31 yr old female. Healthy. New patient to us. Have models, photos and mounted models.

Recent History: Bicycle accident in her native country 2 yrs ago. Lost #'s 8 and 9 with boney damage, #7 damaged requiring RCT. #6 chipped. Bone graft plus implants at #'s 8 and 9. Crowns #'s 7 - 9. Minor fixed orthodontics to correct lower anterior crowding. Did not wear the retainer.

CC: Restored teeth are too large, no papillae between, and black triangles. Excessive flare of restorations. #7 too big and too opaque. Facial lacerations left scars and damage to her upper lip.

Problem list: All the issues mentioned in chief complaint above. Insufficient incisal display, #8 implant distal bone health questionable, #7 possible mesial resorptive defect, implant placement (too shallow, too angled facially, and perhaps not centered in the edentulous space on either side of the incisive canal (see radiograph). She mentioned that she occludes on the implant crowns first when she bites and #8 incisal edge is already chipped so we could have a constriction of envelope of motion. She would accept orthodontics if it were necessary to improve the appearance and function of the case.

Initial thoughts after going through steps of EFSB:

-Best to remove #7 or leave?

-Best to remove implants and start over with grafting or bury? Best to work with what’s there?

-Best to rely on pink ceramic to manage the deficiency or attempt a surgical correction or combo? but where are the borders of pink

We are sending the patient to a plastic surgeon to consult with them about her scars and perhaps upper lip. We will have consults arranged with a periodontist and an orthodontist as soon as we can prepare an initial evaluation of the case. Historical snap shots of her appearance before the accident enclosed.[image:DSC0316black.jpg][image:X06271_1.jpg][image:X06271.jpg][image:DSC0347.jpg][image:DSC0335.jpg][image:DSC0337.jpg][image:DSC0353.jpg][image:DSC0336.jpg][image:DSC0346.jpg][image:X06271_13.jpg][image:X06271_14.jpg][image:X06271_15.jpg][image:DSC0322.jpg][image:DSC0345.jpg][image:DSC0320.jpg]

Other issues: Provisionalization during staging of treatment, implant parts as necessary, will we really be able to make this look significantly better after considerable time and expense?

WWSDD? What would a Spear Dentist Do?

Jim