Esthetic failures start as soon as we fail to plan

Dr. Justin Moody discusses how to save time and money and reduce stress


When we think of esthetic failures in dentistry we think of color, size, shape, position, gingival height, symmetry, etc. Implant dentistry takes this one step further. In addition to all the above, we need to take into consideration such aspects as bone height, quality, quantity, keratinized tissue, gingival scallop, temporary restorations, and materials. Having recently treated a case where this is was so true, I wanted to share how starting with a plan can save everyone time, money, and hard feelings down the road.

Prior to walking into my clinic, the patient had been given a cosmetic treatment plan for some veneers so that she could show more incisal edge when she smiles. The previous doctor prepared the teeth for veneers, things got away from them, and they ended up in full coverage, and ultimately tooth No. 9 was going to require extraction. It is at this point that decisions need to be made that will affect the long term survivability and esthetic outcome of the implant and ultimately the entire case.” Knowing this is an esthetic case, one must determine the best way to ensure an ideal outcome. With the removal of tooth No. 9, an immediate implant was not considered and was taken straight to a bone graft and a temporary bridge. This decision led to the flattening of the papilla, decreased height of buccal bone, and overall loss of bone quantity and quality.

The placement of the implant ended up in a supra-crestal position, limiting the emergence profile and handicapping the restoration from having an ideal outcome. It is at this stage that the case entered my world; the fork in the road was either to remove and try to rebuild for a possible better outcome or leave the integrated implant and see what could be done with what we got. Ultimately, after long discussions with the patient as to the difficulty of rebuilding the site and with restoring what she had, we agreed upon the decision to fix what we had. A custom IPS e.max® screw-retained crown was made with an authentic BioHorizons® titanium base followed with IPS e.max crowns from ProSmiles dental studio on teeth Nos. 7, 8, and 10.

The outcome was esthetically pleasing to the patient and clinically acceptable to me, but it always reminds me of how important proper planning is to the final outcome. Try to remember that old carpenter adage, “Measure twice and cut once,” as it is so true. In my 20 years of placing implants, I too have many cases that are far from perfect from lack of planning, mostly because I didn’t know what I didn’t know. As long as we learn from our mistakes, then it is worth the effort!

Justin Moody, DDS, DICOI, DABOI, is a Diplomate of the American Board of Oral Implantology and of the International Congress of Oral Implantologists, Fellow and Associate Fellow of the American Academy of Implant Dentistry, and Adjunct Professor at the University of Nebraska Medical College. He is an international speaker and is in private practice at The Dental Implant Center in Rapid City, South Dakota. He can be reached at or at

Disclosure: Dr. Moody is a paid speaker for BioHorizons®.

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