Selecting Treatment Options and Sequencing Treatment in the Replacement of 2 Maxillary Central Incisors with Implants: A Case Report

SELECTING TREATMENT OPTIONS ANDSEQUENCING TREATMENT IN THEREPLACEMENT OF 2 MAXILLARY CENTRALINCISORS WITH IMPLANTS: A CASE REPORTCLINICALPatrick F. McEvoy, BDSKEY WORDSDental implantsImmediate implant placementSoft tissueEdentulous ridge expansionPatrick F. McEvoy, BDS, is in private practiceat 105 South Drive, Suite 200, MountainView, CA 94040 (e-mail: [email protected]).278 Vol. XXIX/No. Six/2003This article describes treatment provided to replace 2 maxillary central incisorswith implant-supported restorations. The site of a missing maxillary centralincisor was treated utilizing a bone expansion technique to augment the labialhard and soft-tissue profiles at the time of implant placement. The adjacentcentral incisor tooth, although destined to be extracted, was retained to serve asan abutment for a fixed provisional restoration until the first implant was deemedto have successfully integrated. At the appointment to uncover this implant, thefractured tooth was extracted and an implant was immediately placed into thesocket. The first implant was then used to support the provisional restorationduring the healing phase of the second implant. The techniques utilized resultedin optimum soft-tissue contours, allowed the patient to have a comfortable andesthetic provisional restoration, and minimized the number of surgicalprocedures.po w Trted crowns. One of the critical con- tation of the soft tissues alone.ugm a b ced nhan e b y ma e p dges, i bdrentures,andresin-bimplant-supondedrestorofilrative meodality, theysoft-tissu3ipa anti e th n o ding n pe De 2 ion. t a p v o m re dtoothentures,include fixableed parrtialtial esthoratetic outcome of any planncedHorestedth mise o ompr c y a t a t c s u l t ri ante missing e aNTRODUCTION Iresinglatment options to replorace audoeficienspate labihalm contour in the edenenee---siderations in the selection of a particulartreatment modality is its effect onthe esthetic outcome. Restoration of thesoft-tissue contours is equally as importantas restoration of the tooth form.1Loss of a tooth due to trauma andconsequent loss of bone often result inever, if an implant is the chosen methodof restoration, bone augmentation isoften necessary to make it possible toplace the implant in an ideal position.Thus, site development is of the utmostimportance.4 In many cases, multiplesurgical procedures are required toFIGURES 1-2. FIGURE 1. This shows the condition at initial presentation and demonstrates the deficient labial bone contour. The fracture intooth #9 is highlighted by cement penetration. FIGURE 2. The preoperative radiograph illustrates the mesial bone loss related to the fracturein tooth #9.prepare the receptor site so that theend result will satisfy the patient'sfunctional and esthetic expectations.5,6If the requirement is to augmentthe bone horizontally, available techniquesinclude onlay grafts,7 guidedbone regeneration,8 and expansion ofthe edentulous ridge.9 Careful selectionfrom the available surgical techniques,with appropriate consideration of theclinical circumstances, may reduce thenumber of surgical procedures that thepatient has to undergo, avoid the needfor a donor site for autogenous bone,and potentially shorten the overalltreatment time.Extraction and replacement of acentral incisor requires careful managementto preserve the existing softtissuecontours, preserve the fragile labialplate of bone, and avoid the needfor still further augmentation procedures.10Immediate placement of implantsinto extraction sockets in the correctcircumstances is now widely acceptedto have comparable success rates to delayedplacement.11,12However, attention should be given tothe timing of the removal of a hopelesstooth, as this may influence the treatmentoutcome.CASE REPORTA 30 year-old man presented complainingthat his upper anterior bridgewas loose. The bridge replaced theright central incisor, which had beenlost due to a baseball injury 10 yearspreviously. It was retained by full-coveragecrowns on the right lateral incisorand left central incisor, with metalposts in each root. The patient requestedreplacement of the missing toothwith an implant-supported crown, ashe desired to have front teeth that werenot joined together.The patient's medical history wasunremarkable, and his dentition wasotherwise intact.At the initial appointment, thebridge was easily removed with fingermanipulation. The posts had becomeseparated from the roots but were stillattached to the bridge. Examination revealedthat some of the coronal toothtissue of both abutments had fracturedinside the prosthesis. The lateral incisorappeared to be restorable in a conventionalmanner. However, the leftPatrick F. McEvoycentral incisor had a root fracture thatappeared to extend to the osseous crest(Figure 1). This fracture significantlycompromised the restorability andlong-term prognosis of the tooth.Radiographic examination revealedacceptable endodontic therapy hadbeen completed for both teeth. Theheight of bone at the crest of the ridgewas within 5 mm of the contact pointsof the planned restorations, suggestingpredictable soft-tissue esthetics.13,14There had been some bone loss atthe mesial of the left central incisor,which was probably related to the fracturein the root (Figure 2). Utilizing awide platform implant and placing itslightly to the mesial of the originalroot position would obliterate thissmall bone defect. This would have theadded benefit of slightly increasing thewidth of bone between the implantand the adjacent tooth distally. Theedentulous ridge had good verticalcontour but was deficient labially, aClass 2 site according to the classifi-cation of Salama and Salama.15 Itwould therefore be necessary to augmentthe ridge buccally to allow place-Journal of Oral Implantology 279REPLACING 2 CENTRAL INCISORS WITH IMPLANT-SUPPORTED RESTORATIONSment of an implant of the desired diameterin the ideal location.TREATMENT PLANAfter discussion with the patient regardingthe options, risks, and bene-fits, the treatment plan was finalized.The first surgical phase would involveplacement of an implant into the edentulousspace after expanding the bonelabially, utilizing the edentulous ridgeexpansion (ERE) technique16 to restorethe osseous and soft-tissue contour. Atthe same appointment, prior to the implantplacement, the adjacent teethwere to receive new bonded posts toenable them to support a fixed provisionalrestoration during the healingperiod.The second surgical appointmentwas to occur after osseointegration ofthe first implant and involve uncoveringthe implant, extraction of the fracturedleft central incisor, and immediateimplant placement. The first implantand the lateral incisor would beused to support the provisional restorationduring the period required forintegration of the second implant andmaturation of the soft tissues after exposureof the first implant. Ultimately,both implants and the lateral incisorwere to be restored with individual ceramiccrowns.Staging the surgical phases oftreatment would allow preservation ofthe necessary support for an estheticallypleasing and functional fixed provisionalrestoration.SURGERY 1Fiber-reinforced posts (Fiberkor, JenericPentron, Wallingford, Conn) werebonded into the roots of teeth #7 and#9 and they were prepared to accept aprefabricated provisional bridge (Biotemps,Glidewell Laboratory, NewportBeach, Calif; Figure 3). Once the restorativetreatment had been completed,the area was irrigated copiouslywith a solution of chlorhexidene digluconate0.12%.17 (Oris, Dentsply International,York, Pa).A partial-thickness flap was raised,280 Vol. XXIX/No. Six/2003preserving the papillae on the adjacentteeth. The edentulous bone ridge wassplit vertically at the crest in a mesiodistaldirection, using a #64 Beaverblade (Sable Industries, Oceanside, Calif),the handle of which was tappedusing a mallet. The labial bone wasgradually expanded using bone expanders(Friadent North America, Irvine,Calif). This was facilitated bymaking vertical relieving incisions inthe bone, again using the #64 Beaverblade (Figure 4). Once the desired labialexpansion had been achieved, theapical portion of the osteotomy wascompleted with internally irrigateddrills, with the assurance not to involvethe fragile, expanded crestal bone (Figure5). A 4.5-mm 3 13-mm, stepped,tapered screw implant (Friadent NorthAmerica) was placed and the flap wassutured with 5.0 silk (Ethicon, Somerville,NJ; Figure 6). In accordance withthe ERE technique, no attempt wasmade to obtain primary closure, andthe suture served merely to maintainthe vertical position of the soft tissues.The crestal soft tissue was left to healby secondary intention.The provisional bridge was adjustedso that there was no pressure fromthe pontic on the surgical site, and wascemented with temporary cement(Tempocem, DMG, Hamburg, Germany;Figure 7). Healing was uneventful.SURGERY 2Four months after the initial surgery,the provisional bridge was removed.The implant was exposed by raising afull-thickness flap from the palatal aspectof the implant. The flap was thenrolled forward to increase the soft-tissuethickness on the labial aspect. A titaniumMH6 (Friadent North America)abutment was placed on the implant inthe #8 position and the provisionalbridge was modified to be retained bythis implant and the #7 natural tooth(Figures 8 and 9). The fractured tooth,#9, was extracted carefully using periotomes.The socket was inspected toverify that there was no loss of integrityof the labial plate of bone and wasdeemed to be suitable to receive an implantimmediately. A trial implant wasused to verify that the chosen implantwould obliterate the socket. After thoroughcurettage and irrigation of the extractionsocket with a solution of tetracyclinein saline, the osteotomy wasprepared and a 5.5-mm 3 13-mm, tapered,stepped screw implant (FriadentNorth America) was placed. Acustomized healing abutment was fabricatedby adding composite to a stocktemporary abutment (Protect Abutment,Friadent North America) in orderto support the soft tissues, and themodified provisional bridge was recemented(Figure 10).Healing was uneventful and, afteran additional 4 months, the restorativephase was completed. Implant levelimpressions were made, ceramic abutments(Cerabase, Friadent NorthAmerica) were fabricated for the 2 implantsand final preparation of the #7natural tooth was completed. Individualceramic crowns were cemented tocomplete the case (Figures 11 and 12).DISCUSSIONCareful selection of available surgicalmodalities and the sequencing of treatmentis necessary when consideringreplacement of anterior teeth with implant-supported restorations.In a recent case report,18 El Askaryachieved similar results by harvestingsymphyseal cortical bone and placingan onlay bone graft to augment a de-ficient edentulous ridge. In the case describedin this report, the desired ridgecontour was restored and existing softtissueprofiles were preserved withoutthe need for an additional surgical site.At the same time, retaining the fracturedincisor slightly longer thanwould normally have been requiredensured adequate support for the firstfixed provisional restoration, therebyavoiding the need for an additionalprocedure. This treatment plan wasmade possible because there wereteeth adjacent to the edentulous sitethat had previously been prepared forfull-coverage restorations. If the adja-Patrick F. McEvoyFIGURES 3-7. FIGURE 3. Tooth #9 is shown after restoration with a post and core. The fracture is clearly visible. FIGURE 4. The crestal boneincision and labial relieving incisions are demonstrated. FIGURE 5. The ridge is expanded to the desired dimension using osteotomes.FIGURE 6. After the implant had been seated, a cover screw is seated firmly. FIGURE 7. The provisional bridge is placed to complete theinitial surgical appointment.Journal of Oral Implantology 281REPLACING 2 CENTRAL INCISORS WITH IMPLANT-SUPPORTED RESTORATIONSFIGURES 8-12. FIGURE 8. Immediate postoperative radiograph of #8 implant. FIGURE 9. A temporary abutment was placed on the implant#8 and the soft tissues were displaced labially to further enhance the labial contour. The implant has been placed in the extraction socketof tooth #9 and a custom healing abutment was fabricated to support the labial gingival contour. FIGURE 10. Custom ceramic abutmentswere seated on both implants (the final preparation of tooth #7 has not yet been completed). FIGURE 11. Radiograph of the finished caseshowing the implants with ceramic abutments and crowns. FIGURE 12. The final presentation shows the esthetically pleasing ceramiccrowns and preservation of the interdental papillae.282 Vol. XXIX/No. Six/2003cent teeth had been intact, a differenttreatment approach would have beenindicated.ACKNOWLEDGMENTThe author declares he has no financialinterest in any of the products or manufacturersmentioned in this article.REFERENCES1. Garber DA, Salama MA. Theaesthetic smile: diagnosis and treatment.Periodontology 2000. 1996;11:18-28.2. Johnson K. A study of the dimensionalchanges occurring in themaxilla after tooth extraction. Part 1:normal healing. Aust Dent J. 1963;8:428-433.3. Garber DA. The edentulousridge and fixed prosthodontics. CompendContin Educ Dent. 1981;2:212-234.4. Garber DA, Belser UC. 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