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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 5  |  Issue : 1  |  Page : 85-88

Replacement of missing tooth in esthetic zone with implant-supported fixed prosthesis


1 Department of Maxillofacial Prosthodontics and Implantology, Peoples College of Dental Sciences and Research Centre, Bhopal, Madhya Pradesh, India
2 Department of Maxillofacial Prosthodontics and Implantology, Rajarajeshwari Dental College, Bengaluru, Karnataka, India
3 Department of Maxillofacial Prosthodontics and Implantology, Nanded Rural Dental College and Research Centre, Nanded, Maharashtra, India
4 Department of Maxillofacial Prosthodontics and Implantology, Gitams Dental College, Visakhapatnam, Andhra Pradesh, India

Date of Web Publication16-Jun-2017

Correspondence Address:
Sunil Kumar Mishra
Department of Maxillofacial Prosthodontics and Implantology, Peoples College of Dental Sciences and Research Centre, Bhopal, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_22_17

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  Abstract 


In the anterior region, the common reason for tooth loss is due to traumatic injury or congenital anomaly. Loss of a single tooth may cause functional and esthetic deficits to the patient. There are different treatment options available for replacing a missing incisor. Implant dentistry should be considered as first treatment alternative for replace a missing tooth. This case report presents the replacement of a missing maxillary left central incisor in a compromised site with dental implants along with bone graft followed by frenectomy to obtain a good clinical result and for better function and esthetics of the patient.

Keywords: Dental implants, delayed loading, frenectomy, single tooth implant


How to cite this article:
Mishra SK, Chowdhary R, Patil PS, Rao SB. Replacement of missing tooth in esthetic zone with implant-supported fixed prosthesis. Arch Med Health Sci 2017;5:85-8

How to cite this URL:
Mishra SK, Chowdhary R, Patil PS, Rao SB. Replacement of missing tooth in esthetic zone with implant-supported fixed prosthesis. Arch Med Health Sci [serial online] 2017 [cited 2019 Aug 25];5:85-8. Available from: http://www.amhsjournal.org/text.asp?2017/5/1/85/208190




  Introduction Top


Tooth extraction usually accompanies alveolar ridge resorption along with loss of preexisting tissue morphology. Replacing missing teeth with dental implants has become popular, but restoring anterior teeth with implant-supported restorations is a technique-sensitive task and poses challenges for dentists.[1]

Loss of a single tooth may cause functional and esthetic problems. There are different treatment options available for replacing missing incisors. One of the very economical options is removable partial denture, but patients are often not satisfied with this due to the bulk of the prosthesis, and also it is not fixed in nature. Other option is resin-bonded bridges, but they are not strong, and they do not have a good long-term track record. The most common treatment option is the fixed partial denture, but it is not very conservative as natural remaining teeth as abutment have to be prepared to support the prosthesis.[2] Dental implants are a very good treatment option available considering the economic status and esthetic demands of the patient to replace a single missing tooth.[3] Following the conventional 2-stage implant placement procedure (delayed loading), the implant stabilization is ensured during early stages of bone healing.[4]

The main goal of current implant restorative protocol is the preservation of remaining tissues. To obtain a good clinical result and for better function and esthetics of the patient, this case report presents the replacement of a single missing maxillary central incisor in compromised site with dental implants and bone graft followed by frenectomy.


  Case Report Top


A female patient aged 18 years, reported with missing left maxillary central incisor to Department of Prosthodontics, HKE'S SN Institute of Dental Sciences, Karnataka, India for the replacement of her missing tooth [Figure 1]. Patient gives a history of trauma and loss of tooth 5 years back. A thorough clinical examination was done followed by radiographic evaluations by taking intraoral periapical (IOPA) radiographs and orthopantomographs. On intraoral examination, it was found that there was missing left maxillary central incisor with labial frenum attached near to the crest of the ridge. Maxillary and mandibular diagnostic impressions were made to obtained diagnostic cast. A thorough medical history was taken, followed by complete haemogram to rule out any systemic disease. All the available prosthetic treatment options were explained and patient had given her consent for dental implants as treatment modality. Bone mapping was done for the implant site and it revealed the labiopalatal cortical bone width to be 5.6 mm and mesiodistal length as 6.8 mm. It was planned to place an implant of size 3.5 mm × 12 mm in the left central incisor region. The patient was prepared for the surgery and left infraorbital nerve block was given along with local infiltration at site where implant was to be placed. Incision was given to elevate the mucoperiosteal flap. The osteotomy was started with a pilot drill initially and gradually, enlarged in width to depth of 12 mm. Once the osteotomy site was prepared, an implant fixture of dimension 3.5 mm × 12 mm was placed (Biohorizon, Birmingham, USA) [Figure 2]. Alloplast bone graft (Periobone G, Top-Notch Health Care Product Pvt. Ltd., India.) was placed and guided tissue regeneration membrane was placed on the labial cortical plate were there was slight bony defect [Figure 3]. Cover screw was placed and flap was sutured back with 4.0 nonresorbable silk sutures [Figure 4]. Postoperative instructions were given along with prescription of analgesics and antibiotics. Follow-up was done after every 2 weeks. It was planned to do the frenectomy during the second stage surgery and before giving the implant-supported prosthesis. After 6 months, the second stage surgery was done in the left central incisor region and a gingival former of size 3.5 mm × 3 mm was placed [Figure 5]. The maxillary frenectomy surgery was performed simultaneously. Labial frenum was located close to the crest of the residual ridge. The existing frenum was broad, so the periodontist decided to perform the frenectomy with the Z-plasty technique because of its usefulness in such situation as it provides frenum elimination along with vestibule lengthening [Figure 6]. After 1 week the suture placed were removed and gingival former was also removed and abutment was placed. A closed tray impression was made with elastomeric impression material. Abutment was positioned back into the impression along with implant analog and was poured in dental stone and later cast was retrieved [Figure 7]. The milling of the abutment was done on the cast and try in done in the patient's mouth [Figure 8]. A porcelain fused metal crown was fabricated and cemented. Chair-side postoperative IOPA radiograph was taken to assess the complete seating of implant abutment on implant fixture [Figure 9]. The patient's occlusion was checked and the implant retained fixed prosthesis (FP) was evaluated for esthetics and phonetics [Figure 10].
Figure 1: Missing left central incisor

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Figure 2: Implant placed in the left central incisor region

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Figure 3: Alloplastic bone and guided tissue regeneration membrane placed

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Figure 4: Suture placed after surgery

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Figure 5: Gingival former placed

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Figure 6: Frenectomy with Z-plasty technique

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Figure 7: Impression with implant analog and cast with abutment

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Figure 8: Try in of the milled abutment

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Figure 9: Intraoral periapical radiograph showing complete seating of abutment on implant fixture

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Figure 10: Postoperative view of cement retained implant prosthesis

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  Discussion Top


Fixed dental prosthesis although is a viable treatment alternative in different situations, but still dental implant restoration has definite advantages. It was reported that the survival rates for tooth replacement with single tooth implants was higher.[3] The use of dental implants in the esthetic zone is well-documented in the literature, the survival and success rates are similar to those reported for other segments of the jaws in various controlled clinical trials.[2] There should be a period of at least 4–6 months before any restoration can be planned as stated by Prof. Branemark PI. Compare to other loading protocols conventional loading protocol is a predictable and an accepted treatment modality.[5] In this case report, delayed loading protocol was followed seeing the clinical condition and available bone present to get good treatment outcome. Compare to traditional prosthodontic approach the single implant placement, in this case, has many biological advantages such as preservation of the natural dentition and supporting periodontium, improved esthetics, improved hygiene accessibility, and less long-term costs.[2] Romanos et al. studied the survival rate of immediate versus delayed loaded implants and stated that although immediate loading of oral implants is a beneficial treatment protocol in implant dentistry that increases the comfort of the patient, but the clinical outcome and the peri-implant bone response of immediately loaded (IL) implants is poor in comparison to conventional loading protocol.[6] Reports indicate that IL may be unpredictable in cases with poor bone quality,[4] so it was decided not to go for IL as the patient had bone loss present with labial aspect of the cortical plate and the delayed loading ensures the implant stabilization during early stages of bone healing.

Every effort was done to meet the surgical and esthetic goals of the patient. The loss of a tooth is followed by a major alveolar bone resorption, so to preserve the bone volume the main goal of the clinician should be bone volume augmentation with the placement of implant as a valid alternatives.[7] The Same principle was followed in this case report and bone graft placed along with implant, and later frenectomy was done for the long-term preservation of bone and success of the implant. An FP type 2 was given to the patient as she had a low lip line and the cervical aspect of the crown was not visible while smiling.


  Conclusion Top


Implant-supported restorations provide considerable advantages over other treatment options available. Placement of dental implants in the esthetic zone is a very technique-sensitive procedure with little margin for error. It is the responsibility of each clinician to weigh up the benefits and risks as when to load the implant. There are often situations in which delayed loading, or 2-stage protocol is very beneficial. The clinician must carefully evaluate all the factors present to ensure a long-term success of the single tooth implant.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fu PS, Wu YM, Wang JC, Huang TK, Chen WC, Huang JW, et al. Optimizing anterior esthetics of a single-tooth implant through socket augmentation and immediate provisionalization: A case report with 7-year follow-up. Kaohsiung J Med Sci 2012;28:559-63.  Back to cited text no. 1
    
2.
Tuna H, Uzun G, Keyf F. The single-tooth implant treatment for maxillary central incisors loss after trauma: Case reports. Clin Dent Res 2011;35:47-52.  Back to cited text no. 2
    
3.
Shenoy VK. Single tooth implants: Pretreatment considerations and pretreatment evaluation. J Interdiscip Dent 2012;2:149-57.  Back to cited text no. 3
    
4.
Crespi R, Capparé P, Gherlone E, Romanos GE. Immediate versus delayed loading of dental implants placed in fresh extraction sockets in the maxillary esthetic zone: A clinical comparative study. Int J Oral Maxillofac Implants 2008;23:753-8.  Back to cited text no. 4
    
5.
Abichandani SJ, Nadiger R. Maxillary immediate implant loading: A comprehensive review. J Dent Implant 2013;3:52-7.  Back to cited text no. 5
  [Full text]  
6.
Romanos G, Froum S, Hery C, Cho SC, Tarnow D. Survival rate of immediately vs. delayed loaded implants: Analysis of the current literature. J Oral Implantol 2010;36:315-24.  Back to cited text no. 6
    
7.
Ariano V, Mancini M, Cardi A, Condà R, Cerroni L, Pasquantonio G. Immediate nonfunctional loading of two single-maxillary postextractive implants: 6-year postloading results of two case reports. Case Rep Dent 2016;2016:6816907.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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