Complex treatment of the anterior zone combining implant and orthodontic therapy

In this complex patient treatment, a 44 year old male patient presented with the following concern: he required a restorative aesthetic treatment of the maxillary anterior teeth. All natural teeth in the posterior areas were healthy and they didn't require any therapy; they provided good occlusal support and function. 

The upper incisors present an unpleasant aesthetic due to dental migration, important rotation of tooth #21 (#9 US) and a soft tissue defect on the papilla between teeth # 21 & 22 (#9 & 10 US). Tooth #22 (#10 US) is missing. Moreover, gingival recessions on the teeth #12, 21 & 22 (#7, 9 & 10 US) are present.

The treatment was approached in an innovative way with the implant placement completed before the orthodontic therapy. This approach requires thorough and anticipatory treatment planning.

The patient presented with good systemic and oral health. He is a light smoker with history of periodontal disease. The radiographic analysis showed a moderate loss of periodontal support in the maxillary incisors and the presence of severe root lesions on teeth # 12 and 21 (# 7 and 9 US). 

These two root lesions compromised irreversibly the maintenance of the teeth # 12 and 21 (#7 and 9 US). These will be replaced by dental implants.

An orthodontic therapy is also required in order to idealize the teeth positions, re-equilibrate the restorative space and favor the re-establishment of a new papilla between teeth # 21 and 22 (#9 and 10 US).

Based on the clinical and aesthetic evaluation, the treatment planning included a digital wax-up in order to plan both the implant placement and also the orthodontic therapy according to the final prosthetic plan. Digital software allowed ideal planning that included occlusal, prosthetic, bone and soft tissue evaluation.

The treatment plan contained the following steps:

• extraction of teeth # 12 and 21 (# 7 and 9 US) with an immediate implant placement, immediate loading and connective tissue graft
• orthodontic therapy finalized to correct the position of tooth #11 (#8 US) and extrude tooth # 21 (#9 US)
• final restoration with all-ceramic restorations on teeth #11, 22 (# 8 and 10 US) and two screw-retained crowns on implants placed in position of teeth #12 and 21 (#7 and 9 US)

Two N1™ system (Nobel Biocare) implants, RP 13mm and NP 13mm, were selected for the positions #21 and 12 (#9 and 7 US) respectively. The restorative planning included to use N1 base 2.5mm height in order to optimize the tissue and bone integration and do not disturb the soft tissue and bone healing during all clinical procedures.