Single tooth replacement using dental implant

Standard of care: tooth replacement using dental implants. Other options include removable denture and bridgework (involves removal of natural tooth structure which is irreversible).

Treatment plan involves placement of immediate implant and temporary crown: patient leaves the dental office with a full smile. Treatment time is one and a half hours.

Missing upper lateral incisor.

Note the loss of hard and soft tissues causing ridge defect where the bone “melted away”. To treat this site and create a natural emergence profile, we need to consider ridge augmentation simultaneously during implant placement. In some cases we need to augment the ridge to allow adequate bone volume and quality before implants can be placed.

Final porcelain crown is retained by internal screw.

Final implant supported porcelain crown improves patient aesthetics and confidence.

Single Missing Tooth

Standard of care: tooth replacement using dental implants. Other options include removable denture and bridgework (involves removal of natural tooth structure which is irreversible). Treatment plan involves placement of immediate implant and temporary crown: patient leaves the dental office with a full smile. Treatment time is one and a half hours.

Complex aesthetics Reconstructive procedures: case study 1: Dental Implant: single tooth

Patient is referred for implant replacement of failed upper central incisor tooth.

Risk assessment:

1. High smile line, difficult with implants to always achieve optimal aesthetics
2. Patient has good oral hygiene
3. Regularly attends her recare visits at the dentist
4. Good bone support
5. Thick gingival biotype: this helps to form the nice madding – the gums around the implant crown.
6. Non ‐smoker

Implant placed in the bone, unloaded and is allowed to integrate with the bone.

Laboratory procedure

Approximately 4‐5 months later, implant has now fused with the bone. Now we are ready to connect the laboratory constructed crown to the implant and load the tooth (bring this implant into normal oral function). For most patients, the implant integration into oral neurophysiology occurs immediately. For some, including myself (I, Dr Nalbandian have implants in my mouth as well) took about 1‐3 months to accept that this is a normal part of my mouth. So patients do differ and quite frankly, after placement of implants and crowns, bridges etc. and treatment of thousands of patients, no one has asked me to remove a single implant. On the contrary, they come back for more dental implant placements. This is the real test, since patients have had time to evaluate their past experience with dental implants. The patients do come back, because they can eat, speak and smile with their new fixed teeth!

Critical aesthetics: high smile line. Note the natural aesthetics achieved in this complex case.

Do you know which one is the implant supported crown?

Now the patient has the responsibility to carry out home care and maintain the health and the stability of the tissues around the implant crown.

Failing upper right lateral incisor. Patient has been referred for immediate implant placement.

Complex aesthetics Reconstructive procedures: case study 2: Dental Implant: single tooth

Tooth 12 was removed and immediate implant placed at this site with provisional abutment and temporary crown in One Visit.

Provisional abutment at healed implant site. The healed sinus tract (small tissue tag remains)

Initial trial of the implant crown. Note the natural gum margins achieved, as the patient has maintained excellent oral health. The aim is to maintain biology and integrity of soft and hard tissues.

Restorative and surgical planning is the key for optimal aesthetic & functional outcome.

Although we cannot control biology, with the help of our patient, who does not smoke and is regularly attending our clinic and the referring dentist for regular dental maintenance and implant reviews, our patient understood the limitations of complex aesthetics that Dr Nalbandian could achieve.

The implant tooth is the upper lateral incisor. However, if the patients insist that they are perfect aesthetics, let me tell you that there is no such thing as perfect smile or perfect aesthetics. In other words there is no golden standard for dentofacial aesthetics. It is all relative as we do not make judgements. Dr Sarkis Nalbandian maintains his intense efforts for the best possible outcome.

We always emphasise the problems with gum aesthetics around the implant and that patients reveal gums considerably when smiling. Due to the presence of thin tissues and possible bone loss from past infection, there may be some compromise in this respect, where the consideration of pink porcelain around the margins of the final crown may be required as we have considered before. The x‐ray shows the possibility of adequate bone present; however the final decision will be made at a time of implant placement. If adequate bone is present for immediate implant placement and grafting‐fine, otherwise we may opt for a staged approach: grafting wait 4 months, followed by implant placement and final implant crown some 4 months later. We will be trying to improve the predictability of soft tissue around the proposed implant crown.

A general reminder is that original natural aesthetics is not always possible to create on a single tooth. Please remember that we are trying to always reconstruct/augment or preserve soft (gum) and hard (bone) tissue first and finally the missing tooth.

Please help us, so we can help you!

The implant tooth is this one.

Replicating nature.

This is a concept called Bio‐mimesis.

Complex aesthetics Reconstructive procedures: case study 3: Dental Implant: single tooth Right Central Incisor

Diagnostics: initial composite mock up to for an overall aesthetic evaluation. Naturally it is for the patient to decide.

Patient is happy to consider the complete smile makeover in conjunction with replacement of the missing tooth with implant This will help to achieve overall improvement of teeth display during smile and speech dynamics: complimenting patient’s dentofacial aesthetics.

Supported crown. Smile enhancement using porcelain veneers on nine upper teeth.

Patient with temporary removable palatal plate replacing missing tooth 11. Note the asymmetry of the front four incisors

(Tooth 11 is missing). As a part of diagnosis we decide to consider composite veneers and decide future aesthetic treatment to improve symmetry. This is important to decide to either accept the current level of display and restore the missing tooth only, or consider smile makeover to improve symmetry, teeth display, and upper arch width.

Diagnostics: composite mock, note the smile symmetry and how the future planning is important and not simply placing an implant. Patient must be informed of all the possibilities. This is an important part of the consenting process. This process save time, additional effort and most of all gives the patients a brilliant smile. The composite mock up‐smile makeover serves the basis for future planning. Why? Because the patient can see, feel and understand how her smile and dentofacial aesthetics will be affected. Our patient (pictured) was happy to proceed with porcelain veneers and implant crown placement.

Porcelain veneers are placed as per diagnostic planning shown previously. New smile line and facial aesthetics established. Now we are ready to restore the missing tooth 11. This implant was placed by another surgeon. The angulation of the implant was most difficult to correct. However after considerable effort, we have achieved a satisfactory outcome

Patient did not ask to have a dental implant. Patient simply wanted to smile with confidence.

The implant was surgically placed in a more facial direction by another specialist. This made the final crown restoration most difficult. Numerous visits were required that tested everyone’s patience to correct the missing tooth form and position. However we achieved what we feel is an extremely desirable outcome for this beautiful patient.

We must view the complex aesthetic cases with extreme caution and plan treatment according to each and every patient’s aesthetics desires, which can be solved with a simple practical approach.

This patient understood the limitation of the clinical situation. After we discussed all options of treatment, patient was most receptive to my recommendations; therefore I feel we were able to achieve the optimal outcome as shown on the picture below.

All above procedures were performed by Dr Sarkis Nalbandian.

Education and Experience are everything.

Designer Smiles® is a one stop shop for most implant, surgical and reconstructive (prosthodontic) oral rehabilitation solutions.