Removing the ‘microgap’ and restoring function posteriorly with tissue level implants
Figure 1 - PA X-Ray of failing LL7 needing extraction.
Figure 2 - X-ray taken post removal to ensure no root fragments left in situ. This was only taken due to the difficult nature of the extraction.
Figure 3 - CBCT image taken 3 months after healing to assess bone dimensions and identify nearby anatomy including Inferior Alveolar Nerve and Lingual mandibular bony undercut.
Figure 4 - Guide pin to assess direction and depth of initial osteotomy.
Figure 5 - Clinical pic demonstrating insertion tool in implant fixture to assess angulation.
Figure 6 - X-ray with wider guide pin taken to assess direction of osteotomy prior to implant placement.
Figure 7 - BioHorizons Tapered Tissue Level implant 5.8 x 9mm.
Figure 8 - PA X-Ray immediately post-implant placement.
Figure 9 - PA X-Ray of impressions coping seated in implant 3 months after placement. This X-Ray is crucial to verify seating of the impression coping into the fixture head platform. Incorrect seating will lead to the fabrication of a non-seating prosthesis.
Figure 10 - Intra-oral image pre-removal of healing abutment following 3 months of healing
Figure 11 - Beautifully healed peri-implant soft tissues with emergence already developing with use of healing abutment.
Figure 12 - Occlusal image demonstrating emergence profile and sufficient band of buccal and lingual keratinised tissue.
Figure 13 - Working model with implant analog following pouring up of the fixture level impression demonstrating good 3 dimensional positioning of implant fixture.
Figure 14 - Screw-retained crown with screw emerging in the mid-occlusal area. Zirconia framework on a hybrid base abutment layered with Emax ceramic with ultra-polished zirconia subgingivally.
Figure 15 - Image demonstrating contours and high glaze of crown surface.
Figure 16 - Crown seated in situ and torqued in to 30Ncm with access cavity filled with PTFE and Composite restoration.
Figure 17 - Crown seated in situ and torqued in to 30Ncm with access cavity filled with PTFE and Composite restoration.
Figure 18 - Crown seated in situ and torqued in to 30Ncm with access cavity filled with PTFE and Composite restoration.
Figure 19 - Final X-ray showing fully seated screw-retained crown with favourable emergence profile to aid long-term cleansibility.
Tissue level implants: the result
This case beautifully demonstrates the emergence profile that the tissue level implants facilitate along with the ease of cleansability for the patient, even when the prosthesis is placed posteriorly in difficult to reach areas.
Although many studies have suggested that there is no statistical difference between bone level implants and tissue level implants with regards to long-term crestal bone stability, the adjustment of the microgap to be away from the bone level in a vertical dimension certainly facilitates in the reduction of bone remodelling long-term around implants with this specific design. In my opinion, this makes them a very suitable and evidence-based choice for posterior dental implants in the correct cases.
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Article Author
BDS (Bristol 2008) DipImplantology (Bristol 2018) Toheed graduated from the University of Bristol in 2008 and limits his clinical time to implants and oral surgery only. He has developed a reputation for being an empathetic, thorough and well-mannered dentist. Over the past 5 years, Toheed has held the role of Foundation Dentist Trainer with great enthusiasm. In this role he is responsible for training, mentoring and guiding newly-qualified dentists during their transition from university to general practice. Toheed has furthered his postgraduate education by undertaking 2 years of the MSc in Dental Implantology course at the University of Bristol as well as attending numerous advanced implant training courses. He has been placing implants since 2014 and spends most of his time travelling between practices placing and restoring implants. Toheed provides a full range of implant treatments, including full-arch treatments and complex hard and soft tissue grafting. He also mentors dentists who are new to dental implantology and helps their development and growth through his own ‘starter’ course for dental implantology - www.learnimplants.com.
