Solving Dilemmas in Clinical Practice

 After consulting with the company that manufactured the implant and abutment, I discovered that they had an angled abutment that would emerge in a more favorable location. However, the coronal portion of this abutment was still shorter in the apical direction than I would have liked (Figure 13). This meant that the crown margin would not be buried under gingival tissue, creating an unaesthetic result. If I were to use this newer abutment, what, if anything, could I do to create more length in the apical direction to allow the crown margin to be placed subgingivally? Finally, another possibility was to leave the implant buried and make a conventional bridge across the affected area. 

     Clearly, we had multiple options, but none seemed truly desirable. After discussing the options with Eli, he decided to retain the existing implant and have me try to create a more favorable platform for a new crown to sit on. I explained to him that if this didn’t work, we’d have to revisit his decision and try something else.

Treatment 
A Stylus ATC high-speed handpiece (DENTSPLY) with an 856-01C coarse diamond was used to roughen the coronal surface of the abutment. This handpiece is air-driven with electronics inside to maintain torque that is similar to that of an electric handpiece. After sandblasting the abutment surface with the microetcher, a piece of No. 1 cord (Ultrapack) was placed around the abutment using a Fischer Ultrapak Packer 45° Regular to obtain sufficient retraction (Figure 14). 
     Two coats of metal primer (Alloy Primer [Kuraray]) were then applied to the abutment metal and left to dry for a few seconds. Alloy Primer (Figure 15) is a metal primer used to increase the bond strength of composite and acrylic resins to gold, base and semi-precious metals, and titanium. This product eliminates the necessity for tin-plating and enables bonding to metal surfaces, according to the manufacturer’s product description (kuraraydental.com).
     Next, 2 thin coats of adhesive resin were applied, air-dried, and cured with a halogen curing light. Clearfil Majesty Esthetic (Kuraray) was carefully added to the abutment and shaped with an IPC carver (Premier) to increase the apical length of the coronal part of the abutment and to create a more ideal incisal edge. The additions were cured and then shaped with a very fine diamond. I had no concern regarding subgingival recurrent caries because a titanium abutment cannot decay. A temporary crown was made using a polycarbonate crown (Polycarbonate Adult Anterior Crown [3M ESPE]) with a palatal extension of quick-setting, self-cured temporary crown and bridge resin (Alike [GC America]). The palatal contour of the temporary crown illustrates the actual palatal position of the implant and the severity of the situation (Figure 16).
     A few weeks later the gingival tissue was healthy and ready for the final impression (Figure 17). EXAJET Fast Set (GC America) mixed in a Pentamix 2 and EXAFAST NDS Injection (GC America) wash were used for the impression. A bite registration (O-Bite [DMG America]) was done, and a shade photo (Figure 18) was taken (Canon Powershot intraoral photography system [PhotoMed]) and sent to the dental laboratory. The porcelain-fused-to-gold crown (Figure 19) was fabricated (Shofu Vintage Halo porcelain [Shofu Dental]). After returning from the laboratory, the restoration was cemented (Premier Implant Cement [Premier Dental]) (Figure 20). Two years have passed since restoring this complex case and the crown and abutment have never loosened.

CONCLUSION
Sometimes a situation presents that has no simple solution. This may be due to technical, medicolegal or ethical issues, or patient-centered issues. When this occurs, we may have to think outside of the box in order to best serve our patient. It is my hope that the solutions for the 2 patient cases described above will offer some insight on how the dental team can solve some of the dilemmas faced in clinical practice.