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Anterior implants in high lip line cases can bring a shudder to any implant surgeon. Nothing is trickier than trying to place an implant in an upper central position, as any abnormality in symmetry is instantly picked up by the eye.
This lovely lady has had a history of treatment carried out on both of her upper central incisors since she was a child. A previous swing accident has resulted in large fillings, leading to crowns, then root canal treatment and, ultimately, the loss of the UR1. When I first saw the patient, the UR1 had a draining sinus, and required removal (figure 1).
The UR1 was atraumatically extracted using periotomes and forceps. The socket was thoroughly curetted out, and a combination of calcium sulphate and collagen plugs were placed into the extraction site. The UL1 was used to fabricate a temporary bridge to help start developing the soft tissue profiles. Due to the recession around the UR1, not much soft tissue development could occur until the site was grafted at the time of the implant placement (figures 2-4).
An Astra Tech TX Osseospeed implant size 4.5mm x 11mm was placed in the UR1 site. The entire buccal envelope was grafted using a bovine graft material and covered with a collagen membrane. The periosteum was undermined, helping to increase flexibility of the flap, allowing for adequate primary closure (figure 5).
The patient healed without incident and the temporary bridge was reinserted with the pontic adjusted to help develop the soft tissue profile. The site was allowed to heal for three months (figure 6). The UL1 tooth was restored with an e.max (Ivoclar Vivadent) crown, with a temporary composite crown made to further develop the soft tissue in the UR1 site.
Figures 7-10 – The temporary crown on the UR1 was left in-situ for six weeks, with occasional adjustments made to the apical section. After six weeks, another fixture level impression was taken and an Atlantis Zirconia CAD/CAM abutment fabricated, with a final e.max crown cemented on top (figures 11-20).
Treating anterior cases is always tricky. A step-by-step process can help to simplify the procedure and give us predictable, aesthetic outcomes.
I always tend to prepare my patient for the worst and over-deliver, thereby managing their expectations.