Sarah reports to the periodontal implant practice with a history of biting into a cookie and hearing a popping sound of her endodontically treated front tooth.
A close-up of tooth #9, shows inflammation at the gingival margin created by a root fracture.
A palatal view shows an obvious vertical fracture apical to the endodontic access.
The vertical root fracture extends so far apically that it eliminates the possibility for extrusion of the remaining root or crown lengthening surgery.
Tooth #9 is extracted using the surgical dissecting microscope to remove all root fragments without traumatizing any of the surrounding soft tissue or alveolar bone. All granulation tissue is removed and decortication is performed.
A freeze-dried demineralized bone allograft is placed to the height of the bony crest.
A collagen (Biomend™) membrane is placed over the bone graft and under the soft tissue extending to and over the borders of the remaining alveolar bone.
Dr. Jacinthe Paquette prepared a Maryland Bridge with gold wings for ease of removal. Because the total treatment time may take a year, the gold wings will facilitate the ability to remove the Maryland Bridge multiple times.
The ridge lap pontic was converted to an ovate pontic using a flowable composite (Revolution™).
The ovate pontic is cemented to the adjacent teeth making sure that the surrounding soft tissue is supported in all directions. Some additional flowable composite is used to increase the contour at the palatal gingival margin.
Facial view of the Maryland Bridge cemented into place with all surrounding soft tissues well-supported.
A small circular incision to the implant head is made to minimally uncover the implant. Because a small flap-less incision is made, the surgical dissecting microscope and ¼ round bur are used to remove any bone overgrowth around the implant that can block proper seating of the hex head. A provisional crown is cemented into place.
Once 6 months of bone healing has been achieved, there is a residual soft tissue deformity or flattening which is plumped using a connective tissue graft.
Postoperative view once soft tissue healing has been achieved with a more desirable convex contour.
An opaque is added to diminish dark show through interproximally.
Removal of the Maryland Bridge with placement of a Nobelbiocare 3.75 x 12mm implant. Indexing is accomplished at the time of implant placement surgery.
Indexing provides for a model to create a provisional abutment to help insure ideal soft tissue contours and emergence profile.
A provisional crown is fabricated to the indexed model with ideal contours.
Soft tissue healing is accomplished for 6 weeks following provisionalization to allow for maturation of the epithelium.
A provisional abutment is placed to allow for additional tissue maturation.
Once final tissue healing has been achieved, then the final restoration can be placed.
A close up detailing the soft tissue maintenance and contours achieved when ideal soft tissue and bone are maintained.
