14 Jun 2017
By Sergio Rubinstein, Maurice A. Salama et al
Sergio Rubinstein, Maurice Salama, Henry Salama, David Garber and Mark Jacob present multidisciplinary enhancement of hard and soft tissue profiles
Achieving optimal aesthetic restorative results associated with anterior extraction and tooth replacement continues to be one of the most challenging endeavours in reconstructive cosmetic dentistry. When implant therapy is the treatment of choice, the margin for error is further decreased dramatically and methods to minimise and/or eliminate the potential for failure must be employed.
This is especially relevant when the tooth to be extracted is associated with significant hard and soft tissue deficiencies. Assessing the patient’s expectations, establishing a thorough diagnosis, and choosing the optimal therapeutic options to sequence and design treatment are key considerations for predictable success. Part one of this two-part article describes just such a clinical challenge related to the replacement of a severely compromised central incisor, with special emphasis placed on the utilisation of pre-extraction orthodontic therapy to enhance the hard and soft tissue profile of the future implant receptor.
Extraction and implant placement is a functionally predictable therapeutic modality. Aesthetic predictability, however, can sometimes prove elusive. This is especially true for the implant replacement of severely compromised anterior teeth with hard and soft tissue deficiencies within the aesthetic zone. For the exacting patient facing such circumstances, it becomes incumbent on the clinician to recognise the challenge(s) through a thorough diagnostic protocol and thereafter to choose the optimal therapeutic options for overcoming them.
With so many documented therapeutic techniques and materials available to clinicians today for reconstructing hard and soft tissue deficiencies, making optimal choices depends very much on the patient’s expectations and the specific nature of the site being reconstructed. This article highlights the decision-making process for the successful replacement of a hopeless maxillary central incisor exhibiting significant deficiencies in a challenging aesthetic environment. In addition, special focus is placed on the benefits of utilising pre-extraction adjunctive orthodontic eruption therapy to optimise the hard and soft tissue of the potential implant recipient site.
A 57-year-old female presented with a non-contributory medical history except for oral bisphosphonate therapy over a five-year period. The bisphosphonate therapy was discontinued just prior to seeking a dental consultation. The patient’s chief complaint at her first appointment was a significant concern about the existing right central incisor, particularly related to the considerable recession, exposed root, and associated cosmetic deformity (Figure 1).
An oral examination recorder generalised (+) mobility levels across her entire dentition except for the maxillary right central incisor, which exhibited a class II+ mobility. All posterior teeth presented with a balanced occlusion, a little localised recession, and a history of mild bone loss but were otherwise periodontally stable. The upper right lateral and central incisor had undergone endodontic therapy several years earlier, with the upper central incisor requiring a subsequent apicoectomy (Figure 2).
In conjunction with the gingival recession and apicoectomy, the majority of the osseous labial plate of the right central incisor had resorbed. While the defect on the labial of UR1 was significant; it was also localised. Important influencing considerations were the anatomy of the soft tissue defect, having a triangular shape, as well as the lack of any attached gingivae (Figure 3).
Relevant diagnostic influences were as follows:
The interdisciplinary team evaluated all possible treatment options for addressing the patient’s chief complaint and enhancing the smile display. Principal among them were regaining balance, harmony, and continuity of form within the aesthetic zone. A major concern was the expected position of the interproximal papillae around the central incisor with the anticipated treatment modalities.
To accomplish this goal, reconstruction of the lost bone and soft tissue in the area of the right central incisor is a primary consideration. Myriad surgical techniques are available today that are capable of accomplishing this. To correct such an extensive defect, however, all surgical protocols would require a staged approach of multiple procedures involving both bone and soft tissue augmentation with subsequent corrective procedures often required (Touati, 2009; Saadoun, 2009).
A patient with a recent five-year history of bisphosphonate therapy would need to be cautioned about such an aggressive approach if a suitable option presented itself. A possible alternative, adjunctive orthodontic eruption, is often considered when the hopeless tooth in question retains a relatively intact apical fibre apparatus capable of influencing the surrounding tissue. This orthodontic therapeutic modality is well documented and has been utilised effectively to help correct restorative, periodontal as well as aesthetic clinical challenges (Salama and Salama, 1993; Rubinstein et al, 2006).
The literature also validates that orthodontic eruption stimulates bone deposition at the crest as the tooth migrates coronally. In addition, it has also been widely demonstrated that coronal soft tissue enhancement and an increase in keratinised gingivae can also be predictably accomplished utilising orthodontic eruption, (Salama and Salama, 1993; Ogihara and Marks, 2006; Mantzikos and Shamus, 1997). Therefore, whenever possible, the orthodontic solution is always considered right along with surgical options in the correction of hard and soft tissue defects. For this patient in particular, with a history of bisphosphonate therapy, it would also allow the team to more safely evaluate, along with appropriate blood tests, the clinical osseous response and metabolism prior to extraction or more involved surgical intervention such as bone and soft tissue grafting.
Figure 1: Image displaying the patient’s high lip line. She also was unhappy with the cosmetic deformity related to her right central incisor
Figure 2: PeriapicaI of UR2 and UR1
Figure 3: Advanced gum recession of 9mm with loss of the labial bone. No attached gingivae, with surrounding tissue extremely inflamed and exhibiting bleeding upon probing
Figure 4: There was a history of aggressive occlusal adjustment on the UR1 crown
Figure 5a: Labial view of the right central incisor without the PFM crown
Figure 5b: lncisal view of teeth in occlusion. The gold post is touching the opposing incisor with no clearance for the final restoration
Figure 5c: Adequate incisal clearance must be created for the orthodontic eruption of the root to be accomplished in the absence of occlusal trauma
Figure 5d: lncisal view of the canal preparation, creating enough internal retention to prevent dislodgement of the provisional
Figure 5e: Provisional restoration permanently cemented
The porcelain-fused-to-metal (PFM) crown was removed to evaluate the remaining tooth structure, existing post, and tooth preparation (Figure 5a). An incisal view showed the tooth/post structure had no lingual/incisal clearance with the opposing dentition, possibly leading to active occlusal trauma and the mobility pattern evident at initial examination (Ramfjord and Ash, 1981; Poiate et al, 2009) (Figure 5b).
Figure 6: As the tooth is erupted, a narrower part of the root is brought coronally and diastemas appear
Figure 7: Modification of existing provisional to maintain original mesiodistal tooth width and form. Gingival tissues are rapidly adapting to the new tooth position
Figure 8: Radiograph after five weeks of orthodontic treatment
Figure 9: New orthodontic treatment completed in five weeks to meet the original objective of improving soft tissues and balancing gingival levels
Figure 10: The UR1 pontic using a subgingivally under-contoured provisional restoration splinted and cantilevered to the lateral incisor and bonded to the adjacent central incisor
Figure 11: Lingual wire bonded to the adjacent central incisor to prevent rotation on the provisional
The lack of the lingual concave contour on the post did not allow for a proper anatomy on the final crown, which precluded the final restoration from functioning properly in a harmonic occlusal scheme, either in centric occlusion or excursive movements. With caution, the post/tooth interface was opened with a thin diamond bur and, using an ultrasonic scaler, the post was removed and followed by significant tooth preparation to provide the necessary occlusal clearance of tooth/root structure. This allowed for enough clearance during orthodontic eruption (Figure 5c).
The intaglio of the canal was prepared as well, to be a part of the provisional restoration and provide the required retention so that the temporary would not dislodge during orthodontic treatment. This retention was maximised by also permanently cementing it with a resin glass ionomer cement (Figure 5d).
Utilising a transparent index from a study model and wax-up, a direct technique provisional was fabricated utilising a bis-acryl composite material. The anatomy of the central incisor was reproduced to match the contour of the adjacent central incisor (Figure 5e).
Any orthodontic intervention must be instituted only after inflammatory control has been accomplished. Therefore, oral hygiene instruction, scaling, and rootplanning, as well as closed curettage, were performed prior to commencing orthodontic therapy. In addition, adequate retention is always necessary and often requires the inclusion of a minimum of two adjacent teeth, one on each side of the tooth being erupted, to be included in the mechanics deployed.
The orthodontic plan was to bring the root coronally and in a palatal direction to enable the adjacent soft tissue to cover the exposed root (Salama and Salama, 1993; Ogihara and Marks, 2006; Mantzikos and Shamus, 1997). Occlusal adjustment to create space with the opposing arch was implemented periodically and as needed, so that the tooth would not be under any undesirable occlusal load. As the tooth was erupted, a narrower part of the root was brought coronally and diastemas appeared (Figure 6).
Therefore, a direct composite facing was created over the existing provisional to reproduce again the full contour of the upper central incisor. New bracket was placed, again more gingivally, as orthodontic treatment had not been completed (Figure 7). Following five weeks of the new orthodontic treatment, a periapical radiograph was taken to verify the progress and evaluate how much root still remained (Figure 8).
It was determined that orthodontic treatment was complete as the desired gingival architecture had been regenerated. At this point, the orthodontic mechanics were stabilised for three months to allow the tissue surrounding the erupted tooth to fully mature and mineralise prior to any surgical procedures (Figure 9). After three months of splinting, the braces were removed, the remaining root fragment of the central incisor was extracted, and the lateral incisor previously endodontically treated was prepared for a new provisional supporting a cantilever central incisor. The gingival contour of the central incisor was purposely undercontoured to allow for a larger volume of soft tissue to mature around it. Having a normal gingival contour would tend to direct the healing soft tissue in a gingival direction and the intent was to create as much volume of soft tissue as possible (Figure 10). To prevent any undesirable rotation of the provisional, it was cemented temporarily on the lateral incisor and a lingual wire was bonded to the adjacent central incisor (Figure 11). Three months after extraction and temporisation, a flap revealed adequate bone volume was created post-orthodontic eruption (Figure 12). However, given the demanding aesthetic environment and the expectations of the patient, it was decided to overengineer the case and further enhance labially utilising a corti-cancellous autogenous graft in a staged approach (Figure 13).
After proper healing of the bone graft and allowing the soft tissue to mature (Figure 14), implant planning was done with the advantage of computerised tomography (CT). Not only was the intent to plan for the best implant position in relation to an aesthetic outcome, but also to measure the bone density after all implemented treatment modalities. After four months of healing, colloidal silver was painted on the provisional to have as a radiopaque reference of the outer contours of the provisional in relation to the available buccal palatal bone. A CT scan was taken to generate a digitally planned surgery (Figure 15).
With the CT information, the implant type, size, width, and length were selected and placed in the best position to enable the projected final restoration to have a properly placed implant (Figure 16). A final impression was taken to create an accurate model to use for a computergenerated surgical guide. Four months later the provisional was removed
and the implant placed with the use of the computergenerated guide, which resembled the computerised planned position. The tissue was allowed to heal for six months (Touati, 2009; Saadoun, 2009; Rubinstein et al, 2006; Schropp et al, 1999) (Figure 17).
Once it was determined the implant was osseointegrated, it was conservatively uncovered and a stock abutment was utilised to support a provisional (Figures 18a and 18b). It is important to let the soft tissue heal for several weeks and mature around the abutment. Once the proper soft tissue profile has been created around the implant abutment provisional restoration, a final impression can be taken in order to finalise the restoration in the laboratory.
Figure 12: Bone profile post-orthodontic enhancement
Figure 13: Bone graft in place, screw retained for increased stability
Figure 14: Provisional in place after the healing of the bone graft
Figure 15: Colloidal silver painted over existing provisional to highlight tooth contours on the CT image
Figure 16: Computerised planning for best possible implant placement
Figure 17: Periapical radiograph showing implant in position
Clearly, when a tooth has been lost or recently extracted and is associated with significant deficiencies, surgical reconstruction or restorative illusions are the only options remaining to clinicians. However, when a hopeless tooth still retains a critical degree of intact apical attachment apparatus, then ‘orthodontic extrusion’ may be a viable modality to recreate lost hard and soft tissue profiles.
This is especially true for patients that may require a cautious surgical approach. Therefore, we must revise our treatment design and make the necessary adjustments during therapy based on the implemented techniques, anticipated results, and host response. Mid-course evaluation can be critical and extremely helpful, even if a change of treatment modalities or sequencing is required.
In the case discussed here, multiple treatment modalities – orthodontic, surgical, digital, and restorative – were utilised to regain balance, harmony, and continuity of form in a challenging aesthetic environment.
Knowledge and experience can lead us to a proper decision-making process. Part one of this article described the diagnosis and tissue reconstructive phase of a severely deficient and hopeless central incisor. Through orthodontic enhancement of bone and soft tissue followed by surgical bone augmentation, an optimal foundation was established for an ideally positioned implant placement. In part two of this article, the authors will describe the restorative and finalising steps required to successfully follow through on the tissue reconstructive phase and achieve the desired aesthetic result.
Figure 18a: Implant conservatively uncovered and stock abutment placed to support a provisional restoration
Figure 18b: Lateral and central incisors with provisional restorations
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DISCLOSURE: the authors have relationships with numerous manufacturers and have financial interest in most new developments in the science and art of dentistry over the past two decades. They did not report any disclosures specific to the content of this article.
Touati B (2009) Treatment planning for esthetic anterior single-tooth implants. In: R Romano (ed). The art of treatment planning: dental and medical approaches to the face and smile. London: Quintessence: 67-73
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