Management of a Fractured Central Incisor

A 38-year-old male patient presented with a maxillary left central incisor that was "loose." He reported that when he was younger, he suffered an accident that lead to multiple teeth being broken, including both of his maxillary central incisors, which required endodontic treatment and were restored with PFM crowns. The patient explained that, recently, he was eating when his tooth suddenly felt like it became loose. Upon examination, tooth No. 9 exhibited significant clinical mobility, so a cone-beam computed tomography (CBCT) scan was performed. After reviewing the images, a horizontal root fracture was noted (Figure 1), and the tooth was deemed non-restorable. At that time, the pros and cons of restoration with a dental implant versus a fixed partial bridge were discussed with the patient. Preoperative photos were taken (Figure 2 through Figure 6), and a full clinical examination was completed. It was also noted that the patient demonstrated significant crowding among his lower anterior teeth as well as significant pathway wear and a deep bite-all of which contributed to the fracture of tooth No. 9 (Figure 5 and Figure 6). After a detailed workup, the patient was referred to an orthodontist for evaluation and possible treatment. He was presented with a comprehensive treatment plan that included correcting his overall bite and tooth position; however, he declined all longer-term treatment modalities, requesting only that his front tooth be replaced with a dental implant and that he receive a fixed provisional restoration as opposed to a removable partial denture. After a discussion, the decision was made to replace the crown on tooth No. 8 at the time that tooth No. 9 was extracted and replaced with an implant so that tooth No. 8 could be used to cantilever a fixed partial temporary restoration at the No. 9 site.

On the day of surgery, tooth No. 9 was removed atraumatically, and a 4.3 mm x 13 mm implant (NobelActive^®, Nobel Biocare) was placed along with a mineralized bone graft material (Figure 7). Primary stability was achieved (50 Ncm), but with the patient's strong history of parafunctional habits, it was determined to be a high risk to immediately load the implant. The PFM crown on tooth No. 8 was removed, a buildup was performed (Build-It^™ FR [A2], Pentron), and a cantilevered provisional restoration (Luxatemp^® [A2], DMG) was placed (Figure 8 through Figure 10).

After a healing period of approximately 4 months, the provisional restoration was removed, and a final impression was acquired of both the tooth No. 8 preparation and the implant at site No. 9. Shade tab photographs were taken of the prepared tooth (Figure 11), and additional photographs were taken with a contraster to help communicate tooth characteristics to the laboratory (Figure 12).

The patient returned to the office, and the provisional restoration was again removed. After a zirconia abutment was placed (Figure 13), the final lithium disilicate crowns (IPS e.max^®, Ivoclar Vivadent) were cemented (Panavia^™ SA Cement Universal [translucent], Kuraray Noritake) into place with careful consideration to the occlusion and excursive movements. Cement retention was selected to maximize the overall strength and esthetics in light of the patient's very deep bite, which would have made it challenging to ideally locate a screw access channel. The patient expressed his satisfaction with the end result (Figures 14 through Figure 18). A final posttreatment periapical radiograph was taken to ensure a proper fit and the complete removal of cement (Figure 19).

Jeffrey Lineberry, DDS
Fellow
Academy of General Dentistry
Fellow
International Congress of Oral Implantologists
Accredited Member
American Academy of Cosmetic Dentistry
Private Practice
Mooresville, North Carolina