Extraction and Immediate Implant Placement Provides Patient Satisfaction
A 29-year-old male patient undergoing a comprehensive oral exam had one chief complaint: “My front tooth has been tingly and causing [me] some pain.” The patient said a dentist previously told him he might eventually lose his front teeth because he had shallow roots.
A digital periapical x-ray and panoramic x-ray of teeth Nos. 7 through 10 showed morphologic changes consistent with rapid orthodontic movement that the patient had experienced years ago (Figures 1 and 1A). This analysis was confirmed during further discussion with the patient. The patient’s full medical history was non-contributory, there were no functional issues present, and his periodontal status was healthy.
Next, my associate, Dr. Lisa Minkowski, wanted a CBCT of the region and used our practice’s ProMax 3D imaging unit (Planmeca). After we reviewed the scan, Dr. Minkowski and I discussed all treatment options, and she presented several treatment plans to the patient. Dr. Minkowski was able to review the CBCT with the patient, using Planmeca Romexis software, and we virtually placed the proposed implants. After the patient could clearly see where the new implants would be located, he elected to do 4 anterior implants (Figure 2).
A full field-of-view CBCT, polyvinyl impressions, and bite were performed and sent to our surgical guide lab (3D Solutions).
The patient was referred to our oral surgeon, Dr. John Domanico, for evaluation of the proposed treatment plan. Dr. Domanico explained in detail the surgical phase of the proposed treatment. We informed the patient of the possibility that only 3 implants could be placed, and not the proposed 4 implants. We also explained that it was entirely possible that we might not place implants that day and just extract and graft the area. Because of the clear and detailed images we were able to review, we were confident that we could get 3 to 4 implants placed.
To cover all the bases, we devised a backup plan in the unlikely event that on the day of surgery, we were not able to place provisional crowns. We elected to have a treatment partial ready to be inserted, if needed.
The patient was brought back to our practice so that Dr. Minkowski and I could discuss the treatment plan with him:
1. Extraction and immediate placement of implants.
2. Placement of temporary crowns
3. Possible placement of a treatment partial and burying the implants for 20 plus weeks.
Virtual Meeting and Surgery
The next phase was to hold a virtual meeting to complete the final plan. The laboratory, per my instructions, understood this would be a guided key surgery using a guided surgical kit (BioHorizons). We began our meeting reviewing the size of the implants, direction, and placement (Figure 3).
Two weeks later, the 3D-printed surgical guide (Figure 4) arrived back in our office.
On the day of surgery, the patient was administered nitrous oxide and IV sedation. His teeth were extracted atraumatically with the use of a Periotome (Hu-Friedy) and Physics Forceps (Golden Dental) (Figure 5), and the roots were clinically resorbed (Figure 6).
The sockets were denuded, the surgical guide was placed, and the fit was verified. (Figures 7A and B). A keyed surgical kit was used to place the implants. Tapered Internal Plus Implants (BioHorizons) were then placed. A panoramic radiograph was taken to verify placement and parallelism of the implant bodies.
We then placed temporary abutments that were provided by the lab. The crowns were tried in, and this is where Plan B was so important. We did not like the facial and incisal orientation of the temporary crowns, so we elected to place healing caps and the treatment partial. We relieved the intaglio portion of the treatment partial to avoid applying any pressure to the implant bodies.
The patient returned to our office the following day for treatment partial adjustments. The patient was monitored weekly and then on a monthly basis. The patient returned to Dr. Domanico for postoperative evaluation of the implant bodies 1-week post-surgery, and then for monthly evaluation. After 5 months of integration, we began the prosthetic restoration of the implants.
Open tray impressions were taken using Splash! Max impression material (DenMat). The patient was then sent to our local cosmetic laboratory for custom shading and characterization. The difficulty with this case is that we were unable to use zirconia abutments because of the narrow diameter of the implants. The final restorations were a low translucency e.max (Ivoclar).
Dr. Minkowski tried in the abutments, and fit was verified using the ProMax HD Sensor (Planmeca). The crowns, on the other hand, did not seat. I instructed Dr. Minkowski to anesthetize and use the NV Diode Laser (DenMat) to remove the offending tissue that was preventing seating of the crown. When completed, the crowns slipped into place.
We evaluated the esthetics and it was decided that pink porcelain was required to provide the proper gingival zenith. The patient became tired of his treatment partial, so we decided to make him temporaries to go home. Each screw was torqued to 30 ncm and Teflon tape was placed. Then, crowns were placed, and we proceeded to use ClearBite (DenMat) in an anterior tray to obtain a clear matrix to fabricate temporaries.
The temporaries were fabricated using Perfectemp 10 (DenMat). The patient was then sent to Advanced Dental Studio in Chicago for more customization and characterization. The patient returned to our office, and the case was successfully delivered.
This case was a success because we were able to properly anticipate and plan the case out virtually. The use of CBCT technology in the general dentist’s office is critical for proper treatment planning. The amount of detailed information we gain about the maxillofacial complex is invaluable to ensuring the best outcome possible for our patients.
In February, we will have had our Planmeca ProMax 3D for 5 years. Throughout this period, we have relied on this technology to improve and enhance our diagnostic and treatment skills.