Hello all,

I am attaching pictures of my patient. She is 17 yo and has been in ortho for almost 4 years due to an impacted #11. After multiple surgeries to try to expose and move #11, it was finally extracted and the bone was grafted. The initial thought process was to (when growth and development is finished) place an implant to replace #11. I was not part of this conversation, as it was led by the orthodontist. When the orthodontist sent the patient to the periodontist to evaluate the space for an implant, the periodontist called me to get my opinion. So now we can do what should have been done a few years ago.....full restorative evaluation and plan, including the potential for "what if".

Mom and patient are tired of surgeries, and of course the patient wants the ortho off yesterday, but they both understand that more needs to be done. There is a tooth size / arch length discrepancy, and in general, her teeth are small. We plan to move #8,9,10 and then bond the diastemas between #6-10, and plan for some crown lengthening to help uncover buried enamel. It might only be laser soft tissue crown lengthening at this point because of their fatigue with larger surgeries. So bone contouring, if necessary, might not happen but they are fully aware of the compromises, and are happy knowing that restricting to laser soft tissue work should still result in a nice improvement. They were given the option of waiting and seeing if the gingiva "resolves" on its own after ortho is removed, but they don't want to wait.

The main question I have is about #11. Because there is a Buccal defect, the patient has a very high smile line, and the bone in the area has been grafted (surgeon estimates that the palatal 1/2 of the crestal 10 mm or so is grafted bone), I am very concerned about the esthetic emergence of the implant crown and the stability of the emergence. Meaning, even if we can get the emergence the way we want it, how stable will the hard and soft tissue be? It seems likely that some additional hard and soft tissue grafting would be necessary to help get the initial emergence, but again, how stable would that be?

So I am considering having ortho move #12 into the space for #11, using restorative to make #12 look like a canine, then placing the implant into the newly created space for #12. I think moving #12 into the space for #11 this should help bet more Buccal bone for the new canine, and better, more stable emergence. Because the grafted bone in this are is on the palatal, I am hoping it will not be a negative factor.

In CR she has no anterior guidance, and must protrude to get to her MI. Regardless of whether we place an implant in the #11 or #12 space, I will plan to create group function on that side, because the #11 will either be an implant into grafted bone or will be a premolar, and I'm not secure basing all lateral guidance off of a premolar due to its root anatomy. This #12 does have decently long roots though.

I am going to try to attach a few photos, including 1 in which I show improved tooth outlines at 76% w:l for the centrals. As you can imagine, if we have shorter teeth because we are limited by the crown lengthening, then we will still can get 80% or even 85% and make an improvement. But shorter teeth for #6-10 will make the emergence of #11 even trickier.

Lots to think about. I would love to hear what everyone thinks, and especially if anyone has tried to move the first premolar into the canine space as I am describing.

The pan is from summer 2015, just before #11 was extracted. The orthodontist tells me that the roots for #10 and #12 are now much more parallel.

Thanks, and may your March Madness bracket be successful!

Bill

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