Helping patients smile for the big day
Dr Jamie Kerr presents an immediate implant case, restoring a patient’s smile and confidence in time for a major family event.
Introduction
When providing dentistry in the anterior region of the mouth, it is crucial to achieve both aesthetics and function. The former can often be a major motivational factor for patients who are looking for more than a replacement for a missing or failing tooth – but who often seek an increase in self-confidence too.
The literature confirms the suitability of immediate placement in the anterior zone, demonstrating that good aesthetics can be achieved.[i] Favourable aesthetics are documented for several years post placement, supporting both survival of implants and longevity of the outcomes.[ii] There is also evidence that patient satisfaction remains high after receiving this treatment modality.[iii] The below case details the treatment pathway for an anterior immediate implant, highlighting how well this step can integrate within a comprehensive treatment plan that enhances the aesthetics of the entire smile.
Case presentation
A female patient in her mid-30s presented having issues from an existing post crown on the UR1. She also felt it looked darker and made her very self-conscious, and her own GDP had advised that it was unlikely to last due to a short post and presence of infection. She was to be a bridesmaid at her sister’s wedding two years later and was looking to improve the appearance of her teeth so that she felt confident to smile in photographs.
A comprehensive assessment was completed to identify if the patient was suitable for dental implant treatment. A low smile line was noted with no extraoral pathology present. Intraoral examination was completed, and the patient was found to have good general dental health, good periodontal health with minimal bleeding on probing, and no other abnormalities were revealed. Both incisal Class I and skeletal Class I relationships were recorded, with dynamic canine guidance present and posterior support was considered adequate. A thick, low-scalloped biotype was noted, with a lower zenith height above UR1 compared to the adjacent central incisor.
Fig 1: Patient smile on presentation
Fig 2: Pre-operative anterior view
Fig 3: Pre-operative radiograph
Fig 4: Pre-operative radiograph
Medically, the patient was fit and well, was a non-smoker and reported low consumption of alcohol.
Radiographs were taken to assess for caries and pathology, with periapical radiolucency noted at the UR1 indicating chronic infection and a guarded prognosis. The post in situ was short and unlikely to remain stable for much longer. Clinical photographs were taken for treatment planning purposes. A CBCT scan was taken, identifying a thick buccal plate which the localised periapical periodontitis lesion affecting UR1 had not yet perforated.
Treatment planning
The treatment options discussed with the patient included:
- Do nothing
- Provide resin-bonded fixed bridgework – although this would come with an increased risk of debonding and shine-through of metal
- Conventional fixed bridgework – would require the loss of 15-20% healthy tooth structure and may lead to loss of tooth vitality
- Partial denture
- Implant restoration with a single crown
Despite the anterior location of the proposed implant, the aesthetic risks were considered low and resulted in the decision to proceed with an immediate implant placement protocol. This treatment modality was chosen due to the available surgical techniques and the patient’s realistic expectations, together with the presence of an intact thick buccal plate, low lip line and favourable soft tissue height.
Fig 5: Surgical guide and pre-milled provisional crown with locator wings provided by lab
Fig 6: UR1 extracted atraumatically
Fig 7: Immediate implant placed ensuring palatal positioning in socket
Fig 8: De-epithelialised CTG to create optimal soft tissue contour
Fig 9: CTG secured under labial tissue to improve soft tissue contour
Treatment would begin with oral hygiene and dietary advice to improve daily routines, with a referral to the dental hygienist for oral hygiene phased therapy. This would be followed by digital intraoral scan and a wax up, in preparation for an immediately placed implant and provisional crown. Also discussed were tooth whitening and composite restorations on the UR2, UL1, and UL2 post-whitening to enhance general aesthetics.
All the clinical challenges, risks, and benefits of immediate implant treatment were explained to the patient to ensure informed consent. The digital scans were used to fabricate digital surgical guides.
Surgical treatment
Pre-operative antibiotics were provided and a chlorhexidine mouthwash was used to rinse the mouth and create an optimal environment for surgery prior to local anaesthetic being administered.
The UR1 was elevated and extracted atraumatically using a combination of luxators and forceps ensuring the buccal bone remained intact. Any remaining granulation tissue was curettaged and the socket was disinfected.
The osteotomy was prepared using a fully guided protocol and the drill sequence recommended by the manufacturer. A 4.6mm x 12mm BioHorizons Tapered Plus, 3.5mm platform implant was placed and torqued to 35Ncm using a motor, and then
hand-torqued to the required depth of 4mm from the planned zenith height. Good primary stability was achieved.
Fig 10a: Provisional crown (with locator wings) connected to abutment
Fig 10b: Provisional crown after shaping and polishing
Fig 11: Temporary crown fitted in the mouth
Fig 12: Immediately post-operative smile
Fig 13: Immediately post-operative radiograph
Soft tissue regeneration was performed by harvesting a free gingival graft from the palate in the premolar/molar region, to a depth of 0.5mm. The donor tissue was de-epithelialised with a scalpel and the connective tissue graft placed under the buccal tissue at the implant site. GBR was conducted by mixing autogenous bone, collected during the osteotomy preparation, with MinerOss Allograft (BioHorizons), and placing this into the jump gap.
To provisionalise the implant, a provisional abutment was placed, onto which a pre-milled acrylic shell, with locator wings, was connected using flowable composite. This was then removed, shaped and polished to provide the immediate provisional restoration. Verbal and written post-operative instructions were given to the patient to facilitate healing and recovery. A radiograph was also taken to confirm the implant position, ensure full seating of the provisional crown, and establish baseline bone levels.
Review and treatment conclusion
The patient returned two weeks later for suture removal and to review healing. The patient reported no abnormal discomfort or concerns, and the surgical site appeared to be progressing as expected. Impressions were taken for whitening trays.
A month later the patient was given the whitening trays and instructions on how to use them. She was advised to use the 10% carbamide peroxide Enlighten Whitening system at night for two weeks, followed by the 16% solution for another two weeks. Desensitiser swabs were provided to help with any sensitivity experienced. Starting shade recorded was B2, which lightened to B1.
Fig 14: Provisional Crown removed showing good soft tissue contour prior to restorative stages for final restoration
Fig 15: Good healing four months post-operatively
Fig 16: Final crown providing optimal final aesthetics
Fig 17: Final crown with custom abutment in situ
Anterior composite restorations were placed on the UR2, UL1, and UL2 as planned, designed to match the new brighter shade for seamless aesthetics.
The implant was reviewed to confirm successful osseointegration after three months of healing, where the ISQ (Implant Stability Quotient) was recorded. Small additions of flowable composite were then applied to the provisional crown over the following few weeks. This was performed to place light apical pressure and shape the tissue to match the adjacent central incisor zenith height, and achieve optimal aesthetics. Restoration of the final implant restoration then commenced, using an intraoral scan to capture the implant position and soft tissue emergence created by the provisional crown.
This final restoration was then fitted approximately one month later, providing the patient with a screw-retained crown on a custom abutment. The total treatment time was approximately five and a half months from initial assessment to final restoration. The patient was delighted with the result and was able to enjoy her sister’s big day with a smile she was proud of.
