Upper Lateral Incisor Implant Case: Thoughts?

This post is in response to a posted case I just left a comment for.

This patient is a 22 year old female with a congenitally missing # 10 and an extremely high esthetic demand.

After years of orthodontics, retention with different kinds of retainers, failed adhesive bridges, I saw this case an the lower limit of mesio-distal width where an implant could be safely placed and restored with a good short and long term esthetic outcome. AT the crest this ridge measured 4.5 mm mesio-distally. The orthodontist had done everything they could do at this point to optimize the site for a dental implant.

I used a Nobel Biocare Active 3.0 fixture, with a platform switch to 2.5 mm. This left me about .8 mm on either side of the implant if I could get it perfectly in the middle. I do not use guides for these cases, I’m more comfortable free handing it and taking lots of check films. I took 4 check films to place this implant.

The implant has been temporized, and 6 months out it looks great.

I posted this case in response to a previously posted lateral incisor case. The surgeon did an excellent job doing surgery, but failed the most important step, treatment planning. When implants are placed in tight spaces, it is imperative to understand that huge restorative problems can be created. A thorough work up, models, calipers, etc… All necessary to make these things work.

As adhesive dentistry gets better and better, so must our results with dental implants. This patient had several consultations regarding Maryland type bridges. I did feel that an implant was the best solution here. If the site was any smaller- not sure if I could pull it off.

Interested to hear what you all think.

3.0 Nobel Biocare Active

11 Comments on Upper Lateral Incisor Implant Case: Thoughts?

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Alex Zavyalov
A perfect surgical placement. What kind of prosthetic problem do you have? Not enough room for a 1.5 mm-min crown thickness? E.max or IPC Empress are the best cosmetic materials for any patient with an extremely high esthetic demand.
sb oms
I posted this case in reponse to another lateral incisor case that was posted a few days ago. There is no prosthetic issue here, it looks great, and is functionally very healthy. A screw retained temporary was placed the day after surgery to begin tissue engineering. There is adequate room on either side of the implant for an emergence profile, and a papilla. On the previously posted case, the implant was placed to close to both teeth, so no chance for emergence profile or a papailla. Take home message- 1. Many Lateral incisors are very challenging cases that require many levels of work up 2. The 3.0 platform switched implants are great tools in tight spaces 3. To the poster of the previous case, learn form this treatmenmt planning mistake. I learned this the hard way as well about 8 years ago. I then switched to smaller diameter one piece implants. These were good, but resulted in deep crown margins and high peri-implantitis risk from cement issues. Now that we have multiple reliable 3.0 mm fixtures out there to use, these cases are more predictable. We must remember that adhesive dentistry techniques are evolving as well, and some lateral cases are best treated by minimally invasive (Maryland type) fixed bridges.
Beautiful, thanks for posting!
nice work can you please show a photo that shows crown
myonphu yip
Excellent job! Thank you for sharing.
peter Fairbairn
Nice surgery , these cases are one of the hardest as bone undeveloped and space always an issue .... Peter
Orthodontics treatment to gain proper m-d space symmetry to #22. Then implant.
peter Fairbairn
Most of these cases come to you after they have just completed 2 years of orthodontic treatment ....they want their teeth now not more orthodontic attempts ! It happens regularly and in most cases the roots have not been moved merely tilted so even bigger issues ... Peter
k e wirth
Just a question here. Isn't this implant placed such that the interproximal bone/implant interface is in an area of bone associated with the PDL/lamina-dura? As such, isn't this area/bone always in a state of flux? How will this affect stability over months? At recall,..what if the lamina dura has lost continuity? Don't you need something like 2mm space twixt the fixture and pdl? Just checking. kw
Looks great . Just did a 4 hour course last week. He spoke of one issue and that was the concave abutment . Apparently you got the memo . Baker v
sb oms
K E Wirth, you ask an excellent questions and raise some good points. I've been placing implants in my solo private practice for 10 years now. I was "trained" in my OMS residency, and we learned those rules about 2mm of healthy undisturbed bone between an implant the lamina dura of adjacent teeth. Cases were designed around those limitations, and things worked pretty much most of the time. After developing an implant practice, and treating case after case after case, I began to realize that many of the original implant guidlines were not written in stone. Year after year, case after case, I began to challenge these original concepts that I was taught, and again, the vast majority of cases worked. I am at the point now where I can look at the case above and say, "yes, that will work." There is enough room on each side of the implant shoulder for a healthy emergence profile. As the adjacent teeth are healthy, and have no periodontal issues, I can put an implant that close to the lamina dura of the adjacent teeth. If I looked at this case 10 years ago, I would have shivered and said to myself, that will never work. So again, your points are valid, and the implant textbooks still talk about certain spacing requirements that "cannot be violated." I have learned through experience, and thoughtfull patient by patient analysis, that a lot of what I was originnaly taught is not written in stone. I'm sure anyone reading this with a couple of thousand cases under their belt will agree.

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