Challenges in the Esthetic Zone A Case Report

Abstract

To ensure aesthetics in implant treatment one has to respect the many biological and biomechanical concepts. In this case report we will show different techniques that were used to create a more pleasing result in the esthetic zone.

Keywords: Dental Implant, Esthetics, Anterior zone, Dental papilla, Bone grafts, Connective tissue graft, Crown lengthening. Introduction

Jihad Abdallah BDS, MScD, FAAID, FICD, ABOI/ID - Teaching Staff and Implant Program Coordinator - Oral & Maxillofacial Surgery Dept., School of Dentistry - Beirut Arab University (B.A.U) - Diplomate, American Board of Oral Implantology/Implant Dentistry (ABOI/ID) Beirut, Lebanon beirutidc@hotmail.com

Implant therapy in the anterior maxilla is made difficult by the high demand of the patient and the complex pre existing anatomy. The clinician is often confronted with soft and hard tissue deficiencies that have resulted from different conditions. Some of these include congenitally missing teeth, dental trauma, disuse bone atrophy and acute or chronic infections.1 To ensure optimum esthetics around a dental implant one must consider multiple factors. Implants should not only be functional but also cosmetically pleasing. In the maxillary anterior region, the replacement of missing teeth is only one part of the treatment.2 Another important aspect of therapy consists of replacing the lost portion of the alveolar process and the associated soft tissue. The re-establishment of a normal alveolar contour is a critical step in esthetic success. Therefore successful outcome depends on bone volume and density; soft tissue Seal & thickness; and physiological environment and esthetic demand. Some of the failures in the esthetic zone are insufficient bone anatomy/volume; selection of wrong implant configuration; inappropriate 3-D implants position; unacceptable Restoration (size, shape, color, position). To recreate the perfect combination of pink on white esthetics multiple techniques can be utilized that include but not limited to: 1. Platform switching 2. Correct positioning of the implant 3. Bone grafting/soft tissue grafting 4. Sometimes pink porcelain/composite might be needed 5. Try to avoid multiple extractions next to each other 6. Use temporary restorations to sculpt the tissue Several authors identified factors that influence a satisfactory aesthetic final result in oral implantology. Implant dentistry contributes not only to the restoration of oral function but also to beauty. Much of what comprises a beautiful and appealing smile is influenced by emotion and personality. Patients in a modern, affluent society often demonstrate an obsessive interest in achieving optimum esthetics and it is our job to recreate what they lost and give them the optimum gingival contour and tooth shape combination. Some clinicians have advocated the immediate placement of dental implants into prepared extraction sockets to preserve the contour and dimensions of the alveolar ridge after tooth extraction.3,4 The supporting bone influences the establishment of overlying soft tissue compartments and the bone quality and quantity must be carefully assessed.5,6 The vertical bone height in the interproximal sites, as well

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(Fig. 1) Clinical and radiographic pictures, pretreatment.

as the horizontal thickness and vertical height of the buccal bone wall in the edentulous site are important determinants of esthetic success.7 The bone crest should be within a physiological distance of 2 to 3mm of the cemento-enamel junction or, when recession is present, 2 to 3mm of the buccal gingival margin. Tarnow evaluated the effect of inter implant distance on the height of inter implant bone crest, and eventually the presence of the papilla. He concluded that the papilla was almost always present when the distance from the contact point to the crest was 5mm. But when the distance was increased to 6mm, the papilla filled the embrasure space only 55 % of the cases, thereby decreasing the probability that the papilla will fill the whole interproximal area by half.8 Studies have shown

(Fig. 2) Removal of implants, presence of ridge defect, placement of particulate graft and membrane and an RPD was used as a provisional restoration that was relieved over the graft.

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(Fig. 3) Placement of Bicon Dental Implants in site of 11 and 22, placement of particulate graft and sutures.

that, in addition to the vertical component, there is a lateral component to the crestal bone loss around the implant.9 Based on these findings, a minimum distance of 1.5 to 2mm should be maintained between implants and neighboring teeth and, in the case of multiple implants, a space of 3 to 4mm at the implant abutment level should be maintained between implants.8 A healthy 24-year-old male patient walked in to the Beirut Implant center. The patient came in complaining of a fixed partial denture over implants replacing teeth number 11, 21 and 22. From the clinical picture (Figure 1), pink ceramic used to replace the soft and hard tissue defect and a metallic hue is evident on the gingival margin of implant #11, the patient was complaining from the ugly appearance. In the radiographs (Figure 1), we notice the improper placement of the implants, which were placed too deep.

A hard tissue defect can be detected on the x-rays; the patient claims that he lost these teeth when he was involved in a motorcycle accident. In such a trauma there should be rehabilitation of the implant bed prior to implant placement. In addition multiple authors do not recommend two adjacent implant-supported restorations in the esthetic zone as this might end up in interproximal bone loss and eventually loss of papilla. We will proceed to show the different techniques that we tried to correct this defect and to show the mistakes that can be made during rehabilitation of the esthetic zone.

Surgical Phase

On the first visit after impressions and occlusal record registration, the implants were deemed unrestorable and needed to be replaced. Local anesthesia was applied and all three implants were extracted. Thin buccal plate of bone was detected in addition to a short alveolar

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(Fig. 4) Uncovering phase and placement of abutments and adjustment of temporary restoration.

(Fig. 5) The soft tissue healing around the abutment and placement of a lab fabricated temporary fixed partial denture to further mold the tissues.

ridge with an apicocoronal deficiency. It was decided that a particulate bone graft procedure would be appropriate for reestablishment of proper ridge architecture. After placement of particulate graft and collagen membrane the site was sutured with no tension and a removable partial denture was used during the healing period. The patients FPD was trimmed, all pink acrylic from fitting surface was trimmed and this was important because all pressure should be removed to allow proper healing. Four months later the patient came back for implant placement, this period allowed healing of the surgical site and maturation of the grafted bone. In order to avoid the previous problems, the treatment

planning of implant locations was important. It was determined that the implants will not be placed in close proximity to teeth and they will not be placed adjacent to each other. Two implants will be enough to restore this edentulous ridge and give an esthetically pleasing result. This will allow for proper alveolar ridge support and proper papilla between the implants as the soft tissue usually follows the bone. Two Bicon press fit implants were placed in # 11 and # 22 positions (4 x 11mm HA coated Bicon implants). Two-stage surgery was done here and this staging approach was important as it allowed us to further graft the area adding more bulk and allowing more time for

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(Fig. 6) Upper panels show crown lengthening procedure; lower panels show the tunneling and grafting procedure.

(Fig. 7) Intra-oral pictures before and after; extra-oral picture of the patients smile after completion of treatment.

(Fig. 8) Panoramic radiographs before and after treatment.

healing of the gingival architecture to allow for better emergence profile of the crowns. Five months later the implants were uncovered and abutments were placed. Further contouring of the gingival tissues was achieved by adjusting the acrylic temporary restorations. The two central incisors were elongated and this allowed for growth of the papilla and sculpting of the tissues. Multiple visits were required to help achieve better soft tissue architecture. It was noticed that the gingival margins on the lateral incisors both on the left and the right sides was longer

than the canines, and this is not what the golden proportion of optimum esthetics dictates. Also the posterior occlusal plane and the gingival margins of all the posterior teeth was lower that the anterior giving a reverse curve of Spee. Therefore a crown lengthening procedure was in order. The upper panels of figure 6 show this procedure. Then a tunneling technique was done in order to create a minimally invasive approach to graft the site and further increase the buccolingual width of the ridge and this procedure is shown in the lower panels of figure 6.

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Prosthetic Phase

Impressions were done about 4 months later for both the anterior fixed partial denture over the implants and on the canine number 23 that was prepared for full ceramic restoration. Shade selection was done and both metal and ceramic try ins were done on multiple visits. After establishment of the proper width and height proportion of the anterior teeth and the pleasing esthetic shade, the fixed partial denture on implants replacing teeth number 11 and 22 was cemented, keeping number 21 as a pontic. In addition porcelain fused to metal crown was cemented on tooth number 23. Postoperative care and hygiene techniques were explained to the patient and the importance of maintenance care was emphasized.

Conclusion

Proper positioning and number of implants are important in producing an esthetic outcome in the anterior zone. In this case we achieved a better result than when the patient walked in on his first visit, but further plasty of the tissue might be needed. The patient was satisfied with the esthetic result that was achieved.
1. Belser UC, Schmid B, Higginbottom F, Buser D Outcome analysis of implant restorations located in the anterior maxilla: a review of the recent literature. Int J Oral Maxillofac Implants. 2004;19 Suppl:30-42. 2. Buser D, Martin W, Belser UC. Optimizing esthetics for implant restorations in the anterior maxilla: anatomic and surgical considerations. Int J Oral Maxillofac Implants. 2004;19 Suppl:43-61. 3. Gomez-Roman G, Kruppenbacher M, Weber H, Schulte W. Immediate postextraction implant placement with rootanalog stepped implants: surgical procedure and statistical outcome after 6 years. Int J Oral Maxillofac Implants. 2001;16(4):503-13. 4. Wagenberg BD, Ginsburg TR. Immediate implant placement on removal of the natural tooth: retrospective analysis of 1,081 implants. Compend Contin Educ Dent. 2001;22(5):399-404, 406, 408 passim; quiz 412. 5. Saadoun AP , Le Gall MG. Periodontal implications in implant treatment planning for aesthetic results. Pract Periodontics Aesthet Dent. 1998;10(5):655-64. 6. Garber DA, Belser UC. Restoration-driven implant placement with restoration-generated site development. Compend Contin Educ Dent. 1995;16(8):796, 798-802, 804. 7. Belser U, Buser D, Higginbottom F. Consensus statements and recommended clinical procedures regarding esthetics in implant dentistry. Int J Oral Maxillofac Implants. 2004;19(Suppl):73-4. 8. Tarnow DP , Cho SC, Wallace SS. The effect of inter-implant distance on the height of interimplant bone crest. J Periodontol. 2000;71(4):546-9. 9. Esposito M, Ekestubbe A, Grondahl K. Radiological evaluation of marginal bone loss at tooth surfaces facing single Branemark implants. Clin Oral Implants Res. 1993;4(3):151-7.

References

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