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Introduction
When it comes to single tooth
replacement in the esthetic zone, an implant-supported crown
is often the treatment of choice because it requires no
preparation or involvement of other teeth and still provides
an acceptable result. However, managing the soft tissue
enclosure around the restoration is a key challenge in
achieving a life like appearance in the final result. This
challenge is met with a very high level of mastering and
coordinating multi-disciplines to accomplish the surgical,
prosthetic and functional requirements that are necessary in
producing a seamless restoration which is harmonious with
the adjacent teeth.
History
The patient was a 41-year-old
professional male in excellent health. Patient presented to
the office as an emergency after a bicycle accident that
resulted in vertical and horizontal fractures of his upper
right central incisor. Patient had already been admitted to
a hospital’s emergency room to treat his forehead, nose and
lips’ cuts, and where it was confirmed that he had no bone
fractures.
Clinical Data
Clinically, all soft and hard tissues
were within normal parameters. Radiographs indicated sound
bone support.
Periodontally, the patient had some
gingivitis with no significant pocketing and minimal
bleeding upon probing. His home care was fair; there was
generalized calculus and stain. The anterior gingivae were
normal and scalloped, and gingival heights were relatively
even. The papillae were normal and fairly even.
The posterior teeth were sound, most
unrestored and not in need of treatment. His
tempromandibular joint was asymptomatic with no internal
derangement and no crepitis or clicking of the joint. He had
a class I occlusion with a minimal overbite and overjet
relationship. The entire dentition was carries free and
there was no tooth mobility. Radiographs revealed no
periapical pathology.
The axial inclinations of teeth # 8 and
# 9 were canted with wear of the incisal edges giving a
reversed smile line. The upper and lower incisors were
misaligned and crowded with mesial and buccal rotation of
tooth # 9 contributing to the upper centrals’ width
discrepancy and the cant of the midline. Tooth # 8 had
several micro cracks due to the trauma. Tooth # 25 distal
incisal corner was chipped.
After analyzing his study models,
careful consideration was given to the midline and the two
centrals to achieve a symmetrical result. Overall, improving
patient’s smile will enhance his image and his personal
satisfaction.
Diagnosis
The upper right central incisor had a
hopeless prognosis due to the vertical fracture and required
extraction and prosthetic replacement. Once tooth # 8 was
extracted, especially if a delayed fixture placement or a
two-stage immediate implant placement surgery protocol were
considered, there will be an increased risk of soft tissue
loss. Also, the patient’s original smile was not
esthetically pleasing. There was a tooth width discrepancy
between teeth # 8 and # 9 and the midline appeared to be
canted. It was determined that veneering tooth # 9 in
addition to replacing tooth # 8 with an implant-supported
crown would accomplish the patient’s goal of a more
uniformed and symmetrical smile. Longer incisors would
result in fuller, more pleasing smile that would correct the
reverse smile line. Central dominance would be achieved by
increasing their length. Finally, composite bonding to
restore the distal incisal corner of tooth # 25. Patient was
motivated to improve his appearance with conservative
treatment modalities.
Treatment Plan
A complete set of records was taken
which included full radiographs, study models and a set of
35mm digital photographs showing all twelve views as
recommended by the AACD.
Before initiating treatment, diagnostic
casts were mounted on a semi-adjustable articulator. This
allowed for analysis of the occlusal factors influencing
this case, as well as for a diagnostic wax-up to be
fabricated to assess the effects of the proposed treatment,
which was to be an implant-supported Lava Zirconium crown
for tooth # 8, Feldspathic veneer for tooth # 9 to improve
symmetry, and composite bonding to restore the broken distal
incisal corner of tooth # 25.
A lengthy discussion of treatment
modalities aided in the formation of the treatment plan.
The proposed treatment sequence was as
follows:
- Extraction of the upper right
central incisor, followed by
- Immediate placement of a root-form
endosseous implant and the immediate placement of a
provisional crown on a temporary abutment in order to
preserve the interdental papillae and labial soft tissue
margin
- After a sufficient healing phase
that allows integration of the implant fixture and
stabilization of the labial soft tissue, assessment of the
soft tissue enclosure and the need for and performance of
any additional periodontal procedures
- A fixture-level implant impression
for a custom zirconium abutment for the implant replacing
tooth # 8
- Preparation of tooth # 9 for a
Feldspathic veneer and an impression to capture both the
veneer and the implant custom zirconium abutment for a
Lava Zirconium crown
- In-office teeth whitening
- Direct resin bonding of distal
incisal corner of tooth # 25
- Permanent placement of the veneer
and temporary placement of the crown on the permanent
implant abutment, to continue to assess soft tissue issues
and to allow for shade adjustment of the crown
- Permanent placement of the Lava
Zirconium crown of tooth # 8
- Fabrication of a night guard
An upper and lower maxillary
impressions were taken to construct study models for a
diagnostic wax-up. Impressions of the wax up were made in
polyvinyl siloxane putty material. The wax up models were
duplicated in stone in order to create a vacuum formed stint
that was used as prep guide for tooth # 9 to help preserve
as much tooth structure as possible and direct resin bonding
of tooth # 25.
Armamentarium
- 20D EOS Digital Camera (Cannon;
Tokyo, Japan)
- 3.5 magnification loupes (Designs
For Vision; Ronkonkoma, NY)
- Jeltrate Plus Alginate (Dentsply /
Caulk; Milford, DE)
- Yellow Hydrox Stone (Kerr; Orange,CA)
- Topex 20 % benzocaine topical
anesthetic (Sultan Chemists; Englewood, NJ)
- Septocaine with 1:100,000
epinephrine (Septodont; New Castle, DE)
- The Wand (Milestone Scientific;
Livingston, NJ)
- Periotomes (Salvin Dental
Specialist)
- Root-form Tapered Groovy implant 5/
16 mm (Nobel Biocare; Yorba Linda, CA)
- Torque driver (Nobel Biocare)
- PepGen P-15 Flow & PepGen P-15 1.0
enhanced bone graft (Dentsply Frident CeraMed; Lakewood,
CO)
- Temporary abutment NobRpl WP (Nobel
Biocare)
- Ultra-etch 35% phosphoric acid (Ultradent;
South Jordan, UT)
- Optibond Solo Plus bonding agent
(Kerr; Orange, CA)
- Optilux 501 curing light (Kerr;
Orange, CA)
- Pink opaque composite (Cosmedent;
Chicago, IL)
- Microbrush disposable applicator
brush ( Microbrush International; Grafton, WI)
- Splash polyvinyl siloxane impression
material (Discuss Dental; Culver City, CA)
- Vaccum-formed copyplast stent:
temporary fabrication (Schofu; San Marcus, CA)
- Luxatemp provisional crown material
(DMG/ Zenith; Englewood, NJ)
- Fine diamond finishing burs (Brasseler;
Savannah, GA)
- Fine articulating paper (Bausch;
Nashua, NH)
- Unwaxed Floss (John O. Butler Co.,
Chicago, IL)
- Procera zirconium implant abutment
(Nobel Biocare)
- Vacum-formed copyplast pin hole
preparation guide (Schofu)
- Gingival Retraction Cord (Ultradent;
South Jordan, UT)
- Diolase Plus, soft tissue laser (Biolase
Technology; San Clemente, CA)
- Impergum polyether impression
material (3M Espe; St. Paul MN)
- Denar semi-adjustable articulator (Waterpik)
- Vaseline petroleum jelly (Chesebrough
Ponds USA; Greenwich, CT)
- TempBond Clear temporary bonding
material (Kerr; Orange, CA)
- Zoom2 Whitening System (Discuss
Dental; Culver City, CA)
- Vita 3D shade guide (Vident; Brea,
CA)
- Microetch air abrasion (Denville
Engineering)
- Superoxol hydrogen peroxide (EPR
Industries Chemists; Pennsauken, NJ)
- Consepsis (Ultradent)
- Peridex cholorhexidine gluconate
rinse 0.12% (Omni; West Palm Beach, FL)
- Implant Provisional temporary cement
(Alvelogro; WA 98592)
- Silane coupling agent (Ultradent)
- Gluma desensitizer (Hereaus Kulzer;
Armonk, NY)
- Rely-X veneer cement (3M ESPE)
- De-Ox oxygen inhibiter gel (Ultradent)
- # 12 scalpel (Bard-Parker; Franklin
Lakes, NJ)
- Vision Flex diamond strips (WS37ET)
(Brassler)
- Ceramiste points (Shofu)
- Dialite porcelain polishing kit (Brasseler)
- Morely Anterior preparation and
contouring kit (Brassler)
- Renamel Creative Color Composite
Stains (Cosmedent; Chicago, IL )
- Renamel microfill, hybrid, and
opaquers (Cosmedent; Chicago, IL)
- IPC Carver (Cosmedent; Chicago, IL)
- Clear Mylar Strips (3M ESPE; St.
Paul, MN)
- #1 & #2 brushes (Cosmedent; Chicago,
IL)
- Mopper anterior composite
preparation and finishing system (Brassler)
- Sof-Lex finishing and polishing
strips (coarse, medium, fine, super-fine) (3M ESPE; St.
Paul, MN)
- Blue and pink cups and points (Cosmedent;
Chicago, IL )
- Flexibuff discs and Enamelize
polishing paste (Cosmedent; Chicago, IL)
- Diamond burs 6844 0141, 6844-016,
6850-014, 6850-018 (Brasseler)
- Accufilm indicator liquid and
articulating paper (Parkell; Farmingdale, NY)
Treatment
Before commencing the surgery patient
was shown the wax up which he liked and approved the start
of treatment.
Topical anesthetic was applied on the
gingival tissues above the maxillary central incisors and
the surgical site was anesthetized with Septocaine with
1:100,000 epinephrine local anesthetic infiltration.
Special attention was given to preserve
labial and interproximal bone and not to disturb the
surrounding soft tissue as much as possible; therefore tooth
# 8 was extracted using periotomes. Also, in order to remove
any remaining granulation tissue, the site of the extraction
was thoroughly curetted. Immediately after that, a tapered
root-form implant fixture (tapered groovy 5 x 16 implant,
Noble Biocare) was then placed into the extraction site
which had been sized and extended to provide immediate
fixation. The preparation of the socket extension was
positioned to follow the long axial of extracted tooth.
When approximately two thirds of the
implant fixture’s length had been placed, bone graft
material (mixture of PepGen P-15 Flow and PepGen P-15 1.0 g;
Dentsply) was placed into the differential between the
fixture and the socket wall, and the fixture was advanced a
few turns. This sequence was repeated until the fixture was
fully seated to the level of the bony crest, approximately 3
mm below the gingival margin as measured on the labial. This
technique causes the particles to be slightly compressed
into the defect and results in excellent primary implant
fixation.
Then a temporary abutment for the
implant fixture was cut to length to keep it out of
occlusion and it was coated with an opaque composite in
order to eliminate any gray shine-through of the metal
abutment. The temporary implant abutment was screwed into
the fixture and a vacuum-formed matrix was fitted over the
anterior teeth to locate the screw access hole for the
abutment. Then a matching hole was created through the
matrix. A cut section of large size disposable applicator
brush handle was placed into the hollow center of the
abutment so that when the temporary crown form filled with
provisional crown material was seated, the brush handle
protruded through the hole in the matrix and the screw
access hole was maintained clear of the provisional
material.
When set, the temporary crown on the
abutment was unscrewed and removed. Additional composite was
added from the abutment collar to the soft tissue margin
area to support and maintain the soft tissue contour,
creating a natural emergence profile for the provisional
crown. The provisional abutment /crown was then contoured,
adjusted to position it just out of occlusion, and polished
all the way down to the collar of the temporary abutment.
This assembly by hand onto the fixture and the access hole
was closed with cotton and flowable composite.
The patient was monitored over the
following three months to allow soft tissue healing and to
ensure that a stable gingival margin around the implant
abutment existed. During this phase, some gingival margin
contouring was performed on tooth # 9 using Biolase laser.
A fixture-level implant impression was
taken with polyether impression material in a custom tray
(open tray implant impression technique). The impression was
taken immediately on removal of the provisional, therefore
giving very accurate gingival placement. It was very
important that the implant abutment be waxed to the correct
subgingival contours in order to give the identical tissue
support as the provisional had done, and to ensure that
contours led to a maximum distance of 5 mm from bone to
interproximal contact. This would give good papilla support
and prevent black triangle from developing.
By using the accurate gingival contours
from the impression, the margin was placed approximately 1
mm subgingivally; this would allow excellent esthetics and
ease of resin cleaning during seating and bonding of the
crown. The provisional had established the accurate
positioning of the gingival margin.
The plan was for a custom zirconium
abutment shaped with a central incisor-like cross section
with a 1-mm subgingival margin created for the accompanying
Lava Zirconium crown. Some shade-matching challenges were
anticipated because of the pure opaque white nature of the
zirconium abutment. When dissimilar restorative materials
are used, it is important to establish similar values before
any addition of chroma is made. Excellent communication with
the laboratory, with a mutual understanding of both clinical
and technical challenges, will facilitate the pursuit of
excellent treatment outcome. The provisional abutment crown
was installed back in the mouth in the same manner as
before.
Patient’s teeth were bleached with
Zoom2 Whitening System (Discuss Dental). Post-op
instructions were given. Patient came few days later and
shade selection was made.
Three weeks later, the custom-made
zirconium abutment was tried onto the implant fixture and a
radiograph was taken to confirm complete seating of the
abutment. The abutment screw was torqued down to 32 N cm
with a torque driver. Tooth # 9 was prepared for a veneer
and an impression was taken for the # 9 veneer and the # 8
crown. Provisional restorations were fabricated in a clear
matrix material. The provisionals were trimmed, polished and
cemented.
A laboratory prescription was prepared
with a detailed description of the requested restorations,
including a shade map, specification of crown form and
length, surface texture, and incisal edge treatment. This
was sent to the laboratory along with preoperative
photographs, photographs of the preparations and
provisionals, and the impressions and models. A wash bake of
dentine was performed on the high value coping until the
shade of the coping was identical to that of the stump shade
of the prepped veneer of tooth # 9, then the Lava Zirconium
crown of tooth # 8 and the Feldspathic veneer of tooth # 9
were layered simultaneously to mimic each other.
Prior to the insertion appointment, the
restorations were thoroughly inspected and placed on the
articulated master cast to assess them on the dies for
marginal fit, crown form, and occlusal contacts.
After the patient was given local
anesthetic, the provisional restorations were removed, the
prepared teeth were cleaned, and the completed restorations
were tied in place with the aid of try-in paste for the
veneer. Aspects of fit, color, and contour were then
revaluated and the restorations were shown to the patient
for approval.
When both the patient and I were
satisfied, the restorations were prepared for insertion. The
veneer was thoroughly cleaned and the inside surface was
etched with 35% phosphoric acid, dried, and then treated
with a silane coupling agent. It was coated on the interior
with bonding agent and set aside under a light proof cover.
To prepare it for bonding, the veneer
preparation was etched for 15 seconds with 35 % phosphoric
acid, rinsed, lightly dried, then wet again with a
desensitizing agent and blotted to a damp surface. The
veneer preparation was then coated with bonding agent,
gently air-dried, and cured for 20 seconds. The interior of
the veneer was filled with the light-cured resin cement. The
restoration was carefully positioned, held securely in
place, and then tacked in place with the 2-mm tip on the
curing light for 10 seconds. The excess cement was carefully
removed from around the margins and interproximally with
soft brushes and dental floss. Oxygen-inhibitor gel was
placed over the marginal areas and the restoration was cured
for 90 seconds on each surface with the curing light.
The Lava Zirconium crown was assessed
for shade match with the bonded veneer additional staining
was applied, and the crown was reglazed in the porcelain
oven. The crown was then temporarily cemented into place
using Implant Provisional temporary cement. Lateral and
protrusive excursions were checked with fine articulating
paper, minor adjustments were made, and any excess cured
cement was removed from around the margins of the veneer
before the restorations were polished using a porcelain
polishing kit.
Bonding was initiated with the
placement of 37% phosphoric acid on the preparation of tooth
# 25 for 15 seconds. Acid was rinsed off, and then teeth
were damped with cotton pellets, leaving the surface moist.
Next, a dentin sealer was placed (Gluma). A dentin primer
and resin adhesive (Optibond Solo Plus; Kerr) was placed on
the surface of the teeth and cured with a 501 Opilux light
for 10 seconds. The polyvinyl siloxane matrix was then
positioned on the lingual aspect of tooth # 25. This initial
layer created a lingual shell to act as a support for the
rest of the restorations. A thin layer of pink opaquer was
placed to block out any shine through or transition from
tooth to composite. After 20 second cure, a second layer of
microfill A1 was sculpted to mimic the mamelons then cured
for 20 second. In the incisal one third, room was left to
add light incisal microfill. This was sculptured with IPC
carver and #1 and #2 brushes to create slight developmental
depressions. Then it was cured for 60 seconds with De-Ox.
Long flame shaped, red-stripped diamonds were used to create
the shape of the central incisors.
The patient returned four weeks later
for reassessment of the # 8 crown for stability of the
gingival margin position; it appeared unchanged. The crown
was then removed and recemented with Rely-X Unicem resin
cement. An impression for an occlusal mouthguard was made at
this appointment. An examination two weeks later revealed no
functional or esthetic problems. The postoperative
photographs were taken at this time.
The contours were refined with the
upper anterior composite finishing kit. The finish was
generated with blue and pink points and cups: coarse,
medium, fine and super fine finishing and polishing strips
and Flexibuff discs with enamelize paste. Occlusion was
adjusted in centric occlusion and eccentric excursions prior
to the final finishing and polishing.
Summary & Conclusion
The patient was very satisfied with the
treatment outcome – a natural-appearing replacement for his
extracted central incisor. He was particularly pleased that
at no time during the course of the treatment did he require
a removable appliance. He also appreciated that other teeth
did not require preparation as bridge abutments. We were
able to exceed his expectations in creating an esthetic,
bio-acceptable restoration.
The innovations and advancements in
implant techniques and technology have greatly added to our
treatment options for esthetic tooth replacement.
References
Frank Spears, DDS, MSD, Advanced
Esthetic & Restorative Management, Seattle, WA (May, 2004)
Jimmy Eubank, Jeff Morely, Advanced
Anterior Esthetics, Hands-on Lectures (February - April
2005)
Jimmy Eubank, Jeff Morely, UCLA
Esthetic Continuum, Level I (July – September 2001)
Dennis Tarnow, DDS “Biological and
Clinical Factors for Ultimate Esthetics Around Implants”,
AACD Atlanta, 2007
Peter E. Dawson, DDS, “Combining Smile
Design with Function”, AACD, Nashville, 2005.
Lynn Jones, DDS “The Art of Matching
Select Porcelain Restorations to the Anterior Teeth:
Accreditation Case Type 2”, AACD Atlanta, 2007
Brian LeSage, DDS “Single Tooth
Replacement: Turn the Challenge into Predictability”, AACD
Atlanta, 2007
Frank Spears, DDS, MSD, State of the
Art Esthetics, Seattle, WA (October, 2004)
Frank Spears, DDS, MSD, Occlusion in
the Clinical Practice, Seattle, WA (January, 2004)
Frank Spear, DDS “Contemporary Esthetic
Technique and Materials Part 1 & Part 2”,
AACD Atlanta, 2007
Corky Whillhite, DDS, “Freehand
Cosmetic Bonding Techniques”, AACD, Nashville, 2005
Douglas A. Terry, DDS, “Imagination +
Form + Color = Natural Esthetics”, AACD, San Diego, 2006
John Weston, DDS, “Direct Freehand
Bonding: Creating Esthetic Success for Accreditation Cases”,
AACD, San Diego 2006
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