Aesthetic challenges in the anterior maxilla
David Furze presents a case where a combination of high patient expectation and multiple aesthetic risk factors lead to complex treatment needs.
In the anterior maxilla, many risk factors often present (Cho et al, 2015) as a thin buccal bone wall, often combined with a thin tissue biotype and the visibility of the peri-implant mucosa and the future crown during smile and speech.
In the visible anterior maxilla, prosthetic perfection is often challenging. Ideal overall outcomes of the pink and white aesthetics have to be achieved.
It is essential that a ‘backward’, prosthetically-driven treatment plan is completed. All of the patient’s wishes must be considered for an aesthetically pleasing result.
This 43-year-old Caucasian female was referred for the potential placement of a single implant to replace the upper left central incisor. This tooth had been traumatised, had an endodontic treatment and had been crowned.
She was also complaining of the overall aesthetic appearance of her upper front teeth. She had previously had orthodontics but felt that some relapse had occurred, she would like whiter teeth and did not like the ‘mottled’ appearance of her upper left lateral incisor.
The extraoral examination revealed a very high smile line. Full gingival contour was visible on smiling.
Other than the presenting complaint, she had a very healthy mouth with no caries or periodontal disease present (Figures 1 and 2). A class I incisal relationship was noted.
The upper left central incisor was deemed unrestorable. There was no relevant pathology associated with the upper left lateral incisor. Spacing and proclination of the anterior teeth was noted.
Diagnosis and treatment options
A diagnosis was made of an unrestorable upper left central incisor, anterior spacing, discolouration of the upper and lower teeth, and hypoplastic enamel of the upper left lateral incisor.
The following treatment options were discussed:
Upper left central incisor
- Adhesive bridge
- Conventional bridge
Upper left lateral incisor
- External bleaching
Spacing and proclination
- Conventional orthodontics
- Removable orthodontics.
The upper left central incisor tooth was extracted and an immediate denture was placed. The patient completed external bleaching using her pre-formed bleaching tray and 16% carbamide peroxide on a nightly basis.
Clear aligners were used over a four-week period to correct the proclination and spacing.
Implant surgery was performed at six weeks following tooth extraction (Figure 3) in accordance with an early implant placement protocol. Immediately placed and immediately restored implants were not considered due to the increased level of aesthetic risk (Cosyn et al, 2016).
Systemic antibiotics (single dose: 3g amoxicillin orally) were administered to the patient one hour prior to the procedure, followed by 500mg of amoxicillin eight hourly for the first postoperative week.
A 0.2% chlorhexidine mouthwash was given to the patient for one minute preoperatively. Local anaesthesia was achieved by means of infiltration with articaine hydrochloride 4% together with adrenaline (epinephrine) at 1:100,000.
A full thickness periosteal flap (Figure 4) was raised by means of a crestal incision that was positioned palatally of the mid crest and completed with intracrevicular incisions on the adjacent teeth.
The flap was relieved on one side with vertical releasing divergent incisions starting at the base of the neighbouring interproximal papillae to create a triangular flap. The flap was retracted by means of a 4-0 vicryl suture.
Straumann SL Active bone level implant
A Straumann SL Active bone level implant was placed (Figures 5-8), with a preparation made according to the manufacturer’s guidelines. The shoulder of the implant was placed approximately 3mm below the proposed cervical margin of the future restoration.
The implant was kept at least 1mm away from the adjacent roots and placed 1-1.5mm palatally to the proposed emergence point. The long axis of the implant exited through the proposed cingulum rest of the crown.
A 2mm healing cap was placed to allow tension-free flap closure following a fully submerged implant placement protocol.
Autogenous bone chips were first collected from the flutes of the twist drills and locally harvested where access allowed from the anterior nasal spine using a reverse action hoe.
The autogenous bone chips were placed over the exposed implant surface in any dehiscence or fenestration defects (Figure 9).
Further contouring of the ridge was performed by a layer of deproteinised bovine bone mineral (DBBM) (Bio-Oss; granule size 250-1000µm) over the already placed autogenous bone chips (Figure 10).
This in turn was covered by a double layer of a 25x25mm porcine-derived collagen membrane (Bio-Gide) (Figure 11).
A tension-free flap was created by periosteum dissection at the base of the flap by means of a 15 scalpel.
The flap was coronally positioned and sutured using 5.0 prolene sutures.
Vertical suspended mattress sutures were utilised in the reconstruction of the papilla with single interrupted sutures for the relieving incisions.
Postoperative instructions and infection control
Paracetamol (1g every six hours) and ibuprofen (400mg every eight hours) were prescribed for pain control, at the patient’s discretion. The patient was instructed to refrain from toothbrushing in the operated area and rinse with 0.2% chlorhexidine digluconate mouthwash, three times per day, for one week.
To avoid postoperative infection, the patient received systemic antibiotics – amoxicillin 500mg every eight hours for the first postoperative week.
Following week one, the patient was instructed to resume normal oral hygiene procedures, including full interproximal cleaning and to discontinue chlorhexidine mouth rinsing. All sutures were removed at the review appointment 14 days post procedure.
Following a period of between 12-16 weeks of healing, access to the implant was achieved by means of a crestal ‘D’-shaped incision, not extending to the adjacent papilla. The 2mm healing cap was changed to a 4mm conical healing cap for a further week of soft tissue healing.
The provisional implant-supported restoration was a laboratory constructed composite screw-retained crown.
A closed tray impression (Figure 13) was taken in silicone (Honeygum) using a stock tray. Photographs were taken with shade guides in situ and emailed to the dental laboratory.
A Straumann temporary cylinder was modified with dentine and enamel composite to obtain optimum aesthetics and emergence profile. The provisional crown was inserted and torqued to 15Ncm (Figure 14).
Peri-implant tissue conditioning occurred utilising the dynamic compression technique, with compression of the tissues followed by sequential reduction of the provisional restoration. The provisional crowns were left in situ for six months to allow for soft tissue maturation (Figures 16 and 17).
Completion of definitive crown and porcelain veneer
It was decided that the best aesthetic outcome for the patient would be to place a porcelain veneer on the upper left lateral incisor. This would be completed at the same time as the definitive implant-supported crown.
Depth grooves (Figure 18) were cut into the tooth to ensure correct reduction of enamel thickness.
A customised impression coping was constructed by removing the provisional crowns and replacing onto the initial cast (Figure 19).
A light-bodied, fast-setting addition silicone impression was taken of the apical half of the provisional restoration (Figure 20). The provisional restoration was replaced in the patient’s mouth to prevent soft tissue collapse.
Open tray impression copings were inserted onto the cast with notable voids present between coping and silicone index.
Bis-acrylic temporary crown and bridge material was injected into the space created in order to customise the impression coping and accurately record the emergence profile of the provisional (Figures 21-24).
The customised impression cylinder was transferred to the patient to support the soft tissues with no soft tissue blanching.
An open tray silicone impression was taken using a customised individual tray, followed by an irreversible hydrocolloid impression of the provisional in situ.
Clinical photographs were provided to the dental laboratory as additional guidance in terms of adjacent teeth shape and colour and gingival contours.
The abutments were designed using the CAD abutment function in the Straumann Cares CAD/CAM system.
The exact emergence profiles were then duplicated. The crown was torqued to 35N and composite placed in the screw access cavity.
Occlusion was checked in centric occlusion and in anterior and lateral excursions to ensure a mutually protective occlusion (Figures 25 and 26).
The patient was very happy with the aesthetic result achieved. The implant crown has a very high Pink Esthetic Score and White Esthetic Score (sic) (Belser et al, 2009; Jones and Martin, 2014).
Symmetry has been achieved between the lateral incisor teeth and the overall whiteness of the teeth has improved.
Due to the patient’s high aesthetic demands and high smile line, this case had to be planned and executed to the highest level for success.
The outcome in this case has exceeded the patient’s expectations.
Belser UC, Grütter L, Vailati F, Bornstein MM, Weber HP, Buser D (2009) Outcome evaluation of early placed maxillary anterior single-tooth implants using objective esthetic criteria: a cross-sectional, retrospective study in 45 patients with a 2- to 4-year follow-up using pink and white esthetic scores. J Periodontol 80(1): 140-151
Cho SC, Froum SJ, Kamer AR, Loomer PM, Romanos G, Demiralp B (2015) Implants in the anterior maxilla: Aesthetic challenges. International Journal of Dentistry ID: 152420
Cosyn J, Eghbali A, Hermans A, Vervaeke S, De Bruyn H, Cleymaet R (2016) A 5-year prospective study on single immediate implants in the aesthetic zone. J Clin Periodontol 43(8): 702-709
Jones AR, Martin W (2014) Comparing pink and white esthetic scores to layperson perception in the single-tooth implant patient. Int J Oral Maxillofac Implants 29(6): 1348-1353.