Written by: Lindsey Hoppe, DDS
I first met Ella when she was 11 years old (Figure 1). She was adorable, but she was congenitally missing 5 teeth: Nos. 5, 7, 10, 11 and 12 (Figure 2). I think we can all agree that these cases are difficult to manage: planning orthodontic treatment for future implants, retention to hold those spaces that are typically hard-fought to develop orthodontically, and finally, how to provide the patient with an option for temporary teeth to wear until they are old enough for implants.
Figure 1. The patient.
Figure 2. (a and b) Preoperative images. (c) Panoramic of the case.
All her deciduous teeth were also mobile, which did not bode well for them in the long term. She has such a low-stress, easygoing personality. Her caring parents easily understood the details and challenges of their daughter’s case. Together, we formed a team, “Ella’s Dream Smile Dream Team,” which served as the basis for our ability to come together and manage this challenging case successfully.
She was referred to an orthodontist to monitor her development until the time was right, then level and align her teeth as best he could, and, of course, create space for future implants. My hope in these cases is always to delay orthodontics for as long as possible to minimize the challenging period of retention between the completion of orthodontic treatment and implant placement. The treatment was difficult, considering how mobile the deciduous teeth were. Additionally, as tooth No. 6 began to erupt, it became apparent that it was poorly developed, deficient in size, and peg-shaped in contour (Figure 3).
Figure 3. Tooth No. 6 in occlusion showing malposition.
Implants are certainly an answer to a situation like this, but there are age considerations. The literature varies on this topic, and the general consensus is that we should wait until the patient is finished growing and developing.1 There are, of course, other restorative possibilities.
I tried to make every effort to delay treatment as long as possible to intervene at the latest possible point in development—I did not want to send this patient to college with a flipper! A part of this is due to my own life experience. My husband was in a bicycle accident when he was 10 years old and broke all 4 maxillary incisors: Nos. 7 to 10. Living with a spouse who had to wear a flipper will open your eyes to the misery very quickly! The story of him sneezing at a pub in London while socializing with his new coworkers after a long day at work, and watching his flipper bounce across the bar in front of all of them…we have all heard the stories. I respectfully submit that we can—and should—do better.
Advances have been made with single-wing Maryland Bridges that can be bonded. These designs appear to be performing better than some of their PFM and/or double-wing predecessors.2 Some practitioners are now recommending them initially as the definitive restoration, especially in younger patients whose development might not be mature enough for the placement of dental implants.
Unfortunately, a bonded bridge was not an option with such long spans of missing teeth. It also became apparent early on that tooth No. 6 was not developing properly, and it was proving difficult to move orthodontically. She was totally frustrated with her situation and, because of her smile, was losing self-confidence and didn’t know which direction to take. Her deciduous teeth were tiny, unsightly, and mobile. One key aspect of Ella’s case that was in our favor was her low smile line (Figure 4).
Figure 4. Low smile line.
After many discussions, we took CBCT scans, performed the diagnostic wax-up, completed all digital planning, and determined that she did indeed have enough bone to support predictable implant placement (Figure 5). Ultimately, as she was heading off to college and now 17.5 years old, we made this decision.
Figure 5. CBCT and preliminary plan.
Planning began with CBCT scans, iTero scans (Align Technology), and digital photos, which were sent to the NDX nSequence dental lab in Reno, Nevada. With their proprietary implant and prosthetic planning software, Maven Pro, they can assist with the design and planning phases of dental implant cases, enabling virtual treatment planning, bone reduction, and implant placement simulation. Maven Pro can also import treatment plans from other guided surgery software, such as Simplant (Dentsply Sirona), NobelGuide (Nobel Biocare), and In2Guide (Cybermed). Using their workflow, we can mesh the planned tooth positions with the available bone, choose our sizes, angles, and types of implants, and place them digitally to ensure they work for both maximizing bone engagement and exiting at angles favorable for the planned prosthesis. Based on the finalized plan, we can have the surgical guide and prefabricated provisionals manufactured accordingly, with all implants, angled abutments, and prosthetic abutments selected and ordered in advance to facilitate a smoother same-day conversion of the provisional prosthesis on the day of surgery (Figure 6). The surgeon and I chose NobelActive conical connection implants (Nobel Biocare) for this case, and the surgical guide was created using the NobelGuide protocol. Looking at tooth No. 6, we decided that due to the position and the restorative needs, it would be best to remove it for a more successful and aesthetic case.
Figure 6. NDX nSequence and Maven Pro planning (NDX Dental Labs).
The day of surgery, we brought Essix retainers with pontics made in advance as a backup plan in case any of the implants lacked adequate initial stability to support same-day provisionalization. The IV was started, local anesthetic was given, the deciduous teeth were extracted, and the surgical guide was placed into position and secured.
As each implant went in, initial stability for each one was verified. I delivered the fixed provisionals the same day as surgery, which had been prefabricated using PMMA by nSequence (Figure 7). They weren’t perfect, but they were so much better than what she had for all these years leading up to surgery. The immediate transformation, while far from perfect, was undeniable.
Figure 7. Preliminary temps.
We let the implants heal for 6 months, which was basically uneventful. We updated Ella’s photos and took iTero scans for a new diagnostic wax-up, which was sent to Frontier Dental Laboratory in El Dorado Hills, Calif. Our plan was to place 3-unit implant-supported bridges for teeth Nos. 5 to 7 and 10 to 12, along with porcelain veneers for teeth Nos. 8 and 9 to achieve the most symmetry. We performed in-office whitening on the opposing and surrounding natural teeth to match them with the lightest possible shade of porcelain (Zoom [Phillips]).
Once the wax-up was ready, local anesthetic was administered. The surgical provisionals of Nos. 8 and 9 were prepared in order to place a new provisional over these via the “taco shell technique”. The prepped surgical provisionals were removed, open-tray impression copings were placed on the implants (Figure 8), and final impressions were taken using the open-tray technique with Aquasil Ultra heavy- and light-body impression material (Dentsply Sirona). The prepared surgical provisionals were placed back into position, and the screw access openings were obturated with Teflon plumber’s tape. New provisionals were fabricated (Figure 9), based on the diagnostic wax-up, using the shrink wrap/spot etch and bond technique and Integrity bleach shade temporary material by Solventum.
Figure 8. Prep for Nos. 8 and 9 and implant impression copings.
Figure 9. Shade for final with provisional in place.
After a week of assessment, Ella and her parents agreed to proceed with the case. The provisionals seemed a little large to me, but Ella loved them. We made minimal changes to the provisionals and asked the laboratory to fabricate the final restorations as closely as possible to the provisionals. We sent photos and iTero scans of the provisionals to facilitate this request. The case was again sent to Frontier Dental Laboratory.
My preference is to always have custom single-piece abutment/crown, screw-retained, fixed implant restorations when possible, and I knew this was a tall order for a case involving 6 teeth on 4 implants. Ultimately, we were able to accomplish this design on the left side. Still, on the right side, the screw access openings would have come out of the incisals and facials, even with proper planning, custom abutments, and angulated screw channel designs. Ultimately, for the best aesthetic outcome, we chose custom titanium implant abutments with a conventionally cemented bridge on the right side. The implant bridges were yttirium zirconia, and the veneers were lithium disilicate (IPS e.max [Ivoclar]).
On the day of delivery, she was anesthetized, all provisionals were removed, and the restorations were tried in. Ella and her family were given the opportunity to preview them, and they were ecstatic. Each abutment was torqued to 35 Ncm. The bridge from teeth Nos. 5 to 7 was treated with Ivoclean (Ivoclar) and Z-Prime Plus (BISCO), then cemented with 3M Rely X Unicem (Solventum). The veneers were bonded using Ivoclar Monobond to the intaglios, etch and Adhese Universal (Ivoclar) to the prepared teeth, and Variolink Dual Cure (Ivoclar) in translucent shade. The screw access openings for the implant bridge from Nos. 10 to 12 were obturated with Teflon tape and TPH composite in shade BW (Dentsply Sirona). Occlusion was checked, adjusted, and polished (Figure 10). We scanned her for Vivera retainers (Invisalign [Align Technology]) and sent them to Invisalign for fabrication. She was ecstatic (Figure 11).
Figure 10. (a to d) Final restorations.
Figure 11. Smiling patient.
The best part: we completed this case just 3 days before senior prom, so Ella was able to show up to prom as the most confident version of herself she had ever experienced (Figure 12). I still get teary-eyed when I think about her case, and we all do when we run into each other in the community. Practicing dentistry in this manner is the greatest honor of my life. I will never tire of changing lives through the gift of healthy, functional smiles patients can feel confident in and proud of.
Figure 12. Prom-ready patient.
This story just goes to show how we can pull together as a team—family, patient, specialists—listen to everyone’s input, the patient’s goals and needs, what is clinically possible, what is too risky vs what is not, make a plan together, double check it, and in some cases bend the rules for a functional and beautiful outcome that can truly change a life. Don’t forget to think outside the drill and the “rules” a little bit the next time an Ella comes into your office. It is worth it—I promise!
REFERENCES
- Shah RA, Mitra DK, Rodrigues SV, et al. Implants in adolescents. J Indian Soc Periodontol. 2013;17(4):546-548. doi:10.4103/0972-124X.118335.
- Mendes JM, Bentata ALG, de Sá J, Silva AS. Survival Rates of Anterior-Region Resin-Bonded Fixed Dental Prostheses: An Integrative Review. Eur J Dent. 2021;15(4):788-797. doi:10.1055/s-0041-1731587
ABOUT THE AUTHOR
Dr. Hoppe earned her BA in biology with a minor in chemistry from Texas A&M University in 1999. She earned her DDS degree from the University of Texas Health Science Center in Houston in 2003. She has studied in some of the most elite postdoctoral programs in the country and was awarded the prestigious Fellowship in the AGD in 2012. After a brief associateship in a dental practice in The Woodlands, Texas, Dr. Hoppe took over a small dental practice in Austin, Texas, and owned and operated it for 10 years. Upon relocation to the 30A area in Florida, Dr. Hoppe immediately stepped into the role of dental director for the Children’s Volunteer Health Network (CVHN), treating more than 1,000 children and providing more than $300,000 in free dental care for underprivileged children in Walton and Okaloosa Counties. While fulfilling her role at CVHN, she simultaneously planned and executed the opening of her state-of-the-art comprehensive care dental office, 30A Smiles, which she co-owns in the Inlet Beach area. Dr. Hoppe’s particular professional interests are cosmetic and advanced restorative dentistry. She can be reached via her Instagram handle, @drlindseyhoppe, or at her website, 30asmiles.com.
Disclosure: Dr. Hoppe reports no disclosures.
