My PEAK Presentation: Esthetic Dilemma

Raymond Johnson, DMD, MAGD

When a patient present with fractured teeth in the esthetic zone, a case can quickly become challenging and that is exactly what is presented here. A male patient in his late thirties presented to the office with both his left central incisor and left lateral incisor fractured. Figure 1 A brief history from the patient revealed that these teeth were previously crowned and had been splinted together. The patient’s occlusion also would present a problem as there are signs of cross over wear by the angled right central incisor and there is an anterior crossbite at the right lateral incisor. A radiograph is presented for completeness and for analysis of the depth of the fracture in relationship to the bone. Figure 2

After a thorough discussion of the treatment options and a brief history on the limits of the manipulation of the soft and hard tissues in combination with implant therapy the patient chose to have tooth #9 restored conservatively with a core buildup and crown with minor soft tissue crown lengthening and tooth #10 to be extracted and an implant placed. An immediate implant was placed at the time of extraction. Figure 3 The area was temporized with the patients previous FPD and it was immediately noticeable that there was a gingival discrepancy post surgery. Figure 4

Following a healing period of eight weeks, the implant was uncovered and provisionalized. Tooth #9 was also crown lengthened and temporized at this time. Figure 5 A laser was used to complete the crown lengthening and expose the margins on tooth #9 following bone sounding such as to not invade biologic width. An appropriately shaped temporary on the implant will encourage the tissue to migrate in a given direction and also to facilitate papilla formation (a lesson learned from Dr. Dennis Tarnow’s presentation at PEAK 2017).

Modern dentistry allows for the final planning of the restorations in a virtual format. Using an intraoral scanner and software the final restoration were impressed, and then designed digitally. Figure 6 The patients wear pattern was taken into account. The final restorations were made of zirconia and the implant abutment and crown were screw retained. The case was completed and inserted just under four months from the initial date of tooth extraction and implant placement. Final photographs were taken four months after delivery. Figure 7

Figure 6


Many factors were included in this case. Wear, esthetics, tissue, bone, healing time, and patient desires were all taken into consideration. A relatively conservative approach was taken and a good esthetic outcome was achieved and never left the patient toothless. Careful consideration must always be taken as to stay within one’s comfort zone when dealing with esthetically demanding issues. The PAGD and the AGD have been remarkable ambassadors for education and facilitated learning so that doctors may continue to raise the bar in our profession.