Dr Herminio García
Adjacent implants in the esthetic zone
The patient, a 45 years old Caucasian woman, non-smoker in good general health, was referred to the authors’ private dental office. She was unhappy with the esthetics and the function of his anterior prosthesis. She had a frontal trauma 20 years ago. Since then he has had problems with the crowns of 1.1, 1.2 and 2.1 (FDI). All three teeth have an endodontic problem but the main problem is restorative because they do not have enough healthy tooth structure (no-ferrule situation).
Knowing that the prognosis of his current dental situation was poor, he desired a long-term definitive restorative option. Several possible treatment options were discussed with the patient. The initial treatment plan for 1.2 and 2.1 was exodontia and immediate implant placement and immediate provisionalization. For 1.1 the initial treatment plan was reendodoncia, crown lengthening and vertical preparation ( BOPT) to increase ferrule without violating the biologic width. Once 1.2 and 2.1 implants were placed, the teeth 1.1 fractured. Therefore it was decided to place a new implant in this location. The patient refused a 1.2 to 2.1 bridge.
Preliminary studies requested were cone beam Tomography, panoramic and periapical series of both upper and lower jaws, study models and extra- and intra-oral pictures. All data were imported in to Straumann® coDiagnostiX™ software, and the images married together to show detailed relationship between guides and patient scan. Implant positions and angulations can then be precisely planned in a virtual environment. Once approved, the plan was digitally sent to the laboratory for production an upper guided surgery drill positioning guides.
Following administration of local anesthesia, atraumatic tooth extraction was accomplished without flap reflection to preserve the interproximal papillae and the remaining buccal and lingual plates of bone. The extraction socket was carefully examined for dehiscences and fenestrations and debrided of residual periodontal fibers using curettes.
Following socket debridement, a Straumann Bone Level Tapered Implant (Regular CrossFitTM Connection Ø 4.1mm, SLA® 16mm) was placed in tooth position 2.1 (FDI) and a Straumann Bone Level Tapered Implant (Narrow CrossFitTM Connection Ø 3.3mm, SLA® 16mm) was placed in tooth position 1.2. The surgical guide was used to help ensure ideal three-dimensional placement. The implants showed adequate initial stability when placed with a torque driver at 35 Ncm. A semilunar flap was made on 1.2 to ensure the correct cleaning of the periapical lesion.
A customized provisional titanium cylinder ( Temporary Abutment,) was then placed and hand-tightened onto the implant and trimmed using a positioned guide to ensure the correct height. The provisional crown was relined with flow resin and adapted to the custom provisional abutment using a positioned guide to ensure exact positioning. The provisional shell was precisely finished with flow composite resin on the temporary abutment to create a concave cervical emergence abutment that gives more space for the tissue to grow.
A bone graft substitute was placed between the buccal plate of bone and the implant in order to fill the space and maintain the soft tissue contour and in the periapical defect of 1.2. After immediate implant placement and bone augmentation, a supraperiosteal envelope was made labial to the socket. These tunnels, used to accommodate the connective tissue graft, were dissected sharply with a microsurgical blade. Care was taken to leave the periosteum attached to the bone during dissection. A connective tissue graft from tuberosity was inserted into the prepared envelope space and secured with nonresorbable sutures. The immediate provisional restorations were tightly screwed onto the implant by hand. The provisional restoration were adjusted to clear all contacts in centric occlusion and during eccentric movements. A periapical radiograph was obtained to ascertain the fit of the provisional restoration.
1 week postop it was observed a partial necrosis of the vestibular epithelium of 1.2. The necrosis caused an epithelial groove that could be solved in the 1.1 implant placement surgery.
Tree months later, the critical contour of the provisionals was modified in order to improve the scalloping. A implant impression was made using a custom impression copings to transfer a record of the healed anatomic tissues to the laboratory. A definitive hybrid cemented-screw retained zirconia crowns on Straumann® Variobase® abutments (3mm) with specific gingival emergence profiles and anatomical shape established by the provisional restoration was fabricated.
Rationale
Immediate implant placement following tooth extraction might be a viable alternative to delayed placement. However, it requires a careful case selection. The implant position and the available peri-implant soft tissue become increasingly important in a patient with a high lip line. These case report describe a surgical technique that preserves anterior aesthetics combining minimally invasive extraction, immediate implant placement and provisionalization, grafting of the buccal space and a connective tissue graft from tuberosity.
