the dilemma of the missing anterior single tooth - restorative parameters

The Dilemma of The Missing Anterior Single Tooth

- Restorative Parameters

Shankar Iyer DDS, MDSAsst. Clinical Professor, AEPP, NYU, UMDNJ

“ It is what we know that prevents us from learning more”

Albert Einstein

Clinical ScenariosThe Missing Single anterior tooth:• Congenitally missing anterior tooth

Clinical ScenariosThe Missing Single anterior tooth:• Past Perio/Endo involved partial edentulism

Clinical Scenarios

The Endodontically involved tooth:• The non-restorable fractured incisor

The OptionsRemovable Partial Denture

OptionsFixed Partial Denture

OptionsImplant Supported Crown

OptionsNo Treatment

10

Evidence For Single Tooth Implants“Although posterior single-tooth replacement is a relatively new treatmentalternative, many studies have been published since 1990, and survivalrates reported range from a low of 94.6% to a high of 100% for a 1 to 15 years. 35-45”

Misch CE, Contemporary Implant Dentistry III Ed. 2008 Mosby pp 7

Evidence Based Decision• “Systematic Review of The Scientific Literature failed to

demonstrate any direct comparative studies assessing clinical performance of single implant-supported crowns and tooth-supported fixed partial dentures”

Salinas TJ, Eckert SE. In Patients Requiring Single-Tooth Replacement, What Are the Outcomes of Implant – as Compared to Tooth-Supported Restorations? IJOMI , 22: Suppl, 71-107, 2007

Survival Rates of Options*

FPDTooth supported

FPD Implant Supported

Implant Supported Single Crown

Five Years 93.8% 95.2% 94.5%

Ten Years 89.2% 86.7% 89.4%

*No RCTs only observational studies and case cohortsPaetursson BJ. Osseointegration and Dental Implants ed. Jokstad A. 2009, Wiley-Blackwell, pp 14 - 23.

“While Single Crowns on vital teeth have the best prognosis, those on endodontically treated teeth have a slightly poorer prognosis over 10 years. Crowns on teeth with posts and cores and implant-supported Single Crowns

displayed the highest incidence of (biologic and technical) failures and complications”

Schmidlin K, et al. Complications and failure rates in patients treated for chronic periodontitis and restored with single crowns on teeth and/or

implants, Clinical Oral implants research,21:55-557, 2010

Paradigms For Decision Making


INDUCTION


INDUCTION Clinician’s Experience


INDUCTION

DEDUCTION

Clinician’s Experience


INDUCTION

DEDUCTION


Evidence Based


INDUCTION

DEDUCTION

SEDUCTION


Evidence Based


INDUCTION

DEDUCTION

SEDUCTION


Evidence Based

Corporate Lure

Factors Influencing DecisionsScientific Criteria Clinical Criteria

Factors Influencing DecisionsScientific Criteria• Long-term Data

Clinical Criteria

Factors Influencing DecisionsScientific Criteria• Long-term Data• Structural Durability

Clinical Criteria

Factors Influencing DecisionsScientific Criteria• Long-term Data• Structural Durability• Periodontal Factors

Clinical Criteria

Factors Influencing DecisionsScientific Criteria• Long-term Data• Structural Durability• Periodontal Factors• Endodontic Factors

Clinical Criteria

Factors Influencing DecisionsScientific Criteria• Long-term Data• Structural Durability• Periodontal Factors• Endodontic Factors• Biomaterials and

Biomechanics

Clinical Criteria


Biomechanics

Clinical Criteria• Trauma


Biomechanics

Clinical Criteria• Trauma• Esthetics


Biomechanics

Clinical Criteria• Trauma• Esthetics• Preservation of Natural

Teeth


Biomechanics


Teeth• Time


Biomechanics


Teeth• Time• Cost

Diagnostic Considerations• Available bone

Diagnostic Considerations

• Esthetic Involvement – The Low Smile Line

Diagnostic Considerations• Esthetic Involvement

– The High Smile Line

Vertical Bone Loss

Class I Class II

Class III P. Palacci , Quint Pub 2001

Papillary Prediction

Tarnow DP et al. The effect of the distance from the contact point to the crest of Bone on the presence or absence of the interproximal dental papilla. J Periodontol 63:995-996, 1992Choquet V, Tarnow DP et al. Clinical and radiographic evaluation of the papilla level adjacent to single-tooth dental implants. A retrospective study in the maxillary anterior region. J Peridontol 72:1364-1371, 2001

Diagnostic Considerations• Three Dimensional Diagnosis

– Apical/coronal


– Mesio-distal


– Bucco-lingual

Treatment Considerations

Risk Assessment Scale:

1 = Excellent2 = Good3 = Fair4 = Poor

EstheticsFPDs

EstheticsImplant

11Esthetics

Single Tooth Implant3 Unit FPDRisk Assessment

44Esthetics


Teeth PreparationFPD Implant


14Tooth PreparationSingle Tooth Implant3 Unit FPDRisk Assessment

Abutment Bone SupportFPD Implant

Risk Assessment 3 Unit FPD ImplantBone Support 2 2

CostFPD Implant

11 CostSingle Tooth Implant3 Unit FPDRisk Assessment

CostFPD Implant

CostFPD Implant

41 CostSingle Tooth Implant3 Unit FPDRisk Assessment

22Bone Support14Teeth Preparation31Esthetics


2-31-2Augmentation22Bone Support14Teeth Preparation31Esthetics


2-31Provisionalization2-31-2Augmentation22Bone Support14Teeth Preparation31Esthetics




11Long Term Studies

2-41-3Time



11Long Term Studies

2-42-3Cost2-41-3Time



11Long Term Studies




11Long Term Studies

3 - 42Trauma

11Overall Predictability




11Long Term Studies

3 - 42Trauma

The Dilemma

The Dilemma

Mesio-Distal Width• Loss of Golden Proportion

Loss of Anterior Coupling• Attrition

Atrophic Ridge #9 site• Lack of bucco-lingual width • Multiple restorations


31Predictability

32Cost31Time

31Provisionalization31Augmentation22Bone Support44Teeth Preparation31Esthetics


22Long Term Results

32Trauma

The Tapered Atrophic Ridge

The Dilemma

The Dilemma

Atrophic Ridge• Inadequate Bucco-lingual width

Root Proximity• Inadequate Mesio-distal width

Recession• Compromised Emergence profile


21Predictability

32Cost31Time



11Long Term Results

31Trauma

Pre-Op

Pre-Op

Post Implant Restoration

Optimal Vs Ideal Treatment Plan

Close root proximity• Converging roots

Esthetics• High smile line

Post Orthodontic result• Inadequate space


31Predictability

32Cost31Time



22Long Term Results

32Trauma

68

Illiac Crest Graft Failure

95

Orthodontic Intervention

The Dilemma

Non restorable root• Vertical Fracture

Healthy abutments• No restorations

Distinct Papillae• Esthetic Demands


11Predictability

22Cost21Time



11Long Term Results

22Trauma

The Dilemma

Space Availability• Mesio Distal Width


Thin biotype• Esthetic Demands


12Predictability

32Cost21Time



22Long Term Results

32Trauma

Non Restorable Central with Failing Retreatments

Evaluation of Gingival Architecture

The Dilemma

Extreme bone loss• Loss of buccal plate

3 – D loss• Loss of Soft Tissue

Esthetic Demands• High Smile Line


23Predictability

32Cost21Time



22Long Term Results

32Trauma

The Dilemma

Extreme bone loss• Inadequate width

3 – D loss• Loss of Soft Tissue

Esthetic Demands• Metallic Hue

31Predictability

32Cost31Time

11Provisionalization41Augmentation42Bone Support13Teeth Preparation

1-21EstheticsSingle Tooth Implant3 Unit FPDRisk Assessment

22Long Term Results

32Trauma

The Dilemma

Non restorable root• Horizontal fracture


Esthetic Demands• High Smile Line


11Predictability

22Cost2-32Time



22Long Term Results

22Trauma

Immediate Placement and Function – Immediate Post-op 4 months post - op

Immediate Placement and Function – Pre op 6 months post op

Restoring Category I Treatment Sequence

• Fabrication of Removable Occlusal overlay appliance at increased vertical


• Diagnostic wax up at the desired vertical dimension


• Fabrication of definitive provisional restoration

Chang SW, Romberg E, Driscoll CF, Tabaco M. An In Vitro evaluation of the Reliability and validity of an electronic pantograph by testing with five different

Articulators, J Prosthet Dent 2004;92:83-9“The pantograph was determined to be both reliable and valid”

The Dilemma

The Dilemma

Failing Restoration• Repeated Decementations


Patient Factors• Emotional Intolerance


11Predictability

21Cost2-31Time



22Long Term Results

22Trauma

the dilemma of the missing anterior single tooth - restorative parameters

Health & Medicine