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EDITOR’S NOTE: As of the printing date of this publication, the Ankylos SynCone and Cercon abutments were not yet
approved for use in the United States. Ankylos implants are approved for single stage surgical placement and immediate
loading in the United States, but immediate loading is restricted to the anterior mandible, based on 4 intraforaminal placed
implants, and is not indicated for single, unsplinted implants.
T
the success of the final implant cal point of view, the major dif-
tooth in the anterior
restoration. This is especially true ference in implant systems
region of the maxilla
if tissue atrophy is well advanced. available to dentists today is the
represents a par-
In spite of the excellent sur- type of implant-abutment con-
ticularly difficult
vival rate of 97.2% during a period nection used. Mechanical fail-
clinical situation for
of 6 years for single-implant ures—such as the loosening or
the placement of a single-implant
restorations that has been re- breakage of occlusal screws for
restoration that is both estheti-
ported by Lindh et al,6 the success the screw-retained restorations,
cally and functionally acceptable.
of the implant restoration should abutment screws, or abut-
The success of the single-implant be measured not only by the ments—are directly related to
restoration depends not only on survival rate but also by how well the type of implant-abutment
restoring clinical function, but it has satisfied the success criteria connection.25 Precisely machined,
also on integrating the restoration that are internationally accepted.7 internal-tapered implant–abut-
harmoniously into the patient’s These widely accepted criteria ment connections have been
overall appearance. The loss of include data related to the degree reported to provide more me-
a natural tooth is often followed of change in the peri-implant chanical stability than either the
by the collapse of the hard and bone level during a specific pe- external hex connections or butt-
soft tissues that make up the riod8 and data related to patient joint designs. The precision-fit
mucogingival complex. This re- satisfaction.9,10 Patient satisfac- tapered abutment-implant con-
sults in hard and soft tissue tion with any dental procedure nection of the Ankylos implant
relationships that are rarely fa- is a major consideration in den- has been shown to provide better
vorable for the insertion of a sin- tistry. This is particularly true short-term and long-term clinical
gle-implant restoration. when the implant restoration is performance.26-29
The esthetics associated with located in the frontal (anterior) At the Free University of
the final implant restoration are region.11,12 Berlin, the authors have been
greatly affected by both the The literature contains numer- using the Ankylos implant sys-
shrinkage of the adjacent inter- ous reports of complications that tem (Friadent GmbH, Mannheim,
dental papillae and the loss of the have been associated with the Germany) for single-tooth re-
scalloped tissue contour around prosthetic components of various placements since 1995. It has
the implant restoration. These implant systems during the load- provided highly functional resto-
structures are very important to ing phase. These complications rations that are esthetically and
the esthetics of the final restora- can have a negative influence on functionally very similar to the
tion because of the visibility of the the patient’s comfort13 and ap- natural tooth when a strict clinical
mucogingival complex during pearance. The potential for such procedure is carefully followed.
laughter.1 The shape, color, and problems should always be con- The procedure is based on sys-
surface structure of any replace- sidered when planning implant tem-specific features of the Anky-
ment for missing natural teeth treatment and when selecting an los implant (ie, the progressive
must be optimal. The extensive implant system. Complications thread design of the implant
loss of supporting tissue contours associated with implants fre- [Figure 1], the internal-tapered
may require grafting of the hard quently involve abutments that connection between the implant
and/or soft tissue in order to become loose from the im- and abutment, and the reduced
achieve a restoration that is sym- plant14-18 or crowns that become sulcus emergence region of the
metric and harmonious with its detached because of the loosen- abutment [Figures 2 and 3] with
neighboring teeth and the contra- ing or breakage of the retaining its special shape30). The proce-
lateral tooth.2 The immediate screws.19 These complications dure described in this paper
placement of implants has gained can be as high as 43% after only makes it possible to achieve opti-
considerable popularity in recent 3 years20 of clinical function. Soft mal treatment results while re-
years because this procedure pre- tissue problems such as the for- storing a high level of esthetics
serves the height and volume mation of fistulas are also possi- and clinical function for missing
relationships of bone structure.3-5 ble.21-23 single, natural teeth using im-
In actual clinical cases, however, Technical and prosthetic com- plant restorations. This is based
esthetic and functional restora- plications have been related to on successful outcomes that have
FIGURE 4. (A) Surgical stent aids in the correct positioning of the implant. (B) The implant is placed slightly below the crestal bone
level. (C) A sulcus former can be placed and used to support any augmentation materials. (D) A larger sulcus former is in place,
following uncovering, to establish the emergence profile within the soft tissue. (E) ‘‘Balance Anterior Abutment.’’ The thin neck of
the abutment and the preformed margin can be modified for custom crowns. (F) Customized balance abutment modified on
laboratory cast so that final restoration provides a harmonious relationship with natural teeth. (G) Precise fit of crown on
customized Balance abutment. (H) Relationship of customized abutment and crown to be transferred to mouth with customized
transfer stent (key). Transfer stent is made of self-curing acrylic resin. (I) Balance abutment has been seated in implant. (J) The final
esthetic crown is cemented to the customized Balance abutment. (K) Excessively wide space evident between natural right cuspid
(tooth #6) and implant-supported crown (#7). (L) Adhesive composite material is applied to the mesial surface to eliminate the gap;
note the natural esthetics and healthy tissue around restoration and the interdental papillae.
provides an important point of avoid a steep ascent angle. Be- Ankylos implant can be set
reference for implant placement. cause of the density of the in- slightly deeper into the bone, or
When planning the depth for ternal-tapered connection,31 there bone can be grafted above the
implant placement, the diameter is also the option of grafting bone level of the implant shoulder to
of the single-tooth restoration in over the top of the Ankylos achieve an esthetically favorable
the area of the mucous membrane implant shoulder (Figure 3) to ascent (emergence) profile (Fig-
emergence region should be com- provide increased support and ure 4B). A sulcus former can be
pared to the cross section of the stability to the implant. This is inserted during implant place-
width of the implant shoulder not possible with other conven- ment and used as support for
area. Large discrepancies be- tional 2-stage implant systems. the grafted material (Figure 4C).
tween these 2 fixed quantities The crestal bone in the region When the implant is uncovered,
could result in an unfavorable of the implant shoulder generally the sulcus former, used to stabi-
mucous membrane emergence remains in place during the lize the grafted bone, can be
profile and create a problem functional loading phase or may replaced with another sulcus
maintaining oral hygiene. It may, even increase in density, as con- former that is customized for
therefore, be advisable to insert firmed by various reproducible the specific esthetic situation
the implant somewhat deeper to X-ray exposures. Therefore, the (Figure 4D).
FIGURE 5. (A) Small sulcus former (incisal view). (B) Small sulcus former (frontal view). (C) Pressure shaping of emergence profile
within soft tissue with large sulcus former: note blanching of tissue. (D) Shaping of tissue margin: note healthy tissue color. (E)
Emergence profile formed within soft tissue: note that thick dense tissue covers the coronal portion (shoulder) of implant. (F)
Healthy, well-formed soft tissue following removal of sulcus former. (G) Esthetic crown cemented on abutment. (H) Final esthetic
crown closely follows the patient’s ‘‘smile line.’’
tion of anterior (front) teeth. They an esthetic and functional final tomized transfer key (index) must
are fabricated using either tita- restoration that harmoniously therefore be fabricated to facili-
nium (Figure 4E) or zirconium- blends with the remaining natu- tate the accurate transfer of
oxide (Figure 6C through E) and ral teeth for each clinical case the relationships between the
have the following unique fea- (Figure 4F). new implant restoration and the
tures: (1) their shape corresponds The thickness of the mucous remaining teeth, from the work-
to that of a natural tooth that has membrane, the axial inclination ing laboratory cast to the mouth
been prepared for an esthetic of the implant, and the cervical (Figure 4H). The index can be
crown restoration, (2) the abut- crown diameter must all be fabricated from self-curing resin
ment shoulder conforms to the considered when selecting the (Pattern Resin, GC, Tokyo, Japan).
natural gingival contour, (3) a 1- abutment to be customized. The The exact procedure has been
mm-wide chamfer allows the superstructure of the final resto- described by the authors in a pre-
fabrication of an esthetic crown ration is fabricated on the cus- vious publication.32 After instal-
design, (4) the reduced sulcus tomized abutment. The final lation of the abutment with
region aids in the formation of esthetic crown can be formed a torque of 15 Ncm, the crown is
a healthy, dense gingival collar very precisely to the abutment to initially cemented in place with
around the small diameter of the maximize esthetics and function provisional cement and is then
abutment, which provides pro- (Figure 4G). The tapered abut- permanently cemented at a later
tection for the underlying bone, ment connection allows the abut- date (Figure 4I and J). If esthetics
and (5) the balance abutments can ment coping to be rotated and are required to be improved
be easily customized by grinding positioned on the implant to further, some localized shaping
to make it possible to fabricate obtain the best position. A cus- of neighboring teeth with abra-
FIGURE 6. (A) Implant following uncovering: note sulcus former. (B) The soft tissues have been shaped to provide natural contours.
(C) Ankylos implant with the Cercon ceramic abutment. (D) Cercon abutment has been customized on laboratory cast. (E) Cercon
abutment with full-ceramic crown. (F) Esthetic ceramic crown: note the emergence profile from shoulder of implant analog. (G)
Cercon abutment in place (tooth #8). (H) Cemented final crown. (I) Patient’s high smile line: note healthy soft tissue around
implant-crown restoration.
sive instruments and adhesive possible to improve the esthetic aluminum oxide ceramics.33 Cer-
restorative materials can be per- color of final ceramic crowns and con abutments can also be cus-
formed in conjunction with the the esthetic appearance of the tomized and are manufactured
actual crown restoration. This surrounding healthy gingival tis- with the same precisely tapered
improves the contour to compen- sues. The white coloring of the abutment connection as that
sate for gap asymmetries and to Cercon zirconium oxide abut- found in the titanium abutment.
support the papillae (Figure 4K ments eliminates this blue-gray In addition to its excellent bio-
through O). coloring and makes it possible to compatibility, the zirconium ce-
Conventional metal abut- improve the esthetic natural tooth ramic abutment does not promote
ments often produce a blue-gray appearance of the final ceramic bacterial accumulation when
shadowing effect in the cervical crown restoration. A full-ce- compared to titanium abut-
region of the restoration, which ramic crown with the Cercon ments34 (Figure 6C through I).
can be visible in patients with ceramic abutment system pro-
very thin soft tissue. An impor- vides natural translucence, which
tant prosthetic option of the An- is impossible with metallic struc-
RESULTS
kylos implant system is the tures. While the Cercon abutment
addition of a full-ceramic abut- has excellent optical properties, it A total of 275 single Ankylos
ment for anterior teeth—the Cer- also has high mechanical strength. implant tooth restorations in the
con abutment made of zirconium The bending resistance and frac- anterior and posterior jaw regions
oxide (Y-TZP) (Figure 6C through ture toughness values are signif- were placed and monitored for 8
E). This esthetic option makes it icantly higher than those of years. Of these, 264 implants were
DISCUSSION
In agreement with previous gen-
eral experience with single-tooth
implants,6 the authors were able
to achieve a success rate of 98.2%
with the Ankylos implant system
after 8 years of use and an average
observation period of 38 months.
The literature describes some gen-
eral mechanical complications
that exist during the functional
loading phase for other implant
systems with butt-joint connec-
tions (eg, the frequent loosening
of abutments or abutment-retain-
ing screws).15-17,19 Our experience
with the Ankylos implant system
FIGURE 7. (A) Implant restoration (tooth #8): note the healthy tissue and contours
is in contrast to this, and we did
around implant restoration. (B) Implant restoration after 5 years of clinical function: not experience these problems in
note that there is no detectable loss of crestal bone surrounding implant restoration. our patient group. Soft tissue
complications such as fistulas,14,35
restored using the titanium Bal- The peri-implant soft tissues which often coexist with loosen-
ance abutments, and only 11 were were extremely stable, with no ing problems, were not observed
restored using ceramic abut- evidence of fistulas, recession, or in the clinical study database. Our
ments. The final restorations were infections. A slight increase in the data indicated that the loosening
either metal-ceramic or full-ce- height of the papillae was seen; or breakage of Ankylos prosthetic
ramic crowns and were cemented however, no sign of clinical in- components is not a problem with
with glass ionomer cement. The flammation was observed. In one implant-supported restorations.
survival rate was 98.2%, with prospective and one retrospective Such complications are described
only 5 implants being lost during study, no measurable losses of in the literature but are associated
the healing phase. There were no crestal bone were recorded dur- with other implant designs that
other implant losses in the post- ing the functional prosthetic pe- feature different diameters of im-
loading period that averaged 3.2 riod for a total of 72 single-tooth plants and abutments. This ap-
years. To date, there have been no implants, either in the anterior or pears to be particularly true with
mechanical complications associ- posterior region for this type of molar replacements.15
ated with the prosthetic compo- restoration. In our study, in 50% Our results with the Ankylos
nents (ie, screw loosening, screw of the cases, X-ray examination system show that mechanical
breaking, or crown breaking) for after 1 year of prosthetic loading complications with single-tooth
either the titanium or the ceramic showed crestal bone at or slightly implants can be prevented, even
abutments. Two Procera crowns above the level of the implant in the molar region. This agrees
on posterior dental implants were shoulder. 8 years of scientific with the retrospective study
replaced because the ceramic ma- data (Figures 4P through R, 7A by Romanos and Nentwig29 on
terial had been chipped. and B, and 8A through C) confirm single-tooth restoration of molars
the clinical performance and with this system, although the
as is frequently assumed.43,46 In 3. Lazzara RJ. Immediate im- treatment. Int J Oral Maxillofac
addition to the positive effects of plant placement into extraction Implants. 2003;18:113–120.
a favorable load transmission to sites: surgical and restorative 14. Jemt T, Laney WR, Harris
the bone via the special thread advantages. Int J Periodont Re- D, et al. Osseointegrated im-
of the Ankylos implant29,30,47 storative Dent. 1989;9:332–343. plants for single tooth replace-
and a stable internal-tapered 4. Werbitt MJ, Goldberg PV. ment: a 1-year report from
abutment connection, the lack of The immediate implant: bone a multicenter prospective study.
complications can be attributed to preservation and bone regenera- Int J Oral Maxillofac Implants.
the thick deposition of soft tissue tion. Int J Periodont Restorative 1991;6:29–36.
in the narrowed neck of the Dent. 1992;12:206–217. 15. Becker W, Becker BE. Re-
abutment. This collar of soft 5. Ericsson I, Nilson H, Lindh placement of maxillary and man-
tissue, which appears wedge T, Nilner K, Randow K. Immedi- dibular molars with single
shaped in cross section, seems to ate functional loading of Brane- endosseous implant restorations:
provide a supplementary protec- mark single tooth implants. An a retrospective study. J Prosthet
tive function for the peri-implant 18 months’ clinical pilot follow- Dent. 1995;74:51–55.
bone.48,49 up study. Clin Oral Implants Res. 16. Engquist B, Nilson H, As-
2000;11:26–33. trand P. Single-tooth replacement
6. Lindh T, Gunne I, Tillberg by osseointegrated Branemark
CONCLUSION
A. A meta-analysis of implants in implants. A retrospective study
Experience with the Ankylos partial edentulism. Clin Oral Im- of 82 implants. Clin Oral Implants
system with single-tooth re- plants Res. 1998;9:80–90. Res. 1995;6:238–245.
placement indications may be 7. Albrektsson T, Zarb GA, 17. Lazzara R, Siddiqui AA,
considered positive with regard Worthington P. The long-term Binon P, et al. Retrospective mul-
to the esthetic and functional efficacy of currently used dental ticenter analysis of 3i endosseous
results of the treatment. The lack implants: a review and proposed dental implants placed over
of mechanical complications and criteria of success. Int J Oral a five-year period. Clin Oral Im-
problems with the hard and soft Maxillofac Implants. 1986;1:11 plants Res. 1996;7:73–83.
tissue in the loading phase of –25. 18. Scheller H, Urgell JP,
the implants suggests the func- 8. Norton MR. Marginal bone Kultje C, et al. A 5-year multi-
tional safety of the tapered con- levels at single tooth implants center study on implant-sup-
nection between implant and with a conical fixture design. ported single crown restorations.
abutment. The influence of surface macro- Int J Oral Maxillofac Implants.
and microstructure. Clin Oral Im- 1998;13:212–218.
plants Res. 1998;9:91–99. 19. Levine RA, Clem D, Bea-
ACKNOWLEDGMENT
9. Smith DE, Zarb GA. Crite- gle J, et al. Multicenter retrospec-
The authors thank Michael ria for success of osseointegrated tive analysis of the ITI implant
Krause, master dental technician endosseous implants. J Prosthet system used for single-tooth re-
(Dentallabor Krause, Berlin), for Dent. 1989;62:567–572. placements: results of loading for
carrying out the dental technical 10. Zarb GA, Albrektsson T. 2 or more years. Int J Oral
work. Towards optimized treatment Maxillofac Implants. 1999;
outcomes for dental implants. 14:516–520.
J Prosthet Dent. 1998;80:639–640. 20. Ekfeldt A, Carlsson GE,
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NOTE
tissue integration of immediately an endorsement of the evaluated
loaded implants in the posterior The results and opinions pre- implant by the American Acad-
macaque mandible: a histomor- sented are those of the author emy of Implant Dentistry.