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Inside Dentistry
November 2021
Volume 17, Issue 11
Peer-Reviewed

Re-treatment of a Central Incisor With Vertical Root Fracture

Effects of infection necessitate systematic grafting to restore the papilla and create an esthetic emergence profile for the implant-retained crown

Hanno Venter, BDS

As time progresses, there are many factors that can affect the integrity of the teeth. These factors can be intrinsic or extrinsic, such as tooth wear from abrasion, abfraction, or erosion related to an acidic environment created by diet or stomach acids in reflux. These changes affect the way that the upper and lower teeth occlude during function and can lead to isolated or widespread areas of increased deterioration. How the mandible is postured in order to create maximal intercuspation, which can be affected by the loss of teeth or skeletal discrepancies in the mandible when compared with the maxilla, will also have an impact on both the function and esthetics.

In the case described here, a healthy 38-year-old female patient presented to the practice with soft-tissue swelling overlying the distal papilla of tooth No. 9. The swelling was resulting from an undetected vertical root fracture that had caused internal damage from the presence of chronic granulomatous tissue. By the time the fracture was detected and acted upon, the osseous and gingival architecture had remodeled to such an extent that, after healing, there was a complete loss of the distal papilla. Subsequently, this led to a cascade of restorative and reconstructive challenges in order to restore the patient's smile.

In addition to this hard- and soft-tissue dilemma, there were flaws inherent in the existing smile that had been previously created with bonded porcelain crowns and veneers. The smile had to be assessed in order to identify these flaws and determine how they could best be corrected. Therefore, a systematic approach was undertaken to evaluate the existing smile, its inherent flaws, and the changes that needed to be made to restore it to its former glory.

About the Author

Hanno Venter, BDS
Master
International Congress of Oral Implantologists
Orange Moose Dental
Bundaberg, Australia

Pretreatment retracted photograph with the teeth apart showing visible soft-tissue swelling associated with a root fracture on tooth No. 9. The examination also revealed the presence of a flat, canted smile line, ratio discrepancies in terms of lengths and widths, deficient buccal corridors, and asymmetry among the gingival zeniths.

Fig. 1

Pretreatment radiograph of the existing root canal-treated tooth No. 9 exhibiting the vertical root fracture.

Fig. 2

Digital smile design overlayed on the existing smile to assist in planning where the ideal incisal edge positions should be for the new smile. After assessing a 3D cone beam computed tomography (CBCT) image, the removal of tooth No. 9 was planned, and immediate tooth replacement with a dental implant in the ideal position was possible. It was important to ensure that the site would allow osseous support to accommodate a future interdental papilla and col. To facilitate this, a staged treatment approach with multiple future grafting procedures would be required.

Fig. 3

After removal of all of the chronic granulomatous tissue, the implant (NobelActive® RP 4.3 mm x 18 mm, Nobel Biocare) was placed. No grafting procedures were performed during this visit. This permitted visualization of where the natural osseous and soft-tissue limitations would be after initial healing.

Fig. 4

After removal of all of the chronic granulomatous tissue, the implant (NobelActive® RP 4.3 mm x 18 mm, Nobel Biocare) was placed. No grafting procedures were performed during this visit. This permitted visualization of where the natural osseous and soft-tissue limitations would be after initial healing.

Fig. 5

Bone graft (Bio-Oss® Spongious bone substitute [0.25 mm to 1 mm], Geistlich Pharma AG) was placed with a membrane (Bio-Gide® resorbable bilayer membrane [13 x 25 mm], Geistlich Pharma AG) in the desired position where it would provide support for the future soft-tissue papilla. The soft tissue was coronally advanced to facilitate coverage of the bone graft and a simultaneous frenectomy was performed to reduce future muscle pull in this area.

Fig. 6

A complete absence of tooth No. 9’s distal interdental papilla can be seen here after 3 months of healing.

Fig. 7

Two types of soft tissue (subepithelial connective tissue from the palate and a denser type of soft tissue from the maxillary tuberosity area) were harvested for the initial soft-tissue grafting procedure (Monosyn® Quick 5/0 DS12 45 cm Undyed 3/8 Circle Rev Cut sutures, B Braun Aesculap) in an attempt to increase the amount of keratinized mucosa at the cervical boundary of the new crown and simultaneously coronally advance the soft-tissue profile.

Fig. 8

After 6 months of healing, the soft-tissue profile around the implant demonstrated a newly established interdental papillae and wide col.

Fig. 9

The next phase of treatment was temporization, which guided and trained the soft tissue to sit in a more favorable position and develop an emergence profile that would present a more natural appearance and be conducive to good oral hygiene as well (Impression Coping Open Tray Conical Connection RP [3.6 x 14 mm], Nobel Biocare; G-ænial® Universal Flo [shade A2], GC America).

Fig. 10

Minor changes were made during the period of temporization (Structur 3 [shade B1], VOCO). The design was evaluated using digital photography, and the patient was allowed to provide input. While reconstructing the lost hard and soft tissue at the tooth No. 9 site, changes were made to create symmetry in the gingival zenith positions and ultimately in the appearance of teeth Nos. 8 and 9.

Fig. 11

Image of the pressed porcelain framework (IPS e.max® Press LT [shade BL2], Ivoclar Vivadent) before layering and staining. Working closely with a master dental technician helped tremendously in achieving the final highly esthetic result (laboratory work completed by Szabi Hant, MDT).

Fig. 12

Staining of the porcelain framework before the ceramic layering was performed to replicate natural esthetics.

Fig. 13

View of the unpolished raw texture porcelain after ceramic layering (IPS e.max® Ceram, Ivoclar Vivadent) was performed on the pressed ceramic frames.

Fig. 14

Try-in of the porcelain restorations to evaluate the lip relationship to the incisal edges in repose.

Fig. 15

Final porcelain restorations after finishing and final polishing. Digital photography was used to evaluate the soft-tissue levels and symmetry as well as to help with the planning of corrections and improvements.

Fig. 16

After the final porcelain restorations were inserted and a 6-month healing period was allowed for the final soft-tissue profile to develop, a small soft-tissue defect was noted around the zenith of the implant crown in position No. 9.

Fig. 17

Coronal advancement of the soft tissue was accomplished by creating a split-thickness plane that could be advanced and sit passively on the crown before suturing (ETHICON® Prolene 5-0 P3 13-mm 3/8 circle reverse cutting sutures, Johnson & Johnson). This permitted minor soft-tissue changes to be made by repositioning the dense keratinized mucosa that would create the final soft-tissue contour around the crown.

Fig. 18

Close-up follow-up photograph of the implantretained crown at site No. 9 taken 2 weeks after the initial healing period and suture removal visit. Note the improved position and contour of the soft tissue around the gingival zenith of the crown.

Fig. 19

Posttreatment retracted view with the teeth apart showing the inserted porcelain restorations after complete healing had occurred.

Fig. 20

Posttreatment close-up maxillary photograph of the porcelain restorations demonstrating the improved smile line, buccal corridor progression, and a feminine and youthful appearance with life-like esthetics.

Fig. 21

Hanno Venter, BDS

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