Multidisciplinary treatment of an impacted maxillary canine with immediate implant installation

Abstract

Maxillary permanent canines are the second most frequent cases of impacted teeth; their resolution demands a multidisciplinary evaluation to delineate a viable treatment plan based on the individual esthetic and functional outcomes required. An impacted maxillary permanent canine which was ankylosed in a horizontal position was extracted followed by a regeneration technique, filling the bone defect with biomaterial. An implant was immediately installed in the alveolus of the extracted deciduous canine, and a connective tissue graft was buccally positioned. After the osseointegration period, a modified Palacci and Nowzari surgical technique was performed to gain papilla, and the implant was loaded with an interim restoration with a proper profile to manipulate the soft-tissue contour. Finally, the definitive restauration was cemented achieving the desired outcomes. The achieved clinical outcomes remain stable during a 2-year follow-up. A successful management of this challenge esthetic case lies in the details at surgical and prosthetic phases based in biological response of the peri-implant tissues.

INTRODUCTION

Permanent canines are the second most frequent cases of impacted teeth, following third molars.[1] They are more common in the maxilla than in the mandible reaching an incidence around 1%–2%, which varies according to population characteristics mainly related to gender being more frequent in females.[2] Moreover, impacted maxillary canines (IMC) are more frequently found on the palatal than on the buccal side of the arch. In order to avoid undesired complications around the impacted tooth, therapies such as orthodontics alignment and trans-alveolar transplantation are commonly performed.[1,3] Unfortunately, in more complicated cases where larger displacement is required or where proximity to anatomic structures could jeopardize the treatment prognosis, the tooth extraction is unavoidable. The replacement of this, as a maxillary anterior tooth, establishes a challenge to the implant treatment since the soft tissues (pink aesthetic) and the new restoration (white aesthetic) must to harmonize to achieve as possible the individually esthetic desires.[4,5]

In the present case is described a multidisciplinary treatment planning involving the extraction of a palatal impacted maxillary canine followed by an immediate implant placement. To achieve the functional and esthetic outcomes desired some strategies were undertaken.

CASE REPORT

The patient sought for treatment mainly complaining of right deciduous canine mobility. At the clinical evaluation, this tooth displays a nonharmonious color and size when compared with the other teeth, which was more evident due the high smile line [Figure 1].

Figure 1.

Initial situation: Smiling photography and lateral photography

The cone-beam computed tomography showed a palatal location of the IMC lodged apically to the right incisors and premolars roots very close to the maxillary sinus [Figure 2]. Some regions exhibit the absence of the periodontal ligament space, suggesting a diagnosis of ankylose, and also, a dilaceration on the apical part was identified [Figure 3]. Sagittal cuts showed a larger resorption of the deciduous canine root leaving an advantageous bone height for the immediately implant installation. Moreover, a microdent palatal to the lateral incisor was identified.

Figure 2.

Cone-beam computed tomography evaluation Sagittal cut

Figure 3.

Cone-beam computed tomography evaluation. The arrow show the ankylose of the permanent canine and resorption of the primary tooth root

Surgical phase

After extra-and intraoral asepsis, the patient was locally anesthetized. Full-thickness palatal muco-periosteal was raised to get access to the apical region of incisive and premolar teeth, the papillae of the canine was not harmed. A 10 mm trephine with a low rotation 400 rpm was used to facilitate the osteotomy of the palatal bone, then the access was accomplished with round-shape surgery drill [Figure 4]. Odontosection was mandatory for easier extraction of the crown and root parts. The microdent was effortlessly removed. The bone defect was fulfilled with a hydroxyapatite and β-tricalcium phosphate bone substitute (Nanosynt FGM, Joinville-Brazil) [Figure 5].

Figure 4.

Osteotomy to get access to the impacted canine

Figure 5.

Palatal defect filled with bone substitute and alveolus of the deciduous canine. Observe the papillae integrity

The deciduous canine was minimally traumatic extracted with especial care to maintain the papillae integrity. A Morse taper connection implant was immediately installed (3.3 mm × 11 mm FGM, Joinville-Brazil) achieving an insertion torque of 20 N. cm and submerging 2 mm below the palatal bone ridge [Figure 6].

Figure 6.

Implant installed. Observe the implant submerged below the palatal bone wall

Nevertheless, a dehiscence was identified in the facial alveolus wall and the thin biotype gingiva was evidenced. In order to avoid changes of dimensional bone and soft-tissue alterations, a connective tissue graft was planned preserving the architecture of the canine papillae. A split-thickness flap at facial gingiva of the canine region was prepared by an ophthalmic scalpel to lodge the connective tissue obtained of the palatal full-thickness already raised [Figure 7]. Finally, an immediate interim restoration was adhesively bonded to the adjacent teeth, avoiding any compression of the soft tissues and respecting the distance between papillae and contact points [Figure 8].

Figure 7.

A split-thickness flap divided by an ophthalmic scalpel. Observe the transparency of the soft tissues

Figure 8.

Connective tissue graft suture and interim adhesive restoration

After 7 days, the sutures were removed [Figure 9]. Unfortunately, at 3 months postsurgery control, the patient returned with swollen and red peri-implant tissues, reporting that the interim restoration came out and sought for outside assistance.

Figure 9.

Seven days follow-up. The peri-implant tissue displays the typical “whitish” appearance related to epithelial sloughing in the process of healing

Remarking the esthetic challenge as a regard in high smile, the second stage surgery was performed with a modified Palacci and Nowzari technique aiming to gain papillae height lost.[6] First, a horizontal incision was made palatal to the implant, a full-thickness flap including papillae was raised until the beginning of the facial gingiva [Figure 10]. Then, a Polyether Ether Ketone healing abutment was installed, the flap dislocated from the palate was imaginarily divided in apical and coronal section, de-epithelizing the coronal section with a round-shape diamond burs. After, a vertical incision was performed aiming to dislocate the coronal part towards the mesial papilla. Finally, a suspensory suture without pressure and anchored around the interproximal contact point was done [Figure 11]. Furthermore, a gingivoplasty was performed in the right incisive to harmonize its gingival zenith location with the contralateral incisive.

Figure 10.

Modified Palacci and Nowzari technique. Note the de-epithelization of the coronal part of the flap

Figure 11.

(a) Incision palatal to the implant; (b) PEEK healing abutment installed and de-epithelization of the full-thickness raised coronal section; (c) Vertical incision of the de-epithelized section; (d) Dislocation of the coronal part toward the mesial papilla; (e) Suspensory suture anchored around the interproximal contact point. Interim crown installed. PEEK – Polyether Ether Ketone

Prosthetic phase

Three months after second surgery, it was installed a cement-retained abutment angulated 10° to the distal with the purpose of giving enough and well-distributed space to both papillae, then a new provisional crown was fabricated [Figure 12]. After a month, the transfer healing was customized coping the soft-tissue contours and then delivered to the laboratory for the metal-ceramic crown fabrication.[7] Special care was taken to wear the metallic coping to have a proper emerging profile; moreover, the ceramic was make-up by the ceramist [Figure 13].

Figure 12.

Abutment installed. Observe the peri-implant tissue health and the peri-implant contours

Figure 13.

Clinical steps of metal-porcelain crown fabrication

After 2 years follow-up, the patient showed to maintain the soft-tissue contour [Figure 14].

Figure 14.

Two year follow-up. Final restoration: Smiling photography and lateral photography

DISCUSSION

First, the orthodontic department evaluated the case denying the possibility of orthodontic canine exposition and alignment in dental arch due to the ankylosis and the horizontal position near to the maxillary sinus. Hence, it was planned to remove the IMC and immediately install a dental implant. Alternatively, a more conservative approach could have been done grafting the bone defect and planning the implant installation after healing. Nevertheless, the existing bone has sufficient height to accomplish a proper primary stability, reducing the numbers of surgeries as well as healing time.

The literature describes other treatment options to avoid surgical extraction of an impacted teeth. Mazor et al. (2015) describe an alternative approach employing computer guided to precisely place the implant adjacent to the IMC without contact it.[8] Other study report the implant placement through the impacted tooth with 1–8-year follow-up showing no postoperative pain or implant failed; however, further investigations are recommended.[9]

Despite, a bone and connective tissue graft was performed at the immediate implant placement, the esthetic outcomes was still compromised. This fact could be explained by the negligent restoration adhesively bonded to the adjacent teeth that compressed the papillae and reducing the distance between the contact point to the bone crest and became difficult the daily hygiene during the healing period.[10]

The main complaints of the patient, the mobility and the esthetic of the deciduous canine were solved with an implant-supported restoration. However, to fulfilled the functional and esthetic outcomes desired and to maintain them overtime, a multidisciplinary diagnose and treatment plan was designed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.