The Esthetically Hardest Case to Do
Dr. Randy Mitchmore graduated from
Southwestern University in Georgetown,
TX in 1975 and the University of Texas Dental Branch In Houston in 1978. He still resides and practices in Houston today in a unique office setting: a restored 1930’s mansion that overlooks a backyard pool. He is passionate about what he does and “absolutely loves the practice of dentistry more now than at any time over the previous 33 years”. Dr. Mitchmore is committed to Continuing Education, having attended the Pankey Institute, the Schuster Institute, Implant Seminars and has completed all of the courses at the Las Vegas Institute for Advanced Dental Studies (LVI). He trained at Duquesne University and is licensed to give IV Sedation for all procedures including cosmetic. Dr. Mitchmore holds an Academy of General Dentistry (AGD) Mastership and is a Master, American Dental Implant Association along with being Immediate Past Chairman, Board of Trustees American Academy of Cosmetic Dentistry Charitable Foundation. He is a member of AACD, IACA and volunteers for Give Back a Smile. Dr. Mitchmore lectures across the country and has authored a number of journal articles as well as a chapter in a new textbook on Ethics in Esthetic Dentistry.
This 26 year old healthy white male presented seeking a second opinion for his missing upper left central incisor. (Figures 1 and 2) He was currently wearing a removable acrylic partial denture – a “flipper”. He hated the flipper but he was on a limited budget being a student. We discussed a variety of options including: no treatment at all, a cast removable partial denture, a fixed bridge, or a dental implant and crown. He elected to go with the dental implant and crown.
Now, it has been my experience that the second most esthetically challenging procedure to perform in dentistry is a restoration on a single upper central incisor. The MOST esthetically challenging procedure is a dental implant and a restoration. This procedure presents a series of special challenges starting with gingival architecture (including papilla, zenith, arch, and root prominence). The restorative challenges we face include shade, hue, value, chroma, metamerism, shape, texture, lobbing, and translucency with shape matching being more critical than colour matching.
In this case, most of the mesial papilla was present but there was no distal papilla. (Figures 3 and 4) No bone grafting was done when the tooth was lost. He was fortunate to have bone within 5mm of the distal contact point. That fact let me know that I could predictably recreate the soft tissue. Had the bone level been lower, esthetic success would have been compromised without more extensive plastic periodontal procedures.
We began by placing a Zimmer® 3.7 x 11.5 mm tapered Screw-Vent® Titanium dental implant (Figures 5 and 6) – after obtaining informed consent signatures for the dental treatment and model release of the photographs. Local anesthesia was one carpule of 2% Xylocaine 1:100K Epinephrine. Preoperatively, one Gram of Amoxicillin was given. A small periodontal flap was raised, being careful not to cut through the papillas, to gain visual access to the alveolar ridge as this was not computer guided surgery. A small pilot hole was drilled slightly lingual to the center of the ridge and centered between the teeth.
Since this was soft bone, the osteotomy was enlarged to only 2.8 mm. The top of the implant was placed level with the most apical crest of bone. A flat cover screw was placed. Human cadaver freeze dried bone mixed with Platelet Rich Plasma was placed around the implant to plump the tissue and fill any small gaps between the implant and bone. Primary closure was achieved with 4-0 chromic gut suture. The tissue side of the flipper was remodeled to begin forming the tissue, without placing pressure on the tissue. The patient was given Ibuprofen 800mg PO and an Rx for 10mg Hydrocodone and Acetaminophen.
At three months post operatively, the second stage uncovering surgery was done. A small flap from the palatal side excluding the papilla was raised. The cover screw was removed and replaced with a healing collar. Then the flap was curled under itself on the facial aspect and sutured around the healing collar. This began this important process of forming the gingival architecture for the final restoration. The tissue side of the flipper was remodeled to the desired contours of the soft tissue.
Two months of gingival healing was given and a transfer impression was made for the abutment and crown. At that time, a shade tab with a black and white holder was made to calibrate color photograph coordination with the Advanced Esthetic (AE) Team™ at Aurum Ceramic Dental Laboratories. (Figure 7) The final crown was cemented with SensiTemp over one year from the time of implant placement after screwing the abutment with 35Ncm2 torque. (Figures 8 – 10) The patient was extremely pleased with the results as can be seen in his final photo.
Now, it has been my experience that the second most esthetically challenging procedure to perform in dentistry is a restoration on a single upper central incisor. The MOST esthetically challenging procedure is a dental implant and a restoration.
Conclusions: The most salient parts of the process begin with discussing the enormous challenges of this situation, with the patient and agreeing on realistic expectations and possible less than perfect results. From the procedural point of view, the most important parts are managing the soft tissue and giving adequate healing time. A case like this cannot be rushed. It is extremely important that no cement be allowed to ooze under the gingiva. That is why thin resin cement was not used.
In this case, the abutment/implant connection was too far sub gingival to be certain all resin cement could be removed. The SensiTemp is quite easy to remove and was used only around the margins because of its thicker film thickness. It is my experience that resin cement left on abutments/implants can lead to implant failure.
Things that could be done differently on this case today would be to place the healing collar at the time of implant surgery to begin the tissue shaping process earlier. However, the safest most predictable implant surgery for the beginning Implantologist is to cover the implant with primary closure on the day of surgery.