The Power of Preparation: Achieving Ideal Esthetic Results

INTRODUCTION
Success does not happen by accident; it happens with hard work and preparation. Being prepared for a speech, exam, or sporting event will give you more confidence and allow you to perform better in whatever task you are attempting. “There are no secrets to success. It is the result of preparation, hard work, and learning from failure.” – Colin Powell

Take sports, for example. Athletes spend more time in the gym or practicing than they do in actual competition. This dedication and commitment is one key to becoming a better athlete. Many people think that Tiger Woods woke up the world’s greatest golfer, or was born with an inordinate amount of talent. This is simply not true. Mr. Woods spent more time watching, practicing, and playing golf by the time he turned age 5 years, than most people will do in a lifetime. He also spends countless hours preparing for specific events, courses, and shots, so no matter what the situation, he is ready for whatever comes at him.

Being prepared in dentistry is just as important as being prepared for the US Open, especially when it comes to anterior esthetics and implants. If not properly planned, the result can be disastrous not only for the patient’s smile, but for the patient’s confidence in you as a practitioner.

Of all the problems that can occur with implant placement in the anterior region, not controlling the soft-tissue height and health may be the most problematic when it comes to anterior esthetics. Gingival zenith, or height of gingival contour, is defined as the apex of the gingival height. Many factors can result in the apical displacement of the soft tissue. If this occurs, it may result in insurmountable limitations in anterior implant esthetics.

How Do We Ensure Proper Soft-Tissue Management and Gingival Zenith Location for a Single Implant Restoration?
There are 3 keys to this answer: proper planning, placement, and provisionalization. When preparing for an esthetic implant case with my periodontist, we both decide where we want the zenith to be esthetically, and then plan implant placement accordingly. The usual rule of thumb is 3.0 mm apical and 2.0 mm palatal to the desired location of the gingival zenith. Keeping biology at the forefront of my decision, this location will allow us to preserve the zenith from a surgical standpoint, similar to the technique utilized during esthetic extraction site development via ovate pontics. This is only possible if the underlying foundation, the osseous structure, is exactly where we need it to be to support the tissue. If the health of the tissue, and more importantly, the osseous architecture, are not ideal prior to placement, other measures need to be taken to establish soft- and hard-tissue health.

Of equal importance in controlling the gingival architecture is fabrication of the provisional. Prosthetic control of peri-implant tissue, achieved by properly utilizing the abutment and provisional form, is extremely important. The gingival zenith should be maintained at the time of placement of the provisional. When creating an immediate provisional restoration, a flat or slightly convex surface is created facially and lingually, and a concave surface interproximally. The facial aspect, when slightly convex, allows us to create a scaffold to “hold up” the tissue and prevent it from collapsing. A concavity interproximally will minimize impingement on the tissue interproximally and may result in overgrown tissue. This tissue can be contoured prior to final placement to give an ideal esthetic gingival architecture. If the provisional is overbulked and causes any undesired loss or change in gingival tissue, it will be impossible to recover or regrow it.

It is evident that proper planning is critical to esthetic implant success, as it is in achieving success in general. Ideally, we would like the gingival zenith to be exactly where we want it and the health of the tissue to be ideal. In order to do that, we need a stable foundation of bone with the proper osseous architecture to support it. From there, an atraumatic extraction with ideal implant placement and a well-contoured provisional can lead to world-class results. A study by Calesini et al¹ showed anatomic evidence that the morphology of overlying tissues is dependent on the underlying support (bone, implant, roots) but also significantly influenced by the overlaying structures (fixed or removable prostheses). However, what if the tissue and/or bone is not in good health, or the tooth cannot be extracted atraumatically for immediate implant placement (Figure 1)? What type of provisional do we go with as an alternative option? Do we graft soft tissue, hard tissue, or both? There can be numerous options, hence it is critical to be prepared for any and every situation.

If our “go-to shot” (ie, immediate extraction and provisionalization) fails, we must be prepared for whatever comes next. Tiger Woods has been known to drop golf balls into a sand trap and step on them; then he practices shots from a seemingly impossible lie. Although he may only face this shot a few times per season, he wants to be fully prepared for the situation. It is this kind of mentality that clinicians must take into treatment planning and executing these multidisciplinary esthetic challenges.

CASE REPORT
Diagnosis and Treatment Planning
This 36-year-old male patient has been a friend and patient of mine for many years. He presented to our office initially with a “black tooth” in site No. 8 (Figures 2 to 4). When asked how this happened, he told me that he had a pillow fight when he was a teenager, hitting both front teeth on a dresser, leaving a mark in the wood. The following day, he went to a dentist who placed a splint on both front teeth. About a year later, the tooth became symptomatic and discolored. Root canal therapy was completed and the tooth remained asymptomatic over the years since. However, it had slowly discolored.

Figure 1. Fractured tooth with gingival inflammation.	Figure 2. Pre-op full-smile 1:2 photo.
Figure 3. Pre-op retracted 1:2 photo.	Figure 4. Pre-op retracted 1:1 photo.
Figure 5. Pre-op radiograph, tooth No. 8.	Figure 6. Extraction of tooth No. 8 (in 2 pieces).
Figure 7. Occlusal view of implant placement site No. 8.	Figure 8. Retracted view of implant placement.

Unfortunately, due to finances, the patient did not have the means for proper treatment of this tooth, which obviously would include extraction and placement of a dental implant. However, with the help of an excellent and generous team, we were able to provide treatment that worked within the patient’s current financial budget.

From the preoperative radiograph (Figure 5), it was obvious that the patient had internal resorption on the right central incisor, tooth No. 8. The treatment plan was not only going to be dependent on its extraction, but also significantly influenced by the existing osseous and gingival conditions. Upon bone sounding, we found a probing depth to bone of 3.0 mm on the facial, and 4.0 mm interproximal. These depths were ideal and clearly helped explain the health of the tissue regardless of the presence of internal resorption in the tooth. Stated simply, the “foundation” was ideal for immediate extraction and implant placement. The other critical factor in diagnosis is seen radiographically. As seen in the pre-op radiograph (Figure 5), the osseous structure interproximally had adequate thickness and was not “paper thin.” This is critical for the case because the thicker the interproximal bone, the less likely we are to lose the entire interproximal height. Inevitably there would be some loss following extraction and implant placement; however, as long as the bone closer to the adjacent teeth stayed at its original height, enough osseous structure would be available to support the soft tissue across the facial aspect of the implant, as well as interproximally. This would make it less likely to develop the dreaded “black triangles” in the final prosthesis and be critical in maintaining the tissue height at its original starting point.

On the day of extraction, if the buccal plate is intact following extraction, and an implant is able to be placed immediately with initial torque of 35 Ncm or greater, the patient will receive immediate provisionalization. If not, a bone graft will be placed, followed by a resin-bonded Maryland bridge that incorporated an ovate pontic design.

The restorative treatment plan would consist of a zirconium abutment, followed by a pressed lithium disilicate crown (IPS e.max [Ivoclar Vivadent]).

Treatment Protocol
Following acceptance of the treatment plan, upper and lower alginate impressions were taken and poured up in dental stone. A face-bow transfer (Denar [Whip Mix]) was done, and photographs were taken. Our laboratory team fabricated a silicone putty (Sil-Tech [Ivoclar Vivadent]) matrix to be used to make the provisional restoration. In addition, facial and incisal reduction guides were fabricated using the upper study model.

Figure 9. Immediate provisional on temporary abutment and implant analog.	Figure 10. Post-op photo of provisional, 4 weeks after insertion.
Figure 11. Post-op full-smile 1:2 photo.	Figure 12. Post-op retracted 1:2 photo.
Figure 13. Post-op retracted 1:1 photo.	Figure 14. Post-op radiograph of the completed implant and lithium disilicate (IPS e.max [Ivoclar Vivadent]) restoration.

The patient then proceeded to the periodontist for extraction of tooth No. 8, with the hope of an immediate placement of a dental implant. Using peritomes, a palatal approach was taken to minimize any trauma to the buccal plate. Although the root was retrieved in 2 pieces atraumatically, the surgeon was indeed able to place the implant (Replace Select 4.3 x 13 mm implant [Nobel Biocare]) at the time of extraction (Figure 6). The implant torque tested greater than 35 Ncm and was ready for immediate provisionalization (Figures 7 and 8).

The patient presented from the surgeon’s office with a healing abutment above the height of the tissue, and 4-0 vicryl sutures (Ethicon). The abutment was removed and a temporary cylinder was tried-in and marked with a permanent marker in order to adjust the height out of the mouth. The abutment was adjusted in the laboratory and placed back in the mouth. The previously fabricated silicone putty matrix was filled with InstaTemp (Sterngold) and then seated in the mouth for 3 minutes. Next, an access hole was prepared with a high-speed handpiece in order to utilize the provisional as a screw-retained prosthesis. The margins were then sealed with a flowable composite (Tetric EvoFlow [Ivoclar Vivadent]) and the occlusion was adjusted so that the provisional was out of occlusion in centric occlusion, as well as lateral and protrusive movements. The cervical areas of the temporary crown were made concave in order to relieve any pressure on the soft tissue during healing (Figure 9). This, at worst, would allow for some overgrowth of tissue, which could then be contoured later (Figure 10). Finally, written and verbal postoperative instructions were given to the patient.

After 4 months of healing, per the surgeon, the patient was cleared for implant-level impressions. The provisional was removed and an impression coping was placed on the implant in site No. 8. A periapical radiograph was taken to confirm seating. A full upper arch impression tray with a polyether impression material (Impregum Soft [3M ESPE] was used for the impression. A face-bow transfer, bite registration (Futar D [Kettenbach LP]), and an opposing alginate impression were taken.

Laboratory Instructions
The patient and I agreed upon a base value shade of VITA 3D shade 2M2 with effect enamel shade tabs utilized for the characterizations of the tooth. Multiple photos were taken with numerous shade tabs and sent to our dental laboratory team. My laboratory prescription included the following:

• Upper polyether impression
• Lower yellow stone model poured from alginate impression
• All 12 American Academy of Cosmetic Dentistry required photos (visit aacd.com)
• Photos of stump shade and provisional
• Photos of stick bite and face-bow in place
• Face-bow transfer
• Written details of required outcome.

Prior to fabricating the final restoration and, after a conversation with my laboratory technician, the decision was made to fabricate an Atlantis Zirconium abutment with a lithium disilicate crown. The ingot was pressed to full contour, and then cut back and microlayered for ideal esthetics.

Delivery of the Final Restoration
On the day of insertion, the patient was anesthetized with 3.6 cc 4% Septocaine (Septodont) via infiltration. The provisional was removed, and the gingival area was rinsed with Peridex (3M ESPE). The abutment was tried-in followed by the crown, and a radiograph was taken to confirm the full seating of both. Photographs at a 1:1 magnification were taken and reviewed to evaluate, size, shape, and shade. When all aspects of the crown were exceptional, the abutment screw was torqued to 25 ncm. The access hole was filled with a cotton pellet followed by a semi-flexible resin temporary (Fermit [Ivoclar Vivadent]). A transparent resin-based temporary cement (TempBond Clear [Kerr]) was used in order to not affect the value of the crown (Figures 11 to 14).

CLOSING COMMENTS
This case was not only extremely rewarding; it was very challenging as well. Due to the long-term damage of the original tooth, care and precision were required from start to finish in order to obtain an optimal result. With an exceptional team approach adhered to by the periodontist, the dental laboratory team, and the restorative dentist, and with adequate time allowed for discussions needed to prepare for all aspects of the case, an incredible result was achieved, and the patient was satisfied above and beyond his expectations.

The truly rewarding part of this case was being able to change a patient from someone who avoided dental treatment because of past fears, neglect, and finances, into someone who is now preaching good oral health to others and is looking for more ways to improve his smile and overall oral health.

Usain Bolt, the world’s fastest man, trained for years to prepare for a 10-second Olympic race; a race that made him a world superstar. He did not walk up to the track the day of the Olympics and blow away the competition. He spent countless hours preparing physically and mentally for that one moment in the spotlight. This same dedication, along with plenty of patience, certainly applies to dentistry. When an anterior implant case, or any case for that matter, is properly team planned, the result can be as good as Olympic Gold.

Acknowledgment
The author would like to acknowledge the dental laboratory team at San Diego Aesthetic Dental Studios (San Diego, Calif) for the excellent collaborative and technical work, as well as Dr. Anthony Polimeni, periodontist, Huntington, NY, for his outstanding surgical treatment in this case.

Reference

1. Calesini G, Micarelli C, Coppè S, et al. Edentulous site enhancement: a regenerative approach for the management of edentulous areas. Part 1. Pontic areas. Int J Periodontics Restorative Dent. 2008;28:517-523.

Suggested Readings
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Chiche GJ, Pinault A. Esthetics of Anterior Fixed Prosthodontics. Chicago, IL: Quintessence Publishing; 1994.
Chu SJ, Devigus A, Paravina RD, et al. Fundamentals of Color. 2nd ed. Chicago, IL: Quintessence Publishing; 2010.
Colvin G. Talent is Overrated. New York, NY: Penguin Group; 2008.
Cooper L. Contemporary concepts for dental implant treatment planning . Presented at: 54th Annual AES Meeting; February 25-26, 2009.
Cranin AN, Klein M, Simons A. Atlas of Oral Implantology. New York, NY: Thieme Medical Publishers; 1993.
Dawson PE. Functional Occlusion: From TMJ to Smile Design. St. Louis, MO: Mosby Elsevier; 2007:159-172, 365-377.
Irvani A. A five-step protocol for immediate-load implant treatment planning. Inside Dentistry. 2009;5:46-50.
Kois JC. Esthetic extraction site development: the biological variables. Oral Health. 2004;94(pt 4):62-72.
Notarantonio AE. The power of preparation: how to ensure proper gingival zenith position for a single dental implant restoration. surgicalrestorative.com/articles/2012/12/the-power-of-preparation-for-a-single-dental-implant-restoration.html. Accessed September 23, 2013.
Photographic Documentation and Evaluation in Cosmetic Dentistry: A Guide to Accreditation Photography. Madison, WI: American Academy of Cosmetic Dentistry; 2009.

Dr. Notarantonio is a graduate of the State University of New York at Stony Brook School of Dental Medicine (2002). He is a member of the ADA, the AGD, the American Equilibration Society, the American Academy of Cosmetic Dentistry (AACD), the Academy of Osseointegration, and the International Congress of Oral Implantologists. Dr. Notarantonio is a certified basic, intermediate, and advanced trainer for the CEREC 3-D chairside CAD/CAM system and has completed the Dawson Academy Core Curriculum Series. He is currently training at the Kois Center under Dr. John Kois. He is certified in the surgical placement of dental implants, Invisalign invisible braces, and CEREC single-visit crowns/onlays. He has recently received his Fellowship in the International Congress of Oral Implantologists and has recently passed the accreditation process in the AACD. Dr. Notarantonio volunteers for the AACD’s Give Back A Smile program. He has been published in Compendium and Dental Products Report. He can be reached at (631) 425-0300 or at hbdental.com.

Disclosure: Dr. Notarantonio reports no disclosures.