Dream Team Treatment for a Healthy Forever Smile

In a recent case study published by, The Journal of Implant & Advanced Clinical Dentistry (JIACD), Dr. Razdolsky, his daughter Elizabeth R. Michalczyk along with their colleagues, Sergio Rubinstein, DDS and Barry P. Levin, DMD show us that a collaborative approach to treatment of an esthetic challenging case, which includes oral surgery, orthodontics and prosthodontics is often the only way to provide the most efficient standard of care. This in-depth study involved a seven-year-old patient with a congenitally missing (missing since birth) upper left central incisor. Although the patient had received orthodontic treatment for 6 years with another orthodontist, his parents were unhappy with the results and the long-term impact of his smile on his welfare was in serious jeopardy. You see, the patient’s previous course of treatment resulted in loss of time and proper treatment during critical stages of growth and development. Making matters more challenging, other disciplines had been excluded from the onset of treatment planning and care, leaving the patient in a distressed situation and further amplifying the patient’s unsatisfactory progress.

In search for a better outcome, an interdisciplinary dream team was created. With the guide of Prosthodontist, Dr. Rubenstein, the patient’s parents were presented with the new treatment plan. The goal? To reposition the patient’s teeth in their proper location, allowing for the missing central incisor to be replaced with an implant and implant supported crown. Consequently, leading to the initially expected esthetic, as well as a healthy and long-lasting result. You see, a single missing tooth is a common occurrence which has a not only an impact on the esthetics, but on the long-term health of the compromised bone, gum tissue, as well as potential for implant and final prosthesis. Time here, was of the essence.
With an interdisciplinary approach, our collaborative team evaluated the patient’s bite and esthetics in the case and determined that to treat the problem area in this patient, an implant crown on the upper left central incisor and direct bonding on the upper right central incisor were the best course of treatment.
To start, orthodontic treatment will position the teeth in the most esthetic, functionally optimal position, revealing not only a noticeably straighter smile, but also creating the necessary spatial distance between adjacent teeth to accommodate the future implant. Framing an implant-supported restoration with healthy hard and soft tissue for long-term stability is critical. Therefore, team collaboration throughout treatment necessary to ensure implant success.
In cases where teeth are congenitally missing as with our patient, there is typically an inadequate ridge, or surface area thickness to receive an implant without additional staging. Adequate bone thickness must be achieved to sustain the implant and achieve a healthy, esthetic success. Therefore, adequate tissue dimensions must also be created through surgical augmentation and provisional restorative therapy.

Here, three-dimensional CBCT scans are of paramount importance to our team for communicating and planning the proper implant location, proximity to adjacent teeth and evaluating the foundation to receive the implant. Any concerns must be addressed throughout treatment to avoid any potential miscommunication with the final implant position and design for the final restoration.
A person’s smile is more than a first impression or a way to communicate, it is a personal trademark that often determines an individual’s confidence and it plays an integral role in psychological­ social wellbeing and emotional health. This case study demonstrates how an example of poor planning and execution, can be converted by a new esthetic-prosthetic management to create a best-case-possible healthy result and optimal smile. With challenging cases such as these, an inter­disciplinary approach from the onset of treatment can provide patients with the best, and often most efficient standard of care.