Patient s Presenting Complaint V.C. presented with discomfort and mobility from the crowned maxillary left central incisor tooth. Fig 1. A longitudinal root fracture was suspected and confirmed when the ceramic crown was removed. The prognosis for this tooth was considered hopeless and its extraction and options for restoration of the resulting space discussed. 1
Figure 1 Previous Dental History The patient has been a regular attender but has a heavily restored dentition. She was reluctant to wear a removable prosthesis on a long term basis. The 21 had been endodontically treated many years before and restored with a post crown. The adjacent teeth had large composite resin restorations and the patient was reluctant to have full coverage crowns or veneers. Past Medical History 2
The patient has a clear medical history. She is allergic to Tetracycline. Habits Although there was evidence of tooth surface loss, parafunctional activity could not be determined. Erosion as an aetiological factor was suspected but not on-going. Family History V.C. is a 54 year old married female Caucasian. She is a personal language tutor. Extra Oral Examination Normal facial profile with an average symmetrical lip line with gingival margins exposed only with a very broad smile. No facial asymmetry with normal mouth opening and Temperomandibular joint function. No evidence of muscle hypertonicity. Intra Oral Examination Soft Tissues Healthy lining mucosae. Periodontal Health Good periodontal health with an isolated pocket mesio buccal 11. Root fracture suspected as cause of this pocket. Thin gingival tissues with generalised recession. Thin bio-type. Teeth Present 18 17 16 15 13 12 11 21 22 23 25 26 27 28 48 47 46 45 43 42 41 31 32 33 35 36 37 38 3
Restorations Present Ceramic crown & inlay Amalgam Restoration Composite resin filling Occlusal Relationship Half unit Class I incisor and molar occlusion. Average complete overbite. Bilateral canine guidance. Protrusive excursions guided on incisors. Special Investigations Alginate impressions secured in Rim Lock trays. Study casts mounted in Denar II semi adjustable articulator. Radiographic Investigation A long cone periapical radiograph was taken to assess bone height in the 21 site. Aesthetics Aesthetics were compromised by the missing 21 and the loss of surface enamel on 11 and 22.The provisional removable partial denture improved the aesthetics but compromised diction, perception of food and function. Diagnosis Poor aesthetics and function due to loss of 21 and partial denture. Prognosis Fair long term prognosis of heavily restored dentition. 4
Patient s Attitude Well motivated with good oral hygiene. The patient makes a round trip of 180 miles for dental appointments. Patient s Desires The patient requested a fixed solution to replace her provisional denture with a good long term prognosis. Treatment Aims Improvement in function, diction and perception of taste with improved aesthetics. Treatment Options 1) Removable partial denture. 2) Resin bonded bridge. 3) Conventional bridge using 11 and 22 as crown retainers. 4) Implant retained crown 11 and crown 21 to improve aesthetics. Treatment Plan The patient asked for a fixed solution but declined preparation of the adjacent teeth. However once implant treatment was commenced she decided that she would like the adjacent central incisor crowning to improve the aesthetics. Phase 1 Extraction of 21and insertion of immediate acrylic partial denture. Surgical guide derived from original study cast. Phase 2 Implant placement 21 site. Phase 3 Second stage exposure and placement of healing abutment. Phase 4 Definitive implant retained crown 21 and tooth borne crown 11. Phase 5 Review appointments and regular maintenance visits. 5
Treatment Phase 1 Impressions to fabricate immediate removable partial denture to replace fractured 2. Atraumatic extraction of 21 with LA using periotomes. Fig 2 Figure 2 Vertical deficiency of labial plate. 5mm sub gingival and perforation of labial plate near socket apex. Bio-Oss Collagen block placed into socket as preservation technique. Bio- Gide resorbable membrane placed over coronal aspect of socket and sutured with 3 x 5 Ø Vicryl sutures. Fig 3 6
Figure 3 Provisional removable partial denture was fitted. Fig 4. Figure 4 Phase 2 Inspection of soft tissue profile. Fig 5. Figure 5 7
L.A. Septanest 4%100,000 4ml. Labial mucoperiosteal flap reflected. Crestal and mesial and distal relieving incisions. Bone contours favourable. Fig 6 Figure 6 Surgical guide placed. 2.0 Ø x 13mm drill. 3.5 Ø x 13mm Tapered drill. Direction indicator to check alignment. 4.3 Ø x 13mm Tapered drill. Direction indicator to check osteotomy alignment. Fig 7 Figure 7 Nobel Replace Tapered Groovy Implant 4.3 Ø x 13mm at insertion torque 40Ncm. Primary stability favourable. Head of implant 3mm subgingival to adjacent 11 amelo cemental junction. Fig 8. 8
Figure 8 Cover screw placed. 7 x 6 Ø Vicryl sutures flap sutured. Healing two months post surgery. Fig 9 Phase 3 Figure 9 Second stage exposure 21 implant. Crestal incision. Healing abutment placed 4.3 Ø x 3mm Radiographic verification of seating of healing abutment. RPD eased. Phase 4 Preparation of 11 for a Procera all ceramic crown Closed Tray fixture level impression, polyvinyl siloxane 21, for zirconia customised abutment and Procera crown. Fig 10 Radiographic verification of seating of impression coping. Fig 11 9
Figure 10 Figure 11 Try in of Zirconia abutment 21 Fig 12 and radiographic verification of seating. Fig13 Figure 12 Figure 13 10
Try in of Procera crowns 11, 21. Occlusion checked and adjusted; 4 layers of 8 ų shimstock clear in intercuspal position. 21 abutment torqued to 35Ncm, access cavity sealed with PTFE tape and both crowns cemented with Rely X resin modified cement. Fig 14 Figure 14 Phase 5 Review appointment at three months and further check of occlusal contacts with shimstock. Regular six monthly examination appointments arranged. Figure 15 Discussion V.C. was pleased to receive the implant crown as she found difficulty in tolerating the denture. Initially, following implant restoration she was aware of her palatal rugae which may have been due to irritation from the denture or exposure to hot liquids. 11
A compromised aesthetic situation resulted in that there is a disparity in gingival levels between 21 and 11 despite using a socket preservation technique. The patient is not concerned by this but an improvement could have been achieved by using a crown lengthening procedure at 11. Re entry for implant placement was undertaken at two months before labial plate resorption occurred. The collagen block was placed to prevent soft tissue shrinkage and develop an optimal soft tissue profile. However, as there was a 5mm deficiency in labial plate height following the extraction, a compromise in gingival margin height was inevitable without a vertical augmentation technique such as a block graft or distraction osteogenesis. (1). The use of a socket preservation technique should be viewed as an attempt at preservation of soft tissue volume and not bone regeneration. (2). References 1) Araujo M, Lindhe J.: Ridge preservation with the use of Bio-Oss collagen; A six month study in the dog. Clin. Oral Implants Res. 2009;20:433-440. 2) Ackermann K.L. Oral presentation, International Osteology Symposium. Monaco 2007. 12