Single Stage Implant – Extraction, Placement, Grafting, and Loading of the Implant

Featured case of May 3, 2016May 3, 2016 Oral Surgery

BDS MBBS FDS RCS MRCS

The Implant Centre

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Introduction to the case

This patient has almost perfect teeth, but then developed external resorption of their upper right central incisor. They saw an endodontist who told the patient that it wasn’t restorable, and then the patient found their way to me. The patient has kindly allowed me to show their case.

Here’s more of a close-up. Nothing looks too bad so far.

Even the retracted view is fairly good. Note that the gingival margin of the right central is slightly higher than that of the left. The patient says they would like to keep the midline diastema though they would like it reduced in size a little.

Uh oh – there’s your problem! So we decide to be a little ambitious and do all of her surgical treatment in a single stage – extraction, immediate placement, grafting and immediate loading of the implant.

Atraumatic extraction

The hole goes in quite a long way

Make a small dent in the palatal wall – something to rest your pilot bur onto

Pilot bur in position (a surgeon’s eye view)

For a screw-retained crown, this is the only position for the pilot hole – the bur MUST be touching the palatal soft tissues to pull this off correctly. This is NOT where I would position the pilot hole for a cement-retained restoration

An Ankylos implant, 3.5 x 11mm

Looks good from the front

I’m going to use the extracted tooth for the temporary restoration – you can’t normally do this because usually the extracted tooth is not something that’s aesthetic enough to use

Drill out the pulp horns and remove the material where the implant carrier needs to go

Try it in for size – seems to fit OK

Etch

Wash and dry

Apply unfilled resin and light cure

That’s a big hole there – you can even see the implant itself. I don’t want my composite resin going all the way up there…

These collagen cubes are cheap – I’ll shove one of these up by the implant to block that big hole up

That’s looking better.

A tiny blob of composite to temporarily tack the hollowed-out crown in place.

A little PTFE tape in the screw-hole of the carrier. Now I can use a little flowable composite to attach the hollowed-out crown to the roughened-up carrier

Looks OK from this angle…

But with a little bit of work, the rough outline starts to appear. You can just see the “submergence groove” I’ve created just below the CEJ

Now you’ve got the shape right you can go right ahead and give that crown a little love – really buff it up

And you end up with this. I’m a surgeon, so this is the only restorative stuff I ever do.

And the other side. Please note how the implant is NOT in the middle of the crown, but off to the palatal side of it…

…how else are you going to screw-retain it?

I’ve removed the collagen sponge, and attached a spare carrier to seal the inside of the implant off, ready for the grafting – but just look at that fraenum

Let’s see how much of the fibres of the frenum we can cut through the socket. You won’t get them all but maybe we’ll do just enough

Graft – this is Osteogen moistened with some metronidazole

The Osteogen is packed into the space between the implant and the labial wall of the socket

Take some blood and spin it to create some PRF (this is the latest version of PRF called A-PRF+)

Put the PRF “slug” into the PRF box to squash it down

…a disc of wonderful healing goodness!

Make a hole in the disc – but not in the middle of it. It needs to be off to the side…

It needs to be off to the side because the implant is off to the side of the crown. Feed the PRF disc onto the temporary crown…

…and fit the crown onto the implant – the PRF covers and protects the graft. It’s also going to do one more thing.

Remember that fraenum that I cut the inside of with the scalpel?

Now’s the time to place some periosteal sutures to try and stick it down a little.

PTFE tape to the screw hole. And a final composite seal over that

Before checking the occlusion

And here’s the view from the front. If that PRF does its job, those gingival margins should level off nicely. Note how the incisal tip is slightly higher than the adjacent incisor to reduce the occlusal forces

And here’s the post-op PA. For me, this is the perfect position for this implant system. I understand that others will think it’s too deep – and that’s fine

And the view today, 11 days later. The patient is delighted and so am I

Still looking a bit sore (I’m obviously a rough surgeon!) but look at this gingival margin levels – they seem to be evening up nicely

Here is after 3 months. Fraenum looks a little angry on the photo. The patient is very happy with the temporary crown. Part 2 with the final crown to be posted tomorrow!