I have an anterior implant supported bridge to do. Any suggestion or recommendations on approaching this case? The buccal plate is extremely thin, and I feel theres no margin for error. I was considering doing a socket shield but I’m not sure how this will go considering the state the roots are in (also will be my first time doing it…).

DR. Jesse Kane:

A few thoughts that go through my head on cases like this

1) What would ideal teeth look like

Weve all heard of restoratively driven implant placement at pretty much every CE course / conference for the last 10 years. So much so that it tends to lose its meaning/ importance. As a prosthodontist, I still find this EXTREMELY important. I tell my patients you cant build a foundation until you know what the house is going to look like! Nowadays this has become so simple. Quick intraoral scan, digital mock up of the anteriors, which is then overlayed with the CT scan. Now you can look at implant position anatomically AND restoratively.

2) How cosmetically challenging is this

This is why I am sure to get a full smile picture. Do you see gingiva or papilla when they smile? If so it increases the difficulty of this significantly. For very highly cosmetically demanding cases we start considering more advanced procedures like ortho extrusion to create excess bone and soft tissue, keratinized tissue grafting, socket shield, etc.

3) Guided vs free-hand

What is the margin of error both anatomically and restoratively. Anatomically as in how much bone and are there anatomical limitations like nerve or sinus and restoratively as in nailing the angulation so these are near parallel for passive restorations and angled so the restoration can be screw-retained. I know many surgeons who would/could do this free hand but for me this is a guided case every time.

4) Implant position