CHIEF COMPLAINT:
The patient did not like the result of the treatment in the middle of it. The colleagues had placed an implant in the 2.1 site and performed two periodontal surgeries with the goal of improving the gingival architecture of the area. “I don't like the look of the gums or the temporary teeth and I don't want to do any more surgery”. In short, the patient wanted to improve her esthetics without surgery.
DIAGNOSIS:
42-year-old female patient, non-smoker. He had missing teeth 2.1 and 2.2 and an implant placed in the location of tooth 2.1. This implant supported a screw-retained 2-element temporary bridge. Teeth 1.2 and 1.1 were rehabilitated with 2 crowns, teeth 1.2 had a buccal ceramic fracture and teeth 1.1 had an exposed and infiltrated cervical margin. The gingival architecture of the edentulous area showed an absence of interdental papilla and a high cervical margin, despite having already undergone two periodontal surgery interventions. The temporary bridge over the implant had little anatomical contours and a lot of bacterial plaque. The absence of tooth 2.5 was noted and tooth 2.6 had endodontic treatment and appeared to be extruded. The patient has a medium gingival phenotype and good oral hygiene.
TREATMENT PLAN:
The patient was asked to make a 2-element bridge screwed to the implant placed in the 2.1 site and a 2-element bridge to rehabilitate teeth 1.2 and 1.1. After correcting the anatomy of the provisional bridge over the implant, the gingival architecture of the area would be evaluated, and the hypothesis of using a bridge with a ceramic coronary and gingival component could be considered. In the treatment plan for the 2nd quadrant, the placement of an implant in the location of tooth 2.5 and making a 2-element bridge, cemented over tooth 2.6 and screwed to the implant, was planned.
TREATMENT NOTES:
The provisional bridge was unscrewed to assess the underlying gingival architecture. The soft tissues were inflamed and it was necessary to correct the emergence profile and anatomy of the pontic. The provisional bridge was also duly cleaned and polished. However while we were waiting for the improvement of gingival health in this area, a temporary acrylic bridge was made in the laboratory to rehabilitate teeth 1.2 and 1.1. The crowns were removed and the abutments re-prepared. The temporary bridge was relined in the mouth first with self-curing acrylic and then with composite resin in the cervical area. The provisional bridge, after being properly finished and polished, was temporarily cemented in the mouth. After 3 months, the definitive impression of the teeth and implants was performed. The gingival retraction of teeth 1.2 and 1.1 was performed simultaneously using the retraction cord technique and the kaolin compressed by the temporary bridge. The impression used an open tray technique with silicone of two viscosities. In the laboratory, two 2-element bridges were made, one over teeth 1.2 and 1.1 and the other over the implant placed in the location of tooth 2.1 with the 2.2 pontic in extension. This bridge only had ceramic in a coronal shade. The bridge was checked in the mouth and the fit was good, but the patient did not like the esthetics. Particularly in the bridge over the implant, the inter-proximal zone. He noticed the lack of interdental papilla. The other bridge proved to his liking. Composite resin with a gingival shade was placed in this inter-proximal area, trying to reproduce the final appearance if ceramic with a gingival shade were used. Functioning as a mockup, this procedure allowed the patient to visualize the difference between using or not using gingival shade ceramics. The patient approved this option and decided to incorporate the gingival shade ceramic in this area.
The bridge over teeth 1.2 and 1.1 was definitively cemented with a resin-reinforced glass ionomer cement. A drag impression was made with the bridge modeled with the composite resin of gingival shade. In the laboratory, low-melting gingival-toned ceramic was added to the initial work. The patient approved the treatment, which was definitively tightened and the access hole filled. In the 2nd quadrant, tooth 2.6 was prepared and an impression was made using the open tray technique with silicone of two viscosities. In the laboratory, a 2-element bridge was made, screwed to the implant and cemented to the tooth. Note that the fitting part on the implant does not have an anti-rotation element. After the verification was done in the mouth and the work was accepted by the patient, it was definitely placed in the mouth. The definitive tightening of the implant is done simultaneously with the hardening of the cement in the distal pillar. The initial goal of improving esthetics without surgery was achieved.