Show Your Work: A Collaborative Effort on 3 Fronts by Dr. Elizabeth DiBona

Show Your Work: A Collaborative Effort on 3 Fronts 

Dr. Elizabeth DiBona shares a case study of a patient whose fractured tooth created an opportunity for restorative dentistry, implantology and orthodontics to combine for a remarkable result

by Dr. Elizabeth DiBona

This case involved collaboration between my in-house periodontist, Dr. Francesca Failla, an orthodontist, Dr. Timothy Finelli, and me, the restorative dentist.

The patient, a healthy 67-year-old woman, had a fractured #8 and had long deliberated her options between implant and bridge. She was on no medications and showed no signs of periodontal disease. Her occlusion was not ideal for either an implant or a bridge, and after many conversations regarding risks, benefits and alternatives, she chose an implant to avoid prep on the adjacent teeth.
Surgical notes
Periodontist places implant and does additional soft-tissue grafting.
  • The patient came for implant placement #8, RMH: NSC, consent given.
  • Implant Direct ref 823711U LOT 168591 simply legacy 3.7x11.5 mm.
  • Bone graft placed ACE Alloss ref 01-104-000 lot 185202.
  • Membrane ACE ref 5091520 lot CMLN18N2.
  • Emdogain ref 309585 lot YE236B PREF GEL ref 309591, lot WP001.
  • Anesthesia: Infiltration buccal and palatal from distal #11 to distal #6.
  • 4x1.8cc articaine 4% 1:100,000 epi.
  • Flap: Intrasulcular #7–#10 with full/split thickness to advance tissue coronally. Palatally crestal incision with connective tissue attached on distal #8 and avoiding papilla on mesial of #8.
  • Pref gel was used after scaling on all buccal surfaces #7,9,10 before coronally repositioning the flap. Full closure obtained.
  • 6-0 VYCRIL sutures.
  • Amoxy 500, Medrol, Periguard.

Treatment plan
The plan involved a multidisciplinary approach:
  • First, the implant site was evaluated with a CBCT.
  • Next came the extraction of #8 and a bone graft for socket preservation.
  • Subepithelial connective grafting was completed before the patient began Invisalign with a pontic.
  • After orthodontics was completed, the implant was placed, along with a temporary acrylic crown to shape the soft tissue.
  • Lastly, the final crown was placed.
The patient was delighted with the result.

Implant considerations
When examining implant-eligible patients, I screen for the following:
  • The patient is consistent with preventive appointments and has good home care.
  • The patient has reasonable treatment expectations.
  • The patient does not have periodontal disease (or not active perio disease).
  • The patient does not have a severe bruxism habit (or, if he or she is a bruxer, commits to wearing a nightguard).
  • The patient is not a smoker.
  • The patient is medically stable.

restorative dentistry, implantology, orthodontics case
Fg. 1: Preoperative CBCT scan shows fenestration on buccal plate.

permanent first molar extraction
Fig. 2: Preoperative PA shows the fracture at the area of the post.
permanent first molar extraction
Fig. 3: Ribbond temporary/composite made at socket preservation/bone graft appointment. Note that the interproximal bone level at #9 mesial is high, so the periodontist was hopeful she could gain back some height with additional bone grafting at the time of subepithelial connective tissue grafting.

restorative dentistry, implantology, orthodontics case
Fig. 4: Three months after bone grafting.

permanent first molar extraction
permanent first molar extraction
permanent first molar extraction
permanent first molar extraction
restorative dentistry, implantology, orthodontics case
Figs. 5–9: Preoperative photos. Note the crowding and the position of #26 and how it would interfere with the future restoration of #8. Thus, the patient was referred to an orthodontist to collaborate on the case.

permanent first molar extraction
Fig. 10: At the time of implant placement. Note the grafting up to the interproximal area of #9. No surgical guide was used for this case.
permanent first molar extraction
Fig. 11: Immediate placement radiograph. An Implant Direct Legacy 3 implant was used.

restorative dentistry, implantology, orthodontics case
Fig. 12: Toward the end of Invisalign. Note that one lower incisor was extracted before orthodontics. Temporary crown shaped to allow for support of papilla between #8 and #9. At this appointment, I remade the patient’s temporary crown and removed some excess soft tissue along the facial gingival margin to better match #8 and #9.

restorative dentistry, implantology, orthodontics case
Fig. 13: At the time of implant impression. Note the papillae, which were supported with a well-designed temporary acrylic crown.

restorative dentistry, implantology, orthodontics case
Fig. 14: This photo collage focuses on #8. Note the thick connective tissue along #8 and #9 because of the periodontist grafting the patient’s connective tissue. This type of case works beautifully when doctors collaborate as a team.

restorative dentistry, implantology, orthodontics case
Fig. 15: Postoperative photo. Despite her frequent recall visits, the patient builds up calculus quickly. Note the soft-tissue architecture along #8 and #9 gingival margins. If the patient had higher aesthetic expectations, I could have done a crown at #9 to control the emergence profiles a bit more to block out the slight black triangle, but this patient was beyond pleased with the existing result.

Author Bio
Dr. Elizabeth DiBona Dr. Elizabeth DiBona received her bachelor’s degree from Brown University and her DMD from Boston University School of Dental Medicine, where she graduated magna cum laude. She completed an advanced general dentistry residency at BU. She is a third-generation dentist. DiBona’s practice in Exeter, New Hampshire, combines an assortment of specialists into a robust, 4,000-square-foot multidisciplinary office. She is currently presenting cases to the American Board of Oral Implantology in pursuit of diplomate status. She has amassed more than 1,000 hours of continuing education credit hours and a growing collection of implant accreditations.
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