The science of implantology has continued to evolve through the years and is one of the fastest-growing segments in our profession. The focus of implantology seems to have emerged from simply getting the implant in the bone to proper placement with bone grafts and, finally, to creating excellent long esthetics and function.
In other words, the days are gone when we try to place the implant and then make the esthetics and function work.
This article reviews a case in which a central incisor is extracted and an immediate implant is placed followed by an immediate temporary crown on the implant. The patient presented with a high smile line that displays the entire tooth when smiling, thereby creating the challenge.
Case prep
An iCAT scan was taken to evaluate the bone around the tooth prior to extraction and implant placement. From the diagnostic casts a stint was made to use for the provisional restoration.
Great care must be taken when extracting the tooth so that tissue architecture and interproximal papilla is preserved (Fig. 1).
An Astra Implant, 4.0 X 13 mm, was used in this case. After placement, a temporary abutment was placed and prepped outside of the mouth to the gingival margin. Luxatemp provisional material was used to fabricate the temporary crown.
The temporary crown was taken out of occlusion and the interproximal contacts were slightly opened. The crown was carefully polished so that no tissue irritation would occur (Fig. 2). This photo was taken immediately after the surgery and temporary placement.
After three months of integration, the temporary was removed and a fixture level impression taken, so an Atlantis Custom Anatomical Zirconium abutment could be fabricated. The temporary abutment and crown were then placed back in the mouth.
The impressions were sent to our lab technician, who then poured the model with the implant lab analog in place and sent it to Atlantis with the correct prescription. In this case, a zirconium anatomical abutment was prescribed with the facial margin prescribed for 1 mm subgingival and the lingual margin .75 subgingival.
Atlantis then sent the case back to our lab technician, who made the case ready to fabricate the crown. Photographs to assist with shade selection were also enclosed with the case. An Empress crown was then fabricated and the case returned to my office.
The Atlantis Abutment was tried in (Fig. 3). Note the excellent tissue contours and the width of the custom abutment (a discussion of custom abutments is below).
The crown was then placed and custom shaded. On most anterior cases, custom shading by painting the desired porcelain shades on the crown in the mouth and then re-firing the crown allows for subtle changes that can truly enhance the final outcome. After re-firing, the crown bonded into place.
Figure 4 exhibits the completed restoration at the time of cementation. Careful observation reveals an intact papilla, correct anatomic contours of the abutment, healthy and firm gingival tissues and an excellent shade, contour and glaze effect that blends with the natural dentition.
Discussion
• Implant type: There are distinct advantages to using bone level implants in the anterior area, especially with immediate extraction and placement cases. This allows for the use of custom abutments, which mimic the anatomy and shape of the natural tooth.
• Abutments: Many companies make custom abutments. Atlantis is an exceptional company that will work with your lab, and its work is outstanding. The company fabricates anatomical abutments to the correct shape and width of the tooth at the gingival margin. As indicated above, specifications to the placement of the margin enhances the health and esthetics of the crown. The use of custom abutments, such as Atlantis, is almost a “no-brainer” and the costs are similar to stock abutments of major implant companies.
• Soft tissue: Using the immediate extraction/implant placement/immediate provisionalization technique allows for the preservation of soft tissue and papilla architecture. Using a “plastic” temporary abutment that can be prepped allows for fabrication of a nicely contoured provisional crown that prevents the collapse and deterioration of these structures.
• Esthetics: The advent of custom zirconium abutments allows the use of all-ceramic crowns. Emax and Empress restorations are two systems that allow control of the translucency, glaze and custom shading.
Implant esthetics and use is on the rise as patients are more educated and savvy than in the past. This is an exciting time to be doing implants and restorative care. Patients like not using a flipper for the interim period. These techniques allow the dentist more predictable and successful restorative prosthetics.
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About the author
Ronald W. Konig, DDS, is a graduate of the University of Texas, Austin and Baylor College of Dentistry. He completed post-graduate training at LVI for advanced dental studies and is an alumnus at the LD Pankey Institute. He is a fellow at LVI for advance dental studies and a fellow of the Academy of General Dentistry; a member of The American Academy of Sleep Dentistry, The International College of Craniomandibular Orthopedics and The International Academy of Comprehensive Aesthetics. He maintains a private practice in the Houston Medical Center with special interests in TMJ, reconstructive and sleep dentistry.
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