Int J Periodontics Restorative Dent. Cornelini R. Cordaro L. Int J Oral Maxillofac Implants. all rights reserved. 7. 2009. thus helping maintain the peri-implant gingival contours. Biomechanical factors affecting the bone-dental implant interface.5(suppl 1):10-20. et al. Aglietta M. Immediate functional loading of Brånemark System implants with enhanced initial stability: a prospective 1. Other advantages encountered with this accelerated approach include decreased cost for the clinicians and discomfort to the patient due to the reduced number of procedures and appointments. Straumann USA LLC. the small-diameter implant used here decreased the need for additional procedures such as soft-tissue grafting to bulk up the highly scalloped thin gingiva and hard tissue grafting to support the soft tissues.24(suppl):147-157. Int J Periodontics Restorative Dent. A wider implant would have also obliterated the socket with possible buccal crestal bone dehiscence. The manufacturer purports that the implant described herein has superior mechanical and biological properties that could expand treatment options for small-diameter implants. Brunski JB.52:155-170. 1997.10:153- 201. Romanos GE. Human studies are needed to validate these claims. 2010. J Prosthet Dent. 2009.24:1106-1112. Int J Oral Maxillofac Implants. 4. Implant loading protocols for partially edentulous maxillary posterior sites. its parents. 3. Rangert B. with a 6-month follow up. A wider implant would have likely resulted in a larger fenestration than the one created during the osteotomy. Covani U. direct bone-to-implant anchorage in man. Grusovin MG. Immediate functional loading in the maxilla using implants with platform switching: five-year results. Clin Mater. et al. References 1. 6. Osseointegrated titanium implants. Esposito M. the authors believe that this difference was important. 2005. SUMMARY This article presented the immediate provisional and definitive restoration at 6 weeks of a novel small-diameter titanium-zirconium implant. 2. Immediate restoration of implants placed into fresh extraction sockets for single-tooth replacement: a prospective clinical study. Int J Oral Maxillofac Implants. putting at risk the support for the soft tissue and compromising aesthetics.0 mm implant. The aesthetic benefits of this approach are evidenced by the rapid and favorable soft-tissue response obtained. Ten-year results for Brånemark implants immediately loaded with fixed prostheses at implant placement. Rubenstein JE. 8. 2003. The insertion of the definitive restoration at 6 weeks allowed the patient to resume normal function earlier. Immediate and early implant loading protocols: a literature review of clinical studies. While the implant diameter was only 0.Cochrane Database Syst Rev. et al. Brånemark PI.12:495-503. Immediate loading of dental implants in the edentulous maxilla: case study of a unique protocol. Tomatis M. Attard NJ. 5. 9.From a practical perspective. Achille H. Nentwig GH. Schnitman PA. Balshi TJ.94:242-258. Roccuzzo M. making the immediate insertion of a provisional restoration questionable. affiliates or subsidiaries. . et al. Acknowledgment All images except for Figure 2 in this article are courtesy of Straumann USA.25:439-447. 2003.

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