The Challenge of the Lower Anterior Implant Bridge

I’ve been very fortunate to have tackled quite a few complex implant cases.  For me, the hardest of these is the patient missing the lower anterior incisors.  This situation presents some unique challenges.

  1. Combination Defect.  Those who have lost their lower anterior teeth typically have periodontal disease.  So they have both hard tissue (bone loss) and the accompanying tissue defect.
  2. Aesthetics.  Anytime you have to replace pink the difficulty goes up.  Where to put the papillae?  How to match the pink?  How not to make the teeth look too long?
  3. Implant Positioning.  These areas have minimum bone width, limited prosethetic spacing, and often have divergent roots of the neighboring canines.

Here’s an example of a such a case and how we handled it.  It’s not perfect, but overall I am pleased with the result.

Jerry has been a long time patient.  He lost his lower front teeth due to perio disease.


Our first order of business was to do a ‘crown down’ prosthetic approach to implant planning.  I did a virtual waxup using CEREC and merged it with his CBCT.


From this I was able to determine that placement in site #23 and #26 (my preferred sites) was not possible due to root divergence of the canines.  Instead we needed to place implants in site #24 and #25.

Luckily, in this case there was enough bone width to avoid the need for lateral bone grafting.  Even more important, we were able to plan the implants parallel.

This would give us the ability to produce a screw retained restoration with engaging abutments.



The final result is a screw retained bridge that replaces both the ‘pink’ and the ‘white’.

The final result is monolithic zirconia without any porcelain – just stain and glaze.  Special thanks to Michael Keeter at Real Time Dental Lab for the lab work.


We make every effort to do nearly all our cases as screw retained restorations.  Are you currenctly doing screw retained restorations? Why and why not?  Please let us know in the comments section below.

Update 02/12/2016 – here is a picture of the provisional and the provisional in the mouth.  As you can see i needed to adjust the provisionals in the mouth for working movements.  This was then translated to the final restoration (above).





About the Author:

Dr. Tarun Agarwal represents the next generation of leadership for the dental profession. As a respected speaker, author and opinion leader, he is changing the way general dentists practice. His common sense approach to business, dedication to clinical excellence, integration of technology and down to earth demeanor has made him a recognized educator.


  1. Paul Gilreath February 12, 2016 at 7:21 am - Reply

    Beautiful case Tbone. A couple of questions. How did you do the final case…scan or impression? And how did you choose the color of the go vial tissue stain?

    • T-Bone February 12, 2016 at 7:23 am - Reply

      Paul the final was done with a traditional impression for this case. I have down many of these with total digital workflow.

      The final shading and characterizations were determined through a provisional. Basically the provisional serves as a trial shade guide, especially for the tissue.

      • Paul Gilreath February 12, 2016 at 10:10 am - Reply

        Thanks T. So what shading/characterizations did you use on the provisional? Where these the same shades (corresponding colors) that the lab has? Thx.

        • T-Bone February 12, 2016 at 10:11 am - Reply

          the lab made the provisional for me from photos of the shade tab of the tooth and the gingiva.

          the provisional is a pretty good guess and then the photos of the provisional in the mouth helps communicate any changes necessary.

        • T-Bone February 12, 2016 at 10:17 am - Reply

          Paul… take a look above i added some photos – the provisional (made of milled PMMA) and it in the mouth.

  2. jason February 18, 2016 at 12:06 pm - Reply

    Tarun, if you had implant angulation problems here and couldnt do a traditional screw retained finish would you use angled multi unit abutments to still allow for a screw retained bridge?

    • T-Bone February 18, 2016 at 3:47 pm - Reply

      @jason… depends on how severe the angulation ‘problems’ were.

      if they were within roughly 10 degrees (and still lingual access) then i would consider non engaging abutments (ideally one engaging and one non engaging)

      if angulation was more severe then i would consider custom abutment and cemented bridge

      if they were really severe and i had the restorative room (reconstructing tissue and tooth) then i would consider multiunit intermediary abutments

  3. Melinda M Byers December 19, 2016 at 7:46 pm - Reply


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