Missing Front Teeth
This was one of my favorite cases to work on because of the complexity and the ability to use technology for almost all of the steps! I will spare you the history, but this patient lost her front teeth very early in life and was wearing a partial for the majority of her life thereafter. Her chief complaint was that she wanted to get implants so that her teeth were permanently attached.
The most significant issue was the occlusion, with a notable cant, gingival zenith discrepancy on 6 and 11, and missing teeth in the posterior.
Utilizing technology made this case much easier. To begin, a digital waxup was performed to model out her new smile and bite. I used the CBCT to align the soft tissue landmarks and correct the cant, and place the centrals in the best location possible. The final treatment plan was for 3 implants. The goal was to make as much screw retained as possible, 2 crowns, and an FPD. Implants at 7, 10, and 14. FBD from 11-13, and a single unit crown on 6. Implant FPD from 7-10. CBCT analysis shows we have sufficient bone for some narrow platform 3.5 implants in the anterior, and regular platform in the posterior. Soft tissue was compromised due to such a long time without these teeth, but with such a low smile line, screw retained crowns were possible. A 3D printed surgical guide was designed and printed, as were models of the waxup.
The staging of this case is perhaps what made it the most interesting. I placed the implants with cover screws, so the patient just kept wearing her partial during the healing period. During the second stage surgery, healing abutments were placed but the implants were not loaded. Finally, the point of no return was when I fabricated a fiber reinforced provisional FPD chairside based on the 3D printed digital waxup to temporize between 6-13, and finally open the bite. The patient was able to try this new VDO, which was +2mm, during the provisional stage while the crowns were cut and the teeth on the lower arch were bonded. She wore the FPD for about 1 month, minor adjustments were made to her occlusion but she tolerated the new VDO well.
Finally, a miraculous impression was made with splinted open-tray implant impression copings to capture the entire upper arch, and restorations were fabricated. I used layered zirconia for strength in this case, although I do feel that compromised the esthetics. I was still playing with the gingival embrasures between 8 and 9 when the patient said, “Stop playing with my teeth! There is nothing you will be able to do to make me love them more!” As I smiled, I realized that perfection is in the eyes of the beholder – the patient in this case. She loves her new smile, which reminds me of the old adage, ‘better is the enemy of good’…. my hand could have slipped and ruined the facial of 8/9 so its probably better that we left it alone.
