#Esthetics 10. Nov 2016

Esthetic tooth replacement

A clinical case report by Ron Leehacharoenkul, Thailand

Ron Leehacharoenkul

Self-Directed Learning (SDL), a process by which individuals take the initiative – with or without the assistance of others – in diagnosing their own learning needs and formulating learning goals, has been identified as an essential skill for clinicians. As dental clinicians, our busy patient schedules and time constraints prevent us from updating our knowledge with regular CE courses. SDL is therefore fundamental in meeting the challenges of today’s dental care environment, helping us to learn more and to learn better, as a “lifelong learning” process for acquiring both clinical skill and knowledge on our own.

Introduction

I would like to thank Straumann Thailand for organizing such an excellent campaign with the “Dental Implant Esthetic Competition”, the first ever regional dental implant competitive award for Thailand or Asia. It provided me with the opportunity to write up and evaluate my patient’s case report for the competition. Writing a case report is a good example of SDL since I have to organize the manuscripts systemically by reviewing the patient’s chart record, radiography and photos, and self-evaluation is part of the outcome. Not only was I updating my awareness of the literature and my knowledge in order to provide the optimal treatment plan, but processing the completed consent form correctly was an additional benefit for me when collecting the legal documentation prior to publication. SDL is an important expertise for all dental clinicians since its main purpose is to enhance individuals’ knowledge and clinical skill. Dental clinicians who pursue SDL are continually developing and, more importantly, constantly acquiring new knowledge and skills for the rest of their lives. As for me, the SDL clinician, I realize that the better I properly document my patient/case report and clinical photos, and the more new knowledge I acquire, the better clinician I become since I am able to learn from my mistakes and experiences and am willing to improve and learn more as a lifelong learning process.

Initial situation

The following case report describes the management of replacing a maxillary lateral incisor with a hopeless prognosis with the Straumann® Bone Level Implant to achieve “a natural look and feel” for the patient. The replacement of a missing anterior tooth with an implant-supported prosthesis has become an accepted treatment modality. It counts as one of the greatest challenges in dentistry since it must meet functional requirements and satisfy patients’ high esthetic demands in this visible area. A 36-year old woman presented with the principal complaint that her front tooth was broken. The patient was aware that her tooth had a bad prognosis and desired a single-tooth implant replacement. She was very concerned about the final esthetic result and her expectations were extremely high (Figs. 1-3).

Treatment planning

Tooth #12 had a complicated crown-root fracture at sub-gingival level. The existing coronal structure was attached with gingival tissue. Intra-oral examination showed the tooth was discolored with 2 degrees of mobility. Minimal discomfort was reported. The gingival tissue presented with very thin biotype. Radiographic and CT examination revealed the root fracture at the cervical third and deficient labial plate thickness. The diagnosis was “crown root fracture with pulp involvement” (Figs. 4, 5). Several options were discussed with the patient regarding management of the tooth. Risks and benefits were explained. The patient agreed that the treatment of choice was extraction of the tooth followed by a dental implant. Type II implant placement was planned since the condition of the labial plate and the tissue biotype were compromised, however the palatal bone was thick enough to place the implant in a 3D position without any need for ridge preservation at the time of tooth extraction. The patient was informed of the compromised esthetic result due to the thin labial plate thickness and gingival tissue biotype.

“Self-directed learning is fundamental in meeting the challenges of today’s dental care environment, helping us to learn more and to learn better, as a ‘lifelong learning’ process for acquiring both clinical skills and knowledge on our own.”

Surgical procedure

Prior to extraction of tooth #12, an acrylic partial denture was fabricated as a temporary prosthesis. Atraumatic tooth extraction was performed but the labial plate was still lost about 8 mm from the gingival margin. The immediate denture was then delivered. The extraction socket had been left for 8 weeks to achieve soft and hard tissue healing (Figs. 6, 7). A Straumann® Bone Level Implant NC (Narrow Neck CrossFit®, Ø 3.3 mm, L 12 mm) was submerged in the site of #12 with a bone graft followed by surgical guide and CT evaluation (Figs. 8, 9), and a soft tissue graft was then performed to achieve the proper thickness (Fig. 10). The acrylic partial denture was adjusted so there was no undue load on the implant during the healing period. The patient was told to maintain good oral hygiene. After a twelve-week healing period (Fig. 12), a second soft tissue graft was performed to achieve optimal soft tissue thickness again (Figs. 11-14). The second-stage surgery was then completed for healing abutment delivery 8 weeks later (Figs. 15, 16).

Prosthetic procedure

About 5 months after implant placement, the implant was seen to be well osseointegrated with a satisfactory soft tissue profile and was ready for the implant prosthesis. An impression was taken at fixture level for the temporary abutment and crown. They were then delivered to create an optimal soft tissue emergence profile around the implant (Figs. 17, 18). The dental implant fixture and abutment used in this patient are the original Straumann components for ensuring consistent quality through high-precision manufacturing.

Final result

Six weeks later, the surrounding soft tissue had acquired an esthetic and natural profile. The customized impression coping was then fabricated and taken at implant fixture level for the final prosthesis (Fig. 19). The zirconia abutment had been carefully selected and prepared and the ceramic crown of the implant (IPS e.max) was then delivered (Figs. 20, 21). The patient was extremely happy with the final result at the three-week follow-up (Figs. 22, 23).

Acknowledgements

Bangkok Hospital Dental Center: Atraumatic tooth extraction by Dr. Jarinda Thaisangsa-Nga. Implant and soft tissue surgery by Assistant Prof. Pintippa Bunyaratavej. Prosthetic work by In-House Dental Lab (Thailand): Mr. Uthai Mhudvongse