by John Nosti, DMD, FAGD, FIOCI, FACE
If you want dental implant aesthetic results like these… it’s easy. Do I what I did.
About this case:
The patient goals were to restore just #7 and #10 without touching the adjacent virgin teeth.
She had completed several rounds of orthodontics to get implants in the lateral position and implants were placed and integrated by the time I saw her. The patient’s centrals were small and the lateral space was asymmetrical by about a millimeter. I requested the lab wax up and control the line angles to eliminate the appearance of being same size as centrals. It was important that I work with a lab on this case that understands how to control optics of the case to overcome the compromises.
Conclusion: After evaluating the implant sites, I discovered a few compromises. The implants had been placed slightly angled and on different bone level heights due to to the root placement and bone available. I ordered custom fabricated long term temporaries that were designed to support and form tissue to idealize gingival zenith heights. Straumann SLA3.3mm implants were utililized by surgeon. They were placed slightly to the facial which did not allow for screw retained fabrication, which would have been my preference. The patient was in long term temporaries for more than 3 months to mature the tissue and create symmetry in gingival heights., At removal of temporaries and final impression, I made custom impression copings to create ideal emergence and tissue position for the lab. ( On tooth #7 the depth of tissue to platform was 3.5mm on lingual, 4mm on distal and medial and 2.5mm on facial. #10 had 5mm at the lingual, 4mm at distal, 5mm at medial and 3mm at facial.) I originally requested custom fabricated gold hue abutments and e.Max crowns, but due to the facial placement of the implants, we ended up fabricating zirconia abutments with e.Max as the final restoration. Ingot selection was critical to matching the centrals and a LTBL3 ingot was chosen. The crowns were cut back and layered for ideal matching of the centrals and canines.The crowns were cemented with Multilink Implant CS.
I have a busy restorative practice. As part of my service mix, I personally chose not to place dental implants but stick to restoring them. And I restore a lot of dental implants.
I struggled with achieving the dental implant aesthetic outcomes that I wanted for my patients. Whether the architecture of the tissue was compromised post op, or placement was not ideal, I wanted to find a predictable way to get the best outcomes for my patients and reduce the stomach acid produced at final cementation!
A really good friend of mine, Dr. Lee Ann Brady invited me to attend a 2 day dental implant prosthetic program she had developed in conjunction with her periodontist Dr. David Barget. It was the first course and she was looking for some feedback. I agreed, not really knowing what I could or would learn, especially since there was a specialist involved and I lack the desire to place implants.
What I learned was that I was attending the single most valuable course on implants aesthetics I have taken. With observing the protocols and techniques that Lee Ann and David have integrated into their patient care, I was stunned. Simple custom impression copings. Hands on temporary techniques. Surgical guidance and treatment planning the provisional stage appropriately. My biggest regret is that I didn’t bring my surgeon.