Treating young patients with missing teeth in the anterior area has very unique challenges. They can be missing anterior teeth for different reasons, most commonly from trauma or from congenital reasons. And often times, they are growing physically and learning to manage their emotions as they grow to be responsible young adults. Socially, they want to look their best as they go through important milestones in their life whether it be their first date/prom, first job interview or simply being confident out there with their friends. On the financial side of things, their parents are often the ones who pay for their treatment. And the dentistry required is not simple often requiring multidisciplinary efforts from the orthodontists, oral surgeons, periodontists and/or restorative dentists. And for most, dental implants are the most suitable treatment options but they may not be ready until later in life when they stop growing. So they need some treatment solutions that help manage these edentulous spaces from a few months to a few years.
There are many short term solutions to manage these anterior edentulous spaces ranging from simple acrylic partial denture (flipper), bonded tooth to the retainer or to adjacent teeth, an essix appliance or more. I find many patients prefer to use the essix appliance. But one of the problem with an essix appliance is it alters the occlusal relationship as the appliance essentially covers the occlusal surface of the dentition. Recently, I came across a case where I thought I witnessed the slight change in gingival contour and in occlusal relationship as the patient transitions from wearing an essix appliance to a temporary implant supported crown.
As an aside, I always temporize my anterior implant cases prior to fabricating the definitive prosthesis. This gives me an opportunity to objectively evaluate the aesthetic elements with the patient and to test drive their occlusal function and to evaluate my patient’s esthetic expectation before moving forward to the definitive prosthesis.
This young patient was referred to me with 21 (#9) already extracted. According to the history, she had an accident as a child and the tooth 21(#9) was deemed non restorable and was extracted by the referring dentist and temporarily replaced with an acrylic partial denture.
I ended up placing an implant at the site with simultaneous bone grafting. I didn’t want the flipper to put any pressure on the surgical site so I made an essix appliance for her instead.
She has been quite comfortable with this phase of the treatment and has been wearing the essix appliance until she is ready for uncovery. During the uncovery appointment, I fabricated a provisional implant supported restoration chairside to condition the tissue. It is expected that if there is adequate interproximal bone and the temporary restoration properly contoured, the gingival tissue should fill in the void you see in the picture. I checked very carefully to ensure the tooth is out of occlusion
The patient had to leave the country for two months. I instructed her to be careful as I really don’t know any dentists who can look after her implant crown should it come loose in her travel destination. Few weeks after this appointment, I received an email from her stating she thinks her implant crown was loose. She managed to find a local dentist who would tightened up her implant crown until she can come back to see me. She also informed me that she thought the tooth looked shorter. At the time, without seeing the tooth myself, I assumed the dentist may have shortened the tooth to relieve the occlusion. I told her not to worry but I will look after that problem when she comes back to see me.
So when she came to see me, I was curious how the interproximal soft tissue looked. This is the picture I took when she first came back:
I noticed the following:
- The gingival tissue did fill into the void interproximally. I was happy to see that!
- The gingival level on the implant crown is slightly higher than I had remembered
- The incisal position of the implant crown is shorter than the adjacent teeth and it didn’t looked like the dentist had shortened my temporary crown based on the contour of the incisal edge
As a comparison, I would put these pictures side by side for comparison
At the time, I didn’t have time to process the significance of this finding. I just went ahead to recontour the temporary so that it is aesthetically pleasing and functionally stable. But thinking back to see what went wrong, I really thought I had been very careful to adjust the occlusal contacts prior to sending this patient away for two months. Then it dawned on me that her teeth must have shifted as she now no longer wears the essix appliance and the occlusion may have settled a bit. And I wondered if this slight occlusal change may be responsible for the loosening of the temporary implant crown and the slight change in gingival level between adjacent teeth? I know this is one case report and the hierarchy of evidence is very low. But had I fabricated a permanent implant crown and to find out two months later that the crown looks shorter than the adjacent teeth, I would have a very unhappy patient let alone the consequences of sending this case back to the lab for adjustment or a remake.
This experience all the more reinforced my belief and protocol that all anterior implant restorations should be provisionalized to test out the occlusion and the aesthetics prior to fabricating the permanent restoration. Many of my patients don’t understand the significance of this portion of the treatment and I often feel the pressure to finish the case so that my patient can have the smile of their dream in time for their prom, their graduation or for their wedding. But I am much more cautious if my patient have the following:
1/Had been wearing an essix appliance
2/Immediate post-orthodontic treatment
3/Recent esthetic periodontal procedures
I would be more inclined to wait for a few months to wait for the teeth to settle and the gingival position to stabilize prior to finishing the implant restoration in the aesthetic zone. In most situations, I include the cost of fabricating a provisional implant crown as part of the treatment plan. This provisional implant restoration can also come in handy should the patient fractured the permanent restoration years later. This has saved me many time as the panic of having to deal with a chipped anterior implant crown can be relieved quickly with the knowledge that you have a backup provisional implant crown you can use.
I hope you find this experience useful in managing your young patients requiring implants in the aesthetic zone. Thanks for reading.
Please check out my other posts too.