Author: Prof. Msc. João Moretti
The execution of an adequate temporary component that fulfills a patient’s desire both for esthetic as well as for functional purposes in reference to immediate implants, is critical because those temporary pieces provide the gingival conditioning needed to receive the permanent crown, obtaining the natural format of the emergence profile. The clinical case presented here reports the esthetic reestablishment with Arcsys implants and immediate temporary pieces after the exodontia of two deciduous anterior dental elements that could not possibly be maintained. Also, the clinical case aimed at maintaining the bone and gingival architecture.
Keywords: dental implants, immediate load, immediate temporization, dental agenesis, emergence profile.
Dental agenesis is the most common form of dental anomaly reaching around 20% of the population. Its etiology is related to nutritional, traumatic, infectious or hereditary factors. Other factors such as viral pathologies and endocrine problems may also be involved (Moreschi et. al., 2010). The most affected teeth are inferior pre-molars followed by upper lateral incisive teeth (Ribeiro et.al., 2011).
The installation of implants followed by the placement of immediate temporary crowns guarantees, besides the psychological benefits from the patient’s perspective, a shorter treatment and a lower number of surgeries, with the consequent reduction in the cost of treatment, besides the preservation of the soft tissue and of the bone architecture (Misch 2007).
The present case report aims to demonstrate the different options that the Arcsys system provides for making immediate temporary pieces. The permanent teeth were manufactured in ceramics three months after osseointegration.
20-year-old leukoderma female patient with presence of anterior maxilla deciduous teeth (Figure 1, 2, 3 e 4).
Figure 1: Frontal intraoral photograph of the patient.
Figure 2: Anterior sextant, seen in detail.
Figure 3: close view of deciduous element 52.
Figure 4: Close view of element 63.
In the radiography, it is noticeable that the preservation of the deciduous teeth was compromised (Figure 5).
Figure 5: Panoramic radiography showing the absence of the medium and apical portion of the roots of elements 52 and 63.
After syndesmotomy, the sufficiently invasive exodontia was carried out, aiming at maintaining the integrity of the bone and gingival architecture of the area to be rehabilitated with the implant. Therefore, the option was to perform a surgery with immediate implant with immediate load.
The site for the installation of the implant was prepared with the use of one single 2.4mm drill. It was introduced for 13mm having the vestibular gingival margin as a reference. The option was for a 3.3mm-diameter x 11mm long implant, which obtained a primary stability of 45N (Figures 6,7,and 8).
Figure 6: single-step drilling with the 2.4mm drill.
Figure 7: Installation of the implant after single-step drilling.
Figure 8: Measuring the final insertion stability in the region of element 12.
For that area, a foldable abutment for cement-retained restoration (transmucosal height of 2.5mm) was customized at an angulation of 8.5° by means of the folding device and was activated onto the implant, with previous aspiration of its interior, with the use of the abutment placement tool (Figures 9 and 10).
Figure 9: positioning the 3x4mm abutment for cement-retained restoration and assessment of the prosthetic spaces.
Figure 10: Fixation of the 3 x 4 abutment for cement-retained restoration with the abutment placement tool.
As for the area of the canine tooth, a 3.8x11mm implant with 60N of load was installed. The professional opted for the utilization of the PEEK multifunctional healing abutment, which was previously coated and finished with acrylic resin, which resulted in an emergence profile favorable to healing (Figures 11, 12, 13, 14, 15, 16 and 17).
Figure 11: bone condition after the removal of the deciduous element.
Figure 12: installation of the frictional connection implant 3.8X 11.
Figure 13: measurement of the final implant insertion stability.
Figure 14: multifunctional healing abutment in PEEK.
Figure 15: Positioning of the healing abutment.
Figure 16: temporary tooth adapted to PEEK following the emergence profile.
Figure 17: temporary tooth installed.
The patient was discharged after receiving the prescription for antibiotics, anti-inflammatory and analgesic medicines, besides the post-operative recommendations. One week after the surgery, the stitches were removed together with the resin from the interproximal walls, leaving the temporary tooth individualized. She came back to the office for follow-ups after 1 week, 3 weeks and 90 days (figures 18. 19 and 20).
Figure 18: healing of the lateral area after 1 week.
Figure 19: healing of the canine area after 1 week.
Figure 20: gingival conformity obtained.
Three months after healing, an abutment was installed in the area of the canine and was followed by transfer molding, metallic burn-out coping, transfer molding of the coping, application of ceramics and glaze, according to the selected shade (Figures 21 and 22).
Figure 21: impression caps for molding in position.
Figure 22: positioning of the analogs.
The abutment for cement-retained restoration of the lateral area was previously submitted to a metal primer application. The cementation of the crown was carried out with dual resinous cement (Figures 23 and 24).
Figure 23: application of metal primer on the abutment for cement-retained restoration for cementation.
Figure 24: cementation of the crown.
The crown in the area of the canine was screwed and, after the protection of the head of the screw, the crown received a restoration with composite (FGM Opallis) (Figure 25).
Figure 25: visual aspect right after the installation of the ceramic crowns.
The patient received follow-up six months after the finalization, and the peri-implant tissues have remained stable since the surgical procedure (Figure 26).
Figure 26: 6-month follow-up.
The immediate implantation has the advantage of achieving better, faster and more functional results under a predictable treatment strategy with a high success rate. Those implants allow for a reduction in the number of surgeries and of the length of time between the extraction of the tooth and the final restoration of the prosthesis, prevent bone reabsorption and help maintain the alveolar ridge in terms of height and width (COVANI et. al., 2004).
The installation of type 1 immediate implants (in the exodontia procedure), in spite of being technically more difficult, may present a series of advantages related to tissue conservation. Depending on the alveolar architecture and the presence of the alveolus in favorable conditions, it may be possible to reach optimum primary stability, which will allow for immediate prosthetic rehabilitation, promptly giving back to the patient their visual appearance (HAMMERLE. et al., 2004)..
The installation of immediate prosthetic components together with peri-implant plastic surgeries, eliminating a second surgical step, aims at reducing treatment times, preventing gingival recessions and minimizing the loss of the remaining bone, favoring the tissue accommodation around the component2. In that aspect, the development of new and biocompatible materials help the professional to reach a harmonious gingival contour (JAMBHEKAR et al., 2015).
Exodontia combined with the installation of the implant and the temporary crown presents esthetic, psychological and functional advantages and, at the same time, it reduces treatment duration. Healing of soft tissues happens concomitant to osseointegration, promoting the stability of the gingival level.
For ideal results, in cases with immediate installation, the professional must be aware of the primary stability and the effective cleaning of the contaminated site. When it is possible to use customizable components, the prosthetic viability is evident, favoring the surgical care taken for the surrounding tissues with the most natural emergence of the prosthesis. Presently, esthetics is determinant for the success of rehabilitations with dental implants, especially in the area of the anterior maxilla.
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