A Comprehensive Treatment Approach
Focusing on the Restoration of the Anterior Maxilla
By Debora G. De Farias, DDS, MS
Clifford Starr, DMD, FAGD, MAGD, ABGD
Featured in General Dentistry, November-December 2008
Proper diagnosis, thorough evaluation, and a comprehensive treatment plan are fundamental to restoring each patients oral health and esthetic concerns. This case report presents the strategy of a comprehensive evaluation, diagnosis, and treatment focusing on the patients compromised anterior maxillary dentition. Oral rehabilitation was accomplished through selective dental extractions, immediate placement of dental implants, elective endodontic treatment, and fixed restorations. Adequate surgical, restorative, and preventive protocols were utilized to achieve optimal function and esthetic results.
Received: July 9, 2007
Accepted: August 29, 2007
A dentists initial assessment should include the patients medical history, dental history, and deleterious habits. Dental treatment plans may be modified or adapted for patients with systemic, uncontrolled diseases to meet their therapeutic and esthetic requirements. Clinical and radiographic examination of dental restorations, the periodontium, endodontic status, esthetics, occlusion, and temporomandibular joints (TMJs) must be well-documented. This information, together with mounted diagnostic casts, diagnostic wax-ups, and preoperative photos, will lead to a differential diagnosis and assist in developing a definitive treatment plan.1-3
The dentist and patient should discuss alternative options and examine the benefits and risks. The patients chief complaints, expectations, and finances play an important role in the decision-making process. Patients should be made aware of how dental implants and prosthetic dental rehabilitation work and how this type of treatment can improve both masticatory function and esthetics. The patient also should be able to understand the more cost-effective option and the long-term prognosis when comparing implants to other treatment options, such as the maintenance of an endodontically involved tooth. Once the dentist and the patient agree on the treatment plan, the patient should sign an informed written consent.2
Another important aspect to proper care is the interdisciplinary approach, depending on the cases complexity and the dentists level of confidence. If the patient requires evaluation by one or more specialists, the general dentist should lead the team, providing not only a rational and sequenced treatment plan but also relevant information that will allow for a smooth transition between the different offices. Adequate communication and integration with laboratory technicians also are expected.2,4
Finally, patient compliance with an appropriate recall regimen must be emphasized. Long-term success or failure of the established treatment will be determined in part by the prevention of caries, periodontitis, and peri-implantitis.2
This case report presents the strategy for a comprehensive evaluation, diagnosis, and treatment of a patient, focusing on the compromised anterior maxillary dentition.
A 37-year-old man sought treatment; his chief complaints were the presence of several broken teeth and unsatisfactory esthetics of both the anterior maxillary teeth and the existing acrylic-metal base crowns.
The patients medical history was unremarkable. Extraoral and intraoral examinations were within normal limits. The patient was TMJ asymptomatic with Class II, division 1 occlusion and an anterior open bite. He had multiple carious posterior teeth; in addition, teeth No. 7 and 8 demonstrated incomplete and failing endodontic treatment, periapical pathology, failing cast posts, and failing crowns (Fig. 13). Periodontal evaluation revealed mild localized periodontitis, a thick gingival biotype with normal gingival scallop, and an uneven gingival height of the anterior maxillary teeth. Esthetically, the patient had a high smileline, an uneven plane of occlusion, and defective anterior acrylic-fused-to-metal crowns. Diagnostic mounted casts and a diagnostic wax-up were obtained and a treatment plan was selected.
After initial periodontal treatment and an initial improvement in oral hygiene, a rigid surgical acrylic guide was fabricated, based on the diagnostic wax-up, tooth position, angulations, and the anticipated soft and hard tissue contours. Sleeve rods were placed in the stent, making it possible to use drills of different sizes during osteotomy preparation. The patient was placed on a seven-day regimen of antibiotics, analgesics, and anti-inflammatory medications, beginning 24 hours prior to implant surgery.
The surgical procedure was carried out under local anesthesia only. A flapless, atraumatic extraction of teeth No. 7 and 8 was accomplished with periotomes, with care being taken not to fracture the buccal alveolar plate. The sockets were evaluated and no apical fenestrations were noted. The granulation tissue was removed using a surgical curette and a slow-speed round bur under saline irrigation (Fig. 4 and 5).
Prior to the surgical procedure, a wide platform implant (5.0 mm diameter x 16 mm long) coated with hydroxyapatite (HA) (Replace, Nobel Biocare, Yorba Linda, CA; 800.993.8100) was chosen for tooth No. 8, while a narrow platform HA implant (3.5 mm diameter x 16 mm long) was chosen for tooth No. 7. The osteotomy sites were prepared using drills of graduated sizes along with copious irrigation, per the manufacturers instructions. The implants were placed against the palatal aspect of the socket, approximately 3.0 mm apical to the cemento-enamel junction (CEJ) of the adjacent teeth (Fig. 6 and 7).
Forty-five Ncm of insertion torque was achieved at both sites, indicating excellent primary stability. Healing abutments were placed (Fig. 7 and 8) and an interim maxillary removable partial denture was inserted and adjusted. Healing was uneventful at a follow-up visit one week after implant surgery.
The patient proceeded with dental treatment as planned but the final anterior restorations were postponed for 18 months due to the patients personal circumstances. Meanwhile, he continued to receive preventive maintenance every three months.
The patient returned 17 months after fixture placement to have the implants restored. Clinical and radiographic examination revealed successful osseointegration and healing abutments covered by gingival tissue. Because of the apical position of tooth No. 7 and the reduced quantity of attached gingiva on the buccal aspect, the patient was referred to a periodontist for the second stage surgery and uncovering of the implants. A palatal pedicle roll flap was performed on tooth No. 7 to increase the thickness of soft tissue on the facial aspect. One week after the second stage surgery, the patient received temporary abutments and temporary acrylic crowns.
Elective endodontic treatment was performed on tooth No. 10, followed by placement of a pre-fabricated titanium post and full-coverage crown. The patient was aware of his anterior open bite and this treatment was performed to reduce it slightly by positioning the anterior crowns in a more palatal direction. Based on the diagnostic wax-up, temporary crowns were fabricated and adjusted on teeth No. 710 until the patient was pleased with the result.
One month after second stage surgery, a final full-arch impression with implant-level impression copings was taken. Photos and an alginate impression of the provisional restorations were sent to the laboratory as guides. Custom implant abutments and Captek crowns (Precious Chemicals Company, Inc., Altamonte Springs , FL ; 800.921.2227) were fabricated for teeth No. 710. The custom abutments were torqued to 35 Ncm and the crowns were cemented (Ketac-Cem, 3M ESPE, St. Paul , MN ; 888.364.3577) (Fig. 912).
The patient returned at three-month intervals after his second stage surgery and placement of the anterior restorations. After nine months, all recall visits revealed healthy dental and periodontal status, suggesting that the established therapy had been successful (Fig. 1315).
Proper case selection, accurate comprehensive treatment planning, and the use of proper surgical and restorative protocols help to achieve optimal function and esthetic goals in dentistry. Although replacing compromised anterior teeth with implants remains a challenge, osseointegration and successful outcomes still are predictable.5-9
In the present case, the approach for rehabilitating the anterior maxilla had to consider the unfavorable prognosis of the right maxillary central and lateral incisors. Those teeth revealed questionable strength, large posts, and a need for endodontic retreatment and crown lengthening. Under those circumstances, extractions and immediate placement of implants are a more predictable alternative therapy than attempting to salvage the debilitated teeth.10
Immediate postextraction implants without incisions or flap elevation were selected to preserve the alveolar bone and soft tissue architecture. In addition, immediate implant placement has demonstrated a high success rate with a minimally invasive surgical technique, reduced operative time, and increased patient comfort.5-8,11
The diameter and length of the teeth, proximity to adjacent roots, and proximity to the nasal floor all are factors in determining the size, width, and positioning of the implant fixture. Immediate dental implants usually achieve primary stability when 3350% of the implant body (3.05.0 mm) extends beyond the apex of the socket; as a result, long fixtures were selected.12-14 The implants were placed approximately 3.0 mm apical to the CEJ of the adjacent teeth to establish a biological width around the implants and to obtain an adequate, natural emergence profile for the crowns.
The width of the implants also influenced their positioning in the apical-cervical direction. Since a narrow implant was selected to restore the lateral incisor, the fixture could be positioned further apically, allowing a natural emergence profile from the top of the implant interface to the future restoration. A larger implant was chosen for the central incisor, allowing greater surface area for osteointegration.12-14
In the mesial-distal direction, there should be at least 1.52.0 mm of clearance between the implant and the adjacent tooth, favoring proper osseointegration and optimum esthetics and reducing the risk of damaging the adjacent natural tooth.12-14 A minimum clearance of 3.04.0 mm between the two implants is required to decrease crestal bone loss and allow for correct interproximal contacts between the crowns.12 In the buccal-lingual direction, the implants in the present case were placed toward the palatal wall so that they would be surrounded by at least 1.02.0 mm of bone; this placement also prevents compression necrosis of the thin buccal plate. Proper angulation was achieved by placing the implants parallel to the adjacent teeth.
A connective tissue graft performed during the second stage surgery improved the tissue topography. A palatal modified roll flap helped to increase the soft tissue height labially and improved minor ridge defects without bone grafting.1
The selection of the final abutments is a matter of professional preference. In the present case, a custom-made screwed abutment was chosen that would allow the dentist to alter the finishing margins to match the dimensions of the tissues.1 Captek crowns were selected because of their strength, precision fit, optical effects that simulate vital tooth esthetics, and compatibility with soft tissue.15
A rational and multidisciplinary approach is essential when restoring the patients oral health. Using proper documentation, good case selection, technology, and patient education, dentists can offer successful treatment to patients on a daily basis. The treatment strategy presented in this case achieved acceptable esthetic and functional results, with minimal patient discomfort.
Dr. De Farias is in private dental practice in Jacksonville , Florida . Dr. Starr is a clinical professor and Director, Advanced Education in General Dentistry Residency, Jacksonville Clinic, University of Florida , College of Dentistry in Jacksonville , FL.
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Original Article: “Effect of Anticipatory Guidance on Oral Health and Oral Hygiene Practices in Preschool Children.” Published in the Journal of Clinical Pediatric Dentistry, Vol. 30, number 1, 2005.
Original Article: “Salivary Antibodies, Amylase and Protein from Children with Early Childhood Caries”. Published in the Clinical Oral Investigation, Vol. 7, Number 3, September 2003.
Researched and wrote “Salivary Organic Composition of Children with Early Childhood Caries.” Presented at 80 th IADR General Session and Exhibition. San Diego, CA, March 6 – 9, 2002. Published abstract in the Journal of Dental Research, Vol. 81, Special Issue 2002.
Researched and wrote “A Comparative Study of Microleakage on Class V Restorations.” Presented at 77 th IADR General Session and Exhibition. Vancouver, BC, Canada, March 10 – 13, 1999. Published abstract in the Journal of Dental Research, Vol. 78, Special Issue 1999. Published article in the Pesqui Odontol Bras, Vol. 16, No. 1, 2002.
Researched and wrote “Caries Prevention in Children from Zero to Thirty Months of Age.” Presented at AADS International Women’s Leadership Conference. Cannes/Mandelieu, France, June 20 - 22, 1998. Published abstract in the Journal of Dental Education, Vol. 63, No. 3, 1999.
Researched and wrote “Prevalence of Dental Fluorosis in School Children of Brasilia – Federal District.” Presented at VII International Congress of Dentistry. Brasilia- DF, Brazil, March 18 – 22, 1997. Published article in the Revista de Odontologia da Universidade de Sao Paulo, Vol. 12, No. 3, 1998.
Researched and wrote “Gingivitis Prevention and Plaque Control in Children from 06 to 18 Months of Age.” Presented at 74 th IADR General Session and Exhibition. San Francisco, CA, March 13 – 17, 1996. Published abstract in the Journal of Dental Research, Vol. 75, Special Issue, 1996.
Outstanding Academic Achievement , College of Dentistry. University of Florida , 2003 -2005 .
Outstanding Achievement Award, Multicultural Student Awards Ceremony. College of Dentistry. University of Florida , 2004 .
1 ST Prize Kolynos- Anakol Award for the academic research in the field of “Dental Caries and Periodontal Disease Prevention.”, Brasilia - DF, 1994.