The definition of success in implant dentistry has changed. Osseointegration is no longer the sole criterion. As techniques and technology have improved, we have raised the bar to include more stringent esthetic parameters.
Examining an esthetically-compromised case is an excellent way to learn what not to do when treatment planning and executing implant therapy for your patients.
Here’s a patient from my office that had implant work completed a few years ago by another dentist:
Yikes. Fortunately she has a low lip line and is not concerned about the appearance.
If the patient is perfectly fine with the cosmetics and has no disease present, why make them feel bad about their smile? I have a critical eye, but I keep it to myself unless a patient requests me to share my thoughts or they are unhappy with the esthetics.
Anyway, let’s get back to the diagnostics. Since I don’t have much information about what happened and I’m not going to pursue it (remember, she was happy with the result), I’ll just have to play “Forensic Treatment Planner.” I just made that term up and I like it.
This case reveals several failures in implant treatment planning.
Not respecting dimensions
Mesio-Distal: The implants in sites # 7 and 8 were placed within 3.0 mm of one another. This has lead to destruction of the interproximal bone and interdental papilla. Note that the contact area had to be extended to fill the space and prevent a large “black triangle.”
Bucco-Lingual: Implants # 7 and 9 have been placed within 2.0 mm of the facial bone. This has caused the recession of bone and soft tissue to reveal underlying abutments and implant threads. The grayish hue further apically is due to old apicoectomy procedures, not the implant showing through.
For more information on implant placement guidelines, check out my Chairside Implant Space Planning Guide.
Not anticipating the future
Note that implant restoration # 7 is not splinted to # 8 and 9. This would lead me to believe that it was restored at a different time. The patient recalled that # 8 and 9 were done first, then # 7 was done within a year or so.
This is a real shame. If I knew my patient was going to have # 7-9 replaced with implants, I would ask the surgeon to only place implants in the # 7 and # 9 positions and leave # 8 as a pontic.
The rational for this is the ability to predictably generate papilla between implants.
There are several studies that have measured how much soft tissue you can predictably generate in a papilla above the bone between two structures; the two structures being two teeth, a tooth and an implant, two implants, etc. The studies have produced similar data and the verdict is you can grow more soft tissue between an implant and a pontic than between two implants. More on that subject in another post.
Note the gingival asymmetry of the papillae mesial to the lateral incisors:
The bone and soft tissue were blown out by the close proximity of implants # 7 and 8. Thus the restoring dentist had to lengthen the interproximal contact to eliminate a black triangle. Unfortunately this is not symmetrical to the contra-lateral papilla.
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