Hello curious dentists! It’s my pleasure to welcome back Dr. Dan Bruce. He is a general dentist in private practice in Boise, Idaho and has studied the areas of implantology, sleep apnea, and occlusion. He is also a co-founder of Valitics, a search engine optimization (SEO) and online marketing firm.
The anterior FPD vs. implant is a common clinical dilemma dentists often face. The benefits of an FPD are never having to be without a permanent tooth and that the soft tissue can be more predictably managed through immediate provisionalization. The implant benefits include easier flossing and that adjacent teeth do not need to be prepared. Short roots or adjacent teeth with a questionable prognosis may also make an implant a better option for certain cases.
This case involves #8, which has a history of trauma. The patient presented with mild pain to percussion. An endodontic referral was made and vertical root fracture was diagnosed.
I discussed the advantages and disadvantages of both an anterior implant vs. an FPD. Ultimately the patient was happy with the existing appearance and did not want the added difficulty of threading floss under an FPD. He also did not want to prepare the 2 adjacent virgin teeth. Finally, his smile line was low enough that the gingival 1/3 was not visible.
Sutured flap
The vertical defect
On the day of surgery the tooth was removed atraumatically. A vertical defect was present, extending to the apex of the tooth. A vertical flap was made to curettage and irrigate the area. The area was grafted with corticocancellous demineralized freeze-dried bone and a resorbable collagen membrane was placed from the apical portion of the vertical defect extended across the extraction site to the palatal portion of the site. I used 7-0 vicryl and 5-0 silk sutures to secure the flap.
We then used the original crown and rounded the root to form an ovate pontic. A groove was cut into the lingual of the tooth and a orthodontic wire was bonded across to the adjacent teeth. Fortunately, there was sufficient lingual clearance for this procedure, which is not always the case.
Ovate pontic bonded into place
At this point, it appears that a mm or more of facial tissue height has been lost, but I feel good about sculpting the tissue contour with the ovate pontic. The patient was aware and warned that tissue recession was likely, so he is also OK with things as they stand.
Surgical guide in place. Note the soft tissue contour created using the temporary pontic
We waited a full 5 months before performing a Galileos 3D CT scan for guided implant surgery. As this was my first guided surgery, Dr. Eric Ballou aided in placing the implant digitally. The advantage of this method was we could use the optimum length and width of implant while having complete control of the depth. The implant was also placed lingually. This provided the option for a screw retained final restoration and also provided ample space on the facial of the implant for soft tissue contouring.
A 4.3 x 11 Nobel Replace Select was placed using a flapless technique. Dr. Ballou had used the guide to previously place an implant analog in a stone model.
temporary restoration
He then brought a prefabricated temporary abutment which was prepared based on the tissue levels and the position we knew the implant would be placed. A composite temporary was made over this abutment. The facial of the abutment was slightly undercontoured in hopes that the soft tissue would travel coronally. The temporary was left out of occlusion and splinted to the adjacent teeth. The patient was also warned to avoid eating with his front teeth for the next few months.
We also noted #7 had a concavity on the mesiogingival portion of the tooth. A MFL composite was placed to close the embrasure. I believe this also more closely resembles #10. At this time a MFL composite restoration was also placed on #9 to make the tooth wider and ensure #8 and #9 had the same width when the final crown was made. We waited another 5 months for healing before the final impression. Since we actually had more tissue than we needed with the temporary, the normal steps to maintain tissue architecture when taking an impression where not strictly followed. Instead I took a quick impression and had my lab technician place a small CEJ line where we wanted the tissue to migrate to. This also helps to deflect food from getting trapped on the facial aspect. A custom Zirconia abutment was fabricated with an e.max layered crown. The initial try-in was too high in value, so Mitch Hurst, our lab technician did a customized stain to reduce the value of the crown and match the color variations in #9. We felt the final product turned out very nicely.
There are a few reasons this case worked:
There was enough room on the lingual to place a solid pontic to contour the tissue from the time of extraction. To be fair, the pontic did de-bond twice during the process. The patient was given a clear retainer/essix that could be used if the pontic fell out while he was out of town.
There was room to add composite to the mesial aspect of both #7 and #9. This aided in getting the ideal tissue contour. The drawback of doing this is they may need re-treatment in the future as the composite bond degrades. I have had good longevity with this type of bond in the past, though, and the gingival margins can be finished ideally when the tooth is not in place.
Final restoration
Final restoration