IM0210

implants2_2010 soft and hard tissue, remaining dentition, occlu- sion and parafunction, current and required oral hygiene and maintenance. The patient was noted to have a high smile line, clearly showing thedentogingivalcomplexinfunction.Afulldis- cussion outlined the options available to the pa- tient, who after consideration, elected a fixed option, with implant restoration being her solu- tion of choice. The patient was fully aware of the risks and alternatives to the procedure, and given her very recent root fracture affecting the tooth, surgery was scheduled for the same week. Mounted study models were produced, upon which, two vaccum formed stents were made over the tooth in question. Full radiographic as- sessment was undertaken to determine the con- dition of the remaining root, adjacent teeth and roots, while assessing the area dimensionally for implant placement. The patient was prepared for surgery following pre operative consent and an- tibiotics together with repeated pre operative rinsing with chlorhexidine gluconate 0.2 %. Standard surgical scrub and drapes were em- ployed. The upper left lateral incisor tooth was carefully extracted using periotomes to preserve bothhardandsofttissuearoundthesocket.3 This technique facilitates tooth removal without traumatising the alveolar bone of the socket or surrounding gingival tissue. The technique can be performed for any extraction, but it is of par- ticular importance when the subsequent place- ment of dental implants is envisaged. Following atraumatic tooth removal, the socket was thoroughly irrigated, debrided and fully assessed (Fig. 3). The socket was found to be intact, stable and formed from solid bone. The buccal crestal bone was found to be intact, at a good level and supporting the thick gingival genotype overlying it. Having fully assessed the socket, the implant osteotomy was undertaken, following a flapless surgery protocol with both external and internal irrigation, and using the surgical stent as a guide to the final required po- sition. Bone removed during the procedure was harvested (Fig. 4). The osteotomy was prepared and the fixture placed slightly towards the palatal plane. The implant was seated to the de- sired vertical position to allow ideal soft tissue position after healing. The implant (Nobel Bio- care RST 16 mm NP) was inserted and torqued to 35Ncm (Fig. 5). After implant placement, the socket was then reassessed. As expected there was found to be a slight void between implant andbuccalplate.Theharvestedbonewaspacked into this defect, as an adjunctive graft, in order to support the buccal plate and its overlying gin- givae.4 Having placed the implant and harvest graft, the bony socket was now supporting its overlying hard and soft tissues once more. At- tention then turns towards gaining support for the crestal soft tissues. An immediate temporary abutment was torqued on to the implant again to 35 Ncm, and a Teflon cap placed over this (Fig. 6). Using the second vaccum formed stent, a temporary crown was constructed using a flowable composite resin, and light cured before being removed. Following removal, the crown is added to and carefully polished, especially in the cervical area, to give a highly polished, er- gonomic temporary restoration which is ade- quately supportive to the cervical gingival tis- sues, providing a circumferencial seal around the marginal area. Following final polishing, the Fig. 9 Fig. 10 Fig. 11 Fig. 5 Fig. 6 Fig. 8Fig. 7

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