by crown-lengthening on teeth #7
and #8, to correct for a biological
width problem we thought was re-
sponsible for continued inflamma-
tion in the area.
proceeded uneventfully. However,
the gingival area around #8 never
looked quite right. Three years later,
a small gingival fistula was noted in
the papillae between #8 and #9 (Figs
13&14). This appeared shortly af-
ter the patient had reported feeling
a "crack" when biting off a piece of
French bread crust. After consulta-
tion with the periodontist, endodon-
tist, and oral surgeon, it was thought
that the tooth hadafracture at the
junction of the coronal and middle
thirds, and a poor prognosis. There
was a sense of urgency because the
crestal bone between #8 and #9 was
barely visible on the radiograph.
Only a small amount remained
against the root of #9. We felt we
had to act quickly if there was to be
a chance of maintaining the critical
interdental bone and papilla.
togenous bone into any visible os-
and place an immediate-load im-
plant. Impressions were taken to
fabricate a surgical guide and provi-
sional matrix in the event the exist-
ing crown could not be used. On the
day of the appointment, there stor-
ative dentist sectioned off the coro-
nal part of the tooth in such a way
as to facilitate its use as a provisional
(Fig15). This was accomplished by
cutting from the lingual at the gingi-
val margin to a level just above the
osseouscrest on the facial. Care was
taken not to damage any gingival or
osseous structures.
described in the previous two cases
(Fig 16). The granulation tissue in
the interdental osseous defect was
excised and the area examined. It
appeared that the defect did not
affect the root surface of the adja-
centtooth.Theosteotomywasper-
formedasintheothertwocasesand
autogenousbonewasplacedinthe
rich plasma was injected into the os-
teotomy and the 4.3-mmx16-mm
Nobel Perfect tapered scalloped im-
plant was placed and torqued to a
position of 2.5mm below the level
of the gingival crest.
visional abutment (Figs 17 & 18),
seated the existing hollow ground
tooth/crown, and refined the mar-
ginsontheanalog. The provisional
was cemented with Temp Bond.
After a three-month healing phase,
retreatment of the apicoectomy
on #7 was performed by an endo-
dontist prior to final impressions
for the implant crown. At the time
this article was written, the provi-
sional was in place and serving well
(Figs19&20).
sive cosmetic cases. Fracture of key
endodontically treated teeth can
occur any time before, during, or
after cosmetic enhancement. In-
formed consent should be obtained
and implant placement should be
considered in advance for severely