Dental Tribune Middle East & Africa Edition

Media CME DENTALTRIBUNE Middle East & Africa Edition 6 By Joe Carrick, DDS Whendoingadiagnosticwork- up, if we line up each chal- lenge that is an obstacle in our quest to provide both a func- tional and an esthetic end re- sult, each solution we find brings us much closer to a pre- dictable overall result. This article will address the challenge of soft-tissue asymme- try in the cosmetic zone with a new approach to a very challenging problem that, until recently, had few pre- dictable solutions. The area extends from molar to molar in the maxillae in pa- tients with Type II and III lips. These are patients that show some soft tissue when smiling (Type II lip) to those that show significant soft tissue (Type III lip). Two cases The first case will deal with the anterior segment of soft-tis- sue asymmetry cased by trauma. The ERA implant is used pri- marily to provide sup- port for dentures in areas where the re- maining bone will not support conventional implants without sig- nificant bone grafting and other invasive proce- dures. It accomplishes this by reduc- ing the size but not the mate- rial composition of the conven- tional implants while adding an aggres- sive thread design that provides a self-tapping feature to the implant. The second case deals with a patientwithaTypeIIIlip,sig-nif- icant bone loss before implant placement and presents with an esthetic challenge. Case No. 1 The first patient presented with a bridge that had been placed after trauma to the ante- rior maxillae. Although one hard-tissue and two soft-tissue grafts had been performed and the new bridge constructed, the defect was still unacceptable to the patient. The hard- and soft- tissue defect was 6 mm inferior and 4 mm palatal to where it was necessary to create ideal tissue symmetry (Fig. 1). After a complete work up, the patient also needed his oc- clussal plane leveled for ideal function. While it would be relatively predictabletodoanonlaygraftto correct the facial defect, the ver- tical defect utilizing conven- tional grafting tech- niques was not predictable, as the patient had already experienced. We presented the patient with a treatment option that in- cludedorthodontics to correct the func- tional challenges, and offered him a treatment option that would incorporate a varia- tion of distraction osteogenisis in combination with surgical verti- cal displacement of the previous onlay graft utilizing thesmalldi- ameter ERA implants. With their aggressive thread design and subsequent fine tun- ing with three-dimensional dis- place- ment of the bone, the ERA implant allows for conservative surgery to maintain blood supply while sepa- rating the cortical bone plates and allowing con- trolled movement of the bone in the healing surgical site. We di- vided the treatment into three phases. Treatment phase No. 1 We made a resin bridge from the upper left cuspid to the upper right central incisor, replacing theleftlateralandcentralincisor (Fig.2).Wethenplaceda 2.2 x 10 mm ERA implant in the area of the upper left central and one in the upper left lateral in- cisor, making sure that weengagedtheprevious graft site extending well into the residual bone that was grafted (Figs. 3, 4). The resin bridge was cemented but out of con- tact with the implants that were placed without an incision with the abutment supragingival(Fig.5).Theortho- dontic treatment was initiated during the four months while bone integration took place around the implants. Treatment phase No. 2 The pontics were removed and altered by measuring the clinical crown of the upper right central and lateral incisor (mea- sured from the gingival crest to the incisal edge) then connected totheimplants.Thisthencreated a step in the incisal edges in this area corresponding to the hard- and soft-tissue defects (Fig. 6). After connecting the new resin crowns that correspond in size to the adjacent central and lateral, a conservative vertical incision was placed mesial to the upper left cen- tral and distal to the left lateral. The soft tissue was raised via tunneling to bone on the facial, but not on the lin- gual, in an attempt to preserve the blood supply to the bone around the implant, and was also the reason no horizontal incision was placed. The cortical plate was cut such that the implants and the bone between them was freed to allow us to pull the implants via altered resin crowns in- cisally to have the “in edges” as close to being level with- out blanching the tissue (Fig. 7). The area was grafted with mineralized and dem- ineralized cancellous bone, collagen membrane was placedand the vertical incisions were closed with 4-0 sutures. The surgical site was stabi- lized using the wire that was se- cured to the adjacent teeth and orthodontic brackets (Fig. 8). After the soft tissue healed and the sutures were removed, the active controlled orthodontic was reinstated. Treatment phase No. 3 After four months of ortho- dontic intervention to create an ideal func- tional occlussal scheme and osteoge- nisis in the anterior region (Fig. 9), we re- moved our ERA implants using a 2.4trephineburthatwasidealfor placing our 3.3 mm implant in the lateral area and 3.75 mm im- plant in the central incisor area. We gained the necessary verti- cal height in bone via our com- bined surgery and small amount of orthodontic osseous distraction, but were still defi- cientfacially, whichweachieved (mCME articles in Dental Tribune (always page 6) has been approved by HAAD as having educational content accept- able for (Category 1) CME credit hours. Term of approval covers issues published within one year from the distribution date (September, 2010). This (Volume/Issue) has been approved by HAAD for 2 CME credit hours. 2 Hours Utilizing the ERA over-denture implant to create soft-tissue symmetry in the esthetic zone Fig. 1: Case No. 1 — The patient already had one block bone graft and two soft-tissue grafts that pro- duced this result. (Photos/Provided by Dr. Joe Carrick) Fig. 2: We made a resin bridge from the upper left cuspid to the upper right central incisor, replacing the left lateral and central incisor. F Fig. 3 Fig. 4: A) Residual bone area; B) previously grafted bone area; C) exaggerated arch that will be addressed with orthodontics. C A B Fig. 6: The altered crowns over the implants were made to the same size as the adjacent teeth and this created a step on the inci- sal aspect, which was the amount of movement necessary to move bone. Fig. 7: The arrows mark areas of vertical incision. Fig. 9: Four months after ERA implant placement and prior to primary implant placement. A B B Fig. 5: A) Mark pontic position for implant placement; B) single-stage implant place- ment without incision, palatal to pontics. { Fig. 8: Implants and bone secured using the orth- odontic brackets.