Reconstruction of Function and Form in Maxillary Central Tooth Loss - A Case Report with 4 years follow-up

Introduction A healthy, athletic, 34-years old female presented with a long standing endo-perio breakdown on her maxillary left central incisor. This was secondary to a sport related trauma to the area some years ago. The tooth remained symptomless after endodontic therapy, although there was a gradual, darkening change in color of tooth, and presence of progressive facial gingival recession and tooth mobility. Eventually, the tooth was functionally compromised to a point where chewing was not possible due to significant mobility and fremitus. Pain was also present on chewing. The tooth also became a cosmetic compromise.

Method The case was treatment planned for a single tooth replacement with an endoessous dental implant. A 3D CT study revealed total lack of facial bone plate, and enlarged periodontal ligament space. Site preparation involved surgical removal of the tooth, complete debridement of the socket environment, and guided bone regeneration with mineralized bone allograft, teflon membrane, and subepithelial connective tissue graft together with advancement

of facial mucoperiosteal flap to regain the lost facial soft tissue. A removable partial denture was utilized. After 4 months of uneventful healing, the alveolar ridge regained adequate vertical height, yet horizontal dimension was inadequate. A 3.5mm diameter Ankylos implant with 14mm length was surgically placed. The facial aspect of the ridge was further augmented with mineralized allograft, bovine xenograft and a teflon membrane. The implant was uncovered in 4 months. At the time of uncovery, a plastic temporary abutment was placed with resin provisional restoration which was contoured over a period of further 3 months until symmetrical soft tissue morphology was attained. Once the fill of the central papilla was observed, a definitive zirconia abutment was fabricated, and a pressed ceramic restoration was cemented. The upper right central incisor which lad a large composite restoration was restored with a porcelain laminate veneer.

Results A very acceptable clinical outcome was achieved, from both functional and cosmetic aspects. Although principles of guided bone regeneration was applied in site preparation, ideal result was not achieved after the first extraction defect grafting.

The second grafting procedure involved titanium reinforced membrane that aided in more predictable facial volume enhancement. The series of surgical procedures resulted in 100% gain of facial soft and hard tissue from the original 5mm deficiency. Patient satisfaction was extremely high.

Discussion Anterior esthetic cases with significant facial hard and soft tissue loss may be challenged in many ways. A delicate case such as this one required significant soft tissue gain earlier, in order to fulfill cosmetic and functional restoration. Preserving soft tissue on the adjacent natural teeth throughout the process was important in the final esthetic outcome.

Conclusion A clinically acceptable cosmetic and functional outcome was achieved in this case that involved a total treatment time of 11 months. 32 -month follow up shows stability of crystal bone, as well as the peri-implant soft tissue contours. The interdental papilla in-between the two central teeth seems to have closed much tighter in 52 months.

Jin Y. Kim*, DDS, MPH, MS, FACD Kenneth Kim¶, DDS, Mark Tillman‡, CDT

* Lecturer, UCLA School of Dentistry, Private practice limited to Periodontics & Dental Implants, Diamond Bar, California USA ¶ Private practice, Los Angeles, California USA ‡ Spectrum Dental Laboratories, Tustin California, USA

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