University of Groningen. Soft tissue development in the esthetic zone Patil, Ratnadeep Chandrakant

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1 University of Groningen Soft tissue development in the esthetic zone Patil, Ratnadeep Chandrakant IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Please check the document version below. Document Version Publisher's PDF, also known as Version of record Publication date: 2016 Link to publication in University of Groningen/UMCG research database Citation for published version (APA): Patil, R. C. (2016). Soft tissue development in the esthetic zone: a clinical trial on abutment geometry and it's effect on muco-gingival esthetics [Groningen]: University of Groningen Copyright Other than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons). Take-down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim. Downloaded from the University of Groningen/UMCG research database (Pure): For technical reasons the number of authors shown on this cover page is limited to 10 maximum. Download date:

2 CHAPTER 1 Introduction 8

3 The replacement of lost or missing teeth by means of implants has revolutionized oral rehabilitation for fully and partly edentulous situations. The successful long term performance of implants and restorations has been demonstrated in several studies, both for the maxilla and for the mandible (Slot et al, 2010; Pjetursson et al, 2012; Papaspyridakos et al, 2014; Moraschini et al, 2015). Osseointegration of implants being predictable over the years, sustainable esthetics related to the implant crown including its surrounding soft tissues have gained focus of both; the professionals and the public (Romeo et al, 2004; Simonis et al, 2010; den Hartog et al, 2008). Studies on predisposing factors that influence esthetic success or failure in dental implant cases correlate multiple attributes of predictors to favorable or unfavorable outcomes (Sterrett et al, 1999; Belser et al, 2004; Kois, 2004; Ahmad, 2005; Zetu & Wang, 2005). Worth mentioning are presurgical diagnostic factors like form and biotype of the periodontium, tooth shape and position, position of the osseous crest, techniques such as precise three dimensional placement of implant, socket preservation, orthodontic extrusion, onlay grafts, distraction osteogenesis, soft tissue grafts and restorations mimicking the precise form and shade. It is also critical to ensure uniformity and repeatability in documenting the esthetic outcomes with objective rather than subjective measures (Jemt, 1997; Belser et al, 2004; Meijer et al, 2005; Furhauser et al, 2005). No therapy can be successful unless the patients accept it and hence their opinions on the outcome of the therapy have to be recorded objectively (Esposito et al, 2009). The preservation of labial and proximal marginal bone levels that support the interdental papilla and cervical mucosa is considered of utmost importance and implant concepts and techniques, both surgical and restorative to achieve and improve it have been a challenge for the surgical and bio-engineering field for decades. One way would be to influence the implant design, particularly the neck portion of the implant. Traditionally the neck of an implant is round, with a butted interface between the implant and the abutment. In the last decade attempts were made to reduce marginal bone resorption by modifying the implant-abutment connection. Platform switching, moving the implant-abutment margin away from the marginal bone level proved a successful concept (Lazarra & Porter, 2006; Atieh et al, 2010; Canullo et al, 2010; Telleman et al, 2014). Another way would be 9

4 to adjust the marginal geometry of the implant, for example by manufacturing a scalloped-neck implant platform design, which rendered varying clinical success (Wöhrle, 2003; McAllister, 2007; Kan et al, 2007; den Hartog et al, 2011). With respect to the abutment, traditionally titanium cylindrical abutments were used, yielding a stable and healthy permucosal seal, which protected the underlying tissues from the intraoral environment as result of adhesion, proliferation and colonization of fibroblastic cells to the implant abutment material. Abutment surface properties, among which are biocompatibility (i.e. chemistry), surface topography (i.e. roughness) and surface-free energy are key influencing factors (Quirynen et al, 1993; Quirynen et al, 1994; Bollen et al, 1996; Rimondini et al, 1997; Abrahamsson et al, 1998; Rasperini et al, 1998; Grossner-Schreiber et al, 2007; Abrahamsson et al, 2002; Hamdan et al, 2006; Rompen et al, 2006; Teughels et al, 2006; Linkevicius & Apse, 2008). Zirconia and titanium implant abutments seem to elicit a similar soft tissue response in vivo (van Brakel et al, 2011a, 2011b, 2012). The geometry of the abutment may also be of influence on mucosal stability. From results reported by Rompen et al (2007) an inwardly narrow abutment showed favorable results with respect to the maintenance of the periimplant mucosa. This was attributed to the creation of an O-ring type connective tissue attachment due to the concavity in the abutment geometry, which increased the surface area, signifying enhancement of the gingival biotype and a probable improvement in bacterial resistance. Their findings were not verified by others to date. The formation of soft tissue around the implant, its quality, its endurance against bacterial invasion and its resilience after years of function is a clinically relevant topic. Better understanding of influencing factors provides future leads for the development of new implant connections, abutment morphology and implant surfaces, especially those in contact with soft tissue. The research in this PhD project predominantly focused on the effect of implant abutment geometry on soft tissue development and maintenance. The entire project was also approved by the Smile Care Ethics Committee for Human Research (National Registration Number ECR/463/Int/MH/2013). A randomized split mouth blinded prospective clinical trial was set up. An exploratory study on 10

5 gingival biotypes and crown dimensions comparing Caucasian and Indian subjects was undertaken in order to compare and objectively determine gingival biotypes in the Dutch and Indian population in order to eliminate the effect of possible racial differences. The specific aims were: To evaluate, in a unicentric, left-right randomized split mouth clinical trial, the effect of two different abutment designs on soft tissue healing post 6 weeks of function in a delayed healing protocol (Chapter 2). To quantitatively measure, in a unicentric, left-right randomized split mouth clinical trial, the peri-implant tissue thickness and to assess the change in biotype post 6 weeks of function in a delayed healing protocol (Chapter 2). To assess, in a unicentric, left-right randomized split mouth clinical trial, the mucosal marginal stability and soft tissue resistance upon pulling pressure (deseating force) measured by a calibrated gauge, post 6 weeks of function in a delayed healing protocol (Chapter 2). To assess, in a unicentric, left-right randomized split mouth clinical trial, the effect of two different abutment designs, over one year of loading, the soft tissue response through clinical Pink Esthetic Score (PES) parameters; namely: mesial and distal papilla, soft tissue level and contour, alveolar process deficiency, soft tissue color and texture (Chapter 3). To assess, in a unicentric, left-right randomized split mouth clinical trial, the effect of two different abutment designs, over one year of loading, the marginal bone levels by clinical recording of marginal bone levels (Chapter 3). To correlate, in a unicentric, left-right randomized split mouth clinical trial, the effect of two different abutment designs, over one year of loading, the interproximal papilla fill by means of Papilla Index Score (PIS) related to the radiological maximum bone level between the implant and adjacent root as 11

6 well as the peri-implant marginal bone level (Chapter 4). To compare, in the randomized clinical trial, patients satisfaction and dentists observations, especially on muco-gingival esthetics, for divergent and curved titanium abutments for single implant crowns in the esthetic zone (Chapter 5). To correlate gingival biotype and natural crown dimensions across Caucasian and Indian subjects (Chapter 6). The results are discussed and summarized in chapters 7 to 9. 12

7 References Abrahamsson, I., Berglundh, T., Glantz, P.O. & Lindhe, J. The mucosal attachment at different abutments. An experimental study in dogs. J Clin Periodontol 1998; 25: Abrahamsson, I., Zitzmann, N.U., Berglundh, T., Linder, E., Wennerberg, A. & Lindhe, J. The mucosal attachment to titanium implants with different surface characteristics: an experimental study in dogs. J Clin Periodontol 2002; 29: Ahmad, I. Anterior dental aesthetics: gingival perspective. Br Dent J 2005; 199: Atieh, M.A., Ibrahim, H.M. & Atieh, A.H. Platform switching for marginal bone preservation around dental implants: a systematic review and meta-analysis. J Periodontol 2010; 81: Belser, U.C., Schmid, B., Higginbottom, F. & Buser, D. Outcome analysis of implant restorations located in the anterior maxilla: a review of the recent literature. Int J Oral Maxillofac Implants 2004; 19: Bollen, C.M., Papaioanno, W., van Eldere, J., Schepers, E., Quirynen, M. & van Steenberghe, D. The influence of abutment surface roughness on plaque accumulation and peri-implant mucositis. Clin Oral Implants Res 1996; 7: Canullo, L., Fedele, G.R., Lannello, G. & Jepsen, S. Platform switching and marginal bone level alterations: the results of a randomized controlled trial. Clin Oral Implants Res 2010; 21: den Hartog, L., Huddleston Slater, J.J., Vissink, A., Meijer, H.J. & Raghoebar, G.M. Treatment outcome of immediate, early and conventional single tooth implants in the aesthetic zone: a systematic review to survival, bone level, soft tissue, aesthetics and patient satisfaction. J Clin Periodontol 2008; 35: den Hartog, L., Meijer, H.J., Stegenga, B., Tymstra, N., Vissink, A. & Raghoebar, G.M. Single 13

8 implants with different neck designs in the aesthetic zone: a randomized clinical trial. Clin Oral Implants Res 2011; 22: Esposito, M., Grusovin, M.G. & Worthington, H.V. Agreement of quantitative subjective evaluation of esthetic changes in implant dentistry by patients and practitioners. Int J Oral Maxillofac Implants 2009; 24(2): Fürhauser, R., Florescu, D., Benesch, T., Haas, R., Mailath, G. & Watzek, G. Evaluation of soft tissue around single tooth implant crowns: the pink esthetic score. Clin Oral Implants Res 2005; 16: Grossner-Schreiber, B., Herzog, M., Hedderich, J., Duck, A., Hannig, M. & Griepentrog, M. Focal adhesion contact formation by fibroblasts cultured on surface-modified dental implants: an in vitro study. Clin Oral Implants Res 2007; 17: Hamdan, M., Blanco, L., Khraisat, A. & Tresguerres, I.F. Influence of titanium surface charge on fibroblast adhesion. Clin Implant Dent Relat Res 2006; 8: Jemt, T. Regeneration of gingival papillae after single-implant treatment. Int J Periodontics Restorative Dent 1997; 17: Kan, J.Y., Rungcharassaeng, K., Liddelow, G., Henry, P. & Goodacre, C.J. Peri-implant tissue response following immediate provisional restoration of scalloped implants in the esthetic zone: a one-year pilot prospective multicenter study. Int J Periodontics Restorative Dent 2007; 97: Kois, J.C. Predictable single-tooth peri-implant esthetics: five diagnostic keys. Compend Contin Educ Dent 2004; 25: Lazzara, R.J. & Porter, S.S. Platform switching: a new concept in implant dentistry for controlling post restorative crestal bone levels. Int J Periodontics Restorative Dent 2006; 26:

9 Linkevicius, T. & Apse, P. Influence of abutment material on stability of peri-implant tissues: a systematic review. Int J Oral Maxillofac Implants 2008; 23: McAllister, B.S. Scalloped implant designs enhance interproximal bone levels. Int J Periodontics Restorative Dent 2007; 27: Meijer, H.J., Stellingsma, K., Meijndert, L. & Raghoebar, G.M. A new index for rating aesthetics of implant supported single crowns and adjacent soft tissues The Implant Crown Aesthetic Index. Clin Oral Implants Res 2005; 16: Moraschini, V., Poubel, L.A., Ferreira, V.F. & Barboza Edos, S. Evaluation of survival and success rates of dental implants reported in longitudinal studies with a follow-up period of at least 10 years: a systematic review. Int J Oral Maxillofac Surg 2015; 44: Papaspyridakos, P., Mokti, M., Chen, C.J., Benic, G.I., Gallucci, G.O. & Chronopoulos, V. Implant and prosthodontic survival rates with implant fixed complete dental prostheses in the edentulous mandible after at least 5 years: a systematic review. Clin Implant Dent Relat Res 2014; 16: Pjetursson, B.E., Thoma, D., Jung, R., Zwahlen, M. & Zembic, A. A systematic review of the survival and complication rates of implant-supported fixed dental prostheses (FDPs) after a mean observation period of at least 5 years. Clin Oral Implants Res 2012; 23: Quirynen, M., van der Mei, H.C., Bollen, C.M., Schotte, A., Marechal, M., Doornbusch, G.I., Naert, I., Busscher, H.J. & van Steenberghe, D. An in vivo study of the influence of the surface roughness of implants on the microbiology of supra- and subgingival plaque. J Dent Res 1993; 72(9): Quirynen, M., Bollen, C.M., Eyssen, H. & van Steenberghe D. Microbial penetration along the implant components of the Brånemark system. An in vitro study. Clin Oral Implants Res 1994; 5(4): Rasperini, G., Maglione, M., Cocconcelli, P. & Simion, M. In vivo early plaque formation on 15

10 pure titanium and ceramic abutments: a comparative microbiological and SEM analysis. Clin Oral Implants Res 1998; 9: Rimondini, L., Farè, S., Brambilla, E., Felloni, A., Consonni, C., Brossa, F. & Carrassi, A. The effect of surface roughness on early in vivo plaque colonizationon titanium. J Periodontol 1997; 68: Romeo, E., Lops, D., Margutti, E., Ghisolfi, M., Chiapasco, M. & Vogel, G. Long-term survival and success of oral implants in the treatment of full and partial arches: a 7-year prospective study with the ITI dental implant system. Int J Oral Maxillofac Implants 2004; 19: Rompen, E., Domken, O., Degidi, M., Farias Pontes, A.E. & Piattelli, A. The effect of material characteristics, of surface topography and of implant components and connections on soft tissue integration: a literature review. Clin Oral Implants Res 2006; 17(2): Rompen, E., Raepsaet, N., Domken, O., Touati, B. & Dooren, E.V. Soft tissue stability at the facial aspect of gingivally converging abutments in the esthetic zone: a pilot clinical study. J Prosthet Dent 2007; 97: Simonis, P., Dufour, T. & Tenenbaum, H. Long term implant survival and success: a year follow up of non submerged dental implants. Clin Oral Implants Res 2010; 21: Slot, W., Raghoebar, G.M., Vissink, A., Huddleston Slater, J.J. & Meijer, H.J. A systematic review of implant-supported maxillary overdentures after a mean observation period of at least 1 year. J Clin Periodontol 2010; 37: Sterrett, J.D., Oliver, T., Robinson, F., Fortson, W., Knaak, B. & Russell, C.M. Width/length ratios of normal clinical crowns of the maxillary anterior dentition in man. J Clin Periodontol 1999; 26:

11 Telleman, G., Raghoebar, G.M., Vissink, A. & Meijer, H.J. Impact of platform switching on peri-implant bone remodelling around short implants in the posterior region,1-year results from a split-mouth clinical trial. Clin Implant Dent Relat Res 2014; 16: Teughels, W., van Assche, N., Sliepen, I. & Quirynen, M. Effect of material characteristics and/ or surface topography on biofilm development. Clin Oral Implants Res 2006; 17(2): van Brakel, R., Cune, M.S., van Winkelhoff, A.J., de Putter, C., Verhoeven, J.W. & van der Reijden W. Early bacterial colonization and soft tissue health around zirconia and titanium abutments: an in vivo study in man. Clin Oral Implants Res 2011a; 22: van Brakel, R., Noordmans, H., Frenken, J.W., de Roode, R., de Wit, G.C. & Cune, M.S. The effect of zirconia and titanium implant abutments on light reflection of the supporting soft tissues. Clin Oral Implants Res 2011b; 22: van Brakel, R., Meijer, G.J., Verhoeven, J.W., Jansen, J., de Putter, C. & Cune, M.S. Soft tissue response to zirconia and titanium implant abutments: an in vivo within subject comparison. J Clin Periodontol 2012; 39: Wöhrle, P.S. Nobel Perfect Esthetic scalloped implant: rationale for a new design. Clin Implant Dent Relat Res 2003; 5: Zetu, L. & Wang, H.L. Management of inter-dental/inter-implant papilla. J Clin Periodontol 2005; 32:

University of Groningen. Soft tissue development in the esthetic zone Patil, Ratnadeep Chandrakant

University of Groningen. Soft tissue development in the esthetic zone Patil, Ratnadeep Chandrakant University of Groningen Soft tissue development in the esthetic zone Patil, Ratnadeep Chandrakant IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite