Ross Enfinger This case was one of the most challenging esthetic and structural situations I've ever been faced with. We knew going into this case that it was going to fall far short of ideal because of the poor position surrounding the existing implant #9. It was an old Calcitek implant that was placed far too deep and much too far buccally. We made the easy decision to bury the implant in favor of a FPD #8-9-10 and have the periodontist perform hard and soft tissue grafting to gain as much bulk as possible in the ovate pontic #9 site. Here's what he was able to accomplish:
As you can see, even after extensive grafting there was still a considerable vertical defect remaining. So I made a mid-crestal incision and used pressure from the ovate pontic to push the tissue as far facially as I could. We were still quite deficient, so I then injected Juvederm hyaluronic acid filler into the papillae and facial tissue to shape it around the provisional bridge contours. Next, I had to deal with the very dark stump (ND9 prep shade) on endo-treated #8, so internal bleaching was performed using sodium perborate. This took the stump shade from ND9 to ND3, making the difficult block-out much more manageable...
The next challenge was to match the very translucent enamel on her natural teeth with the e.max LT bridge block. To attempt to accomplish this, I milled an LT BL2 block and layered lavender stains first, followed by some brown chroma, and finished with a white-wash to match her striated enamel. After several layers of stain/glaze characterization, we ended up with approximately B1 as a final ceramic shade. It's not perfect, but here are the before and after shots:
After struggling with every aspect of this restoration, the biggest take-home message I learned was: once the soft tissue becomes deficient, it's very hard to recover and create a truly natural look. The papillae loss meant we would never have a biomimetic result, but we pulled out all the tricks to make it as natural-looking as we could. I'm honestly just very happy to have this one finally completed, even with it's shortcomings.
