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 Table of Contents  
Year : 2021  |  Volume : 15  |  Issue : 2  |  Page : 140-143

Interdisciplinary approach for replacement of missing tooth in esthetic zone

1 Commandant CMDC (SWC) and Command Dental Advisor (SWC), New Delhi, India
2 Dte Gen Dental Services, New Delhi, India
3 Classified Specialist (Periodontics) CMDC (SC)

Date of Submission12-Aug-2020
Date of Acceptance02-Dec-2020
Date of Web Publication17-Sep-2021

Correspondence Address:
E Mahesh Gowda
Commandant Commannd Military Dental Centre (SWC), c/o 99 APO Pin: 900337, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JODD.JODD_53_20

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Dental implants play an important role in rehabilitation of the missing teeth with adequate esthetics with patient acceptance. Implant dentistry is multidisciplinary team approach involving disciplines for the diagnosis, treatment planning, and execution. This approach will help in establishing the appropriate esthetic objectives with the morphology and biology of tissues and thus provide the best level of care to the demanding clientele. All efforts should therefore be directed toward achieving this main goal of preserving the remaining tissues by utilizing the multidisciplinary approach. One such case report where a patient was rehabilitated for loss of anterior tooth with implants providing excellent esthetics is presented in the article.

Keywords: Dental implant, implant esthetics, interdisciplinary approach, platelet-rich fibrin, screw-retained implant restoration

How to cite this article:
Gowda E M, Sahoo N K, Satisha T S. Interdisciplinary approach for replacement of missing tooth in esthetic zone. J Dent Def Sect. 2021;15:140-3

How to cite this URL:
Gowda E M, Sahoo N K, Satisha T S. Interdisciplinary approach for replacement of missing tooth in esthetic zone. J Dent Def Sect. [serial online] 2021 [cited 2022 Oct 2];15:140-3. Available from: http://www.journaldds.org/text.asp?2021/15/2/140/326224

  Introduction Top

The goal of esthetic dentistry is to enhance smile by improving the appearance of teeth by restoring the form, contour, shape, and function. There are multiple options to replace missing anterior teeth which includes removable prosthesis, resin-bonded bridges, and the most commonly used fixed denture prosthesis. These options have disadvantages such as dislodging of prosthesis, need to include adjacent healthy teeth as abutments, pulpal and soft-tissue injuries, and marginal caries. By utilizing dental implants, we can successfully achieve the goal of restoration of orofacial structures without these disadvantages.[1]

Esthetic outcome is one of the key elements critical to defining the success of implant supported restorations. Alveolar ridge resorption with loss of tissue morphology is a common sequelae following tooth extraction, especially in the maxillary anterior region, and this poses a significant challenge for the clinician to restore the lost architecture. The most significant esthetic concern following implant placement is the lack of papilla and surrounding soft tissues which leads to a poor emergence profile and thereby compromising the goal.[2]

Multidisciplinary dentistry is a team approach involving different dental disciplines for the diagnosis, treatment planning, and execution planned treatment for oral health anomalies. This approach will help in establishing the appropriate esthetic objectives with the morphology and biology of tissues and thus provide the best level of care to the demanding clientele. All efforts should therefore be directed toward achieving this main goal of preserving the remaining tissues by utilizing the multidisciplinary approach.[3]

The present case explains a multidisciplinary treatment approach involving the extraction of fractured tooth, immediate placement of dental implant along with regenerative therapy using platelet-rich fibrin (PRF), and development of the gingival emergence profile to improve the function and esthetics of the patient.

  Case Report Top

A female patient aged 45 years reported to our department with a fractured and discolored tooth [Figure 1]a. She presented a history of trauma to her upper front tooth couple of years back which later developed discoloration. She was undergoing root canal therapy, and during this period, she had another injury causing severe pain in the same tooth which was under treatment. Clinical examination revealed that the right maxillary central incisor (#11) was tender on percussion, discolored with Grade I mobility. Radiographic evaluation [Figure 1]b confirmed the diagnosis of horizontal root fracture in the middle third of tooth, and the patient was advised for the extraction of tooth and subsequent prosthodontic rehabilitation [Figure 1]. All the available prosthetic treatment options were explained, and patient provided her consent for extraction and immediate dental implant as treatment modality to restore the missing tooth.
Figure 1: (a) Clinical Presentation, (b) Presenting IOPA Radiograph

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Patient evaluation was done by means of thorough medical history; routine clinical and hematological examinations and presence of any systemic contradictory conditions were ruled out. Maxillary and mandibular impressions were made to obtain diagnostic casts. The available dimensions of the tooth and root were measured on the cone-beam computed tomography (CBCT), and a mock implant was placed on the CBCT software to confirm the implant dimensions to be placed based on the available bone. It was planned to place an implant of size 3.5 mm × 14 mm (Bredent, Sky Implants, Germany) in the right central incisor region immediately after extraction.

After obtaining the written consent on the day of the procedure, phlebotomy on the antecubital fossa of the left hand of the patient was done to draw blood into plain 2 ml × 5 ml vacutainers to generate PRF using a centrifuge at a speed of 1300 RPM for 8 min. The patient was prepared for the surgery and regional anesthesia was achieved with local infiltration at implant site. The fractured tooth and root was carefully removed atraumatically with the help of forceps and periotomes gently severing the periodontal ligament. The socket was curetted followed by osteotomy for the placement of the preselected dental implant. The implant was placed slightly palatal and sound bone was engaged in the apical direction to achieve primary stability. The PRF prepared earlier was placed along with an alloplastic bone graft (Nova bone) [Figure 2] in the socket along with the implant and a guided tissue regeneration membrane was placed over the implant, and the flap was sutured back with 4.0 resorbable silk sutures.
Figure 2: Root extraction with immediate implant placement

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Postoperative instructions were given along with prescription of analgesics and antibiotics. The healing was uneventful and the patient was recalled for suture removal after 1 week. After 3 weeks, a removable partial prosthesis was given due to patients' insistence.

The implant was uncovered in the second stage surgery after 5 months and a temporary chairside composite crown was fabricated and placed with selective addition of flowable composite to achieve desired emergence profile [Figure 2].

The patient was recalled after a week for necessary modifications of emergence profile [Figure 3]. After 3 weeks patient was recalled to make impression using additional silicone rubber base impression material with abutment in place. Abutment was positioned back into the impression along with implant analog and cast was poured in type IV dental stone and retrieved. The abutment was casted using castable abutment and selected shade of porcelain was fused to metal screw retained crown [Figure 3]. Try in of the screw retained crown was made, necessary characterization of the crown was carried out and final placement of the crown was done after ascertaining satisfactory shade and occlusion. Chair-side postoperative intra oral radiograph was taken to assess the complete seating of casted implant abutment on implant fixture. The patient's occlusion was rechecked and the implant retained fixed prosthesis was evaluated for esthetics and phonetics [Figure 4].
Figure 3: Second stage surgery: Implant uncovering with emergence profile and placement of abutment

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Figure 4: Final Restoration

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  Discussion Top

Fixed dental prosthesis although is a viable treatment alternative in different situations, the dental implant supported restorations provide definite advantages. The use of dental implants in the esthetic zone is well-documented in the literature. It is reported that the survival rates for tooth replacement with single tooth implants was higher compared to multiple dental implants.[4] The survival and success rates are similar to those reported for other segments of the jaws in various controlled clinical trials. There should be a period of at least 4–6 months after placement for any restoration to be provided for the patient. As compared to other loading protocols, conventional loading is a predictable and an accepted treatment modality.[5]

In this present case, conventional loading was followed owing to the clinical condition and available bone and to fabricate implant osseointegration. The traditional approach for rehabilitation of single dental implant provides biological advantages such as preservation of the natural dentition and supporting periodontium, improved esthetics and improved hygiene accessibility.

Most studies about survival rate of immediate versus delayed loaded implants reveals that although immediate loading of oral implants is a beneficial treatment protocol in implant dentistry which increases the comfort and esthetics of the patient, but the clinical outcome and the peri-implant bone response of immediately loaded implants are poor when compared to conventional loading protocol.[6],[7]

Reports indicate that immediate loading may turn unpredictable in cases with poor alveolar bone quality hence achieving adequate implant stability with esthetic success would be difficult. Due to thin labial alveolar bone available, it was decided not to go for immediate loading and as per the literature available and thus the delayed loading technique was used in our case which ensures the implant stabilization during early stages of bone healing.[8],[9]

Addition of PRF to the surgical protocols provides better results as the PRF can be prepared chairside and utilised to close the space in the socket after placement of implant. The PRF contains many growth factors and signalling molecules that will accelerate the healing potential for rapid bone formation and improved tissue predictability outcome.[10] The screw retained casted porcelain fused to metal implant crown has the advantage of nonuse of dental cement and thus less chances of peri-implantitis due to extrusion of cement. The other advantage was the ease of screw tightening through the channel made in the palatal aspect of the crown.

In the present case, esthetic goals were fulfilled by obtaining a good soft-tissue profile which is the standard of care and every effort was made during surgical and prosthetic rehabilitation to achieve the desired result.

  Conclusion Top

Implant restorations present most beneficial advantages over other treatment options to rehabilitate missing teeth in the anterior region. Placement of dental implants in the esthetic zone is technique-sensitive and demand skill with less margin for errors in planning and execution. Responsibility lies with the implant team to judge benefits and risks related to timing of implant and choose appropriate loading protocols to harness maximum results. The clinician must carefully evaluate all the factors present to ensure a long-term success of the single tooth implant.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

el Askary AS. Multifaceted aspects of implant esthetics: The anterior maxilla. Implant Dent 2001;10:182-91.  Back to cited text no. 1
Chee W, Jivraj S. Treatment planning of implants in the aesthetic zone. Br Dent J 2006;201:77-89.  Back to cited text no. 2
Davda LS, Davda SV. Implant dentistry: A multidisciplinary approach. J Interdiscip Dent 2013;3:52-6.  Back to cited text no. 3
Shenoy VK. Single tooth implants: Pretreatment considerations and pretreatment evaluation. J Interdiscip Dent 2012;2:149-57.  Back to cited text no. 4
Kushaldeep, Tandan A, Upadhyaya V, Raghuvanshi M. Comparative evaluation of the influence of immediate versus delayed loading protocols of dental implants: A radiographic and clinical study. J Indian Prosthodont Soc 2018;18:131-8.  Back to cited text no. 5
Romanos G1, Froum S, Hery C, Cho SC, Tarnow D. Survival rate of immediately vs delayed loaded implants: Analysis of the current literature. J Oral Implantol 2010;36:315-24.  Back to cited text no. 6
Zhu Y, Zheng X, Zeng G, Xu Y, Qu X, Zhu M, et al. Clinical efficacy of early loading versus conventional loading of dental implants. Sci Rep 2015;5:15995.  Back to cited text no. 7
Tettamanti L, Andrisani C, Bassi MA, Vinci R, Silvestre-Rangil J, Tagliabue A. Immediate loading implants: Review of the critical aspects. Oral Implantol (Rome) 2017;10:129-39.  Back to cited text no. 8
Schimmel M, Srinivasan M, Herrmann FR, Muller F. Loading protocols for implant-supported overdentures in the edentulous jaw: A systematic review and meta-analysis. Int J Oral Maxillofac Implants 2014;29(Suppl):271-86.  Back to cited text no. 9
Rajaram V, Theyagarajan R, Mahendra J, Namachivayam A, Priyadharshini S. Platelet-rich fibrin application in immediate implant placement. J Int Clin Dent Res Organ 2017:9:35-40. DOI: 10.4103/2231-0754.201435.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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