Dental Tribune United Kingdom Edition

A medically and periodontal- ly stable 37-year-old man presented with coronally fractured tooth #9, which had a history of endodontic treatment (Fig 1). The tooth was deemed re- storatively hopeless. Treatment Plan 1. Extraction of tooth #9 and sock- et preservation 2. Three-month healing period 3. Placement of implant #9 and connective tissue graft 4. Three-month healing period 5. Implant #9 exposure, placement of healing abutment and connec- tive tissue graft 6. Three-month healing period 7. Final implant #9 crown restoration Extraction and Socket Preser- vation of Tooth #9 After oral sedation with 0.25mg tri- azolam one hour prior to surgery and local anaesthetic induction using two per cent lidocaine with 1:100,000 epinephrine and 0.5 per cent bupivacaine with 1:200,000 epinephrine, a sulcular inci- sion was made circumferentially around tooth #9. The remaining root was extracted atraumatically using a piezoelectric periotome device (Fig 2). Thorough degranu- lation of the extraction site with a pear-shaped carbide finishing bur and Prichard curette proceeded. No dehiscence or fenestration was detected. Freeze-dried bone allograft (FDBA) was used to ob- literate the extraction socket. A bi- oabsorbable collagen plug (Colla- Plug®, Zimmer Dental, Carlsbad, CA) was used to cover the graft. The area was secured using 4-0 expanded polytetrafluoroethylene (ePTFE) suture (Fig 3). The re- storative dentist temporised space #9 with an interim removable partial denture. After three months of uneventful healing (Fig 4), Stage 1 implant placement was initiated. #9 Fixture Placement and Connective Tissue Graft After oral sedation with 0.25mg triazolam and local anesthetic in- duction using two per cent lido- caine with 1:100,000 epinephrine and 0.5 per cent bupivacaine with 1:200,000 epinephrine, a flap was created using a trapezoidal papil- la-sparing incision design that in- volved a palatally-oriented crestal incision over the #9 site with two vertical releasing incisions made on the buccal, both avoiding the mesial and distal papillae. A full- thickness flap was raised past the mucogingival junction. De- granulation of the site with a pear- shaped carbide finishing bur and Neumeyer bur revealed adequate apico-coronal, bucco-lingual and mesio-distal dimensions for implant placement. After osteoto- my preparation, a rough-surfaced, internal hex 4mm (diameter) x 13mm (length) implant was placed into the filled site (Nano- Tite® Parallel Walled Certain® Implant, Biomet 3i, Palm Beach Gardens, FL) (Fig 5). Primary sta- bility was achieved, and a cover screw was placed. In order to form an aesthetic soft tissue profile by expanding mucosal dimensions, a connective tissue graft was harvested from the palate and placed on the buccal aspect of the ridge overlying the implant. The graft was stabilised using 5-0 chromic gut sutures (Fig 6). After periosteal release via lateral scalpel incisions, the flap was primarily closed with 4-0 ePTFE sutures in an interrupted and horizontal mattress fashion (Fig 7). The area was re-tempo- rised with a resin-bonded fixed partial denture. Implant Exposure with Con- nective Tissue Graft The #9 site healed well and without incident after three months (Fig 8). After using a tissue punch technique to remove the mucosa immediately coronal to the fixture (Fig 9), a one-piece 4.1mm (platform) x 5mm (emer- gence profile) x 4mm (height) healing abutment (Certain® EP® HealingAbutment,Biomet3i,Palm Beach Gardens, FL) was placed on the #9 implant. To further augment the buccal ridge dimen- sion, another connective tissue graft was harvested from the pal- ate. A pouch-like envelope flap was raised over the labial ridge aspect into which the connec- tive tissue was transplanted and fixed using 5-0 chromic gut suture (Fig 10). The healing abutment remained exposed. A periapical radiograph revealed sufficient bone height around the fixture (Fig 11). The resin-bonded fixed partial denture was replaced. Final Prosthetics Final restoration of the #9 implant was performed three months post-exposure (Fig 12). The marginal height and contour of the #9 implant crown matched that of adjacent tooth #8, and a periapical radiograph showed suitable peri-implant bone height (Fig 13). The patient was satisfied with the functional and esthetic result (Fig 14). Post-Operative Instructions After each surgical proce- dure, the patient was instruct- ed to take ibuprofen 600mg every 4-6 hours, hydrocodone 7.5mg/acetaminophen 750 mg every 4-6 hours as needed for pain, and doxycycline 100 mg every day for 10 days. The pa- tient was instructed not to brush at or near the surgical site but instead to rinse with 0.12 per cent chlorhexidine or warm saline twice daily. The patient was also directed not to chew in the affected area for at least two weeks. Suture removal occurred at 10-14 days post-surgery. DT Aesthetic management of a single dental implant Dr Michael Sonick details a case involving both form and function in the aesthetic zone page 12DTà Implant trIbune pages 20-22pages 13-15 Nawrocki and Almog provide implant in- formation A second case study presented by Dr Michael Sonick A case of FPD Aesthetic managment Implant Tribune pages 16-19 Richard Brookshaw discusses anterior implants The ultimate challenge Implant Tribune For more information please contact your dental retailer www.septodont.co.uk Anaesthetics • Endodontics Restorative Dentistry • Dental Surgery Prosthetic Dentistry • Disinfection & Hygiene Racegel is a brand new gel specifically designed for gingival preparation procedures. It is easy to put in place, is not traumatic for the gingival tissues and eliminates the need for retraction cord. Racegel opens the sulcus without applying any pressure, keeping the gingival passive and the cervical margins ideally exposed making it the ideal preparation for impression taking. Dentists in the know use Racegel Implant Tribune