Immediate placement and loading with provisional screw retained crown at #21

Situation

Patient Information

Patient: 62 years old female

Medical history: Hepa B, DM, HBP

Chief complaint: "The upper front teeth are mobile."

Pre-operative observation

Diagnosis & Treatment Planning

Tooth 21: Chronic periodontitis and tooth migration with mobility 3

Tooth 11 and 22: Periapical lesion

Treatment plan: Immediate placement and loading on #21

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Careful extraction of #21 and thorough irrigation with saline solution.

The extraction site was drilled 1 to 2mm deeper than implant length and prepared with a one size narrower final drill to obtain primary stability on the apex.

4.0x11.5mm IS-ll active implant was connected to a fixture driver. The fixture driver is to be accurately placed if an orange line is leveled at the most coronal part of an implant.

Implant was inserted and bone grafting was not performed since labial fenestration has not occurred. Implant depth should be subgingivally measured deeper than 3mm beneath the gingival zenith by an orange line and 1mm interval of graduation of a fixture driver.

The implant has been placed palatally. The labial gap between the implant and the bony walls needs to be filled with bone materials.

Provisional abutment is being connected to the fixture.

The soft tissue harvested from the palatal donor site was grafted to the labial side.

The gaps between the implant and the bony socket walls were filled with bone materials (Calpore & RegenOss) and connective tissue was grafted to make thick soft tissue on the labial side.

40Ncm of primary stability and MI fixation had been achieved with D032 of bone density, so the decision for immediate loading was confirmed. The CT graft was placed utilizing the Buser suture technique.

Postoperative radiograph of the implant in place with a provisional restoration.

Donor site was simply sutured.

Two weeks outcome shows revascularization of the graft.

4 weeks later, the graft appeared to be well healed.

Thick biotype generated on the labial side after 3 months of placement.

A SCRP type of final restoration is being delivered 3 months after the surgery.

The interdental papilla is healthy and remained in a stable position. The gingival level was lower than expected due to flapless immediate placement and loading with CT graft

#21 keeps a convex contour at the labial aspect as a result of lingual placement and CT graft on the labial side.

Periapical radiograph taken a year after immediate loading shows no bone loss.

3 years follow-up shows healthy and well maintained gingival level on #21 implant.

3 years postoperative panoramic radiograph shows well maintained implant without any noticeable bone loss.