Featured Case History

Reproduced with the kind permission of Dr. Robert Oretti. Pentangle Dental Transformations

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This 32 year old lady was unhappy with the aesthetic appearance of her upper front teeth.

The history included the replacement of her failing upper central incisor post/crowns with implant retained crowns 18 months earlier by her previous dentist. She was unhappy with the overall look of her new restorations and in particular, the gaps on either side of these crowns. She did not wish to have the implants removed and hoped that a prosthetic solution could be implemented which would provide a more aesthetic outcome.

Assessment revealed that the width of the central incisors was 9mm, the adjacent gaps were almost 2mm and the lateral incisors 7mm wide.

The existing crowns were considered wide already and replacement with new crowns would necessitate an increase in restoration width to 11mm to avoid any spacing. This was not considered acceptable. The addition of composite to the upper lateral incisors to close the spaces would result in an increase in width to almost 9mm which would make them a comparable size in terms of width to the central incisors and again was not considered acceptable.

It may have been aesthetically possible to provide new crowns for the central incisors and composite restorations for the lateral incisors somewhere between these two limits but a different option was proposed.

The patient was willing to accept a short course of fixed orthodontics (6 months) and that, in view of the compromised circumstances, this would provide her with the best aesthetic result.

The existing abutments and crowns were replaced with temporary restorations and straightwire fixed appliance therapy was instituted to close all spaces. At completion, zirconia abutments and ceramic crowns were fitted to complete the case.

The final restorations were designed with a positive emergence profile to cause buccal recession of the gingival tissues thereby creating a better length to width ratio. This was only possible because the Branemark implant heads were situated 3mm under the gingival tissues and the improved aesthetic result was attributed mainly to this fortunate finding.

Of note was the zirconia abutment fracture (UR1) during insertion. The placement of small and thin reinforced ceramic abutments on the narrower (3.5mm wide) implants carries a much higher risk of fracture compared to the stronger abutments utilised for standard diameter implants.