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ORAL IMPLANTOLOGY Figure 4. Clinical appearance of final restoration 42 to 32 with “modified ridge lap” design from implant platforms to achieve lip support and esthetics: a) buccal view; b) buccal view – maximum intercuspation; c) lateral view; d) occlusal view; e) patient reports adequate lip support and “feel” CMs native language) to further explain the issues, but again, it was not clear to us what was really the blueprint Mr. CM wanted us to use for his FPD. After a considerable lab and clinical lapse of time we made the decision to disregard the last months of trea tment, and just go back to the drawing board and start over from the moment after the implant placement. As we analyzed the implant positioning with respect to the assumed positions of lower incisors, we realized that the implant platforms were situated more lingually than desired, and if we kept holding the idea that the best emergence profile (1) for efficient cleaning (widely open embrasures) is to be employed, then the implant platforms (especially 32) would appear rather in the embrasures than corresponding to the implant abutments (Fig.3 a). We also considered some of the complaints of Mr. CM - too big spaces between teeth, uncomfortable tactile sensation on the lower lip – and with that in mind, we made a new wax-up, following anatomic principles only (Fig.3 b, c). Then we fabricated a provisional according to the new wax-up, understanding that a “modified ridge lap” design was inevitable not only in the area 31 and 32, but also in front of the implant platforms 32, 42 (Fig.3 d). Our last provisional restoration (Fig.3 e) was a success, we earned the patient’s acceptance and requested the laboratory to fabricate the 134 definitive PFM implant supported FPD with a similar shape. It took a couple of attempts for the laboratory to generate a definitive prosthesis close enough to our provisional design, but once that was achieved we had a happier patient (Fig.4). Mr. CM reported that the feel on the lip is right and the look is great, but noticed the difficulties in cleaning around the implants. Mr. CM was explained that considering the position of the implants, transitioning from the round shapes of the implant platforms to the flattened shapes of lower incisors without large embrasures and without sacrificing the anatomy was not physically possible. He accepted the outcome as the best compromise and agreed to spend the extra-time with the floss around his fingers. After a few weeks we heard again from Mr. CM stating that the shape of the crown 11 is not right (Fig 5 a). Intraoral adjustments and polishing did not bring any success, so the existing crown was removed and a new provisional was made trying to better mimic the anatomy of the incisal third of 21 while providing a smooth emergence profile from the implant platform (Fig. 5 b). At that time we also learned that the 11 implant platform was situated more lingually and more mesially as compared to expected emergence if symmetry with the tooth 21 is to be considered. STOMA.EDUJ (2014) 1 (2)