Missing a Front Tooth?

I want this post to be just as informative for my patients as it is my fellow dentists. I will try to keep this readable for both groups but forgive me if it doesn’t fit your reading preference perfectly.

Two weeks ago I had a patient with a mandibular incisor (see photo) that had failing root canal therapy and a large abscess forming in the bone. The tooth had been bothering her for about 6 years but was too afraid to lose the tooth so she just put up with it. She finally came to the office because the pain was too great and we extracted the tooth. We talked about treatment options before the extraction and she decided to place an implant if there was enough quality bone left after healing. We took impressions to fabricate a flipper (removable single tooth denture) and start evaluating the dentition for the implant. Ordinarily I would tell her to come back in two weeks for a replacement tooth but since she was so self-conscious I decided to try something a little different.

 

The office had a Cerec Omnicam chair-side acquisition units and the MCXL in house milling unit. I began thinking of a way to replace the missing tooth more quickly than the traditional two week turnaround.

 

Begin dentisty talk:

I began by scanning the casts of my patient into the Cerec software. After many attempts at failed settings and incorrect design I finally came upon a suitable solution. I utilized the InLab software due to its ability to mill bridge restorations more effectively, but if that is not an option in your office I believe this same process will work in the standard browser.

On the home screen select “bridge” restoration. Select veneer on the proximal teeth and crown in the missing space. I got caught up here multiple times by replacing the missing tooth with a pontic. I am not sure if this did not work because it was in the anterior or if “pontic” will never work here, but this is something you may want to pursue on your own.

I only need this restoration to last for a few months until I can place an implant so I decided to use the Paradigm blocks by 3M. This is a composite block to be used as a temporary but if you need it to last longer try a something a little more durable like lithium disilicate (eMax).

 

I designed the veneer margins on the lingual of the proximal teeth with all margins visible from one viewing angle (path of draw). If any of the veneer margin is not visible a significant amount of adjustment will be required at the insertion appointment. A standard cervical design was made for the pontic space and the template for the Maryland bridge was created.

Due to the lack of proximal contact in this situation due to the path of draw, I added a significant amount of bulk to the lingual of the entire restoration to decrease the susceptibility to fracture. The Paradigm block was then placed in the milling unit and the interim Maryland bridge was complete. I did a significant amount of adjustments on the cast to ease the delivery at the appointment.

 

Back to normal speak:

The Maryland bridge was tried in and the patient verified the esthetics and the fit. The bridge was etched, bond and cemented with dual cure resin cement. The patient was ecstatic and was so happy to not have a removable device until an implant can be placed.

 

After this whole process I would definitely recommend this as an option for an immediate replacement of an anterior tooth especially when an immediate restoration is required. The restoration is beautiful and can be fabricated in under an hour.

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