Case Study: Central Incisor Immediate Implant and Provisionalization

![]3ddx_logo](http://www.3ddx.com/)Case Posted by: 3D Diagnostix Inc
Case By: Dr. Jeffrey Brooks and Dr. Michael Backer Case Background & Description
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Immediate implants with provisionalizations are becoming the surgery of choice for patients when extractions are indicated in the esthetic zone. Immediate implant placement with particulate bone grafting can preserve the buccal/lingual width and crestal height of the residual alveolar bone. Additionally, clinical research has shown that immediate provisionals with anatomical crown contours can aid in maintaining the gingival architecture reducing the need for secondary bone and gingival grafts.

Recently, we were consulted on a patient who was motivated to have her maxillary teeth aligned with immediate implants and restorations. This patient is a 41-year-old female who was referred to the University of Tennessee Oral and Maxillofacial Surgery clinic for extraction of teeth #9 and #10 with socket preservation. The patient stated she had been neglecting her dental care for several years, and had been diagnosed with severe, local periodontitis at #9 and #10. (Figure 1) This was confirmed by full mouth radiographs showing approximately 8 mm of bone loss between #9 and #10. (Figure 2) Both teeth had only a third of the root in alveolar bone.

Clinically, tooth #9 had drifted distally and facially resulting in a diastema. (Figure 3) She had been informed that #9 and #10 would require extractions, socket preservation with bone graft, and replacement with a flipper until implants could be placed 4-6 months later. She expressed during her consultation that she would prefer to not wear a removable appliance. We presented the option for extractions and immediate implants with provisional crowns. She was informed of the potential benefit of retaining the papilla between #9 and #10 and retaining the gingival height.

However, we clearly informed her that if the implants and provisionals could not be stabilized during surgery, she would be grafted and her extracted crowns for #9 and #10 would be glued into an essix retainer until a flipper could be fabricated. Additionally, she understood there could be a need for gingival grafting even with immediate provisional crowns. She understood the potential that could be gained with this treatment plan and agreed to proceed with the surgery. The shade for the temporary crowns was selected at this time using a Vita classic shade guide. The restorative aspect of the case was referred to the AEGD department at UT. They recommended only a single 4.3 mm implant to replace #9 with a temporary PMMA crown for #9 and a cantilever pontic for #10. This decision was made because of limited space for two implants between #8 and #11 and to allow for contouring of #10 pontic during the osseointegration phase to help preserve the interdental papilla between #9 and #10. The patient agreed with this modification, and we moved forward with computer planning. The patient™s CBCT was uploaded into implant planning software from 3D Diagnostix (Figure 4) Stone models were digitally scanned into STL files using a 3Shape Trios scanner and software. (Figure 5) The maxilla was segmented from the patient™s CBCT and was merged with the STL maxilla file. (Figures 6, 7, and 8) Teeth #9 and #10 were replaced digitally with stock crowns from 3D Diagnostix™s planning software (Figures 9 and 10)

Once the crowns had adequate contours and were positioned to close the diastema, the implant for #9 was digitally inserted. We chose to use a Nobel Active 4.3 x 13 mm implant due to its higher initial stability. (Figures 11 and 12) It can be seen in Figure 13 that the screw access would have to come out the facial of the provisional due to inadequate buccal bone. The implant could not be reclined palatally without dehiscing out of the buccal plate. (Figure 14) The depth of the implant was placed to the remaining height of the alveolar bone. The plan and patient™s STL files were sent to 3DDX lab for guide and provisional fabrication. The lab was also directed to make any design changes necessary to the crowns created in the plan to better the contours and esthetics. The patient was scheduled for surgery about 2 weeks after the plan was sent to the lab.

At the time of surgery, the patient pre-medicated with 2 gm of amoxicillin and rinsed with Peridex for 60 seconds. She elected to have the procedure under local anesthesia because she was breast feeding. The patient was anesthetized with 2% lidocaine with 1:100k epinephrine and 0.5% Marcaine with 1:100k epinephrine. Teeth #9 and 10 were extracted using a #9 periosteal elevator and 150 forceps. (Figure 15) Care was taken to preserve the papillas and no flaps were created to preserve the buccal periosteum. It should be noted that the lab requested the alveolar ridge at #9 should have a ridge split procedure. Instead, #9 was intentionally luxated buccally and lingually multiple times and held in each direction to give the ridge the expansion indicated in the guide plan. Once the teeth had been extracted, the surgical guide was seated. (Figure 16) There were no discrepancies noted. The implant osteotomy at #9 was completed per protocol using the Nobel Active surgical placement kit. (Figure 17)

The depth and angulation of the osteotomy was checked using digital PA films. The implant was then inserted through the guide using the depth controlled implant drivers on the screw driver handle. (Figure 18) The torque wrench was attached after placement to verify the implant had at least 70 Ncm of stability. The titanium temporary abutment was then seated and verified with a PA radiograph. (Figure 19) The temp crowns were fitted to the temporary abutment and the implant timing was adjusted using the torque wrench. The extraction site at #10 and the space between the implant at #9 and the buccal plate were bone grafted using MinerOss. A membrane was placed over the graft and sutured with 4-0 vicryl in figure 8 fashion. Glustitch Periacryl was the applied over the membrane and sutures. (Figure 20)

The patient was taken to the AEGD department for bonding of the temporary crowns. The temporary crowns were inserted over the abutment to again confirm proper timing and to verify there are no gross occlusal discrepancies. (Figures 21 and 22) The abutment was removed and the screw access was packed with Teflon tape. The temp crown for #9 was cemented to the abutment using RelyX Unicem. Teflon tape was removed and the abutment reseated with the bonded crowns to the Nobel implant. The abutment was hand tightened to the implant. Finally, cotton pellets were inserted into the screw access and the facial hole of the temporary was filled with packable A2 composite to match the shade of the crowns. After finishing and polishing the composite, the occlusion was checked with articulating paper. The crowns were taken completely out of occlusion and excursive movements. (Figures 23 and 24)

Conclusion
The patient was given a mirror to look at her new smile. She was beyond ecstatic because we had fulfilled her esthetic requirements, and negated the need for a flipper. The photographs at the conclusion of the surgery show normal anatomical crown appearances for #9 and #10 with the closure of her diastema. The position of her gingival showed little change post-operatively as well. Antibiotics were given for 1 week and the patient was reminded to not chew anything with her anterior teeth for at least four months. She will be followed by the AEGD department every month to bulk #10 apically for gingival sculpting until she is ready for her final crowns. If necessary, a connective tissue graft will be placed on the facial #9 and #10.

5 Comments on Case Study: Central Incisor Immediate Implant and Provisionalization

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David Anson

12/22/2015

Very nice case, but is the abutment fully seated on the implant?

DrDave

12/22/2015

Integrating. I notice the smile line so he high cervical isn't an issue, now. Did the patient decide to forgo a bone grafting to restore the defect prior to placement of bone level implants? Just curious if that was a decision made by the practitioner or the patient.

DrDave

12/22/2015

Never mind. I skipped right to the images and didn't read the text. My bad. No one wants to wear a removable appliance for the time required to build the proper foundation. So instead of that, took chance, made the caveat that may still have to graft and may need to do a ct graft later, where that probably won't occur if built the proper base. Glad she's happy and thanks for posting

David Barget

12/25/2015

What would have made this a learning exercise, is to present a concern list , what happens to the hard and soft tissue when a single incisor is removed and even more of a concern if the central and lateral are removed together. Much more could have be learned for all of this if this was evaluated significantly differently instead of showing a dental procedure. immediate initial healing looks completely different than how it will look in -1.5 years. respectfully, david

Keith Reber

12/30/2015

Nice case and thanks for posting all the pics too. Few questions: ---- what type of Mineross? ---- resorbable membrane I'm guessing? I'm still learning this cbct and guided surgery planning, so was a diagnostic impression taken and a waxup done to close the diastema and then this model was scanned into the software for implant planning? Thanks so much for posting and any pics of the temp outside the mouth after you cemented it to the abutment? Keith Reber DDS

Case Study: Central Incisor Immediate Implant and Provisionalization

5 Comments on Case Study: Central Incisor Immediate Implant and Provisionalization

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