Immediate Implant Placement After Extraction and Single Crown on a CAD/CAM Abutment
A Case Study
Bernard Touati, DDS, MS
A 45-year-old male patient presented with unaesthetic anterior restorations. Following comprehensive clinical and radiographic examination and removal of the existing crown restoration, root decay and a root fracture were observed. The treatment plan consisted of extracting the left central incisor and immediately placing a single implant into the site.
First, the adjacent teeth were prepared, and a three-unit provisional bridge was fabricated to temporize the case after implant placement. The thick biotype and positive gingival architecture of the patient were favorable factors for this type of treatment (Figures 1-2-3).
At time of surgery, a flapless, atraumatic extraction was performed. Flapless surgery was used whenever possible to preserve the vascularization of the buccal plate (Figure 4). After three-dimensional bone probing and evaluation, a 4.3-diameter implant was inserted in the palatal bony wall of the alveolus, avoiding any contact with the buccal plate. This placement resulted in a 15-degree buccal angulation, which had to be managed at the prosthetic stage. Any contact between the implant and the buccal bone at this stage could have resulted in buccal bone resorption and eventual soft tissue recession on the buccal aspect. A large healing abutment was secured, and the gap between the implant and the buccal bone was filled with a mixture of autologous bone, xenograft, and tetracycline. The interdental papillae were secured with sutures to allow their tight approximation against the healing abutments (Figures 5 and 6).
At that time, the provisional bridge was cemented and the tissues were allowed to heal (Figure 7). After 12 weeks, the provisional bridge was removed for soft tissue evaluation. Only minimal loss of vertical soft tissue height was observed, and the buccal contour was maintained. At this stage, final impressions were taken (Figure 8). In the laboratory, a waxup was created and used for the CAD/CAM fabrication of a zirconia abutment. This customized, functionally designed abutment allowed the clinicians to optimize the prosthetic components and the aesthetic outcome (Figures 9-10-11).
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The implant restoration, fabricated of zirconia, had excellent physical properties (eg, flexural strength) and was seamlessly integrated with the zirconia crowns placed on the adjacent natural teeth. The definitive restoration had a concave transitional subgingival profile on the abutment that would provide soft tissue stability and thickness and consequently soft tissue integration (Figures 12-13-14).