Indication 4, Case 5

Single tooth gap maxilla

Restorative Dentist: Frank Higginbottom, Dallas TX, USA
Surgeon: Tom Wilson, Dallas TX, USA
Technician: Jeff Singler

An 18 year old white Female presented with congenitally missing maxillary lateral incisors. The patient had completed orthodontic treatment without incident. The lateral incisor spaces were left open with the plan to place root form dental implants. The patient had no other dental needs.

1) Pre-operative appearance of the patient. Since the patient was congenitally missing the permanent maxillary lateral incisors the alveolar ridges did not develop completely. The patient needed ridge augmentation to allow appropriate placement of two ITI dental implants. However, due to logistic problems it was decided to place the ITI dental implants in a submerged approach with the simultaneous application of non-resorbable membranes.

	2) Pre-operative appearance.

	3) Pre-operative appearance.

	4) Pre-operative appearance.

	5) Radiograph of diagnostic templates showing projected path of insertion of the implants. Note the need for better communication with the orthodontist in the area of the patients right maxillary lateral incisor. Radiograph of right side.

	6) Radiograph left side.

	7) Radiograph of the placement of two prototype narrow neck implants in a submerged approach. Radiograph of the right placement.

	8) Radiograph of the left placement.

	9) After six months of healing a second surgery the membranes were exposed and removed. Connective tissue graphs were placed. Emergence profile provisional restorations were fabricated on titanium provionalization copings that were shortened, sandblasted, and opaqued. Impressions were not taken due to instability of the gingival tissues.

	10) The emergence profile provisional restoration, which exhibits normal tooth anatomical form starting at the shoulder of the implant and extending into the edentulous space. Such a provisional restoration will shape and guide the gingival tissues. Since a second surgery was needed the final impression was delayed for two months at the time the soft tissues were stable.

	11) Provisional restorations are viewed at the day of uncovering, membrane removal, connective tissue grafts. Provisional restorations are placed for soft tissue shaping.

	12) Provisional restorations after two months healing. Final impressions are made at this time.

	13) Final development of the peri-implant sulcus using the concept of "Guided tissue shaping" with the provisional restoration.

	14) Palatal view of the final restorations

	15) Final view of the right lateral incisor at the date of placement.

	16) Final view of the left lateral incisor at the date of placement.

	17) Patient presentation at six month recall.

	18) Patient presentation at two year recall. Patient's right lateral incisor.

	19) Patient presentation at two year recall. Patient' left lateral incisor.

	20 )Final rehabilitation of the patient at two years post-operative treatment.

21) Final rehabilitation of the patient at two years post-operative treatment. A successful treatment was possible by following a prescription for success. Predictably results can be obtained by having the proper volume of bone and soft tissue at the site of implant placement. In addition the proper three dimensional placement of the implant is necessary in esthetic sites. Additional advantages come from a stable abutment connection, an accurate microgap, and an emergence profile restoration. If, our ceramist provides us with an acceptable reproduction of natural tooth color we have a success.