Introduction to the case
Autogenous dentin grafting preserves the socket using the patient’s own tooth as graft material.
An interesting case of a bad initial prosthetic choice. Vital incisor crowned after fracture at 18 yrs old. The neighboring incisor tooth has a thin incisal margin, a very deep palatal concavity, and a quite flat labial wall. In this case, a crown is the worst choice because you will have a problem to find the correct space for lab work. The best choice is a veneer. But now we have this problem. Patient presents asking for a new crown, complaining about the thickness of the current crown, chipping of the incisal edge, bleeding gums, and the difference in height between the central incisors. After removing the crown, there was a vertiprep with a buccal undercut, open margin, horizontal over-contouring, and invasion of soft tissues. I decided for a full adhesive veneer (little space for lab, less than 1 mm) and I decided to put my finish line by probing the healthy neighboring tooth and wait for the gums to follow my prep. After one week everything looks fine!
In this case report I demonstrate the importance of taking a radiograph when seating the custom abutment and crown before final torquing of the gold implant interface connecting screw.
Replacing a single anterior tooth with an implant is a challenge for every dentist. The risk of losing vestibular bone height and soft tissue is unacceptable from an aesthetic point of view. The presence of osteoclasts on the inner surface of the socket walls indicates that the bundle bone will undergo resorption.
Anatomically, the buccal bone of the teeth is thinner than lingual or palatal bone. Therefore, as bundle bone is a tooth-dependent tissue, it will gradually reduce after extraction. Since there is more bundle bone in the crest of the buccal wall than the lingual wall, hard tissue loss will become most pronounced in the buccal wall (Lindhe, Clinical Periodontology and Implant Dentistry, 2008).
These scientific evidences and the clinical experience of immediate implant placement in fresh extraction sockets have led us to think that by preserving the periodontal tissues on the buccal part of the socket, we could prevent bone resorption in this critical area.
The socket-shield (SS) technique provides a promising treatment, better manages the risks, and preserves the post-extraction tissues in aesthetically challenging cases. We need to preserve and use the bundle bone to our advantage.
The principle is to prepare the root of a tooth indicated for extraction in such a manner that the buccal root section remains in-situ with its physiologic relation to the buccal plate intact. The tooth root section’s periodontal attachment (periodontal ligament (PDL), attachment fibers, vascularization, root cementum, bundle bone, alveolar bone) is intended to remain vital and undamaged so as to prevent the expected post-extraction socket remodeling and to support the buccal / facial tissues. (Howard Gluckman, Jonathan Du Toit, Maurice Salama).
Under a rubber dam positioning marginal ridges on multiple teeth can be tenuous. If the marginal ridges are too high there is a risk of adjusting through the contact when finalizing the occlusion. The Greater Curve system allows you to create contacts with depth. The risk of adjusting through the contact is mitigated.
The dreaded single central. Patient was concerned because her “front tooth had been getting darker over the past three months”. Endodontic therapy had been performed 10 years prior. Sketchy mid-root region, endodontist confirmed resorption. Patient wouldn’t be able to get the exo for a while. This restoration is meant to be a long term provisional, but I saw no better way to address the situation given the circumstances.
This 50 year old patient was in today for a check-up on his teeth. I had not seen him for 20 months since we restored his lower teeth. We had restored his upper teeth 2 months previous to doing his lower teeth. He came from another neighboring dental office where they don’t do composite rehabs. He has been into this other office for several cleanings since we did his rehab but he smokes, loves his coffee and has lots of stain. Anyway I was wondering how he was making out with his new teeth and he was very satisfied. In his words “no pain or sensitivity or problems”. So I was quite happy with his rehab. His wife came as well and we knew each other from 30 years ago when my daughters and I were riding horses in the same horse club. There were a few air bubbles that I didn’t like and a small open margin that I repaired and that was all he needed to spiffy him up.
43 year old female presented with chief complaint of “I need to fix my smile, I have a wedding to attend in August (in 3 months)”. Patient had generalized moderate chronic perio, decided to not pursue ortho tx. Initially, we decided to exo canine in lateral incisor position, and create a 4 unit FPD 8-9-x-“11”. After FPD and the wedding, we will proceed forward with endo and PCC on #9. However, due to careful preparation, we managed to preserve the teeth, avoid the extraction, and altered the treatment plan to four emax crowns.