The Central Lateral Dilemma

Last week I attended the Seattle Study Club Annual Symposium. As is always the case when I attend continuing education, I think of all the patients in my practice this learning applies to. Sometimes I get lucky and I haven’t finished their treatment and still have a chance to implement this new learning. Last week was no exception, and several of the speakers spoke on the challenges of anterior esthetics using implants and how we can optimize the results through planning. Dr. Maurice Salama presented on “The Central Lateral Dilemma”, and the timing was perfect as I am just embarking on a complex restorative case with this exact scenario.

The most challenging of all the anterior esthetic situations is when we are missing two adjacent natural teeth. It is far easier to get fabulous esthetic results when either a single tooth or three or more are missing. The reasons behind this have to do with the changes to horizontal and vertical bone and tissue volume that occur when we loose natural teeth. Most specifically the challenge comes in achieving final papilla esthetics due to the loss of interproximal bone height to support the tissue. Placing two adjacent implants is challenging and can result in a deficient papilla between the two implants, even when we maintain 3mm of space between the fixtures. Planning the case prior to extraction of the teeth and utilizing techniques such as orthodontic extrusion, the retention of a vital root, and surgical procedures to maintain bone and soft tissue at the time of surgery as critical elements.

With the best planning we still will have to select the restorative option we feel has the best possible outcome based on the patients desires. The challenge is selecting from the multiple options and approaching it as an interdisciplinary team will increase the likelihood of success.

• Two Adjacent implants, with or without bone and soft tissue preservation/grafting
• One Implant and a cantilever bridge, with or without bone and soft tissue grafting, ovate pontic site development
• One Implant and a cantilever, retaining a submerged root in the pontic site, with or without soft tissue grafting & Ovate pontic site development.
• Orthodontically repositioning canine into the lateral site to create a one site defect, then implants with or without bone and soft tissue augmentation.