Two upper central implants with bone loss: tips for aesthetics?

What does the soft tissue look like? There is no shame in placing long implants and adding some pink porcelain. Bone height is difficult to gain in the anterior maxilla sometimes a connective tissue solution can help the esthetics. Emergence profile and the finish line is key. Also a little Botox, just kidding.

Black triangle can be easily corrected with any shade pink material (such as "AnaxGUM"- composite; "Creation CC Gingival Kit-porcelain), but the main problem is to determine the correct gum tissue line after atrophy.

If it were me I'd try to build up the ridge first with bone and soft tissue. But what makes these cases work is the provisionalization. Either an Essix or a new temporary between #7-10 while the grafts are healing. Placing an immediate at #8 may be tricky since there is low bone on #7 which will compromise the case but the distal on #9 is better. I'm pretty conservative, I would extract 8, maybe 7 place a sonic weld, prgf and bone graft see what you get. Then place the implants and guide the soft tissue. Otherwise pink porcelain to fill in the soft tissue loss, with consideration of the finish line. No shame in fixed bridgework with building up the soft tissue with a pediculed graft. The important thing is not to place the implants too quickly if it is an esthetic failure then the patient will be seeking the original treatment I outlined above. This is a difficult case.

Great Case! There are several advanced surgical techniques you could try to augment the ridge. Bock grafts, mesh with infuse and particulate, ridge splits with a piezo..... The list goes on and on. How about this though, look carefully at this radiograph why did this case fail? Fractured joint 7/8 with a cantilever off of 8? Was the endo done after the bridge insert through the crown on 8 (looks like it)? How did this patient loose 9 originally? Best tmt plan with a high lip line? Exo 7--->10, implants grafts sites 7&10. Then ridge aug 8,9 with CT grafts and bone (cosmetics only) and a nice 4 unit bridge on implants. Maybe CLP 6 and 11 and veneer to match 7-->10. You can develop the I/P papillae with your provisional after temp abutments are placed on 7&10. (Pink porcelain is an alternative for irreversible trauma cases)

My preference for adjacent max central implants is sequential placement. I would place a provisional FPD #7-10 and implant in the #9 site. Once integration reaches two months, I would extract #8 and implant. This approach maintains attachment of the midline bone via the PDL. Once integration of #9 is achieved, the bone is secured to the implant in 9 and loss is mitigated. Single crowns 7-10. If instead,#8 is extracted immediately, the bone between 8 and 9 will flatten out. Of course all of our suggestions are conjectural without clinical images. Of note,pink comp resin is more esthetic than pink porcelain but it degrades in the mouth and requires touch up. If you intend to use it, try to design the restoration as screw retained.

I'm surprised to see so much enthusiasm for pink porcelain. In my opinion pink porcelain and a high lip line make a toxic combination. Invariably looks like a bridge with a chunk of bacon stuck underneath it.

The bone level on #7 doesnt look great and you many want to consider extracting both 7 and 8 place a single crown on 10 then place implants at 9 and 7 with grafting to fill in 8 and get a better pontic area then restore with a 3 unit bridge 7-9

John T : You are so right.

To John T and Drg: Can you suggest a better cosmetic solution then a pink material if a tissue atrophy volume is supposed to be unpredictable in this case? I am not sure in it.

Agreed Pink composite or porcelain is when all else has failed in very extreme cases ..... I am with MMontana on this with his approach achieving increased bone height is now more achievable consistently using newer materials and protocols . Plus the use of soft tissue correction using screws ( to resist the muscular forces during healing ) can help in achieving an acceptable outcome ...... I see high lip line cases every day from around Europe and each has their own needs and difficulties but believe that expectation can be merely premeditated disappointment ...... so beware Peter

I f you consider the potential problems with 7, You could consider implants at 7 and 9 and an implant bridge. You will get a better papilla at the 6/7 and 9/10 if implants next to teeth. You may be able to erupt 7 and 8 orthodontically and bring the bone up before implants You can't build up the bone at 9 greater than a line from the bone crest of 8 and 10 if they stay where they are but if you erupt them you may be able to use an implant at 9 to tent up the tissue for your bone graft at that position using the erupted bone as support The Bone height on 10 looks good You can always fall back with a 7-10 bridge It would be good to see the soft tissue. Many options here. Lip length?

I would look to maximise the benefit of two implants for this patient. The laterals will be great abutments for your provisional 7-10. Than you can augment the ridge area 8-9 with bone and soft tissue In conjunction with the extraction of #9. Once that heals you can place two immediate implants in the lateral positions. They can be 3.5 x 15-16 mm and immediate load if stable. I would avoid placing implants in the 8-9 area. The bone is already compromised and we don't know how large the incisive foramen is. We as dentists have lots of ways to make two central pontics look proportional. The ridge augmentation and pink restorative materials will help. Very interesting case good luck. Sincerely , David Furnari

i would take a cbct before stating any opinion about this case i have one in my office and i see all kinds of anatomical variations from one case to the other. Its funny noone mentioned a cbct. If i have to treatment plan pink porcelain then someone else should be doing this case (periodontist, oms)

Thank you for all the varied responses and suggestions. Will discuss a few of the ideas mentioned above with the patient and will post pictures later today. Thanks again

Thanks for all the varied responses and suggestions. Will discuss a few of the ideas mentioned above with the patient and will post pictures later today. Thanks again

Dear Confrere, There are a lot of bright and talented people with a lot of experience who actively offer suggestions on OsseoNews...however, if you want good information, you have to submit more than just the xrays..... we need to see photographs, and have an idea of the patient's age and health...and then you will get the proper suggestions.

I agree with Dr Rudnick. More information is needed to make appropriate suggestions. But without the benefit of photos, study models AND a CBCT, I would treatment plan fixed temporization from #7-10, extraction of #8, shoring up the bony support of #7, repairing or replacing that non-integrated graft (note the midline radiolucency that resembles a fracture), overbuilding both the #8 site and the most likely deficient #9 site in three dimensions (horiz and vert) using whatever method you are most comfortable with (ie. tenting screws and membranes, autogenous or allogenic onlay grafts, assisted by LPRF, PGDF or BMP), grafting the nasoplatine foramen if necessary and countersinking two implants to create the bony "peaks" to support your papillae. All pre-planned carefully to insure an acceptable outcome. No guessing here....this is the cosmetic zone!

If, and that's a big "if", the aveolar width in the area of #9 and what remains of the socket of #8 after extraction (assuming the buccal plate remains relatively intact) is sufficiently wide (4mm at the crest at least), then implants for #s 8 and 9 can work just fine. Such a senario also relies on a relatively robust gingival biotype to displace tissue with the contours of the restoration/abutment to achieve an esthetic result. If the the alveolar ridge is too narrow, then an onlay graft must be considered. Alternatively, a 6 unit FPD may be planned, extracting and grafting #s 8 the buccal of #9 to produce a broad band of attached gingiva that can be shaped (using the pontics to displace the tissue).