Implant supported restorations in the aesthetic zone are often difficult to execute due to challenges in achieving harmony with the adjacent soft and hard tissues .
I deemed Miss SD to be at low aesthetic risk due to low smile line, adequate restorative space, favorable soft tissue phenotype, as well as the symmetrical replacement of the teeth needed. But the patients high expectations , it was quite a challenging case.The low smile line precluded the need for additional bone augmentation procedures to achieve good gingival aesthetics.
Patient had an accident 20 years ago and fixed orthodontics 5 years later to correct her malocclusion,which resulted in the upper anterior teeth to undergo root resorption. These teeth were extracted about 1 year ago. She was concerned with her appearance and requested for fixed option to replace her missing teeth.Treatment involved, extraction of her upper right lateral incisor with root resorption and bone loss,placement of 2 implants,followed by restoration of these with an implant retained bridge conforming to her OVD(Occlusal vertical dimension)
Wax -Up and mock up
The advantage of a wax up is that it can be converted into a surgical guide, but especially in this type of case, it can gives false hope to the patient as the lips were plumped out with the buccal flange on the removable denture as in the first picture.In this case as we were not planning any bone grafting - I also did a mockup in protemp from a wax up done without a buccal flange to give more realistic expectations- as on the picture on the right side.
Extraction of UR2 immediate denture
UR2 was deemed to have longevity as there was some root resorption and some bone loss and was extracted (its was patient's choice as she wanted to have a long-term solution) and immediate dentures were issued to replace the missing anterior teeth.
Stage 1 - Implant Placement
Stage 1 placement in the UR1 and UL1 position using a surgical stent made from the immediate denture
Stage 2 - Healing abutment
Stage implant fixture exposed cover crew replaced with healing abutments for gingival collar.Adjusted the immediate denture to accommodate for this space needed with pressure indicator paste.
Fixture level Impressions
Fixture level(implant level) impressions with impression coping (using astra implants so the lilac is 4.5 and aqua is 3.5 diameter), in an open tray technique with impregum .
Provisionals with PMMA (similar to acrylic), Patient was unhappy with teeth show and size , so we decided to do some composite addition chair side .Patient also whitened her remaining teeth after we decided on the shade and send the impressions , and so the shade is more yellow compared to her teeth.
Provisionals corrected with composite,until patient was happy, and copied it for the definitives.
Abutment level impressions
Definitive implant bridges are always best to avoid at fixture level and bringing it higher using a ' uni abutment' which also compensates for some angle correction between the implants - upto a 15 degree taper / a 45 degree taper, but the general advice is for every bridge not to have more than one of the 45 degree abutments.
Post treatment photograph
Patient was really happy with the result .
If you want to understand this case in more detail , you can check this link here.