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Compendium
April 2017
Volume 38, Issue 4
Peer-Reviewed
Fig 1. Presentation of a healthy 27-year-old male after a hockey injury and horizontal fracture of tooth No. 8.

Figure 1

Fig 2. At presentation, protracted view showed composite resin used by a previous dentist to replace the fractured crown.

Figure 2

Fig 3. Presentation of nonrestorable horizontal root fracture No. 8.

Figure 3

Fig 4. Esthetic risk assessment at presentation: Low to medium based on 12 presenting esthetic risk factors (key No. 1).

Figure 4

Fig 5. Pretreatment CBCT scan with preplanning for a screw-retained final crown. Sagittal root position noted as Class 1 (key No. 2).

Figure 5

Fig 6. Subgingival and subosseous palatal fracture noted on tooth No. 8.

Figure 6

Fig 7. ACSGT used for prosthetically guided implant placement for a screw-retained final restoration after minimally invasive extraction of tooth No. 8 (key Nos. 3 and 4).

Figure 7

Fig 8. Confirmation of an intact buccal and palatal wall noted; a bone-level tapered 4.1-mm x 14-mm Roxolid®-SLActive® implant (Straumann) placed along the palatal wall of No. 8 with a buccal gap of 3 mm. The implant was placed apically 4 mm from the buccal aspect of No. 8 on the ACSGT (key Nos. 4 and 5). A 20-Ncm insertion torque dictated that an immediate provisional restoration not be fabricated and a transitional removable partial denture was to be used during early healing.

Figure 8

Fig 9. Bone graft of 3-mm buccal gap and palatal SCTG placed in a pouch created facial to the buccal plate and under the buccal flap and sutured, with a tall tapered healing abutment placed (key Nos. 6 and 7).

Figure 9

Fig 10. Due to inadequate primary stability (insertion torque of 20 Ncm), a transitional removable partial denture was adjusted and placed post-surgery. The undersurface was not in contact with the healing abutment.

Figure 10

Fig 11. Similar case treated of immediate tooth No. 8 replacement using a 2-piece PEEK healing abutment for immediate contour management; PEEK healing abutment is shown after chairside customizing. Note that the buccal aspect of the PEEK abutment is beveled to prevent any undue pressure on the buccal soft tissues when placed. Like a screw-retained provisional, it should be flat or undercontoured subgingivally when placed with a passive fit against the undersurface of the buccal tissue with promotion of an ideal central incisor emergence profile.

Figure 11

Fig 12. Day of immediate implant placement No. 8: The 10 keys were used with correct 3-dimensional placement with the aid of an anatomically correct surgical guide template, mineralized bone graft of the buccal gap, CTG from the palate placed and sutured under the buccal flap and immediate contour management with a PEEK healing abutment (shown in Figure 11), which will be used during the initial healing phase of 8 weeks. The patient wore a transitional removable partial denture during the 8-week healing phase, followed by a screw-retained provisional crown, which (finalized the transitional zone within) was customized further to create the final transitional zone contour before the final impression in 6 weeks.

Figure 12

Fig 13. Laboratory-fabricated screw-retained provisional with subgingival contours created for anatomic emergence profile and soft-tissue support of the midbuccal and proximal papillae (key No. 8).

Figure 13

Fig 14. Laboratory-fabricated screw-retained provisional, day of insertion. Note tissue blanching.

Figure 14

Fig 15. Four weeks after initial provisional placement, modification of the provisional was completed by adding acrylic midbuccal to further support the tissues (key No. 8).

Figure 15

Fig 16. Two weeks later, interproximal papillae looked favorable. Further support of the mesiobuccal was necessary for more tissue support, which was done by adding more acrylic to the provisional (key No. 8).

Figure 16

Fig 17. Two months later, final soft-tissue positions, as agreed upon by the team. Buccal and interproximal tissue support was complete (key No. 8).

Figure 17

Fig 18. Final transition zone created by the provisional, which will be duplicated in the custom impression coping technique. This developed transition zone will become the “blueprint” for the final crown (key Nos. 8 and 9).

Figure 18

Fig 19. Custom impression coping technique: the provisional was attached to the appropriate implant analog and placed (analog first) into the quick-setting VPS material midway up the buccal aspect of the provisional (note midbuccal marking). After setting, the provisional was unscrewed and the appropriate open-tray impression coping inserted. The space is now filled in with flowable composite. This duplicates the transition zone (key No. 9).

Figure 19

Fig 20. Final contoured provisional (after 2 modifications) (left) next to the custom impression coping (right), which is an exact replica of the transition zone (key Nos. 8 and 9).

Figure 20

Fig 21. Custom impression coping inserted in situ. This will be unscrewed and inserted into the impression after impressions are made (key No. 9).

Figure 21

Fig 22. Custom impression coping reinserted into the maxillary impression (key No. 9).

Figure 22

Fig 23. Duplicated transition zone on the laboratory model.

Figure 23

Fig 24. The provisional (top) is the “blueprint” for the final screwretained crown (bottom) (key No. 10).

Figure 24

Fig 25. Final case at 1-year post-surgery (key Nos. 1 through 10). The case design: gold-hue milled titanium abutment (ionized). The crown, a layered ceramic, porcelain-fused-to-milled zirconia, was a “screw-ment” design that was cemented to the abutment in the laboratory with self-curing resin-based cement (Newtech Dental Laboratories, ndlsmile.com; ceramists: Ruben Duany, MDT, and Amish Shah, MDT).

Figure 25

Fig 26. Partial occlusal view shows the convexity of the soft and hard tissues aided by the strict adherence to the 10 keys for excellent final esthetics.

Figure 26

Fig 27. Final smile at 1 year.

Figure 27

Fig 28. Final crown (palatal view) shows a screw-retained position (key No. 10). Teflon tape and composite resin were placed to occlude the screw-access hole.

Figure 28

Fig 29. Final periapical radiograph, No. 8 at 1 year. Note favorable bone healing and emergence profile of the final restoration aided by using the 10 keys for successful esthetic-zone immediate mplants. (Periodontist: Dr. Robert A. Levine, Philadelphia, PA; Prosthodontist: Dr. Harry Randel, Philadelphia, PA.)

Figure 29

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