Management of a Complication with a Fractured Zirconia Implant Abutment in the Esthetic Zone Tim Joda, Dr Med Dent, MSc1/Urs Brägger, Prof Dr Med Dent2 Technical complications in implant prosthetic cases represent a major challenge in dentistry. This case report describes minimally invasive management to recover an implant with a fractured remnant of a zirconia abutment, including provisional rehabilitation during a sequential treatment protocol in the esthetic zone. A patient was treated with a screw-retained one-piece implant-supported reconstruction made of a customized zirconia abutment with direct ceramic veneering in the maxillary right central incisor position. During the prosthetic try-in, a fracture in the apical portion of the abutment was evident. The first rescue attempt led to fracture of the retrieval instrument. Immediately, an individualized wired construction was applied to bond the existing fractured reconstruction to the neighboring teeth to maintain the peri-implant mucosal architecture. Because the implant screw canal was blocked, a customized round bur had to be manufactured and was placed in the implant axis with a specific bracket tool from the service set to protect the interior implant threads. Then, the drills of the service set were guided by the newly created access to remove the fractured remnants. The implant screw was retapped and the area rinsed with chlorhexidine solution. All remnants were removed without the need for surgical intervention. Neither the implant connection nor the bone-to-implant interface was damaged. The stepwise treatment approach with the customized round bur combined with the system-specific drills of the service set saved the blocked implant so that the patient could be successfully rehabilitated with a new implant reconstruction. Int J Oral Maxillofac Implants 2015;30: e21–e23. doi: 10.11607/jomi.3827 Key words: abutment fracture, dental implants, implant-abutment interface, technical complications, zirconia
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echnical complications in implant prosthetic cases represent a major challenge in dental practice.1–3 The removal of nonretrievable fractured components involves a high risk of damage to the inner implant configuration or even loss of the implant.4,5 Especially in the esthetic zone, complication management often is more complex because implants may be placed subcrestally, with supraimplant mucosal heights of 4 to 6 mm. Direct visualization of the affected area is limited, and fast treatment solutions are needed to maintain the sensitive soft tissue
1Division
of Fixed Prosthodontics, School of Dental Medicine, University of Bern, Bern, Switzerland; Department of Prosthetic Dentistry, Center for Dental and Oral Medicine, University Hospital Hamburg-Eppendorf, Hamburg, Germany. 2Division of Fixed Prosthodontics, School of Dental Medicine, University of Bern, Bern, Switzerland. Correspondence to: Dr Tim Joda, Division of Fixed Prosthodontics, School of Dental Medicine, University of Bern, Freiburgstrasse 7, Bern 3010, Switzerland. Email: [email protected] ©2015 by Quintessence Publishing Co Inc.
architecture.6,7 In addition, the compromised patient must be restored with an adequate provisional prosthesis for social integration. This case report describes the minimally invasive management to recover an implant with a fractured remnant of a zirconia abutment on a conical implantabutment connection including temporary rehabilitation during sequential treatment in the esthetic zone.
CASE REPORT AND DISCUSSION A 24-year-old female patient was treated for singletooth replacement in the maxillary right central incisor position. After implant placement (Bone Level Crossfit RC 4.1-mm implant, Straumann), the mucosal emergence profile was conditioned with a fixed implantsupported provisional for preparation of the definitive screw-retained one-piece implant reconstruction, which consisted of a customized zirconia abutment with direct ceramic veneering (CARES, Straumann). During the first clinical try-in procedure, a fracture in the apical portion of the unworn zirconia abutment was evident. The remnant was trapped inside the implant and could not be removed. The goal in The International Journal of Oral & Maxillofacial Implants e21
© 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Joda et al
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b
c
Figs 1a to 1c (a) Fractured zirconia abutment of the definitive implant reconstruction; (b) detail of the fractured extraction bolt; (c) occlusal overview of the clinical situation with remaining remnants in the implant in the maxillary right central incisor position.
a
b
c
Figs 2a to 2c The intermediate provisional rehabilitation with modified fractured implant crown was bonded to neighboring teeth to support the individualized peri-implant mucosal architecture.
managing this complication was to remove the ringshaped remnant without surgical intervention or damage to the interior of the implant. A system-compatible extraction bolt was used to remove the fractured abutment. Although the bolt was used gently, its apex also fractured within the zirconia ring, further blocking the prosthetic screw access hole (Fig 1). In addition, neither the provisional implant crown nor the fractured definitive reconstruction could be replaced and connected to the implant temporarily. Therefore, an individualized wired construction was applied to bond the existing fractured reconstruction to the neighboring teeth to maintain the peri-implant mucosal architecture (Fig 2). An attempt was made to remove the combined fractured portions of zirconia and the extraction bolt through the use of the implant manufacturer’s service set. However, the fragments could not be freed because the material of the extraction bolt was too hard for the drills of the service set. A customized round bur made of tungsten carbide was therefore manufactured (JOTA). Tungsten carbide is characterized by a Young’s modulus of approximately 550 GPa and a stiffness two times greater than that of steel. The newly constructed round bur had the same shaft design as the drills of the service set. This was a prerequisite to determine the shaft’s length for the protection of the inner threads of the implant. The
tip of the customized bur had a small diameter, with which an initial access was created into the fractured extraction bolt. The customized bur was placed in the implant axis with the specific bracket tool from the service set. The drilling speed was controlled and did not exceed 600 rotations/minute with constant water cooling.8 Under these conditions, the sharp edges of the customized round bur efficiently cut into the remnants blocking the implant interior. Next, the drills of the service set were guided by the newly created access and could reach the defined sink depth of the centralized bracket. In the final step, the implant screw was retapped with the manufacturer’s tap guides. Continuous rinsing with chlorhexidine solution led to the removal of any remaining remnants (Fig 3). The fractured remnants of the abutment and the extraction bolt were successfully removed without the need for any surgical intervention. Neither the implant connection nor the bone-to-implant interface was damaged, and the individualized peri-implant mucosal architecture was also maintained with the application of the wired provisional. The stepwise treatment approach with the customized round bur combined with the system-specific drills of the service set saved the implant so that it could be successfully restored with a new reconstruction (Figs 4 and 5). The presented approach carries a low risk of damage to the bone-to-implant interface when removing
e22 Volume 30, Number 1, 2015 © 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Joda et al
a
b
c
Figs 3a to 3c (a) Treatment sequence with inserted system bracket in the implant screw canal and customized round bur made of tungsten carbide; (b) intermediate use of the specific drills until reaching the final sink depth; (c) retapping of the implant screw.
a
b
c
Figs 4a to 4c (a) Clinical situation showing the inner part of the implant screw canal and maintained peri-implant mucosal architecture after minimally invasive removal of all fractured remnants; (b) labial view of the rehabilitated patient with inserted implant crown made of a direct veneered zirconia abutment; (c) occlusal view.
fractured abutment components. Moreover, it is beneficial for the patient because there is no need for additional extensive treatment, such as removal of the implant.
ACKNOWLEDGMENTS The authors would like to thank JOTA (Rüthi, Switzerland) for technical support. The authors reported no conflicts of interest related to this study.
REFERENCES 1. Braegger U, Karoussis I, Persson R, Pjetursson B, Salvi G, Lang N. Technical and biological complications/failures with single crowns and fixed partial dentures on implants: A 10-year prospective cohort study. Clin Oral Implants Res 2005;16:326–334. 2. Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical complications in fixed prosthodontics. J Prosthet Dent 2003;90:31–41. 3. Sones AD. Complications with osseointegrated implants. J Prosthet Dent 1989;62:581–585. 4. Joda T, Wittneben JG, Braegger U. A novel cryo-mechanical approach for the removal of blocked nonretrievable implant components. Int J Oral Maxillofac Implants 2013;28:e45–47. 5. Salvi GE, Braegger U. Mechanical and technical risks in implant therapy. Int J Oral Maxillofac Implants 2009;24(suppl):69–85. 6. Schwarz MS. Mechanical complications of dental implants. Clin Oral Implants Res 2000;11(suppl 1):156–158. 7. Yilmaz B, McGlumphy E. A technique to retrieve fractured implant screws. J Prosthet Dent 2011;105:137–138. 8. Braegger U, Wermuth W, Torok E. Heat generated during preparation of titanium implants of the ITI Dental Implant System: An in vitro study. Clin Oral Implants Res 1995;6:254–259.
Fig 5 Final radiographic appearance showing successful rehabilitation with the new implant-supported crown.
The International Journal of Oral & Maxillofacial Implants e23 © 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
T
echnical complications in implant prosthetic cases represent a major challenge in dental practice.1–3 The removal of nonretrievable fractured components involves a high risk of damage to the inner implant configuration or even loss of the implant.4,5 Especially in the esthetic zone, complication management often is more complex because implants may be placed subcrestally, with supraimplant mucosal heights of 4 to 6 mm. Direct visualization of the affected area is limited, and fast treatment solutions are needed to maintain the sensitive soft tissue
1Division
of Fixed Prosthodontics, School of Dental Medicine, University of Bern, Bern, Switzerland; Department of Prosthetic Dentistry, Center for Dental and Oral Medicine, University Hospital Hamburg-Eppendorf, Hamburg, Germany. 2Division of Fixed Prosthodontics, School of Dental Medicine, University of Bern, Bern, Switzerland. Correspondence to: Dr Tim Joda, Division of Fixed Prosthodontics, School of Dental Medicine, University of Bern, Freiburgstrasse 7, Bern 3010, Switzerland. Email: [email protected] ©2015 by Quintessence Publishing Co Inc.
architecture.6,7 In addition, the compromised patient must be restored with an adequate provisional prosthesis for social integration. This case report describes the minimally invasive management to recover an implant with a fractured remnant of a zirconia abutment on a conical implantabutment connection including temporary rehabilitation during sequential treatment in the esthetic zone.
CASE REPORT AND DISCUSSION A 24-year-old female patient was treated for singletooth replacement in the maxillary right central incisor position. After implant placement (Bone Level Crossfit RC 4.1-mm implant, Straumann), the mucosal emergence profile was conditioned with a fixed implantsupported provisional for preparation of the definitive screw-retained one-piece implant reconstruction, which consisted of a customized zirconia abutment with direct ceramic veneering (CARES, Straumann). During the first clinical try-in procedure, a fracture in the apical portion of the unworn zirconia abutment was evident. The remnant was trapped inside the implant and could not be removed. The goal in The International Journal of Oral & Maxillofacial Implants e21
© 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Joda et al
a
b
c
Figs 1a to 1c (a) Fractured zirconia abutment of the definitive implant reconstruction; (b) detail of the fractured extraction bolt; (c) occlusal overview of the clinical situation with remaining remnants in the implant in the maxillary right central incisor position.
a
b
c
Figs 2a to 2c The intermediate provisional rehabilitation with modified fractured implant crown was bonded to neighboring teeth to support the individualized peri-implant mucosal architecture.
managing this complication was to remove the ringshaped remnant without surgical intervention or damage to the interior of the implant. A system-compatible extraction bolt was used to remove the fractured abutment. Although the bolt was used gently, its apex also fractured within the zirconia ring, further blocking the prosthetic screw access hole (Fig 1). In addition, neither the provisional implant crown nor the fractured definitive reconstruction could be replaced and connected to the implant temporarily. Therefore, an individualized wired construction was applied to bond the existing fractured reconstruction to the neighboring teeth to maintain the peri-implant mucosal architecture (Fig 2). An attempt was made to remove the combined fractured portions of zirconia and the extraction bolt through the use of the implant manufacturer’s service set. However, the fragments could not be freed because the material of the extraction bolt was too hard for the drills of the service set. A customized round bur made of tungsten carbide was therefore manufactured (JOTA). Tungsten carbide is characterized by a Young’s modulus of approximately 550 GPa and a stiffness two times greater than that of steel. The newly constructed round bur had the same shaft design as the drills of the service set. This was a prerequisite to determine the shaft’s length for the protection of the inner threads of the implant. The
tip of the customized bur had a small diameter, with which an initial access was created into the fractured extraction bolt. The customized bur was placed in the implant axis with the specific bracket tool from the service set. The drilling speed was controlled and did not exceed 600 rotations/minute with constant water cooling.8 Under these conditions, the sharp edges of the customized round bur efficiently cut into the remnants blocking the implant interior. Next, the drills of the service set were guided by the newly created access and could reach the defined sink depth of the centralized bracket. In the final step, the implant screw was retapped with the manufacturer’s tap guides. Continuous rinsing with chlorhexidine solution led to the removal of any remaining remnants (Fig 3). The fractured remnants of the abutment and the extraction bolt were successfully removed without the need for any surgical intervention. Neither the implant connection nor the bone-to-implant interface was damaged, and the individualized peri-implant mucosal architecture was also maintained with the application of the wired provisional. The stepwise treatment approach with the customized round bur combined with the system-specific drills of the service set saved the implant so that it could be successfully restored with a new reconstruction (Figs 4 and 5). The presented approach carries a low risk of damage to the bone-to-implant interface when removing
e22 Volume 30, Number 1, 2015 © 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Joda et al
a
b
c
Figs 3a to 3c (a) Treatment sequence with inserted system bracket in the implant screw canal and customized round bur made of tungsten carbide; (b) intermediate use of the specific drills until reaching the final sink depth; (c) retapping of the implant screw.
a
b
c
Figs 4a to 4c (a) Clinical situation showing the inner part of the implant screw canal and maintained peri-implant mucosal architecture after minimally invasive removal of all fractured remnants; (b) labial view of the rehabilitated patient with inserted implant crown made of a direct veneered zirconia abutment; (c) occlusal view.
fractured abutment components. Moreover, it is beneficial for the patient because there is no need for additional extensive treatment, such as removal of the implant.
ACKNOWLEDGMENTS The authors would like to thank JOTA (Rüthi, Switzerland) for technical support. The authors reported no conflicts of interest related to this study.
REFERENCES 1. Braegger U, Karoussis I, Persson R, Pjetursson B, Salvi G, Lang N. Technical and biological complications/failures with single crowns and fixed partial dentures on implants: A 10-year prospective cohort study. Clin Oral Implants Res 2005;16:326–334. 2. Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical complications in fixed prosthodontics. J Prosthet Dent 2003;90:31–41. 3. Sones AD. Complications with osseointegrated implants. J Prosthet Dent 1989;62:581–585. 4. Joda T, Wittneben JG, Braegger U. A novel cryo-mechanical approach for the removal of blocked nonretrievable implant components. Int J Oral Maxillofac Implants 2013;28:e45–47. 5. Salvi GE, Braegger U. Mechanical and technical risks in implant therapy. Int J Oral Maxillofac Implants 2009;24(suppl):69–85. 6. Schwarz MS. Mechanical complications of dental implants. Clin Oral Implants Res 2000;11(suppl 1):156–158. 7. Yilmaz B, McGlumphy E. A technique to retrieve fractured implant screws. J Prosthet Dent 2011;105:137–138. 8. Braegger U, Wermuth W, Torok E. Heat generated during preparation of titanium implants of the ITI Dental Implant System: An in vitro study. Clin Oral Implants Res 1995;6:254–259.
Fig 5 Final radiographic appearance showing successful rehabilitation with the new implant-supported crown.
The International Journal of Oral & Maxillofacial Implants e23 © 2015 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
