CAMLOG Special Issue – Implant Replacement

Case Report 01 | 2010 The patient a healthy, 44 year old male, was concerned when his right ma- xillary central incisor became loose and slightly extruded. On examination it became apparent that the tooth was fractured. The esthetics of the region were compromised, with the clinical crown length of the central incisors being excessive. The alveolar housing appeared thin and there was concern that the labial bone in the region might have dehiscences and fenestrations. An Angle’s Class II Division 1 malocclusion with an anterior deep bite was present. Traditional modes of tooth replacement were discussed with the patient. All involved suspending a replacement crown over a resorbing ridge. While this might be able to supply a reasonable esthetic solution at the outset, the INFORMATION ABOUT THE PATIENT AND THE TREATMENT Fig. 6: The two central incisors were sectioned off at gum level and the lateral incisors were prepared for crowns. This ensured a clean operating field while fitting the provisional restoration. Fig. 7: The provisional bridge also serves as a surgical stent. It shows the location of the gingival margins at the start of the procedure which is useful if these are to be moved. Fig. 8: The roots of the two central incisors have now been removed and the bone sockets curetted and inspected. The sockets are intact though very wide (8 mm). Interceptive therapy esthetics would become worse with increasing resorption. For this reason, discussion turned to implant based solutions. There was not much point in placing a single implant and attempting to match the gingival level around the implant to that of the adjacent central incisor. While “long crowns” can often be overcome by eruption therapy, the vertical fracture of the one incisor meant that the prognosis for eruption therapy in this particular case would be poor. So replacement of both central incisors by implants supporting crowns was the therapy selected. Augmen- ting the vertical ridge height at the time of implant placement was desirable. It was also decided to enhance the cosmetic result by crowning and increasing the size of the lateral incisors. Fig. 1: Original view. The right central incisor is mobile and slightly extruded. Fig. 2: Palatal view, which shows the evident fracture of the supporting tooth. Fig. 3: Initial radiograph. Notice that the adjacent central incisor has endodontic and post therapy. Initial presentation Fig. 5: Close-up view of the central incisors showing the excessively long clinical crowns. Fig. 4: Panorex showing the intact dentition and generally good supporting structures. The right central incisor was hopeless and needed to be extracted quickly. Three management pro- tocols to avoid a resorbed ridge were available. First was socket regeneration. Secondwas to allow the ridge to heal after extraction, with later recon- struction of the resorbed ridge and later still im- plant placement. Third was immediate implant placement with augmentation. The choice comes at the time of extraction. Therapeutic considerations