Download Orthodontic and Esthetic Consideration for Anterior Single Tooth

CASE REPORT
Manoj Varma et al
Orthodontic and Esthetic Consideration for
Anterior Single Tooth Implant
1
Manoj Varma, 2Mukesh Kumar Singh, 3Abhay Lamba, 4Anil Sharma
ABSTRACT
Implant restorations have become a primary treatment option for permanent replacement of compromised or missing teeth. The tooth which
has undergone structural damage is usually an endodontic failure and frequently associated with multiple episodes of reinfection. The
adjacent teeth may be tipped with or without unesthetic rotations. In such situations, a preprosthetic orthodontic treatment is frequently
required. Derotation of the central incisor and/or premolars correction of the tipped canine, space closure and correction of root proximities
may be required to create appropriate space in which the implant has to be placed to achieve an esthetic restoration. This paper discusses
aspects of preprosthetic orthodontic diagnosis and treatment that need to be considered with implant restorations.
Keywords: Preprosthetic orthodontics, Corrective orthodontics, Single tooth implant, Multidisciplinary orthodontics.
How to cite this article: Varma M, Singh MK, Lamba A, Sharma A. Orthodontic and Esthetic Consideration for Anterior Single Tooth
Implant. J of Ind Ortho Soc 2010;44(4):134-137.
INTRODUCTION
We often treat patients with missing or malformed teeth.
Treatment alternatives for missing teeth include removable
partial dentures, conventional fixed bridges, resin-bonded
bridges, autotransplantation and dental implants. A number of
criteria are evaluated before a choice of the type of restoration/
treatment rendered is made. Over the years, with improved
predictability and success in the use of dental implants, it is
increasingly advocated that prosthetic replacement of such
missing teeth, especially the missing anterior teeth, be done
with single tooth implants.1 Such a treatment modality provides
a fixed prosthetic rehabilitation to the patient without involving
the adjacent teeth. In addition, implants also help maintain the
alveolar ridge, enhance occlusal function and provide optimal
esthetics.2 However, for a successful replacement of such teeth
with an implant, preprosthetic orthodontic intervention may be
necessary in order to create adequate space and alignment of
the adjacent teeth. This is in addition to other elements of
anterior design esthetics involving single-tooth replacement,
which include shade mapping, length/width ratio, golden
proportion, incisal edge position, arch form, gingival symmetry,
lip line, papilla height, contact gradient, emergence profile, and
occlusal relationships, such as centric, anterior guidance, overjet
and overbite.
Therefore, a full set of orthodontic records, including
radiographs, models and clinical photographs are recommended
to plan the preprosthetic orthodontic alignment. A diagnostic
wax set-up is also beneficial for planning treatment and
esthetics.3 Participating clinicians—the orthodontist, endodontist and prosthodontist should determine the patient’s
treatment plan collaboratively and communicate throughout the
course of treatment to ensure all aspects of treatment are
considered and the overall treatment objectives are achieved.4,6
The following case study involves all the restorative challenges
described, and demonstrates a multidisciplinary approach to
the treatment of an endodontically failed maxillary lateral incisor
with anterior restorative principles for esthetics.
CASE REPORT
1,4
Professor, 2Ex-Professor, 3Implantologist
Department of Prosthodontics, Rama Dental College, Hospital and
Research Centre, Kanpur, Uttar Pradesh, India
2
Department of Orthodontics, Teerthanker Mahaveer Dental College
Moradabad, Uttar Pradesh, India
3
Private Practice, SFS Sector 14, Faridabad, Haryana, India
4
Department of Prosthodontics, ITS Dental College, Ghaziabad
Uttar Pradesh, India
1
Corresponding Author: Manoj Varma, Department of
Prosthodontics, Rama Dental College, Hospital and Research
Centre, A/1 Lakhanpur, Kanpur-208024, Uttar Pradesh, India
e-mail: [email protected]
Received on: 09/10/10
Accepted after Revision: 13/12/10
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A 25-year-old female patient reported to the department with a
chief complaint of pus discharge from the labial aspect of the
upper front tooth. The patient gave a history of multiple episodes
of the same complaint for the past 12 months for which she had
undertaken treatment elsewhere, without permanent relief. She
had undergone multiple root canal procedures with the
associated maxillary left lateral incisor (Fig. 1). The IOPA
revealed a well-defined radioluscency in periapical region. The
fact that the tooth was still infected along with the patient’s
desire that she wanted to be cured, it was decided to extract the
offending tooth and subsequently prepare for a prosthetic
rehabilitation. A CT scan of the region (Fig. 2) showed
periapical radiolucency suggestive of chronic infection in
relation to 22. Since her adjacent canine was palatally placed
JIOS
Orthodontic and Esthetic Consideration for Anterior Single Tooth Implant
Fig. 1: Preorthodontic view
Fig. 4: CT scan after orthodontic correction
Fig. 2: IOPA of the region
Fig. 5: Acrylic teeth in Hawley’s appliance to
maintain space before implant
Fig. 3: Orthodontic correction and space creation
Fig. 6: Implant restoration after cementation
and in cross bite, an orthodontic intervention was sought. Fixed
orthodontic treatment was undertaken to correct the alignment
of adjacent individual teeth as well as create an ideal space for
the extracted lateral incisor (Fig. 3). After regaining space for
the lateral incisor (Fig. 4), the dimensions of alveolar bone were
buccopalatally 5.8 mm and occlusogingivally 17 mm. Therefore,
3.8 mm diameter and 13 mm long dental implant was placed
into the alveolar bone after the osteotomy. The correction was
The Journal of Indian Orthodontic Society, October-December 2010;44(4):134-137
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Manoj Varma et al
Fig. 7: Crown cemented after 10 weeks, healing phase showing good
interdental papilla stability created during healing phase with the use
of ovate pontic fixed in a removable orthodontic retainer
maintained using a Hawley’s retainer with an acrylic tooth in
place of the missing lateral incisor (Fig. 5) Provisional
restoration with an ovate pontic placement was given to create
ideal bed for the final prosthesis. A final impression was taken
after 10 weeks and a cement-retained prosthesis given (Figs 6
and 7).
DISCUSSION
Preprosthetic orthodontic treatment plan usually deals with the
alignment of adjacent crowns and roots before implant
restoration.4-6 Along with the orthodontic considerations, it is
important to predefine the goals of the orthodontic treatment
in consultation with the prosthodontist and/or other concerned
specialists. The principles for maintaining a healthy biological
width around natural teeth and im p l a n t s n e e d t o b e
considered. 8-10 In the present scenario, sufficient space
between the roots of the central incisor and canine had to
be created with additional orthodontic treatment to allow
placement of the implant fixture. During the course of the
orthodontic treatment, a rider pontic was given to maintain space
and improve esthetics. Following removal of the fixed appliances,
orthodontic retention was necessary to maintain this space and the
position of the teeth,11-13 so long as the implant-retained final
prosthesis is delivered. For this purpose a Hawley’s retainer with
the tooth (lateral incisor) was used.4
To accommodate a standard implant there should be a
minimum of 10 mm of incisogingival bone and a minimum of
6 mm of facial-lingual bone.12,13 In the presented case, there
was sufficient alveolar bone for implant placement, therefore,
ridge augmentation was not necessary. A minimum of 6 mm of
space mesiodistally is required to replace a lateral incisor crown.
The roots of the central incisor and canine should be almost
parallel or slightly divergent so as to avoid complications
resulting from root proximity during implant placement.
Usually, the tip of the central incisor is approximately 5° while
that of the canine is 13°, which means that the roots are slightly
divergent. Additional mechanotherapy, like the use of a “V”
bend to orthodontically position the roots of the adjacent teeth
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might be made use of for the purpose. The use of a nickeltitanium open coil spring is usually sufficient to create space.
Once created, an acrylic crown with a bonded bracket is ideal
to maintain the space. Additionally, a closed coil spring can be
used for the same purpose. Other considerations from an
orthodontic perspective include—an ideal placement of brackets
to achieve the correct root and crown positions; bending the
archwire to accentuate root divergence and bonding a
contralateral bracket on the central incisor (such as placing the
maxillary right central incisor bracket on the maxillary left
central incisor) to accentuate root divergence in the implant
area.5 Once the edentulous space has been created and the tissues
have stabilized following orthodontic treatment, the quantity
and quality of alveolar bone needs to be assessed before implant
placement. Considerations of occlusal factors, such as bruxism,
parafunctional activity, muscular dynamics, as well as tooth
mobility need to taken into account.7 A radiopaque guide stent
can be used with a CT scan to define tooth position better.
The correct surgical placement of a dental implant is
mandatory to obtain the ideal esthetic result. During preparation
of the osteotomy, care should be taken not to create excessive
heat, which can lead to necrosis of bone. A bur speed of 800
rpm (35-50 Ncm2 torque) sharp osteotomy burs, copious
irrigation, and sequential preparation of the osteotomy site is
required.
A mucoperiosteal flap is raised for osteotomy preparation
which assures maintenance of adequate blood supply. Papillasparing incisions with broad-base, full-thickness flaps are useful
in minimizing esthetic problems.14 It is important to evaluate
the bone buccal to the dental implant placement site, and place
the implant with a slight lingual direction so that adequate bone
is present buccal to the implant (Figs 8 and 9). This aids in
implant stability and soft-tissue coverage and provides ideal
emergence profile (Fig. 10). Restoration is the last stage in the
Fig. 8: CT cross-sectional image showing good bone implant
integration with stable labial plate
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Orthodontic and Esthetic Consideration for Anterior Single Tooth Implant
CONCLUSION
Single-tooth implants are the treatment of choice for most
patients with missing or grossly damaged anterior teeth.
Successful restorative treatment involving implants depends on
interdisciplinary treatment planning, especially when
preprosthetic orthodontic tooth alignment is required. This
article has illustrated the steps needed to create ideal esthetics
in the maxillary anterior region, to replace a maxillary lateral
incisor with an implant-supported prosthesis.
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Fig. 9: CT scan after implant placement
Fig. 10: Well-positioned implant with a natural emergence profile at
the crestal bone level
sequence. Improper restoration of a dental implant can negate
good pretreatment planning and good surgical technique. The
concept of emergence profile is particularly important when
treating the maxillary anterior region. The emergence profile,
in the present case, was obtained by creating an ovate pontic
allowing the tissues to form around a provisional restoration.
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