Combining implant and composite to achieve better proportions

Nowadays, as the world is influenced more and more by social media, patients and dentists are often obsessed by the hunt of the perfect smile. On the other side however, patients coming to our office all have different preferences, and sometimes the perfect smile is rather a distant dream. A good professional has a simple and predictable solution in every situation. Just as the use of adhesive procedures, dental implants are a scientifically well documented treatment option and a cornerstone of recent years dental evolution. This case is a combination of direct composite restorations, implant and bone augmentation treatment, all carried out by the author. Not all the initial disease or deviation from the ideal was corrected, only those that were mentioned by the patient or could affect the longevity of the results.

styleitaliano style italiano implant incisor composite restoration space midline proportions papilla preservation bone augmentation custom transfer impression

Fig.1

Initial situation. Middle-aged female patient came to my office after loss of her upper left central incisor in an accident. Further diagnoses are: tooth 23 missing, tooth 24 rotated, 11, 22 fractured, diastema between anterior teeth.
styleitaliano style italiano implant incisor composite restoration space midline proportions papilla preservation bone augmentation custom transfer impression

Fig.2

Initial situation. Right lateral, retracted.
styleitaliano style italiano implant incisor composite restoration space midline proportions papilla preservation bone augmentation custom transfer impression

Fig.3

Initial situation. Left lateral, retracted.
styleitaliano style italiano implant incisor composite restoration space midline proportions papilla preservation bone augmentation custom transfer impression

Fig.4

Initial situation.
styleitaliano style italiano implant incisor composite restoration space midline proportions papilla preservation bone augmentation custom transfer impression

Fig.5

Initial situation.
styleitaliano style italiano implant incisor composite restoration space midline proportions papilla preservation bone augmentation custom transfer impression

Fig.6

After thorough clinical and radiographic examination and discussion with the patient, the treatment plan was to place an implant supported crown at the left central incisor and composite resin restorations on teeth 11, 22 and 24.
styleitaliano style italiano implant incisor composite restoration space midline proportions papilla preservation bone augmentation custom transfer impression

Fig.7

In position 21, an implant (Nobel Biocare Replace CC 3.5x13mm) was placed with simultaneous bone grafting procedure. Because the bone augmentation, a 2-stage surgical procedure was utilised. A metal reinforced composite Maryland bridge was placed as a temporary restoration.
styleitaliano style italiano implant incisor composite restoration space midline proportions papilla preservation bone augmentation custom transfer impression

Fig.8

After 5 months healing period, the implant was uncovered with a roll flap procedure, and a closed tray impression was taken for a temporary crown. On the right image, you can see the Maryland bridge in place.
styleitaliano style italiano implant incisor composite restoration space midline proportions papilla preservation bone augmentation custom transfer impression

Fig.9

A screw retained plastic temporary crown was fabricated to shape the soft tissues.
styleitaliano style italiano implant incisor composite restoration space midline proportions papilla preservation bone augmentation custom transfer impression

Fig.10

After wearing the temporary crown for 1 month, a check-up was done. The soft tissues showed appropriate healing and shape.
styleitaliano style italiano implant incisor composite restoration space midline proportions papilla preservation bone augmentation custom transfer impression

Fig.11

The patient was very happy about the result already at this stage. We decided, that more ideal proportions can be reached with modification of the central incisor shapes.
styleitaliano style italiano implant incisor composite restoration space midline proportions papilla preservation bone augmentation custom transfer impression

Fig.12

Rubber dam isolation was placed to ensure a clean and dry working field and to retract the soft tissues.
styleitaliano style italiano implant incisor composite restoration space midline proportions papilla preservation bone augmentation custom transfer impression

Fig.13

We decided to place an additive composite resin restoration on the mesial side of 11, to achieve the desired shape. One dentin layer was used, covered with a very thin layer of enamel material.
styleitaliano style italiano implant incisor composite restoration space midline proportions papilla preservation bone augmentation custom transfer impression

Fig.14

An individual impression coping was fabricated to precisely copy the transmucosal profile of the provisional crown. An impression was done with an individual impression tray and polyether material with open-tray technique.
styleitaliano style italiano implant incisor composite restoration space midline proportions papilla preservation bone augmentation custom transfer impression

Fig.15

The soft tissue profile was analysed again and instructions were given to the dental technician for small modifications.
styleitaliano style italiano implant incisor composite restoration space midline proportions papilla preservation bone augmentation custom transfer impression

Fig.16

A screw retained zirconia framework was fabricated and veneered with feldspathic porcelain. Particular attention was paid to copy the shape of the contralateral central incisor and to achieve a proper transmucosal profile. This should be concave in the vestibular and oral sides to achieve ideal soft tissue thickness, and convex in the approximal areas to push the papillae in the incisal direction.
styleitaliano style italiano implant incisor composite restoration space midline proportions papilla preservation bone augmentation custom transfer impression

Fig.17

The ideal soft tissue healing is visible at the fitting appointment.
styleitaliano style italiano implant incisor composite restoration space midline proportions papilla preservation bone augmentation custom transfer impression

Fig.18

After the insertion of the final prosthesis, a radiographic control was done to check the fit. A limited volume CBCT was also done to check the amount of bone around the implant, especially on the facial side.
styleitaliano style italiano implant incisor composite restoration space midline proportions papilla preservation bone augmentation custom transfer impression

Fig.19

Final situation just after fitting of the final crown.
styleitaliano style italiano implant incisor composite restoration space midline proportions papilla preservation bone augmentation custom transfer impression

Fig.20

Final situation, 1 month after finishing the treatment.
styleitaliano style italiano implant incisor composite restoration space midline proportions papilla preservation bone augmentation custom transfer impression

Fig.21

Final situation, 1 month after finishing the treatment.
styleitaliano style italiano implant incisor composite restoration space midline proportions papilla preservation bone augmentation custom transfer impression

Fig.22

Final situation, 1 month after finishing the treatment.
styleitaliano style italiano implant incisor composite restoration space midline proportions papilla preservation bone augmentation custom transfer impression

Fig.23

Final smile of the patient, 1 month after finishing the treatment.

Conclusions

State of the art dental treatment is not about creating a perfect set of teeth every time, sometimes by placing restorations on teeth which wouldn’’t need any. It is more important to carefully listen to the patients complaints and expectations, and have a good overview over treatment possibilities.
After finishing the treatment, the patient was happy with the result.

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