Introduction

A significant advancement in this area is the development of implant systems specifically designed to meet the demands of immediacy. The Straumann® BLX implant, created for challenging clinical scenarios where immediate insertion and loading are indicated, is a prime example. Fabricated from Roxolid® material—an alloy combining titanium and zirconium—the BLX implant provides enhanced strength, allowing for smaller diameters without compromising stability. This characteristic is particularly beneficial for preserving hard and soft tissues, which are crucial for achieving optimal esthetic outcomes in anterior restorations.

Additionally, the TorcFit™ connection further augments the implant's versatility, offering a secure and flexible interface between the implant and the abutment, which is essential for attaining optimal results in immediate restoration cases. One notable advantage of the TorcFit™ connection is that the abutment’s transmucosal design is the same, from the healing abutment to the definitive abutment.

This unique feature prevents bone remodeling promoted by the connection and disconnection of restorative components during the restorative phase. This case report presents the successful treatment of a hopeless anterior tooth using the Straumann® BLX implant. The patient underwent immediate implant insertion and loading, with a follow-up period of two years after the delivery of the definitive restoration. The outcome demonstrated not only the functional stability of the implant-prosthetic complex but also the high level of esthetic maintained over time, highlighting the efficacy of the BLX implant system in achieving reliable and lasting results in the esthetic zone.

Initial situation

A 62-year-old healthy female (ASA I), a non-smoker with no history of medication use or allergies, presented to our clinic with complaints of pain and crown mobility at tooth #21. The patient expressed a desire to restore function while preserving esthetics and a natural appearance.

During the intraoral examination, it was observed that the patient had multiple dental restorations and a crown on tooth 21 (Fig. 1). Probing revealed depths less than 3 mm around all sides of the crown on #21, with no bleeding or suppuration noted upon probing (Fig. 2). The patient's plaque index (PI) was 8%, and there were no signs of inflammation. She mentioned that she had undergone periodontal cleaning treatment prior to the consultation. However, the crown was mobile, and a horizontal fracture was clinically observed (Figs. 3,4).

The tomography revealed a horizontal fracture in tooth #21, which had a crown with a post and root canal treatment. The CBCT analysis demonstrated a favorable anatomical situation for extraction, immediate implant placement, and immediate loading (Fig. 5)

Treatment planning

Based on the tomography results, the suggested treatment plan for the patient involved the following steps:

1. Digital planning and design of a surgical template with coDiagnostiX® for static computer-aided implant surgery (S-CAIS) to enhance the 3D position of the implant based on a prosthetically driven approach (Fig. 6).

2. Extraction of the hopeless tooth #21 due to the horizontal fracture.

3. Immediate implant placement.

4. Gap filling with cerabone® and the use of a connective tissue graft (CTG) in the buccal zone.

5. Immediate loading using a pre-selected Variobase® and the patient's same crown.

6. Final prosthetic rehabilitation with a screw-retained monolithic zirconia CAD/CAM implant-supported crown.

This treatment protocol was selected based on the favorable anatomical conditions observed during the clinical examination and CBCT analysis, which likely included a preserved buccal bone wall, intact interproximal bone peaks and adequate bone density and volume to engage the implant in a favorable prosthetically driven position. The aim was to provide the patient with both function and esthetics soon after the procedure and to maintain the emergence profile during the healing phase.

Surgical procedure

The patient was premedicated with amoxicillin 2 grams administered 1 hour prior to the surgical procedure. Local anesthesia was administered using 2% lidocaine with epinephrine 1:100,000. The atraumatic extraction of tooth #21 was performed using a flapless approach to reduce the risk of a buccal bone wall fracture and avoid soft tissue damage. Following the extraction, the site was thoroughly debrided, the surgical guide was placed, and the drilling protocol was performed according to the manufacturer's instructions. A Straumann® BLX Implant, Ø 3.5 mm RB, SLA® 14 mm, Roxolid® was then placed in the extraction socket with the aid of the handpiece at a speed of 15 rpm. 55 Ncm of insertion torque was achieved. Gap filling was performed with botiss cerabone®, and a connective tissue graft was harvested from the palate and placed with a tunneling technique in the extraction site. Implant stability was assessed using the implant stability quotient (ISQ), achieving a score of 77, allowing for immediate loading. An RB/WB Variobase® abutment for the crown, with GH 3.5 mm, made of TAN (Titan alloy), was utilized. The extracted crown was used to pick up the abutment with resin, and the provisional restoration was polished to prevent irritation and accumulation of biofilm. It was adjusted to ensure no occlusal contact with the opposing arch during both centric and eccentric movements. The provisional restoration was screw-retained, hand-tightened and sealed with Teflon and composite resin (Fig. 7).

Healing was uneventful at the suture removal appointment after 10 days. The patient was scheduled for periodic follow-up appointments.

Appropriate contour management of provisional restorations directly influences the shaping of the emergence profile. Key factors include making necessary adjustments, regularly reshaping, timing modifications appropriately, and respecting biological principles. The results observed at 4 and 6 months demonstrate how these practices contribute to achieving the desired esthetic and functional outcomes for the final restoration (Fig. 8,9).

Prosthetic procedure

After six months, with adequate tissue healing and the emergence profile properly created, the final impression was taken using an intraoral scanner. A monotype scan body was screwed into the implant, and scans were performed of both the upper and lower jaws (Figs. 10-12). The bite registration was digitally transferred for precise alignment.

Based on the STL file generated from the scans, a full-contoured screw-retained monolithic zirconia crown was designed and enhanced with a labial layer of porcelain material. This crown was bonded to an RB/WB Variobase® abutment (Fig. 13).

In the mouth, the restoration's interproximal fit and marginal integrity were evaluated. The occlusion was checked in centric and eccentric positions, and esthetic aspects were verified. The crown was then secured with a torque of 35 Ncm and sealed with Teflon and composite. Comprehensive oral hygiene instructions were given (Figs. 14,15).

The patient underwent follow-up evaluations to assess the function and longevity of the prosthetic components and overall clinical outcomes. At the one-year follow-up, the restoration showed excellent clinical outcomes with no signs of complications, and good tissue health (Figs. 16,17).

By the two-year follow-up, the prosthetic restoration was continuing to perform well, with no issues concerning the implant or abutment. The soft tissues remained healthy, and the occlusion was well aligned. The patient expressed high satisfaction with both the functional and esthetic aspects of the restoration, demonstrating the long-term success and stability of the treatment (Figs. 18,19).

Treatment outcomes

The patient’s treatment outcomes were highly successful, with the prosthetic restoration performing well at both the one-year and two-year follow-ups. The restoration maintained excellent function and esthetics, with stable prosthetic components and healthy surrounding tissues. Overall, the patient expressed high satisfaction with the functional and esthetic results, highlighting the long-term success of the treatment.

The patient stated: “I was very concerned about my situation since I’m a very social person and my front tooth was moving. I was also feeling pain. After my evaluation and treatment plan presentation, I was confident to take the decision to proceed with an implant after the extraction of the fractured tooth. I was impressed by the level of technology that is being used today and how easy it is for us patients to get involved with our treatments and decisions. My surgery was performed without any complications and, to be honest, was way less invasive than what I had imagined. The whole treatment was finished in less than 8 months, and I’m very happy with the result. It looks very natural, and I returned to my social activities with confidence.”

Author’s testimonial

The patient appeared very stressed due to her esthetic concerns with a mobile fractured front tooth. After the analysis, and with the aid of digital planning, I was able to calm her down and present her the planned treatment option in a very didactic way. After the decision was taken to proceed with the treatment, all the planning was accurately transferred to her mouth using S-CAIS. The selection of the appropriate implant placement protocol, the adequate hard and soft tissue management and giving biology the time needed to do its job resulted in a stable and beautiful result.