Upper Lateral Incisor Replacement With
Socket Preservation and An Implant After
A Failed Resin-Retained Bridge (RRB): A Case
Report and Literature Review
Barry K Ramcharan and Reisha N Rafeek*
University of the West Indies, Trinidad & Tobago
Submission:November 15, 2018; Published: December 05, 2018
*Corresponding author: Dr Reisha Rafeek, Faculty of Medical Sciences, School of Dentistry, University of the West Indies, Trinidad & Tobago.
How to cite this article: Barry K R, Reisha N R . Upper Lateral Incisor Replacement With Socket Preservation and An Implant After A Failed Resin-
Retained Bridge (RRB): A Case Report and Literature Review. Adv Dent & Oral Health. 2018; 10(2): 555781. DOI: 10.19080/ADOH.2018.09.555781
Introduction: Several options exist for practitioners to replace an upper lateral incisor such as a denture, conventional bridge, resin-retained bridge or an implant. Patients have to make choices based on finances and other considerations and the options vary in terms of long term success rates.
Case Report:This report focused on a patient with a failed resin retained bridge where socket preservation technique with freeze-dried bone aggregate (FDBA) and collagen membrane was performed and subsequently five months later an implant was placed to replace the missing upper lateral. The implant was osseo-integrated for nine months before the patient returned to have the abutment and temporary crown placed. The patient remained with the temporary crown for over ten months before returning for treatment.
Conclusion: Well-designed treatment plans can benefit practitioners and patients to avoid undesirable consequences with failed restorative options. Advanced surgical and restorative techniques must be carefully planned and the need for teamed collaboration between restorative specialists and general dental practitioners be considered. The report shows the more ideal and predictable option of socket preservation prior to implant placement for replacing an upper lateral incisor.
The case of a missing incisor in patients due to history of trauma, congenital absence and non-optimal hygiene is common ranging from childhood to adulthood [1,2]. Despite the causes, treating space closure has largely remained similar and unchanged for three (3) decades; a single tooth removable prosthesis, a fixed bridge, (either fixed-fixed design or cantilever winged prosthesis, conventional preparation or resin retained), or with titanium dental implants assisting with rehabilitation of similar anterior sites.
As expected, not all sites are the same as patients are either forced to conform to one of the three treatment options mentioned above. Factors to include are costs , hard and soft tissue site condition due to patient history, aesthetics, occlusal function and timing amongst others. Systematic reviews indicate that the five-year survival rates for resin-retained bridgework is 87.7%, conventional bridgework over 90% and an implant retained single crown 94.5% . With respect to resin-retained bridges, although survival rates may be high, complications like de-bonding are frequent .
The use of socket preservation, as a precursor stage of treatment to ultimately include implants as the final definitive treatment may be considered a fourth addition to traditional treatment options offered to patient at first consultation. Following extraction, recent literature has documented horizontal bone loss of 29% to 63% and vertical bone decreases of 11% to 22% after 6 months . The physiologic benefits of alveolar ridge preservation are well documented in the literature . Preservation of extraction sockets (either infected or not) and augmentation of post extraction sockets, positioned early in the management of edentulous sites with >5mm bony defects, may be a useful tool utilized by clinicians early in the decision process when determining treatment options with patients.
Implants placed into socket-grafted sites performed as well as those placed into non-grafted sites . Araujo et al. , also demonstrated that placing a biomaterial into the extraction socket enhances bone remodeling and compensates for marginal ridge resorption. Different socket preservation techniques have been widely used in controlled and uncontrolled studies with different materials and systems; bone grafting alone including autografts, xenografts, allografts and alloplasts, membrane alone (resorbable
or not) and bone grafts with a membrane . A graft integration
period (about 3-9 months) with use of a transitional denture or
transitional winged Maryland type bridge as in the case being
described to rehabilitate edentulous sites over a prolonged
treatment period to maintain optimal functionality and aesthetics
may be best suited to certain patients.
A fifty-four (54) year old male of mixed ethnicity, in good
medical health with no known allergies, presented with pain in his
upper right lateral incisor in April 2015. History revealed trauma
secondary to motor vehicular accident. The patient was examined,
and a periapical radiograph revealed periradicular periodontitis
with severe vertical and horizontal bone loss with the patient
being advised to extract the tooth. The patient was also advised
on short-term tooth replacement treatment options with either an
immediate upper denture or a resin-retained bridge and long term
care with titanium dental implant. The tooth was subsequently
extracted immediately with metronidazole 400mg bid and an over
the counter (OTC) non-steroidal anti-inflammatory drug (NSAID)
prescribed for a week. At the one-week review, 5mm gingival
pockets were charted around upper central incisor. The patient
opted for a resin-retained (Maryland) bridge option, non-desirous
of a removable prosthesis.
In May 2015 a resin-retained bridge preparation was
completed with minimal palatal reduction, extending from the
upper right central incisor and upper right canine with suitable
guide planes but no incisal reduction. The occlusion was checked
and cleared of interferences and an upper polyvinyl siloxane
(PVS) impression (Defend Super Hydrophilic VPS light body and
putty impression material, Mydent, IL, USA) taken and sent to the
laboratory with shade selection along with a lower opposing study
model and fabrication instruction prescribing for a Resin retained
bridge (RRB). Two weeks later the RRB was returned, tried in and
cemented with a dual cure adhesive resin luting cement (Rely X
Ultimate, 3M ESPE, Irvine, CA, USA). The patient was satisfied with
both fit and aesthetics of the bridge.
Three (3) months later in August 2015 the bridge de bonded
at the metal cement interface of the central incisor but retained
in situ. The RRB was re- cemented with Rely X dual cure luting
cement after the metal fitted bonding surfaces were piezo electric
ultrasonically scrubbed with a stainless steel attachment (Beyes
Dental Canada Inc, Scarborough, ON, Canada).
However, only one and a half months later, the bridge de
cemented again and this time was re cemented with glass ionomer
luting cement (Glassline glass ionomer cement, PULPDENT
Watertown, MA, USA) upon cleaned and etched bonding surfaces.
The bridge stayed seated for another 6 months before de bonding
for a 3rd time within one year. The bridge was then re bonded
with Panavia (Kuraray America Inc, New York, NY, USA) and wing
perforations were incorporated with the attempt to enhance
surface area and mechanical lock bonding. At this stage the patient
was referred to the first author (BKR) for implant placement.
In April 2016 it was decided that bone grafting was necessary
prior to implant placement so bone particulate (size 0.25-1.0mm)
(mineralized freeze-dried bone aggregate, FDBA) (Osteolife
Biomedical, Miami, FL, USA) and an H shaped 20 by 20 collagen
membrane graft (Osteolife Biomedical, Miami FL, USA) were
placed over upper right lateral incisor position to a depth of
13mm and gingival tissues manipulated for primary closure as
an “uninfected socket preservation technique”. A buccal mucoperiosteal
full thickness three sided flap was raised using mesial
and distal relieving incisions with number 15 blade and periosteal
elevator blunt dissection. The graft site was identified into which
fissure burr slow speed on low torque setting used to debride
alveolar and lamina dura bone with soft tissue and callous
removal under copious irrigation. The particulate aggregate was
incrementally introduced and packed into the debrided clotted
blood pooled site to the targeted, desired vertical bone height
(Figure 1). The resorbable membrane was measured and trimmed
to the defect dimensions and carefully overlaid onto alveolar ridge
with emphasis to tuck sheet margins beyond flap incision lines
both labially and palatally for stability, as well as to occlude the
newly grafted socket (Figure 2a). Resorbable, loosely tacked 3/0
vicryl sutures were placed achieving hemostasis and primary
surgical site closure.
The RRB was reattached with glass ionomer luting cement
after relief adjustments to the pontic gingival porcelain surface
(Figure 2b). The patient was then reviewed one week (Figure 2c)
and one month (Figure 2d) respectively thereafter for healing assessment. The patient was reviewed once monthly to assess
The implant surgery was then performed five (5) months later
in September 2016. The stages are shown pre-operatively (Figures
3a), then initial drill hole (Figure 3b), guide pin placement (Figure
3c) and implant fixture (Figure 3d). A periapical radiograph taken
(Figure 4) that shows implant placement at approximately 13mm
using Biomorse internal hex 4.0 diameter 13.0mm long implant
from Bionnovation (Bionnovation Biomedical Bauru, SP, Brazil).
The patient was then left for 9 months with periodic review
visits to assess continued osseointegration of implant and graft
integration. Figure 5a is a periapical radiograph which shows
implant after 9 months with the RRB cemented still in place
and Figure 5b shows the clinical view. A putty stent heavy body
polyvinyl siloxane (VP Mix Putty, Henry Schein, New York, USA)
of the anterior teeth was made (Figure 5c) in order to fabricate a
temporary crown. The RRB was then removed (Figure 6a), then the healing screw was exposed (Figure 6b) via a second stage surgery
performed with gingival tissue full thickness subperiosteal flap
with mesial and distal relieving incisions introduced to advance
the flap to allow for suturing. The cover screw was removed
(Figure 6c) and the abutment placed (Figure 6d). The abutment
was then torqued with rotational force of 30Ncm pressure (Figure
7a) and the flap was folded upon itself to create a better emergence
profile after 4.5 by 1.5 by 6.0mm straight abutment placement and
then sutured (Figures 7b & 7c). The temporary crown was then
fabricated using a polysiloxane stent of the RRB and temporary
crown material (Protemp, 3M ESPE, St Paul, MN, USA) as seen
in the labial and palatal views (Figure 8a). Final anterior view of
patient with temporary crown (Figure 8b).
Patient then returned 10 months later in April 2018 with the
temporary crown still intact and tissues healed and said he was
happy with his temporary crown hence the delay in definitive
treatment. He then had the final crown placed and has been very
pleased up to the six months follow up (Figure 8c).
The survival rates for resin retained bridges are lower than
for implants  but patients may have to opt for the RRB due to
financial constraints. They may also choose the fixed RRB option
over the removable denture for a transitional provisional before
implants as in this case. With respect to RRBs and its design, best
outcomes show that cantilevers survive better than fixed-fixed
RRB [11,12] and anterior survive better than posterior . The
restoration design and operator skill also positively influence
the RRB success . The reasons for failure are wringing forces
[11,15], the resin layer of cement , initial occlusion  and
the retainer- prosthesis design . Re-bond failure rates are high
. In this case report, the initial RRB debonded after 3 months
and was probably due to the lack of coverage on the palatal surfaces
plus the fixed-fixed design debonding due to differential tooth
movement. A cantilever design may have been more successful.
The extraction of a tooth results in the socket healing from apex
towards the crest [6,20]. This bone loss reduces the possibility of
implant placement later on and so simple socket preservation of
the extraction site should become a routine procedure following
extraction of teeth . The benefits of socket preservation
have been documented  however there are many different
techniques used  but no consensus has been reached on
the ideal protocol . In this case report, an uninfected socket
preservation technique was used where a flap was raised, the socket prepared with a slow speed burr to debride the socket and
encourage bleeding and then packed with FDBA and covered with
a collagen membrane graft .
Implant surgery was performed 5 months after the graft and
the patient returned after 9 months of osseointegration of the
implant before the abutment and temporary crown were placed.
The patient was happy with the temporary and did not seek
definitive treatment until 10 months later.
Well-designed treatment plans can benefit practitioners
and patients to avoid undesirable consequences with failed
restorative options. Advanced surgical and restorative techniques
must be carefully planned and the need for teamed collaboration
between restorative specialists and general dental practitioners
be considered. The report shows the more ideal and predictable
option of socket preservation prior to implant placement for
replacing an upper lateral incisor.