Immediate Tooth Replacement using Advanced Digital CEREC Technology

This case involves a 39-year old male in good overall health presents pain in the anterior maxillary right area. His smile shows a gum line fracture of his right lateral Incisor. A history of endodontic treatment was reported.

A limited oral examination and radiograph reveals mobility and a vertical root fracture of a previous endodontic treatment on # 7. Radiographically, the obturated and post cored root shows an apical radiolucency. Prognosis is determined to be hopeless, and treatment options are discussed. Having the desire to leave with an immediate replacement tooth, the patient elects a proposed for treatment for the immediate extraction and the placement of a root form titanium implant supported ceramic prosthesis.

Treatment Plan

IV access is established in the right antecubital fossa, and blood is collected for the purpose of preparing a PRF (Platelet Rich Fibrin) graft per protocol. Two carpules of lidocaine with epinephrine are used for local anesthetic.

A Periotome is the instrument of choice with careful adherence to an atraumatic technique in order to preserve the buccal plate. Luxation and elevation of the root is achieved, Forceps can be used for the final delivery. The socket is thoroughly debrided and irrigated leaving only hard tissue.

A pilot hole is initiated with a palatal bias and an osteotomy performed to accept a Nobel Active type implant, in this case a 5mm x 13mm was selected. The Implant is delivered and torqued to a minimum of 35 Ncm, with 70 Ncm as ideal.

An anti-rotational Ti-base is connected to the implant platform for the purpose of screw retaining a crown. Next, the site is digitally scanned for the design and fabrication of a screw retained CEREC e.max ceramic type prosthesis. The final prosthesis, a screw retained ceramic Right Maxillary Lateral Incisor, was produced in fourteen minutes. Its design and fabrication is digitally assisted using the Sirona Cerec technology. The milled crown is then characterized with stain and glaze to meet then patient’s specific esthetic and function criteria, then fired Using an ivoclar oven with preset parameters required for this material crystallization phase.

After cooling and proper etching and priming, the prosthesis is cemented to Ti-base outside of the oral cavity using an opaque cement to preserve natural appearance. The crown is then delivered onto the implant Platform and torqued to 35 Ncm, a teflon plug and flowable resin are used to cover access hole. Contact and occlusion are confirmed and checked for any occlusal interferences which would threaten the integration of the implant.

An impression is taken and an occlusal guard is fabricated to protect the implant and prosthesis against periocclussal forces during sleep. Patient is given a regimen of antibiotics, instruction on the nightguard wear and care, and is scheduled for a week post op.

Seven days later, our patient reports no symptoms or concern, and is thrilled to have no further treatment required. Clinically, healing is uneventful, and the architecture of the soft tissue appear stable. His oral function is within normal limits. Patient will be seen in 90 days for routine care.

16 Comments on Immediate Tooth Replacement using Advanced Digital CEREC Technology

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Oleg Amayev

11/6/2018

5x13 tooth#7 ? Do you have a CT scan you can post.

Dr. Rayment

11/6/2018

So you fully loaded the case in occlusion on day one? While it is amazing that we have the technology to do this type of treatment today, I can't think of one scientific article that would recommend placing an immediately loaded, single tooth replacement implant restoration. You could point out that dentures are placed in occlusion on day one but that is not the same as a single tooth implant supported restoration. Help me out??

Connor

11/6/2018

The prosthesis is in light occlusion and free of any para-functional interference and the patient is wearing a bruxing appliance at night time. Here is a published article from 2008 detailing the same process- https://www.aegisdentalnetwork.com/id/2008/08/done-in-a-day

Oleg Amayev

11/6/2018

There no problem with loading on the same day. I can tell you that when you placing crown on the same day when you pull a tooth you will preserve all gingival architecture, and you can achieve great esthetic result. As long as you achive proper stability you should have no problem loding Implants.

bigjulie

11/6/2018

Dr Rayment, what journals on Implantology do you subscribe to regularly?

11/6/2018

Very nice case and work, I attended a lecture from prosthodontist all he does is single implant with final restoration same day.

Dr. Rayment

11/6/2018

I'm a bit surprised about this thread, but let's try a different approach. I fully support the idea of placing a restoration on this implant on the day of implant placement. This is a great way to temporize instead of an Essix or Flipper and will help to really sculpt the gingival tissue. However, I would place a provisional crown, out of occlusion. You could use acrylic or even Enamic if you want to get fancy. If the crown is in occlusion and "loaded" you will create movement and micromovement which will jeopardize the osseointegration. I am not sure which lecturer you saw that recommended doing this but I would ask for my money back on that course. No disrespect meant and thank you for your post.

11/6/2018

All what they do in their practice is final restoration on single implants to immediate full arch load, the practice in Dubai prosthodontist and oral surgeon together . I can’t remember the names at the moment but that’s most of their work, if you disagree, it’s okay , I disagree too and I will get a better results by putting a temp and shape the gingival architecture like that but there is another way of doing things which may help other people.

Dr A

11/6/2018

A cbct would be very helpful here. All in all I have alot of respect for this approach. My only concern is that maxillary lateral incisors are frequently lacking in bone volume. It frequently requires a buccal only graft. I wouldnt place without a CT and I probably wouldn't invest in the final restoration without it either.

Ed Dergosits

11/6/2018

It would be wise to have a CBCT image before and after the implant was placed. I think this is a fantastic service for many reasons if there is enough buccal bone. A 5mm diameter implant placed in an upper lateral incisor site is unusual.

Oleg Amayev

11/7/2018

It’s very unusual, my experience showing that lateral incisor implant size between 3.0-4.0 ( Max), the average 3.5,3.6 5.0 most of the time if not always will engage into the thin buccal bone and will cause bone loss and gingival recession.

roadkingdoc

11/7/2018

I would hope in the coming months for this implant and crown to be stable and successful. I wish the doctor and patient nothing but success. Having said that, about any immediately placed implant can be restored with a final restoration. I would like to see long term followup on many of the cases presented on this site. Thanks for contributing.

SFDIndy

11/7/2018

Ive read comments in this forum of how the tongue may be a contributing factor in failing implants/healing abutments and now this. Perhaps because this is a lateral?

Yassen Dimitrov

11/9/2018

Dear colleague. First of all- congratulations for the beautifuly documented and technically precisely performed case. It is good that thanks to modern CAD/CAM technology helps in making things faster, quicker,easier. But it is the technical aspect of our treatment. Nothing more. Biology doesn`t care about CAD/CAM. BIology, however does cares about time. In this case, you count only upon primary stability, for the success of your case (because, you are loading with a permanent crown without waiting for the osseointegration to occur . It is not wrong. And the case can be successful if you deliver a protected occlusion (absence of occlusal contact, etc), meaning, you play with lesser occlusal load, to allow asseointegration to occur when biology takes its time. It is a compromise, but - it is OK. But then let me tell you this- the MAIN reason for using two piece implant systems has always been to allow the implant to integrate, disconnected from an abutment. If this is not needed in such cases- why not go back to the Tramonte or Bauer implants like they did 50 years ago? Why make our life complex with micro abutment screws, which sometimes tend to unscrew or break? Of course there is the benefir of screw retained crowns, but the problem of cementation can be eleganly solved. Tidu Mankoo already showed how. Best regards and good luck: Dr Yassen Dimitrov

Greg Kammeyer, DDS, MS, D

3/11/2019

Interesting: I applaud your posting more detail than most and clearly you have done a fair bit with implantology. I cannot support your experimenting with patients even tho you know others doing it too. That tendency doesn't help our profession, nor serve the public that trusts us. Several concerns I have are: 1) "The standard of care by a reasonable prudent practitioner" would call for something more traditional. So the one that will blow up, fail, wipe out alot of bone and that will need a bone and tissue grafting will well offset the convenience of your technique. 2) The Standard for when a new technique, to be recommended is a MINIMUM of 2 peer reviewed articles in Implant Journals (not advertorial magazines)....preferably multi centered studies that show that multiple people come up with successful intermediate - long term results. 3) This type of "Research =EXPERIMENTATION, is to be left to teaching institutions/universities that have IRB's to protect the patient from gross experimentation which is how I view this technique at this stage of implant dentistry (Sargenti, Bicon, Camillian/Mirage veeners, and a whole long list of composites are a few ideas that come to mind that were not researched well before being released). This is critical, because if their best results shows too low a success rate than how can we expect to achieve any better? I'm not saying it isn't a cool, convenient technique, I'm saying don't you have other techniques to refine that should take your time rather than this cowboy experiment? 4) Just because we CAN do something doesn't make it right. Who is really in that much of a hurry? you or the patient? Whom is responsible for the success or failure? Our creed calls for putting their interest first. 5) Lastly- Occlusion!!! An immediate temp on an implant is well out of occlusion and the final crown should bear some of the occlusal load or it is only an esthetic solution and can cause the occlusion to get worse. Personally, I'd love to see us doing these treatments regularly and I predict that in the coming years they will become routine.....after proper research is done in university settings......After all isn't that why implant dentistry enjoys such a high reputation? Branemark did the research for 15 years before releasing his system. Remember how many extra visits, how much hand holding the patient will need, how much extra expense you'' have, how much lost practice momentum due to staff disappointment and your disappointment, how the patient will feel about you, the expense, the practice and the repeat surgeries and how much heart muscle and stomach lining for you and the patient when failures occur!!!!

david

4/6/2019

I am struck by the following; There is clear evidence of patient being a bruxist in the photographs and the DPT It is not unreasonable to assume as a result of bruxing the lateral incisor split I cannot see evidence anywhere of the patient being draped or the operator being draped for sterility The implant is touching the soft tissue during its placement, so it is far from sterile by the time it is finally positioned. The diameter of the implant is most unusual for a lateral incisor. The apical portion of the implant is extremely close to the apex of the central incisor. Placing an implant at 70ncms torque generates significant bone compression and post surgical pain. Such torque values are not in the interest of the bone, surrounding tissues or the patient, they are for the benefit of allowing an operator to feel more secure. Two weeks after implant placement the associated inflammatory process decreases the implant stability significantly and how should such a restored implant cope in bruxist then?

Immediate Tooth Replacement using Advanced Digital CEREC Technology

16 Comments on Immediate Tooth Replacement using Advanced Digital CEREC Technology

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