Achieving Long-Term Single Tooth Esthetics Through Interdisciplinary Care and Implant Planning

by David Little, DDS

Each case involving the restoration of one or two fractured or otherwise traumatized anterior teeth requires precise diagnosis and treatment planning procedures. Depending upon the patient’s age at the time of presentation, the initial findings and diagnosis could indicate the need for staged, interdisciplinary treatment that spans not merely months, but years. Likewise, the disciplines involved could range from endodontics to orthodontics, and the ultimate treatment could require a combination of modalities, such as composite bonding, all-ceramics, and implants.1

Young patients who present with traumatized and/or missing teeth require treatments that are planned differently and account for long-term function and esthetics.2 When sufficient root remains and the tooth or teeth can be stabilized endodontically, subsequent orthodontic treatment can be completed to successfully extrude the root to re-establish biologic width so that restorative treatment can follow.1 Such restorative treatment can be minimally invasive and involve direct composite bonding. Alternatively, if the long-term prognosis for a fractured and/or traumatized tooth becomes poor, or if the condition of the tooth and surrounding bone and soft tissue changes and necessitates extraction, then conserving the tooth until the patient is old enough for implant placement should be attemped.1,3,4

Of paramount importance to implant success is ensuring mechanical stability and biocompatibility of its corresponding components. The gingival tissue and corresponding abutments should be shaped to accommodate each specific clinical situation so that a natural emergence profile is created within the peri-implant soft tissue. Additionally, for maximum esthetics and function, single-implant tooth restorations should be planned taking the correct implant position into consideration to ensure the fabrication of an accurate prosthetic.

An adolescent high-school female presented following a volleyball accident during which she sustained trauma and fractures to teeth #7 and #8 (Figs. 1 & 2). It was immediately apparent that interdisciplinary care for this patient would be required in order to ensure appropriate healing, restoration, and long-term functionality of the affected gingival and hard tooth structures.

Following a thorough examination, the patient was referred to an orthodontist to splint teeth #7 and #8 (Fig. 3), after which root canal therapy was performed by the endodontist to stabilize both teeth to facilitate their conservation (Fig. 4). The general dentist then placed direct composite veneers on teeth #7 and #8 (Figs. 5 & 6). Following treatment, the patient’s parents were advised that should any possible complications arise, such as the need to extract either tooth, artificial roots (i.e., implants) could be placed and restored.

Unfortunately, four years post-accident and after the patient had survived cancer treatment, tooth #7 presented with internal resorbtion and required extraction. The tooth was subsequently extracted, and the socket grafted with allograft resorbable membrane (Fig. 7).

Diagnostic and implant treatment planning protocol then was undertaken to ensure a predictable and ideal result for the patient. A removable Essix appliance was used to shape the tissue. To create the Essix appliance, a matrix (Fig. 8) was loaded with composite and seated into the mouth in order to shape the site for future implant placement (Fig. 9) and then sutured.

Successful implant placement is predicated on starting with the end result in mind. This is incumbent upon incorporating proper diagnostic tools and protocols, along with comprehensive treatment planning.5 Therefore, after sufficient healing (Fig. 10), additional tools were used, including diagnostic models, digital radiography, and cone beam computed tomography (CBCT) scans to ensure that sufficient, stable bone existed and that where the implant would be placed would promote optimal retention.6,7

In this case, innovative and advanced CBCT (CT 9000D, Carestream Dental) that demonstrates zero distortion was used. This enabled the dentist to measure the exact width and depth of the patient’s hard tissues.8,9 By providing a 3-dimensional image, the CBCT images allowed the dentist to view cross-sections and all other aspects prior to initiating treatment (Fig. 11).

Implant planning in this case also was facilitated by incorporating a diagnostic software program (SimPlant, Materialise Dental), which enabled the dentist to capture diagnostic information, transfer it into the software program, and use it to virtually plan the case (Fig. 12). The entire case could be viewed and the final result confirmed by rotating the case 3-dimensionally (Fig. 13 & 14). Overall, the program provided valuable information for the treatment planning process.10

Because oral implant systems rely on the abutment to provide stability for the dental prosthetic, this aspect of the overall treatment in this case was given consideration. The selected implant (Ankylos, DENTSPLY Implants) was placed using a surgical guide (Fig. 15), after which a provisional abutment and crown were placed (Fig. 16 & 17). The unique TissueCare, conical cone connection of the Ankylos implant would provide a precisely machined, tapered-cone abutment (Morse taper) connection for high resistance to bending and rotational torque during clinical function, which significantly reduces the possibilities of screw fracture or loosening. By preventing mechanical influences (i.e., virtually no micro-movement) and microbial attack on peri-implant tissues, this tapered connection would provide the increased abutment/ implant interface stability so critical for both hard and soft tissues, as well as predictable esthetics. Further, additional space on the implant shoulder would support the surrounding tissue (i.e., platform switching).11,12

The provisional abutment chosen for this case was fabricated from titanium oxide (PEAK), while the provisional laboratory fabricated crown restoration (Fig. 18) was composed of a processed resin material (Radica, DENTSPLY Prosthetics).

Following osseointegration, a fixture level impression was taken that enabled the laboratory to fabricate a definitive zirconia abutment (Atlantis) and zirconia crown. The all-ceramic zirconia restoration (Cercon, DENTSPLY Prosthetics) and zirconia abutment would provide ideal biocompatibility and esthetics, as demonstrated in the 5-year postoperative clinical photograph and radiograph (Figs. 19 & 20), which show that it is nearly impossible to differentiate the natural teeth from the implant restoration.

The ultimate goal in all implant dentistry is satisfying both the patient’s and the dentist’s criteria for function, esthetics, and oral health. By visualizing the end result first, using advanced diagnostic technologies, and selecting an implant system that would deliver overall stability to ensure predictable results, the goals of the case presented here were achieved (Fig. 21). Although the definition for success differs from patient to patient and among dentists themselves, when anterior implant restorations are involved—particularly for a single tooth—and the patient is young, an interdisciplinary approach also can facilitate optimal results and satisfying outcomes.OH

David Little, DDS, received his dental training at the UTHSCSA and now maintains a multidisciplinary, state-of-the-art practice in San Antonio, Texas, to provide patients with dramatic restorative treatment results. An accomplished national and international speaker, professor, and author, he is also a respected clinical researcher focusing on implants, laser surgery, and dental materials, as well as a consultant on emerging restorative techniques and materials.

Oral Health welcomes this original article.

1. Krastl G, Filippi A, Zitzmann
NU, Walter C, Weiger R. Current aspects of restoring traumatically fractured teeth. Eur J Esthet Dent. 2011 Summer;6(2):124-41.

2. Priest GF. An interdisciplinary approach to aesthetic single implant outcomes for young patients. Pract Proced Aesthet Dent. 2008 Apr;20(3):167-75.

3. Goenka P, Marwah N, Dutta S. A multidisciplinary approach to the management of a subgingivally fractured tooth: a clinical report. J Prosthodont. 2011 Apr;20(3):218-23. doi: 10.1111/j.1532-849X.2010.00682.x. Epub 2011 Feb 1.

4. Mendoza A, Solano E, Segura-Egea JJ. Treatment and orthodontic movement of a root-fractured maxillary central incisor with an immature apex: 10-year follow-up. Int Endod J. 2010 Dec;43(12):1162-70. doi: 10.1111/j.1365-2591.2010.01790.x. Epub 2010 Sep 6.

5. Tischler M. The future of implant dentistry for general dentists. Interview by Dr. Damon Adams. Dent Today. 2009;28:60-64.

6. Rossi R, Morales RS, Frascaria M, et al. Planning implants in the esthetic zone using a new implant 3D navigation system. Eur J Esthet Dent. 2010;5:172-188.

7. Angelopoulos C, Aghaloo T. Imaging technology in implant diagnosis. Dent Clin North Am. 2011;55:141-158.

8. Patel S, Dawood A, Whaites E, et al. New dimensions in endodontic imaging: part 1. Conventional and alternative radiographic systems. Int Endod J. 2009;42:447-462.

9. Cucchiara R, Franchini F, Lamma A, et al. Enhancing implant surgery planning via computerized image processing [in English, Italian]. Int J Comput Dent. 2001;4:9-24.

10. Danza M, Carinci F. Flapless surgery and immediately loaded implants: a retrospective comparison between implantation with and without computer assisted planned surgical stent. Stomatologi

11. Romanos GE. Present status of immediate loading of oral implants. J Oral Implantol. 2004;30:189-197.

12. Weigl P. New prosthetic restorative features of Ankylos implant system. J Oral Implantol. 2004;30:178-188.