Replacement of an upper right canine
This young woman presented requesting the replacement of a retained upper right deciduous canine with an implant-supported crown and closure of the space distal to the upper right central incisor. Her age on presentation (in September 2002) was 27-years-old. She was medically fit and healthy, and a non-smoker. At this time a complete dental, periodontal, radiographic and soft tissue examination was carried out.
The complexity of the case was discussed with the patient with reference to the unerupted canine and the over-eruption of the opposing canine into the upper right canine space (see Figures 2, 3, 4 and 5). Having discussed these issues with the patient, as well as her available options, she was still keen to proceed with implant treatment. She was therefore discharged with an appointment to return and discuss the treatment in detail, along with informed consent. An independent orthodontic consultation was also arranged for the patient.
The course of treatment described to the patient involved:
1. Surgical removal of the unerupted upper right canine and augmentation of the site with particulate graft material
2. Provision of a removable orthodontic appliance to close the space distal to the upper right central incisor and increase the interocclusal space in the right canine region
3. Removal of the deciduous tooth and implant placement in the upper right canine region
4. Restoration of the integrated implant and probable reduction of the incisal edge of the lower right canine.
The anticipated timescale for this treatment was between 18 months and two years.
In December 2002 the unerupted canine was removed. Even though we originally planned to keep the deciduous root fragment in situ at this stage, it was removed as it could have some space-maintaining and soft tissue profiling benefits.
This procedure was carried out making use of 3g Amoxil prophylaxis. Local anaesthesia was achieved by administering buccal and palatal infiltrations of 2% lignocaine with 1:80,000 adrenaline 2.2ml in each site.
A palatal envelope flap was raised to allow adequate access to the surgical site. Bone was removed/harvested from around the most bulbous aspect of the canine, taking care to ensure that the root of the adjacent lateral incisor was not compromised. A slot was cut into the canine to allow engagement of the tip of an Ash luxator and the tooth elevated. The socket was curetted and then filled with the harvested autogenous bone mixed with ß tri-calcium phosphate (Resorb, Fortoss) before closure with four interrupted 4/0 vicryl rapide sutures. The patient was reviewed 14 days later and the sutures removed. Healing was uneventful.
Six weeks later, upper and lower alginate impressions were taken to allow construction of the upper removable orthodontic appliance. This was fitted in early March 2003. The patient was instructed in the care and use of the appliance and a series of bi-monthly review appointments organised.
The space between the upper right central and lateral incisors closed readily, and 3mm additional interocclusal space was achieved by December 2003.
On 3 December 2003 the patient was seen and an Osteo-Ti Ezeeplant 3.75*15mm placed in the region of the missing canine (Figure 6).
The procedure was carried out under 3g Amoxil prophylaxis. Local anaesthesia was achieved by administering buccal and palatal infiltrations of 2% lignocaine with 1:80,000 adrenaline 2.2ml in each site.
A small flap was raised from the palatal aspect to allow visualisation of the ridge width. The osteotomy site was formed and the implant placed using the Ezeeplant protocol. The site was closed with one vicryl 4/0 suture. The patient was reviewed one week later and the suture removed. Healing was uneventful.
The patient was reviewed again on 25 February 2004. A periapical radiograph was taken and arrangements made to expose the implant.
This procedure was carried out on 23 March 2004 and a healing collar (CB3) fitted to the implant with a low profile screw. An impregum impression was recorded to allow selection of the definitive abutment and construction of a provisional crown. The healing collar was left in situ and the patient discharged, after a Doric Easy First impression had been taken of the opposing dentition and a Blue Mousse bite registration recorded.
On 12 May 2004 the abutment and provisional restoration were fitted. The occlusion was carefully checked using 40 micron articulating paper and 8 micron shimstock, and adjusted to allow clearance of the shimstock in centric relationship and all excursions.
On 6 July 2004, a pick-up impression was taken of the current situation to allow construction of the definitive restoration, which was then fitted with retrieve cement on 28 July. The case was reviewed two months later and the restoration found to be stable.