M AccreditAtion EssEntials - Dr. Merriman · PDF file• Lucia jig (Great Lakes...

46 TheJournalofCosmeticDentistry•Summer2006 Volume22•Number2

AccreditAtion E s s E n t i a l s

Accreditation Case Report, Case Type III: Tooth Replacement with an Implant-Supported Crown

Dr. Merriman graduated from the Med-ical College of Georgia School of Den-tistry in 1980. He maintains a solo general practice with an emphasis on complex restorative and cosmetic den-tistry in Marietta, Georgia. A firm be-liever in continuing education, Dr. Merriman is a graduate of the Dawson Center for Advanced Dental Study, The L.D. Pankey Institute, and LSU Esthetic Continuums I and II. He has also stud-ied extensively with the Seattle Institute for Advanced Dental Education and with the San Francisco Institute for Ad-vanced Dental Learning. An Accredited Member of the American Academy of Cosmetic Dentistry, he also is a Fellow of the Academy of General Dentistry. Dr. Merriman’s hobbies include tennis and hiking, and trips with his wife and three children to the North Georgia Mountains.

byJames Merriman, D.M.D.

IntroductIon

The restoration of a single implant in the esthetic zone is a complex task. It involves a coordination of disciplines to accomplish the surgical, prosthetic, and functional requirements necessary for a seamless restoration harmonious with the adjacent teeth. Managing the soft tissue enclosure around the restora-tion becomes the key challenge in achieving a lifelike appearance in the final result.

The use of an implant as a treatment modality would not involve treating any other teeth, an important factor in terms of our patient.

HIstory

The patient was a healthy 16-year-old female high school student. An ac-cidental blow from an elbow to her mouth while performing a cheerleading routine had resulted in the complete avulsion of her maxillary right central incisor. An oral surgeon had attempted to reimplant the tooth and secure it, with an arch bar. Approximately one week later, the patient was evaluated by an endodontist, who advised that due to the amount of time the tooth was out of the mouth before reimplantation and due to the degree of mobility present, the tooth had a very poor prognosis. The patient then presented at my office for an evaluation (Fig 1).

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Volume22•Number2 Summer2006•TheJournalofCosmeticDentistry 47


clInIcal data

The patient’s medical history was negative. Soft tissue examination revealed moderately even tissue lev-els with the presence of significant gingivitis. The teeth were minimally restored, and she had no decay or other periodontal pathology. Func-tionally, the patient presented with a Class I molar relationship and an anterior open bite despite previous orthodontic treatment. Radiographs of the maxillary incisors showed compromised crown-to-root ratios, suggesting root resorption related to the orthodontic movement of these teeth. The right and left mas-seter muscles, the left lateral ptery-goid muscle, and the area above the right temporomandibular joint (TMJ) were slightly tender to palpa-tion. The left TMJ emitted a recip-rocal click (Piper Stage IIIa).1 The patient also exhibited discomfort in the retrodiscal tissue of both joints, as well as slight pain during transla-tion. Both joints were comfortable

to loading using bimanual manipu-lation and leaf gauges. Tooth #8 dis-played Class III mobility, including the ability to depress the tooth ap-preciably into the socket. The tooth was deemed hopeless and the patient was then referred to a periodontist for input regarding the placement of an endosseous implant and possible connective tissue graft. Impressions were made and a shade was select-ed for the fabrication of an interim partial denture. Tooth #8 was subse-quently extracted atraumatically by the periodontist, and a bone graft was placed in the extraction site. The acrylic partial denture, inserted by the periodontist at the time of the extraction, was utilized to serve as an interim restoration for the miss-ing central incisor. At the patient’s subsequent cosmetic preclinical interview, it was determined that she wanted to improve the overall color of her teeth to a lighter value and to have her maxillary central restored without involving adjacent

teeth. A thorough dental and sup-porting structure examination was performed, including a full series of radiographs, a cephalametric film, preoperative photographs, facebow, models, and centric relation records. The models were duplicated using a thermoplastic forming machine and both sets were mounted on a semi-adjustable articulator.

dIagnosIs

Utilizing the photographs, mod-els, and measurements made dur-ing the examination, a mock-up using composite resin was made on a duplicate mounted model of the patient’s teeth. Due to the resulting Class III ridge defect from the ex-traction of tooth #8, pink-colored composite was used to demonstrate to the periodontist where additional soft tissue grafting would be required to surround the missing central inci-sor2 (Fig 2). Orthodontic treatment was presented and discussed with the patient as a possible approach

Figure 1: Before treatment; remaining teeth have reasonable symmetry, color, and proportion, supportive factors in considering a minimally invasive approach.

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for correcting the anterior open bite and as a possible treatment modal-ity for her temporomandibular dys-function (TMD) symptoms.3 Fur-ther, orthodontics could be used to improve gingival scalloping around the missing tooth via forced erup-tion. Also discussed, however, was the risk of continued root resorp-tion should orthodontic treatment be utilized again. Given the risks and time involved, the patient was opposed to a second round of or-thodontics at this time in her life. Instead, it was decided to consider a combination of connective tissue grafting and restoration contouring as a means of developing the proper tissue framing for her new tooth.

treatment Plan

It was determined that a single-tooth endosseous implant would best restore the missing central inci-sor. Due to their short root lengths, it was suspected that the adjacent teeth would not provide sufficient

support for a fixed bridge and might require additional abutments (Fig 3). The use of an implant as a treat-ment modality would not involve treating any other teeth, an impor-tant factor in terms of our patient. Considering her young age, it was agreed that it would be best to de-lay placement of the implant until she had stopped growing. In light of this, the proposed treatment se-quence was as follows:

• establish healthy periodontium

• continue treatment of TMD symptoms using orthotic splint therapy

• perform in-office whitening

• perform ongoing maintenance of the interim partial denture for appropriate site develop-ment

• perform the connective tissue graft; place the implant fixture; the provisional abutment; and, finally, the custom abutment and ceramic crown for tooth #8.

armamentarIum

• Pentax ZX-50 Camera System (Lester A. Dine; Palm Beach Gardens, FL)

• Oroscoptic 3.8x loupes (Oroscoptic Research, Inc.; Madison, WI)

• Jeltrate (Dentsply; Milford, DE)

• Lucia jig (Great Lakes Ortho-dontics; Tonawanda, NJ)

• Futar D (Great Lakes Orthodon-tics)

• whale tails (Great Lakes Ortho-dontics)

• leaf gauge (Great Lakes Ortho-dontics)

• Velmix die stone (Kerr USA; Orange, CA)

• Mini Star thermoplastic forming machine (Great Lakes Ortho-dontics)

• Artex articulator (Jensen Indus-tries; North Haven, CT)

• Trubyte tooth size indicator (Dentsply)

Figure 2: The loss of tooth #8 ultimately resulted in a significant horizontal and vertical tissue deficiency.

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• Triad VLC provisional material (Dentsply)

• Renamel Gingafill (Cosmedent; Chicago, IL)

• Trubyte square occlusal plane (Dentsply)

• Sil-Tech putty (Ivoclar Vivadent; Amherst, NY)

• Nite White Excel 3 (Discus Den-tal; Culver City, CA)

• Replace Select 3.5 x 16 mm implant fixture (Nobel Biocare; Loma Linda, CA)

• Articaine hydrochloride 4% with epinephrine 1:100,000 (Septodont, Inc.; New Castle, DE)

• provisional abutment (Nobel-Biocare)

• EZ Seat 2% hydrocortisone and 5% tetracycline dental oint-ment (Ballard Plaza Pharmacy; Seattle, WA)

• Liner Bond 2V (Kuraray America Co.; New York, NY)

• Renamel (Cosmedent)

• IPC-L instrument (Cosmedent)

• Creative Color opaquers and tints (Cosmedent)

• Apollo 95E plasma arc curing (PAC) unit (DMD Systems, Inc.; Woodland Hills, CA)

• AccuFilm II (Parkell; Farming-dale, NY)

• VisionFlex diamond finishing strips and diamond disk (Bras-seler; Savannah, GA)

• Ceramiste (Shofu Dental Corp.; San Marcos, CA)

• FlexiStrips and FlexiDiscs (Cos-medent)

• Enamelize and FlexiBuff disks (Cosmedent)

• Cavit G provisional material (3M ESPE; St. Paul, MN)

• Nikon D-100 Digital Camera (Calumet Photographic, Chi-cago, IL)

• Dento-surg unit (Ellman Int.; Hewlett, NY)

• tincture of myrrh and benzoin (Ellman)

• Impregum impression material (3M ESPE)

• Omega 900 custom porcelain-fused-to-gold abutment (Vident; Brea, CA)

• Inceram all-ceramic crown (Vi-dent)

• torque driver (Nobel Biocare)

• IRM provisional material (Dent-sply)

• Temp Bond cement (Kerr)

treatment descrIPtIon First, a stable and healthy peri-

odontal condition was established with proper home care instructions and visits with the hygienist. Next,

Figure 3: Radiographic evidence supports the choice of the implant prosthesis as the optimal restorative option for this case.

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the patient’s TMD symptoms were addressed by adjusting the bite with equilibration and the use of an oc-clusal orthotic appliance overnight. During the course of treatment, bite stability was revisited by evaluating the teeth and the nighttime appli-ance for wear or chipping. Muscles and joints were also reexamined; TMD symptoms had subsided with the use of the nighttime appliance.4

The patient was then treated with two in-office whitening sessions. Meanwhile, the patient was instruct-ed to remove the interim partial denture only for hygiene purposes, (at least twice a day), and to reinsert it within 10 minutes to minimize proximal tissue collapse.2 Approxi-mately one year after the extraction of tooth #8, a connective tissue graft was performed with the intention of adding dimension both vertically and horizontally to the extraction site. An Essex bridge provisional with the appropriately shaded acryl-ic was utilized to allow for the least amount of pressure on the surgical

site, and at the same time provide an esthetically acceptable result. A surgical guide for optimal implant fixture position was also fabricated and sent to the periodontist. A sec-ond cephalametric film was taken and compared to the original to verify completion of growth for this patient. Two months later, a 3.5 x 16 mm implant fixture with a 3.5 x 3 mm healing abutment was placed for tooth #8, using the surgical guide provided. The implant fixture was positioned such that there was approximately 3.0 to 4.0 mm from the top of the fixture to the intended gingival margin, 2.0 to 2.5 mm from the facial aspect of the implant to the facial aspect of the buccal plate at the crest, and the angle created by the implant fixture was in line with the intended incisal edge.5 The Essex bridge was adjusted to support the adjacent tissue and was used as the provisional during the healing pe-riod after implant placement.

Because of the advancements in dental materials and techniques, dentists now have more options in esthetically restoring missing

anterior teeth.

An indexing impression to im-plant coping for the construction of a temporary abutment was also taken at the time of surgery by the periodontist (Fig 4). With this im-pression, the laboratory was able to fabricate a one-piece screw-re-tained provisional abutment for the implant fixture. After appropri-ate healing of the implant site, the provisional abutment would then be sculpted and shaped at the time of placement in an effort to develop the tissue around the implant. Eight weeks later, the patient was sched-uled for the insertion of the provi-sional abutment. The appointment began with the delivery of topical anesthetic to the area above tooth #8, and the surgical site was anesthe-tized with Articaine local anesthetic

Figure 4: The surgical guide and indexing impression are important tools for the surgical/restorative team.

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infiltration. The healing cap was removed and the implant site was thoroughly cleaned and irrigated. After minimal adjustment of the in-terproximal contacts, the laboratory constructed provisional abutment was coated with a 2% hydrocorti-sone and 5% tetracycline ointment, aligned into the fixture and finger-tightened to place with the implant screw. A radiograph was taken to verify complete seating. Special at-tention was paid to the influence of the new abutment on the tissue surrounding the fixture. On the me-sial half of the implant site, the tis-sue was quite blanched even after 10 minutes in place and consequently these areas were lightly reduced. On the distal half, the tissue appeared insufficiently supported and com-posite hybrid resin was carefully added to the provisional near the base of the abutment in an effort to add vertical height to the interproxi-mal papillae between #7 and #8. It appeared that the tissue dimension

directly facial to the implant site was sufficient and well supported by the provisional abutment. A cotton pel-let was placed above the screw head and the access channel was sealed with provisional material. It was de-cided that due to the significant chal-lenge of “growing tissue” vertically on an implant site, multiple visits would be necessary to groom the tissue gradually by altering the pro-visional abutment. Due to the pres-sure exerted by the provisional con-tour, some fluid movement within the tissue would take place and then would stabilize between each visit. Diagnostic photographs were taken approximately three weeks after each appointment in order to carefully examine the progress. After three sessions of this kind over a period of 12 weeks, it was determined that the appropriate provisional abutment contour had been accomplished to achieve the optimal esthetic result.6 Further, enough time had passed to allow soft tissue to completely heal

and stabilize around the provisional abutment.

ImPressIon

At the very beginning of the final impression visit, slide photographs of the teeth with shade tabs were taken to aid in communication with the laboratory about shade, texture, light reflectance, and luster. Topical anesthetic was placed and infiltra-tion anesthesia was delivered in the area above the maxillary right inci-sors. Using a radiosurgery unit, a gingivectomy was performed to raise the facial gum levels of tooth #7 in an effort to better match the length and gingival margin of tooth #10.7 This procedure would also have the effect of increasing the apparent length of the papillae between #7 and #8. Before the gingivectomy, the existing facial sulcus depth of tooth #7 measured 2.0 mm. After heal-ing, the expected increase in clini-cal crown length for tooth #7 would be approximately 0.5 to 1.0 mm.8

Figure 5A: The provisional contours influence the fluid movement within the implant site.

Figure 5B: Mirrored images of the final restoration showing contours that match the final provisional

implant abutment.

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A myrrh and benzoin solution was used as a postoperative dressing.

Immediately after the removal of the provisional abutment, the trans-fer assembly was seated and verified with a radiograph. Next, a fixture-level implant impression was taken with polyether impression material, utilizing an open tray technique. While the impression was setting in the patient’s mouth, photographs of the final provisional abutment were taken from all angles. The provision-al abutment was then installed back in the mouth in the same manner as before.

Instructions were sent to the lab-oratory along with the impressions, opposing mounted models, bite registration, preoperative and shade tab slides, mock-up models, and a color map. Also included were the images of the provisional abutment in order to communicate the exact contour characteristics desired in the final restoration (Figs 5A & 5B).

FInIsHIng

The shade-matching challenges often accompanying restoring an implant in the anterior region were addressed by the use of porcelain fused to metal on the custom abut-ment, and the use of an aluminous core on the all-ceramic crown. Also used were highly florescent ceramic materials, with their capacity to bet-ter transmit light. These efforts had the effect of minimizing the poten-tial lower value of tooth color often experienced when restoring metal implants (Fig 6). Upon receiving the case from the laboratory, the crown was checked for esthetics, fit, and contact on the solid model. At the insertion visit, the custom por-celain-fused-to-gold abutment was coated with ointment and tried onto the implant fixture and a radiograph was taken to confirm complete seat-ing of the abutment. The all-ceramic crown was inserted and the contact and margins were checked under magnification. The appearance and

occlusion were approved by both the patient and by the doctor. The decision was made to proceed with the insertion of the final custom abutment and the implant-sup-ported all-ceramic crown. The teeth were isolated using cheek retractors. The abutment screw was torqued down to 32 Ncm with a torque driver. A small cotton pellet covered the screw head and a provisional material was used to seal the screw access hole. The all-ceramic crown was then cemented with temporary cement. Since the crown margin was designed 1 mm below the tissue level, excess cement was easily and completely removed from around the crown. The occlusion was then verified in centric relation and in all excursions. The patient’s existing orthotic appliance was then relined and adjusted to fit her new crown. An examination performed two weeks later and again three months postoperatively revealed functional stability and pleasing esthetics.

Figure 6: Skillful layering of porcelain by the ceramist results in optimal tissue support, value match, and microesthetic characterization.

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summary

Traumatic injuries to teeth and supporting structures are not un-common in any general dental prac-tice. On any given day, a patient can present with a missing front tooth and it then becomes our challenge to restore their smile as closely as possible to its original appearance. In certain cases the situation allows us to not only restore the status quo, but also to actually improve the smile. The patient in this article was particularly pleased with her natural-looking replacement and appreciated that other teeth did not require preparation as bridge abut-ments. Because of the advancements in dental materials and techniques, dentists now have more options in esthetically restoring missing ante-rior teeth (Fig 7).

Acknowledgments

The author thanks Wayne Crutch-field, C.D.T., for his incredible ceramic skills; and Dr. David Pumphrey for the

exceptional periodontal treatment ren-dered in this case. Special thanks go to Drs. Jeff Morley and Frank Spear for their encouragement and support. Also essential to the success of this case were a very dedicated staff, a supportive family, and a willing and appreciative patient.

References1. Piper M. Dawson Masters Course [seminar].

Presented at Pankey Institute, Key Bis-cayne, FL; September 1999.

2. Kois JC. Predictable single tooth peri-implant esthetics: Five diagnostic keys. Compend Contin Educ Dent 22(3):199-206, 2001.

3. Williamson EH, Lunquist DO. Anterior guidance: Its effect on electromyographic activity of the temporal and masseter mus-cles. J Prosthet Dent 49(6):816-823, 1983.

4. Dawson P. Evaluation, Diagnosis, and Treat-ment of Occlusal Problems, 2nd Edition (pp. 41-47). St. Louis, MO: C.V. Mosby Co.; 1989.

5. Donitza A. Prosthetic procedures for opti-mal aesthetics in single-tooth implant res-torations: A case report. Prac Proced Aesthet Dent 12(4):347-353, 2000.

6. Raigrodski AJ. Clinical considerations for enhancing the success of implant-support-ed restorations in the aesthetic zone with

delayed implant placement. Prac Proced Aesthet Dent 14(1):21-28, 2002.

7. Morley J, Eubank J. Macroesthetic ele-ments of smile design. JADA (1):39-45, 2001.

8. Spear FM. Advanced Esthetic and Restorative Management [seminar]. Presented at Se-attle Institute for Advanced Dental Educa-tion, November 2002.

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Figure 7: After treatment, implant restoration in harmony with untouched surrounding teeth.

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M AccreditAtion EssEntials - Dr. Merriman · PDF file• Lucia jig (Great Lakes...

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