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ePaper created 2017-03-17, 11:08:54 | version 1.38.0
I m p l a n t a n d o r t h o d o n t i c t r e a t m e n t Before implant placement, the stereolitho- graphic surgical template was adapted to the master cast. The patient underwent profes- sional oral hygiene and received prophylactic antiseptic (0.2% chlorhexidine for 1 min) and antibiotic therapy (2 g of amoxicillin and clavu- lanic acid). Local anesthetic was administered with a 4% articaine solution with epinephrine 1:100 000 (Ubistein, 3M ESPE). The surgical template was placed intraorally in relation to the opposing arch using the silicone surgical index derived from the mounted casts and sta- bilized with two anchor pins. A flapless guided pilot drill was employed using the surgical tem- plate, and the continuity of the implant site was evaluated with the aid of a periodontal probe (PCPUNC156, Hu-Friedy, Milan, Italy). The im- plant was placed freehand in the planned ana- tomical site according to a one-stage approach, without tissue grafting. The final insertion torque was 37.5 N cm (iChiro Pro, Bien-Air Dental, Biel, Switzerland). A new definitive impression of the maxilla was made using a polyether material (Imp- regum) and poured in Type IV stone (Techim Super Stone). This master cast was cross-mounted in a semi-adjustable articulator and a temporary acrylic restoration was fabri- cated using a temporary titanium abutment (Osstem). The temporary restoration was screwed to the implant with prosthetic screws tightened according to the manufacturer’s instructions (30 N cm) 24 h after implant place- ment, as directed by an immediate loading protocol. The prefabricated temporary acrylic restoration was trimmed and polished chair- side. A nonoccluding occlusal scheme was de- livered (Fig. 6). After implant placement, the patient received oral and written instructions regarding medication, oral hygiene mainte- nance and diet. A periapical radiograph was taken with the paralleling technique in order to exclude radiolucency or other complications. The final restoration was delivered three months after implant placement. The zirconia framework was fabricated using CAD/CAM technology (New Ancorvis, Bargellino, Italy) and veneered with ceramic. The screw-retained definitive restoration was finally attached at the torque setting recommended by the man- ufacturer (30 N cm; Figs. 7 & 8). The occlusion was carefully adjusted and the patient was recalled every 4 months for hygiene mainte- nance and annually for occlusal adjustment (Figs. 9 &10). Discussion In the present report, the case was treated successfully with orthodontic space opening and prosthetic replacement of the missing lateral incisor with a single implant-supported crown. This case report aimed to describe the novel Osstem TSIII 3.0 mm (Osstem) implant used, which allows for the replacement of maxillary lateral incisors and mandibular in- cisors. Prompt diagnosis and an interdisciplin- ary approach, guided by functional and es- thetic demands, are essential for the proper management of such complex cases. Teenag- ers with late mixed dentition or newly devel- oped permanent dentition often seek treat- ment for the congenital absence of maxillary lateral incisors, because, during this period, the esthetic problem becomes more evident. When maxillary lateral incisors are miss- ing, there are several factors to consider be- fore treatment with space opening or closure. These factors include the type of malocclu- sion, crowing/spacing, tooth size relation- ships, canine position, shape and color of the canines, and upper lip length.6–8 The choice between these two modalities of treatment should not be made empirically. In most in- stances, the presence or absence of major occlusal problems serves as the primary cri- terion for either space closure or space open- ing.9 Lateral incisal spaces should be closed in cases in which malocclusions require the ex- traction of permanent mandibular teeth.4 Mandibular extractions may be indicated to relieve anterior or posterior arch length defi- ciency, to reduce mandibular dentoalveolar protrusion or to compensate for a Class II molar relationship. Some orthodontic patients may be missing several permanent teeth, in- cluding maxillary lateral incisors. If teeth have been missing for several years, the remaining teeth may have drifted. In these patients, ortho dontists and restorative dentists may not know what the restorative requirements are or what the eventual restorative treatment plan should be. For these types of patients, it is suggested to predetermine the final occlu- sal and restorative outcomes by creating di- agnostic wax setups.10 In addition, the trial setup will allow identification of tooth surfac- es that require functional and esthetic reduc- tion so that equilibration may be initiated either at the beginning of or during the ortho- dontic treatment. Journal of Oral Science & Rehabilitation Volume 3 | Issue 1/2017 13