The patient presented with a missing lateral incisor, requesting an implant-supported restoration. While this may initially appear to be a straightforward case, the presence of a high smile line and a buccal concavityposed significant challenges, particularly in achieving a natural and aesthetic result.
The Challenge: Recognising the Complexity
The lateral incisor lies within the highly visible aesthetic zone, where even minor discrepancies can be noticeable.
The patient’s high smile line meant that both the soft tissue and prosthetic outcome needed to blend properly with the natural dentition. Compounding this challenge was the presence of a buccal concavity, a result of bone loss that created insufficient soft tissue volume.
Failure to address these challenges during implant placement could lead to:
- Poor soft tissue contour and visible concavity
- Recession of the implant mucosa margin gingiva
- A crown that appears elongated or poorly integrated
- Long-term instability of the peri-implant foundation
It was clear that soft tissue augmentation would be necessary to achieve an optimal outcome.
The Solution: Pedicled Soft Tissue Graft
To overcome the challenges of this case, a pedicled soft tissue graft was performed as part of the treatment.
- Why was an Autogenous Pedicled Graft chosen?
- Maintained Blood Supply: Unlike free grafts, the pedicled graft remained partially attached at the donor site, ensuring a natural blood supply for better integration and healing. Compared to allografts or xenografts, using the patient’s own tissues is the ‘gold standard’ in terms of safety, and vitality.
- Volume Augmentation: The graft effectively addressed the buccal concavity, restoring soft tissue volume and contour to achieve a natural appearance.
- Aesthetic Harmony: In a high smile line case, the pedicled graft allowed for the creation of a seamless and harmonious gingival margin, essential for achieving a lifelike result. Colour matching to peri-implant site is therefore better than harvesting from remote site
- Long-Term Stability: By thickening the peri-implant tissue, the graft provided long-term protection against gingival recession and soft tissue collapse, ensuring both functional and aesthetic success.
Treatment Process
- Implant Placement: A Reduced diameter implant (3.5mm) was carefully placed to ensure correct spacing for the lateral incisor
- Pedicled Soft Tissue Graft: A pedicled CTG (connective tissue graft) was prepared from the palatal and repositioned to augment the buccal tissue, correcting the concavity and improving soft tissue volume. Careful papillary preservation & micro-surgical approach was necessary to avoid the loss of papillae & producing the unsightly ‘black triangle disease’
- Restorative Phase: After 6 months of soft tissue development using a custom abutment/provisional crown, and a definitive ceramic crown was designed to match the shape, colour, and texture of the adjacent teeth.
Mitigating Factors for Success
- Good Oral Hygiene (OH): The patient demonstrated excellent oral hygiene, which was critical for supporting healing and implant integration.
- Regular Follow-Up: Consistent follow-up appointments allowed for close monitoring of soft tissue healing and early identification of any potential complications.
Outcome
The CTG addressed the issue with the buccal concavity and ensuring the implant crown blended in with the surrounding teeth and tissues. The result was a natural, harmonious restoration that met the aesthetic requirements of this patient.
Key Takeaways
- Cases that appear unassuming, such as a missing lateral incisor, can present complex challenges, particularly in the aesthetic zone.
- Recognising the importance of soft tissue management is crucial in achieving predictable and natural outcomes.
- A pedicled soft tissue graft plays a vital role in cases with high smile lines and buccal concavities, offering enhanced soft tissue volume, long-term stability, and aesthetic success.
By combining careful planning, appropriate soft tissue techniques, and close patient follow-up, such challenging cases can deliver long lasting & pleasing results.
