Surgical and Prosthetic Treatment of a Failed Maxillary Central Incisor
Immediate implant placement is a key to success
Robert A. Levine, DDS, FCPP, FISPPS
An esthetic zone implant restoration can be a complex, technique-sensitive procedure that frequently requires a collaborative effort. The case presented demonstrates immediate placement of a Bone Level Tapered (BLT) Roxolid® SLActive® implant (Straumann, www.straumann.us) to replace a maxillary central incisor. In addition to comprehensive case planning, the case entailed the use of an anatomically correct surgical guide, hard- (bone grafting of the buccal gap) and soft-tissue grafting (palatal connective tissue graft), and soft-tissue sculpting in the provisional phase.
A healthy 26-year-old, non-smoking man (ASA 1) presented in November 2014 complaining chiefly of discomfort apically in the area of tooth No. 8, which had a prior root canal treatment resulting from a traumatic event to the face (Figure 1 through Figure 3). A full-mouth periodontal examination revealed minimal to no bleeding on probing depths greater than 3 mm. The patient was aware that No. 8 was hopeless due to a chronic periapical lesion and was interested in permanent tooth replacement. He presented with high esthetic expectations, a medium lip line and gingival biotype, and slightly triangular-shaped maxillary anterior teeth (Table 1).1-4
The comprehensive team treatment plan discussed with the patient was based on clinical and radiographic (including maxillary CT scans)5 examinations and comprised of several components. First, mounted study models were used with final restoration consultation among the author and restorative dentist for an anatomically correct maxillary surgical guide and a transitional Essix appliance for replacement of tooth No. 8. Then, surgical extraction of No. 8 would occur with evaluation for either immediate implant placement with hard- and soft-tissue reconstruction or ridge preservation with implant placement delayed for 3 to 4 months. The decision would be made after tooth extraction and 3-dimensional (3D) evaluation of the socket after full debridement of the apical lesion as well as insertion torque values.
Then, a screw-retained provisional for No. 8 would sculpt soft tissues and act as the “blueprint” for the final restoration. The patient would wear the provisional for 6 to 8 weeks, at which time the clinicians would reevaluate it for any modifications needed. Finally, upon establishing favorable soft-tissue scalloping and contours, a single crown would be completed for No. 8.
Treatment of Site No. 8 With Bone-Level Tapered Implant
The patient was medicated prior to surgery with amoxicillin, NSAIDs, and a chlorhexidine rinse. Tooth No. 8 was extracted using a flapless approach. The periapical lesion was debrided and removed separately and sent out for oral pathology evaluation. The diagnosis was confirmed as a periapical granuloma and abscess. The socket was sterilized using the ablation setting on the PerioLase® MVP-7™ laser (Millennium Dental Technologies, Inc., www.lanap.com) after vigorous use of the Piezosurgery® device (OT4 insert) (Piezosurgery Inc., www.piezosurgery.us).
The goal was to place the implant immediately, if possible. Site preparation was done with Straumann twist drills and completed using an index finger for tactile sense along the buccal plate of bone to confirm no buccal vibration or fenestration. All socket walls were intact except the most apical buccal wall where the abscess was removed, resulting in a fenestration without a fistula. A Straumann BLT Roxolid SLActive 4.1-mm x 14-mm implant was installed using the rules for 3D placement per the ITI Treatment Guide, Volume 1.1 This was done with the aid of the anatomically correct surgical guide template—placement was along the palatal wall and in an apical position of 4 mm below the mid-facial position of the surgical guide (Figure 4). Because the coronal buccal wall was totally intact and soft tissue measured 3 mm mid-buccal, the position of the buccal implant shoulder was 1 mm deeper than the buccal height of the bone (Figure 5).
The insertion torque value of the implant was approximately 25 Ncm as it was hand-tightened to final seating. A 2-mm buccal gap was packed tightly with anorganic bovine bone (BioOss®, Geistlich Biomaterials, www.geistlich-na.com), which had been previously soaked for 10 minutes in platelet-derived growth factor (Gem-21S®, Osteohealth, www.osteohealth.com) to aid in both soft- and hard-tissue healing.
A palatal soft-tissue connective tissue graft (CTG) was harvested from the Nos. 4 and 5 site. The CTG was placed and sutured under the partially elevated buccal flap from the mesiobuccal to distobuccal line angles and, apically, approximately 10 mm to further aid in long-term soft-tissue contours. This was done to mimic the root eminence of the extracted tooth and to act as a membrane to aid in guided bone regeneration of the buccal gap (Figure 6). In addition, the CTG changed the periodontal biotype from medium to thick (ie, biotype conversion).6-8 A 7-mm tapered RC healing cap (Straumann) was placed to lightly support the soft-tissue graft and beveled to the level of the palatal tissues to prevent transmucosal loading by the tongue (Figure 6).
The dental laser was then used on the palatal incisions (hemostasis setting) to aid in bleeding control and postoperative comfort for the patient. The Essix appliance was relieved to avoid placing pressure on the surgical site. Postoperative plaque control measures were reviewed with the patient. They included normal brushing and flossing in all areas except site No. 8, where a cotton swab dipped in chlorhexidine rinse would be used to locally clean the site. The patient was also instructed to rinse with chlorhexidine twice daily until it was used completely and to finish his other medications as prescribed.