Esthetic Management of Compromised Ridge in the Anterior Maxilla, a Modified Prosthetic Approach.

Replacing a missing tooth with an implant, especially in the esthetic zone has been increasing demand for the patient. Placing dental implants in the esthetic zone, especially in the compromised ridge with thin gingival thin biotype is considered to be the ultimate challenge for many dentists. This case report illustrates the implant placement in the traumatic anterior maxilla with thin gingival biotype (Class IV) and a modified approach in prosthetic placement.

INTRODUCTION

Replacing a missing tooth with an implant, especially in the esthetic zone has been increasingly demand for the patient.[1] The use of dental implants in the esthetic zone has overcome many of the disadvantages such as preservation of adjacent tooth structure, supraeruption, tilting of the adjacent tooth structure, and also improves the wellbeing of the patient.[2] Placing dental implants in the esthetic zone, especially in compromised ridge is considered to be the ultimate challenge for many dentists.[123] The correct surgical placement of a dental implant is important to obtain the expected esthetic result. The clinician should consider the time needed for implant integration, soft tissue healing, creation of emergence profile, and occlusal forces.[4] For anterior maxilla, other factors to be considered such as lip line, scalloped gingival line including distinct papilla without any abrupt changes in the vertical height of the clinical crown.[56] Therefore, the anterior region represents the most critical area from esthetic standpoint and the most complex one with regard to the osseous and gingival architecture.[467] Replacing a maxillary central incisor with an implant becomes extremely challenging in patients with thin gingival biotype (Class IV).[37] This case report illustrates the implant placement in the traumatic anterior maxilla with thin gingival biotype (Class IV) and a modified approach in prosthetic placement.

CASE REPORT

A 39-year-old male patient reported to the Department of Prosthodontics, CSI Dental College and Hospital with the chief complaint of unesthetic appearance due to the missing teeth in the anterior tooth region. On examination, missing 21, patient extracted the tooth due to periapical abscess and had a history of trauma 26 years back and underwent endodontic treatment before 16 years patient advised to wear removable partial denture (RPD) in that healing period. The patient explained about all the treatment options for the replacement of 21. On clinical examination, extreme bone resorption observed in relation to 21. Patient advised for diagnostic aids such as orthopantogram, Dentascan. On Dentascan evaluation, the available bone volume was assessed, was favorable for implant treatment. After examination, implant size and screw retained prosthesis were planned. After proper treatment planning, endo-osseous implant (MIS-Biocon) measuring 3.75 mm × 11 mm in dimension was selected. Installation of the implant was done as per the classical Branemark surgical procedure, 2 mm pilot drill was used, followed by 2 mm twist drill, finally, 2.8 mm twist drill was used. Primary stability achieved about 35N due to the fact the final drill was used upto the length 9 mm less than the determined length. Cover screw was placed. Interrupted sutures were placed to close the surgical site. Postsurgical instructions given to the patient. Sutures removed after 10 days and the patient advised to wear the RPD after 2 weeks after relieving the pressure spots.

Six months after implant placement, intra-oral radiograph was made to examine the osseointegration of the implant. On clinical evaluation, collar of the implant was exposed [Figure 1]. Second stage implant surgery was planned, 3 mm healing abutment was placed to create gingival collar. After 1 week, sutures removed, gingival healing was observed and also adequate amount of interdental papilla, labial contours similar to adjacent tooth structure was examined. Special tray was made from the diagnostic cast. Open tray implant level impression was made. Due to the increased labial defect, the implant access hole was labial to the inter-cingulum line. Even the available angulated abutment both 17° and 32° could not be used in this case as the collar height of the angulated abutment was is in excess. To mask the collar of the implant due to the thin gingival biotype, a modified prosthesis was planned. Customized angulated abutment was fabricated with ceramic compatible Ni-Cr alloy. The customized abutment was fabricated similar to ¾ crown preparation with relative grooves on the proximal sides and abutment screw access hole on the labial side of the abutment [Figure 2]. Palatally, the abutment was similar to the untouched palatal surface of ¾ crown. After receiving the work from the laboratory, customized abutment torqued to the patient for a passive fit and radiograph was taken to confirm the complete seating of the abutment without any gap. The final restoration was in two pieces partial veneer crown for the labial side and customized polished palatal metal surfaces [Figures 3 and 4]. Screw retained abutment torqued to the implant using torque controller. Final tightening was done up to 25 N. The access hole was closed with composite resin. Once the screw retained abutment was completely torqued [Figure 5], bisque trial was done with labial partial veneer ceramic crown [Figure 6]. After checking the proximal contacts and occlusion, both the labial partial veneer crown and opaque labial surface of the screw retained abutment was etched with hydrofluoric acid, silane coupling agent applied and crown was luted with resin cement of selected shade [Figures 7 and 8].

Figure 1

Exposed collar in the implant

Figure 2

Customized abutment with opaque labial veneer

Figure 3

Labial veneer crown (labial side)

Figure 4

Palatal aspect of labial veneer crown (palatal side)

Figure 5

Customized screw retained abutment with polished metal surface similar to ¾ crown

Figure 6

Customized abutment with labial veneer

Figure 7

Labial veneer crown cemented on the customized screw retained abutment

Figure 8

Finished prosthesis

DISCUSSION

This case report discussed the concepts of treatment planning in compromised ridge as well as a modified approach in the placement of prosthesis. The use of implants in the anterior maxilla for replacing a missing single tooth is a reliable treatment option.[8] There are many advantages in placing dental implants than other treatment options such as FPD, RPD. Maintenance of residual bone, oral hygiene, and noninvolvement of adjacent teeth are the advantages to be high lightened.[9] Ideally, the implant position should be determined primarily by the planned future prosthesis and not by the local bone anatomy alone.[4] As well as the manipulation of the soft tissue adjacent to implant enables proper peri-implant tissue healing and can result in soft tissue architecture similar to the gingival anatomy around the teeth creating an exact emergence profile is a challenging task for the dentist.[12] In majority of the cases, labial bone is thin and it needs preservation and augmentation. The thickness of the cortical bone varies depending on its vertical level and the tooth on the arch.[10] The proposed classification system for sagittal root position will provide availability of bone.[3] In this case, Dentascan evaluation revealed the bone thickness and quality. Bone graft augmentation was not possible due to the presence of scar tissue. In this case, implant was positioned labially to intercingulum line. In this case, exposure of implant collar labially, due to the no availability of bone as well as thin gingival biotype needs a modification in the prosthesis. In this case, customized screw retained abutment with polished palatal surface with opaque labial veneer was torqued, followed by luting of labial partial veneer crown. This prosthesis has the advantage of both cement and screw retained prosthesis.

SUMMARY

Placing dental implants in the maxillary anterior requires precise treatment planning, surgery and prosthetic treatment. This case report illustrated the steps needed to create ideal esthetics in the anterior region. Rigorous treatment planning allows the dentists to select location, angulations to achieve the ideal esthetics. This case report has discussed the importance of a comprehensive and a different approach in treatment planning, surgery and restoration of dental implant in the compromised ridge in the anterior maxilla.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.