Bites Institute | Thread - Difficult Anterior Implant

[Prosthetics] Difficult Anterior Implant

by Sokhi Sandhu at Wed, Nov 25, 2015 5:02 AM

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Mark Kwon Replied at Wed, Dec 16, 2015 6:53 PM

Ho-young made few good pointers. STI of anterior is one of the toughest to do. Especially pt w high smile line. But i can happen to the best of us. Option 1. Re make temporary. Using old temporary often leads to porosity w bateria buildups which prevents from good tissue healing. Minimal compression to inter prox tissue to allow tissue to heal itself. Option 2. Per dr. Chung advise. Ideal depth: 4mm below proposed buccal gingival margin when placing Narrow platform 3mm below when using Regular platform.

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Sokhi Sandhu Replied at Fri, Nov 27, 2015 7:13 AM

Thank you Ho-Young. Option 2 sits best with me, a tough decision as it means doing it over but patient education is what needs to happen here. I will see the patient next week and perhaps break the news to her and will alsoperhaps contact you soon as well, I appreciate it, thank you.

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Ho-Young Chung Replied at Wed, Nov 25, 2015 2:30 PM

Hi Sokhi, what's happening is the bone is settling into the implant's biological width. the implant needs to be countersunk deep enough that you get proper emergence profile. I know It seems counterintuitive to place the implant any deeper and often, what you think is deep enough is often too shallow. Your image 10 of the temp is better than your initial temp. The S curve starts from the base of your temp abutment of which the PEEK portion is radiolucent (and hence doesn't show up on PA). Your patient has a thin biotype and hence tissue is not responding well to "tissue moulding". There is only so much you can "push" tissue. By the way, I think your placement BL is bang on seeing as you got the screw access coming out the cingulum. It just needed to be a bit deeper that's all. You have 2 options here. 1) trim the temp more until tissue is healthy again. Because patient has thin biotype, she may get further recession and possibly thread exposure in the future. She also has a very high smile line and a final crown with the implant at this level may not achieve an aesthetically acceptable result. 2) another perhaps more drastic option is remove the implant and place one at current bone level and make a temp that will give better short-term and long-term aesthetics. This would all depend on what your patient desires and what you deem to be best long-term solution for your patient. It's a tough call. I know it's a bit of a drive from Kelowna to Kamloops, but if you want a second set of eyes to look at the case, I could see your patient for a no-charge assessment. If you want to ask me more questions, call me at my office Sokhi 250-372-7177 and tell Bailey that I'm expecting your call. Ho-Young

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Sokhi Sandhu Replied at Wed, Nov 25, 2015 6:14 AM

The ISQ last week was 75 from the ever side except the buccal which was initially as high as 74 but would also give a reading as low as 64. The patient left with the contoured temp and the blanching of the gingiva as seen in the final picture. \\\\\will be seeing the patient tomorrow to assess but unsure what my next step should be?

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Sokhi Sandhu Replied at Wed, Nov 25, 2015 6:11 AM

Okay guys, I may have bit off a little more than I can chew on this one. Patient is a healthy 32 year old female with a high smile line. First picture is a pre-op of the failing root canal. The Tooth was exo'd atraumatically in June and grafted with Raptos cortico-cancellous and PRF. The implant was placed immediately and temporaized as in figure 2 and 3. Looking back it is obvious that the temporary crown was too wide and this lead to a lot of pain a couple of days later. Image 4 and 5 shows the area and patient was having pain due to maybe not fully seating the temporary and impinging upon the bone? Image 6 is of the adjusted temporary and patient pain subsided shortly after. The patient then presented with concerns about the gingival contour in October as can be seen on image 7 (she owns a coffee shop hence the staining). The temporary was then adjusted to push the gums apically twice and even some very minor laser recontouring was done. ISQ readings were in the 70's. However the area appeared to have more inflammation over time by doing this. Image 8 and 9 are from earlier this month and shows the inflammation when the temp is removed. Images 10 and 11 are of the contour of the temp which in my opinion is no longer a nice "S" curve but rather juts out buccally rather sharply. I am concerned that we will not be able to obtain proper gingival esthetics and we may now be running into some bone loss as evident on the next picture.