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)