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Immediate Implant Placement to Replace a Fractured Central Incisor: A Case Study

September 1, 2012
by Les Kalman, B.Sc.(Hon), DDS


Abstract
Immediate implant placement in the anterior maxilla can be an ideal treatment option for patients, provided that the clinician properly plans the treatment. Treatment factors relating to the patient, the biology of the site and the experience and skill of the clinician must be evaluated to result in a predictable and esthetic outcome.

INTROCUTION
Immediate implant placement in the esthetic zone is an ideal treatment option, provided that proper treatment planning has been completed. Martin et al1 have outlined several crucial patient factors for success, including: patient expectations, smile line, gingival biotype, absence of infection and the width and height of the hard and soft tissues.

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Provided that proper candidate selection and treatment planning have occurred, it is crucial for the clinician to follow established surgical protocols for a predictable esthetic outcome. Buser et al2 have outlined several surgical considerations, including proper implant size selection, implant placement and management of the soft tissues.

CLINICAL CASE

Presentation
A 68-year-old male patient presented with a fractured central incisor. Medical history was non-contributory. Clinical and radiographic examination indicated an asymptomatic fractured tooth, without pulpal involvement (Figs. 1-3). Diagnosis of tooth #11 indicated a fractured crown with caries. Treatment options included a restorative option: endodontic treatment, post and core, crown lengthening and a crown, or a replacement option: extraction and immediate implant placement with a porcelain-fused-to-metal (PFM) crown. Based on the prognosis, the patient agreed upon the replacement option and was rebooked the following day for surgery. Informed consent was given for the patient to review prior to the appointment.

Surgery
Prior to surgery, informed consent was obtained, vitals were taken and the patient rinsed with a 0.12% chlorhexidine rinse for 30 seconds. Local anesthetic was administered. Tooth #11 was extracted as atraumatically as possibly (Figs. 4, 5). It was crucial to maintain the integrity of the buccal plate3. The apex and socket walls were gently curetted and irrigated with saline. Palpation verified wall integrity. An osteotomy followed, increasing the socket width to 4.2mm and depth to 13mm. A depth guide was placed (Fig. 6) and a radiograph taken to verify depth and angulation. The osteotomy was then tapped. A 12mm long, 4.8.mm diameter regular neck Straumann implant was placed. A radiograph confirmed the position. A healing cap was then placed (Fig. 7). An alginate impression was taken to indicate the type of abutment that would be required (Fig. 8). The patient was dismissed with a course of analgesics, antibiotics, a 0.12% chlorhexidine rinse and post-operative instructions. It was decided to leave the edentulous area untemporized due to the patient’s low lip line and request (Fig. 9). One week post-operative examination was unremarkable.

Prosthodontics
The patient returned six weeks following surgery. A periapical radiograph and clinical examination indicated that healing was within normal limits. The healing cap was removed. An impression coping was threaded into the implant and was verified by a radiograph. A modified open tray poly-vinyl siloxane (PVS) impression was taken using the Reseat Technique4 (Figs. 10, 11). An alginate mandibular impression was taken, as well as a PVS bite registration. Shade selection followed. The healing cap was replaced and the patient dismissed.

When the laboratory case was completed, the custom abutment and crown were assessed on the master cast (Figs. 12-15).

After two weeks the patient returned. The healing cap was removed (Fig. 16). A custom milled titanium abutment was threaded into the implant (Figs. 17, 18). A radiograph confirmed seating. The abutment was torqued to specifications (30 Ncm). A cotton pellet was placed into the crew head, followed by a drop of PVS material to act as a seal. The PFM crown was placed onto the abutment and was assessed according to fit, marginal integrity, esthetics and occlusion (Figs. 19, 20). The patient confirmed the esthetics (Fig. 21). The crown was cemented with permanent glass ionomer cement (Fujicem (GC America). Excess cement was cleaned, occlusion refined and the crown polished. A post-cementation radiograph was taken (Fig. 22). The patient was given post-cementation instructions and dismissed. The patient returned 48 hours later for a follow-up appointment to confirm the occlusion.

Discussion
The immediate implant placement is an ideal treatment option for the proper candidate. Several factors were evident with this case for clinical success. That the tooth fracture resulted in an unrestorable crown and that a poor prognosis of the restorative treatment existed favoured the implant option. The lack of apical pathology allowed for the opportunity for immediate implant placement. The patient’s occlusion was also favourable, allowing for the proper distribution of occlusal forces. During the osteotomy, it was apparent that the patient had dense bone (D2), allowing for tapping of the bone and a very stable implant following surgery.5 The abundance of thick, keratinized tissues eliminated the need for tissue augmentation. The presence of a low lip simplified the esthetic component. Lastly, the patient was extremely motivated and proactive during the healing and maintenance phase.

Conclusion
Immediate implant placement is a predictable and esthetic treatment option. Crucial factors exist for a successful outcome, including patient selection, biological considerations and proper surgical and prosthodontic protocols. When the criteria are properly satisfied, the immediate implant option is a viable treatment modality.OH

Les Kalman B.Sc.(Hon), DDS, Assistant Professor: Restorative Dentistry, Schulich School of Med­icine & Dentistry, Western University, London, ON N6A 5C1. lkalman@uwo.ca

Oral Health welcomes this original article.

REFERENCES

1. Martin, W.C., Morton, D. and Buser, D. Pre-operative analysis and prosthetic treatment planning in esthetic implant dentistry. In Buser, D., Belser, U. and Wismeijer, D. editors: Implant Therapy In The Esthetic Zone-Single Tooth Replacements (Volume 1) p11-19, Berlin, 2007, Quintessence.

2. Buser, D., Martin, W.C. and Belser, U.C. Surgical considerations for single-tooth replacements in the esthetic zone: standard procedure in sites without bone deficiencies. In Buser, D., Belser, U. and Wismeijer, D. editors: Implant Therapy In The Esthetic Zone-Single Tooth Replacements (Volume 1) p26-31, Berlin, 2007, Quintessence.

3. Sammartino, G., Marenzi, G., Espedito di Lauro, A. and Paolantoni, G. Aesthetics in oral implantology: biological, clinical, surgical and prosthetic aspects. Implant Dentistry. 2007;16:54-58.

4. Kalman, L. The Reseat Impression Technique: An Open Tray Alternative. In Press

5. Misch, C.E. Bone Density: A key determinant for clinical success. In Misch, CE, editor: Contemporary Implant Dentistry (2nd Ed.) p113-114, St. Louis, 1999, Mosby.