implants - the journal of oral implantology UK Edition

I 23implants1_2012 technique_ immediate placement I rent and required oral hygiene and maintenance. The patient was noted to have a high smile line, clearly showing the dentogingival complex in function. A full discussion outlined the options available to the pa- tient, who after consideration, elected a fixed option, with implant restoration being her solution of choice. The patient was fully aware of the risks and alterna- tives to the procedure, and given her very recent root fracture affecting the tooth, surgery was scheduled for the same week. Mounted study models were produced, upon which, two vaccum-formed stents were made over the tooth in question. Full radiographic assessment was undertaken to determine the condition of the re- maining root, adjacent teeth and roots, while assess- ing the area dimensionally for implant placement. The patient was prepared for surgery following pre-oper- ative consent and antibiotics together with repeated pre-operative rinsing with chlorhexidine gluconate 0.2 per cent. Standard surgical scrub and drapes were employed. The upper left lateral incisor tooth was carefully extracted using periotomes to preserve both hard and soft tissue around the socket.3 This technique facili- tates tooth removal without traumatising the alveolar bone of the socket or surrounding gingival tissue. The technique can be performed for any extraction, but it is of particular importance when the subsequent placement of dental implants is envisaged. Following atraumatic tooth removal, the socket was thoroughly irrigated, debrided and fully assessed (Fig 3). The socket was found to be intact, stable and formed from solid bone. The buccal crestal bone was found to be intact, at a good level and supporting the thick gingival genotype overlying it. Having fully as- sessed the socket, the implant osteotomy was under- taken, following a flapless surgery protocol with both external and internal irrigation, and using the surgical stent as a guide to the final required position. Bone removed during the procedure was har- vested (Fig 4). The osteotomy was prepared and the fixture placed slightly towards the palatal plane. The implant was seated to the desired vertical position to allow ideal soft tissue position after healing. The im- plant (Nobel Biocare RST 16mm NP) was inserted and torqued to 35Ncm (Fig 5). After implant placement, thesocketwasthenreassessed.Asexpectedtherewas found to be a slight void between implant and buccal plate. The harvested bone was packed into this defect, as an adjunctive graft, in order to support the buccal plate and its overlying gingivae.4 Having placed the implant and harvest graft, the bony socket was now supporting its overlying hard and soft tissues once more. Attention then turns towards gaining support for the crestal soft tissues. An immediate temporary abutment was torqued on to the implant again to 35 Ncm, and a Teflon cap placed over this (Fig 6). Using the second vaccum formed stent, a temporary crown was constructed using a flowable composite resin, and light cured before being removed. Following re- moval, the crown is added to and carefully polished, especiallyinthecervicalarea,togiveahighlypolished, ergonomic temporary restoration which is adequately supportive to the cervical gingival tissues, providing a circumferencial seal around the marginal area. Following final polishing, the temporary crown is luted to the temporary abutment using temporary ce- ment.Thepost-operativeradiograph(Fig7)showsthis situation and highlights a small excess of temporary cement which can be easily removed with floss. The temporary restoration is kept clear of the occlusion. Fig. 4 Fig. 5 Fig. 6 Fig. 7 Fig. 8 Fig. 9