Extraction of #7 and 8 with Immediate Astra A discussion among dental professionals on the message boards of Dentaltown.com. A terrific case from Dr. Scott Erikson that takes you through the entire process from surgery to final restorations on #7 and 8. Log on today to participate in this discussion and thousands more. Post: 1 of 44 Posted: 7/12/2006 Introduction: Hopeless #7 and 8 removed with immediate implants. I decided not to load them immediately, as I usually do. I thought I would try it this way instead with six-week impressions and handmade acrylic provisional crowns on temporary abutments. The case is still in progress with temps in place for threeto-four months, to allow soft-tissue regrowth. Pre-treatment. Flapped with teeth removal. Hopeless, no loss of facial plate noted with usual atraumatic extractions. Implants placed with surgical guide for cemented crowns through the incisal edges. Cover screws were placed after this photo. Interim RPD [removable partial denture]. Six-weeks. (Far Left) Impressions. (Middle) Made these myself for fun, used Coe- Soft for tissue base. Astra temporary abutments prepared on model. continued on page 18 16 July 2007 dentaltown.com
continued from page 16 In the mouth at 15 Ncm. Sorry, off-axis X-ray. One month with them in place. I will be adjusting the contacts every month to allow the papilla to grow back as much as possible. Three-month observation. Papilla are growing back. Temporary crowns removed. Tissue is scalloped as much as possible with this patient. Verify seating of impression transfers. Impression done for the referring doc as a favor. Impression posts seated. Final crowns with zirconium abutments and allceramic restorations. Smile Palatal. Close-up facial photo. Scott continued on page 20 18 July 2007 dentaltown.com
continued from page 18 figo I would like to thank you for your Post: 2 of 44 case presentation. I have been reading many of your previous cases and I have Total Posts: 15 learned a great deal. I am starting to use Astra and generally am happy with the system. It just takes time getting used to the different restorative components and when to use them. I would be grateful if you could answer a few questions: 1. What size of implants did you use in this case? 2. When doing immediate implants, what is your protocol with dealing with the space between the implant and buccal plate? Do you place any Bio Oss here? Also, when you flapped this case, did you cover the implant and cover screw by repositioning the flap coronally over the implants? 3. Do you find that six weeks time is sufficient time to start taking impressions with the Astra system in the maxilla? kal dr-debbie How long were these Post: 3 of 44 implants? Also, how do you adjust the contacts Total Posts: 216 every month to allow the papilla to grow back as much as possible? This is a really helpful case. Thanks for the great post! Kal wrote: What size of Post: 5 & 6 of 44 implants did you use in this case? 4.5 x 13 and 3.5 x 13 I think. Kal wrote: When doing immediate implants, what is your protocol with dealing with the space between the implant and buccal plate? Do you place any Bio Oss here? I placed collagen in this case, as the defect was very small. In larger ones, I place autogenous bone or xenograft, sometimes FDBA [freeze-dried bone allograft]. Kal wrote: Also, when you flapped this case, did you cover the implant and cover screw by repositioning the flap coronally over the implants? No, I placed the flaps back to their original positions. Kal wrote: Do you find that six weeks is sufficient time to start taking impressions with the Astra system in the maxilla? Yes, all the time, all day long. Also, it is the usual time with Straumann implants. No reason to wait unless the site is extensively grafted. continued on page 22 20 July 2007 dentaltown.com
continued from page 20 Debbie, these are 3.5 and 5.0 x 13 or 15. They were tapped into the nasal floor with osteotomes, in response to your arrows. Just remove the temporary crowns and add acrylic on the lateral portions, and watch the tissues fill in over time. Hope this helps. Scott jmaya Post: 8 of 44 Total Posts: 6,166 Great placement Scott. Please allow me to expand here a little bit. This technique hasn t failed me, yet I do it in reverse. What means is you need to know what the distance from the crestal bone to the contact point is for this phenomenon to occur. If 5mm or less, you can add acrylic about 1mm from the gingiva, and the tissue tends to be sucked coronally. Cut back the contact on the temps in a coronal direction another mm, creating a new gap and the tissue will again grow coronally. Do this until you are about 5mm from the crestal bone, the papilla will stay. If you go beyond this point, the tissue will recede. Now, 5mm is the maximum distance that one should allow, but every patient is different so one needs to be careful because on certain patients, the papilla may only be supported 4mm from the crestal bone. dmd3000 Post: 10 of 44 Posted: 7/21/2006 Total Posts: 54 I used to shape the tissue with my temps and adjust the acrylic many times. Now, I just make sure that my contact is about 4.5mm from the crest of bone with a natural emergence profile and the papilla will grow in. This saves me a lot of time. Alexander Vasserman DDS, BS Post: 13 of 44 Posted: 9/10/2006 Total Posts: 2,087 Scott, I would rethink the titanium abutment and use zirconium instead. Then, you can go all-ceramic, such as Empress. Difference is the ceramist has more thickness to make the zirconium disappear and have a more natural looking tooth. You could bond to zirconium, just do not use silane on it. Your method I m not sure you can bond zirconium to titanium. If it was gold it would be different, but you would need to use a metal primer. Post: 14 of 44 Posted: 9/13/2006 Alex, those are great points and I have advised the GP [general practitioner] to consider using the Astra-zirconium abutments from the start, but she had originally wanted to use titanium. After looking at the case carefully, we have decided to move ahead with this methodology. We are all in agreement here. All the best. Scott tennis nut Post: 20 of 44 Posted: 11/2/2006 Total Posts: 725 Nice result! My questions are: Why not provisional crowns instead of interim RPD? Did you not have enough torque levels for it? Could this have been done without raising a flap? Did you use any bone graft/membrane to cover the exposed threads? Thank you for posting this case and allowing us all to learn. Raj continued on page 24 22 July 2007 dentaltown.com
continued from page 22 Post: 22 of 44 Posted: 11/2/2006 Raj, you could have done this without a flap, but I get more precise placement vertically with a small flap, so I can reshape the bone and see where I am placing the implant crestal portion. I think flapless surgeries are OK, but you oftentimes don t know where you are placing them within the context of the crestal bone. You can also place them too shallow, which can cause nightmares. I don t think I used any bone graft or membrane here. I could have loaded them with provisional crowns, but in my experience, when doing implants in the #7-8 or #9-10 sites together, I get a better aesthetic result this way by allowing the tissues to heal, then working with using provisionals at a later date. More predictable and these implants loaded at only six-weeks anyway, so not that much of a big deal in terms of her wearing a flipper, except the cost. Scott drsami Post: 25 of 44 Posted: 11/4/2006 Total Posts: 87 Dr. Erikson, first of all superb case presentation. Second, I am looking at the X- rays and at the picture of the implants on insertion, why did you bury them that much in the bone? I am no expert, just trying to learn. To my knowledge: 1. The fixture should be at the level of the CEJ [cemento-enamel junction]. 2. Bone level will stabilize about 1.5mm apical to the interface between fixture and abutment, so you are looking at some bone loss in the next year. Please correct me if I am wrong, I do not place implants and I have limited experience (about 100) in restoring them. Again, not trying to find fault with your work, just asking. Dr. Sami, thanks for Post: 26 of 44 the comments. This type Posted: 11/6/2006 of implant should never be placed at the CEJ level, as this would have disastrous aesthetic consequences. It should be placed several mms apical to this level, to allow for proper emergence and for the abutment room. These implants were placed within the confines of these parameters. Single-stage implants, like Straumann implants with a pre-machined abutment margin can be placed at the CEJ level, but still should be placed apical to this level. These implants will never lose bone. Older implants will lose bone, which is why they are outdated, especially external hex implants. Hope this helps. Scott FREE FACTS, circle 5 on card Find it online at This is an excerpt from a case dentaltown.com presentation on the Dentaltown message boards. To read the complete thread or to join in the conversation please visit www.dentaltown.com, type in 7-8 Immediate Astra in the global search text box above the header and click, Search. 24 July 2007 dentaltown.com