Maxillary Anterior Aesthetic Reconstruction on Natural Teeth and Dental Implants – A Case Report
It is commonplace to see dental implants as a single tooth replacement option in today’s world of restorative dentistry. When a patient presents with a broken tooth in the aesthetic zone that is not restorable, the clinical question is whether choose between a conventional fixed bridge or a single tooth implant and crown restoration. Often times the condition of the adjacent teeth must also be involved in the ultimate treatment decision. Are the adjacent teeth already restored with direct restorative materials? What is the clinical condition of those restorations? Are the teeth in the immediate area in good position aesthetically and functionally? The following is a case report describing a case of a hopeless maxillary lateral incisor that is unrestorable due to root fracture necessitating removal and replacement.
Case Report: An Unrestorable Maxillary Lateral Incisor
The patient shown in Figures 1 through 3 presented with a failing crown in the tooth #10 (22) position. As the radiograph demonstrates, the tooth had an “unusual” accessory canal as well and lacked a post and core foundation under the previous crown, which had now come off revealing a “gutted” pulp chamber and a lack of ferrule to retain any full coverage restoration. The instrumentation of the accessory canal may have also caused a root perforation due to the invagination of the root morphology, but that diagnosis is inconclusive. Regardless, a decision was made because of a lack of coronal tooth structure, a potentially failing root canal, and aberrant root morphology with a “gutted” pulp chamber, that this tooth was unrestorable and would be needing to be extracted. The question was how to replace it? The immediate loss of the PFM crown and impending extraction of the tooth necessitated that a removable transitional partial denture be made to replace tooth #10 (22) while the socket graft and gingival tissues healed, and treatment options were discussed (Figure 4). Some of the aesthetic concerns that were discussed with the patient were:
- The large, unsightly composite restoration in tooth #8 (11) and the diastema between tooth #’s 8 and 9 (11 and 21).
- The rotation of tooth #7 (12) toward the mesial aspect. Minor tooth movement (orthodontics) was discussed as a corrective treatment prior to restorative therapy, but the patient was not interested in “braces to fix one tooth”.
- The overall symmetry of his maxillary incisor teeth (Golden Proportion).
It was decided with the patient that to meet all aesthetic and functional goals, the four maxillary incisor teeth would be restored, tooth #10 (22) being a single tooth implant. Another consideration was not to involve the maxillary left cuspid prosthetically, if at all possible, since porcelain over the opposing natural tooth in lateral excursive movement could potentially accelerate the wear of the opposing natural tooth. Figure 4 shows a facial view after soft tissue grafting and placement of an implant in the tooth #10 (22) position. It is important to have an adequate amount of attached gingiva in the edentulous site on the facial surface prior to placement of the implant to avoid potential stripping of soft tissue and bone over time. After about 4 months of healing to ensure osseointegration, a master impression is made to restore tooth #’s 7, 8, 9, and 10 (11, 12, 21, 22). A double cord retraction technique using a #00 cord at the base of the sulcus and #1 cord at the restorative margins are placed around each of the natural teeth and a closed tray impression coping is hand tightened to the implant platform with complete seating verified by radiograph (Figure 5). Once the master impression was created (Affinity: Clinician’s Choice) (Figure 6), opposing impressions were also taken using a highly detailed alginate alternative material (CounterFit II: Clinician’s Choice) and a centric check bite was made using a non-brittle, highly carvable bite registration material (Affinity Quick Bite: Clinician’s Choice) (Figure 7).
A preoperative provisional stent made with a PVS material (Template: Clinician’s Choice) was chosen due to its ability to capture precise detail, while having an ultra-fast setting time, with the transitional partial denture in place was used in conjunction with a strong and esthetic bis acrylic provisional crown material (Inspire: Clinician’s Choice) to fabricate a provisional restoration for tooth #’s 7, 8, 9, and 10 (11,12, 21, 22) and it was then cemented with resin-optimized provisional cement (Cling2: Clinician’s Choice) (Figure 8). Cling2 contains a unique polycarboxylate resin so it has great retention and is easy to clean up – two very important features of a provisional cement. Figure 9 is a retracted facial view of the provisional restoration after the temporary cement has been cleaned up. Note the corrected tooth positions and gingival zeniths are now in a more symmetrical position when compared to preoperative views. Shade matching is done using a digital camera (Shofu Eyespecial II; Shofu Dental) which has a dedicated isolate shade mode to better help the ceramist see the nuances of hue, value, and chroma in the patients’ natural teeth (Figure 10). At the following visit, the provisional restoration is removed, and the preparations cleaned using a piezo scaler to remove any remaining provisional cement. The custom implant abutment for tooth # 10 (22) is placed and torqued to 25 ncm (Figure 11).