Prosthodontics. Periodontics. Endodontics. Research. Laboratory Considerations VOLUME 4 No 2 MARCH 2002 .Aesthetic RestorativeOptions and Implant Site Enhancement Using Orthodontic Extrusion .Immediate Implant PlacementWith Immediate Provisional Crown Placement \ .Multidisciplinary Approach for Achieving Aesthetics in a Cleft lip and Palate Patient ,~,~..i":~"~ A Montage'Media, Publication MONTAGE MEDIA CORPORATION IS AN ADA CERP RECOGNIZED PROVIDER Practical Procedures & AESTHETICDENTISTRY Figure 2. The metal try-in of multiple single units. It is difficult to distinguish between implants and natural tooth abutments. Figure 1. The implant site consists of the surrounding socket walls of an extracted tooth, the shape of the root, and the continuity of form emerging from the implant leading to the proposed restoration. W hile the treatment of hopeless, fractured, or miss- ing teeth has traditionally presented difficulties within the anterior region, one of the primary consid- Figure 3. Size 30 endodontic files with rubber erations in deciding on tooth replacement procedures stops were used to measure the interproximal has been a lack of predictability in constructing an aes- peak of bone on the adjacent sites and their distance from the final contact points. thetic restoration, particularly following implant therapy. Most clinicians have limited guidance in the evaluation and then selection of the appropriate restorative options in the "aesthetic zone." Recent investigations have focused on the diagnostic evaluation of a site prior to selecting a particular restorative option for tooth replace- ment (Tablel. This selection criteria is based upon a thorough evaluation of the alveolar bone surrounding the site, particularly the interproximal bone, which sig- Figure 4. Radiographic measurements display the impor- nifiCantly influences individual tooth form and aesthet- tance of the measurement of the adjacent sites in predicting ics (Figures 1 through 41. anticipated soft tissue position interproximally between implants, natural teeth, and pontics. One of the primary reasons for failure in this region has been ineffective or missing "diagnostic indicators" that cause aesthetic tooth replacement sele<;;tion of a sounding .of the interproximal peaks must be performed, site to be unpredictable. If) an attempt to simplify the and the laI:Jial plate must be located prior to selection of diagnostic process, the authors defined future restora- the appropriate restoration (Figures 5 and 6). As described tive sites as: 1) existing edentulous spans (ie, delayed by Tarnow and Kois, as well as Salama et al, the loca- sites), and 2) hopeless teeth prior to planned extrac- tion of the interproximal peak of bone will allow deter- tions (eg, immediate sites). During the treatment of a mination of the an!icipated quality of the interproximal previously extracted tooth in an edentulous ,5pan, bone soft tissues around the restorations."3 The interproximal \ 126 Vol. 14, No.2 Salama Figure 5. An ovate pontic preparation was Figure 6. Labial plate and interproximal bone performed prior to delayed implant placement. sounding is required prior to implant placement. Figure 7. The fractured left central incisor was Figure 8. Bone sounding was performed prior radiographically observed and a poor prognosis to extraction on the mesial and distal aspects of was determined. the hopeless tooth. Adequate bone support for interdental soft tissue response was indicated. peak of bone has been indirectly utilized in the middle of bone on the adjacent teeth, implants, or pontic areas of the contact area to suggest the predictability of papilla should, therefore, facilitate appropriate selection of a around dental implants.4 Probing of the site adjacent to proposed restoration. Based upon a variety of clinical the proposed implant has also demonstrated efficacy in data (Table!, the preoperative bone sounding measure- predicting the postoperative location of the interproxi- ments should facilitate the selection of an optimal restora- mal soft tissue levels.3 Probing of the interproximal peaks tive option that corresponds to the surrounding bony PPAD 127 Practical Procedures & AESTHETiC DENTISTRY Figure 9. Preoperative facial view Figure 10. Orthodontic extrusion and Figure II. Immediate implant place- demonstrates the presence of a sub- occlusal adjustment was performed ment was performed following atrau- gingival fracture on the maxillary left to enhance the bone and soft tissue matic extraction utilizing a tapered central incisor within the lip perimeter dimensions 8 to 12 weeks prior to implant, approximately 5.5 mm in and the oesthetic zone. extraction. diameter, to replace the extracted central incisor. Figure 12. A healing abutment was Figure 13. Postoperative facial view Figure 14. Periotomes are ideal for used for vertical support of the soft demonstrates enhanced aesthetics atraumatic extraction following ortho- tissues. Note the added dimension and surrounding soft tissue health. dontic extrusion, as they place no of soft tissue provided by the ortho- added pressure on the surrounding dontic treatment. bony walls. anatomy of the individual patient.5 Since many post- a vertical direction and thereby relocate the bone and operative complications are developed due to poor soft tissues coronally to extraction (Figure 10). This tech- diagnosis and not from lack of technical expertise, this nique generally requires approximately 8 to 1 2 weeks of information will significantly influence the development orthodontic extrusion followed by 4 to 6 weeks of stabili- of an aesthetic result. zation. The levels of orthodontic forces applied are light Bone sounding is an important aspect of the diagnos- tic phase during the treatment of teeth that are scheduled for extraction (eg, immediate sites) (Figures 7 and 8). The site can then be evaluated and orthodontically altered if it is determined to be inadequate:6 Orthodontic tooth movement will allow for a simplified nonsurgical approach to enhancing areas with poor soft tissue levels, recession, or missing papillae with inadequate interproximal peaks of bone prior to extraction and immediate implant place- ment (Figure 9). The orthodontic augmentation technique utilizes the remaining attachment apparatus around the hopeless Figure 15. Selection of the implont diameters is based tooth by providing orthodontic tension on the periodon- upon the anticipated location of the head of the fixture in tal ligament to manipulate the attachment apparatus in relqtion to the mesial distal diameter of the root anatomy. 128 Vol. 14, No.2 Solomo Figure 16. Following extraction with Figure 17. Utilizing a temporary Figure 18. Five months postoperative the periotomes, the implant site is cylinder, a healing abutment was healing and maturotion of the soft internally and externally reevaluated customized to reestablish the proper tissue. Note the health and contour of with a probe. subgingival contours and support the soft tissue that was formed utiliz- the interdental papillae and labial ing a customized healing abutment. gingiva. Figure ]9. A permanent abutment Figure 20. The all-ceramic cerabase Figure 21. The all-ceramic abutment sleeve was placed to facilitate the use abutment was placed on the labora- was placed on the soft tissue model of an all-ceramic (cerabase) abutment. tory model. prior to preparation of the final Screw access was palatal to the adja- abutment chamfer line. cent incisal edges. (approximately 80g to 120g 1and the teeth should demon- cases without the need for raising a flap -and avoids strate no sign of inflammation or periodontal or periapical stripping of the periosteum and compromising the vas- pathology. Following stabilization, extraction and imme- cularity of the buccal plate. Utilization of this technique diate implant placement are suggested (Figure 111.7 can provide the practitioner with a shorter, simplified, To account for potential recession and shrinkage of and more efficient approach to management of tooth the hard and soft tissues following surgery, the authors replacement procedures in the anterior region. Clinicians recommend approximately 20% to 25% overcorrec- have been utilizing this technique since 1996 with the tion of the site prior to extraction and immediate implant results comparable to traditional single-stage implant tech- placement (Figure 121. Following atraumatic extraction, niques (Figure 13). it is necessary to once again reevaluate the site utilizing Once orthodontic treatment has optimized the site the aforementioned bone sounding techniques. Selection and overcorrected the hard and soft tissue dimensions of the appropriate implant diameters, shape, and thread vertically, the teeth are extracted with periotdmes in an design then becomes paramount in managing the implant atraumati~ method. The periodontal ligament spaces site. A tapered implant system with different anatomic should be engaged in an apical direction to slowly tear diameters may allow for a true anatomic reconstruction those fibers and release the tooth without destruction or beginning at the neck of the implant and may allow for pressure of standard elevators to the surrounding socket an enhanced engagement of the tapered implant to the and bony walls (Figure 14). Once the tooth is extracted, tapered extraction site. As with other implant systems, the extraction site is internally and externally evaluated this allows for atraumatic surgical placement- in many via bone sounding (Figures 15 and 16). In the absence