Single visit replacement of failing maxillary central incisor
A 24 year-old female patient presented with pain and previous episodes of swelling in the region of endodontically treated tooth #21 FDI (#9 US). During clinical examination mobility of tooth #21 FDI (#9 US) was noticed. After clinical examination and radiographic analysis the patient was diagnosed with fracture of the maxillary left central incisor. Immediate implant placement was selected as the treatment of choice for this situation.
Progress & Completion
Immediate implant placement in #21 FDI (#9 US).
Implant positioned in palatal wall of post-extraction socket. Gap of more than 2mm between implant and facial bone wall.
Deproteinized bovine bone material placed in the gap up to the soft tissue level (dual zone grafting).
Crown of the extracted tooth separated from the root, polished and placed in pre- operatively made silicon guide.
Positioning of the crown using silicon guide
Temporary crown bonded on neigh-boring teeth with glass reinforced fibre.
Temporary crown bonded on neigh-boring teeth with glass reinforced fibre.
Screw retained provisional restoration after 4 months healing. Screw access hole located at the incisal edge
X-ray of provisional restoration.
2 months after provisional restoration placement
Impression of emergence profile
NobelProcera ASC Zirconia abutment.
Definitive restoration placement
Definitive restoration X-ray
Minimally traumatic extraction of tooth #21 FDI (#9 US) was performed. A tapered implant was inserted into the post- extraction socket without raising a flap. Bone graft was placed between the implant and buccal bony wall, and a healing abutment was hand tightened. Despite achieving high insertion torque of more than 35 Ncm, an immediate restoration was not placed due to an unfavorable occlusal relationship (deep vertical overlap). The crown of the extracted tooth was separated from the root and bonded to neighboring teeth using glass reinforced fibre and previously fabricated silicone guide.
Four months later, a provisional restoration was placed. After two months of soft tissue healing, an emergence profile impression was made for fabrication of a definitive crown. An angulated screw channel abutment was chosen because the screw access hole was located at the incisal edge.
Follow-up & Outcome
Eruption of contra-lateral maxillary central incisor #11 FDI (#8 US) noticed on 3 years follow- up visit.
4 years follow-up. Stable gingival margin level and papilla levels.
4 years follow-up. Slight loss of orofacial dimension.
4 years follow-up X-ray. Stability of inter-proximal bone levels.
After 4 years of follow-up, stable interproximal bone levels are observed on a radiograph. Stable papilla levels and marginal gingival level were observed clinically while slight oro-facial volume loss was present. However, there was an incisal edge discrepancy present between the implant restoration and contralateral central incisor after 3 years. No other technical nor biological complications were noticed during the follow- up period.
Immediate implant placement in the esthetic zone can provide favorable results in terms of function and esthetics with stable gingival margin and papilla levels. Angulated screw channel abutments allow the clinician to use a a screw retained restoration. However, eruption of adjacent maxillary anterior teeth can continue in adulthood and results in an incisal edge discrepancy between the single implant restoration and neighboring teeth.
Questions
Ask a questionHow temporisation done to neighboring teeth as it seems to be a deep bite and low overjet? Seems open bite in temporisatio photo
Photo no. 6
Photo no. 6
In the frontal photo of the temporary restoration (picture 6) patient did not bite so it may look like the open bite. Temporary crown was bonded to neighboring teeth using glass reinforced fibre. The position of the fibre was quite apical, as can be seen in the occlusal photo (picture 7).
Nice case presentation. Thanks a lot Dr Marko.
Thank you dr Aggarwal
Hi Marko, thank you for sharing this case with us. Great placement, beautiful restoration. Cheers, Neal
Hi Neal,
Thanks for the comment! Cheers
Nice Report
May i know, how you make sure, bone graft sufficiently inserted between implant and the bone gap?
How you make sure the bone graft inserted don't drop off of only cover screw/healing abutment is placed?
Thank you!
- May i know, how you make sure, bone graft sufficiently inserted between implant and the bone gap?
- How you make sure the bone graft inserted don't drop off of only cover screw/healing abutment is placed?
Thank you!
Thank you for the question.
Narrow healing abutment was placed after implant placement, and bone graft was carefully pushed in the apical area and around healing abutment with narrow bone plugger. Once the grafting was completed, larger diameter healing abutment was selected.
Being a prosthodontist I must say it is very nicely executed. The healing phase, the temporization phase and the definitive restoration.
Thank you!
Thank you for the question.
The bone graft has been stabilized between the facial bone wall and implant surface, and healing abutment was placed to cover the coronal portion of the graft. On top of that provisional crown bonded on neighbouring teeth was further protecting wound area. Since the buccal bony wall was intact membrane was not necessary for graft stabilization.
What size implant was used?
In reply to What size implant was used? by DEEPAK PAI
It seems to me a Nobel Active NP 3.5x15 mm possibly
In reply to What size implant was used? by DEEPAK PAI
Dear dr Pai,
It is Nobel Active implant 3.5 x 13 mm