CHIEF COMPLAINT:
The patient did not like the appearance of the upper right central incisor. The tooth “clashed” and did not look “natural”. This was the reason that brought the patient to the consultation for the first time. After 5 years, the patient goes to the consultation because the implants placed in the place of teeth 1.2 and 4.6 “were not well”.
DIAGNOSIS:
Female patient, 36 years old, non-smoker. It presented tooth 1.1 with a darker shade than the adjacent teeth. After the imaging exam, it was observed that tooth 1.1 had endodontic treatment, the patient had 3 implants placed, two in the location of teeth 1.2 and 2.2 and the other in 4.6. The patient had been treated orthodontically, had a medium gingival phenotype and good oral hygiene. Five years after the first intervention, the patient presents at the consultation with infectious symptoms compatible with peri-implantitis in implants 1.2 and 4.6. After clinical examination, it was confirmed by imaging. Vertical bone loss was more than 4mm in both situations.
TREATMENT PLAN:
In the first intervention, the patient was offered a full crown with Zr infrastructure covered by ceramics. The fact that the tooth has an endodontic treatment was decisive in this option. In the second intervention, it was proposed to remove both implants. In the implant placed at the place of tooth 1.2, bone regeneration would be carried out simultaneously with the placement of the new implant. With the inevitable gingival retraction in the cervical area of the crown of the 1.1, it was also proposed to remove the crown of tooth 1.1. It was also said that for reasons of symmetry, if necessary, it could also be necessary to intervene in tooth 2.2. Thus, in the anterosuperior zone, we would have a crown screwed over a new implant placed in 1.2, a new crown on 1.1 and a veneer or crown in tooth 2.1 if necessary. In the implant placed in the 4.6 area, we propose to remove it, place a new implant, later rehabilitated with a screwed crown.
TREATMENT NOTES:
First phase.
Tooth 1.1 was prepared for a full crown, the gingival clearance was made with kaolin compressed by the provisional restoration. The impression was done with a double mixing technique with double viscosity. In the laboratory, a crown with Zr infrastructure covered by ceramics was made. The crown was cemented in the mouth with resin-reinforced glass ionomer cement.
Second phase.
5 years after the first intervention, the patient appears in the consultation with a peri-implantitis in the implants placed at the site of teeth 1.2 and 4.6. We begin by addressing peri-implantitis at the location of tooth 2.2. A temporary laboratory bridge was made of acrylic with 2 elements. Tooth 1.1 as a pillar and 1.2 as a pontic, the latter had distal support. The crown of the 1.2 was removed from the abutment with a longitudinal cut made with a turbine and then was fractured with a mini luxator. The abutment was then unscrewed from the implant. The same procedure was done to remove the crown from 1.1. Tooth 1.1 was re-prepared and the provisional bridge was relining in the mouth with self-curing acrylic. After the correct finishing and polishing of the provisional was done, it was temporarily cemented with polycarboxylate cement. In a later consultation. the temporary bridge was removed, surgery was performed to explain the implant, a new implant was placed and bone regeneration of the area was performed with a non-resorbable membrane. 3 months after the implant crown placed in 4.6 was removed. A horizontal cut was made with a turbine in the cervical area and with a mini luxator the crown was detached. After this procedure, the implant was explanted. After 6 months, a new implant was placed at the 4.6 site. After osteointegration, the impression was made using the open tray technique and a crown was screwed onto the implant in the laboratory. Approved by the patient, it was definitively screwed in the mouth. After 1 month, we removed the anterosuperior temporary bridge, reinforced tooth 1.1 with an intra-root post and reconstructed the abutment with a dual polymerization resin. In that same consultation, we exposed the implant placed in 1.2 and made an impression using the open tray technique with double viscosity silicone and fast setting. In the laboratory, a temporary bridge of 2 elements was made, screwed over the implant and cemented over the tooth. The first temporary bridge was removed and the second was placed on the implant. The cervical finishing line of 1.1 was relined with composite resin during the tightening of the implant screw. After it was removed, the finishes were made and finally pressed on the implant and temporarily cemented on the tooth. After 2 months of soft tissue maturation due to the emergency profile created by the new provisional bridge, we were able to assess the aesthetics achieved in conjunction with the patient. In this long process, tooth 2.1 had to undergo endodontic treatment. It was thus decided to make a crown on tooth 2.1 as well. Tooth 2.1 was prepared in the same consultation in which the impression was made on the implant. The temporary bridge was used to individualize the transfer part, copying its emergency profile and then the gingival clearance was performed with kaolin. The impression was made using the open tray technique with double viscosity silicone and fast setting. After choosing the color, the impression was sent to the laboratory where 2 crowns were made with infrastructure in Zr. ceramic coated for teeth 1.1 and 2.1 and a crown screwed onto the implant in tooth 1.2. The final work was approved by the patient and was definitively placed in the mouth. The crown on the implant was screwed with 35 N and the crowns were cemented with resin-reinforced glass ionomer cement.