Dr Ángel Manchón Miralles, Clínica Dental Sanchinarro, Madrid, Spain
A 37-year-old male patient presented in the clinic after tooth loss in region 36 (Fig. 2). The loss of teeth had been preceded by failed endodontic treatment four months earlier. The patient was healthy and showed very good oral hygiene.
A mucoperiosteal flap was prepared and the bone was exposed. The alveolar bone in region 36 had a height of 13 mm and a width of 7 mm. The preparation of the implant bed was carried out according to the drilling protocol of the manufacturer (BEGO Implant Systems, Bremen). The Semados ® RSX implant (Ø 4.5 and length 11.5 mm) was subcrestally set at 0.5 mm with an insertion torque of 35 Ncm. The implant stability quotient was 81 (Fig. 3-5).
The prosthodontic restoration was performed immediately with a provisional single-tooth crown. The final restoration with a cemented single-tooth crown was performed three months after implantation.
The One Care Package (Fig. 1, OCP, BEGO Implant Systems, Bremen) was chosen for the prosthodontic restoration. The PS OCP abutment was screwed in after implantation, the impression coping was placed and a closed-tray impression taken. The PS OCP multifunction cap serves as a healing cap for the first few days (Fig. 6-9). Eight days post-operatively, the healing process is good and the provisional crown (PMMA, VIPI Produtos Odontológicos, Brazil) has been cemented to the PS OCP abutment (Fig. 10-14).
The final restoration was performed. three months after implantation. The soft tissue had a well-shaped contour. After the closed-tray impression had been taken, the final crown of zirconium (Zirkonzahn, Germany) was cemented (Fig. 15-20). Radiographic check performed seven months post surgery showed good, stable bony integration of the implant (Figure 21).
The system components of the One Care Package (OCP, BEGO Implant Systems, Bremen).
The concept of restoration behind the One Care Package from BEGO Implant Systems is based on the approach of introducing the final abutment in the first prosthodontic session and leaving it in situ. The following steps are performed at soft tissue level to promote the undisturbed apposition and contouring of the soft tissue.
There are few studies focussing on this approach and are based on different indications. In an animal study ABRAHAMSSON et al. (2003) investigated whether the change of the prosthodontic abutment has an influence on the soft tissue. After three months of healing the prosthodontic abutments were fixed. On the one hand, the abutments were removed once a month, cleaned and re-inserted, while on the other hand, the abutments remained undisturbed in situ. After 6 months, the abutments that were repeatedly removed, showed an apically displaced connective tissue associated with a loss of marginal bone height, which the authors attributed to the formation of an attached biological width (ABRAHAMSSON et al., 1997). In a similar study design, the final abutments or healing posts were inserted three months after implantation. After the further 2 weeks the healing post was replaced by the final abutment. After 6 months the repeated change in the abutment had no effect on the length of the epithelium, the height of the fixed gingiva and the marginal bone level.
ANGELIS et al. (2016) found no positive influence of the concept on the preservation of the marginal periimplant bone level. They concluded from a comparison with existing literature that in addition to the concept of prosthodontic restoration, other factors such as the time of implantation also influence the maintenance of the peri-implant bone level. A comparison of provisional and final abutments on immediately inserted implants platform switch showed a significant difference in preserving peri-implant bone level at 12 months. For the restoration with final abutments, a better preservation of the bone level was measured (0.11 mm, SD 0.06 mm) than with the provisional abutments (0.58 mm, SD 0.11 mm), although the observed bone level differences are not clinically significant (GRANDI et al., 2014).
Although the existing literature so far provides no compelling evidence for the superiority of the concept of introducing the final abutment in the first prosthodontic session (BECKER et al., 2012), it does offer significant benefits. It ensures that the soft tissue is formed from the beginning in its final contour. Subsequent aesthetic corrective measures and risks are eliminated (BEUER et al., 2014 & 2015). By saving treatment time and sessions, due consideration is given to patient welfare. The further steps can be carried out quickly and efficiently and this implies less stress and burdens for the patient. For the clinician, shorter treatment times and fewer sessions open up the possibility of treating more patients.