Planning The Dental Implants For 3 Missing Front Teeth

Here is a case that if you don’t plan properly, can quickly turn into a disaster! 

The short story here is that we need to get rid of the denture, we need a fixed set of teeth on implants (I think a bridge is too risky) and we need to make is look awesome. 

The patient has been waiting a long time to have this done is he is keen to have it done properly. 

His lip line is low, and you might think that this is great, because it doesn’t matter what the gums look like, and if we can make the teeth look okay, then the patient should be happy. 

I don’t think its a good idea to look for a quick way out of this. 

Patients will look under the gum, and although you can explain that the top of the teeth will not look great, I believe its always a good idea to do your absolute best for the patient and aim for perfection every single time. 

Here is a summary for the treatment plan we have discussed: 

  • Bone graft and dental implants in the ULQ 
  • Possible Connective Tissue Grafting
  • Veneers on the UR1-3, possibly more, we can deicide this later. 

How do we know that we need a bone graft, and how should we plan this? 

The simplest way to see if a bone graft is needed is either to have a wax up done, or plan the teeth on the CBCT planning software

When the case is planned like this, we follow the archform of the other teeth, so the teeth look symmetrical, and are of a similar width and height. 

It is difficult to see, but when this is done, there is a large gap between the teeth and the gums. 

An easier thing to see is the position of the implant and the tooth, in cross section. 

Now, you can see that if we want to place a dental implant in the correct position for a screw retained crown, then we will need to add about 7mm of bone. 

This is not an easy task! 

You can see from another view that the idea implant position looks correct when compared to the roots on the opposite side. 

There are a number of ways to do this kind of bone grafting to achieve this, and one of my more preferable ways is to use the Khoury technique and place bony plates to support the new bone graft. 

This is what we have planned, and we should be ready to place dental implants from between 4-6 months. 

For a temporary, we cannot have a denture, this will put pressure on the graft, and it will fail. We also need the gums to heal, so the plan is:

  • Intensive denture OH from now, and removal of the denture at night. 
  • Then we will have an Essex retainer made with false teeth, this will be used for the first two weeks, and then after all the sutures are removed, we will fit a temp adhesive bridge. 

The hardest part of this case is to place the dental implants in the correct position and build up the bone so that it looks symmetrical at the end of treatment. 

Once the implants are in, I will write another post specifically about how to carry out the restorative portion of this treatment, and if we need the connective tissue graft. 

But What about the Recession on the UR1?

It is always a good idea to try and correct this if possible, and I think it should be possible. 

When a large bone graft is carried out, the gum is always advanced coronally – to cover the new bulk. 

In this case, we will make the incisions detailed below, and de-epithelialize the UR1/2 papilla. 

The new papilla will then be sutured into the old papilla’s position and the will naturally bring the gingival margin to the CEJ. 

We will prepare the root surface slightly, but its unlikely that I will do a connective tissue graft at the first instance. 

The reason for this is that the palatal tissue is currently traumatised, and it is likely that I will need a connective tissue graft at a later date to increase gum thickness, and I would just prefer to do all the soft tissue work in one sitting. 

I will often help the dentists I am mentoring with cases like this, and simpler ones. There is almost always a way to achieve excellent results for our patients, and its worth talking to more experienced dentists to show you what is possible. 

If you would like to find out more about the mentoring, you can find out more by clicking here.

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