Immediate treatment to manage an unscheduled patient esthetic crisis following an anterior tooth, crown, or prosthesis loss is important. The immediate management of the anterior esthetic crisis allows for definitive treatment at a separate appointment. Following initial esthetic management, the hopeless tooth or teeth can be replaced with definitive implant prosthetic treatment a short time later on an appointment basis. Most esthetic anterior tooth replacement is done with a delayed surgical implant protocol. This delay can result in loss of both soft and hard oral tissues during the healing period, necessitating soft tissue and bone augmentation procedures, including surgical bone expansion, guided tissue regeneration, bone block grafting procedures, or a combination. These losses often can be avoided at the time of tooth removal with immediate implant replacement. This article demonstrates a technique for management of a patient's unscheduled prosthesis loss with traditional dental treatment and then at a separate appointment, definitive treatment using immediate implant replacement with grafting for the extracted teeth. The article further describes the diagnostic and radiographic planning for immediate implant replacement with necessary bone expansion and grafting requirements, the fixed screw retained provisional restoration which stabilizes the implants following extractions and facilitates ease of removal for treatment, and lastly the final prosthodontic restoration of the missing teeth, restoring the esthetics of the affected area.
The management of a patient's unscheduled anterior clinical crown or tooth loss can be handled with techniques for rapid replacement using traditional dentistry, then with definitive immediate implant treatment a short time later. The immediate treatment is important to manage the unscheduled patient esthetic crisis and allow for records and planning for treatment and consultation with definitive treatment a short time later. The esthetic restoration of facial appearance and dental function with implant prosthodontics is directly related to preserving intraoral hard and soft tissues and the esthetics and technical abilities of the dentist and dental technician.1 The use of dental implants for oral rehabilitation has revolutionized prosthodontics over the past 3 decades. Multiple studies have proven the efficacy and excellent long-term prognosis with dental implants.2–5
While initial research and clinical use were directed primarily toward the edentulous patient, more recent studies have focused on the esthetic and functional use of implants in the partially edentulous patient.6 The most challenging area of modern implant dentistry remains the “esthetic zone” in the anterior maxilla and mandible. Replacing single and multiple anterior teeth in the otherwise dentate patient requires careful consideration of the location and volume of residual bone, soft tissue esthetics, and room for implants and the prosthesis.
Most dental implants in the past have been placed in a delayed manner, following tooth extraction allowing for both hard and soft tissues to heal prior to implantation. Unfortunately, this allows for resorption of the alveolar ridge in both the buccolingual and coronoapical directions. Studies have shown that as much as 3 to 4 mm of resorption can occur during the first 6 months post extraction without the intervention of implant therapy, tissue grafting, or regeneration techniques.7,8 This treatment can result in a less esthetic dental result. Dental implants, if placed with a delayed surgical technique, may display teeth of unnatural length with spaces between their root structures, unless tissue-colored porcelain or acrylic resin is used to restore the missing soft tissue.9
Immediate replacement of extracted or avulsed teeth with an implant maintains soft tissue size and position as well as bone and its dimension and density in a manner similar to healthy natural teeth. As a result, the patient's facial esthetics are not compromised by tooth size and its relation to soft tissue height and interproximal papilla. An implant-supported restoration should be positioned in relation to physiologic requirements of soft tissue, bone, and adjacent teeth, resulting in an esthetic and functional restoration.
The purpose of this clinical report is to present the concept of initial stabilization management of a patient's unscheduled anterior clinical crown or tooth loss with a technique for rapid replacement, then with definitive immediate implant placement a short time later.
Materials and Methods
The Friadent implant system (Dentsply, New York, NY) was used for immediate implant placement following extractions, with ProTect abutment assemblies used as the abutments for immediate loading and restoration of the implants. Grafting of the sites when needed was with platelet-rich plasma (PRP) and PepGen P-15 (Dentsply).
A 64-year-old Caucasian woman presented for extractions and implant reconstruction of her loose defective fixed partial denture (FPD), numbers 22 to 27 (Figure 1). This prosthesis had been in service for less than 5 years and its prognosis was hopeless. The diagnostic treatment planning was completed using mounted diagnostic casts and photographs, periapical and panoramic digital dental radiographs, and a cone beam computerized tomography (CBCT) scan for bone volume and density and 3-dimensional rendering. Considerations for this patient's treatment also included immediate recementation of the existing defective prosthesis, implant site location in relation to the adjacent bicuspid teeth and the use of PRP with grafting, and immediate provisionalization with stabilization. The patient was also interested in improving the esthetics of the final prosthesis with more individualized tooth shape.
The radiographic findings demonstrated the close proximity of the adjacent bicuspid teeth to the abutments of the FPD numbers 22–27. The traditional-sized radiographs (Figures 2 and 3) give a clear view of the root proximity. In Figure 4, the preoperative panoramic radiograph provides only a 2-dimensional view. Long-term success of the implant-retained FPD numbers 22–27 would necessitate that the bone volume between the implants and the remaining teeth be 2–3 mm, and the final dimension would also be dependent on the size and position of the cuspid restorations.
The CBCT scan for SimPlant (Figure 5) revealed the cuspids numbers 22 and 27 with a thin facial plate of bone over their roots. The root shape was revealed to be rotated and biconcave. This would facilitate bone preservation if the technique for bone expansion with osteotomes were used (Figure 6) instead of osteotomy formation by bone drilling only. This would also result in minimal need for bone grafting. Diagnostic casts were used to plan for the immediate provisionals using ProTect abutment (Dentsply) and the patient's existing FPD.
The implants chosen for the immediate tooth extraction replacement were 3.8 × 18 mm XiVE implants. The rotated position of the roots numbers 22 and 27 in the bone (Figure 7) and the biconcave system of the roots (Figure 8) allowed for the initial osteotomy formation with 2 mm of bone surrounding the drill buccolingually. Final osteotomy site development continued with osteotomes with a compressive fit of the implants of 45–55 Ncm (Figure 9).
Upon removal of the roots numbers 22 and 27 and placement of the implants into the osteotomy sites, parallelism was verified with the TempBase assembly (Dentsply; Figure 10). Following removal of the TempBase assembly, ProTect abutments were placed into the implants for construction of a healing transitional prosthesis, using the patient's original fixed partial denture luted together with auto polymerizing resin (Figure 10). Following acrylic resin pick-up of the ProTect abutments and completion of the interim prosthesis chair side with acrylic resin, healing abutments were placed into the implants to allow grafting of the distal portion of the osteotomy site where the previous tooth root had been with PepGen P-15 and PRP (Figure 11). Following suturing, the healing abutments were removed, and the interim transitional healing prosthesis was inserted (Figure 12). The interim prosthesis was secured to the implants with the screw-retained ProTect abutments and stabilized and immobilized to the adjacent teeth of the mandibular fixed partial dentures with acid etching and auto-polymerizing resin to the porcelain surfaces of the existing bridgework. Next, maximum intercuspation and lateral excursive contacts were evaluated for occlusal clearance (Figure 13), and all contact was eliminated for the immediately placed implants and the implant prosthesis for 3 months following insertion (Figure 14).
The postoperative radiographic findings demonstrated the improved distance achieved with the adjacent bicuspid teeth to the abutments of the FPD numbers 22–27. The traditional-sized radiographs (Figures 15 and 16) show a view of the improved root proximity compared with the original films (Figures 2 and 3).
Long-term success of the implant-retained FPD numbers 22–27 necessitates that the bone volume between the implants and the remaining teeth be at least 2–3 mm. The final dimension would also be dependent on the planned size of the cuspid restoration and its rotated position. The day after surgery with minimal trauma to the soft and hard tissue, the patient had little or no discomfort postoperatively, and the implants and prosthesis were immediately loaded (Figure 17). The patient's 10-day follow-up office visit for observation revealed normal healthy tissue and patient satisfaction with the procedure (Figure 18).
The immediately placed implants were stabilized by the implant's apical thread design, the implant prosthesis, and the etched bond connection with the adjacent teeth for 3 months after surgery. During the 3-month healing period there was no occlusal contact with opposing teeth in maximum intercuspation and minimal contact in excursive movements.
Three months post implant placement, the transitional healing prosthesis was removed, the implants were evaluated for osseointegration (Figure 19), and an open tray technique was used with transfer copings for the final implant prosthesis impression (Figure 20). The prosthesis was designed to harmonize with the patient's existing maxillary dentition using custom abutments and a ceramometal prosthesis.
A case was presented in which an unscheduled dental esthetic site management of a loose mandibular anterior fixed partial denture was necessary. A consultation with a diagnosis for treatment (including extractions, immediate implant placement with a fixed immediate implant loaded provisional prosthesis, and an esthetic fixed, definitive implant prosthesis) was made at that appointment. The purpose of this clinical report was to present the concept of initial esthetic stabilization management for any patient having an unscheduled esthetic treatment need. Following the initial stabilization procedure, appointments can be made for diagnostic records and consultation, with treatment to include extractions, immediate implant placement, and stabilized interim implant prosthesis with immediate loading. Following a normal healing process, the definitive prosthesis would be constructed and inserted on a scheduled basis.
The criteria for unscheduled treatment requiring immediate implant placement are as follows:
The immediate management of a patient's esthetic tooth or prosthesis loss with traditional dental techniques for replacement.
Critical treatment planning of implant position and trajectory in bone with traditional diagnostic planning including facebow mounted casts with photographs and appropriate digital dental radiographs. CBCT scan with specialty software for determination of bone density and positioning and trajectory of implants.
Considerations for a gentle and conservative extraction technique without raising a full thickness flap to preserve soft tissue and bone for an esthetic functional result.
Considerations to existing cortical wall thickness and bone density, prior to extraction with immediate implant replacement and osteotomy site formation. Site developed with either rotary or bone expansion techniques or both.
Use of platelet-rich plasma or growth factor for more rapid healing of soft tissue, grafted bone, and hydroxylapatite.
Stabilization considerations must be given for the immediate implant prosthetic replacement with a screw-retained prosthesis that has light occlusal contact during the healing period in maximum intercuspal position and in lateral excursive contacts.
University of Missouri-Kansas City, Kansas City, Mo, Reconstructive & Implant Dental Center, Overland Park, Kan