Immediate implants: How to correct this aesthetic problem?

This was my first case of placing immediate implants in the anterior aesthetic zone. I placed two implant in palatal bone but the implants collar were tilted a little too far buccally.  This resulted in an unaesthetic soft tissue recession issue on the buccal. After preparing the crowns, they were too long for the patient to accept the aesthetics. The implants themselves are doing just fine, osseointegrated and the tissue has healed well, except for the buccal recession. What is the best and most predictable way to solve this aesthetic problem?

17 thoughts on “Immediate implants: How to correct this aesthetic problem?

  1. CRS says:

    If the buccal plate looks good on X-ray this could be helped with a free gingival graft to disguise the long crowns or pink porcelain with some pigment added to match patient’s gingiva. Do you have a photo of what the original teeth/crowns look like? The lateral is way too long it looks like a central and is not symmetrical with the other lateral. I suspect that this patient needed site preparation soft tissue and bone prior to implant placement, may have needed to be staged vs immediate placement The loss of vertical bone needs to be fixed either naturally with grafting or with a prosthesis with pink porcelain to get the height back. It can’t be done with a crown alone. Please post an X-ray. The problem is unless this was quoted in the restorative estimate the lab fees on this may be problematic. Wrong technique for clinical situation, remember it not just about the teeth but soft tissue and bone replacement. Don’t blame the healing. A good lab may save the case. If the patient had good bone initially then the implants were not angled correctly for esthetics, operator error. I need to see a film to determine if the implants were placed outside of the arch form.

  2. Paul says:

    Take the healing caps off, bury the implants and let the tissue grow back over them. In the meantime, send the models to the best lab you know of and tell them to DISREGARD THE SOFT TISSUE MODEL and MAKE THE TEETH IDEAL and then REVERSE CONTOUR (also called negative contour) from the ideal back to the implant.

    Then after the tissue has healed over the implants, make a LINGUALIZED incision and move the tissue from the lingual to the buccal and seat the IDEAL crowns.

    The best graft in the world won’t help if the crowns are not designed correctly. Many labs do not understand REVERSE/NEGATIVE contour and they over-contour the crowns. FIND A LAB THAT UNDERSTAND REVERSE/NEGATIVE contour.

  3. rsdds says:

    the tissue in my opinion looks acceptable . the bridge needs improvement the crowns are too far out and the lateral needs to be shaped like a lateral and made shorter than the centrals. You can make the lateral #10 thinner to give more room to the centrals.good luck

  4. Gregori Kurtzman, DDS, MAGD, FACD, FPFA, FADI, DICOI, DADIA says:

    Lesson to be learned is dont start doing implants in the esthetic area start in the mandible or posterior maxilla got to learn to walk before running. also these implants appear to have been placed tipped too facially and should have been tipped more palatally when placed. Did you use any guide or was this free hand? question now is how to correct. you can have the lab fabricate custom abutments to move them as far palatal as possible and also minimize the facial portion of the abutments. this will allow the tissue to drop down coronally also as someone suggested a connective tissue graft will help here. if the smile line allows it a great lab can also use gingival colored porcelain to make them appear less long but to do this one needs a gingival porcelain shade guide and needs to pick what shades are there for custom staining One of the esthetic issues in this case is the left lateral is too wide and appears like you have three centrals the lab needs to widen 8 and 9 and narrow 10 also consider alittle gingivectomy on 7 to make it longer that will help getting it all to blend better

  5. Montana says:

    Implants are too facially placed and inclined, therefore the prosthesis will be compromised esthetically unless the implants are rather deep. It may look better with the above suggestions, but it’s pretty difficult to overcome the exit position.

  6. Dr. Gerald Rudick says:

    From the photo using the cheek retractors, it seems to me that this person has a large fleshy upper lip, and does not have a gummy smile…… in almost every natural situation, the full view of these teeth will not show…leave it as it is…….gain from this experience, and take the patient out for a nice dinner, and make sure there is an entrée of “Corn on the Cob” so he can ecstatically dig his new teeth into that delicious corn, and enjoy himself…he will realize the value of your service…..”MMMMMM GOOD”

  7. LSDDDS says:

    I agree with Dr Rudnick. Three Centrals will not be noticed especially if high and low lip line cover this reasonably though patient may perceive interference with upper lip and more labially inclined teeth.

  8. Dr. Gerald Rudick says:

    Attention RSDDS……Look closely at the photo with the healing collars…… the upper left lateral implant is placed too far mesially from the canine…….so that it cannot be made to look smaller. Under the circumstances, the lab did a very good job…….. and leave the poor patient alone…. he is now enjoying biting into apples without any fear!!!!

    • CRS says:

      Gerry I agree with the practical management the lab can only do do much and the dentist is supposed to guide them. I am curious to see an X-ray to see the bone level and determine if my hypothesis is correct. Another thing to learn is that with an immediate using the extraction socket as a guide, compensation in keeping the implant emergence within the arch and cingulum of the final screw retained restoration is key and very easy to get disoriented. I sent you an email on the other matter! Take care!

  9. Jawdoc says:

    ‘Paul’ has a point if u want to make it better from a technical point of view (in fact, it’s brilliant!) ‘Dr Rudick’, on the other hand, makes perfect sense from a practical point of view. It all boils down to 2 things: 1. What’s the ‘exposure’? ( aka lip line); 2. Does the patient mind & can he live with it functionally?
    Sometimes, point 2 supersedes 1 (& vice versa – u can have a fussy patient on whom aesthetics matter more than (or equally to) function. But having said that, the implants are 1. Too labially placed 2. Upper left incisor placed too mesially (another 0.5 mm to the apposing canine would hv made a world of difference). Notwithstanding, it was a very difficult surgical case – immediate placement & all – hindsight is perhaps like a belly button – everyone’s got one! 🙂 press on!

  10. mwjohnson dds, ms says:

    There are several problems with these implants. Two of the problems have been addressed i.e. implants too far facial and #10 too far from #11 to create reasonable tooth size. The other problem is the initial size of the healing abutments. In the anterior I ask my surgeon to place the smallest diameter healing abutments possible. If the healing abutments are too wide (like these look) they act like labioverted teeth and the gingival margin will be pushed apically. I don’t want that to happen. I want as much tissue as possible to manipulate with my provisionals to try and develop ideal emergence profiles and soft tissue contours. You started at a disadvantage immediately because your soft tissue margins were already too apical before you even made your provisional. I agree with Dr. Kurtzman, don’t do anterior esthetic implants until you have done a bunch of posteriors. Esthetic implant restorations are tough enough without starting out compromised!


    Just a thought….
    I have done hundreds of implants and after years of practice when doing multiple anterior implants I ALWAYS place them guided. Yes it adds to the cost but you will MAXIMIZE all the considerations in placement not only of the implants within the bone but also with respect to one another and with respect to adjacent teeth. I let them computer help me in determining the placement experienced clinicians may feel this is unnecessary and a “rookie” move but I don’t sweat it afterwards. The older I get the easier I make life on myself in my opinion a guide accomplishes that! You start out with an optimal result to avoid surgical successes accompanied with restorative failures!

  12. Dr. Gerald Rudick says:

    Robert….while I would agree with you that a computer designed surgical guide is generally a good thing, but there are situations where they end up as prosthetic nightmares……..computers, as smart as they are, have some shortcomings, and if a surgical guide is not placed 100% perfect, the results can be a disaster.
    I am from the old school, doing implants long before CT Conebeam scans came into being.
    I find that the young implantologists who are so ingrained to only work with a surgical guide, are losing something…….. we are soon going to realize that in a few years the driverless cars will be very popular…….. we have not yet learned of the potential damage they will cause to human beings.
    All you younger guys, realize that dentistry is both an art and a science….. don’t be afraid to experiment with the art part of our profession….. it will improve your creativity…..( I know that CRS will approve of my comments…best regards to you!!! )

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