“With modern biomaterials, such as cerabone® and collprotect®, bone augmentation is possible without the need for a second surgical site to harvest autologous bone. This reduces patient morbidity and surgical time, as well as eliminates the additional risks of a second surgery, which is more acceptable to the patient. In this case, the materials used led to unremarkable healing after the operation with no complications.”  Dr. Michael Erbshäuser

Initial situation

A patient (male, 51 years old, non-smoker, good general state of health and good oral hygiene) was seen at our dental clinic with a gap in position 22 in the anterior region. A removable interim prosthesis was used to replace this missing single tooth (Fig. 1). According to the patient, the tooth was removed approximately two years ago. A previous attempt to preserve tooth 22 with endodontics and subsequent apicectomy had failed due to complications apically. The patient’s goal was to have a fixed restoration at tooth position 22, without any need to prepare the neighbouring teeth to support a conventional tooth-borne bridge restoration. Hence it was agreed that an implant borne prosthetic restoration would be the preferred choice for this patient. Clinically, the neighbouring teeth in the anterior region were caries-free and not crowned. There was a secondary finding of aplasia of tooth 13 with complete space closure. The vestibular mucosal deficit in region 22 suggested that the presence of buccal bone atrophy. There was also low-grade vertical bone loss. Soft tissue conditions were unremarkable and wide keratinized gingiva was present. At the mucogingival junction, scar tissue from the previous apicectomy was seen (Figs. 2, 3).

Treatment planning

The preliminary radiographic examination with a two-dimensional OPG ( orthopantomogram ) provided information about the vertical bone loss in the crestal area and the interradicular conditions in region 22 (Fig. 4). For further clarification of the extent of horizontal bone atrophy, a DVT ( digital volume tomography ) was prepared. Tomography in the horizontal plane showed that a single-stage procedure consisting of implant placement and alveolar ridge augmentation is possible (Fig. 5). The study models and diagnostic wax-up were digitized and superimposed with the DVT. The coDiagnostiX™ planning software was used for 3D surgical planning for guided surgery (Figs. 6, 7). Starting from the position of the subsequent prosthetic restoration, a drill template was designed for safe and precise implant placement. The drill template was milled by CADCAM from a polyurethane blank in the on-site laboratory (Fig. 8).

Surgical procedure

Following local anaesthesia, an incision was made in the alveolar ridge combined with an intra-sulcular incision to region 11 and 23 with no relieving incision. A vestibular periosteal incision was made to mobilize the mucoperiosteal flap (Figs. 9, 10). The implant bed in region 22 was then prepared using the drill template (Fig. 11). Following insertion of a Straumann® Bone Level implant made of Roxolid® (∅ 3.3 mm, L 12 mm, SLActive® surface), there was a bony dehiscence exposing the implant surface on the vestibular side (Fig. 12). Guided bone regeneration was used to augment this buccal bone deficit. A mixture of cerabone® (1.0 ml; particle size 0.5 to 1.0 mm) and autologous bone harvested locally at the surgical site was applied to augment the labial bone (Figs. 13-15). The area was then covered using a collprotect® barrier membrane (15 × 20 mm) which was cut to fit the site (Fig. 16). The surgical area was closed in a tension-free manner, using monofilament suture material (Fig. 17)and a post-operative radiograph was taken immediately (Fig. 18). To avoid exerting pressure on the augmented area, the interim prosthesis was adjusted accordingly. The postoperative follow- up included an antibiotic (Clindamycin 600 mg, twice a day for five days), mouthwashes with a 0.2 % CHX solution (twice a day) and 600 mg Ibuprofen as needed. The sutures were removed after 14 days postoperatively (Fig. 19). After 6 weeks of healing without complication (Fig. 20), surgery was performed to expose the implant. A roll-flap technique was used to thicken the buccal soft tissue (Fig. 21). After developing an optimal emergence profile and achieving a stable mucosal condition, the final all-ceramic restoration was incorporated (Fig.22).

Conclusion/discussion

The 3D surgical planning (DVT, digital model data, digital workflow) using CADCAM procedures and the coDiagnostiX™ planning software ensures increased precision and predictability of results when placing implants. As in this case, this is particularly relevant in the aesthetic zone. Implantology provides an increasingly important role in providing convenience for the patient. With modern biomaterials, such as cerabone® and collprotect®, bone augmentation is possible without the need for a second surgical site to harvest autologous bone. This reduces patient morbidity and surgical time, as well as eliminates the additional risks of a second surgery, which is more acceptable to the patient. In this case, the materials used led to unremarkable healing after the operation with no complications. Selecting the right implant for use in the aesthetic zone is particularly challenging.

Thankfully, the Straumann® Bone Level Implant made of Roxolid® offers a suitable solution supported by good clinical data. Enhanced bone preservation, stability and aesthetic requirements are met, even with reduced diameter implants. The Straumann® SLActive® implant surface provides safe, more predictable and faster healing to allow the prosthetic restoration of the implant. In this case, the prosthetic restoration phase was started only six weeks after augmentation of the maxillary ridge and implant placement. This helps to reduce the time required by the patient to wear the removable temporary prosthesis. In many cases, we can manufacture a screw-retained monolithic crown by CADCAM at the chairside, on the day of treatment with an intraoral scanner. With such modern bone augmentation, implant and restorative techniques, we offer the patient exceptional convenience, short total treatment time and excellent results, which were unthinkable not too long ago.