Aesthetic Restoration of an Immediate Implant

Replacement of missing teeth in aesthetically sensitive areas is important to most patients, yet can be quite challenging.1 Dental implants have become a dependable and well-documented means of replacing missing teeth.2 The following case report of a patient with an unsalvageable upper central incisor details its replacement via immediate implant placement with concomitant preservation of acceptable aesthetics throughout treatment.

CASE REPORT

Figure 1. Patient presents with complaint of a “lump” at tooth No. 9.	Figure 2. Radiograph reveals root resorption.
Figure 3. A root form implant is placed into the socket with bone grafting.	Figure 4. A provisional abutment is connected to the implant.

A 51-year-old nonsmoking female, who was a longstanding patient in the author’s practice and had no medical complications, presented complaining of a “lump” at tooth No. 9 (Figure 1). Palatal edema was noted apically at this tooth, which had a prior history of trauma followed by conventional endodontic treatment and a subsequent apicoectomy. A radiograph (Figure 2) revealed root resorption, and the patient was referred for an endodontic evaluation that determined the tooth was hopeless. The author then discussed post-extraction options with the patient: a removable or fixed partial denture, implant placement, or no treatment at all. The patient elected implant placement with immediate sequencing.
The author then referred the patient to an oral surgeon for implant consultation, who found no contraindications to extraction with immediate implant insertion. Next, a treatment plan was developed and coordinated with the oral surgeon’s office. The patient would leave that office directly after the surgery and travel to the author’s office for provisionalization of the immediate implant. After completion of healing, the author would definitively restore the implant.
On the day of surgery, the oral surgeon extracted tooth No. 9 as atraumatically as possible and placed a root form implant (Replace Select [Nobel Biocare]) into the socket (Figure 3) with bone grafting. He also connected a provisional abutment (Figure 4) to the implant and sent the patient to the author’s office with the extracted tooth.

Figure 5. A sleeve is passively secured within the sectioned clinical crown.

When the patient arrived, the author sectioned the natural crown from its root, prepared it to receive a sleeve (Replace Select) fitted for the provisional abutment (Replace Select), and passively secured the sleeve within the sectioned clinical crown using methyl-methacrylate acrylic (Jet [Lang Dental Manufacturing]; Figure 5).

The modified natural crown was luted to the provisional abutment with eugenol cement (Caulk IRM [DENTSPLY]), with the intention of leaving it undisturbed for at least 3 months, during which time it would serve as the immediate interim prosthesis for the healing phase of treatment.³ Occlusion was adjusted to prevent contact in excursive movements or maximum inter-cuspation.⁴ Provisionalizing the immediate implant in this way conveniently restored and preserved the pre-surgical contours of the implant site’s soft-tissue architecture while minimizing the possibility of any discrepancies that even the most carefully fabricated laboratory provisional might introduce. Restoration of the original soft-tissue contour from the minimal discrepancies introduced during surgery occurred in less than a week and ensured an aesthetic gingival framework for the definitive crown (Figures 6 and 7).
The oral surgeon confirmed osseointegration 4 months later, waiting longer than he normally would have due to the resorptive lesion involved. Root resorption is an indication for immediate implant placement,^5,6 and such placement can be successful at chronically infected sites if certain preoperative and postoperative steps are carefully followed.7 There was an additional delay of several weeks thereafter due to an illness in the patient’s family before the author could appoint her to complete restorative treatment. At that time the peri-implant gingival contours were essentially unchanged from their presurgical configuration (Figure 8).
The author then definitively finished the case according to the alternative method for restoring single-tooth implants.8 First, a transfer pin (Replace Select) impression was taken after removal of the provisional abutment and natural provisional crown. The provisional abutment and natural provisional crown were reinserted, and a definitive abutment was prepared using the transfer impression.

Figure 8. Peri-implant gingival contours are essentially unchanged.	Figure 9. Laboratory-fabricated provisional is inserted.

Figure 10. Definitive restoration cemented in place.

The prepared definitive abutment (Replace Select) was sent to the dental laboratory for fabrication of a processed provisional crown (BioTemps [BioTemps Dental Laboratory]).
At the patient’s next visit the provisional abutment and natural provisional crown were removed, and the prepared definitive abutment was torqued in place. A final impression for the definitive crown was taken before inserting the laboratory-fabricated provisional with normal occlusal contacts for implant function (Figure 9).⁹
Three weeks later the definitive unit (Captek [Precious Chemicals Company]) was uneventfully cemented in place (Figure 10) with Rely X Luting Cement (3M ESPE) after removal of the laboratory-processed provisional crown. The patient expressed satisfaction with the aesthetics of the final result as well as with those of the entire treatment course, remarking only that the natural crown provisional had darkened slightly by the 5-month point. Again, occlusal contacts were established for normal implant function, as they had been with the laboratory-processed unit.
Natural gingival profiles with crowns on single-tooth implants in long edentulous sites can be difficult to achieve.¹⁰ When contemplating extraction with concurrent immediate implant placement, one can realize a singular advantage in preserving and maintaining the original gingival form when employing appropriate provisionalization¹¹ that can provide suitable preloading for the definitive crown.¹² Implant restorative protocols should be as similar to conventional prosthodontics as possible. In this case, from the date of extraction to the seating of the definitive crown, the patient retained acceptable aesthetics while regaining her original form and function. The author did this in 4 visits without any dental laboratory procedures other than those ordinarily used in standard crown and bridge cases, making this technique one that any restorative dentist can master, and most dental patients will truly appreciate.

References

1. Oosterhaven SP, Westert GP, Schaub RM. Perception and significance of dental appearance: the case of missing teeth. Community Dent Oral Epidemiol. 1989;17:123-126.
2. Scholander S. A retrospective evaluation of 259 single-tooth replacements by the use of Branemark implants. Int J Prosthodont. 1999;12:483-491.
3. Misch CM. The extracted tooth pontic: provisional replacement during bone graft and implant healing. Pract Periodontics Aesthet Dent. 1998;10:711-718.
4. Malo P, Friberg B, Polizzi G, et al. Immediate and early function of Branemark System implants placed in the esthetic zone: a 1-year prospective clinical multicenter study. Clin Implant Dent Relat Res. 2003;5(suppl 1):37-46.
5. Becker W. Immediate implant placement: diagnosis, treatment planning and treatment steps for successful outcomes. J Calif Dent Assoc. 2005;33:303-310.
6. Becker W, Becker BE, Hujoel P. Retrospective case series analysis of the factors determining immediate implant placement. Compend Contin Educ Dent. 2000;21:805-820.
7. Novaes Junior AB, Novaes AB. Immediate implants placed into infected sites: a clinical report. Int J Oral Maxillofac Implants. 1995;10:609-613.
8. McArdle BF, Clarizio LF. An alternative method for restoring single-tooth implants. J Am Dent Assoc. 2001;132:1269-1273.
9. Jackson BJ. Occlusal principles and clinical applications for endosseous implants. J Oral Implantol. 2003;29(5):230-234 [published correction appears in J Oral Implantol. 2003;29(6):314].
10. Belser UC, Schmid B, Higginbottom F, et al. Outcome analysis of implant restorations located in the anterior maxilla: a review of the recent literature. Int J Oral Maxillofac Implants. 2004;19(suppl):30-42.
11. Kan JY, Rungcharassaeng K. Immediate placement and provisionalization of maxillary anterior single implants: a surgical and prosthodontic rationale. Pract Periodontics Aesthet Dent. 2000;12:817-824.
12. Rotter BE, Blackwell R, Dalton G. Testing progressive loading of en-dosteal implants with the Periotest: a pilot study. Implant Dent. 1996;5:28-32.

Dr. McArdle graduated from Tufts University School of Dental Medicine in 1985 and has been practicing general dentistry on the New Hampshire seacoast ever since. He has served on the active medical staff in dentistry of Concord Hospital in Con-cord, NH, and on the board of directors of Priority Dental Health (prioritydental.com), the New Hampshire Dental Society’s Direct Reimbursement entity. He is a co-founder of the Seacoast Esthetic Dentistry Association (dentalesthetics.com), which is headquartered in Ports-mouth, NH. He is the founder of Seacoast Dental Seminars (seacoastdentalseminars.com), also head-quartered in Portsmouth. He has authored numerous other articles both nationally and internationally in major peer-reviewed publications. He can be reached at (603) 430-1010, drmcardle@seacoastdentalseminars.com, seda@dentalesthetics.com, or by visiting mcardledmd.com.