Patient cases:

Single-unit restorations

(Maxilla)

Maxillary central incisor: Immediate implant placement and periodontal plastic surgery

Lead:

Armando Lopes Pereira

A 37-year-old female patient presented with a 5.0 mm periodontal pocket on the facial surface of the right central incisor with moderate periodontal inflammation. After a CBCT scan was performed, external root resorption was discovered on the facial surface which required tooth extraction. It was observed during the clinical examination that 3.0 mm of gingival recession was present on the facial aspect of the left central incisor.

The objective of the treatment was to replace #11 FDI (#8 US) using immediate implant placement and to perform root coverage of the #21 FDI (#9 US) using a connective tissue graft.

A NobelActive regular platform (RP) 3.5/13 implant was placed, with a temporary abutment. Geistlich Bio-Oss was placed in the gap between the implant and bone. The definitive restoration was fabricated using a Universal Base and 1.5 mm abutment height, a zirconia individualized abutment, and a lithium disilicate (IPS e.max) ceramic crown.

Evaluation & Diagnosis

Note the slight periodontal inflammation on tooth #11 FDI (#8 US) and gingival recession on tooth #21 FDI (#9 US).

Occlusal intra-oral view. Note a correct buccal contour.

CBCT scan showing the external root resorption.

Treatment Planning

Progress & Completion

Frontal view of minimally invasive extraction with delicate forceps.

After extraction socket. Note the soft tissue preservation obtained after minimally invasive extraction.

After NobelActive regular platform (RP) drilling protocol, we see the final implant position a little buccally.

NobelActive System is the solution for fresh extraction socket.

Placement of NobelActive Implant (RP 3.5/13). Note aggressive design of threads that potencialize the chance for immediate loading.

NobelActive in position. Note the palatal position and the apical position was 4 mm below gingival margin. Note the the jumping gap was filled with anorganic bovine bone substitute and a connective tissue graft was stabilised in buccal aspect to increase gingival biotype and to cover the root exposed on the #21 FDI (#9 US).

The temporary anti-rotacional abutment was covered with opaque composite to mask the greyish appearance.

The crown resected from the original tooth was use as temporary implant supported crown. Note the subcritical concave contour.

Provisional crown in place and soft tissue stabilized with double crossed suture. Note the root coverage on #21 FDI (#9 US).

After 3 months, emergency profile post surgery. Note the volume on the #11 FDI (#8 US) at same level of #21 FDI (#9 US).

Full Implant and hard/soft tissue argumentation procedure can be seen step by step in this video.

Follow-Up & Outcome

Final restoration ready for delivery. Universal Base (1.5mm height) with zirconia abutment and lithium disilicate (IPS e.max) ceramic crown.

Universal base and Zirconia abutment try-in.

Final restoration in position after cementation. Note the correct gingival harmony and the complete root coverage of #21 FDI (#9 US).

Radiographic follow-up of 8 months after surgery. Note that there was no bone loss.

Intraoral view of final restoration after 1 year follow-up.

Questions

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asked by Nic kamosi

Justification of the the Extraction

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Comments: 1. The Implant Platform diameter discrepancy corresponding to the 11 root diameter at ECJ! 2. Lack of LCPPA radiograph before and after and follow-up! 3, Simultaneous correction of the recession of the adjacent tooth 21! 4. Extreme vicinity Prov. rest. margin to the Implant-abutment interface or Bone margin violating the Biological width! 5. Lack of GBR technique in the presence of Straumann bone Ceramic (membrane?)! 6. ..............

Armando Lopes Pereira

08.10.2019 | 14:53

Hello Nic, regarding to your topics. Extraction: large resorption with some crestal bone loss and no predictability to any treatment to stop that. The endodontist that indicated the extraction. 1. As we place immediate implants in the aesthetic zone especially, we should leave at least a minimum of 2 mm of buccal gap, that was the motive to install the NP Nobel Active. 2. please explain me LCPPA. WE have a short follow up until now, but I will send here the latest as soon as I have it. 4.The biological width was intact, as the implant was 4mm above buccal mucosa margin. and you can see in X-ray that there was only bone remodelling at the follow up and no bone loss. 5. In our practice, when the buccal plate of the extraction socket is from 3 to 5 mm from de gingival margin after tooth extraction, we just fill the Gap after implant insertion. No need of membrane in this case. I hope was able to help

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asked by Amal Nawasrah

If there was no primary stability, how to manage please?

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Anonymous

24.09.2019 | 18:10

Note the direction of the force direction indicator heading medial to nasopalitine bone

Armando Lopes Pereira

08.10.2019 | 14:35

Hello Amal, using Nobel Active is pretty difficult to have no primary stability, but if there was the case, we would remove the implant e fill all the extraction socket with bovine bone, and cloys with the CTG.

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asked by Anonymous

How did you evaluate grafted site after healing time?

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Armando Lopes Pereira

08.10.2019 | 14:55

We did it clinically as you can see 1 year after, and we asked for CBCT to the patient who didn't find some time to do it.

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asked by Anonymous

extraction can be avoided

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extraction cannot be justified. i feel tooth can be saved. lot of options available for saving teeth

Ramzi Althubaitiy

22.09.2019 | 22:05

Given the relatively large size of root resorption, how would you predictably save the tooth without the of risk of delayed intervention and then jeopardising the relatively intact buccal plate of bone with possible further bone resorption?

Armando Lopes Pereira

08.10.2019 | 14:38

Agree with Ramzi, the extension of the resorption and the begging of buccal bone loss was the main issues that de Endodontist indicated the extraction.

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asked by Mandar Bhosekar

Was an Endo opinion taken before extracting the tooth?? To avoid medico legal scenario.....

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Armando Lopes Pereira

08.10.2019 | 14:57

sure, the Endodontist that referred to me to do the extraction and implant

Team members

Armando Lopes Pereira

Periodontist

Favio Alves

Prosthodontist

Diego Miranda

Dental technician

Maxillary central incisor: Immediate implant placement and periodontal plastic surgery

Evaluation & Diagnosis

Treatment Planning

Progress & Completion

Follow-Up & Outcome

Questions

Justification of the the Extraction

If there was no primary stability, how to manage please?

How did you evaluate grafted site after healing time?

extraction can be avoided

Was an Endo opinion taken before extracting the tooth?? To avoid medico legal scenario.....

Related Publications

Team members