Initial Situation

Thirty-nine-year-old male patient, with no smoking habits, general good health condition presented to the office with the main complaint of a fractured upper first premolar.  During intraoral observation it was possible to remove the crown by hand and observe severe secondary caries on the remaining root which could have the cause of the fracture (Fig. 1, 2). Cone Beam Computed tomography scan (CBCT) confirmed the initial observations the tooth was lost due to severe caries and low amount of retentive surface to maintain the crown in place. (Fig. 3)

Treatment Planning

The CBCT scan evaluation was decisive to diagnose the tooth as hopeless. Different treatment options were presented to the patient who chose the option of tooth extraction and immediate implant placement with immediate provisional crown.  This way his social and professional activities would not be compromised after the surgical intervation, which it would be the case if conventional workflow would have been chosen.

Even though it was not meant to use a restrictive surgical guide, Intra oral scanning was performed in order to initiate the production of a tridimensional surgical reference guide, as well as to transmit the necessary information to the dental laboratory to produce the hollow temporary crown ahead of time for the surgery. The implant of choice was the new Straumann(r) TLX with the diameter of ø 3.75 x 12mm length meant to be placed in flapless approach immediately after the extraction and an immediate provisional crown delivered after the implant placement.   After a period of 3 months a full zirconia crown was planned to finalize the case.

Surgical Procedures

Under local anaesthesia, the extraction of tooth #14 was performed by dissecting the roots int two parts  in the medio-distal direction using a diamond bur. Gentle movements were applied using micro elevators to remove each part individually preserving alveolar bone and surrounding soft tissues(Fig. 4, 5, 6).

   The Implant bed preparation started with the reference guide in position for three-dimensional confirmation and the use of ø2,2 mm drill in full length (12mm)(Fig. 7, 8). The second drill (ø 2,8 mm) was used free-hand and only 4 mm in length was prepared.  A ø3,75 mm x 12 mm  Straumann® TLX implant was placed 2,5 mm deeper in relation to the most apical (buccal) gingival margin reference point with primary stability of 28N/cm when it reached its optimal final position(Fig. 9, 10, 11). To avoid compression of implant shoulder towards the socket walls, a bone profile pin was attached to the implant and surrounding bone was removed with bone profile drill.

Temporary abutment was attached to the implant and an acrylic crown was used to pick up the abutment with the “back-fill” technique using light curing composite. Additional composite was applied to the base of the crown following proper emerging profile requirements and then polished (Fig. 12, 13). The temporary crown was checked for interproximal contact points and left out of occlusion (Fig. 14). Before final seating of the temporary crown, the gap between implant and buccal bone wall was filled with allogenic bone material (Maxgraft®, Botiss®, Germany).  After a month, the patient returned to the office for sinus grafting procedure and implant placement on tooth #16 and at this moment a periapical radiograph was taken to assess the overall healing.(Fig. 15)

Restorative procedures

After three months, the patient returned to the office so implant osseointegration and overall healing could be assessed. With the implant absent from mobility and presenting outstanding soft tissue healing the final restorative phase was initiated

The temporary crown was removed (Fig. 16, 17) and a Mono Scanbody screwed onto the implant and digital impression was performed with intra oral scanner so a monolithic zirconia crown could be designed  and produced by the laboratory (Fig. 18). Two weeks later the definitive restoration was seated and tightened with a torque of 35N/cm.  The screw access was properly protected with Teflon tape and light cured composite used to finalize and protect it. (Fig. 19, 20)

Both interproximal contact points were checked, and occlusion properly adjusted. Patient received hygiene instructions using interdental brushes or irrigator. A final dental radiograph was taken to ensure proper prosthetic seating at the day of the delivery and respectively one year after in the follow up consultation (Fig. 21).

Treatment outcomes

The patient is satisfied with the treatment. After one year during regular check-up, dental radiograph shows adequate crestal bone stability and clinically healthy soft tissues. (Fig. 22) This successful result consists with a combination of factors: the new Straumann^® TLX macro design; Straumann® SLActive^® surface with extensive healing potential, sufficient bone and soft tissue quality around the implant; in addition to properly polished zirconia below the gingival magin.