By using the accurate gingival contours from the impression, the margin was placed approximately 1 mm subgingivally; this would allow excellent esthetics and ease of resin cleaning during seating and bonding of the crown.
Patient’s teeth were bleached with Zoom2 Whitening System (Philips Oral Healthcare, www.philipsoralhealtcare.com) and shade selection was made few days later.
Three weeks later, the custom-made zirconia abutment was tried onto the implant fixture and a radiograph was taken to confirm complete seating of the abutment. The abutment screw was torqued down to 32 Ncm with a torque driver. Tooth No. 9 was prepared for a veneer (Figure 5) and an impression was taken for the No. 9 veneer and the No. 8 crown. The stump shade was recorded with a digital photograph for the laboratory. Provisional restorations were fabricated in a clear matrix material. The provisionals were trimmed, polished, and cemented.
A detailed prescription including a shade map, specification of crown form and length, surface texture, and incisal edge treatment was sent to the laboratory along with preoperative photographs, photographs of the preparations and provisionals, and the impressions and models. A wash bake of dentine was added onto the high value coping until the shade of the coping was identical to that of the stump shade of the prepared veneer of tooth No. 9 (Figure 6), then the Lava Zirconia crown for tooth No. 8 and the feldspathic veneer for tooth No. 9 were layered simultaneously to mimic each other.11
At the seating appointment, the completed restorations were evaluated for fit, color, and contour, and the restorations were shown to the patient for approval.
Some shade-matching challenges were anticipated because of the pure opaque white nature of the zirconia abutment. When dissimilar restorative materials are used, it is important to establish similar values before any addition of chroma is made. Excellent communication with the laboratory will facilitate the pursuit of an excellent treatment outcome.
The veneer was bonded to tooth No.9 and the Lava Zirconia crown was assessed for shade match with the bonded veneer. Additional staining was applied, and the crown was reglazed in the porcelain oven. The crown was then temporarily cemented into place. The patient was evaluated for occlusal contact in the centric, protrusive, and lateral excursive movements to ensure no contact was present at the implant site, and the restorations were polished.
The patient returned 4 weeks later for reassessment of the No. 8 crown for stability of the gingival margin position; it appeared unchanged. The crown was then removed and recemented with Rely-X™ Unicem resin cement (3M ESPE) and a post-treatment digital radiograph was taken (Figure 7). Two weeks later, examination revealed no functional or esthetic problems. The postoperative photograph was taken at this time (Figure 8). Note the perfect matching between the final restorations and the natural dentition.
Slight mucosal asymmetry of Nos.8 and 9 was still observed after final treatment. This could be due to the facial remodeling that occurs even with the flapless extraction approach.12 Another reason could be the use of a temporary abutment after immediate implant placement. It is recommended to insert the final implant abutment as soon as possible after implant placement, preferably on the same day. This will avoid repetitive mutilation of the fragile peri-implant soft tissue collar, which compromises the mucosal barrier and results in a more “apically” positioned zone of connective tissue, thus leading to marginal bone resorption.13
A more predictable esthetic outcome could have been achieved in this case by using a smaller implant (4.3 mm instead of 5.0 mm); by using platform-switched abutments, which causes significantly less crestal bone resorption;14 or by placing a connective tissue graft at the time of immediate placement.15
Immediate placement and provisionalization of anterior single implants is a viable and predictable treatment option for single-tooth replacement in the esthetic zone; however, careful patient selection and treatment planning are still as important as the treatment itself. The treatment outcome in this presentation exceeded the patient’s expectations in creating an esthetic, bio-acceptable restoration.
About the Author
Emil Hawary, DDS, FAACD, FAGD, DICOI
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