Creating an ideal implant site is not always achievable. Sometimes the patient himself will not wish to undergo full treatment in order to achieve a result that will be nice for our pictures. However, it is important for the clinician to understand the biologics behind the decisions he will have to make for the best interest of his patient.
Creating adequate hard and soft tissue anatomy around an implant is proven to be critical for long term stable results.
In this case the presence of interproximal bone loss on the distal of tooth 2.1 is the detrimental factor that would not allow the establishment of gingival symmetry between R and L side. The tooth had already been extruded with no additional benefit. Any further attempt to improve its bone levels, would put in risk its longevity since C:R is already compromised.
Upon evaluating the patient's smile and discussing with him his options, it was concluded that symmetry will not longer be one of our primary goals in this case.
However, good hard and soft tissue quality is important to prevent future breakdown. This is particularly important in post-ortho cases where the anatomy of the alveolus and the position of the teeth has been changed compared to the genetic information of the patient.
Another interesting point is the interproximal bone stability (this is all you can evaluate from regular PA or BW xrays) around the implant. This was a Legacy implant, an implant with no platform shift design for the implant diameter used (3.75mm) and short conical connection (internal hex, 45') and it still shows very stable bone levels.
Possible reasons for the observed crestal bone stability:
1. Bone width around the implant (>2mm)
2. Soft tissue quality and thickness
3. Subgingival material
(no porcelain, only titanium abutment with a 3mm collar. Titanium is a biocompatible material, porcelain is not!)
4. Microgap position (crown-abutment interface) slightly subgingivally and away from the crest of bone
5. Biologic width component - if there is such a thing around implants- (different tissue structure around teeth and implants. There is no real attachment on implant or abutment surface up to this time point).
Best
Ioannis
