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Combining a Single Implant and a Veneer Restoration in the Esthetic Zone

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Combining a Single Implant and a Veneer Restoration in the Esthetic Zone CLINICAL RESEARCH Combining a single implant and a veneer restoration in the esthetic zone Jose Villalobos-Tinoco, DDS Department of Restorative Dentistry, Autonomous University of Queretaro School of Dentistry, Queretaro, Mexico Nicholas G. Fischer, BS Minnesota Dental Research Center for Biomaterials and Biomechanics, University of Minnesota School of Dentistry, Minneapolis, Minnesota, USA Carlos Alberto Jurado, DDS, MS Clinical Digital Dentistry, A.T. Still University Arizona School of Dentistry & Oral Health, Mesa, Arizona, USA Mohammed Edrees Sayed, BDS, MDS, PhD Department of Prosthetic Dental Sciences, Jazan University College of Dentistry, Jazan, Saudi Arabia Manuel Feregrino-Mendez, DDS Periodontal Private Practice, Queretaro, Mexico Oriol de la Mata y Garcia, CDT Dental Technician, Private Practice, Puebla, Mexico Akimasa Tsujimoto, DDS, PhD Department of Operative Dentistry, Nihon University School of Dentistry, Tokyo, Japan Correspondence to: Nicholas G. Fischer Minnesota Dental Research Center for Biomaterials and Biomechanics, University of Minnesota School of Dentistry, 515 Delaware Street SE, Minneapolis, Minnesota 55455, USA; Tel: +1 612 625 0950; Email: [email protected] 428 | The International Journal of Esthetic Dentistry | Volume 15 | Number 4 | Winter 2020 428_Tinoco.indd 428 15.10.20 17:32 VILLALOBOS-TINOCO ET AL Abstract and the soft tissue contouring was started for an im- mediate provisional restoration. A suturing technique Objective: The combination of partial edentulism was executed that aimed at maintaining an interproxi- and a worn anterior tooth in the esthetic zone can mal papilla. Conservative veneer preparation was per- be a challenge for the dentist. This clinical situation formed on tooth 21 in order to bond the restoration requires extensive knowledge of soft and hard tissue to the enamel structure. Final restorations included a management, surgical planning and execution for custom abutment with a lithium disilicate fused to zir- implant therapy, and conservative tooth preparation conia crown for the implant on site 11 and a lithium with ideal bonding protocols for the tooth-supported disilicate veneer on tooth 21. prosthesis. Moreover, an optimal selection of the final Conclusions: A well-planned single implant and a ce- restorative materials is imperative to manage occlusal ramic veneer restoration was able to fulfill the patient’s forces and fulfill the patient’s esthetic demands. esthetic expectations. The selection of materials for Materials and methods: The patient presented with the final restoration was crucial to manage the occlu- partial edentulism on site 11, a worn incisal edge, and sal forces and to mimic the shade and shape of the facial defects on tooth 21. Minimally invasive implant adjacent teeth. therapy for site 11 was performed with a papilla-spar- ing flap design that only included the edentulous site, (Int J Esthet Dent 2020;15:2–11) The International Journal of Esthetic Dentistry | Volume 15 | Number 4 | Winter 2020 | 429 428_Tinoco.indd 429 15.10.20 17:32 CLINICAL RESEARCH Introduction texture, and various other aspects of the implant-associated soft tissue need to look Anterior tooth loss presents a major esthet- similar to the surrounding soft tissue to max- ic challenge to dentists because any small imize the esthetic outcomes.19,20 To achieve defect is projected in the patient’s smile.1 this, provisional implant prostheses help to Partial edentulism can be managed with create and form the ideal peri-implant tis- conventional dentistry and implant pros- sue.21 The timing of the placement of pro- thodontic therapy, but both require proper visional implant restorations (immediate as planning to achieve ideal esthetic results.2-4 opposed to 6 months, for example) is in- Tooth-supported fixed restorations function formed by many factors such as the implant well, but esthetic and oral hygiene may be stability and the amount of graft applied.22,23 compromised if the design of the soft tis- Ceramic veneers are a conservative sue and pontic is not properly achieved.5 treatment option for teeth presenting with On the other hand, while partial remov- defects, fractures, etc. These bonded ce- able prostheses may meet esthetic require- ramic veneers have shown successful long- ments, the lack of stability could interfere term results.24,25 The long-term success of with other functions such as mastication.6 ceramic veneer restorations is dependent For both treatment options, conventional on components such as restoration de- restorations can detrimentally affect the re- sign26 and adhesive methods,27 among oth- tention and/or support of the neighboring er factors.28 While the reduction of tooth teeth. structure is usually needed for the place- Implant therapy is the standard treat- ment of veneers, excessive or overzealous ment provided by most clinicians as it pre- tooth preparation can expose the dentin serves the adjacent teeth and provides a and detrimentally affect the bonding of predictable long-term solution.7,8 Several veneers.29 Recent advances in technology studies have shown fairly similar success have made it possible to produce ultrathin rates for implants placed in the maxillary ceramic veneers with a thickness of only esthetic zone compared with those placed 0.5 mm, which bond to the tooth structure in posterior sites.9-11 While implant survival with little hard tissue removal.30 There are is obviously crucial and many studies have many dental ceramic options and formu- focused on it, fewer have evaluated the es- lations currently available31,32 that produce thetic outcome of implants placed in the acceptable esthetic results and bond dura- maxillary esthetic zone, despite this being bility.33 Minimal tooth reduction can provide crucial to many patients.12-14 positive fracture characteristics when res- Maxillary alveolar ridge (anterior) thick- in-based cements are used to bond ceram- ness can compromise esthetic expectations ic veneers to the underlying tooth,34,35 with for implant therapy. In these situations, hard good survival rates.36 The aim of this report and soft tissue grafting may be required.15 is to show a clinical protocol combining a This complexity could increase when pa- single implant and a veneer restoration in tients present thin gingival phenotypes or the esthetic zone. limited mesiodistal space.16 The tradition- al approach for implant therapy in the es- Clinical report thetic zone might include the extraction of a non-restorable tooth and a bone graft- A 40-year-old female patient presented at ing procedure, followed by a healing time our dental clinic with the chief complaint of about 3 to 4 months.17,18 The thickness, of having lost an anterior tooth. Her wish 430 | The International Journal of Esthetic Dentistry | Volume 15 | Number 4 | Winter 2020 428_Tinoco.indd 430 15.10.20 17:32 VILLALOBOS-TINOCO ET AL a b Fig 1 Patient’s initial smile. Fig 2a and b Initial smile and intraoral situation. was for an implant to replace the lost tooth decided to place an immediate implant on (Fig 1). The patient stated that her tooth (11) edentulous site 11. Implant placement with had been fractured in a car accident and she immediate provisional restorations was had undergone an emergency extraction of planned, as it is a common procedure to es- it 3 months prior to her fi rst visit. She was tablish an ideal emergence profi le in order also concerned about the incisal wear and to provide maximum tissue volume, pre- facial defects on tooth 21 (Fig 2). After the serve the midfacial gingiva, and ensure pa- initial clinical evaluation, the patient was in- tient comfort and treatment acceptance.37,38 formed of the need for a diagnostic wax- A customized, anatomical, screw-retained up to evaluate the tentative position and provisional restoration was selected to contours of the restoration as well as for manage the emergence profi le. The shape a CBCT evaluation to evaluate the residual of the provisional restoration is key to bone in the edentulous site. She approved achieving good esthetics. The plan was to the treatment plan. fabricate the fi nal crown out of lithium disil- Diagnostic casts were made and a diag- icate, which provides excellent strength and nostic wax-up (GEO Classic; Renfert) was toughness compared with other materials.39 fabricated to take the patient’s wishes into At the surgical appointment, local anes- account and provide her with a harmonious thesia was applied by infi ltration with 1.8 ml smile. After presenting the patient with the of 4% articaine hydrochloride with epineph- diagnostic wax-up, a diagnostic mock-up rine 1:100,000 (Septocaine), and infraorbital was performed with temporary bis-acrylic blocks of 3.6 ml of 0.5% bupivacaine hydro- material (Structur Premium; Voco). She was chloride with 1:100,000 epinephrine (Mar- pleased with the initial result and consented caine). A papilla-sparing fl ap was designed to the treatment. and elevated,40 with the aim of exposing the After the CBCT evaluation and treat- area of the edentulous site and preventing ment plan discussion between the patient, gingival recession in the adjacent teeth. An periodontist, and restorative dentist, it was implant (Neobiotech) of 4 × 13 mm was The International Journal of Esthetic Dentistry | Volume 15 | Number 4 | Winter 2020 | 431 428_Tinoco.indd 431 15.10.20 17:32 CLINICAL RESEARCH Fig 3a and b Implant placement. ab Fig 4 Provisional restoration fabrica- tion. Fig 5 Immediate implant provisional restoration. then placed at site 11 following the manu- A titanium custom abutment was de- facturer’s specifications (Fig 3). The pa- signed and fabricated on implant 11, and tient presented a thick periodontal pheno- a conservative veneer restoration was pro- type.41,42 Suturing was performed with 5-0 vided for tooth 21 (Fig 8). A final crown of chromic gut sutures (PolySyn FA; Surgical lithium disilicate fused to a zirconia core Specialties), and a coronally repositioned for implant 11 and a pressed lithium disil- vertical mattress suture was used to achieve icate veneer for tooth 21 were fabricated primary soft tissue closure.
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