Immediate implant placement using a guided surgery approach

Treatment planning

A thorough intraoral and extraoral examination was conducted.

The main findings were:

UR2 is failing, post and crown is mobile grade 1 (fig. 1)

Figure 1 – Failing UR2 post and crown

Periapical radiograph revealed that there is a potential vertical fracture (fig.2)

Figure 2 – Vertical fracture identified

Oral hygiene needed some improvement

The UR2 tooth was considered as unrestorable.

All possible treatment options were discussed with the patient (no treatment or extraction of the UR2 and accepting the gap/removable denture/bridge/implant supported crown). All risks, complications, prices, success rates, and survival rates were discussed. The patient was allowed to ask as many questions as he wanted.

As the patient was only interested in the implant supported crown option, we proceeded with a CBCT (to check the quality and quantity of the bone) and intraoral scanning.

In my practice, almost 100% of the implant cases are fully-guided, so the CBCT scan results (in DCM format) in combination with the STL files from the intraoral scanner are used for treatment planning and the design of the surgical guide. SMOP software was used for the detailed treatment planning (fig.3, fig.4, fig.5).

Figure 3 – Treatment planning

Figure 4 – Treatment planning

Figure 5 – Treatment planning

In this case I was able to offer the immediate placement of the dental implant (due to the lack of acute infection and presence of the bone apically to the socket).

The treatment plan was presented to the patient. All the risks and the benefits of the immediate treatment were discussed with the patient.

Patient was happy to proceed with the proposed treatment, full written informed consent was obtained.

The guide was designed and printed by Veus Dental lab (fig.6).

Figure 6 – Surgical guide design

In my everyday practice, I use Anthogyr Axiom X3 implants in combination with the Anthogyr INTEGRAL fully guided kit (fig.7).

Figure 7 – Anthogyr INTEGRAL fully guided kit

This allows me to achieve predictable results in even the most challenging situations.

In this case, the main challenges were:

Anterior area
Immediate placement
Narrow space

Treatment provision

The UR2 was atraumatically extracted using the elevators (fig.8, fig.9).

Figure 8 – Atraumatic extraction

Figure 9 – Extracted UR2

Socket debridement was performed using hand instruments and degranulation burs with good irrigation.

The guide was tried in the patient’s mouth (fig.10).

Figure 10 – Surgical guided tried in the mouth

Anthogyr Axiom X3 implant (3.4 x 12) was placed through the guide, following fully guided osteotomy (fig .11, fig.12, fig.13).

Figure 11 – Implant placement through surgical guide

Figure 12 – Implant placement

Figure 13 – Implant placement

The torque that I have managed to achieve was 30 Ncm, so I was able to place the healing abutment (hand tight). The buccal gap was filled with a mixture of the allograft bone substitute and autogenous bone that was collected during the osteotomy (fig.14, fig.15, fig.16).

Figure 14 – Implant in situ

Figure 15 – Bone substitute material placed in buccal space around implant

Figure 16 – Post operative radiograph

Following the 12-week healing period, the patient came back for impressions. The soft tissues around the implant looked pink and healthy. The healing abutment was replaced with the In-link abutment – this basically allows us to convert bone level implants into tissue level implants.

As you have probably already noticed on Fig.3, the access channel of the future crown was a bit too buccal. I was fully aware of this, but not concerned thanks to the beautiful solution available from Anthogyr, called Ax-in. With the help of this sophisticated invention, it is possible to correct the angulation by up to 25 degrees, without the need for a cemented crown. Even better, it allows connection of the crown and the abutment without an adhesive, which eliminates the risk of debonding.

SIMEDA milling centre was used for the production of the Ax-in abutment and Zirconia frame. From Steve Butler Ltd, dental technician Magda Frackiewicz completed all the ceramic work (fig.17, fig.18, fig.19, fig.20).

Figure 17 – Ceramic crown

Figure 18 – Ceramic crown

Figure 19 – Ceramic crown on model

Figure 20 – Ceramic crown on model

Outcome

The restoration was fitted in the patient’s mouth without any issues. The patient was very satisfied with the aesthetic and functional result delivered.

Utilising the benefits of the modern day’s implant dental solutions allowed me to achieve the desired result in minimally invasive way.

Figure 21 – Final outcome

In this case I wanted to show that utilising the benefits of the modern day implant dentistry allows you to achieve desired results in minimally invasive way.

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Author biography:
Dr Levs Gavrilovs
GDC 187540 BDS Latvia 2003

Levs graduated in 2003 in Latvia and has since worked as a general dentist with a special interest in restorative and implant dentistry. He has completed a Postgraduate Certificate from the British Academy of Implant & Restorative Dentistry (Leeds), a PG Dip Advanced Implant Dentistry Vita-Salute San Raffaele University (Milan), and a PG Certificate in Advanced Aesthetic Dentistry UCL Eastman (London). He is currently the principal of Spilsby Dental Practice and is a KOL for Anthogyr, offers a range of advanced implant solutions for patients including full arch reconstructions, immediate placement protocols, guided surgery and GBR.