Immediate placement and loading of a molar tooth
Dr Nick Fahey presents an immediate implant case using an innovative new implant from BioHorizons Camlog in a molar site.
Introduction
With the increasing acceptability of immediate implant placement, many clinicians are using the technique in a wider range of cases. As such, there is a growing body of evidence that shows the success of immediacy in the posterior region of the mouth. For example, research has shown immediate implant placement to deliver predictable results in molar extraction sockets, including high survival and success rates with minimal bone loss reported.[i]
The following case shows how success with molar implants can be optimised using a fully digital workflow.
Patient presentation
The patient was referred to the practice following failed apical surgery on the LR6. She was in need of an extraction and potential replacement with a dental implant. The patient was keen to understand her restorative options.
A full medical and dental history revealed an allergy to penicillin and the patient was on HRT. She was a non-smoker, drank no alcohol, and presented with a low anxiety score. She was a regular attender at her normal dental practice and had some existing crowns and composite bonding. With regards to oral hygiene, she reported brushing twice daily, interdental cleaning occasionally and had a BPE score of 111/301. In addition to the failed root canal on the LR6, a soft tissue deficiency was recorded in the area.
The treatment options were discussed with the patient in detail. As she sought a fixed solution, a dental implant-retained crown was decided on as her best option. Information on the benefits, limitations and risks was presented and she provided informed consent to proceed.
Treatment planning
A full suite of clinical photographs and radiographs were taken to assess the bone level and soft tissue health. A prosthetically-driven approach was used to determine the ideal implant position, angle and depth using the digital software. While the bone was deemed sufficient to ensure primary stability, the digital mock-up showed that a soft tissue graft was indicated at the site to treat the existing gingival defect and improve the post-operative gingival phenotype.
Continuing the digital workflow, guided surgery would be utilised for this case to ensure optimal accuracy and minimal complications. The necessary scans were used to fabricate the surgical guides and to transfer the planning to the surgical navigation software.
Figure 1: Buccal view at presentation showing soft tissue deficiency and thin phenotype scaled
Figure 2: Occlusal view upon presentation
Figure 3: Pre-operative radiograph showing failed root canal treatment and apicetomy on LR6
Figure 4a: Digital planning for implant placement
Figure 4b: Digital planning for implant placement
Surgical treatment
On the day of surgery, the area was numbed with anaesthesia and a flap was raised. The LR6 was extracted with an atraumatic surgical approach – the tooth was sectioned and removed in two parts. Thorough debridement of the extraction site was performed, which included a three-minute application of chlorine dioxide gel to disinfect the socket.
The osteotomy was performed using a combination of a static guide and surgical navigation. Slow drilling of <50 RPM was used to harvest autogenous bone.
A 5.2mm x 10.5mm Tapered Pro Conical implant (BioHorizons Camlog) with Laser-Lok® feature was placed into the socket. This was chosen because it affords high primary stability in immediate cases with an excellent connection that improves aesthetics, as well as allowing a simple restorative workflow for the clinician.
Figure 5: Implant being placed with a surgical guide and surgical navigation scaled
Figure 6: Guided implant placement scaled
Figure 7: Implant placed and autogenous bone packed around the site to fill the bony defect scaled
Figure 8a: Harvesting of the connective tissue graft scaled
Figure 8b: Suturing of the donor site with OraAid placed on top to stop bleeding scaled
Figure 9: Zirconia custom healing abutment placed scaled
The previously harvested autogenous bone was mixed with L-PRF® membrane cut into small pieces and MinerOss® cortical and cancellous bone chips 300µm-1000µm 0.5cc with PRP serum to create a sticky bone. The graft material was placed into any spaces found around the implant and packed with a DEGIDI plugger.
A connective tissue graft was harvested from the palatal aspect of the upper arch. This was sutured under the buccal aspect of the flap to increase soft tissue volume for an enhanced aesthetic outcome. The flap was then closed tension-free. L-PRF® membranes were placed over and around the implant to further support the tissue and bone grafts. Everything was stabilised with the placement of a laboratory-made zirconia custom healing abutment. The donor site was also sutured closed, and Ora Aid was placed over the site to reduce bleeding and encourage healing.
Figure 10: One week post operative if you look carefully you can see where the flap was buttonholed below the distal papilla
Figure 11: One week post operative radiograph
Figure 12: Occlusal view at three month follow up scaled
Figure 13: Buccal view at three month follow up buccal view showing good gingival volume scaled
Figure 14: Radiograph at three month review
Figure 15: Intraoral scan of the custom healing abutment overlayed on top of the digital mock up showing the improvement of tissue volume
Figure 16: Scan to show maintenance and improvement of bone and soft tissue volume
Outcome and reflections
Although this case is pending its final restoration, the three-month post-surgical review radiographs and soft tissue scans demonstrate good healing and volume. Upon reflection, the only blemish in this case was a procedure error where I ‘buttonholed’ the very thin receded soft tissue. Therefore, there is some uneven healing of the gingiva which will be addressed fairly simply with some soft tissue re-contouring when the final restoration is fitted.
Otherwise, this was a fantastic treatment for this patient. She came into the surgery with a tooth and left the surgery with a tooth. This protocol has simplified the restorative process, so we can go directly from the custom healing abutment to the definitive crown.
To discuss how you can implement the Tapered Pro Conical into your implant practice, contact our team.
For all your implant educational needs, visit our dedicated education website, where you can find a range of courses to suit you.
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Article Author
Dr Nick Fahey BDS, Mclin.Dent (Pros) MRD RCS(Ed), FRACDS and MFDS RCS (Eng.) has an interest in all aspects of dentistry related to dental implants and fixed and removable prosthodontics. As a pioneer in computer-guided surgery, Nick has taught a generation of dentists about guided surgery and has been a KOL in this field for many companies. He is particularly interested in computer-guided surgery and guided surgical navigation for simplification of surgical placement of dental implants and has authored a textbook called “Guided Surgery. Making Implant Placement Simpler”. Nick is also a co-director of the FitzFahey Academy. Aside from his teaching and mentoring commitments, Nick works as a Specialist in Prosthodontics and is the Principal Dentist of Woodborough House Dental Practice in West Berkshire.
