This is a case that I recently saw for the follow-up pics.

Background: History of trauma to 8,9,10. #9 endo treated,
then fractured. Tooth was removed, site grafted, implant
placed later. Implant was placed too deep, too facial, but
it was restored. This was all done at UI College of Dentistry…

5 years later he presents to a prosth colleague of mine for
help with the failing site. That’s how he got to me, and the
rest is shown in the pics.

I was not able to regenerate a papilla between 9/10, but
all things considered it’s now a healthy & stable site.

Obviously this could have been done many different ways.
I thought I’d throw it out for discussion & I welcome any
comments on different approaches that you might have
used. For example: would anyone have done a pedicled
CTG from the palate to regenerate the soft tissue?

Thanks & Enjoy!

Andy

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As Chuck just said: lets move on & discuss some good stuff!

I think perhaps this case that I sent out Friday got overlooked.
Please take a look & let me know your thoughts. I think it’s
a great case for discussion, as many different techniques could
have been used.

Andy

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Andy,

I just got this for the first time. My first thought would be remove and graft area. However, if the removal of the implant would be destructive, it may be best to put it to sleep hard and or soft tissue grafting.

Chuck

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Chuck,

This was prior to when I had a Piezosurgery unit.
I’d be more inclined to remove the implant using the piezo
versus when I had to drill or trephine it out.

The second surgical pic shows the apical portion of the #10
socket level with the implant neck. It also shows how facial
the implant was. It’s unfortunate that the resident/staff who
did that surgery didn’t look at how deep the implant was and
say: this is too deep! It’s not maintainable… let’s take it out
now and re-do it later, rather than putting the patient through
the cost and disappointment of an early failure totally due to
implant positioning.

Looking at the pics, I wish I had done the release distal to #6
rather than at #7. It’s not bad, but that would have been a
better call.

Thanks,

Andy

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Andy,

Just viewed the treatment section of your post. Originally, I only viewed initial problem and radiographs. Now having seen your treatment out come, I guess all that matters at this point, is the smile line and whether or not the patient is happy. Cosmetically, you did OK with #8,but 9-10 is questionable.
In my mind, you would have done better with fixed bridgework (no implants) 6-11. However, if not involving natural teeth was a priority, you did pretty well with what you had to work with. I assume the restorative dentist did wish to play with provisional crown contours to create a better illusion. Of course the “think pink” approach would have work well.

Chuck

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Andy –

That is a great result. Can’t wait to see the x-rays.
I have more of a prosthetic question (or a few). What is the smile line like? Does the gingival margin of the restoration even show? Was an ovate pontic used during tissue sculpting and, if so, for how long? Lastly, was pink porcelain discussed to assist in getting the teeth back to a shape more consistent with what she started with?
At the NESP recently, either Dr. Weisgold or Dr. Daftary showed aesthetic improvement in papilla shape for up to 3 years. For the prosthetically oriented in the blog, when do you normally feel that you have done enough sculpting and adjusting of the transitional restoration and expect the papilla maturation to plateau? Are there guidelines or more – gut feelings on that?

Bob

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Andy,

Thanks for the post.

Did you use any tenting screws, or consider tacking the membranes at time of GBR or even debate a segmental osteotomy if cosmetics were a big concern? For similar procedures, I have been using titanium reinforced cytoplast with great results and far less complications than ti-goretex.

On a thinner biotype or at time of implant placement, I would have heavily considered bilateral VIP-CT grafts depending on the smile line, but you got a good result with what you were given to start with and seems that you achieved some vertical growth at the #9i site as the pink composite is no more. nice job.

Do you have any final radiographs?

Greg

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Chuck & Greg,

Unfortunately I do not have PAs with the bridge in place.
We must have sent them back to the restoring doc…
I will try to remember to get them sent out later.

I attached some x-ray images post-graft and at implant
placement.

The techniques you suggested are all ones that I considered.
The smile line is low, so the patient is very pleased, although
a papilla or pink porcelain at 9/10 would be nice…
He didn’t feel good about trying to save #8 and he really
wanted an implant solution.

Fugazzotto has made me a believer in tacking… at the time I
did this case I hadn’t been to his course.

If I were to do this over, I’d probably remove the implant using
the Piezosurg; I’d have done a similar particulate graft with tacked
membranes, and a VIP-CT graft over #9… Also, release at 6 distal
rather than 7. And sent the bill to the U of I college of dentistry… 🙂

Thanks again,

Andy

[document redacted]

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Andy,

Thanks again for the post and feedback. I am sure we all have seen and will continue to see plenty of similar cases.

Chuck

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Bob,

I will ask the prosthodontist who did that case how
he managed the transition to the final restoration
and the pontic. I will also ask: why no pink. I
suspect the patient was so unhappy with the previous
pink porcelain that he wanted to avoid it (at least
for now).

I’ll also be seeing the patient back at some point
for a follow-up PA and pics, and I’ll be sure to get
a pic showing his smile line.

I can think of a few cases where a papilla has improved
after I saw the patient for my usual 18 month recall;
probably all of us have. the key question is: how can
we predict who those people are, and what can the
restorative doc do to set the patient up for the best
outcome? We certainly know the answer to some
of these questions…

Best,

Andy