Case example of an anterior esthetic implant restoration with good surgical-restorative communications

 A 37-year-old male with a noncontributory medical history, taking no medic

 A 37-year-old male with a noncontributory medical history, taking no medications with no known food or drug allergies, presents to the office with a chief complaint of “I don’t like the way my upper right bridge looks.” His dental history includes extraction of tooth No. 6 two years ago due to a failed root canal and recurrent decay deemed restoratively hopeless. He was temporized one year after extraction with an acrylic bridge from teeth Nos. 5 to 7. Socially, he denied tobacco, drug, and alcohol use. The patient complained of color match, overcontoured bulkiness, and the inability to perform adequate oral hygiene.

Fig. 1: Preoperative anterior facial view

Fig. 2: Preoperative buccal view

Fig. 3: Preoperative radiograph

Treatment options were reviewed with the patient and because of hygiene considerations, a single-tooth restoration in site No. 6 with single-unit crowns on No. 5 and No. 7 was chosen over a porcelain-fused-to-metal fixed bridge from Nos. 5 to 7. Clinical records were taken, which included preoperative radiographs, a cone beam CT scan, and a diagnostic wax-up. From the diagnostic wax-up, a surgical index was created and used during dental implant placement. Since the site had been edentulous for two years and based on the results of the CT scan, a buccal concavity was noted at the apex of No. 6. After local infiltration, a midcrestal incision was made with papilla sparring incisions. No vertical releases were performed.

Fig. 4: Surgical placement

Using the surgical index as a reference, a 3.8 x 12 tapered implant was placed in a prosthetically driven manner. During placement, a 3 x 3 mm fenestration of the buccal plate occurred at the apical extent of the implant. Using a combination of enamel matrix derivate mixed with cortico-cancellous allograft placed in a bone syringe, the area of fenestration was grafted. Although the implant achieved 35 Ncm of stability, a cover screw was placed and primary coverage was achieved. A conventional two-stage procedure was selected because of the regenerative demands of this particular case. The area was then temporized with a newly fabricated lab-generated acrylic bridge with careful attention to pontic site development.

Fig. 5: Addition of enamel matrix derivate and bone graft material

Immediately post-insertion, a periapical radiolucency was detected on the post-insertion radiograph on tooth No. 7 and the patient was immediately sent for root canal therapy. Four months was allowed for implant integration. At the time of Stage II, a noninvasive punch tissue technique was employed and a 3 mm healing abutment was placed. At the time of impression, an open tray technique was used and a custom abutment was selected. Because of the patient’s canine guidance occlusion, a porcelain-fused-to-metal crown was selected along with all-ceramic crowns on teeth Nos. 5 and 7.

Fig. 6: Postoperative radiograph

Fig. 7: Stage II tissue punch

One year post-insertion radiographs indicate that bone levels around the implant remain stable. Clinical results 1.5 years post-insertion reveal gingival levels to be stable and healthy, and the patient is very pleased with the esthetic result of his treatment.

Fig 8: Radiograph one year post-placement

Fig 9: One year post-placement

Fig 10: 1.5 years post-placement