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Inside Dentistry
January 2021
Volume 17, Issue 1
Peer-Reviewed

Lateral Incisor Replacement Following Failed Endodontics

Two-piece ceramic implant system provides esthetic, screw-retained solution

Paresh Patel, DDS | Apolinar Madrigal, DDS

With ceramic dental implants offering a metal-free, esthetically white option, clinicians may want to investigate incorporating them into their implant practices. Although ceramic implants have historically had a one-piece design, improvements in the technology used to fabricate them have resulted in the development of two-piece ceramic implant/abutment systems. With this advancement, ceramic implants can now be restored following a traditional implant workflow and even facilitate screw retention of the ceramic abutment to the fixture using a carbon fiber screw.

A 36-year-old female patient presented with a maxillary right lateral incisor that had previously received root canal therapy, but the treatment was failing. Endodontic re-treatment was planned; however, during the re-treatment appointment, a vertical fracture was identified as the cause of failure. The patient was then offered the option of having her tooth restored with an implant, and she accepted with some concerns.

Having worked in the dental field many years prior, the patient was very self-conscious about her teeth and feared that others would notice that the new restoration was not her natural tooth. She wanted something that would offer the best long-term potential for maximum esthetics as well as no hint of gray shine from the implant through the tissue. After a thorough analysis based on clinical photography and videography as well as cone-beam computed tomography, the principal aspects of the case that would pose a challenge were identified. The patient had a high lip line, even with a relaxed smile. This, combined with a thin gingival biotype, made the transition between the restoration and the soft tissue perhaps the most critical aspect of the treatment.

With these factors in mind, the decision was made to restore the patient using a two-piece zircona implant system. This system would permit the use of a reduced diameter implant (3.5 mm) as part of the screw-retained solution. Although a metal-free option was not one of the top priorities of the patient, she did see the value in that, long-term, there would be no chance of issues related to corrosion.

About the Author

Paresh Patel, DDS
Clinical Instructor
Reconstructive Dentistry Institute
Private Practice
Lenoir, North Carolina

Apolinar Madrigal, DDS
Private Practice
Ceres, California

Preoperative radiograph demonstrating previous endodontic treatment that was failing.

Fig. 1

Removal of fractured root was facilitated with an ultrasonic bone cutting system (Piezomed, W&H) and standard forceps.

Fig. 2

The extraction site was initially prepared using a round carbide

Fig. 3

Confirmation of the initial osteotomy was accomplished using a small parallel pin and verified with an intraoral radiograph.

Fig. 4

The final shaping of the osteotomy was performed with a carbon-coated shaping drill.

Fig. 5

Once the shaping was complete, a 3.5 x 12 mm zirconia implant (Zeramex® XT, Zeramex) was immediately placed into the osteotomy site and torqued to initial stability.

Fig. 6

Patient-derived leukocyte- and platelet-rich fibrin (L-PRF) and a natural bone substitute (Geistlich Bio-Oss®, Geistlich Pharma) were prepared to help support the hard and soft tissues during healing.

Fig. 7

Occlusal view of the ceramic implant properly positioned in the osteotomy site, demonstrating the 2 mm of required space on the buccal aspect.

Fig. 8

Insertion of the grafting material into the 2 mm of buccal space.

Fig. 9

Occlusal view of the ceramic implant with a flat polyether ether ketone (PEEK) healing cap inserted into its internal aspect and the grafting material in place.

Fig. 10

A PEEK temporary cylinder was attached to the ceramic implant to facilitate the chairside creation of an immediate temporary restoration.

Fig. 11

Chairside temporary crown created on the PEEK cylinder with proper curvature for maximum tissue support and growth.

Fig. 12

A 2-week postoperative image of the temporary restoration in place, demonstrating healthy and well-supported papillae around the ceramic implant.

Fig. 13

Postoperative image of the final screw retained ceramic restoration, which was fabricated on a stock 1-mm cuff height zirconia abutment.

Fig. 14

Radiographic confirmation of the positive seat of the two-piece zirconia implant/abutment system with the carbon fiber screw.

Fig. 15

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