ImplantThis young lady decided to try shooting a handgun that had considerable recoil. Without proper instruction, she pulled the trigger and the gun kicked straight into her mouth. You see the result. See came to me because she thinks the tissue is receding from her teeth and the implant and she has stopped brushing because she is worried she will brush the gums away and expose the implant. There are several options here, so let's think way outside of the box. If we had no restrictions how would we take care of this area of concern? How far out of the box can we go? These are the only photos I have at this point; she was just referred to me and I have not even seen her yet, so let's run with what we've got for now.

Smile from the front

smile retracted


Comments

Commenter's Profile Image Xhoana Gjelaj
July 18th, 2011
Hello Steve, It would be helpful to have a "pre-injury" photo, because it seems that the implant is dislocated. The crown on #9 seems facially and cervically displaced. Also, she may be concerned of brushing the gums away in other areas of the mouth judging from the look of the lower anterior gingiva. The other question I had was how long since the injury and the origin of the periapical pathology on #8.
Commenter's Profile Image Will
July 18th, 2011
No matter what. . . I'm calling my periodontist for a dual consult (if by box you mean office, we're going to his box first). My knee jerk reaction is that there is some opportunity here to lengthen #8 some cervically and with grafting under a pontic, a bridge might work out pretty well. I know that's not a real sexy answer, but it would work pretty well. A little ortho and an equilibration might not hurt along the way.
Commenter's Profile Image Costin
July 19th, 2011
After the Periodontal treatments (debridements, prophylaxis, attachment and mobility assessments), this becomes a perfect case for a Facially Generated treatment planning. The most interesting aspect would be to asses the ratio between the Existing Pathology prior to the traumatic event and the Extent of damage Consequential to trauma.
Commenter's Profile Image Mike Weisbrod
July 19th, 2011
thinking way outside the box and having no restrictions- Let's make it look perfect! Does the patient have VME or hypermobile lip, etc? Look at impacting the maxilla or other alternatives to correct gingival show with the smile. Remove the implant, bone graft and tissue graft. Use Ortho to reposition teeth. Redo the endo on #8, maintain the bone and tissue height, unless the root is resorbing. If #8 has to go, alter the maxillary impaction (if it is the best option) or utilize ortho and grafting in a different manner. Oh yeah, lets not forget to resolve the other perio issues. but of course a full set of photos would be nice to treatment plan with! Thanks for letting me think outside the box out loud.
Commenter's Profile Image Pierre Morin
July 20th, 2011
look at the wear on 7 , intrusion and buccal position of 23. Facially generated treatment planning course: incisal line with smile is not harmonious( I'd like to see lip at rest), gums achitecture is baroque.The anterior guidance is probably on premolars!? Probably the implant was positioned too buccally with an over contoured crown. Looks like there is a crossover which brought the technician to position tooth 9 that way and the surgeon to put the implant the way he thought would be best with the vertical bone she had... I don't like the apical lesion on 8, will need retreatment or apectomy, MTA.
Commenter's Profile Image Mike Weisbrod
July 20th, 2011
I think at minimum she would get an absolutely great result with ortho for realignment, crown lengthening on #8 and #10 (hopefully resolve any perio issues as well), and redo the crowns on 8,9,10. And hopefully #8 apical lesion can be resolved with endo. Thanks again.