Implant Crowns #9 & #10- Options?
Here is a tough implant case that walked through my door a few days ago for impressions. He was referred to me by the oral surgeon, post placement.
This is a young man who has never had a filling, but had got into an unfortunate accident with the handlebars of his bike and the bike obviously won. He went through root canal therapy on #9 and #10, crowns, retreatments, extractions and finally implants. He was ready to be done and have teeth and the surgeon told him I could do it in a day 
.
So this is what I see...
1. two implants next to each other in the anterior that are not easy to restore
2. Not awesome tissue or chance for a great papillae between #9 and #10
3. Distal inclination of #8 and an overlap of #7/8
I have the discussion with the patient:
Do you want ortho to straighten up your central?- "no"
Do you want to add composite on that tooth to make it appear straight?- "not really "
Did you have a gap between your front teeth before or a space?- "no, I want them to touch"
Would you be interested in another gum graft if possible?- "I really just want teeth that don't come out at night"
So here is what I came up with. I could not split this case because there was not enough room unless I put the margins on the abutments up pretty far above the gingival level. These are screw retained.
I was pretty excited about the staining and glazing. I used an A1 LT and carried the shade 1 down towards the incisal to match his other teeth. Here is what I am struggling with:
I don't love the midline slanting and wish I would have just placed composite there instead. The reflection on #9 tells me that I need to flatten that part of the facial wall just slightly and polish it back up to mirror the other central. Last but not least, I don't love the embrasure space between #9 and #10 but I am not sure if that is possible to fix.
Would a graft work here? Pink porcelain might have been an option for an illusion but super tricky, especially without a model. The other option I am thinking of is Anaxdent Anaxgum paste. I have never used it but saw it on another post... Has anyone tried it?
I am hoping to accomplish this:
but how possible is that?
At the end of the day he was happy to have teeth. I am just curious on what other people would have done in this case. I don't think temporaries would have done too much because there isn't a lot of tissue to move around. The implants are shallow. I'm leaning towards trying the anaxgum because I wouldn't have to remove or refire the implant crowns but I would love other ideas too.
Thanks!
Well, I do not know the legal background in the US but here I would nit have asked to much what the patient wants and would just have informed him that we need to put some composite at the coronal mesial face of #8. He would have a few seconds then to contradict but usually the patients don‘t especially if you quickly change the subject after mentioning it.
We all have cases like this that come in, and we want to help them. I think you did a great job in a tough situation. When we take pictures of cases it’s rare we do not see things we could have done better.
Composite on #9 would have helped.
tissue grafting here may be quicksand. I have a few that I did and it made the case worse. I would love to see and Xray and hear what Farhad thinks.
I do think the tissue will look better as time goes on.
I personally hate pink porcelain and if you add it here it may add more of a plaque trap
again great job in a difficult situation.
I think you covered your bases pretty well. If ortho and further perio work was declined and he understood YOUR limitations as a result of HIS current anatomy.. You've done all you can do.
EXCELLENT restoration given the circumstance. I hope he understands what you were able to provide given the limitations of the case
Don't beat yourself up. On our best day, most of us couldn't achieve anything near your caliber of work. Your patient is very lucky and you are an inspiration to all of us. Thank you for sharing.
I agree, an excellent result in a very compromised presentation. I frequently run in to the same issues when I receive cases from O.S. (who I did not refer to). When there is no planning between GP and surgeon it is difficult to get ideal result in the anterior. Perhaps a single implant in #9 site with a 2 unit cantilever would have achieved better esthetics? Or an immediate provisional to help form tissue?
Anyway, at this point I think trying that pink material is worth a shot. It can only improve it I would think. Can you open the cervical embrasure between #9 & #10 in hopes that tissue may eventually fill in??
Thank for posting!! Curious to see how that material works out.
Carmela
There can be a lot of analyzing and over thinking....and there can also be just looking at how awesome that is for what he had and what he wanted. Time will tell how those papilla settle in. Good job Kris!!
Great finish - I totally agree with some of the other comments above, you did the best possible Treatment based on the limitations of the case and what the patient wanted. Really awesome work.
Stunningly good characterization Kris.... as to tissue? Where is the interproximal bone?.... doesn't look promising for regeneration whatever you do, but depending on where the bone is, I may keep the embrasure open to the 5mm coronal to give it a chance, and wouldn't be optimistic about it... nice thing about provisionals, is that you can give every effort to see what biology will cooperate with before you finalize, neither closing off the embrasure too much, nor leaving it too open....
I've had a few cases of adding the GC Lustre pink porcelain, and really the only thing that it added was to define the clinical crown length (matching the tissue was harder than I thought too)... you can't hide the open vertical joint between the two... if position is amenable to screw retained, you could make (rather could have made by your lab unless you have inLab) a screw retained FPD and be able to have better papilla form. Fortunately he doesn't seem to have display of the gingival margin....
Honestly- what you have here is pretty darn good and you didn't have a lot of options to work with..
Mark
Kristine, great job. And I think you're done because of two things: 1) the patient is happy and 2) the area that concerns you is not in his smile.
I second the "nice job on characterization"!! Difficult case for sure I think your outcome is more than acceptable. Thanks for sharing:)
Great result! I think your desire to constantly improve is admirable, but the reality is most people (and certainly this patient) do not have "perfect" smiles. What you produced for him was functional and harmonious with the rest of his smile....again, great result
How old is the post op on that case? Honestly, Im not sure you could have done better - but take another picture in 6 months and see where the tissue is. Too early to start second guessing your treatment.
Kris,
Your work is awesome. Agree with everyone here.your strive to be better is unparalleled. Kudos to you and you lack of fear to share your work. Thank you.
Carrie
Score 100% on meeting patient's expectations, just beautiful!
Score less on your desired outcome, you were limited by patient's desired outcome.
If you could do it any way you like, you could have done ortho and you or lab could do a split and splint with pink porcelain and had the "perfect" result.
As it is, it is the "perfect" result.
It's great for you to look at this case as a "what could I have done differently?" situation, shows you just wanna give your patients the best. #loveit
Now that he has his initial expectations met, he may choose to do it differently in the future as he grows to appreciate the vision you presented.
Thank you for all of the comments. I posted and then left town for a CE course!
Here is the PA:
To answer some questions:
No, I did not do this case in one appointment. He came in at 4pm and was under the impression it was a single visit, but I explained that I needed a little more time to make them than an hour and I had plans after 5pm ;) I did seat them the following day because I am a sucker for a good story and he had a reunion to go to. Normally for implants I schedule two 30 min appointments- one for scanning and the second for seating.
The pictures were from immediate seat but he ended up coming in a yesterday and asked to "speak with the doctor." This always makes my stomach turn and I assume the worst. It turns out he did go back to his surgeon and ask about a gingival graph but when he found out the details and the likelihood of improvement he decided not to go down that path. He said the surgeon was very complimentary on the restorations. He thanked me for the work and let me make some adjustments that I wanted to make after my last set of photos.
After looking at the picture I realized I needed to polish up a bit more but didn't want to harass him for more photos and push my luck. This is why I love photos! For better or for worse, the camera doesn't lie.
I want to be you when I grow up. Awesome job! And remember... you practice in Vancouver, WA :) I'm teasing. He is lucky to have found you!
