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The maintenance and development of an esthetic hard- and soft-tissue complex becomes a prerequisite in implant therapy, particularly when treatment occurs in the esthetic zone.1 An implant that is osseointegrated does not always translate into esthetic success.2 Recession after tooth removal in the anterior maxilla presents a unique restorative challenge for the practicing clinician. The objective after removal is to maintain the hard- and soft-tissue architecture. The most difficult area is the papilla.
Everything possible must be done to maintain the volume of tissue and position and prevent shrinkage. The most effective way of maintaining the papilla and soft tissue height is to prevent its loss at the time of extraction. The gingival architecture must be maintained and supported immediately after extractions. This requires precise surgical technique without removing interproximal or facial bone. The extraction must be as atraumatic to the tissue as possible. Surgical flaps and incising of the papilla should not occur in the ideal situation.
Critical to the preservation of tissue height is to control the gingival embrasure at the time of extraction. If the embrasure space is not filled with a provisional with the same volume as the previously existing tooth, the papilla and surrounding tissue will lack support, causing the gingival scallop to flatten out and the interproximal papilla to recede.3
To select either immediate- or post-extraction implant placement, several factors have to be considered, including the anatomy of the extraction site, the surgical procedure, duration of treatment required, and the esthetic result. The success of the immediate implant placement procedure depends on the primary stability of the implant, attained by drilling the bone beyond the extraction site. It is not early loading that creates the effect of fibrous encapsulation, but rather micro-movements at the bone–implant interface resulting from inadequate primary stability.4
Studies have indicated that immediate placement of an implant in an extraction site is as successful as delayed or staged implant placement in a healed and mature bony site, with the additional advantage of a shorter treatment time.5-7 Before extraction of the tooth, the gingival form and bony architecture must be evaluated. If the existing tissue and bone is acceptable, then the objective is to preserve as much of the original form as possible. Because the soft tissue follows the architecture of the underlying bone, if there is facial bone loss, a degree of recession can be expected. The bone is needed to maintain and support the overlying tissue. Additional treatment may be necessary at the time of extraction, which may include bone grafting.8 The predictability of treatment is also influenced by the thickness of the periodontium, as thicker tissues have a reduced tendency to recede, while thinner biotypes are more prone to recession.9-10
A variety of treatment alternatives are available for the replacement of a missing single maxillary anterior tooth. However, the optimal restorative option in a given case is often defined by the esthetics, biocompatibility, and functional characteristics of the edentulous site and surrounding tissues.11 The basic treatment options include: 1) an adhesive bridge, used in combination with ceramic laminate veneers if necessary; 2) a conventional ceramometal fixed bridge; 3) a conventional non-ceramometal fixed bridge; 4) a single-tooth implant; and 5) a removable partial denture.
To determine the optimal treatment for a specific patient, a complete set of diagnostic records must be obtained. The records must include mounted study casts, obtained by a reliable maxillary model orientation technique on a semi-adjustable articulator,7 a complete set of radiographs, and the results of the definitive clinical examination. The results must include sulcular depth recordings; “sounding” of facial, proximal, and palatal bone levels; photographic documentation; and a diagnostic wax-up if appropriate. Pertinent subjective factors, such as treatment duration, projected longevity of the restoration, potential complications, patient motivation and compliance, and treatment expense must be assessed.8 Patient expectations and the technical skill of the dentist and interdisciplinary team (eg, periodontist, oral surgeon, orthodontist, and dental technician) must be evaluated and considered in the treatment plan. Selection of the most appropriate treatment option should be guided by the interpretation of the individual circumstances of a patient in light of the objective and subjective factors. Establishing the treatment plan in this manner precludes inappropriate and unsatisfactory treatment results.
After tooth extraction in the anterior maxilla, a provisional restoration must be placed to protect and preserve the gingival architecture and underlying bone. Numerous options are available for the dentist. A removable appliance such as a Hawley retainer with a denture tooth is possible, but the movement of the appliance can be detrimental to the papilla and surrounding gingiva. When the patient eats, the upward pressure can flatten the papilla causing dark triangles to be present between the adjacent teeth in the final restoration. If a removable appliance is used, a tooth-borne type should be considered. An example is an Essix retainer. This is a very thin, 0.2-mm plastic retainer that is made in the laboratory and worn over the teeth. The missing tooth area is filled in with a denture tooth or composite resin. Because it is tooth-borne, movement of the appliance will not put pressure on the papilla and underlying tissue. This will help maintain the papilla. Removable appliances are not the first option when considering replacement of a missing anterior tooth due to the inconvenience of removal, speech impediment, and possible tissue trauma.12,13 The ideal provisional for the replacement of a lost anterior tooth is a fixed or bonded type. If the patient is going to be having a fixed partial denture as a final prosthesis to replace the missing tooth, then the adjacent teeth next to the edentulous space must be prepared for full or partial coverage before extraction. This is done before extraction so that nothing will be forced into the extraction site.
If the patient is not sure of the final type of restoration, then no treatment of the adjacent teeth should be done. A provisional restoration that protects the tissue the best is the treatment option of choice. Composite resin can be used by bonding to the adjacent teeth and forming a pontic. This can be difficult due to the inability to control a dry environment. A mesh material along with composite resin could be used along with the crown of the extracted tooth to form a Maryland-type bridge provisional. This type of provisional has worked quite well in the past and continues to be a viable option today. The treatment choice for the following clinical case employs a metal mesh along with resin and resin cement to provisionalize a lateral incisor that needed to be extracted because of infection and periodontal issues.
The imperceptible replacement of a single anterior tooth requires several decisions of critical importance. The first being atraumatic extraction of the tooth. This must be done in a very conservative manner without the removal of bone or possible damage to the facial plate. The second factor is how the extraction socket is handled with the use of a provisional restoration. A removable appliance is the not the treatment of choice when dealing with an esthetic issue in the anterior portion of the mouth. These appliances have a tendency to flatten out papilla and create black triangles in the definitive restoration due to their movement. The best way to maintain the papilla is to prevent its loss in the first place. A bonded provisional into the extraction socket after extraction will maintain the integrity of the tissue and allow the freedom to create the final restoration of choice after healing. Patients are happy that a removable appliance is not needed. If there was adequate bone present and no infection, the treatment of choice would have been immediate implant placement after extraction and provisionalization using the patient’s natural tooth cemented over the abutment.
1. Saadoun AP. The key to peri implant esthetic dent. Implant Update. 1997;8(6):41-45.
2. Phillips K, Kois JC. Aesthetic peri implant site development: The restorative connection. Dent Clinic North Amer. 1998;42(1):57-70.
3. Meyenberg KH, Imoberdorf MJ. The aesthetic challenges of single tooth replacement: A comparison of treatment alternatives. Pract Periodont Aesthet Dent. 1997;9(7):727-735.
4. Favero GA, et al. Considerations preliminary to the application of early and immediate loading protocols in dental implantology. Clin Oral Implants Res. 2000;11:12-25.
5. Block MS, Kent JN. Placement of endosseous implants into tooth extraction sites. J Oral Maxillo Fac Surgery. 1991:49(12):1269-1276.
6. Valentini P, Abensur D, Albertini JF, Rocchesani M. Immediate provisionalization of single extraction-site implants in the esthetic zone: a clinical evaluation. Int J Periodontics Restorative Dent. 2010 Feb;30(1):41-51.
7. Tomasi C, Sanz M, Cecchinato D, Pjetursson B, Ferrus J, Lang NP, Lindhe J. Bone dimensional variations at implants placed in fresh extraction sockets: a multilevel multivariate analysis. Clin Oral Implants Res. 2010 Jan;21(1):30-6.
8. Lansberg CJ, Nichacho N. A modified surgical/prosthetic approach for optimal single implant supported crowns. Part 1: The socket seal surgery. Pract Periodont Aesthet Dent. 1994;6(2):11-17.
9. Sanavi F, Weisgold AS, Rose LF. Biologic width and its relation to periodontal biotypes. J Esthet Dent. 1998;10(3):157-63.
10. von Arx T, Salvi GE, Janner S, Jensen SS. Gingival recession following apical surgery in the esthetic zone: a clinical study with 70 cases. Eur J Esthet Dent. 2009 Spring;4(1):28-45.
11. Spear FM. The use of implants and ovate pontics in the esthetic zone. Functional Esthetics & Restorative Dentistry. 2008;1(2):64-69.
12. Rao J, Fields HW, Chacon GE. Case report: autotransplantation for a missing permanent maxillary incisor. Pediatr Dent. 2008;30(2):160-6.
13. Savarrio L, McIntyre GT. To open or to close space--that is the missing lateral incisor question. Dent Update. 2005;32(1):16-8, 20-2, 24-5.
14. Chiche GJ, Aoshima H. Functional versus aesthetic articulation of maxillary anterior restorations. Pract Periodont Aesthet Dent. 1997;9(3):335-342.
15. Meyenberg KH, Imoberdorf MJ. The aesthetic challenges of single tooth replacement: A comparison of treatment alternatives. Pract Periodont Aesthet Dent. 1997;9(7):727-735.
About the Author
Robert Margeas, DDS, Adjunct Professor, Department of Operative Dentistry, University of Iowa, Des Moines, Iowa; Private Practice, Des Moines, Iowa