Single back tooth replacement using dental implant



Standard of care: tooth replacement using dental implants. Other options include removable denture and bridgework (involves removal of natural tooth structure which is irreversible). Treatment plan involves placement of immediate implant and temporary crown: patient leaves the dental office with a full smile. Treatment time is one and a half hours.






This lovely patient was referred for an aesthetic evaluation of upper front teeth crowding, general discoluration, uneven gum line and the defetc caused by the past removal/lost of upper left first premolar.

To rebuild her smile we cannot simply place veneers or do an orthodontic treatment. The most important thing is meticulous planning of the best treatment for this patient that suits her needs and wants. There is no ideal treatment or ideal veneers, however preservation of biology and regeneration of lost biology (the defect on the left side: shadow present during the smile of this patient)

In may ways we could consider orthodontic levelling and alignment(this will also align the gums as well,) followed by restoring the worn smile(worn edges of the teeth). However this ideal treatment would require considerable timing and at this stage of her life orthodontic levelling and alignment was not an option, hence the patient opted for a restorative intial correction of the smile.

The treatment planning was agreed as follows:

1. Diagnostics: direct composite mock up to assess the gum levels and level of tooth display.

2. Correct the gum levels and teeth arrangement and display and improve the colour of the teeth initially using composite veneers on upper front six teeth.

3. The smile level would help to set up the lateral smile where the defect is on tooth 24 (missing upper left first premolar replaced by defective bridgework) where the both soft and hard tissue defect exists. You note the left lateral smile profile is slightly converging, making upper left side of the arch narrow.

4. The smile line is also flat, that give an aged appearance for this young lady

5. The aim of our diagnosis is to complement the facial aesthetics of this beautiful patient.

This is not straightforward and therefore, meticulous treatment planning and communication with the patient is essential. After all, this is why Dr Nalbandian has trained for so many years.

Once the new smile is established and we have tested the system: speech and smile dynamics as well as function, then Dr Nalbandian is able to proceed to more complex reconstructive processes to be completed in One Visit such as;

A. Removing the existing bridge on upper left quadrant, making good provisional bridgework, placing an implant.
B. Patient leaves the office with new provisional bridgework that will function while the implant is integrating with the bone.
C. After 4 months, the final implant supported crown at site 24 and tooth supported crowns on teeth 25 & 26 will be placed and definitive aesthetics and function will be established.


Initial presentation

Need x‐rays!
Defect at site 24 from traumatic past tooth extraction. This the reason the referring dentist prefers to have this critical tooth



removal performed in our surgery. The aim is to maintain the delicate bone scaffolding that houses the tooth. This helps to reduce ridge volume and improve future implant‐crown function, emergence profile and aesthetics. We need to rebuild this defect to improve aesthetics in this high smile line situation. Also note the erosive lesions on lower premolars from high acidic diet. This also requires
restoration and patient diet modification. Overall we have healthy gums and bruxing (tooth grinding) condition.



General tooth discolouration and tooth wear.

Defect at 24 is quite obvious from this position and can be corrected in most cases during implant surgery and simultaneous augmentation procedure.



Diagnostics: Composite mock up first. Why? Because before we jump to the surgical aspect of implant placement at missing tooth site 24, we need to know what the final result is likely to be.

Composite mock up upper front 6 teeth only Diagnostics: direct composite mock up to assess the gum levels and level of tooth display.



Our patients are given all the opportunities o discuss all aspects of their smile enhancement, diagnostic planning stages. This we feel provides the platform for the best outcome.

Patient agrees, “Yes I am happy with the planning of my new smile. When can we start?”

After gum recontouring and composite veneer application on upper front six teeth. These veneers have the advantage of immediate placement which is less costly since no laboratory fee is required and they can be modified, repaired or have later additions.



One week post gum level

ling and composite veneers



One week post op gum levelling and composite veneers. One Smile says it all!

A. Removing the existing bridge on upper left quadrant, making good provisional bridgework, placing an implant.
B. Patient leaves the office with new provisional bridgework that will function while the implant is integrating with the bone.
C. Note how we have augmented the hard and soft tissue defect at site 24



The augmented tissue remodels, integrates and becomes part of the patient’s natural physiological functional tissue.

Reducing the ridge defect and augmenting these aesthetics has not only improved function, but also provided better lip support and creates an ideal environment to improve overall aesthetics: the implant crown emergence profile. After all our patients are referred to our office to have teeth replaced and not”Dr I need an implant” What they in reality are asking is‐”Dr please replace my missing or failing tooth with a new tooth that will restore my function, comfort and aesthetics. And that is what we do.



Four months have now elapsed and the dental implant has integrated (fused) with the bone. We are now ready to place definitive restorations: implant supported crown at site 24 and tooth supported crowns 25 7 26.

There is nothing permanent in dentistry. For some reason patients think that fillings must be permanent.

Please understand that you use your dental restorations, be it a dental filling, crowns or dentures for 24 hours a day, 7 days a week. You drive a car for average about 6 hours a week that costs $45k‐ 200k and accept that this is not permanent. We dentists provide excellent dental care that stands and exceeds the test of time, but the term permanent does not apply to dentistry or medicine.

Note how we have augmented the site 24, created natural gum anatomy (this is quite difficult to achieve) where the implant crown will emerge to simulate a natural tooth.

Dr Nalbandian prefers direct screw access whenever possible to the implant surface, to allow crown retrievability. Instead of bridgework, we now have separate tooth and implant supported individual




crowns. Feels and functions like a natural tooth. Sites: 24 25 26

Individual crowns crafted by our master ceramists in Australia.

Sites: 24 25 26



Laboratory stages: Australia

Sites: 24 25 26

Clinical: Aesthetic and Functional Integration



Missing molar tooth



Missing upper molar tooth, in this case tooth 26, removed some 12 months ago. The technique requires simple dental injections similar to having normal fillings. Duration is approximately 30 minutes.



Three months later, final crown is placed. Final crown bolted to the implant in the bone. Again, there is no pain or discomfort during the impression and issue of the crown. Final crown and screw that connects the crown to the implant.



The screw hole is covered with a tooth‐coloured filling. This is a fail safe system as the crown can be removed and re‐screwed in place for future repair if required.

One Smile says it all!

All above procedures were performed by Dr Sarkis Nalbandian.

Education and Experience are everything.

Designer Smiles® is a one stop shop for most implant, surgical and reconstructive (prosthodontic) oral rehabilitation solutions.