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implants2_2010 temporary crown is luted to the temporary abut- ment using a temporary cement. The post opera- tive radiograph (Fig. 7) shows this situation and highlights a small excess of temporary cement which can be easily removed with floss. The tem- porary restoration is kept clear of the occlusion. Given the implant is placed directly into the ex- traction socket, and that the adequately support- ive temporary crown provides an excellent crestal gingivalseal,noflapisrequiredandconsequently, no sutures are used in this procedure. Standard post operative protocols are followed. As a result ofthisflaplessapproach,thetraumaofsurgeryis lessened,andreviewoneweekpostsurgeryshows an excellent recovery (Fig. 8), with very little sign of any trauma, swelling or alteration of the sur- rounding gingival tissue, which largely remains unchanged. After a five to six month healing pe- riod, during which regular review is undertaken, the temporary crown is removed using a crown remover.Thetemporaryabutmentisremovedand thesocketirrigated.Astandardopentrayimpres- siontechniqueisusedtorecordthepositionofthe implant, and the temporary abutment and crown replaced. The subsequently produced model is used to construct an abutment and crown, repli- cating the exact support given by the temporary set up. The case is completed by final abutment placement and torque to 35 Ncm. Following trial fit, and approval of the definitive restoration, the occlusionischeckedandadjustedasrequired.The Zirconia crown is cemented using a resin cement, with care being taken to minimally load the ce- ment and remove any excess prior to and after cure. Occlusion is again assessed and adjusted as required. The success of the restoration is evident immediatelyaftercementation(Fig.9),at3month (Fig. 10) , six month (Fig. 11) and 18 month review (Fig.12a&b).Inordertosuccessfullyperformthe procedureoutlinedabove,timingisessential,par- ticularly in the case of the root fractured tooth. In these cases, if such treatment is not initiated in goodtime,theareacanbecomeinfectedwithcor- responding sinus formation and inevitable loss of the buccal plate of bone. This would entail re- assessment and treatment using a multi-staged, delayed placement regime. In order to perform flapless surgery, the operator must have suitable experience, and be competent in the procedure. Added to this, as with any surgery, a full knowl- edge and appreciation of the anatomy surround- ing the surgical site is essential to ensure a suc- cessful outcome. It is sometimes necessary to carry out further special tests or procedures dur- ing the planning stages, to ascertain further in- formation prior to commencement of treatment. These may include CT scanning or ridge mapping of the proposed surgical site. Following atrau- matic tooth extraction and socket assessment it may, occasionally, not be possible to proceed with immediate implant placement for a number of reasons.Insuchcasesproperplanningisessential to ensure that an alternative treatment option may be undertaken. While flapless surgery incurs decreased trauma and faster healing, during any flapless procedure, it must be remembered that the operator can, at any time, raise a flap, if at all concerned with regards to surgical progress. Bio- logical stability has been maintained from re- moval of the damaged root right through to ce- mentation of the definitive restoration. By re- spectingandunderstandingthenaturaltissuesin this way, predictably excellent results can be achieved time after time. The clinical photographs and case discussion are included with the expressed permission of the patient involved. All of the laboratory stages for the case were completed by Lincoln Ceramics, Glasgow. _References 1. Gargiulo et al J.Periodontol,1961,31:261–267. 2. Lazzara R J. Immediate implant placement intio extraction sites: surgical and restorative advantages. Int J Periodont Rest Dent 1989;9:332–343. 3. Quayle A. Atraumatic removal of teeth and root fragments in Dental Implantology. Int J Oral Maxillofac Implants 1990;5:293–296. 4. Botticelli et al. The jumping distance revisited : An experi- mental study in the dog. Clin Oral Implants Res 2003;14(1):35–42. First published in Scottish Dentist March-April 2008._ Fig. 12a Fig. 12b Dr Philip J.Friel Philip FrielAdvanced Dentistry 170 Hyndland Road G12 9HZ Glasgow,Great Britain _contact implants