Trauma Implant Case Final
I am pretty sure I have posted a lot of this before, but I wanted to post the entire case now that I am finished. Many of you in the courses have heard me tell of a good friend of mine that had a nasty trauma to his front teeth. It was a very difficult case to treat, but I think we got a reasonable final and he is very happy.
Here is how he showed up in my office the Monday after the accident. He took a blow to the face and vertically fractured both 8 and 9 all the way down.
I referred to my surgeon who was able to extract the teeth, place the implants, and do pretty extensive bone grafting. The one major compromise that we had was that the teeth were extremely difficult to remove. Because he had to incise the midline papilla with his flap design, I knew that we were going to lose the midline papilla on the final (I was right). I could have prevented this by placing custom healers right away (or immediate provisionals), but the surgeon did not feel comfortable with me doing this. I also could have been more patient with the treatment and let the ridge heal before implant placement or done more extensive soft tissue grafting. However, he was a good friend and I wanted to get him fixed up.... perhaps a regret that I would have not done with other people....
Because he had crowns on 7 and 10, I was able to remove the crowns and create/mill a 4 unit provisional for the healing phase. This really saved me because he would have had to wear a flipper or essix. With his job, that would have been a disaster for him. He is in front of people all day.
He wore the provisional for several months and here he was 4 months later. Notice the swelling above #8... we were freaked out thinking we were loosing the implant. Thankfully it turned out to be a loose healing abutment.
We then started the restorative process with Provisionals to attempt to form the tissue a little bit (although I knew the midline was not coming back at this point). I just sectioned the pontics out and left 7 and 10 provisionalized.
After another month and a half wearing these, we moved on to the final restorations (split technique with infiltrated zirconia abutments and e.max MT crowns on all 4 teeth)
While not a perfect result, I think it worked out pretty good for him. Sometimes, a long midline is required with implants on both of the central incisors. He was happy and he doesn't show everything when he smiles anyway!
That turned out terrific! Do you think the infiltrated abutments really helped your final result?
Probably not in this case. Just was experimenting. Especially with the pink. I think the body color helps because it creates a more natural shade of the abutment and allows you to go thinner with the restoration.
On 5/16/2017 at 2:09 pm, Daniel Wilson said...I need a shortcut button for "Great job Mike!"
+1 Did you use ultimate to bond the crowns to abutments?
Hope you are right Chuck. That part is always a mystery to me. Just when I think I get it.....
The papillae are gone... never to return. Biology is daily predictable when you cut the papillae and don't support immediately. Farhad said that Danny Buser talks about accepting some papillae loss in cases like this and restoring with longer contacts like I did here.
In the final analysis, a few black triangles are not the end of the world. If we live long enough everyone gets them. It can be a big deal for a person with a gummy smile but people notice the teeth first. Regarding the case I posted, the patient's low lip line saves the case, but the papillae are growing back. Will they come back all the way? I don't know. What I do know is that the patient looks better with no gap and two symetrically sized teeth. Black triangles are good subject matter for threads on our discussion boards.
Great Outcome!
Bill Marais usually placed pink porcelain on interpoximals to hide black triangles. But you can try juvederm.
Do you want to do Ortho on his lower anterior teeth ? Gregory
On 5/16/2017 at 2:16 pm, Thad Vincent said...On 5/16/2017 at 2:09 pm, Daniel Wilson said...I need a shortcut button for "Great job Mike!"
+1 Did you use ultimate to bond the crowns to abutments?
Multilink Hybrid Abutment Cement is the way to go.
Ray
I think the case turned out really nice! As you mentioned - the easiest way to support the tissue would have been a custom healer... the surgeon could even have done this chairside with a temp abutment and some flowable.
Another "thinking outside the box" way to treat cases like this is with "socket shield" / PET therapy. Zero loss of the tissue or buccal plate. A great tool to have when working on high smile lines, adjacent implants, etc. This concept/technique is gaining much more popularity as clincians see the huge benefits it can have in the right scenario.
David
Gregory-
I have played around a bit with Bills technique if pink. Need to practice a bit more. No ortho is planned at this time.
David-
I am familiar with socket shield and it's benefits. I have not executed any cases yet.
Great outcome despite the slight compromise. Couple of points:
1.) Average distance from bone to tip of papilla between 2 implants: 3.2-3.4mm...This will not recover much more.
2.) Average distance from bone to tip of papilla between implant and tooth: 4.5-5.0mm...This will likely recover more with time if there is embrasure space left open.
3.) If you have to compromise vertical deficiency then it is better to compromise it in the papillary areas rather than on the facial (such as in Mike's case above). You can recover from missing papillae (slight black triangles are not always unesthetic to the lay population and can be masked restoratively). You cannot (or not very easily and predictably) recover from facial recession on implants.
Farhad
On 5/16/2017 at 4:13 pm, Ray Kessler said...On 5/16/2017 at 2:16 pm, Thad Vincent said...On 5/16/2017 at 2:09 pm, Daniel Wilson said...I need a shortcut button for "Great job Mike!"
+1 Did you use ultimate to bond the crowns to abutments?
Multilink Hybrid Abutment Cement is the way to go.
Ray
Hybrid for the tibase to abutment but what I was asking about is between the infiltrated zirconia abutment and the Emax MT crown.
I always do these the same way... Bond Zirconia to tibase with Multilink Hybrid Abutment HO and cement the final crown with RMGI.
Just playing devils advocate. What are everyone's (and Farhad's) thoughts on sequencing the placement of the implants (ex: place one implant while keeping the root of the adjacent tooth. you can still temporize the same way and remove the crown from that tooth. Then once healing is achieved, come and place the second implant and using tissue contouring healing abutments to help with the emergence profile of the soft tissue.)
I understand there is still some remodeling of the bone/ papilla long term, but I've seen some very highly demanding aesthetic cases had a nice result with this technique. I can't remember how long the post op eval was or the prognosis of the papilla longterm.
Chris
Nice case and contributions.... lot's to learn on what to do, what is possible, best ways to deal with the little details, AND some of our limitations. Excellent delivery and documentation as always Mike.
Mark
On 5/17/2017 at 9:07 am, Chris Richards said...Just playing devils advocate. What are everyone's (and Farhad's) thoughts on sequencing the placement of the implants (ex: place one implant while keeping the root of the adjacent tooth. you can still temporize the same way and remove the crown from that tooth. Then once healing is achieved, come and place the second implant and using tissue contouring healing abutments to help with the emergence profile of the soft tissue.)
I understand there is still some remodeling of the bone/ papilla long term, but I've seen some very highly demanding aesthetic cases had a nice result with this technique. I can't remember how long the post op eval was or the prognosis of the papilla longterm.
Chris
Chris,
This would be an excellent approach if it's feasible from a patient management perspective and if the teeth are not immediately hopeless, i.e. if they don't need to be extracted immediately.
Farhad
I know I'm late to the party, but I think the best solution here would be a new technique called socket shield or partial extraction therapy. Virtually no bone or papilla loss. https://www.ncbi.nlm.nih.gov/m/pubmed/27560672/?i=2&from=/27100812/related
Ive done a few cases with excellent results!
On 6/25/2017 at 5:46 am, Paul Mikhli said...I know I'm late to the party, but I think the best solution here would be a new technique called socket shield or partial extraction therapy. Virtually no bone or papilla loss. https://www.ncbi.nlm.nih.gov/m/pubmed/27560672/?i=2&from=/27100812/related
Ive done a few cases with excellent results!
This looks promising, but it still makes me nervous. Might try it when the research is more substantial.
