Introduction

Clinical history and interview, an extraoral and intraoral exam, additional investigation methods, risk assessment, and referring or consulting with other specialists are all ways to collect data that could be helpful in identifying a patient's issues. In our daily practice, this information helps us establish an effective and practical individual treatment plan for each patient.

Moreover, despite the high success rate for dental implants, complications are still possible. Therefore, maintenance therapy should always be part of the patient treatment, and its goal is to prevent peri-implant diseases and, consequently, ensure long-term implant stability.

There are no shortcuts to achieving long-term successful esthetic effects. The only way clinicians can achieve successful implantation and restoration treatment is to strictly adhere to the treatment plan and discuss with the patient the possible scenarios encountered during the implant treatment journey.

The following clinical case describes a successful immediate Straumann® BL implant placement with bone augmentation in the esthetic zone of a young patient. The patient showed no clinical or radiologic complications throughout seven years of clinical and radiographic follow-up and maintenance therapy. The outcome met all the patient’s expectations.

Initial situation

A 25-year-old, systemically healthy female patient, a non-smoker on no medication and with no allergies, presented to our clinic. Her chief complaint was: "The crown of my front tooth was lost a few days ago; it kept falling off. I can't wait to get a new one that looks natural without damaging the adjacent teeth."

In addition, she expressed her desire for a quick and fixed definitive rehabilitation of the upper central incisor, and to obtain a bright smile with uniform, even teeth, and a smoother look. Moreover, she stated that she did not want to be left with a gap in her front teeth during the treatment.

During the extraoral examination, the smile revealed a medium smile line and showed the cervical margins of the crowns of 14 - 24.

The intraoral examination revealed mild gingivitis and regular plaque control. After the crown of #11 was removed, a pigmented stump was found, and was positive for the vertical percussion test (Fig. 1).

The radiographic evaluation showed thin facial bone, failed root canal treatment with a post, periodontal ligament widening, and root resorption of tooth #11. Otherwise, no local infection was observed (Fig. 2).

The SAC assessment classified this clinical scenario as surgically complex but straightforward in terms of prosthodontics (Fig. 3).

Treatment planning

Immediate implant placement with bone augmentation and delayed loading was decided after a detailed discussion of the different treatment options with the patient.

The main steps of the treatment workflow included:

1. Clinical and radiographic assessment. Preparation of the surgical stent
2. Extraction of hopeless tooth #11
3. Immediate Straumann® BL implant insertion with flap elevation to ensure facial bone integrity.
4. Filling of the gap between bone and implant with a xenograft.
5. Placement of a collagen membrane to cover graft materials.
6. Splinting of the provisional crown to teeth #12 and #21.
7. Placement of a healing cap six months after surgery (2nd stage surgery).
8. Definitive delivery of the cement-retained crown two weeks after 2nd stage surgery. 

Surgical procedure

The surgical stent was first tested on the patient's dental arch to ensure a proper fit. The area to be operated on was anesthetized with local anesthesia (lidocaine 2% with epinephrine 1:100k). An open-flap technique for preserving the papilla was performed to gain adequate access to the future implant site (Fig. 4). Tooth #11 was extracted with minimal trauma to the surrounding tissues, and a suture was applied to help fix the palatal flap (Fig. 5).

The surgical stent was placed in the mouth to ensure insertion of the implant in the optimal 3D position and to visualize the future soft tissue margin, which would ideally be located 3 mm coronal to the implant shoulder. The Straumann® Surgical Cassette was used for preparing the implant bed, strictly following the drilling protocol (Fig. 6). The alveolar ridge was prepared to a diameter of 2.2 mm, which was then widened to 2.8 mm and finally to 3.5 mm. The preparation depth was checked with the 3.5 mm diameter depth gauge. The final implant bed preparation included profile drilling and subsequent tapping. The Straumann® SLActive® BL ∅4.1 x 10 mm implant was inserted with a speed of 15 rpm and torqued to 35 Ncm. The implant was placed in its ideal prosthetically driven position, 2 mm wide, jumping the gap between the facial bone and the implant surface (Fig. 7).

The gap around the implant shoulder was filled with a mix of autogenous bone and xenograft, and covered by a collagen membrane (Fig. 8).

The provisional crown in position #11 was splinted to teeth #12 and #21 to allow proper healing, shape the underlying peri-implant tissue, and for the assessment of any necessary phonetic or esthetic adjustments. The provisional restoration was immediately placed with an ovate pontic. Instructions on oral hygiene were given, and occlusion was checked.

After the implant placement, the patient underwent routine check-ups, and no signs of pain or infection were found. After the sutures were removed, the soft and hard tissue preservation seemed uneventful.

Prosthetic procedure

Six months after implant placement, the intraoral examination showed healthy soft tissues around the implant (Fig. 9). The implant was osseointegrated.

The healing abutment was removed two weeks after the second stage surgery. The soft tissue profile showed optimal healing (Fig. 10). The implant site was irrigated with 0.12% chlorhexidine, the transfer impression coping was placed, hand torqued, and a radiograph was taken to verify adequate placement of the transfer impression coping.

An alginate impression was taken for the lower arch, and a conventional impression with a closed-tray transfer technique using vinyl polysiloxane was taken for the upper arch (Fig. 11).

A cement-retained all-ceramic crown was delivered by the lab. The right and left lateral views show a satisfactory esthetic outcome with a natural bone contour (Figs. 12,13).

Furthermore, the patient's smile reveals a medium smile line with pleasing esthetics (Fig. 14).

Following the final restoration, it was critical that the patient understood the need for regular monitoring and maintenance to ensure long-term implant stability.

Scheduled annual follow-up visits included oral hygiene control and, if appropriate, a dental x-ray. At the 7-year control, the patient presented healthy peri-implant and periodontal tissues, and the CBCT images showed adequate peri-implant bone levels (Figs. 15,16).

Treatment outcomes

The patient had been afraid of losing her front teeth. She assumed that the treatment would be painful and complicated due to the necessary bone augmentation procedure and the esthetic location. We treated her with a dental implant seven years ago, and she is highly pleased with the results. After all these years, she came to the consultation and told us: "I am very happy with the treatment results. I have had my new tooth for seven years now, and I almost forget that it is artificial."

Author's testimonial

Immediate implant placement with flap elevation can be successful in the long term if you follow these conditions:

1. Ideal 3D implant position
2. Keep at least 2 mm distance between implant and buccal bone
3. Fill the jumping gap with DBBM and resorbable collagen membrane