How Do You Treat A Non-Restorable Central Incisor In Your Practice? Immediate Vs Delayed Implant Placement -Part 2

After complete healing, the alveolar ridge appeared favorable for a flap-less implant placement approach.  This can be a challenge to position the implant platform at the ideal level.  If the implant is positioned too shallow, there will be insufficient room to create a proper emergence profile and crown form.  If the implant is too deep, it may be a risk for future recession or inflammation.

I was very careful with measurements made clinically from the existing gingival margin and the new planned gingival margin as well as checking with radiographs.  Using a computer-generated guide is another option for these cases, but will still require good clinical judgement.

The implant was positioned with the platform 3 mm from the future gingival margin to accommodate a favorable emergence profile. It is important to note that the interproximal bone must be modified to create space for the future restoration; otherwise, it may be a challenge to seat the restorative abutment and there is possible risk of developing bone necrosis due to excessive interproximal pressure. (See radiographs)

Interproximal Bone Adjusted At Time Of Surgery To Provide Room For Future Restoration

Provisional And Final Restoration

The gingival recession on the adjacent central incisor #8 (FDI #11), was improved by a semi-lunar coronally advanced flap.

After the implant has osseointegrated, it is time to shape the abundant soft tissue from that of a circular healing abutment to that of a triangular tooth form.  The provisional restoration is fabricated with a sub-gingival profile that will create tissue support and an ideally positioned height of contour to move the gingival margin to the desired level.

After a couple of months, the tissue form created by the provisional restoration can be duplicated by using a custom impression coping during the impression procedures.  The final crown should follow these sub-gingival contours to maintain this soft tissue form.

The restorative phase was completed with a custom cast gold abutment and a cemented PFM crown.  The crown form was slightly flatter at the mesial line angle than the provisional restoration and we can see the change in the soft tissue form.  Overall, the treatment sequence insured a predictable outcome for this patient.

Coronally advance flap #8(FDI #11) and flapless implant placement #9 (FDI #21)

Implant Placed According To Future Gingival Margin

Provisional Restoration

Provisional Restoration

Provisional Restoration At Placement

Provisional Restoration After Tissue Shaping

Final Restoration

How Do You Treat A Non-Restorable Central Incisor In Your Practice? Immediate Vs Delayed Implant Placement -Part 1

In the last blog I presented a patient that had a non-restorable maxillary central incisor.  She was treated with an immediate post-extraction implant placement and a custom provisional crown to immediately support the soft tissues.

Unfortunately, we can not always provide this form of treatment to all patients.  When should we separate treatment into phases?

I had mentioned that we must take into consideration the shape and dimensions of the labial bone, the existing soft tissue profile and the amount of apical bone.

Immediate post-extraction implant placement requires ideal bone volume. The immediate implant is anchored into the apico-palatal bone.  If the bone is this area is compromised, then implant stability may not be achievable.  In addition, the bone on the facial supports the soft tissue profile.  Thin bone or large dehiscences are a risk for future gingival recession. A patient with inadequate facial alveolar bone should not receive an immediate implant.

This next patient I will present also had a non-restorable failing maxillary central incisor. As a teenager, this tooth was traumatized during a sports injury.  It was endodontically treated and crowned.  Ten years later, this tooth required apical endodontic surgery. The patient is now 40 years old, and presents with a fistula at the apex of the central incisor. The patient consulted with members of our team, including an endodontist.  After reviewing his options, he requested to have this tooth replaced with a dental implant.

From the clinical exam, we can determine that the soft tissue profile for this failing tooth is more coronal than the adjacent central incisor, which has slight gingival recession.
We have a very favorable soft tissue position prior to surgery, so soft tissue augmentation may not be necessary.

Further clinical evaluation we note a fistula at the apex of #9(FDI #21).  On the radiographs, we determine that there is a peri-radicular lucency that extends to the floor of the nose.  Since this is the area that I depend on for implant stability, it is unlikely that I can predictably place the implant at the time of extraction.

So how should we manage this site?  How do we extract, debride and graft the alveolar ridge?

My approach follows a sequence of steps, intended to both correct and maintain the alveolar dimensions.

After extraction, I observed that the crestal bone on the facial aspect of the socket was intact and at a favorable level.  However, the lesion had resorbed the overlying bone in the apical zone.

So to gain good access to the lesion, I made a C-shape incision around the apical fistula.  In addition, this allowed access for placement of the bone graft and membrane.  By avoiding flap reflection in the crestal half of the ridge, I was able to maintain the blood supply to the alveolar facial bone.  The ridge was grafted with allograft bone and the socket closed with an epitheliazed graft.

In the next blog, we will discuss implant placement and restoration.

Note Large Apical Lucency

Interproximal Bone Adjusted At Time Of Surgery To Provide Room For Future Restoration

Provisional And Final Restoration

Initial Presentation

Occlusal View Of Socket

Apical Lesion Debrided

Alveolar Grafting Completed

Alveolar Ridge Graft Healed

How do you treat a non-restorable central incisor in your practice?

How do you treat a non-restorable central incisor in your practice?

If an implant is to be placed, should we perform the procedure as an immediate extraction socket placement or should we delay the implant placement?

I am sure we have all had a patient like this walk into our practice. The patient has a history of trauma at a young age with subsequent endodontic therapy.  Years of loading further weaken the tooth.  Her dog recently bumped her in the mouth and now she feels that her tooth is loose.  You determine that the crown is fractured and the tooth has a poor restorative prognosis.

How do you plan this treatment with your team?  Should the surgeon place an immediate implant at the time of extraction?

To determine the most predictable treatment option, we must take into consideration the shape and dimensions of the labial bone, the existing soft tissue profile and the amount of apical bone available for implant stability.

From the clinical exam, we can determine that the soft tissue profile of the hopeless incisor is similar to the adjacent central.  When considering immediate implants or simultaneous procedures, I always prefer to have a favourable soft tissue position prior to surgery.  The slight crestal bone remodeling after the extraction will lead to reduced support for the gingiva with resulting recession.  So we either have a gingival level that is coronal to ideal, or our procedure must provide some additional support or augmentation.

Next we can look at the radiograph to evaluate the interproximal and apical bone.  For this patient, we note that the bone appears to be at a normal level on the mesial and distal of the root and adjacent teeth.  The apical bone is without a lesion and it is sufficient for implant anchorage.

Lastly, we will need to evaluate the facial bone.  This can be done with a CBCT or clinically at the time of surgery.  Insufficient labial bone can be a risk when attempting to place an immediate implant.  It is best to stage the procedure with alveolar ridge augmentation and a delayed implant placement.   For this patient, the labial bone had both a normal crestal level and facial thickness.

The implant was placed immediately at the time of the extraction for this patient.  In the next blog posting, we will look at how I managed the soft tissue form.

Full Smile View

Retracted View

Crown Fracture Resulting In Inadequate Tooth Structure For Predictable Restoration

Dental Implant Placed With Platform 3 mm Below The Free Gingival Margin

Dental Implant Placed Towards Palatal Aspect Of Socket With Bone Augmentation In Residual Socket

Radiographic Evidence Of Large Pulpal Chamber And Extent Of Fracture Line. There Is Abscence Of Any Peri-Radicular Lesion.

Options To Consider For Interim Tooth Replacement And/Or Soft Tissue Management

Now that the implant is placed, we have several options to consider for interim tooth replacement and/or soft tissue management.

If the soft tissue form is favorable, then an attempt to maintain or support the supra-crestal gingival tissues during the period of osseointegration simplifies the restorative process. By simplifies, I mean that the emergence profile will not need to be developed with a provisional crown.

One way to achieve this is to fabricate a custom healing abutment with the proper shape to provide support for the gingival tissues.  To replace the tooth, an interim RPD or a bonded tooth pontic can be used.

Another technique I like to use is a chairside fabricated provisional crown.  If the implant is stable at placement, and the occlusal is favorable, then a crown can be attached on the day of surgery.

In this case, I utilized the patient’s tooth.  The tooth was trimmed to create a shell crown, and then relined on the temporary abutment in the mouth.  The provisional restoration is finished on an analog to ideal contours and then inserted with finger torque.

For this patient, I also added a small piece of connective tissue, that was harvested from the palate.  This helps to increase the thickness of the facial gingiva, to minimize the development of a flat or concave contour that so often happens after normal remodeling of the alveolar complex.

The restorative phase was completed with a porcelain veneer on tooth #8 (FDI #11) and a zirconium abutment/ porcelain crown on #9 (FDI #21).

In our next blog posting, I will talk about a patient that required a staged alveolar grafting and implant placement.