Dental Tribune Middle East & Africa Edition | 4/2016 8 mCME Esthetic replacement of maxillary premolar with immediate implant placement and metal ceramic crown over CAD/CAM abutment mCMEarticlesinDentalTribunehavebeenapprovedby: HAADashavingeducationalcontentfor2CMECreditHours DHAawardedthisprogramfor2CPDCreditPoints CAPP designates this activity for 2 CE Credits ÿPage9 ByDr.LarryR.Holt,USA This article describes treatment to solve a common dental complica- tion(lossoftoothduetoverticalroot fracture). Contemporary implant therapy and subsequent CAD/CAM laboratory procedures provide an elegant solution to this patient’s dental emergency. Treatment was accomplished during a period of ap- proximatelysixmonths. The patient is a healthy, 52-year- old female with an unremarkable medical history. Her dental history and general dental health are excel- lent. Unfortunately, she suffered a vertical fracture of tooth #5, which necessitateditsextraction(Fig.1). The treatment plan was for ex- traction and immediate implant placement with concurrent bone grafting as required. A temporary partial was planned to provide es- thetic replacement and to support and shape tissue during the healing process. Final restoration was to be a cemented PFM crown supported by anAtlantisgoldhueabutment. Material selection was based on patient’s cross bite occlusion that transitionsfromnormaltocrossbite acrossthisparticulartooth’socclusal table. Crown and abutment could potentially be subject to occlusal stress due to this transitional rela- tionship. A restoration that provides maximum strength was desirable for long-term stability of the restora- tion. The patient has a thin biotype, andthegoldhueabutmentprovides bothstrengthandthegoldcolorthat providesamorenaturaltissuecolor.1 The gold color provides ”warmth” of color in the critical transmucosal re- gion. Titanium abutments provide strength but can telegraph a greying affectonthintissues. Treatment began with a preop- erative appointment to take neces- sary records (impressions of both arches, facebow transfer, shade tak- ing, bite registration and clinical photography). Prescription to lab was provided ordering a partial denture fabricated from duracetyl resin and to develop a tooth born surgical guide. Lab was instructedtosimulatetheextraction site by removing the tooth from the study cast provided. This model was duplicated for fabrication of the two appliances. Laboratory product was provid- edtosurgeon.Atraumaticextraction was accomplished and immediate implant (Legacy Three, Implant Di- rect) placed with facial bone grafting (Figs.2-3). Therewasahealingscrewplaced and site was closed with appropriate membraneandsuturingtechniques. The unilateral partial was not deliv- ered at time of surgery. Patient was seen in restorative office, and the partial(Duratek,DrakePrecisionLab- oratories) was modified to provide tissue support and begin develop- ment of an ovate tissue site. Partial was delivered uneventfully. These appliances are extremely retentive and not subject to dislodgement or pressure over the implant site dur- ing function. Patient was seen at one week for postoperative check and adjustment of temporary appliance (Fig.4). Patient was instructed to return to surgical clinic in approximately four months for final evaluation priortorestorativeprocedures. Four months after surgery, the patient was seen by surgeon to un- cover the implant, remove the heal- ing screw and place a temporary abutment. The temporary partial was adjusted to accommodate the added height of the healing abut- ment (Fig. 5). Patient was instructed to return to restorative office for de- finitive restoration of the implant in approximatelythreeweeks. Patient was appointed with re- storative office for evaluation and to developnecessaryrecordsforlabora- tory fabrication of the definitive res- toration. Implant site was evaluated and deemed adequately healed to proceed with restorative procedures (Fig.6). Healing abutment was removed and a closed tray impression cop- ing was fitted onto the implant (Fig. 7). Radiograph was taken to confirm complete seating of the impression coping. A full-arch impression was taken with heavy body PVS impres- sion material (Panasil Tray Soft, Heavy Body Regular Set, Kettenbach GmbH)(Fig.8). Healing abutment was replaced once impression was taken. A bite registration (Futar D Fast Set Ketten- bach GmbH), new opposing impres- sion (Silginate plus Panasil Light Body Fast Set, Kettenbach GmbH) and shade map were taken. All clini- cal product was sent to laboratory along with shade photography and a complete written prescription. A PFM high noble crown and Atlantis goldhuecustomabutmentwerepre- scribed. The abutment was ordered astissuecontouringwith1mmdeep margin placement circumferentially (Atlantis,DentsplyImplants). The use of a custom abutment allows modification of transmucosal tissue profile and to ideally position margins. Tissues were previously shaped with the ovate pontic of the temporary partial. The final crown was planned to be chairside custom stained. Lab was cautioned that oc- clusiononthisrestorationwasinthe path of patient’s crossbite transition fromnormaltocrossbite. The laboratory (Drake Precision Dental Laboratories, Charlotte, N.C.) partnered with Atlantis (DENTSPLY Implants) for abutment design and milling and then fabricated the PFM crown (Figs. 9-10). The patient was appointed for definitive restoration delivery. Delivery appointment was un- eventful. Healing abutment was re- moved and the Atlantis abutment was placed (Fig. 11). Because of posi- tive tissue pressure from tissue con- touring, the abutment was slowly placed with incremental turns of the retention screw. Tissue blanching wascarefullyobserved. The abutment was fully seated and, within five minutes, tissue blanching had disappeared. The Atlantis abutment was torqued to manufacturer’s specifications (30 Ncm). A radiograph was taken to confirm final seating of the abut- ment. The PFM crown was tried on and interproximal contacts adjusted to allowcompleteseatingofthecrown. Occlusion was marked with ap- propriatearticulationribbonandad- justments were accomplished, with particular attention to functional pathandcentriccontacts. Thefinalocclusionrespectedthe cross bite while providing a light oc- clusalcontactthatbecamenormalin intensityuponbitingforce.2 Allfunc- tional contact was adjusted to be in minimal contact during excursions. Adjacent teeth provided partial groupfunction. Once all clinical adjustments were done, a laboratory technician was consulted for final shade match- ing. The initial shade was very close toideal. The technician accomplished minor modifications (minimal characterization staining and reduc- tion in final surface gloss). Proximal contacts and occlusal table were pol- Fig.1.Fractured tooth.(Photos/ProvidedbyDr.LarryR.Holt) Fig.5.Healedimplant sitewithhealingabutment. Fig.3.Bonegraftingandmembraneplacement. Fig.7.Placement ofimpressioncoping. Fig.2.Immediateimplant placement. Fig.6.Wellhealedmucosa. Fig.4.TemporaryDuratekpartial. Fig.8.FinalPVSimpression.