Central-Lateral Dilemma Part 1

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Posted on By Maurice Salama In Failures

Patient presents from a referring doctor very concerned with the poor esthetic result with 2 implants placed for the maxillary left central and lateral incisors. Black Triangle has formed. Notice also crestal bone loss around the implants on PA film. Patient wishes a better esthetic result? Photos #4 and #6 showcase restorative options attempted. Thoughts? Dr. Salama

Central-lateral dilemma
PA radiograph

image sent from previous clinican
attempt to lengthen contacts


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24 Comments

Thoughts? Here is the Poll.
1. Prosthetic repair
2. Regeneration around existing implants
3. Soft Tissue Surgery
4. Remove one or both implants and reconstruct?


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Hi Dr

Would using the Koury plate technique also be considered here ?


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The most difficult task.
Extraction of both implants and ridge augmentation followed with bridge would be a safe way to achieve an aesthetic result. I assume that patient doesn`t want it.
Submerging #8, ex impl. #9, augmentation #9 with slow resorbable bone substitute. After soft tissue closure soft tissue augmentation, preferable in VISTA approach with tuberosity CTG. Reopening #8, another soft tissue graft. Finally implant crown #8 with cantilever #9.
DSD/ mock up to see benefits of crown lengthening.
How it sounds?
Looking forward to see your case management.
Best regards
Snjezana


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All of the above. How old is the patient?


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The patient is 38 yrs old. Snejzana the implants are in the areas of #9 and #10.
Regards Dr. S


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Considering a fact that in my part of world left central and lateral incisor are #21 and #22 I was pretty good 🙊
Best regards
Snjezana


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Snejzana you are MORE than pretty good!


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For Consideration:
1. Laser ablate recipient bed.
2. Rotate Pedicle flap from palate.
3. Coronally repo Pedicle flap from facial.
4. Take free block(s) CTG from tuberositiy(s).
5. Place tuberosities over implants and recipient bed.
6. Close over with opposing Pedicle flaps.
Please see earlier video I did on XP:
"Tuberosity CTG to #7 Implant Site"


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Tough case. I would remove those implants. Second choice is to use peekton material with GC composite as a pink and individual crowns. Gregory


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Mo,

Happy new year my friend

I look at this case from several different aspects but one of the first thing that comes to mind is what are the probing depths on both implants and where is the IHB on mesial of 9 - looking at the overall occlusion, #11as well as the entire left side does not look aligned and could do with a little rotation - intrusion to try to match the right side as well as alignment of the mandibular arch. while this is going on I would possibly remove #10 implant, platform switch te abutment - narrow it down to allow soft tissue migration- if you remove the number 10 Rotate a vascularized palatal flap as well as thick CTG on the buccal then place a pontic on the archwire to develop #10. Based on early progress you may consider planning for a touchof pink prosthetics . cantilever 10 off of 9 which may pose a better correction of gingival architecture.

Another quick thought is that there appears to be a nice papilla on the distal of 10 so for soft tissue development you could exchange both abutments for narrow platform switched place new provisional crowns adjusting the contact area overtime give this a shot to see what type of soft tissue profile you could achieve before committing implants to explantation. Prosthetic surgery rather than the cold hard steel of the scalpel

Happy New Cheers,

Richard


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These don't seem to be platform switched implants hence the crestal bone loss. Explantation of both implants with vertical augmentation to restore 2-3mm of ridge height to even out the line from IHB peaks of both neighbouring teeth. This option is more aggressive but can give a more stable result with new narrower platform switched implants and possible cantilevered new prosthetics.
My other option would be to remove the crowns and place coverscrews on both implants and wait till tissues granulate in. Then go in and remove the #10 implant and add a thick connective tissue graft possibly from tuberosity and bury the site. The site may require a secondary tissue graft ridge augmentation to allow for more vertical tissue height and thickness to use for molding the papillae with a provisional on the 9 with a cantilevered 10 restoration. I would play with the abutments, pontics and transmucosal components to mold and shape the tissues for an acceptable tissue profile prior to finalizing the prosthetics. Similar to what Snjezana has mentioned above. Can't wait to see your solution. A very tough case.
Regards, Naheed. Hope to meet you all in Vegas soon.


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Naheed....thanks for your input. It will be my pleasure to see you in Vegas. regards Dr. S


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Great case for discussion! Thank you for sharing!! My opinion : submerge 10, platform switch for 9 with a nice temporary transition and cantilever 10. I will add with Vista some tuberosity graft before final restoration and why not some pink ceramics. Not a candidate for crown lengthening- I see roots exposures but a good candidate for lip reposition and some Botox :)


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I am agree Delia
According to Maurice's article the highest papilla height can be gain between pontic and implant(5.5mm) . So leave that lateral submerged. Doing a soft tissue graft and shape the area with pontic.
Regards


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The implants seem to be placed too shallow and slightly buccally. Their platforms should be positioned around 3-4mm from the CEJ of the neighboring teeth. I also think they are too close to each other.
I would remove them both.


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Dear XP'ers. Thank you all. The problem with PINK restorative as a solution is her high lipline and the pink transition would be visible? The Botox and Lip STAT procedures have rebound and have a tendency to revert to the mean. Also, these are NOT platform switch capabale implant designs. And what about the bone loss to the 2nd threads on these implants? Dr. Salama


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Mo,

On #9 - loss is down to 2nd thread? What do you think about my ortho comment? Is the collar on implant polished or threaded? Ortho static crown lengthening consider restorations on five through 12 and is that a true lip position ?that smile appears to be a touch exaggerated ?

Cheers,

Richard


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Richard; Ortho...no have not considered it as it would require movement of intact adjacent teeth. Crown lengthening is possible but would be minimal at best. regards Mo


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Maziar; After removal, what would you propose? Dr. Salama


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Regardless of both implants already being integrated, the abutments are too bulky and I believe on creating the best possible environment prior to a surgical procedure. While all the previous comments have an excellent approach, if I am the patient I would like to have if possible a non-surgical resolution or improvement on my cosmetic dilemma and also from a maintenance perspective. I would first change the abutments with a more concave emergence profile and evaluate the tissue response before considering surgery(which ultimately may be needed)!


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Sergio; Good suggestion and this was attempted first but without significant resolution. Onto surgery. Regards Mo


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Ouch. Look at the contra-lateral papilla of the central, very very high. In a patient like this i would tend to resort to a restorative approach as the first line of treatment to see how much you can improve the situation first.

Im not usually the biggest fan of a single implant cantilevered restoration, but this might be a good case for it considering the esthetics, i would consider submergence of #10 with a pedicle graft to enhance the tissue. I don't foresee being able to reconstitute the height of the papilla, but maybe a scalloped tissue profile with improved prosthetics can help mask this defect.

Please keep us posted very interested to see how you would manage this

Warmest regards,
Sherif


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Sherif; I agree with your assumptions here. What would you suggest as YOUR treatment options?
regards Dr. S


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Dear friends, I admire you all.
Great discusion and all very good treatment options.

Before taking any desicion ( Prostho or Surgical)
I want to see the CT and see how much bucal bone does implants have).
If there is a good buccal bone # 8 , give me the posibility to forget of #9 pontic will give me more predictibily to have a papilae, between 8 & 9.
But dont discard, to considere # 8 your only pilar is a wide platform , external hex conection, first of all dont offer space for the papilae, and will have a cantilever , can have screw lose and the following consequenceses it migh bring, so think to change # 8 to a Internal conical connection )

I sugest:
1-let the soft tissue to acomodate, change the #8 with a provitional restoration with a narrow external hex abutment. .More concave emergence profile.
The #8 with a pontic in #9 the presence of the papilae is more predictable.

2- During this stage
Extract #9 and fill with slow resorpt. biomaterial and inmediate free gingval graft .
But I will evaluate to replace this #8 with a immediate internal conical conection implant with a immediate restoration.

3- Prosthetic management of the soft tissue, adding material to the base of the pontic, lets wait for 2 month and see how do much we achieve.

4- Her evalute of a 2nd soft tisse graft with a tunnel technique with Soft tissue , and continue prosthetic managing the soft tissue.

Regards to all
From the Dominican Rep


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