I recently had a patient who lost the right front tooth in a car accident driving north in 95. She is a 29 year old nurse with a joyful personality and made an instant positive impression in me with her pretty yet gummy smile.
She was determined to have an implant placed for “obvious conservation of tooth structure” compared to a bridge . I closely evaluated how much gum she shows as she smiles, the bone defect present after trauma, and the recession of the gum after extraction, and soon after I realized the challenge in giving her a tooth that would be symmetrical to the adjacent natural teeth and its silhouette of gingival (gum) outline.
I had to break the cruel physiological reality and explained to her that the soft tissue profiling necessary to create contours that would be in harmony with the gingival silhouette of the adjacent teeth was indeed the most difficult task especially with her high smile line and bone recession after trauma.
Case selection and communication is key to a satisfying esthetic outcome. Matching natural shades and translucency of enamel against a side-to-side porcelain crown in the midline of the mouth is also very challenging. In this particular case, we opted to have an all porcelain 3-unit bridge allowing for a full confident gummy smile with more predictable gingival contouring, color symmetry and anatomy on both front teeth.
Case #1 Low smile line with positive esthetic outcome
Case #2 High lip line as patient smiles and uneven gum height. Poor esthetics as outcome.
Case #3 Inadequate bone thickness around implant surface; visible implant. Poor prognosis and esthetics.
Case#4 High smile line with severe gum recession that shows extra long clinical crown