Managing the Unexpected Can Be a Challenge!

Dr. Lee Ann Brady
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CASE REPORT
Initial Presentation

A 37-year-old patient presented after losing her left upper central incisor (tooth No. 9) traumatically. Existing veneers were present on the remaining central incisor and both laterals. These restorations were less than one year old. The patient had 2 prior attempts to place an implant in the tooth No. 9 site by her previous dentist. In both cases, the fixture had been placed, not loaded, and allowed to heal for several months. At the time of the uncoverings, neither of the previous fixtures had integrated. The patient then saw Donald Hoaglin, DDS (an oral and maxillofacial surgeon), to see if the lack of integration could be explained and for a proposed solution that would allow for the placement of a single-tooth implant and restoration. Dr. Hoaglin subsequently referred the patient to me for evaluation, diagnosis, and prosthetic treatment.

An initial consultation was scheduled to allow the patient and me to meet and to discuss her desired outcome. The patient shared that she had made the decision to have her upper front teeth veneered to improve the aesthetics of her smile. Her job required her to meet with many top executives, and she wanted to feel confident about her appearance. Since making that decision, she had been on a roller coaster, as the restorative treatment resulted in the loss of the upper left central. The patient had gone through several removable tooth replacements over the months of attempting to have a fixture placed and successfully integrate. The idea of more surgery was not a negative for her, but the alternative idea of continuing to use a removable device or to have a bridge done seemed worse, so she was determined to forge ahead with getting an implant. It was very important to her to understand why the original implant fixtures had not worked, what the treatment plan was, and how confident we were about achieving success this time. After this initial discussion, an appointment was scheduled to complete a comprehensive evaluation so we could gather the information and data to answer her questions and to formulate possible treatment plans (Figure 1).

Comprehensive Examination
The patient had no history of joint or muscle issues or headaches. The joint exam revealed no palpable joint sounds and no history of locking open or closed. Examination of the muscles revealed some minor tenderness to palpation in the medial pterygoid region. Her range of motion measurements were within normal limits. She reported no history of jaw fatigue when eating or during dental visits. She exhibited very little to no evidence of occlusal disease with minimal to no tooth wear; the patient still had mammelons on most of her mandibular incisors. She had a small slide from centric occlusion (CO) to maximum intercuspation (MIC) of 1.0 mm anterior and 1.0 mm vertical.

The patient presented with no history of sleep issues or snoring. The patient exhibited a scalloped tongue consistent with parafunctional activity. The patient’s medical history was noncontributory.

The patient had no restorative treatment other than the ceramic veneers on the maxillary laterals (teeth Nos. 7 and 10) and the right central (tooth No. 8). She reported no history of decay. Remnants of sealants were present on several posterior teeth. She reported having had orthodontic treatment as an adolescent, and the first premolars had been removed. Her third molars were also removed following the completion of orthodontic treatment in her late teens.

A comprehensive periodontal exam revealed pocket depths that were within normal ranges for the entire dentition, with one or 2 isolated areas of bleeding upon probing. She had a history of seeing a hygienist every 6 months. Home care was good, with isolated areas of supra-gingival calculus around lower anteriors and some subgingival plaque.

Aesthetic Evaluation
The patient presented with adequate incisor display at repose, with 3.5 mm of the central incisor (tooth No. 8) visible. She had a slight reverse smile line with centrals about 0.5 mm shorter than the cusp tips of her canines. The maxillary occlusal plane was relatively level, with a slight step to the buccal cusp tips of the premolars and molars from the canines. She showed just the tips of her papilla in a full smile, and her gingival symmetry was acceptable. The patient had triangular necks to her maxillary anterior teeth, with high gingival scallop (Figure 2).

Surgical Evaluation
Historically, an immediate implant was attempted, which failed prior to the restoration phase. A second attempt also resulted in failure prior to restoration. Upon presentation, active infection was noted with labial alveolar perforation and communication of the recent implant osteotomy with the anterior/mesial wall of the incisive canal (Figure 3).

Summary of Concerns
The largest surgical risk factor for this case was the redemption of the surgical site and ability to create optimal hard- and soft-tissue contours prior to implant fixture placement. The 2 previous surgeries that she endured compromised the ability to achieve optimal results. The first challenge was to resect and remove the incisive canal tissue that had grown into what should have been alveolar space. If this could be accomplished successfully, bone and soft-tissue augmentation would still be required prior to fixture placement.

From a prosthetic perspective, multiple risk factors presented. Restoring a single central is one of the most challenging procedures done in dentistry, requiring an incredible amount of effort to create a restoration that blends into the natural dentition. That challenge is magnified in a younger female patient with a relatively high smile line. The adjacent veneered teeth all had a triangular shape with a narrow emergence profile in the gingival one third. When placing a single implant amongst natural teeth, this tooth shape increases the challenge of achieving adequate papilla fill and optimal interdental pink aesthetics. We lose the ability to use increased emergence profile to put pressure on the papilla to fill the gingival embrasure if we are to mimic this adjacent tooth shape. The possible need to place new veneers on the adjacent teeth to allow us to change the tooth contour was discussed with the patient. Lastly, achieving optimal pink aesthetics would depend upon the success of the surgical part of the treatment plan, combined with the prosthetic approach. Given the history, it was reasonable to assume that we would be deficient in hard or soft tissue and may end up with a compromised aesthetic result.

Proposed Treatment Plan Surgical Phase
A 2-stage approach to alveolar and gingival reconstruction was planned. The first stage would involve the removal of incisive canal contents and complete guided bone regeneration, augmentation, and tissue grafting. Following healing from the first stage of surgery and prosthetically driven implant planning, the fixture would be placed and buried. After osseointegration, the implant would be uncovered and a custom healing cap placed.

Prosthetic Phase
Initial diagnostic records would be captured to allow for a wax-up and fabrication of a scan guide and surgical guide. A new Essix retainer would be fabricated to replace the existing prosthesis that was breaking down. A custom screw-retained temporary would be used to allow for tissue profile development and confirmation of tooth shape. Following tissue maturation, a final crown and abutment would be placed.

At the initial consultation, the shape of the existing veneers and the challenge of matching a single central one were discussed. The patient’s preference to not replace any of the existing restorations was balanced against the risk factors, and it was agreed that the final decision would be made during the temporary phase after the fixture was integrated.

CLINICAL PROTOCOL 
Surgical Phase
The maxillary anterior sextant had highly scalloped gingival contours, and papillae-sparing incisions were made with labial and palatal full-thickness flaps for surgical access. Following debridement and the removal of incisive canal contents, a guided bone regeneration procedure and crestal/labial connective tissue graft were completed by the oral surgeon using allograft/xenograft with platelet-derived growth factors (PDGFs), platelet-rich fibrin (PRF), and Emdogain, as well as a subepithelial connective-tissue graft. An Essix retainer was placed and adjusted to prevent soft-tissue compression. Following graft-site maturation, a CBCT scan was obtained and software planning of the surgical guide was completed. The implant (Bone Level Tapered NC, 3.3 x 14 [Straumann]) was chosen for alveolar conservation, and was positioned in anticipation of a screw-retained final restoration at adequate depth for a proper emergence profile. Minor labial/crestal gingival and alveolar deficiencies in the area of tooth No. 9 were corrected at the time of implant placement using additional GBR and connective-tissue grafting. The implant was indexed prior to primary closure of the soft tissue so that a custom-healing abutment could be placed during the uncovery surgery. A 2.0-mm healing abutment was used as a “tent pole” to allow space for additional connective tissue volume development. After the integration period, a prefabricated custom healing abutment was placed, and the patient was directed to proceed with the prosthetic phase of her treatment.

Prosthetic Phase
Following the uncovering of the fixture and placement of a custom healing cap to begin the process of tissue development, the patient was seen for records to fabricate custom screw-retained temporaries. The custom healing caps were removed, and stock Straumann closed-tray impression copings were screwed down to the fixtures. Radiographs were taken to confirm seating of the prosthetic parts using a closed-tray vinyl polysiloxane (VPS) (Flexitime [Kulzer]). In addition to taking a shade and digital photograghs, a facial analyzer (Kois Dento-Facial Analyzer System [Panadent]) was used to capture the aesthetic and functional information that would be used to mount the upper model. The restorations were to be completed in the MIC position due to the low functional risk following initial assessment, so the lower model would be hand articulated.

All records and information were sent to the team at Gold Dust Dental Laboratory in Tempe, Ariz, and a custom PMMA custom-stained screw-retained provisional was fabricated. The emergence profile of the provisional was created by carving the soft-tissue model and taking a best guess at what would be appropriate to create optimal tissue aesthetics. When seating the screw-retained provisional, if the goal is to move the free gingival margin apically, we want to see blanching of the tissue. This blanching is to be monitored and should disappear in about 10 minutes or fewer. If the blanching does not diminish, the emergence profile should be reduced in prominence/convexity and additional tissue pressure can be applied at a follow-up appointment, if required, to obtain the final tissue position. If the goal is to allow the tissue to drape further incisally, the clinician should reduce the prominence/convexity of the emergence profile even more than the custom healing cap. In this case, there was minimal to no blanching when the provisional was seated. So, the interproximal tissue and papilla position were managed by increasing the prominence of the mesial and distal emergence of the crown form to fill gingival embrasures and to move papilla incisally. The biologic limit is 3.5 to 4.0 mm of papilla height, and, in this clinical case, the reference was the bone on the interproximal of each adjacent natural tooth.

The custom provisional was placed, and then the tissue was monitored every 30 days. If not optimal, the emergence profile of the abutment component, or the crown form, can be adjusted until final results are achieved. The provisional was then allowed to stay in place until the tissue showed evidence of maturation to include stippling, a correct light pink color, and a noninflammatory appearance.

In this case, we needed to narrow the facial emergence profile to encourage the tissue to drape incisally in an effort to try to correct the soft-tissue defect from the original failed surgeries while maintaining papilla position. Since the patient had requested that we not replace the adjacent restorations, if possible, we were limited in our ability to increase the mesial and distal emergence profile of the crown form. This would have resulted in one square or ovoid tooth next to teeth with narrow necks and high tissue scallop. The patient was aware of this challenge and knew that the provisional was our test to see if we could get acceptable results.

The provisional was in place for about 5 months. As we monitored the tissue, it was determined that although it appeared that she had proper papilla position aesthetically, the deficiency of tissue volume or tooth volume had resulted in a terrible food trap on the distal. As a result, we revisited the original treatment plan decisions, and the patient opted to have the veneer on the other central (tooth No. 8) replaced, the gingival one-third crown shape changed to allow the 2 centrals to match, and the papilla deficiency corrected (Figure 4).

The patient was anesthetized and the ceramic veneer on the right central (tooth No. 8) removed. A 2-cord retraction technique was used for tissue management to allow for adequate flash on the impression of the natural tooth. The custom, screw-retained provisional was removed and Mach-2 Die Silicone (Parkell) used to hold the tissue form. The custom provisional was attached to an analog, and a custom, single-tooth model was created using snap set stone and Mach-2 Die Silicone. A custom impression coping was made to mimic the exact emergence profile of the provisional by adding a resin cement (SpeedCEM Plus [Ivoclar Vivadent]) around a stock closed-tray impression coping in the custom single-tooth model. This custom impression coping was then used to capture a final fixture-level impression. Final laboratory records were taken, including die shade information and photographs. The custom provisional was screwed back into place. Then, following the application of GLUMA (Kulzer) to the preparation, a single-tooth shrink-wrap veneer provisional was fabricated for the right central (tooth No. 8) using Venus Temp 2 (Kulzer).

The final veneer was fabricated from an aesthetic leucite-reinforced all-ceramic (IPS Empress Esthetic [Ivoclar Vivadent]). The final implant restoration (IPS Empress Esthetic) and lithium disilicate (IPS e.max [Ivoclar Vivadent]) for a custom abutment (Empress Veneer [Ivoclar Vivadent]) were fabricated by the dental laboratory team. The abutment was prepared to match the veneer preparation on the natural tooth. The 2 prosthetic components were designed to be bonded together in the mouth, with one final shade verification, to create a screw-retained final solution. Fabrication of the abutment and veneer in 2 pieces allows more flexibility in customizing the final aesthetics (by varying the resin layer between them as needed) and for adjustments by the laboratory without compromising the lithium disilicate abutment each time it has to be re-fired in a porcelain oven. This is a technique I use routinely in the maxillary anterior segment. The high aesthetic demands presented in restoring a single central and, in this case, the dark natural prep color made the use of this technique even more critical.

At the delivery appointment, the final abutment was seated and the screw hand tightened. The 2 veneers were tried in using a try-in paste to verify the final aesthetics, marginal integrity, and interproximal contacts. Once we had verification that the restorations would be seated, the abutment was radiographed to verify complete seating and then torqued down. The final veneers had been HF-etched in the dental laboratory and, after try-in, a universal cleaning gel (Ivoclean (Ivoclar Vivadent]) was applied for 20 seconds to the intaglio surfaces and then rinsed with water and air dried. Next, the intaglio surfaces were treated using a universal primer (Monobond Plus [Ivoclar Vivadent]) as directed. After isolation was accomplished (OptraGate [Ivoclar Vivadent]) and the access hole was covered with Teflon tape, the e.max abutment was cleaned with Ivoclean and conditioned with Monobond Plus. The veneers were seated one at a time with a light-cured resin cement (Variolink Esthetic LC [Ivoclar Vivadent]), then the margins were checked and the veneer light-tacked into place for 1 second using a 2.0-mm tip.

After seating and light-tacking the second veneer, the resin was taken to a gel phase with a second wave cure on both the buccal and lingual. The excess resin cement was cleaned easily and completely and an oxygen barrier placed using glycerin before fully curing the restorations for 20 seconds each in the gingival third, middle third, incisal third, and then the lingual. The access hole was sealed using Telio CS Onlay (Ivoclar Vivadent).

The final occlusion was adjusted to ensure light anterior contacts without fremitus in the MIC position, smooth transition to crossover, and smooth protrusive guidance. Following occlusal adjustment, the restorations were polished with ceramic polishers (Feather Lite Porcelain Polishers [Brasseler USA]) and a polishing paste (Diamond Polishing Paste [Ultradent Products]) (Figure 5).

CLOSING COMMENTS
In this clinical case, the 2 biggest challenges in completing the replacement and restoration of the upper left central incisor were (1) restoring the hard- and soft-tissue anatomy, and (2) gaining the patient’s trust related to moving forward with more dentistry after 2 prior failed attempts by the previous dentist.

Authentically sharing with patients the risks and benefits of all possible treatment plans, helping them understand the implications those plans have for them, and then allowing them to choose to proceed in a way that best fits their goals is the key to patients moving forward and feeling confident. In this case, none of us could guarantee what the surgical results would be and, ultimately, how compromised the final aesthetic results would be based on the initial compromises. What we could and did share were the options for going forward with the greatest chance for success. This was done by explaining what the next steps would be based on the alternate ways the surgical phase might turn out. Above all, the clinician must work together with the patient and all other team players involved in the planning and treatment of the case to provide the best care possible.

Acknowledgment
The author would like to thank the dental laboratory team at Gold Dust Dental Laboratory in Tempe, Ariz, for the work performed in this case.


Dr. Brady is in private practice in Glendale, Ariz. She is an internationally recognized educator, lecturer, and author. With an extensive history in leadership, she is currently director of education for the Pankey Institute. Dr. Brady has also developed a vast library of online instruction at the websites leeannbrady.com and restorativenation.com. She can be contacted via email at lee@leeannbrady.com.

Disclosure: Dr. Brady has received honoraria from Ivoclar Vivadent and Kulzer.

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