Show-stopping immediate implant placement
Alif Moosajee presents an immediate aesthetic outcome
This 23-year-old female presented with good oral and general health. She was already a patient at the practice and made an appointment on this occasion to ascertain her options for improving the aesthetics of an anterior crowned tooth with a dark root (UR1).
She is an up-and-coming West End singer and actress who had undergone Invisalign and whitening, and was looking to complete the aesthetics she was aiming to achieve, not least because her high lip line meant when she smiled her teeth were very much on show. As it happens, on examination, it became apparent the problem was not just cosmetic – the UR1 tooth was failing.
Offering Options
We discussed not only clinical treatment options, but also what was achievable given the patient’s busy work schedule. The patient opted to proceed with treatment as soon as possible.
In terms of options, the possibility of a denture was discussed, but the patient was worried she would be unable to sing with a denture. The idea of a bridge was also mooted, but that would have been destructive with respect to the adjacent teeth. The patient and I ultimately agreed that an implant would best meet her needs.
She was made aware of all the possible risks, including the risk of implant failure. How to proceed was also discussed; for example, there was the option of removing the tooth and giving the surrounding structures time to heal, but ‘recreating nature’ is challenging as soft tissue architecture has to be reconstructed to some extent.
The alternative was to remove the UR1 and place an implant and temporary crown immediately, which could be performed predictably with the iSy implant from BioHorizons Camlog. This would provide an aesthetic solution and preserve the gingivae. Armed with all the necessary knowledge to make an informed decision, the patient provided consent for extraction of the failing UR1 and an immediate implant.
Figure 1: The natural tooth with the dark root visible through the gingiva, also showing the patient’s high smile line
Figure 2: Retracted view
Figure 3: Gum contour pre-treatment looking reasonable, albeit dark
Figure 4: Initial scan to gather information about the crown
Figure 5: Tooth extraction
Figure 6: Patient’s smile following extraction
Figure 7: Scanning the soft tissues after root remova
Figure 8: Applying Bio-Oss Collagen in the socket
Figure 9: Implant in place – iSy driver shows the angle
Figure 10: Removing the carrier, using iSy components
Figure 11: The milled block showing the outline of the crown to be placed, alongside the iSy titanium base
Figure 12: Generic view of milled and prepped Cerec crown. Image courtesy of Tarun Agarwal DDS
Figure 13: The restoration (with IiSy titanium base attached) showing the narrow top that will underpin the gingiva from the inside. When added to the grafting material, they will provide circumferential support
Figure 14: The restoration engaged into the implant
Figure 15: Characterisation being performed
Figure 16: The immediate outcome
Figure 17: One week later, showing improved gum colour
Figure 18: Final result
Figure 19: Final result
Figure 20: Final result
Treatment Day for implant placement
Firstly, a scan was taken of the preoperative situation, so the team had a clear picture of the starting point. Next, the crown was severed from the tooth, leaving the root. Another scan was taken to gather all the information needed in relation to what the tooth looked like at gum level, so the restoration (crown) could be created to support the gum at the necessary level in the same way.
The root was then removed, and a scan of the soft tissue taken to record the internal surface of the gum at that height, which drives the shape of the subgingival portion of the crown. Implant placement took place alongside the introduction of bone grafting material (Bio-Oss Collagen), to push out the gingiva and form as bone in the desired shape.
A final scan was taken, with an iSy titanium base connected to the abutment, so that the Cerec machine had all the data it needed about the exact location of the implant, its orientation, etc.
The crown could then be created that would fit on to the implant, using the software. The shape of the subgingival portion of that crown was to support the subgingival tissue in the same way – and at the correct level – that the natural tooth had prior to extraction.
The milling process took about 20 minutes. The crown was then fitted and characterised using Ivoclar’s Empress direct colour kit to achieve a natural look. In total, the patient was in the chair for about two-and-a-half hours: 90 minutes of treatment, a break for the milling, then placement of the crown.
Following Up
The patient was told she would experience some soreness and may need painkillers to ease it. She was also advised to be careful when chewing and biting and to choose a soft diet, especially in the initial period where the newly placed implant gets weaker before it gets stronger. Integration usually takes eight to 10 weeks, but because of the grafting it was decided to leave it all a little longer to settle down.
The final restoration was placed after 3 months. We chose a cement retained restoration because of the implant angulation which was of course influenced by the anatomical constraints. It was a technically difficult shade to match so lab communication was key but I feel my technician Lino Adolf achieved a very pleasing final result.
The patient was delighted with the end result, and once treatment had been completed by the implant team, she received advice about how to take care of her new smile, and was returned to her dentist for regular check-ups, as well as hygiene appointments every six months.
Seize control of immediate implant placement solutions with BioHorizons Camlog and visit theimplantrevolution.co.uk
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Article Author
Dr. Alif Moosajee BDS MFGDP(uk) MJDF (RCS eng) is the owner of the prestigious Leicester-based dental Practice ‘Oakdale Dental’ which provides Dental implants, Orthodontic treatment and Facial Rejuvination along with cosmetic and general dentistry. Alif prides himself on being able to communicate very well with patients and present complex ideas in a very simplistic and accessible way. It was this passion for communication that lead to the idea for this book. Alif’s parents are from East Africa and this has fuelled his support for Bridge to aid. A wonderful charity which not only sends dentists to the third world to help some of the poorest people by directly providing dental care to them, It also helps the dentists that go to leave a legacy by training a health care worker so that they can carry on the good work long after the dentist has returned home.
