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Esthetic rehabilitation in the Anterior zone using implants. A case report

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Dr. Vikas Gowd M
Proff. And HOD
Dept. Of Prosthodontics
Meghna Institute of Dental Sciences, Nizambad

Introduction:

Restoration of adjacent implants in the anterior maxilla while maintaining acceptable interdental papillae presents a major restorative challenge. The contours and color of missing teeth may be reproduced using a variety of materials and techniques. However, the success of an implant-supported restoration is often limited by the provider's ability to create gingival contours that harmonize with a patient's remaining oral structures. The presence or absence of the interdental papilla associated with multiple adjacent implants may be affected by the amount of alveolar bone loss prior to implant placement, distance between adjacent implants, position of implants in relation to adjacent teeth, as well as the subgingival contours of the implant-supported restoration. In many instances, the loss of 2 or more maxillary anterior teeth results in flattening of edentulous segments and resorption of interproximal bone crests. The placement of implants may result in additional bone loss following bone remodeling and the establishment of biological widths. Inadequate interimplant spacing (less than 3 mm) may result in exaggerated bone loss and increased distance from proximal contact points to the associated alveolar bone crests. This may result in decreased papillary volume and accompanying black triangles within the esthetic zone. Papillary volume is inversely proportional to the distance from the interproximal contact area to the bone crest. At a distance of less than 5 mm, papillae fill 100% of the time; when the distance measures 5-7 mm, papillae fill the space 56% of the time. Finally, when the distance exceeds 7 mm, the space is filed only 27% of the time.

Many surgical techniques have been developed attempting to regenerate interdental papillae. Unfortunately, no single technique offers consistent clinical success. Therefore, when using implants to replace multiple maxillary anterior teeth, optimal implant positioning should be achieved. When a diminished mesial-distal space exists, the clinician should consider placing implants with smaller diameters. Alternatively, fewer implants with cantilevered fixed partial dentures may be considered. In each instance, the intent is to maximize the interimplant distance, minimize alveolar bone loss, and maintain acceptable soft tissue height for optimum esthetic results. This clinical report illustrates an approach to manage interdental papillae associated with multiple adjacent maxillary anterior implants.

Ridge mapping is a measurement procedure to ensure that the diameter of an endosseous screw implant does not exceed the dimensions of available bone. The long-term success of implants is a prime aim. To achieve this, it is essential for the initial evaluation of the dimensions of the resorbing alveolar process to be absolutely accurate. Ideally, an implant should be covered by at least 1 mm of bone on all sides. The major problem is estimating the thickness of bone, since the mucosal contour can mask the actual dimension of the alveolar ridge. Use of ridge mapping makes possible a reliable evaluation procedure at the initial stage of treatment planning.

CASE REPORT:

A  27   year old  healthy  male patient presented with fractured maxillary central incisors and  long standing missing lateral incisors caused by a  sports injury 12 years back(fig 1). Clinical examination revealed non vital central incisors with a 4mm space for each lateral incisor and a diastema of 2mm between the central incisors. Orthodontic movement of the central incisors was planned to close the diastema and create space for the placement of implants(fig2). Temporary crowns were fabricated on the central incisors and brackets were placed on them and canines in order to bring about bodily movement of the teeth. After successfully creating enough space for the implants, they were surgically placed and ridge mapping was done(fig 3). Care was taken to reconstruct the interdental papilla, hence a papilla preservation flap was reflected palatally during second stage surgery(fig 5 )

Following a healing period of 6 months, it was noted that the healing was uneventful and the interdental papilla was reconstructed as desired with no post operative complication.

Fig 1: pre operative view

Fig 2: temporary crowns placed to aid soft tissue maturation and aid in orthodontic closure of diastema

Fig 3 and 4: ridge mapping

Fig 5: second stage surgery

Fig 6 post operative OPG showing implants in place

Fig 7: prepared abutments

Fig 8. Final restoration in place

DISCUSSION:

Orthodontic movement for bone deposition provides good native bone which in turn provides good primary stability Immediate implant placement with immediate provisionalisation is used in this case where temporary crowns is used as a provisional. Orthodontics is continued to close the space in the central region while the implant is left healing. As the temporary provides exact mesio-distal width required, it is used in this case till the time the gap is covered. It also provided good esthetics and patient psychologically felt better after treatment was completed. Care was taken to see that no relapse of the orthodontic movement occurred. Hence, retainers were given to the patient to be worn in the night.

Summary:

A good pre operative analysis is essential for a successful implant restoration in the anterior esthetic zone. Space evaluation in all three dimensions (mesio distal, labio lingual and apico coronal) is importance with respect to the adjacent teeth and their periodontal ligaments. Design and timing of implant placement adds to the fourth dimension of implant planning. A good orthodontic planning followed by time taken for bone healing and soft tissue maturation are key elements in esthetic implant restoration.

CONCLUSION:

By developing a team approach using a prosthodontist, orthodontist, endodontist and laboratory technician, the team was able to design a biologically sound and esthetic prosthesis.
Using ridge mapping and orthodontics, the space was created for placement of implants and using papilla preservation flap, the interdental papilla was reconstructed respecting the patients esthetic desire.

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