The patient gave a history of hypertension and gastritis for which was taking Lacidipine 4mg, Omeprazole 20mg and Simvastatin 40mg.

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1 A.S. was referred by her general dental practitioner for assessment for possible implant placement to restore the space where her bridge replacing her maxillary central incisors had recently failed. Fig 1,Fig 2, Fig 3 Figure 1 Figure 2

2 Patient s Presenting Complaint A.S. was concerned by having to wear a partial denture. Previous Dental History The patient gave a history of fracturing her post crowned upper left central incisor in This tooth was subsequently extracted by the referring dentist and a two unit bridge cantilevered from the 11. This restoration survived for seven years until 11 fractured at gingival level with a pulpal exposure. This was endodontically treated and the bridge recemented using post retention but was referred when the post fractured. A provisional removable partial denture was provided. Past Medical History The patient gave a history of hypertension and gastritis for which was taking Lacidipine 4mg, Omeprazole 20mg and Simvastatin 40mg. Habits There was evidence of wear of the patient s lower incisor teeth which may have been due to parafunctional activity. The incisal edges did not appear sharp when palpated indicating that this was most likely to have been historic. Family History A.S. is a married retired female 68 year old Caucasian. Extra Oral Examination Normal facial contours and lip profile with removable partial denture in situ. Symmetrical lip line with gingival margins exposed at rest; high smile line.fig 3 Figure 3 2

3 No facial asymmetry. Normal mouth opening and temperomandibular joint function. No evidence of muscle hypertonicity. Intra Oral Examination Soft Tissues Healthy lining mucosae. Periodontal Health Periodontal health was good but with an isolated 5mm pocket mesio buccal 27.There was no bleeding on probing. Oral hygiene was considered good and the patient reported regular attendance at her practise s hygienist. Gingival tissues were firm and stippled with a thick bio-type. Teeth Present Restorations Present 3

4 Composite resin plastic filling Amalgam filling Cast gold crown Porcelain fused to metal crown Occlusal Relationship Incisor and molar occlusion Class 1. Deep overbite complete onto teeth and RPD. Bilateral canine guidance and incisal guidance on lateral incisor teeth with disclusion of posterior teeth. Special Investigations Alginate impressions were secured in metal Rim Lock trays and study casts fabricated and mounted on a semi-adjustable articulator in ICP. (Denar Mk II.) Radiographic Investigation A periapical radiograph was taken to assess bone height in the 21 site and the prognosis of the 11 root. Fig4 Aesthetics Figure 4 4

5 Aesthetics were compromised by the absence of 21 and the crown fracture of 11. The removable partial denture gave reasonable aesthetics but was compromised by the presence of stainless steel clasps. High smile line. Diagnosis Poor aesthetics due to absence of 21 and crown fracture 11. Periodontal pocket 27 but otherwise healthy periodontium and good oral hygiene. Poor perception of taste and temperature due to removable partial denture. Prognosis Good long term prognosis for all teeth except 11 root. Patient s Attitude A.S. was well motivated, with excellent oral hygiene. She relies on public transport with a round trip of 80 miles. Patient s Desires The patient requested a solution which was fixed and had a good long term prognosis. Treatment Aims Maintenance of dental health. More functional restoration with improvement to aesthetics. Treatment Options 1) Retention of 11 root and new removable partial over-denture. 2) Retention of 11 root and provision of post crown and restoration of 21 space with a) Removable partial denture. b) Implant retained crown. 3) Extraction of 11 root and implant retained crowns 11 and 21 sites. Treatment Plan The patient expressed a preference for a fixed option. Although it may have been possible to remove the fractured post within the 11 root this may have compromised the root integrity with an increased risk of root fractures. 5

6 Extraction of 11 and immediate implant placement was planned with an implant placement at 21. The removable partial denture was to be adjusted and used as a provisional restoration. The implants were to retain individual ceramic/zirconia crowns. Phase 1 Diagnostic Wax Up Study casts and face bow transfer. An impression of the existing RPD was used to copy acceptable profiles of 11 and 21. A surgical guide derived from the wax up. Attention to periodontal pocket 27 by referring dentist. Phase 2 Extraction 11 and immediate implant placement. Placement of implant 21. Phase 3 Definitive crowns 11, 21. Phase 4 Post operative review and maintenance visits. Treatment Phase 1 Mounted study casts in inter-cuspal position. Fig 5 6

7 Figure 5 Mounted Study Casts Phase 2 Buccal flap reflected Extraction 11 root using periotomes. Drilling protocol using drilling guide. 11 and 21 sites. Fig Ø mm x 15mm drill 2.4/2.8 Ø mm x 15mm drill. 3.2/3.6 Ø mm x 5mm, partial depth. Placement of 2 x Nobel Active Internal connection implants RP 4.3Ø x 15mm at 45 Ncm. 2 x Nobel Active Healing Abutments RP 3.6Ø x 3mm placed. Hand torqued Healing abutments just supra gingival. 5 x 5 Ø Vicryl resorbable sutures. Fig 7. Post operative radiograph. Fig 8 Figure 6 Surgical guide Figure 7 suture placement 7

8 Figure 8 Post Implant Placement Phase 3 Five months post implant placement closed impression coping were used to secure a fixture level impression. Fig 9. A poly-vinyl impression in a custom tray was used. An impression of the opposing arch was taken in alginate. Figure 9 Open tray impression copings Radiographic confirmation of correct seating of the impression copings was verified with a long cone radiograph. Fig 10 and the copings reseated in the impression. 8

9 Figure 10 Radiograph to confirm seating of copings Figure 11 Copings re-seated in PVS Impression Shade selection was made to match the adjacent teeth. Fig 12. Figure 12 9

10 Figure 13 Nobel Active Replicas As an immediate approach had been used for the 11 site it was difficult to place the implant for a palatal screw access hole. As a result a cemented option was chosen using zirconium abutments with Procera zirconium crowns. The abutments were fabricated in resin, scanned and customised CAD CAM zirconium abutments fabricated. These were scanned and zirconium copings fabricated and layered with feldsphatic ceramic. The abutments were seated Fig 14,15 16 and their correct seating verified radiographically prior to final torque to 35Ncm. Figure 14 Figure 15 10

11 Figure 16 The access cavities were sealed with PTFE tape and the crowns cemented with Rely X resin modified glass ionomer cement. Fig 17 Figure 17 One year post implant restoration, complete papillary infill has occurred as per Denis Tarnow s studies (1), (2), indicating that the distance from the crestal bone to the contact point was 5mm or less and that the inter implant distance in the horizontal plane was 3mm. Fig 18 Good peri implant bone levels with no evidence of inter-implant bone remodelling at one year. Fig 19 11

12 Figure 18 Figure 19 12

13 Figure 20 With hind sight I would have preferred to have delivered screw retained crowns. This would have required extraction of the 11 root, allowing the socket to heal prior to implant placement. Initiating the osteotomy preparation in new extraction sites can be difficult when good primary stability is to be achieved. A slight labial inclination results when the initial start drill for the osteotomy preparation is placed two thirds up the palatal wall of the socket. However, by replacing the root with an immediate implant preservation of the median papilla is more likely to occur than if the root was extracted and the ridge allowed to heal. Phase 4 A.S. was very pleased with the final aesthetic and functional outcome. Regular review appointments have been arranged on a six monthly basis for the first year and annually thereafter. Discussion An excellent aesthetic and functional result was obtained with no preparation of the adjacent teeth. An alternative fixed prosthesis would have been a resin bonded bridge but as the 12 has a mesio-buccal rotation and both lateral incisors have a small surface area on their palatal surface there may have been compromise in aesthetics and retention. 13

14 A conventional fixed bridge would not be indicated due to the risk to preservation of vitality of 22 and 12. The immediate implant was placed 3-5 mm beyond the socket apex as per the study by Devorah Schwartz-Arad et al(3) A platform switching approach was employed with the Nobel Active implant. Soft tissue aesthetics and stability were crucial as the patient has a high smile line. Maintenance of coronal bone levels is expected due to the implant design being narrower at the head compared to the main body allowing less pressure on the bone in this region. At one year no bone resorption is evident radiographically. References 1) Vertical distance from the crest of the bone to the height of the interproximal papilla between adjacent implants. Tarnow D. Elian N. Fletcher P. Froum S. Magner A. Cho SC. Salama M. Salama H. Garber DA. J. Periodontol 2003 Dec;74(12): ) The effect of the inter implant distance on the height of the inter implant bone crest. Tarnow DP, Cho SC, Wallace SS. J Periodontol Apr; 71(4): ) The Ways and Wherefores of Immediate Placement of Implants Into Fresh Extraction Sites: A Literature Review. J. Periodontal 1997;68: Schwartz-Arad D., Chaushu G. 14