Aesthetic complication on a single lateral incisor implant

A 33-year-old female patient with no relevant medical history came to the clinic with the chief complaint of the appearance of her upper anterior teeth. Her lateral incisor 1.2 FDI (#7 US) presented mainly color and size asymmetry of upper anteriors and chipped left central incisor edge.

In the initial situation, she presents with agenesia and central incisors diastema. The patient underwent 3 years of orthodontic treatment and experienced retainer damage 1 year ago. She reports that her teeth were not on an even level. The patient has some composite fillings that are chipped. She also has a history of prior orthodontic treatment during her mid-late 20s to re-create space lost after tooth 1.3 FDI (#6 US) drifted forward and has had an implant to replace the right lateral incisor. The implant (Avinent 4.1 Coral Internal Hex) was placed under sedation at a previous practice in 2014. She has never been happy with the appearance of the implant crown and was left with a slightly misaligned upper anterior. The orthodontic retainer broke approximately 1 year prior to this consultation, but the patient was unaware of any tooth movement. She was anxious about anything related to the right lateral incisor 1.2 FDI (#7 US). 

On the examination: An asymmetric smile was present with the right lateral incisor wider than the left lateral incisor. The midline shows a slightly left-hand shift. The right lateral incisor is flat, and the color, as well as the primary, secondary, and tertiary anatomy, could be improved. Gingival margins match the level of the upper anterior. The right lateral incisor papilla is at approx 20% of the clinical crown length, with the gingival translucency on the buccal aspect and a concave defect. The abutment is visible, as well as the transition to the crown. 

Regarding the occlusion, the patient presents a static inter-arch anteroposterior relationship Class II Angle molar and canine on the right-hand side and a pseudo Class II on the left-hand side. Upper and lower teeth present some mild crowding. The upper dental midline is coincident with the facial midline, whereas the lower dental midline has deviated. The upper and lower arch shapes are triangular.

Initial treatment situation:

The situation was discussed with the patient, including the visible implant collar. The shape of the crown restoration is suboptimal, contributing to aesthetic deficiencies of suboptimal mesial-distal width, a papilla defect, and a buccal concavity. The complete arch space distribution, shape, alignment, and tooth anatomy were also considered.

The goals of the treatment were defined as follows:

• Improvement of the teeth alignment and increase in the symmetric space distribution pre-restorative 

• Reduce the gingival translucency of the implant 1.2 FDI (#7 US) by providing more gingival volume

• Improve overall aspect of upper anterior teeth of shade, shape, texture, and translucency of the upper anterior teeth

• Orthodontic retention

• Dental anxiety and phobia management

Two treatment options were discussed with the patient:

Option 1: explantation of the implant on the lateral incisor position, followed by a Guided Bone Regeneration and Connective Tissue Graft. This option could potentially result in a defect due to hard and soft tissue grafting.

Option 2: this option was considered to be less invasive as there was no bleeding on probing (BoP) present, no overall bleeding, and no suppuration, and the papillae could be preserved. The option included:

• 1.2 FDI (#7 US) temporary lab fabricated crown (as good as possible due to circumstances: immediate improvement in regards to mesiodistal width and shape)
• Connective tissue graft on 1.2 FDI (#7 US): at least 1 attempt, probably more would be needed
• Orthodontic assessment and treatment (the patient was happy with Invisalign Lite as it might be possible to include tooth whitening and retainers)
• Final implant crown on 1.2 FDI (#7 US) and a veneer on 2.2 FDI (#10 US). It was considered to place veneers on all upper incisors. In the end, the patient wanted to include the canines as well so as to make them appear smaller 

The final restorations present good contact points and oval dental anatomy. The canine guidance is visible on the final lateral view.

Materials used:

Lateral incisor: Avinent Coral Internal Hex 4.1x with off-the-shelf abutment and Cerec crown. This crown was replaced by a temporary screw-retained crown with angle correction screw. The final crown was a cemented Emax crown on a  Zirconia. The CTG was harvested from the palate.

• Orthodontic treatment with Clear aligners: Invisalign Lite. 3 set of aligners.
• Tooth whitening. Opalesence 16%
• Minimal prep eMax Veneers.

Conclusions

• A multidisciplinary approach needs to be considered even for a single implant case
• Less invasive treatments/alternatives are to be considered even when the existing implant position and size is not ideal, if the tissues are in healthy condition
• Different prosthetic tools could be used to compensate for a nonideal implant axis, such as angle correction screws or custom abutments for cementing
• The use of an opaquer to mask metallic abutments on temporary restorations could improve the aspect of these restorations. As an alternative, white or golden abutments might facilitate this task
• Soft tissue management and prosthetic design could lead to an enhancement of the aesthetics of the gingiva
• Space distribution, shape, texture and shade are important factors for a more natural result