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Inside Dentistry
June 2016
Volume 12, Issue 6

Postsurgical Follow-Up

Healing of the surgical site was uneventful, and the patient was seen at 2 weeks, 5 weeks, and 12 weeks postsurgery. A periapical x-ray was taken at 12 weeks, and a reverse torque test at 35 Ncm was completed using the manufacturer’s torque driver and RC implant carrier device to confirm bone healing. The patient was jointly scheduled with the restorative dentist for impressions to fabricate a laboratory-made screw-retained provisional restoration using the indirect method.

The patient was seen in the author’s office 3 weeks after placement of the provisional to evaluate soft-tissue healing and tissue support and for a periapical x-ray (Figure 7). Based on clinical healing and the gingival margin being slightly apical for the No. 8 implant compared to the No. 9 natural tooth, further mid-buccal support with acrylic was recommended. The adjacent papillae were healing as expected and the patient was pleased with the results at that point.9

The case was completed using the custom impression coping technique of duplication of the transitional subgingival zone for the laboratory.1,10 Because the screw-access hole in the provisional was near the palatal incisal edge, a custom abutment (with 1-mm subgingival margins circumferentially) was fabricated, and the final crown was cemented with zinc phosphate cement using the copy abutment teflon-tape technique. This technique was employed to prevent subgingival cement remnants.11

Photographs and x-rays of the final case were taken in the author’s office a few weeks after completion. The clinical examination revealed healthy soft tissues and excellent buccal contours mimicking the adjacent natural tooth (Figure 8 through Figure 11). The patient will continue periodontal maintenance visits twice yearly with his restorative dentist and annual examinations under the author’s care for 5 years to document soft- and hard-tissue healing.


Treatment of an esthetic zone case was successfully completed using a team approach that maximized the collaborating practitioners’ combined knowledge for the benefit of the patient.1,2,4,10 The use of the Straumann BLT Roxolid SLActive implant for immediate placement helped in the anatomical management of the central incisor site, where both the nasopalatine foramen and the normal anatomical buccal undercut can be problematic. Comprehensive case planning, the use of an anatomically correct surgical guide, evidenced-based materials—including hard- and soft-tissue grafting—along with taking the necessary time to sculpt the soft tissues in the provisional phase, are all vital to achieving a successful outcome. Because esthetic zone implant placement, as described in this case report, is a complex SAC (Straightforward, Advanced, Complex) procedure,12 surgical know-how and knowledge of the literature in this technique-sensitive area is necessary for the clinician to achieve consistently successful results, and, consequently, happy patients.


The author would like to thank George Segel, DMD, for conducting restorative therapy in the case discussed and NewTech Dental Laboratories, Inc. for its laboratory work. Dr. George Segel practices in Newtown, Pennsylvania and NewTech Dental Lab is located in Lansdale, Pennsylvania.


Robert A. Levine, DDS, FCPP, FISPPS, is a consultant for Straumann and Piezosurgery. He has received honorariums from ITI, Straumann, and Piezosurgery.


1. Buser D, Belser U, Wismeijer D, eds. ITI Treatment Guide, Vol 1: Implant Therapy in the Esthetic Zone for Single-Tooth Replacements. Berlin, Germany: Quintessence Publishing; 2007.

2. Levine RA, Nack G. Team treatment planning for the replacement of esthetic zone teeth with dental implants. Compend Contin Educ Dent. 2011;32 (4):44-50.

3. Morton D, Chen ST, Martin WC, Levine RA, Buser D. Consensus statements and recommended clinical procedures regarding optimizing esthetic outcomes in implant dentistry. Int J Oral Maxillofac Implants. 2014;29 (suppl):216-220.

4. Levine RA, Huynh-Ba G, Cochran DL. Soft tissue augmentation procedures for mucogingival defects in esthetic sites. Int J Oral Maxillofac Implants. 2014;29 (suppl):155-185.

5. Bornstein MM, Balsiger R, Sendi P, von Arx T. Morphology of the nasopalatine canal and dental implant surgery: a radiographic analysis of 100 consecutive patients using limited cone-beam computed tomography. Clin Oral Implants Res. 2011;22(3):295-301.

6. Kan JY, Rungcharassaeng K, Morimoto T, Lozada J. Facial gingival tissue stability after connective tissue graft with single immediate tooth replacement in the esthetic zone: consecutive case report. J Oral Maxillofac Surg. 2009;67(11 suppl):40-48.

7. Grunder U, Gracis S, Capelli M. Influence of the 3-D bone-to-implant relationship on esthetics. Int J Periodontics Restorative Dent. 2005;25(2):113-119.

8. Yoshino S, Kan JY, Rungcharassaeng K, et al. Effects of connective tissue grafting on the facial gingival level following single immediate implant placement and provisionalization in the esthetic zone: a 1-year randomized controlled prospective study. Int J Oral Maxillofac Implants. 2014;29(2):432-440.

9. Ross SB, Pette GA, Parker WB, Hardigan P. Gingival margin changes in maxillary anterior sites after single immediate implant placement and provisionalization: a 5-year retrospective study of 47 patients. Int J Oral Maxillofac Implants. 2014;29(1):127-134.

10. Levine RA, Manji A, Faucher J, Present S. Use of titanium mesh in implant site development for restorative-driven implant placement: case report. Part 1—restorative protocol for single-tooth esthetic zone sites. Compend Contin Educ Dent. 2014;35(4):264-273.

11. Present S, Levine RA. Techniques to avoid cement around implant-retained restorations. Compend Contin Educ Dent. 2013;34(6):432-437.

12. Dawson A, Chen S. The SAC Classification in Implant Dentistry. Berlin, Germany: Quintessence Publishing; 2009.

For more information, contact:

About the Author

Robert A. Levine, DDS, FCPP, FISPPS
Clinical Professor
Department of Periodontology and Oral Implantology
Kornberg School of Dentistry, Temple University
Philadelphia, Pennsylvania
Private Practice
Pennsylvania Center for Dental Implants & Periodontics
Philadelphia, Pennsylvania

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