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15Implant TribuneMay 17-23, 2010United Kingdom Edition positioning of the implant is of critical importance in helping to achieve a lasting aesthetic result and here it is important to place the implant correctly, ie, three mm apical and two mm palatal to the final gingival margin desired on the implant restoration. In this case the teeth were to be crown lengthened, so it was necessary to recontour the osseous architec- ture and establish the correct bio- logic width on the teeth (Figs 7, 8) prior to positioning the implant so that the final gingival margins will harmonise. In effect, this meant that the implant was placed deeper than would have been in a case where no crown lengthening was re- quired and facilitated a good housing of bone for the implant. Despite this, it was still necessary to augment the labial osseous and soft tissue contours for the pur- poses of achieving the correct soft tissue aesthetics. A Nobel Active 4.3 x 13mm implant was placed after prepa- ration of the osteotomy, achieving excellent primary stability, and bone augmentation was carried using the principles described in the previous publications by the author 23 using an organic bo- vine bone mineral (Nu-Oss, Ace Surgical Co, Brockton, USA) and covered with resorbable collagen membrane (Bio-Gide, Geistlich AG) (Figs 9, 10). A narrow healing abutment was placed, the bone augmenta- tion carried out and the tissue on the crest of the ridge was deepi- theliased and rolled under itself to the labial to create an increase of the soft tissue volume on the la- bial of the implant healing abut- ment and the flap sutured using 6-0 mono filament polypropylene sutures (Fig 11). This could be further enhanced with a connec- tive tissue graft if necessary, but in this case, the roll flap created sufficient thickness. The bridge was re-cemented after adjust- ment of the pontic to fit passively against the augmented ridge and healing abutment, and to allow for a slight tissue excess in the area of the implant. The healing process begins After three months of healing, the remaining crowns and pro- visionals were removed and the teeth re-prepared to the new gin- gival margins. The bridge retain- ers were relined and provisional crowns made and cemented provisionally to allow for tissue maturation to occur (Figs 12, 13). After six months, final refine- ment of the tooth preparations (Fig 14) and the achievement of good soft-tissue contours can be seen particularly on the labial as- pect of the implant, where a thick collar of labial tissue is evident (Figs 15, 16). The final impres- sions of the preparations and a transfer impression of the im- plant were made and subsequent steps to try-in the abutment and bisque bake of crowns were car- ried out. After all necessary ad- justments were made the final Procera alumina crowns were finished and final cementation performed with a glass ionomer cement (Fuji 1, GC) over a peri- od of a few weeks. It is essential that retraction cord is used when cementing the crown (whether provisional or final) on the im- plant abutment to ensure that no cement excess travels into the sub-mucosal area as this can lead to peri-implantitis and therefore compromise the result. A Procera Zirconia abutment was fabricated and Fig 17 shows an example of this, demonstrat- ing the ideal contours of the abut- ment with the scalloped margins resembling a tooth preparation. This enables crown margins to be ideally placed for cementation. The design of the Nobel Active implant components lend them- selves naturally to the creation of the transmucosal under-contour that facilitates a thicker trans- mucosal tissue cuff and therefore greater stability. Figs 18, 20 show the final crowns at two-month follow up. It is interesting to note the difficulty in achieving ideal soft-tissue col- our at the gingival marginal area of the teeth restored with metallic post crowns, but good colour is achieved around the implant. DT About the author Dr Tidu Mankoo is in Private & Referral Practice in Windsor, UK, treating Implant, Restorative and Aes- thetic cases, particu- larly complex cases. He is the current President of the European Academy of Esthetic Dentistry. page 13DTà ©NobelBiocareServicesAG,2010.Allrightsreserved.NobelBiocare,theNobelBiocarelogotypeandallothertrademarksare,ifnothingelseisstatedorisevidentfromthecontextinacertaincase,trademarksofNobelBiocare. All-on-4 was developed to provide clinicians with an efficient and effective restoration using only four implants to support an immediately loaded full-arch prosthesis.* Final solutions include both fixed and removable prostheses such as NobelProcera Implant Bridge Titanium or Implant Bar Overdenture. The tilted posterior implants help avoid relevant anatomical structures, can be anchored in better quality anterior bone and offer maximum support of the prosthesis by reducing cantilevers. They also help eliminate the need for bone grafting by increasing bone-to-implant contact. All-on-4 can be planned and performed using the NobelGuide treatment concept, ensuring accurate diagnostics, planning and implant placement. Nobel Biocare is the world leader in innovative and evidence-based dental solutions. For more information, call + 44 (0) 1895 430650 (UK), 1800 677306 (Ireland) or visit our website. www.nobelbiocare.com Nobel Biocare UK LTD, Telephone: + 44 (0) 1895 430650. Fax: + 44 (0) 1895 430636 Ireland, Telephone: 1800 677306. Fax: 1800 677307 * If one-stage surgery with immediate loading is not indicated, cover screws are used for submerged healing. Disclaimer: Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Nobel Biocare sales office for current product assortment and availability. All-on-4™ The efficient treatment concept with immediate loading. Reduced need for vertical bone augmentation. Maximum bone-to-implant contact and preservation of vital structures. High stability with only four implants. Wide variety of prosthetic options with maximum function and fit. NB All-on-four A4 UK.indd 1 10-05-05 15.25.54