Page 14 - GP Fall Final 2017

2.8, 3.4 and 3.8mm drills at 1280 rpm. A sional. The buccal gingival aspect of the (RelyX) (3M, St. Paul, MN)(Figure 13).
4.7x13mm SBM tapered Legacy 1 (Im- crown was undercontoured.
plant Direct, Carlsbad, CA) implant was
manually placed with a straight driver, fix- Guided bone regeneration was performed
ture mount and 2.5mm hex tool (Figure 6). consisting of a mixture of mineralized irra-
diated bone allograph, PRP and PRF. The
mixture was placed in the “gap” located
between the socket walls and the implant
surface. The grafting mixture was packed
and covered coronal to the abutment/im-
plant interface with various size pluggers
(Figure 10). Figure 13. Final prosthesis: all-ceramic crown.

Figure 6. Implant 4.7 x 13mm. Discussion
Immediate implant placement and provi-
A torque wrench set at 35 Newton centi- sionalization (IIPP) is recognized as a min-
meters was applied to the implant body imally invasive approach for replacing a
1mm coronal to final placement to evaluate non-restorable tooth. This concept deviates
the degree of fixation (Figure 7). A torque from a delayed approach where a stress-
value greater than 35 Newton centimeters free loading period is observed during a
was achieved and the implant was seated three to six month osseointegration peri-
completely. od. Studies have supported the concept of
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Figure 10. Healing collar 4.7x3mm. IIPP when comparing histology, survival
The provisional was cemented with a tem- rates, recession and patient acceptance to
porary cement. The occlusion was mod- early, delayed or staged approaches. IIPP
6-8
ified to eliminate all contacts in centric research demonstrates high success rates
occlusion, protrusion and excursions. The based on stable crestal bone levels while
incisal edge was shortened in comparison other studies exhibit bone gain. 9-11 Studies
to the adjacent tooth (Figure 11). exhibit better tissue stability and lower lev-
els of recession around implants restored
with a provisional. 12-14 This finding may be
Figure 7. Torque wrench. in part due to less connections/disconnec-
A 4.7 transfer pin was screwed into the im- tions of component parts which can impair
plant body and a periapical radiograph tak- the mucosal barrier promoting apicaliza-
en (Figure 8). Orthodontic wax was placed tion of the junctional epithelium.
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into the screw access hole and a polyvinyl-
siloxane (Imprint III, 3M, St. Paul, MN) The clinical and diagnostic evaluation is
impression taken. essential when determining if IIPP will
produce a successful outcome. Proper di-
Figure 11. Provisional crown. agnosis and understanding of the biologi-
A commercial laboratory poured the im- cal and periodontal variables of the failing
plant impression and mounted the case. dentition and their response to surgical and
A zirconium abutment was designed and prosthetic procedures are the essence of
manufactured with a buccal margin placed predictability. A class I socket classifica-
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1.5mm coronal to the abutment-implant in- tion comprising of an intact buccal plate
terface. An orientation jig was fabricated to and ideal soft tissue contour provides for
assist in the alignment of the internal hex the best anatomical foundation for the exe-
orientation. An all-ceramic restoration (e. cution of IIPP procedures.
Figure 8. Impression transfer (4.7mm). max) (Ivoclar Vivadent, Amherst, NY) was
A temporary titanium abutment was placed fabricated. The clinical evaluation includes a visual
into the implant body and modified in three inspection of the gingival margins of ad-
dimensions to develop interocclusal clear- After a three month osseointegration pe- jacent teeth, biotype and smile line. The
ance and crown fabrication. The temporary riod, the final placement of the abutment/ presence of a high smile line with uneven
abutment screw was torqued to 20 Newton crown procedure was performed. After gingival margins in a thin biotype patient
centimeters (Figure 9). removal of the temporary crown and abut- is considered a negative prognostic factor.
ment, the final zirconium abutment was
An acrylic crown shell with self-curing Bone sounding is performed to determine
acrylic was utilized to fabricate the provi- placed. A periapical the presence and location of the buccal
radiograph was tak- plate of bone. The presence of the buccal
en and the abutment plate of bone is an essential parameter for
screw torqued down stable soft tissue. Studies have demonstrat-
to 30 Newton centi- ed that when the buccal plate is located ≤
meters (Figure 12). 3mm from the facial gingival margin then
The final all-ceramic <1mm recession occurs within the first
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crown (e.max) was year. A radiographic evaluation of the sur-
Figure 12. Periapical gical site provides clinical insight prior to
radiograph of final bonded in with a res-
Figure 9. Titanium abutment. zirconium abutment. in bonded material www.nysagd.org l Fall 2017 l GP 13