the team approach to replacing the congenitally missing ...hindsdds.com/hindsclempublication.pdf ·...

CASE REPORT

The Team Approach to Replacing the Congenitally Missing LateralIncisor: Restorative and Periodontal Considerations

Donald S. Clem* and Kenneth F. Hinds†

Introduction: The replacement of congenitally missing maxillary lateral incisors can be a challenge from both a re-storative and surgical perspective. The restorative dentist is limited in achieving esthetics by the surgical result not onlyby the implant position but by the surrounding periodontium of the site itself, as well as the adjacent teeth. The presentcase, replacing congenitally missing lateral incisors with an immediate provisional restoration, is important because itdemonstrates the ideal team approach. By each clinician participating in stage I surgery, the restorative dentist andperiodontist can work toward an optimal result. The combination of restorative expertise and regenerative enhance-ments simultaneously can result in a minimally invasive approach with fewer appointments and greater patientacceptance.

Case Presentation: This case report demonstrates the restorative and surgical considerations and techniques forprefabrication of screw-retained provisional restorations placed at the time of surgery. Surgical considerations and tech-niques to support the restoration position, size, and screw retention connection are also presented.

Conclusions: Close communication between treatment team members is critical to achieving predictable estheticsand function for congenitally missingmaxillary lateral incisors. The participation of the restorative dentist at stage I surgery iscritical in demanding esthetic cases such as this. Periodontal hard and soft tissues respond well to prefabricated screw-retained provisional restoration delivered at the time of surgery. Clin Adv Periodontics 2013;3:106-114.

Key Words: Clinical protocols; transplants.

BackgroundAlthough dental implants have arguably been consideredthe most significant advancement in dentistry, there isa lack of long-term controlled data regarding hard- andsoft-tissue complications and poor esthetic outcomes.Kinzer and Kokich1,2 explored the clinical considerationsfor choosing and achieving the most predictable estheticand functional result for replacing congenitally missingmaxillary lateral incisors from orthodontic, restorative,and implant perspectives.

Clearly there are several issues with regard to implant re-placement involving adequate facial lingual bone volume,distance between implants and natural teeth, and implant

position. Although the bone volume required to supportimplants may be arguable, the volume required to supportesthetic outcomes is less controversial. The study by Beckeret al.3 was one of the first to question the need for bonegrafting at the time of immediate placement of implantsat extraction. They were able to demonstrate a cumulativesuccess rate of 93.3% over 5 years. However, analysis ofesthetic results was not done. Schwarz et al.4 demonstratedthat there was a greater likelihood of esthetic compromiseas a result of marginal tissue recession around implantswith incomplete bone formation. Keratinized tissue andsoft-tissue thickness may be related to lower mean alveolarbone loss. In addition, soft-tissue thickness may relate tooverall alveolar contour and may be influenced by connec-tive tissue (CT) grafting, uncovering technique, or the con-tour of a provisional restoration. Grunder5 demonstrateda significant increase in overall facial contour thicknessin those cases grafted with CT grafts to enhance soft tissuearound implants. Considerations with regard to the

* Private practice, Fullerton, CA.

† Private practice, Laguna Niguel, CA.

Submitted September 8, 2012; accepted for publication January 1, 2013

doi: 10.1902/cap.2013.120096

106 Clinical Advances in Periodontics, Vol. 3, No. 2, May 2013

interdental and interimplant papilla rely on both the peri-odontal condition of the adjacent teeth and the interimplantor implant–tooth distance. It is generally accepted that theheight of the interproximal papilla is primarily dependenton the height of the papilla and bone of the adjacent naturaltooth. Ideally, interimplant/implant–tooth distance shouldbe 1.5 to 2 mm at a minimum.6 Although the implant–toothhorizontal distance reported as ideal is small, ranging from1.5 to 2 mm, the significance to esthetic outcome may belarge. If one considers that the smallest implant diameterused in this case report is 3.3mm, thatmeans that one shouldstrive for a site that demonstrates 6.3 to 7.3 mm of space inthe proposed lateral incisor space.

Immediate delivery of provisional restorations at thetime of implant placement, although challenging, can havea predictable outcome on esthetics, integration, and patientsatisfaction.7,8 The question of implant stability at inser-tion has been the subject of several papers.9,10 Radio fre-quency analyses expressed as implant stability quotient(ISQ) readings have been associated with implant stabilityand the predictability of osseointegration. Nedir et al.11

demonstrated that ISQ values ‡47 for implants at the timeof insertion translated to predictable and maintainable os-seointegration.11 The implant position in a facial palatal di-rection is determined presurgically to diagnose restorationdesign, cementable or screw retained. If a screw-retainedrestoration is selected, the position of the implant must al-low for screw access without compromising facial contourand material strength. Once this position is determined bythe restorative dentist, the periodontist must evaluate theproposed site with regard to adequate interradicular dis-tance, facial bone contour, soft tissue, and alveolar boneheight. Immediate provisionalization can be consideredonce implant stability is determined.8,12 The purpose of thisreport is to demonstrate how the periodontist–restorativedentist team can work together at stage I surgery to plan,fabricate, and insert screw-retained provisional restora-tions, while simultaneously managing the surgical and re-storative complexities of replacing congenitally missinglateral incisors with implants.

Clinical PresentationA 22-year-old female patient presented to the restorativeoffice (KFH) in March 2009 with congenitally missingmaxillary lateral incisors, Class I occlusion, and recentpost-orthodontic treatment with an over-retained pri-mary tooth present on the right side and missing primarytooth on the left. The patient’s chief complaint was “Iwant to have adult teeth that look good.” Review ofher medical history was non-contributory, and the patientwas classified as an American Society of AnesthesiologistsCategory I healthy patient.13 Her only previous dentistryapart from routine maintenance and minor restorativecare was the recent completion of orthodontics. Clinicaland radiographic evaluation revealed a normal periodon-tium with good intercuspation of teeth and acceptablealignment of the maxillary anterior segment. The me-sial–distal spaces of the maxillary lateral incisors (#7

and #10) appeared equal, but site #10 demonstrated a sig-nificant facial contour deficiency. As a result, the implantsites were significantly different in both alveolar bone widthand height (Fig. 1). Facial–lingual alveolar width for bothsites were deemed adequate for implant placement as deter-mined by cone-beam computerized tomography. The pa-tient also expressed a desire to avoid the continuation ofa removable temporary device during the healing phase afterimplant placement.Considerationswith regard to treatmentoptions were discussed in detail with the patient and hermother, and written and oral informed consent was pro-vided regarding options for tooth replacement, timing,and provisionalization.

Case ManagementBecause of the demanding esthetic and functional require-ments of this patient, the treatment team consisting of theperiodontist (DSC) and restorative dentist (KFH) outlineda plan that could potentially result in high predictability ofthese requirements with low risk.

Restorative PreparationPresurgical study cast planning and accurate surgicalguide fabrication were essential to assist in the properplacement of implants and indirect provisional fabrica-tion. Proper planning, spacing, and instructions to thelaboratory technician were critical before fabrication ofthe surgical guide. The key elements for surgical guide de-sign (Fig. 2) and indirect provisional fabrication are out-lined below (Figs. 3 and 4).

Material. Rigid clear orthodontic acrylic resin sup-ported by the occlusal surface of the adjacent teeth similarto an occlusal guardwas used. A rigid designwas beneficialpresurgically for accurate placement of the implant replicasinto the study cast, which was used for provisional fabrica-tion prior to stage I surgery.

Designate access opening for implant site/sites. A3-mm access opening was made on the surgical guide to lo-cate the target location for each implant site. Ideal emer-gence for a cement-retained restoration is through theincisal edge andmodified based on alveolar ridge contours.

Indirect provisional fabrication. Using the surgicalguide, a 3-mm opening was drilled in the study casts (lab-oratory osteotomywas performed) completely through thestone. The temporary abutmentwasmarkedwith a verticalline to designate the flat portion of the connector (repre-sents facial position) and a horizontal line to mark the tis-sue depth of 3mmat themidfacial position. The temporaryabutment was connected to the implant replica and placedin the study cast to the designated depth and orientation.The replica was set into the cast from the underside witha fast-set, self-curing acrylic resin.‡ A screw-retainedprovisional restorationxwas fabricated to estimated con-tours (Figs. 3 and 4).

‡ GC pattern resin, GC America, Alsip, IL.x NC Temporary Abutment, Straumann, Andover, MA.

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Clem, Hinds Clinical Advances in Periodontics, Vol. 3, No. 2, May 2013 107

SurgeryAt surgery, the patient was premedicated with 1.5 g amox-icillin given the day before surgery. She fasted at least6 hours before surgery. She was positioned in a semisupineposition, and an intravenous infusion was established inthe left hand. One hundred milligrams pentobarbital||

and 3 mg midazolam{ were titrated to a level of moderatesedation. One hundred forty-four milligrams lidocainewith 0.072mg epinephrinewere given as local infiltrations.A full-thickness flap was established on the facial aspect ofthe maxillary anterior segment extending from the mesialaspect of the maxillary left bicuspid to the mesial aspect ofthe maxillary right bicuspid. Care was taken to only in-volve the facial aspect of the associated papillae and toavoid vertical incisions. Lingual flap reflection was accom-plished in the lateral incisor areas to gain access to the

lingual alveolus (Video 1). Next, a surgical guide wasplaced, and initial osteotomies were established with a2-mm twist drill. An intraoperative radiograph was thentaken to verify implant trajectory with respect to the adja-cent teeth. In addition, the apical position of the implantwas verified against the surgical guide in an effort to placethe implant far enough apically to allow for ideal emer-gency profile of the implant restoration through the over-laying soft tissue (Video 2).

Finally, the internal flat side of the implant# profile waslined up against the facial plate in an effort to allow forseating of the prefabricated provisional crown withscrew-retained retention and engaging the anti-rotationalfeatures of the implant.

Implant site #10. For this site, the implant positionmet all of the above requirements. In addition, the ISQwas 64 at the time of placement. However, when evaluat-ing the facial contour, the shadow of the facial aspectof the implant was visible as a result of the lack of facialcontour in the alveolus. This was grafted with mineral-ized freeze-dried bone allograft (FDBA)** and a long-termresorbable collagen membrane†† (Fig. 5).The provisionalwas placed, the position was verified, and the finalcontacts were addedwith light-cured composite. The pro-visional restoration was then hand tightened to placeusing z10 Ncm.

Implant site #7. Surgical placement of this implantmimicked the surgery for site #10 with one major differ-ence. After initial seating of the provisional restoration,it was determined that the gingival emergence was not con-sistent with the rest of the anterior segment, demonstratinga position that was too far in the coronal direction (Video3). This was because the alveolar ridge at site #7 was cor-onal to the adjacent natural teeth. This is a common con-dition of these sites. Alveoloplasty and osseous crownlengthening was performed to allow for adjustment ofthe apical position of the implant. This was dictated bythe prefabricated provisional restoration. The ISQ read-ing for this fixture was 68. The facial and lingual flapswere then repositioned and sutured with individual,interrupted 6-0 polyglactin 910 sutures.‡‡ Care wastaken to ensure that the provisional restorations werekept out of occlusion in centric occlusion and all excur-sive movements. The patient was administered 60 mgketorolacxx intravenously and given a non-steroidal anti-inflammatory drug for post-operative pain. She was dis-missed in alert and stable condition to the care of hermother. She was told not to brush the areas and only toswab the sites with water until her next visit which wasin 2 weeks (Video 4).

FIGURE 1 Preoperative photographs (1a and 1b) and panoramicradiograph (1c) of a 22-year-old female patient presenting with congenitallymissing maxillary lateral incisors with an over-retained primary toothpresent on the right side and missing primary tooth on the left. As a result,the implant sites were significantly different in both vertical and horizontaldimensions.

|| Nembutal, Lundbeck, Deerfield, IL.{ Versed, Novell Pharmaceutical, West Jakarta, Indonesia.# 3.3 Bone Level Roxolid implant, Straumann.**LifeNet Health, Virginia Beach, VA.†† OSSIX PLUS, OraPharma, Horsham, PA.‡‡ VICRYL, Ethicon, Johnson & Johnson, Cornelia, GA.xx Toradol, Apotex, Toronto, Ontario.

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108 Clinical Advances in Periodontics, Vol. 3, No. 2, May 2013 Team Approach for Replacement of Maxillary Laterals

Immediate ProvisionalsAfter fixture placement, provisionalswere placed one at a timestarting with site #10 (Video 5). First, the surgeon (DSC) con-firmed that the implant fixture flat portion of the internal con-nector was oriented to the facial aspect so that the provisionalwould fit as designed. The restorative teammember (KFH) al-tered the contact points, incisal length, and lingual surface be-fore bone augmentation and closure of the surgical site. The

FIGURE 2a and 2b Study casts marked accurately to designate properimplant site and spacing. 2c and 2d Surgical guide fabricated with hardclear orthodontic acrylic resin and supported by occlusal surface ofadjacent teeth similar to an occlusal guard. The facial gingival most apicalaspect of the guide for each implant site must be made accurately torepresent desired final gingival margin. The surgeon will use the guide tomeasure 3 mm apical to set the proper implant depth.

FIGURE 3a and 3b Temporary abutment marked with a vertical linedesignating the flat portion of the connector and facial position anda horizontal line designating the implant depth. 3c and 3d A 3-mm openingwas drilled completely through the cast at the desired implant sites usingthe surgical guide. A temporary abutment was attached to an implantreplica and positioned into the study cast at the estimated final position.The replicas were set with pattern resin from the bottom of the cast.

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mesial contact on both provisionals was closed with the addi-tion of composite resin and repolished. Care was taken to en-sure that the contact points were not too tight, which maycausemicromovement on the implants and produce a negativeeffect on integration. Dental floss was used to ensure propercontact. Immediate provisionals are typically shorter thanthe definitive restoration to avoid contact in centric or any ex-cursive movements (Fig. 6).

When planning for the use of immediate provisionals, theteam must be prepared if placement is not possible becauseof the following challenges: 1) unfavorable implant stability(low ISQ readings); 2) unfavorable occlusion; 3) unfavor-able site; 4) provisional not fitting; 5) abutment not seating;6) implant position; or 7) implant appears loose. Alterna-tives include the following. 1) Make an implant transfer in-dex to study cast, the restorative team makes minormodifications, and deliver the same day. 2) Reduce provi-sional to the gingival level to create a custom healing abut-ment and place a vacuum-formed retainer. In 2001, Garberet al.14 reported a customhealing abutment as an alternativeto the full contoured provisional, which provided preserva-tion of soft tissue and prevented any unfavorable occlusaltrauma and micromovement. 3) Make an index impressionfor early loading, place a vacuum-formed retainer, and de-liver the corrected provisional within 2 to 14 days. 4)Makean index impression for delayed loading, place a vacuum-formed retainer, anddeliver the provisional in 6 to24weeks.

Clinical OutcomesFinal Radiographs, Tissue Healing, andClinical PhotographsThe 2-week postoperative visit demonstrated normalhealing of the soft tissues with some edema in the tissues

still present. Of note was site #10, which demonstratedthickened, bulky contours with soft-tissue cratering in-terproximally. No recontouring of either the provisionalor soft tissue was done, and the areas were allowed tomature unaided. The patient was instructed in usinga soft toothbrushing technique with light interproximalflossing.

At 4months, the patient demonstrated excellent soft-tis-sue response to the provisional restorations and healthy,stable interproximal papilla. Periapical radiographs weretaken to verify healing of the implant fixtures, and de-finitive impressions were initiated using the “custom

FIGURE 4a and 4b Indirect screw-retained provisionals fabricated withtemporary abutments and composite resin.

FIGURE 5 After fixture placement and provisionals in sites #7 and #10(5a), the facial aspect was grafted with mineralized FDBA (5b) and a long-term resorbable collagen membrane (5c).

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impression coping technique” reported by Hinds in1997.15 Provisionals were removed one at a time, andpickup impression copings were modified with compositeresin and connected to the implant fixture. The compositewas contoured directly in the implant sites and light curedto harden the material. The impression copings were thenremoved and inspected, and composite resin was added tofill any voids and polished. As a result, the copings shouldaccurately represent the healed soft tissue created by theprovisional restoration (Fig. 7).

The custom impression copings were reconnected tothe fixture level, and an open-tray polyether‖‖ impressionwas made. Implant replicas were connected to the impres-sion copings, and the impression was poured in die stoneto create a master cast. All-ceramic, zirconia computer-aided design/computer-aided manufacturing (CAD/CAM){{

abutments and all-ceramic, zirconia restorations werefabricated (Fig. 8).

The definitive abutments were connected and torquedto 35 Ncm. A cotton pellet and elastic, single componentlight-cured resin## was used to close the abutment accessopening. The definitive prostheseswere cementedwith ra-diopaque glass ionomer luting cement*** (Fig. 9). Toavoid complications with residual subgingival cement,the following protocol was followed.

Protocols for Anterior Cement-RetainedProsthesisProvisional restorations. One-piece screw-retained provi-sional restorationwas essential to develop proper soft-tissuecontours, interdental papilla, and facial margin before thefabrication of the definitive prosthesis.

FIGURE 6 Screw-retained provisionals placed at stage I surgery (6a and6b) and at 18 days of healing (6c).

FIGURE 7 At 4 months of provisional healing (7a), the definitive impressionwas made using custom impression coping (7b) and poured in die stone tocreate an accurate master cast.

FIGURE 8 Definitive all-ceramic CAD/CAM zirconia abutments (8a) andcementable all-ceramic prostheses (8b) for implant sites #7 and #10. All-ceramic porcelain veneers for central incisors #8 and #9.

‖‖ Impregum, 3M ESPE, St. Paul, MN.{{ NobelProcera CAD/CAM scanner, Optimet Metrology, North Ando-

ver, MA.## Telio CS Inlay Syringe Transparent, Ivoclar Vivadent Amherst, NY.*** Ketac glass ionomer cement, 3M ESPE.

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Custom impression coping. After soft-tissue healing,custom impression copings16 were used to make an accu-rate transfer, allowing the technician the opportunity tofabricate the abutment margins more precisely, eliminateguessing, and avoid deep subgingival margins from whichexcess cement may be difficult to remove (Fig. 7).

Abutment design (Fig. 8). 1) All-ceramic abutments(zirconia) provided the advantage over metal abutmentsof less gray/darkness displaying through the facial tissueand allowed prosthetic margins to be designed more shal-low. Although zirconia abutments are currently manufac-tured primarily white, the shade can be modified withpressed ceramics17 or layered porcelain techniques.March-ack and Yamashita18 reported in 1997 a modified customabutment with a 360˚ porcelain collar as another alterna-tive to all-ceramic abutments. 2) The facial margin was 5mm below gingival crest. 3) The interproximal marginwas even with the gingival crest. 4) The palatal marginwas 1 mm coronal to the gingival crest.

DiscussionThe term “team approach” has been used throughout thehealth care industry, and as technologies continue to ad-vance, this term has evolved from simply referring a patientback and forth to detailed treatment planning and case se-lection. In this case report, the restorative dentist presenceand participation at stage I surgery was a valuable asset toachieving the ideal esthetic and functional result for thispatient.

Once adequate bone for implant placement was deter-mined using cone-beam computerized tomography, dis-tances between adjacent teeth were verified with thescan. In this case report, the space between teeth measured6.3 mm; thus, 3.3-mm-diameter implants were used. Thefacial gingival-most apical aspect of the guide for the des-ignated implant site must be fabricated accurately to

represent desired final gingival margin of the definitive res-toration. The surgeon will use the guide to measure 3 mmapical to set the proper implant depth. With this particularpatient displaying uneven gingival heights from right toleft, the guide provided a critical reference for fixture place-ment.16,19When designing the surgical guide, the direction/angle of the access opening may be affected by prostheticdesign. The restorative team member must determinewhether the definitive restoration will be cement or screwretained. There is currently significant discussion about ce-ment-retained restorations contributing to the causes ofperi-implantitis.17,20 For this reason, some clinicians haveabandoned cement-retained implant restorations. Screw-retained implant prosthesis may require an implant place-ment in a more palatal position. This could have a negativeeffect on the final esthetic result. Although a screw-retainedrestoration avoids the complication of excess cement, itadds an additional degree of difficulty because of the smallmargin of error for implant placement. Cement-retainedrestorations allow implant placement in an ideal positionbased on available bone, ability to augment ridge, properdepth to create ideal transitional profile, and proper me-sial–distal spacing and not on prosthetic design. Any nec-essary correction in angle in a facial–palatal direction ismade with the custom-contoured abutment. In 2012,Wadhwani et al.17 reported the most effective method toavoid excess cement with cementable restorations was toavoid subgingival margins. The authors recommendedsupragingival abutment–implant crown margins. In addi-tion, it was recommended that the materials used on theabutment is the same shade of the prosthesis to avoid de-tection on recession on the facial aspect.

Replacement of maxillary incisors with implants re-quires a thorough understanding of the periodontal anat-omy, regenerative potential of bone and soft tissue, andthe biomaterial principals of the restorative techniquesused. In this case report, positioning of implant analogsin the ideal positions on a diagnostic cast before surgerywas key in fabricating a surgical guide to aid the periodon-tist in implant positioning. With the restorative dentistpresent, an additional skill set to compliment the regener-ative and surgical esthetic techniques used resulted inhighly accurate, reproducible implant positions so that pre-fabrication of provisional crowns could be accomplished.These crowns engaged the anti-rotational features of theimplants that were verified as “stable” based on ISQ values>60. Screw retention of the provisional restorationsavoided the possibility of cement migration and allowedfor guided bone regeneration (GBR) to be performedaround implant #10 simultaneously. Long-term implantsuccess using GBR has been documented by a number ofauthors, and bone allografts have also been shown to allowfor up to 42% new bone formation at 6 months.21,22

Clearly, the amount of bone required for integration andimplant stability is less than that needed for ideal implantposition and soft-tissue contours. This bony support ofsoft-tissue contour can be an advantage as well as a disad-vantage, as demonstrated by this case. For example,

FIGURE 9 Clinical photographs (9a and 9b) and radiographs (9c and 9d)of definitive prostheses at 1 month.

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because of the coronal position of the alveolar crest in site#7, periodontal surgical crown lengtheningwas required toreposition the implant more apically, dictated by the surgi-cal guide. For site #10, although the implant was posi-tioned accurately to allow for a cementable definitiverestoration, the facial contour of bone was depressedand thin. GBR was used in an effort to prevent facial boneloss and to expand the soft-tissue contour over the implantrestoration. Full-thickness flaps without vertical incisionsin this case report had the advantage of avoiding anysoft-tissue scaring from vertical incisions, allowing for ma-nipulation of soft tissue by repositioning and coronal ad-vancement over the idealized provisional and, of course,facilitating the regenerative and crown-lengthening surgery.

This would not have been possible if a flapless techniquewere used, and there would be a strong likelihood thatthe final restorative resultswould be compromised althoughintegration would have been successful. In addition, thiscase demonstrates that highly accurate restorative and sur-gical procedures can be accomplished without the use ofcomputer-generated guides.

Ultimately, it is the team approach that accounts for theesthetic and functional success of this case, taking advan-tage of the synergy of working together to maximize eachclinician’s skill in contributing to the best, most predict-able, least invasive outcome for the patient. The authors’experience shows that this approach has high predictabilityand high patient acceptance. n

Summary

Why is this case new information? j Prefabrication of provisional implant restorations can be done withoutthe use of computer-generated surgical guides and allow forregenerative/esthetic surgery to support both implant stability andsoft-tissue contour before the definitive restoration.

What are the keys to successfulmanagement of this case?

j Close communication and planning between the periodontist and therestorative dentist before executing the surgical plan

j Periodontist and restorative dentist participating in stage I surgery forhighly demanding esthetic cases

j Verified implant stabilityj Extended healing time to allow for tissue maturation

What are the primary limitations tosuccess in this case?

j Adequate bone for proper implant positionj Accurate surgical guides to communicate implant position in fourperspectives: axial, sagittal, apical, and rotational

AcknowledgementsDr. Clem has received honoraria from Straumann (Andover,Massachusetts). Dr. Hinds reports no conflicts of interest re-lated to this case report.

CORRESPONDENCE:Dr. Donald Clem, 220 Laguna Rd., Suite 3, Fullerton, CA 92635. E-mail:[email protected].

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mailto:[email protected].

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indicates key references.

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