A variety of factors have to be considered when performing implant restorations on the anterior maxillary region given its high aesthetic demands. Dr Kuoching Chen (Taiwan) shares three cases to discuss novel techniques addressing the challenges of anterior implant placement.
By Dr Kuoching Chen
A 50-year-old male patient with fair oral hygiene was presented with a fracture on tooth 11 — associated with mobility, swelling and pain.
Clinical and radiographic examination revealed that the fracture affected the palatal-cervical to facial-crestal region of the offending tooth (Fig. 1). Fistula at the periapical region of the facial gingiva was also noted (Fig. 2).
The treatment plan included extraction of tooth 11 followed by an immediate implant placement. The patient’s extracted tooth will be used as a temporary crown to maintain aesthetics and papilla height.
Atraumatic extraction of tooth 11 was performed using a periotome and elevator. The socket was flushed with saline and the granulation tissue was removed (Fig. 3). Atraumatic implantation was done without flap elevation and the gap was filled with Endobon and freeze-dried bone allograft (FDBA).
Osteotomy procedure leans against the palatal gingiva so the implant can be placed slightly palatal to ensure sufficient buccal bone.
The implant was placed 4mm below the gingiva margin at the palatal side or 3mm below the gingiva of the adjacent teeth (Fig. 4). Gingihue abutment was used to ensure that the gingival space is maintained and the emergence profile is good.
To use the crown of the extracted tooth as a temporary restoration (Fig. 5), the crown was hollowed-out to create space for cementation of temporary abutment (Fig. 6). After the try-in, the internal surface was etched (Fig. 7).
Resin bonding procedure was done and temporary abutment was fixed to the crown using flowable composite (Fig. 8). The gaps were filled with more resin, rounded out and polished well (Fig. 9). The occlusion was then adjusted 0.55mm from the contact surface.
Additionally, the cervical outline was shaped and the surface of composite was polished (Fig. 10). Once done, the provisional crown was delivered to the patient’s mouth (Fig. 11) and periapical radiograph of post-implant placement was taken to confirm its position (Fig. 12).
After four and a half months, the patient came back for the final impression (Fig. 13). The temporary abutment and crown were removed revealing symmetrical facial outline form (Fig. 14) and preserved interdental papilla (Fig. 15).
In delivering the final restoration, the abutment was placed with positional jig to ensure accurate placement (Fig. 16). Then, a gold-tite screw was used for the placement of gingihue abutment with porcelain core (Fig. 17).
Finally, the E-Max crown was issued (Fig. 18). Post-treatment photo (Fig. 19) was taken as well as a periapical radiograph to ensure proper position of the abutment to the implant (Fig. 20).
After seven months, patient came back for recall presenting a satisfactory shape of papilla (Fig. 21). Post-operative radiograph was taken, revealing the occurrence of interdental bone remodelling (Fig. 22).
There is not much difference between the use of resin tooth and natural tooth as temporary crown. But it is easier to use the latter to maintain gingiva type and preserve dental papilla.
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