A 21-year-old fit and healthy young male was referred by a colleague for assessment of a root-filled, symptomatic upper-right lateral incisor. The tooth had been traumatised and root filled about 10 years previously.
The patient had recently become aware of a bad taste from this area of his mouth. On examination, the tooth was noticeably discoloured, had pus discharging from the palatal margin but was firm to touch (Figs 1 and 2). His dental health was otherwise unremarkable and his motivation for treatment was good.
A periapical radiograph was taken (Fig 3) which showed the presence of a radio-opaque root filling but no root structure. This has probably been due to the trauma resulting in external replacement root resorption. This is thought to take place as a result of direct bone contact to the root surface as the periodontal ligament necroses. The osteoclastic activity causes root resorption followed by osteoblastic activity and new bone formation. In this case, it has taken about 10 years to be significant. After discussing the options with the patient, he decided to proceed with an implant-borne restoration as a definitive treatment plan.
At this stage, I consulted my implant dentist, Kevin Bruce, on the likelihood of there being enough bone for implant placement without a grafting procedure. A decision was made to extract the tooth and directly assess the bone quantity and quality. On extraction of the tooth (Fig 4), the residual bone appeared to be of good quality, so much so that it was impossible to remove the apical portion of the root-filling material (Fig 5).
After a healing interval of six weeks, the implant was placed and the residual root filling material removed. A bone augmentation procedure was carried out, using bovine granules and a porcine membrane to restore the bone architecture, to achieve optimum aesthetic results with the final restoration. After a 12-week interval to allow osseointegration of the implant, the patient returned for the restorative procedure. Impressions were taken and the abutment and crown fitted two weeks later (Fig 6). The procedure took five months from initial appointment to finish and the patient was extremely satisfied with the outcome.
The challenges of implant treatment are many. For the patient, the smooth management of the treatment and the aesthetics are paramount. It is important that the pre-op interdental papillae appearance
(Fig 7) is created with the final restoration (Fig 8). Patients do not wish missing papillae, or ‘black triangle disease’ as it is known in the implant world.
At the Village Dental Surgery in Bothwell, I receive referrals from colleagues who are aware of the benefits of the service offered. At the initial appointment, I will discuss the patient’s problem and offer a solution if possible. If special investigations such as CT scans are necessary, arrangements will be made to review the patient and offer a definitive treatment plan. At this stage, the patient will be made aware of the treatment cost and payment options available such as interest-free credit. Once the patient has decided to proceed with the treatment, an appointment will be arranged with my implant surgeon.
The advantages of working with Kevin are many. After graduation, he trained for five years in oral and maxillofacial surgery in both civilian/armed forces units where, as part of a multidisciplinary team, he treated everything from wisdom teeth to advanced trauma cases. His knowledge of anatomy and bone/soft tissue management ensures that the implants are placed perfectly for me to restore with the optimum functional and aesthetic outcome.
Our approach is a restorative-driven one where the final restoration is envisaged and the implants placed to allow this to happen. This can involve CT scans and full-mouth diagnostic wax-ups. Too often, implants are placed in such a position that it can be difficult, if not impossible, to restore satisfactorily.
Over the last three years, I have introduced implant dentistry to my practice. I have attended courses, scientific meetings and study groups to increase my knowledge. Mentoring with an experienced colleague is also important. I would recommend a hands-on introduction to implant dentistry supplemented by continuous learning if you wish to offer an implant service to your patients. Technical back-up from your implant company and laboratory are also important in this ever-advancing field of dentistry.
If you have any questions on this article, feel free to contact
About the authors:
Raymond Murphy BDS (Glas.), MJDF graduated from Glasgow University in 1985 and is the principal dentist at the Village Dental Surgery in Bothwell. He is a member of The Association of Dental Implantology and the FGDP (UK) (RCSEng) and runs a general private practice offering implant dentistry on a referral basis.
Kevin Bruce BDS (Glas.), FDSRCS (Eng.) graduated from Glasgow University in 1995. He has undertaken extensive postgraduate training throughout Europe and the USA in implant dentistry and its associated procedure, and has placed implants for 10 years. He mentors and lectures dentists and ancillary staff from all over the UK in the field of implant dentistry and is a visiting implant dentist at the Village Dental Surgery.
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