Simplicity, predictability, respecting biology, and minimally invasive treatment was the goal in this author's surgical treatment. Creating an ideal prosthetic environment and allowing the dental technician to create an implant restoration with ideal prosthetic soft tissue support and long-term stability was the author's purpose. This slide show displays the incredible teamwork by Dr. Eric Van Dooren and Mr. Murilo Calgaro has they work together through the critical steps of an anterior implant restoration.

1. Diagnosis, Treatment Planning, Workflow, and
Teamwork in Anterior Restorations
Eric Van Dooren, DDS and Murilo Calgaro, CDT
Images are © , All Rights Reserved, Dr. Eric Van Dooren
The Integration of Critical Steps

2. This slide show presents a case regarding a 20-year-old male patient with the
goal being to correct the esthetic problems in the anterior region. Soft tissue
health and hygiene were acceptable, and no pockets were present. The patient
presented a thin biotype with high scalloped gingival margins (which made the
authors more cautious for any surgical soft tissue procedure). A 1-mm overjet
and a 1-mm overbite with a mandibular range of motion within normal limits were
observed. The periapical x-ray exhibited enough space to place a narrow
platform implant in the lateral right incisor position. Silicone impressions were
taken (Virtual, Ivoclar Vivadent; Schaan, Liechtenstein) and models were poured. A
diagnostic wax-up was used to treatment plan the case. Diagnosis and proper
treatment planning would ultimately be the guarantees for treatment success.
Adapted from the full article, which originally appeared in the AACD’s
Journal of Cosmetic Dentistry, Spring 2011, Volume 27, No. 1 issue.
For more information, visit www.AACD.com.
© 2011-2013 American Academy of Cosmetic Dentistry, All Rights Reserved

3. Agenesia of the left lateral
incisor and microdontia with
very conical tooth shape
covered with an old composite
were at the root of the esthetic
problems.
A Maryland bridge for
replacement of #7, with metal
retainers on both central incisor
and canine, was placed by the
referring dentist after
completion of the orthodontic
treatment.

4. The pretreatment
periapical x-ray
exhibited enough
space to place a
narrow platform
implant in the lateral
right incisor position.

5. A narrow-platform Branemark (Nobel Biocare, Göteborg, Sweden) implant was placed and a connective tissue
graft was harvested from the maxillary tuberosity and placed in a buccal pouch. Grafts taken from the
retromolar area are dense and fibrous, and exhibit long-term three-dimensional stability with minimal long-
term volumetric changes. Care was taken to maximize soft tissue thickness around the implant. Seralene
6/0 sutures (American Dental Systems; Vaterstetten, Germany) were placed to secure the graft into position. A
3-mm NP healing abutment was placed at the day of surgery and healing was uneventful.

6. A narrow-
platform, open-tray
impression
coping was secured
and retraction cord
placed. A final
impression (Virtual Light
and Heavy Body, Ivoclar
Vivadent) was taken
and a silicone key was
placed to evaluate the
preparation.

7. In most of the author’s anterior delayed-
loading implant restorations, no attempt is
made to develop the ideal gingival
contour with individualized healing
abutments or impression copings. Shown
right is the final model with soft tissue
mask.
A high-quality full-contour esthetic and
functional wax-up was made. It was
important at that time to incorporate
the ideal form and ideal three-
dimensional gingival tooth position in
the wax-up and draw the ideal buccal
crown contour according to the
wax-up.

8. The concept is to stay 0.5 mm away from the line drawn on the buccal aspect of the implant restoration.
A round, coarse diamond bur is used to reshape the transmucosal space. The final dimensions of the
transmucosal space are related to the silcone index and wax-up and the abutment margin positioned in the
sulcus.

9. The perfect implant
restoration would
be a restoration
where the abutment
occupies 90% of
the transmucosal
space and where
the crown would
only emerge in the
last 1 mm or 10%
of the transmucosal
space.
Abutment 90%
Crown 10%

10. The abutment should have a concave
transmucosal profile to allow for connective
tissue thickness in this critical zone. This will act
as a mechanical barrier and protect the bone
from the oral environment.

11. Layering of the porcelain (IPS e.max Ceram).
Fabrication of a lithium disilicate coping (IPS e.max Press LT). The use of magnification both in the clinical
and laboratory environment are mandatory.
Precision relates to biology and soft tissue health in a direct way.

12. In this particular case, trying in
the second bake, it became
apparent that the prosthetic soft
tissue support was insufficient
and, consequently, the gingival
scallop was flat.
Minor modifications are necessary to
improve color, form, and especially
prosthetic soft tissue support. The final
soft tissue profile and position around
the implant restoration will depend on
the amount of prosthetic pressure and
the prosthetic contour.

13. Allowing for a steeper distal angle
and a softer mesial angle.
Adding low-fusion porcelain during
the last bake on the disto-gingival
portion of the restoration allowed us to
create a high scalloped gingival
design, modify the zenith position, and
relocate the gingival culminating point.

14. Functional adjustments were made to
restore the canine guidance, a
composite was applied to the right
upper and lower canines.
The 12-month postoperative
x-ray revealed a satisfactory
bone remodeling.

15. Final esthetic and functional result.
Acknowledgments
The AACD thanks Dr. Eric Van Dooren (Belgium) and Murilo Calgaro, CDT (Brazil) for this slideshow.

16. To read the details of this case or to
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Journal of Cosmetic Dentistry,
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