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Case Report The Immediate Aesthetic and Functional
Restoration of Maxillary Incisors Compromised by Periodontitis
Using ShortImplants with Single Crown Restorations: A Minimally
Invasive
Approach and Five-Year Follow-Up
Mauro Marincola,1 Giorgio Lombardo,2 Jacopo Pighi,2 Giovanni
Corrocher,2
Anna Mascellaro,2 Jeffrey Lehrberg,3 and Pier Francesco
Nocini2
Universidad de Cartagena, Avenida del Consulado, Calle No. , No.
-, Cartagena, Bol ́ıvar, ColombiaClinic of Dentistry and
Maxillofacial Surgery, University of Verona, Piazzale Ludovico
Antonio Scuro , Verona, Italy Department of Biomaterials,
Implant Dentistry Centre, Arborway, Jamaica Plain, Boston, MA ,
USA
Correspondence should be addressed to Giorgio Lombardo;
[email protected]
Received July ; Accepted October
Academic Editor: Hsein-Kun Lu
Copyright © Mauro Marincola et al. Tis is an open access article
distributed under the Creative Commons AttributionLicense, which
permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited.
Te unctional and aesthetic restoration o teeth compromised due
to aggressive periodontitis presents numerous challenges orthe
clinician. Horizontal bone loss and sof tissue destruction
resulting rom periodontitis can impede implant placement andthe
regeneration o an aesthetically pleasing gingival smile line, ofen
requiring bone augmentation and mucogingival surgery,respectively.
Conservative approaches to the treatment o aggressive periodontitis
(i.e., treatments that use minimally invasive toolsandtechniques)
have beenpurported to yield positive outcomes. Here, we reporton
thetreatment and ve-year ollow-up o patientsuffering rom aggressive
periodontitis using a minimally invasive surgical technique and
implant system. By using the methodsdescribed herein, we were able
to achieve the immediate aesthetic and unctional restoration o the
maxillary incisors in a case thatwould otherwise require bone
augmentation and extensive mucogingival surgery. Tis technique
represents a conservative andefficacious alternative to the
aesthetic and unctional replacement o teeth compromised due to
aggressive periodontitis.
1. Introduction
Te assortment o maladies that constitute the broadly dened
periodontal disease runs the gamut rom relatively benign to
lie threatening [, ]. Te aetiology o periodontaldisease (and
its subsequent severity) has a number o ac-tors, including
deleterious bacteria in the oral environment,genetic
predisposition, and host inammatory and immuneresponses [–]. One o
the more severe orms o periodon-tal disease—aggressive
periodontitis—is characterized by destruction o the
periodontal ligament, recession o the gin-gival smile line,
andhorizontal resorption o thealveolarbone[, ]. Depending on
a number o variables, including theprogression o the disease and
the compliance o the patient,aggressive periodontitis can be
managed through nonsurgical
methods [, ]. However, in cases o advanced
aggressiveperiodontitis, surgical therapy may be indicated [].
In cases o aggressive periodontitis where the extent o the
disease necessitates surgical intervention, procedures thattake a
minimally invasive approach have been shown to beadvantageous in
regard to tooth preservation [, ]. Nev-ertheless, i
treatment o aggressive periodontitis is delayedor extended periods,
then salvage o the affected teethmay be unattainable; and removal o
compromised teeth isadvised []. Dental implants have become a
popular methodto restore the aesthetics and unctionality o teeth
lost toaggressive periodontitis [, ]. However, implant
placementin sites lost to periodontitis (i.e., locations
characterized by horizontal bone resorption) typically
requires concomitantbone augmentation procedures, a modality that
increases
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Dentistry Volume 2015, Article ID 716380, 7
pageshttp://dx.doi.org/10.1155/2015/716380
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Case Reports in Dentistry
F : Extent o the patient’s periodontitis upon presentation.
F : Right side view o patient upon presentation.
F : Lef side view o patient upon presentation.
the length o the healing and cost o the procedure and
hasunpredictable aesthetic outcomes [, ]. Here we report ona
minimally invasive surgical technique using a short implantsystem
that allowed us to ully restore the maxillary ante-rior incisors in
a -year-old emale patient who possessedextensivehorizontalbone loss
due to aggressiveperiodontitis.Using this technique and implant
system we were able to
F : Intraoral periapical radiographs showing horizontal boneloss
at all our maxillary incisors.
F : C scans o patient uponpresentation showing resorptiono
buccal and palatal bone adjacent to maxillary incisors.
unctionally and aesthetically restore the compromised ante-rior
teeth, without the use o bone augmentation procedures.
2. Case Presentation
A -year-old emale patient reported to us expressing con-cern
over the mobility o her teeth, the presence o a recurrentstula, and
overall displeasure with the height o her gingivalsmile line
(Figure ). Upon clinical examination, it wasdetermined that the
maxillary incisors (i.e., teeth numbers, , , and ) were compromised
and that horizontal boneresorption had occurred as a result o
aggressive periodonti-tis. Te right central incisor was extruded
and dislocated dueto secondary occlusal trauma, and the lef central
incisor pos-sessed a horizontal root racture
(Figures and ). Intraoralperiapical radiographs
revealed horizontal bone deects in allour o the maxillary incisors
(Figure ). Severe resorption o the alveolar ridge in the
premaxillary area, along with com-plete resorption o the buccal and
palatal bones adjacent tothe roots o maxillary incisors, was also
observed (Figure ).
Afer apprising the patient o her situation, we offereda number o
viable treatment options; however, the patienthas adamantly opposed
many o them. Because the patientdid not wish to use dentures and
wanted to retain theability to oss between prosthetic teeth, we
were restrictedrom implementing a number o conventional
treatmentoptions. Despite being constrained by both the extent
o patient’s periodontitis and her aorementioned wishes,
wenevertheless outlined a treatment plan that conormed tothe
patient’s desires and would restore the aesthetics andunctionality
o the compromised teeth. In agreement withthe patient, it was
decided that the compromised incisors beextracted and replaced with
our short locking-taper implants
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F : Postsurgical placement o Bicon implants. Te implantslie - mm
below the alveolar crest.
using a minimally invasive surgical technique which wouldnot
require ap raising or bone grafing procedures.
Te patient was treated with a local anaesthetic prior to
extraction (% Articaine with : , adrenaline, UbistesinR; M
ESPE). Care was taken to extract the teeth with mini-mum trauma so
as not to damage the buccal or palatal boneplates. Te compromised
teeth were luxated and extractedwhile avoiding lateral movement.
Following extraction o theaffected teeth, the implant sites were
prepared using a . mmdiameter pilot drill and a . mm drill on an :
hand pieceat RPM with constant irrigation (. mm Standard
PilotDrill, Bicon LLC, Boston, MA). Using a : hand pieceat RPM, the
osteotomies were produced by the sequen-tial use o ., ., and . mm
reamers (Latch Reamers,Bicon LLC, Boston, MA), ollowed by hand
reaming with a. mm reamer (diameter o implant). Bone obtained
romthe reamers was stored in a silicone dappen dish or
latergrafing. Te osteotomies were generated to a nal depththat
would result in the implant shoulders lying . mmbelow the alveolar
crest. Four endosseous root-orm shortimplants (. × .
mm MAX . Implants, part --, Bicon LLC, Boston, MA) were then
inserted usingthe manuacturers inserter and urther tapped in using
aseating tip (Figure ). Te implant placed in position wasinserted
in more vestibular position in order to accommo-date its size and
prevent intererence between prospectiveprosthetics (i.e.,
prosthetic on the lateral incisor). Boneharvested during reaming,
along with tricalcium phosphate(SynthoGraf Pure Phase
Beta-ricalcium Phosphate, part-- Bicon LLC, Boston, MA), was
applied to the
shoulder o the implant; healing plugs were used to avoid
thedeposition o bone graf particles inside the implant well.
Tehealing plugs were then replaced by preormed shoulderedparallel
abutments (Universal Stealth-Shouldered Abutment,Bicon LLC, Boston,
MA) upon which polycarbonate snap-on sleeves (emporization Sleeves,
Bicon LLC, Boston, MA)were adapted to receive an immediate
temporary restoration(Figures , , and ).
Te immediate temporary restoration consisted o a non-unctional
temporary bridge, which was seated and adjustedto clear centric and
eccentric contacts and to support thepapillae without encroachment
(Figure ). Te implemen-tation o a “snap-on” system between the
abutment and
F : Postsurgical X-ray showing implants afer surgery
withprovisional abutments inserted.
F : Preormed shouldered abutments with polycarbonatesnap-on
sleeves.
F : Polycarbonate snap-on sleeves adapted to receive tempo-rary
bridge.
emergence sleeve precluded the use o cementation, whichin turn
abrogated the potential or sof tissue irritation.Postoperative care
included grams o daily oral antibioticsor days (Augmentin,
GlaxoSmithKline, Verona, Italy).Additionally, the patient was given
detailed postoperativeinstructions about analgesic therapy and oral
hygiene, alongwith a .% chlorhexidine mouth rinse to be
administered times a day or days (GUM PAROEX ChlorhexidineGluconate
Oral Rinse ,% CHX + ,% CPC, SunstarSuisse S.A., Etoy, Switzerland).
Tree weeks afer surgery, C
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F : Close-up o tissue graf site and restoration at
ve-yearollow-up.
F : Radiographs at ve-year ollow-up showing interproxi-mal bone
and bone at implant shoulder.
Bone resorption owing to periodontitis in the aestheticzone
makes aesthetically pleasing and convincing restora-tions difficult
by interering with implant placement andpreventing the regeneration
o a natural looking gingivalsmile line [, , –]. Tis
report describes the restorationo anterior maxillary incisors in
the aesthetic zone compro-mised by aggressive periodontitis using a
minimally invasivetechnique and short implants. Due to the
patient’s peri-odontitis and desired nal outcome, treatment options
wererestricted. Patient preerence urther prohibited the use
o removable prostheses or xed bridges, and patient morphol-ogy
and horizontal bone loss limited the number o possibleimplant
system choices. o overcome the challenges this casepresented, we
decided to use a minimally invasive surgicaltechnique in concert
with the postextractive placement o
short implants: a modality that satised both the unctionaland
aesthetic requirements, along with the patient’s wishes.
We were initially concerned that the close proximity o the
implants (both to each other and to the adjacentteeth) might
negatively impact the outcome o the procedure;thereore, we chose an
implant system that was particularly suited or the conditions
described herein [–]. Te smallsize o the selected implant system
allowed the placemento our individual implants with corresponding
crowns inregions where aggressive periodontitis had caused
excessivehorizontal bone loss, a eat which would be impossible
usinglarger implant systems. Te unique macrogeometry o theimplant
system (i.e., sloping shoulder) afforded space or
(a)
(b)
F : Beore and afer image depicting the patient uponpresentation
(a) and the patient at ve-year ollow-up (b).
interproximal bone growth, which consequently supportedthe
aesthetically pleasing interdental papillae that developed[, ].
Furthermore, in comparison to an implant-supportedbridge, the use o
our individual crowns will acilitate greaterhygienic maintenance in
the long term and—perhaps moreimportantly—was in compliance with
the patient’s wishes.
We recognized that choosing not to splint the implants—along
with choosing to use short implants in the rst place—might affect
the long-term success o this procedure, as it hasbeen demonstrated
that the crown height can act as a verticalcantilever, and an
angled prosthetic load magnies the orceapplied on implants (i.e.,
overloading). o offset the potentialor overloading, we minimized
the nonaxial orces applied tosingle crown implants by maintaining
the preexisting canineguide. Additionally, the plateau design o the
implants usedreports a surace area % higher than other screw
ormimplants o similar length, urther reducing the potential
oroverloading [].
However, due to this peri-implant design, probing depthsusing
the periodontal probe must be taken into considerationcareully,
because the implants hemispherical base shouldnegate the vertical
use o a periodontal probe. Nonetheless,the absence o bleeding on
probing along with the absence o plaque around prosthetic
crowns is denitely a positive signsupporting the health o
peri-implant tissues.
While the short implant system imparted much greaterexibility in
regard to potential treatment options, we nev-ertheless were
required to perorm tissue grafs. Destructiono connective tissue and
concomitant gingival recession is ahallmark o periodontitis and is
observed in implant proce-dures in general [, ]. However, in
this particular case, thiswas expected due the vestibular placement
o the implant inposition . Nevertheless, the sloping shoulder o the
implantsystem we implemented allowed or increased interproximalsof
tissue growth and vascularization and yielded betteroutcomes where
mucogingival surgery was concerned.
o the best o our knowledge, this is the rst reportconcerning the
immediate placement and loading o our
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short implants into resh maxillary alveolar sockets to
restorethe incisors group single crown restorations. Based on
thepositive unctional and aesthetic outcomes observed in thiscase
report, we conclude that a minimally invasive, aestheti-cally
pleasing, and unctionally stable restoration o anteriormaxillary
incisors can be achieved using an implant design
with platorm switching at implant level andat abutment levelin
regions o bone compromised by periodontitis.
Conflict of Interests
Jeffrey Lehrberg is unded in part by Bicon LLC. Te underhad no
role in study design, data collection and analysis,decision to
publish, or preparation o the paper.
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