Addressing congenitally missing lateral incisors justifies an interdisciplinary solution. The earlier photo essay covered three solutions — canine substitution, resin-bonded single retainer bridge (resin-bonded fixed dental prostheses=RBFDP), and cantilever bridge. Now, part two details the fourth interdisciplinary solution, a single-tooth lateral incisor implant.

Implant therapy in patients with congenitally missing maxillary incisors has proven to be a predictable and viable interdisciplinary protocol. Restoring these patients requires formulating a comprehensive treatment plan and establishing optimal esthetics, function, and periodontal health; however, in these patients, it is a complex and challenging process, requiring the interaction of the orthodontist, periodontist or oral surgeon, the ceramist, and the restorative dentist.

Solution #4: Single-Tooth Lateral Incisor Implant

The photos show a 35-year-old male who presented with congenitally missing maxillary lateral incisors with a removable flipper-type provisional. The situation is unique since it helps the interdisciplinary team to produce a diagnostic wax-up and guided surgical templates without needing to remove a fixed appliance. Due to this, it aided in obtaining optimal diagnostic information and promoted the start of therapy because the patient could continue utilizing his provisional throughout the osseointegration phase.

The clinical and the CBCT images showed a buccal concavity that needed to be addressed surgically via a contour graft protocol at the time of implant placement. Utilizing a guided surgical approach, implants were placed as a delayed loading protocol allotting three months for osseointegration. Once integrated, an added connective tissue graft was ordered for ideal soft-tissue contours to groom via screw-retained provisional restorations.

Upon healing, screw-retained provisional restorations were inserted, and tissues were groomed to ideal contours. Then the laboratory fabricated the screw-retained ceramic implant-supported restorations, which were inserted. In this case, using a lateral incisor implant provided this patient will have the best solution for the missing maxillary incisors.

A frontal view of the patient wearing his existing removable provisional (flipper).
Figure 1: A frontal view of the patient wearing his existing removable provisional (flipper).
A frontal view of the patient without his removable provisional with missing #7 and #10.
Figure 2: A frontal view of the patient without his removable provisional with missing #7 and #10.
Frontal and occlusal views showing the buccal concavity on #7 and #10.
Figure 3: Frontal and occlusal views showing the buccal concavity on #7 and #10.
Periapical, panoramic, and sagittal views from the CBCT.
Figure 4: Periapical, panoramic, and sagittal views from the CBCT.
Tooth #7 and #10 diagnostic wax-up with adequate proportions.
Figure 5: Tooth #7 and #10 diagnostic wax-up with adequate proportions.
CBCT with digital planning overlay
Figure 6: Digital planning for guided surgery.
3D printed surgical guide
Figure 7: The 3D printed surgical guide.
Surgical procedure
Figure 8: Surgical procedure utilizing Straumann's guided surgery kit.
contour graft and resorbable collagen membrane
Figure 9: The contour graft was performed utilizing xenograft and resorbable collagen membrane.
post-surgery frontal view
Figure 10: A frontal view immediately after surgery and periapical radiographs with implants placed.
connective-tissue tooth grafting procedure
Figure 11: Connective-tissue grafting was performed three months after implant placement during the uncovery appointment.
screw-retained provisional restorations
Figure 12: Screw-retained provisional restorations are used to develop optimal soft-tissue contours.
front teeth with screw-retained provisional restorations inserted
Figure 13: Provisionals were inserted to start the soft tissue grooming procedure.
Frontal views of teeth, full mouth, and smile with the provisional restorations
Figure 14: Frontal views with the provisional restorations.
Frontal views comparing the removable and the implant-supported provisionals and the hard- and soft-tissue volume gained
Figure 15: Frontal views comparing the removable and the implant-supported provisionals and the hard- and soft-tissue volume gained.
Peri-implant soft-tissue contours after the soft tissue grooming with the provisional restorations.
Figure 16: Peri-implant soft-tissue contours after the soft tissue grooming with the provisional restorations.
Personalized impression copings to transfer the precise position of the soft tissue to the laboratory.
Figure 17: Personalized impression copings to transfer the precise position of the soft tissue to the laboratory.
Zirconia layered screw-retained implant-supported prosthesis.
Figure 18: The zirconia layered screw-retained implant-supported prosthesis.
Frontal view before and after zirconia layered screw-retained implant-supported prosthesis
Figure 19: Before and after insertion of the zirconia layered screw-retained implant-supported prosthesis.
Post-insertion front view and periapical radiographs
Figure 20: A frontal view two weeks after insertion and periapical radiographs showing adequate bone stability.


Ricardo Mitrani, D.D.S., M.S.D., is a member Spear Resident Faculty.


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Comments

Commenter's Profile Image Shawn T.
July 1st, 2022
Absolutely stunning treatment result and execution. Thanks for posting this case
Commenter's Profile Image Ricardo M.
July 6th, 2022
Thanks so much for your kind words Shawn !