Implant rehabilitation in the anterior maxilla can be challenging task for dental professionals, but evidence indicates it improves quality of life of those affected. (Grusovin et al. 2009, Sghaireen and Al-Omiri 2016) Aesthetic management of patients with missing teeth in the anterior maxilla becomes more challenging when patients have a high lip line. (Tjan, Miller et al. 1984)
The important prosthodontic parameters for successful treatment include optimal three-dimensional implant position, the utilization of provisional restorations, the choice of prosthodontic platform size and form, the abutment and definitive restoration material, and the mode of prosthesis retention.(Martin, Pollini et al. 2014) Timing of implant placement after tooth extraction has been an issue of controversy, although enhanced soft tissue aesthetics has been associated with immediate and early implant placement, compared to delayed placement. (Esposito, Grusovin et al. 2010) Soft tissue grafting at implant sites can increase aesthetic outcome by thickening the tissue. However, vertical hard and soft tissue augmentation continues to be unpredictable. (Esposito, Maghaireh et al. 2012, Esposito, Grusovin et al. 2009)
In this report, prosthetic management is described in two cases with a high lip line, representing two or more missing adjacent teeth in the anterior maxilla.
Case I: The patient presented with failing previously traumatized maxillary anterior teeth. Implant therapy in sites 8 and 10 resulted in an ideal three dimensional implant position. Connective tissue graft was done to thicken the peri-implant soft tissue. Custom cast metal abutments were fabricated and CAD/CAM zirconia frame was luted extraorally on the abutments. Feldspathic veneering porcelain was baked on the framework to finalize the work. The case was successfully managed without prosthetic soft tissue compensation.
Case II: The patient presented with traumatically avulsed teeth 9 and 10. Significant amount of time passed before patient sought dental care, therefore considerable hard and soft tissue loss had occurred. Unsuccessful grafting procedures were performed and ideal implant positioning therefore challenging. The condition allowed merely placement of narrow diameter implants with considerable buccal angulation. Custom CAD/CAM titanium abutments were made to correct angulation and one-piece metal-ceramic FDP was fabricated for cementation. Pink porcelain was integrated to compensate for soft tissue loss. Precaution was taken to design the prosthesis for adequate cement removal and plaque control.