Anterior Aesthetic Rehabilitation – How to get Success again after the Unexpected Failure: Case Report

Case Presentation

J Dent App. 2015; 2(7): 264-268.

Anterior Aesthetic Rehabilitation – How to get Success again after the Unexpected Failure: Case Report

Toniollo MB¹*, Aguiar SC² and Corrêa MH³

¹Department of Dental Materials and Prosthodontics, Professor of the Specialization Course in Dental Implants of the National Association of Dental Studies, Brazil

²Professor Coordinator of the Specialization Course in Dental Implants of the National Association of Dental Studies, Brazil

³Implant Specialist by the National Association of Dental Studies, Brazil

*Corresponding author: Marcelo Bighetti Toniollo, Department of Dental Materials and Prosthodontics, Professor of the Specialization Course in Dental Implants of the National Association of Dental Studies, Brazil

Received: May 14, 2015; Accepted: September 10, 2015; Published: September 12, 2015


Modern society, with the contemporary dentistry, aim by a proper function accompanied by extreme aesthetics. In order to get increasingly beautiful, harmonic and natural results, the search for development of rehabilitation indirect materials is constant, such as pure ceramic crowns (metal free) and high aesthetic content systems such as IPS E.Max. However, fateful events, such as root fracture, still remain unpredictable in the everyday context, and must be thought on how to have a proper resolution. In this paper it was described a case in which success first achieved, through metal free crowns on the upper incisors, gives way to a fateful situation of longitudinal root fracture of one of the elements rehabilitated. Thus, it is argued in this article one of the viable alternatives to be traced through modern procedures, that brings predictability, to circumvent the failure and go back to get the expected result and patient expectation. The conciliation of surgical and prosthetic procedures, with the aid of reverse planning and modern techniques, for the sake of good results and with respect to the involved tissues, allow obtaining harmonious and satisfactory work.

Keywords: Dental aesthetics; Dental implants; Ceramics


The ceramics have reports of very old usage, but dentistry has focused on this stuff for two centuries. Negative points such as hardness and brittleness or friability became manageable against the high aesthetic and biological quality for the prosthetic work [1]. Technological advances have branched ceramics in numerous types and ways of obtaining, from the conventional mixture of powder and liquid, injected system, infiltrated by Glass and Machined (CAD/ CAM). Until the mid 1980s the only aesthetic option was the metal ceramic crowns. Advances in dental materials and implants led to the use of pure ceramic crowns (metal free) generating high aesthetic gain and biological affinity [2]. One of the systems that have gained prominence in studies and clinic routine is the ceramics reinforced by lithium disilicate, which provides its adequate strength [3,4]. Within this context, the IPS E.Max was consolidated as an option of choice among professionals in front of their great aesthetic and functional qualities. The versatility of these systems for metal free ceramics allowed wide dissemination and extremely viable applicability. For their full and proper use was also need the development of adhesive systems in order to enable effective union between substrate and rehabilitation [5,6]. Along the evolution of materials for indirect restorations, implant dentistry has made great advances in functional and aesthetic concepts, thus allying the use of metal free restorations and adding value among all the characteristics mentioned above. Another highlight along the dental implants refers to the possibility of their conciliation to the immediate restoration, installed together the implants [7]. This technique, which differs from the immediate load [8,9], provides numerous aesthetic and functional advantages, such as improved healing and formation of soft tissue emergence profile and better osseointegration of the implant [10,11]. Furthermore, new approaches with respect to the peri implant tissues (tissue care) and use of prosthetic connections that allow the Switch Platform philosophy and better mechanical stability to the system brought real gains to the final outcome. Even with all the evolutions of contemporary dentistry unexpected factors may occur and cause catastrophic failure. One of the most damaging setbacks in the oral cavity involving teeth is the longitudinal root fracture, there is no solution beyond the extraction. So with the conciliation of the various specialties and the best possible techniques that involve them, always with respect for the correct principles and concepts, the present case report shows that is possible to obtain clinical, functional and aesthetic success, harmonizing rehabilitation with nature, even after a failure episode involving teeth fracture.

Case Presentation

The present case report performed in male patient, 45 years, consisting of the rehabilitation of 4 upper incisors, began by making metal free crowns (pure ceramic IPS E.Max). Patient had unsatisfactory direct resins in elements 11, 12 and 21, and temporary crown in element 22, and showed desire to reinvigorate the look and functionality of that area. The involved elements already had satisfactory endodontic treatment, and element 22 had satisfactorily metallic pin installed. So it was opted for maintaining the metallic pin and make aesthetic fiberglass pins in the other teeth, (Figure 1A). Conventional procedures such as preparation, provisional phase, molding and aesthetic proves were made, and the total of 4 metal free E.Max crowns were finalized (Figure 1B). The teeth were treated with phosphoric acid (Figure 1C) and adhesive system (Figure 1D), and the crowns were treated with hydrofluoric acid (Figure 2A) and silane (Figure 2B) for subsequent adhesive cementation (RelyX ARC, 3M ESPE - Sumaré, SP) (Figure 2C). The entire procedure had no problems, and the resolution was aesthetic and functional appropriated (Figures 2D and 2E). After about 8 months of completion of treatment, the patient returned to dental office complaining of sensitivity in the vestibular region of the element 22, being found early fistula originating from root fracture (Figures 3A and 3B). The choice of treatment in longitudinal root fracture case is the element extraction and immediate implant with immediate restoration. It is also necessary evaluate the need or not in use biomaterial and membrane. Initially the crown was removed leaving only the fractured root (Figure 3C). This time it was possible to clearly identify the area of root fracture and closed the diagnosis and cause of the fistula. To better prognosis after surgical procedure and better tissue behavior with the most possible respect it opted by the root extraction without performing relaxing incisions, using only tooth extractor (Neodent - Curitiba, Paraná) and delicate instruments. To this, there was intraradicular preparation with specific bit (Figure 4A), an adaptation of the traction component to the root (Figure 4B) and thus atraumatic root extraction with the lowest possible injury of surrounding tissues (Figures 4C, 4D and Figure 5A). The irrigation and curettage were performed, in addition to the proof of the surgical guide, which was made according to the standards of previously rehabilitation (Figure 5B). Entire sequence of drilling and bone preparation was performed following the manufacturer’s recommendation to be installed implant with Morse taper prosthetic connection, measuring 3.5x13mm - Drive (Neodent, Curitiba - PR). Completed implant installation in the planned position (Figure 5C) and obtained the minimum torque of 40 N/cm for immediate restoration [12] it was verified the necessary height for a transmucosal component for cemented prosthesis, universal pillar measures 3.3x6x6.5mm, torqued with 20N/cm (Figure 5D). In order to maintain the gingival outline and the “red aesthetic” preserved was inserted biomaterial inorganic mineral bone (Bio-oss, Geistlich Pharma - Switzerland) and collagen membrane of slow absorption (Lumina Coat, Criteria - São Carlos, SP) in gap area between the implant and vestibular bone (Figure 6A and 6B). Thus, the area showed up ready to arrest the provisional tooth with the use of a plastic cylinder on the installed pillar (Figures 6C and 6D). The technique of making the provisional teeth in the region of 22 was following the Technique of wall and adapted facet - Palhares and Toniollo [7] (Figure 7A). Thus, it was obtained good immediately aesthetic results, and the patient can leave the surgical procedure very similar to that when he came in.