[Surgery]  Anterior Implant

Hi all Bites instructors.

This is the case I did the atraumatic extraction on Feb 5th 2015. I did bone graft and PRF and gave him Vacuform as recommended.

The first 4 pics are previous to exo and last 3 are after 6 month.

I posted and consulted this case on Feb 8/ 2015. If you don't mind going back to surgery section with the same topic.

I followed all the guidance.

I will post new pictures and wax up soon.
There is no provisionals on any teeth. He is using the essix as temporary

Please advise for the next step.



by Admin BITES at Wed, Aug 5, 2015 3:17 PM

1174 Views | 6 Replies

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Admin BITES Replied at Wed, Aug 26, 2015 3:23 PM

Thank you Dr. Glen for your guidance. I did not receive any other feed backs. I will update on the case.

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Glenn van As Replied at Sat, Aug 8, 2015 3:16 PM

Hi there: First off thank you for sharing the updated photos and quick helps for the patient to see how long and big the teeth are going to be. I agree with you that the patient is likely not concerned about esthetics at this point ( that may change though when you do give teeth). I would not worry about the position of the papilla at all ...I think your plan is a decent one to put implants in the 13 and 11 and 21 area. The 12 11 area has no papilla so pontic will help with creation of a somewhat more esthetic area. THe biotype looks thick so that is good.... Here is what I would do ... 1. Full flap from 14 distal to 22-23 area with vertical incisions in the 14 and 22/23 area ( 22 d or 23 M) 2. Place three implants as you mentioned in the 13, 11 and 21 areas. I would put 3.5 in for sure in the anterior area ( 11 and 21). Not sure if you can get a 4 mm in on the 13 might have to choose three 3.5 mm. 3. You will likely have to graft dehiscence areas in the apical portion so be prepared to do that...autogenous bone ( nasal spine, canine eminence, bone trap) over the threads, xenograft for buccal contour. Resorbable membrane tacked down overtop or sutured periosteal sutures to hold membrane in place. Periosteal release from vertical to vertical to close. 4. Soft tissue graft to ensure the thickness of this area. CTG harvested at same time. 5. PRF if you can do it. I would personally try to stage this , bury the implants rather than complicating my life with provisionals and you already mentioned that the patient is cool with that....keep the essix of the tissue as there will be a lot of swelling in this area. Go back in 3 months and make a provisional 4 unit bridge 13-21 and see how the patient likes the look and then make the permanent bridge. Does that sound reasonable.....again I found the teeth to big in the mockup ....but you might feel differently.. HOpe that helps...I am sure others will put up other suggestions....One key thing from this exercise for you was to see how treatment planning in the maxillary esthetic area is a whole different bag of worms from a single posterior implant. Photos, smile line, facial photos and closeup of the soft tissue. The mockup is vital to give patients expectations of what the result will be like. This is not an easy case because of the size of the space and in addition the high smile line..... hope it works out for you and the patient....its going to be a long journey. Glenn

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Admin BITES Replied at Fri, Aug 7, 2015 2:53 PM

These are new pictures and a very quick wax up. Dear instructors, I attached new pictures, I took yesterday and the impressions and a very quick wax up to see how it will look like. I thought open bite is a positive point in this case since the patient will NOT put extra force incase of grinding or biting.Am I wrong? Patient has open bite. and while I was doing the quick wax up I noticed if I make the teeth longer it will not look good. The central papilla is there but it is not in the centre. It is more toward right side. I did the wax up from the centre first and centrals were very large and not enough space for 13. Any thoughts how I can use the papilla? I informed the patient that there might be black triangles. Patient seems like not very demanding. He just wants teeth there but I did explain about esthetics since day one. I was planning to put 3 implants, 21, 11, 13 area. single crown on 21 and bridge 11 to 13. I will make the vaccuform for the time of surgery. The Patient is fine with essix temporary. Will that be fine? Please let me know your thoughts.

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Glenn van As Replied at Thu, Aug 6, 2015 4:01 PM

Hi there....thank you for providing the photos...these were done before the extractions and likely very recent after the trauma...they show 1. HIGH LIP LINE...this means it is a very very difficult case 2. Papilla....11, 12 3. Class III - skeletal crossbite...this again complicates your case as the patient will be hammering on these teeth, and so provisionals sometimes are tough because the patient has to be very careful to avoid touching the teeth when eating....they cannot cut the food up during the healing. The papilla will be gone now and after the grafting I suspect that it is a flat ridge. of the situation now are crucial to your success. So be aware...the high smile line and class three occlusion likely make this a tough case. Glenn

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Ho-Young Chung Replied at Thu, Aug 6, 2015 3:55 AM

Hi there, I agree with Dr. van As. next step is to take prelim impressions and take photos. mount on articulator, assess smile line and occlusion, tissue biotype, teeth bioform, etc. A restorative plan needs to be determined prior to determining implant positioning, size, etc. socket grafting was done well. base of bone is narrow as Dr. van As has indicated. Like Dr. Kwon says, there is implant dentistry and then there's single anterior implant dentistry (then multiple anterior implant dentistry). Treatment planning is most important. Making a temporary bridge will be essential. Ho-Young

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Glenn van As Replied at Wed, Aug 5, 2015 10:07 PM

Hi there: Thanks for this post. I can tell you that it is difficult case in my eyes because the bone is so thin apically. You are likely going to have fenestrations. The patient is now missing 4 teeth....are 22 and 23 in provisionals.... There is a big need here for photos to show us the smile line, and models to show us the bite. It is difficult to tell simply from a CBCT how to restore this case... The simplest solution is a 4 unit bridge on 2 implants but without any smile line analysis or soft tissue analysis to determine how big a defect there is then its tough. Is the patient wearing the essix or a flipper or what.... Finally, many times there is a compromise in the final esthetic appearance in a case like this....sometimes it requires pink porcelain, sometimes soft tissue grafting, sometimes more hard tissue grafting....a clear essix after a waxup can yield huge information for what the future holds with respect to the defect that is still present....and whether further soft tissue and hard tissue grafting is needed. Thanks Glenn