Clinical Report
A 45 years-old female patient presented to the clinic with the chief
complaint “My front crowns are loose and they come off sometimes”. The
patient reported that she had had crowns made of porcelain fused to
metal placed on teeth from the maxillary right lateral incisor to the
left incisor, fifteen years ago. (Fig. 1) These crowns had become loose
and come off sometimes; she used to cement them back with an
over-the-counter remedy from the pharmacy. The papilla between the teeth
was also decreased leading to black triangles between them.
After a detailed clinical evaluation, the maxillary right lateral
incisor, both central incisors and left lateral incisor were diagnosed
with mobility grade II, and incisal wear was found on the on maxillary
right and left canines. Radiographic evaluation showed the old crowns
and metal posts on the maxillary left latera incisor, both central
incisors and right lateral incisor. The patient had high esthetic
demands, and showed interest in having fixed all-ceramic restorations
from maxillary right canine to left canine. The patient was informed of
the need to remove the old crowns in order to re-asses the clinical
situation of the teeth, and agreed to the procedure.
The existing restorations of the maxillary incisors were removed, and
secondary caries was found in all teeth, with a fractured core on
maxillary left central incisor, and mobility grade II on all teeth.
Therefore, these teeth were deemed hopeless. (Fig. 2) The patient was
informed of the option of having 2 implants in order to support a fixed
prosthesis from maxillary left lateral to right lateral incisors, and
single restorations on maxillary right and left canines. The patient
approved the plan and the treatment was initiated.
A diagnostic wax-up was performed and a milled provisional restoration
was fabricated for the span between maxillary canines. The maxillary
canines were prepared, and the patient was sent for tooth extractions.
The maxillary central and lateral incisors were extracted and
particulate cortico-cancellous allograft bone (Cortical/Cancellous
Chips, AlloSource Headquarters, Centennial, CO, USA) with collagen
dressing (Puracol, Collagen Wound Dressing, Medline Industries Inc,
Northfield, IL, USA) and resorbable sutures (Polysyn FA, Surgical
Specialties Corporation, Wyomissing, PA, USA) was placed to achieve
complete socket seal. (Fig. 3) The milled provisional restoration, made
of polymethyl methacrylate, was cemented with an ovate pontic shape in
the extraction sites, without interfering with the sutures. The initial
provisional restorations applied a very light pressure, and included a
space between the soft tissue and the provisional restoration to enable
the patient to clean underneath the pontic and in the connector areas.
(Fig. 4)
The patient returned two weeks later. The provisional was removed, and
the pontic units were built-up using self-curing acrylic resin (Jet
Tooth Shade, Lang Dental, Wheeling, IL, USA) in order to establish
contact under slight pressure and maintain the developed ovate soft
tissue contour, while the interproximal areas between the pontic units
were opened with a disc (Acrylic Temporization System, Brasseler USA
Dental, Savannah, GA. USA) in order to provide space for the papilla
tissue. The patient returned again 2 weeks later and same procedure was
performed.
Two months later, the patient was seen again for follow-up and the same
procedure was performed. The thickness of the soft tissue was measured
with a periodontal probe. (Williams Color-coded single end probe,
Hu-Friedy Mfg. Co., LLC. Chicago, IL, USA) Carbide and diamond football
burs (Medium Football bur, Brasseler USA Dental, Savannah, GA, USA) were
used to improve the architecture of the pontic sites. (Fig. 5) The
provisional restoration was built-up again using acrylic resin material
(Acrylic Temporization System, Brasseler USA Dental, Savannah, GA, USA)
in order to match the contour provided by the football burs. Two weeks
later, the provisional restoration was removed to evaluate the final
contour of the soft tissue. (Fig. 6)
The soft tissue achieved the desired shape and the implant therapy was
planned using implant software (SimPlant, Dentsply Sirona Implants Inc,
York, PA, USA). (Fig. 7) Two implants at the sites of maxillary right
lateral incisor and maxillary left central incisor were planned to
support a dental prosthesis from maxillary left lateral incisor to right
lateral incisor. These sites were chosen based on the condition and
thickness of the bone in the incisor region. Implant surgery was
performed with palatally-oriented crestal incision and bilateral
sulcular incisions on the canines to reflect a full muco-periosteal
flap. The incision lines for the flap were planned to avoid damaging the
soft tissue line created during the preparation. Two bone-level implants
of size 4.1mm (BLT RC, Straumann Group, Basel, Switzerland) were
inserted. (Fig. 8) A simple interrupted suture technique (Polysyn FA,
Surgical Specialties Corporation, Wyomissing, PA, USA) was used for
primary soft tissue closure. (Fig. 9) The implants were not loaded, and
the existing fixed provisional restoration was cemented back on to the
canines. During the two months of osseointegration, the provisional
restoration maintained the soft tissue architecture that has been
previously obtained.
After 4 months, the pontic sites of maxillary right lateral incisor and
left central incisor were hollowed with acrylic carbide burs (Acrylic
Temporization System, Brasseler, Savannah, GA, USA) in order to accept
the temporary cylinders (Cylinder RC, Straumann Group, Basel
Switzerland) engaged with the implants. The new screw-retained
provisional restoration maintained the same tissue contour and three
weeks later a final impression was made. (Fig. 10) The final
restorations were screw-retained porcelain fused to zirconia to replace
the incisors with zirconia abutments which were fixed to the titanium
bases and single porcelain fused to zirconia crowns on the canines.
Final restorations were tried-in for clinical and radiographic
assessment, and patient satisfaction was achieved. Final implant
restoration was placed and torqued according to the manufacturer
instructions, while single crowns on maxillary right and left canines
were cemented (RelyX Luting 2 Cement, 3M Espe, Saint Paul, MN,
USA).Occlusion was checked and adjusted as necessary. Patient was
satisfied with the final outcome. (Fig. 11) A night guard was provided
in order to protect the dentition and final restorations.