Tooth in a year and a half
The use of dental implants has become a mainstream treatment method in tooth replacement. In recent years, much emphasis has been placed on rapid restoration of the lost dentition with extraction, implant placement, grafting and restoration on occasion being combined in one appointment to allow the patient to minimise or eliminate time spent in a removable prosthesis. This has been variously described as ’Teeth in an hour’, ’Teeth in a day’, ’Diem’ and ’All-on-4’, as well as several other buzz phrases.
While shortened treatment protocols offer clear benefits in simple tooth replacement cases where rapid restoration of function is the primary objective and all necessary hard and soft tissues are present (ITI Classification “Straightforward”), they have potential shortcomings in more complex and aesthetically demanding situations, which fall into the ITI ’Advanced’ or ’Complex’ classifications.
This article presents a case where treatment over a protracted period of time results in an outcome which could not predictably be achieved with the currently popular more accelerated treatment approaches.
Patient RR was a healthy, non-smoking 44-year-old male, who presented with a complaint of an unaesthetic upper right central incisor, with extensive recession showing a large amount of darkened labial root surface. The situation was worsened by a high smile line and a porcelain crown contrasting dramatically with the root colour.
The patient had experienced periodic swelling at the apical part of the recession over a long period. There was also a history of trauma in his teens, leading to root canal treatment and a crown, and subsequent apicectomy in his 20s.
Clinical examination revealed an otherwise periodontally healthy, well looked-after mouth (Figs 1 and 2).
Diagnosis was of endodontic failure and possible root fracture, leading to loss of labial bone and soft tissue.
The treatment plan was essentially divided into three stages:
Rebuilding the lost soft tissue
Rebuilding the lost bone
Replacing the tooth
Rebuilding the lost soft tissue
1. Fabrication of a tooth-borne immediate partial denture.
2. Extraction and the split root confirmed.
3. De-epithelialise the socket and ensure bone bleeding.
4. A connective tissue and epithelial graft from the tuberosity – using a distal wedge technique.
5. Bilateral pedicles using adjacent papilla to cover the connective tissue surfaces of the tuberosity graft (Fig 3).
6. Fitting and adjusting as necessary the tooth-borne immediate partial denture.
7. Monitoring of soft tissue healing. Tissue from the tuberosity and adjacent papillae gives a better match than palatal tissue. We are ready to re-enter when incision lines are fully closed.
Rebuilding the lost bone1. Re-entry was carried out at four months using a full thickness flap for access.
2. Underlying bone was curetted with a Rhodes chisel and a round bur was used on the labially-facing surface of bone to ensure bone bleeding (Fig 4).
3. Endobon xenograft material (Biomet 3i) was placed after being moistened with blood and saline (Fig 5).
4. OsseoGuard xenograft membrane (Biomet 3i) was trimmed and fitted once it seated passively under the flap (Fig 6).
5. The flap was sutured with 4-0 silk to achieve primary closure over the site (Fig 7).
6. The partial denture was adjusted and refitted after ensuring there was no positive pressure in the area of the grafted bone.v
7. Monitoring of healing. Sutures were removed at two weeks and periapical X-rays taken at two and four months to check for good graft condensation and to ensure there were no voids in the graft material. The timing of implant placement will also depend on bone available beyond root apex position.
Replacing the tooth
1. The graft was left to mature for six months then a full thickness papillae preserving flap was used to access the site, revealing excellent regenerated bone.
2. A 15mm Full Osseotite straight-sided external hex implant (Biomet 3i) was placed with an insertion torque of 45Ncm. Because the implant was largely in regenerated bone, immediate restoration was not attempted. No additional grafting material was needed (Figs 8 and 9).
3. After four months, exposure was carried out using a punch gingivectomy approach.
4. A temporary cylinder was seated and a clear crown form was used with cold cure acrylic to fabricate a temporary crown. This was Torqued to 20N/cm and cotton wool and Cavit placed in the access hole (Figs 10 and 11).
5. Four week’s healing was allowed for gingival contour to be developed (a little longer would have been preferred, however the patient was moving away from the region) (Fig 12).
6. Pick-up coping impression was taken with Impregum injection into sulcus to capture emergence profile developed with the temporary crown. Occlusal records and shade were taken and agreement was reached with the patient on a midline diastema to improve symmetry (Fig 13).
7. The porcelain fused to metal, screw retained crown was tried in, and the fit and occlusion were checked then, after aesthetics had been approved by the patient, a square Goldtite screw was torqued to 32 N/cm and access sealed with cotton wool and composite.
8. A final X-ray was taken and oral hygiene instruction and recall advice were given.
9. The patient returned one year later for a recall examination and X-ray and was still delighted with the aesthetic improvement (Figs 14 and 15).
This case report illustrates that not all tooth replacement problems can be managed by immediate or rapid implant restoration. While the concepts of immediate replacement and immediate loading of implant prostheses certainly has a place in our armamentarium, it is not applicable to all situations and is certainly a long way from being a panacea.
We may all enjoy fast food occasionally, but generally slower, more relaxed fine dining is preferred. It is perhaps appropriate to consider Dennis Tarnow’s maxim: “Do one miracle at a time.”
All laboratory work by DTS Laboratory
Annibale Coia referring dentist
Figure 10Temporary cylinder and a clear crown form fabricated a temporary crown
About the author
Crawford Bain BDS DDS MSc MBA is professor of periodontics and programme director of graduate periodontics at Dubai School of Dental Medicine.