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Managing implant complications in Esthetic Zone

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Introduction

Dental implant success today is judged not only by Osseo integration but also by esthetic results. Cosmetic predictability can often be difficult to attain, and esthetic implant failures can be multifactorial. Many complications are related more to the implant position and the associated many factors anatomical findings.

Surgically malposed implants can be catastrophic and commonly can not be fully corrected replacing the restorations and making the necessary corrections can be costly, but much less so than replacing implants. 

 

Aim

This case show an alternative in the complications of prosthetic treatment with implants in the aesthetic zone, avoiding the explantation of the implant misplaced, using tools such as the digital smile design and Chu’s proportion gauge for the diagnosis and treatment planning that are needed to achieve esthetic and functional prosthetic gingival restoration. 

Case presentation

A 64-year-old female presented with a chief complaint of unsatisfactory smile esthetics.

Intraoral examination revealed the presence of dental disharmony, mal positioned implants ( at the maxillary right central incisor and left lateral incisor sites), gingival recession, papilla loss, and dental and gingival discrepancy.

 To perform an effective evaluation of the implants, a radiography  was also performed to better evaluate the patient´s  condition and the  restorations were removed. Upon so doing a metal abutment was found with the vestibular head of the screw emerging. This confirmed the poor position of the implant. After the diagnosis was made, and taking into a account that the patient did not wish to have the implants removed, the following treatment plan and clinical sequence were suggested.

 

Treatment plan 

The first step of treatment plan was an aesthetic analysis with photographs and the digital smile design was determine ideal proportions, proceeded to mill a provisional with Telio CAD of the same length and with the DSD and the Chu´s proportion gauge was determined the gingival margin, once determined with pinky resin on the provisional, left 3 weeks in the mouth to review aesthetics and function.

The abutment  of the lateral incisor  is removed and an impression coping was used after second surgery stage to uncover implant platform and impression was taken.  A zirconia framework was milling for implant-supported prostheses with pink and white porcelain  and crowns were cemented canine and premolars sites.

Discussion

Maxillary anterior tooth loss results in bone resorption in the direction and inclination of the roots, shortening the ridge and reducing the perimeter of the arch. To compensate for this vertical loss of the ridge and gingiva, the surgeon will typically first place grafts to gain essential height in hopes that this will recreate satisfactory papilla form for the restorative phase. Esthetic failures can also be caused by inappropiate implant positioning and/ or improper implant selection. Placement of implants in a correct 3- Dimensional position is a key to an esthetic treatment outcome . Artificial gingiva as a predictable treatment option for fixed partial restorations in patients with severe ridge defects. 

 

Conclusion

When facing major soft tissue deficiencies, the addition of pink ceramics as an integral part of the implant restoration may become unavoidable to achieve a clinically acceptable result, must also take into consideration the position of the patient’s individual smile line as an important decision-making parameter. Finally, one has to ensure that established design rules for the use of pink ceramics such as convex profile and access for plaque control are strictly enforced.

 

References

1.Coachman, C., Salama, M., Garber, D., Calamita, M., Salama, H., & Cabral, G. (2009). Prosthetic gingival reconstruction in a fixed partial restoration. Part 1: introduction to artificial gingiva as an alternative therapy. International Journal of Periodontics & Restorative Dentistry, 29(5).
2.Salama, M., Garber, D., Calamita, M., & Salama, H. (2010). Prosthetic gingival reconstruction in fixed partial restorations. Part 3: laboratory procedures and maintenance. Restorative Dent, 30, 19-29.
3.Chu, S. J., & Hochman, M. N. (2008). A biometric approach to aesthetic crown lengthening: part I-midfacial considerations. PRACTICAL PROCEDURES AND AESTHETIC DENTISTRY, 20(1), 17.
4.Coachman, C, Van, E, Gurel, G, Calamita, M, Minimally Invasive reconstruction in implant therapy: the Prosthetic Gingival Restoration. (2010) QDT.Vol. 33, p61
5. Heitz-Mayfield LJ, Needleman I, Salvi GE, Pjetursson BE. Consensus statements and clinical recommendations for prevention and management of biologic and technical implant complications. Int J Oral Maxillofac Implants. 2014;29 Suppl:346-50. 
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