CDA Essentials 2019 • Volume 7 • Issue 2

34 | 2019 | Issue 2 S upporting Y our P ractice to the adjacent teeth) and long. It’s quite a large implant to be placed in a lateral position. Spacing requirements The size of the implant and the imagined width for the buccolingual dimension of the ridge probably wasn’t wider than this particular implant. With a 5 mm-wide implant (like this patient had) ideally you would have at least a millimeter of bone on either side, which would translate into a ridge width of 7 mm—in most lateral incisors, you don’t have space. This is likely a cause of the patient’s bone loss. Patient compliance The other important factor to consider is the patient’s compliance with dental care over time. I wasn’t able to assess this aspect, but if she hadn’t been going for frequent cleaning appointments, she could have developed an abscess or other type of inflammation that caused the tissues to recede. Treatment options I asked a colleague for help, to gauge his response to the situation. My first instinct was to try soft tissue grafting. But my colleague thought it would be best to remove the implant and start over, primarily based on the size of the implant. My colleague’s primary concern was the implant’s buccal position, which likely contributed to the patient’s condition. I discussed these two treatment options with the patient. Her response was to save the implant; she preferred the idea of grafting as opposed to removing the implant and starting over again. I explained that she would need multiple procedures to get the tissues to heal properly, and we would also need to replace the crown. Outcome We were successful in changing the tissue type around the implant—one year after treatment, there was a tremendous amount of keratinized tissue in the area ( Fig. 3 ). There was no bone grafting. This is soft tissue grafting, a combination of using free gingival grafts and connective tissue grafts. Before her new dentist replaced the patient’s crown, I made her a temporary 5 mm-wide crown. The shape of her new crown is still long relative to the other lateral incisor and central incisor, but it had a better clinical appearance. The patient was pleased with the outcome. a Learning Points  Plan ahead. In this case, the implant was placed in an infected site, it failed, and then a wider implant was placed. Ideally the site would have been grafted before a subsequent implant was placed.  Assess the status of the soft tissues before placing the implant, immediately after placing the implant or before placing the healing abutment. After implants are placed, yearly recalls to assess soft tissue may be required. There is a long-standing argument about the need for keratinized tissue, versus no keratinized tissue, around implants.  Place the implant that is appropriate for the site. Most implant companies recommend implant sizes based on location in the mouth. Visit CDA Oasis to watch Dr. Kobric discuss the case: wp.me/p2Lv6A-5Z6 How would you have managed this patient? Share your insights confidentially at oasisdiscussions@cda-adc.ca