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implants - international magazine of oral implantology

case report I I 17implants3_2013 Fig. 25_Crowns completed. Fig. 26_Check-up of teeth 11 and 22 and crowns. Fig. 27_Three months after insertion of crowns. 3.5 mm mesially and 4.0 mm distally. The radiological control (Figs. 1–4) also shows a discrepancy between preparationandcrownmodellingintooth11.Thisarti- ficialundercutandtheminimizedbiologicalwidthwere themainreasonsforthelocalinflammation. _Planning Teeth 11 and 22 were to be extracted. A new crown on 11 would not offer any better aesthetic and func- tionalresults.Duetotherootscrew,theroottreatment on22wasriskyanditsresultwasunpredictable.Larger compositefillingson12and21compromisedaesthet- icsadditionally.2-5 Thetreatmentplanincludedthefollowingsteps: 1.Extraction of teeth 11 and 22 with immediate im- plantationandguidedboneandtissueregeneration. 2.MarylandBridgeasatemporaryrestoration. 3.Veneersonteeth12and21afterimplantre-entry. 4.Fullceramiccrownsonteeth11and22. _Surgical phase After extraction of teeth 11 and 22, the ridge was cleanedanddisinfected.Noinjuryorperforationofthe buccal lamella was observed. The implant system used wastapered,withplatformswitchingandhighprimary stability.Thedrillsequencewasfollowedasprovidedby themanufacturerbutwithnoirrigationandalowrota- tionof50to70rpmwithmaximumtorque.10-14 Implantswereplacedslightlysubcrestallysothatthe apicalcoronalpositionwas0.5mmbelowbonelevel.In region11,a4.1x13mmimplantwasinserted(Figs.5-8) andanimplantof4.1x10mminregion22(Fig.9).6-8 The gaptothebuccalplateof1mmwasaugmentedwitha mixof ß-TCPandHA40%–60%.9,15 Noeffortwasmade to manipulate the soft tissue recession or raise a flap. Cuts in this region would have led to major recessions becauseoftheperiodontalsituationoftheneighbour- ingteeth.Forthisreason,therecessionintooth11was leftasitwas.Thecrestalpartoftheextractionsocketwas covered with collagen tissue fleece. At last, a piece of dermismatrixwaspositionedcrestallyandslightlybuc- callytoimprovesofttissuequantityafterhealing.16-19 TheprovisionalMarylandBridgewasmanufactured with pontics on 11 and 22 for optimal soft tissue man- agement (Figs. 10–13). Recall appointments were kept forone,three,seven,14,21and30daysandafterwards monthly. _Provisional and healing phase At four weeks postoperatively, the bridge was re- moved and teeth 12 and 21 were prepared to receive veneers. The soft tissue condition was optimal, with- outinflammationandwithfullepithelialisationofthe wound. With a new temporary restoration, we for- warded soft tissue conditioning. Radiological con- trolsweremadeaftereachcementationprocedureto precludecementrestsandariskofperiimplantitis.Ve- neers were inserted before loading the implant for better colour adaptation of the supra-construction, but also after implant re-entry for an optimal emer- gence profile planning. _Implant re-entry The re-entry was performed three months postop- erativelywithasimplemucoperiostealflap.Thequality ofthesofttissuewasgoodsothatasmallcrestalcutof 4mmwasenoughtoremovethehealingscrew.Instead of inserting a gingival former, we decided for a tempo- rary abutment with a composite crown, resulting in a screw-retainedprovisional.Noriskofcementrestswas takenandthescrew-retainedtemporarycrownenabled us to manipulate soft tissue as desired for an excellent aestheticoutcome.Thepatientreceivedthistemporar- ily for four weeks and afterwards impressions were taken. _Restorative phase The veneers were retained four weeks after im- plant re-entry (Figs. 13 & 14, 19–21). At this time, we had optimal conditions for colour selection and im- pression of the implants with customised implant copies. At the first abutment try-in (Figs. 15–18, 22 & 23) we could see the soft tissue regeneration and forming around the zircon caps. Even the gingival surface texturing is evident. Fig. 25 Fig. 26 Fig. 27