Esthetic management of maxillary central incisors

Fig. 1a: Initial facial view.

Fig. 1b: Smile view. Lack of papillae between #8 and #9 is evident. Patient also reveals gingival asymmetry, inflammation and excess gingiva around #8 and #9.

Fig. 1c: Right lateral initial smile view.

Fig. 1d: Left lateral initial smile view. Teeth #8 and #9 appear to be on a different occlusal plane. Attention is drawn to them.

Fig. 1e: Initial radiograph. Teeth #8 and #9 are failing endodontically.

Fig. 2a: Contact points are broken and the crowns are removed. Trauma to the bone and adjacent teeth is to be avoided.

Fig. 2b: Following a sulcular incision, piezosurgery is used to atraumatically remove the teeth.

Fig. 2c: Utilizing beaked serrated forceps and rotational apical pressure, tooth #8 is removed without any destruction to the alveolar plate.

Fig. 3a: A surgical guide is used to ensure correct orientation during osteotomy preparation. Buccal view of the guide in place with orientation pins is shown.

Fig. 3b: Occlusal view of the surgical guide in place. Note that the osteotomy is located at the cingulum position, the preferred site for a screw-retained restoration.

Fig. 3c: Initial osteotomy orientation confirmed by radiograph.

Fig. 4: Occlusal view following placement of two 4 mm-diameter dental implants. Note the palatal position and the thickness of the buccal plate. A gap is present between the labial aspect of the implant and the facial plate.

Fig. 5a: Temporary healing abutments in place. They prevent soft-tissue and bony collapse while the provisional restoration is being fabricated extra-orally.

Fig. 5b: Radiograph of implants in place with temporary healing abutments. Note peak of bone between the implants.

Fig. 6a: Occlusal view of temporary cylinders. Note ideal positioning for both function and esthetics.

Fig. 6b: Facial view of temporary cylinders.

Fig. 7: Provisional restoration immediately following reline and placement. Papilla is not present.

Fig. 8: Radiograph the day of implant placement.

Fig. 9: Provisional restoration one week post-implantation. Very good soft-tissue healing and minimal recession.

Fig. 10: Provisional restoration three months post-implantation.

Fig. 11: Provisional restoration at six months after gingivectomy and adjustment of interim crown contours.

Fig. 12a: Final #8 and #9 implant restorations.

Fig. 12b: Close-up view of final restoration.

Fig. 12c: Right lateral final view.

Fig. 12d: Left lateral final view.