WRITTEN BY:
Eric Markowitz, DDS
Israel Puterman, DMD, MSD,
Shaun Keating, CDT
Introduction
A 38-year-old female physician presented for a consultation regarding what she referred to as an “uneven smile,” which she wanted to have corrected (Figures 1 and 2). Upon clinical examination using intraoral radiographs as well as CBCT imaging, it was noted that she had a malpositioned, ankylosed, and resorbed tooth No. 9 (Figure 3), with a very thin labial plate of bone (Figure 4). Additionally, she presented with intrinsic discoloration of tooth No. 8. She had very high aesthetic expectations for the corrective procedures that were required. Her treatment required a combination of atraumatic removal of the damaged root, augmentation of soft tissue volume and contours, as well as creating a natural and harmonious smile. Before initiating any treatment, she was informed about the many adverse possibilities involving her treatment. These potential complications included loss of hard and soft tissue, implant failure, and a general possibility of an aesthetic result that might not be up to her expectations. After several consultations with the prosthodontist and periodontist, she opted to proceed with the anterior rehabilitation.
Treatment Planning
The treatment planning for this case required a careful clinical evaluation of her smile aesthetics (both current and desired) as well as a CBCT examination to develop an ideal surgical treatment plan. This included determining the desired implant positioning, selecting the ideal implant size, achieving the best possible implant angulation, and determining the ideal depth to place the implant platform. After joint consultations with the prosthodontist and periodontist, it was determined that the best aesthetic prognosis would be achieved by using a root shield/partial extraction therapy in conjunction with a connective tissue graft (CTG). This would allow for the maintenance of labial contours while avoiding potential loss of the thin labial plate during the extraction of the ankylosed root. The CTG would aid in the coronal repositioning of the gingival margin and thickening of the gingival phenotype.
To help guide soft tissue emergence on the day of surgery, a fixed, implant-supported provisional restoration was planned, assuming sufficient primary stability of the implant was achieved. As a backup, in case of low primary implant stability, a customized (gingival colored) healing abutment would be fabricated, allowing for soft tissue development without any implant loading. In that scenario, the patient would use an Essix retainer during the healing phase. After 4 months of healing, she would return to the prosthodontist for the placement of a provisional abutment and provisional crown, which would be critical to further develop ideal emergence profiles and allow her to approve the prosthetic prototypes prior to finalizing the restorations. A provisional veneer using composite resin was planned for tooth No. 8 to help create ideal widths of teeth Nos. 8 and 9. After 6 to 8 weeks in the provisional restorations, we could then proceed with her final porcelain fused to IPS e.max ceramic (IPS e.max [Ivoclar])] veneer on No. 8 and her final custom (PFM) abutment and ceramic crown (IPS e.max) on implant No. 9. Once she agreed to the details of the treatment plan, treatment was initiated with the surgical phase as outlined above.
CASE TECHNIQUES
Surgical Approach
Due to the ankylosed root and thin labial plate, partial extraction therapy (socket shield technique) was selected. This approach preserves the facial aspect of the tooth root, which in turn supports as much of the bone and soft tissue architecture as possible, minimizing bone loss and gingival recession following the extraction. After the root shield was created, a Straumann bone level tapered 3.3 x14 mm dental implant (Narrow CrossFit [Straumann]) was placed using a tooth-supported surgical guide, engaging the palatal bone. A particulate bovine bone graft (Bio-Oss collagen [Geistlich NA]) was placed to fill the buccal gap between the implant fixture and the root fragment, and an autogenous connective tissue graft was placed to thicken the facial gingival architecture. The donor connective tissue was harvested from the hard palate and placed via labial intrasulcular tunneling technique. This also improved tissue thickness and allowed for coronal repositioning of the gingival margin.
A gingival-colored custom healing abutment (Ti-Base abutment [Straumann]) was placed, as the implant had insufficient insertion torque value to allow for the fixed, implant-supported provisional restoration. This abutment was designed to create ideal gingival healing for an ideal central incisor emergence profile. Initial temporization was achieved using a removable Essix appliance (Figures 5 to 7).
Fixed Provisionalization and Management of Soft Tissue
Following verification of implant integration via reverse torque testing at the 4-month postoperative time frame, an engaging temporary implant abutment (Straumann NC) was selected. Flowable composite resin (Filtek [Solventum]) was used to develop ideal emergence profiles and guide the development of papillae form from the implant platform to the gingival margin.
Composite resin (Filtek Supreme shade A1 [Solventum]) was adhered to the temporary abutment and shaped to create a full-contour restoration shaped ideally, as per the pre-op mockup. This was a screw-retained provisional crown with the access hole exiting through the buccal aspect of the clinical crown. The provisional was placed to 20 Ncm, and the access hole was covered with a layer of Teflon tape and covered with composite resin to match the rest of the restoration.
Simultaneously, a composite resin mockup was performed on tooth No. 8 to create ideal incisal edge positions, contours, and proportions, as well as ideal interproximal contact points to allow for midline papilla maturation (Figure 8).
Final Restorations and Shade Matching
Given the patient’s high smile line and complex shade, as well as high level of enamel characterization of her natural teeth, the final restorations required very detailed customization. This included a porcelain-fused-to-IPS e.max veneer on tooth No. 8, a cast metal abutment with full ceramic layering on No. 9, and a final porcelain-fused-to-IPS e.max crown to match the veneer on No. 8 and the natural lateral incisors on each side. The abutment design required a full-metal casting for optimal strength due to the severe labial angulation of the dental implant. Such angulation made the use of an angled screw-channel abutment challenging and unpredictable. The metal casting provided optimal lateral strength to resist fracture at the implant interface compared to a traditional Ti-base abutment connection. Due to the high aesthetic requirements, the metal abutment was cut back by the dental lab technician and ceramic was layered from the point of the implant connection up to the incisal edge of the abutment.
Ceramic was layered 360° to block out all underlying metal, including over the access hole to eliminate any potential show-through after cementation of the implant crown, thus ensuring a perfect shade match to the neighboring ceramic veneer on tooth No. 8. A series of photographs and a detailed shade map showing desired shade, value, desired translucency, edge halo effects, and scattered yet subtle frosting throughout the body of the teeth was provided to the dental laboratory for these highly customized restorations. The custom abutment was torqued to 35 Ncm as recommended by the manufacturer, and the access hole was filled with Teflon tape and composite resin. The veneer No. 8 was cemented with light-cured RelyX veneer cement shade WO (white opaque) (Solventum) to block out the darkened stump of the tooth, and the implant crown was placed with light-cured RelyX veneer cement shade A3 to provide ideal final shade matching with the adjacent teeth and the veneer. Retraction cord was placed prior to cementation of the implant crown to ensure cement did not migrate into the sulcus. Post-op radiographs were taken to confirm that all cement had been removed after completion of the procedures (Figures 9 to 12).
Outcome
The patient was extremely pleased with the results. The combined use of socket shield technique, a customized healing abutment, and the CTG set the stage for a successful restoration. By placing the midline interproximal contact point at a position apical to the middle portion of the restorations, the interdental papilla was able to migrate coronally to fill in any voids, and thus preventing the appearance of the “black triangle” effect that can occur when there are any interproximal openings between the interproximal contact point and the tip of the interproximal papilla. The combination of these described surgical and prosthetic techniques maintained ideal papilla formation even in this high gingival, scalloped tissue scenario. Slight vertical tissue excess of approximately 1 mm is noted on the facial aspect of the implant restoration. This is currently not a concern for the patient, thus we opted to leave it as is for the time being. Careful adjustments were performed to the incisal edges of both restorations to create ideal incisal edge positions and incisal embrasure shapes to her desired specifications.
She opted to wait on any further alterations at this time (Figure 13).
DISCUSSION
From both surgical and restorative perspectives, this case presented many challenges. Root resorption, root ankylosis, a thin labial plate, gingival asymmetry, high gingival scalloped tissue, a high smile line, implant angulation, highly characterized adjacent natural teeth, and high aesthetic expectations from this young female physician necessitated a high degree of surgical and restorative collaboration to optimize the final aesthetic results.
Fortunately, she was understanding of all challenges that needed to be addressed, and she was cooperative throughout the entire reconstruction. Careful planning and collaboration were mandatory from the start, and the patient had a very high level of confidence in both clinicians. This allowed the case to go as smoothly as possible. While there were unexpected challenges, all were handled carefully and to her satisfaction. Once the fixed temporization was completed, she was immediately satisfied with the aesthetics and function. This allowed for an unlimited timeframe to plan the aesthetics for the final restorations, as well as creating the ideal emergence profiles via alteration of the subgingival contours of the temporary crown. Once this aspect of the reconstruction was completed, it made achieving ideal final restorations much more predictable.
CONCLUSION
Replacement of a failing tooth with a dental implant has become the standard of care whenever conditions allow. Specific local conditions that may affect the final results must be carefully analyzed before initiating any treatment. Proper use of techniques and technology must be utilized from the planning phase through placement of the final restorations. Full collaboration between the surgeon and restorative dentist is critical for the success of these cases. Of equal importance to achieve a successful aesthetic restoration in the anterior segment of the mouth is ideal communication between the prosthodontist and the dental laboratory technician. In this case, the aesthetic team at Keating Dental Arts was patient, professional, and highly motivated to help provide the ideal aesthetic result for this wonderful patient.
ACKNOWLEDGMENT
A special thank you to Shaun Keating and Bob Brandon of Keating Dental Lab for their patience and expertise in providing the exceptional lab work on this case. Their commitment to excellence led to a great result.
ABOUT THE AUTHORS
Dr. Markowitz graduated Magna Cum Laude from the Baltimore College of Dental Surgery in 1993. Following graduation, he completed a 2-year specialty program in prosthodontics and a 1-year Fellowship in dental implants, focusing on the surgical placement of the implants. His areas of expertise include cosmetic, implant, and reconstructive dentistry. He is in private practice in Washington, DC. He can be reached at [email protected].
Dr. Puterman, received his DMD degree from Boston University in 2002. He then attended Loma Linda University where he received 2 residency certificates: one in implant dentistry and one in periodontics, as well as a Master of Science degree. As part of his dual residency training, he obtained expertise in the surgical, prosthetic, and laboratory phases of implant cases. He has limited his private practice in the Washington, DC, area to the surgical fields of implant dentistry, bone and soft-tissue regeneration, and periodontics using 3D microscopy. He can be reached via email [email protected] or his Instagram handle: @implantsdc.
Disclosure: The authors report no disclosures.
