Dental Tribune United Kingdom Edition

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Proven against bacteria and viruses in trials. • Keeps skin dry & hydrated • Free from allergic substances • Economical and easy to apply • New unique formulation and the fixtures exited from the sockets at the cingulum positions (Fig 5a). Primary stability was achieved. Radiographic review of the implants revealed a peak of bone between the fixtures, an inter-implant distance of greater than 4mm and an implant-tooth distance of 2mm (Fig 5b). To bridge the circumferential gap be- tween the socket walls and the im- plant surfaces, freeze-dried bone allograft (FDBA) was used as graft material (LifeNet Health, Virginia Beach, Va.). Temporary cylinders (Pre- Formance® Temporary Cylinder, Certain® Internal Connection, 4.1 mm platform, hexed) were placed on the implants to check the re- storative position (Fig 6). These were removed, and an implant- level pick-up impression was taken. After chair side creation of a cast with implant analogs, the hexed temporary cylinders were connected to the analogs and acrylic resin interim crowns were fabricated using a vacuum- formed template made over ide- ally-shaped central incisors. The resin interim crowns were seated and screwed onto the implants us- ing hexed titanium screws with 20Ncm torque. Cotton pellets were placed over the screw heads, and the access holes were sealed with composite resin. Occlusal adjust- ment prevented functional contact upon excursions. The interim restorations did not fill the papil- lary space between #8 and #9 (Fig 7). A radiograph taken following completion of provisionalisation demonstrated satisfactory posi- tioning and seating (Fig 8). Gingivectomy Over Implants Healing of the implant sites pro- ceeded without incident. At one week post-surgery, the buc- cal marginal tissue remained coronally-oriented and encroach- ment of the papilla into the un- filled interdental space began (Fig 9). Three months after initial surgery, further coro- nal displacement and papilla fill occurred (Fig 10). Minor gingivectomy was performed to create mucosal symmetry between the maxillary central incisors. The contact point and contour of the interim crowns were also adjused to create a~ fuller papilla. Final restoration of Implants Six months after gingivectomy and provisional contour modifica- tion, the implants were ready for final prostheses (Fig 11). Single final PFM crowns were placed on implants #8 and #9. Clinical anal- ysis demonstrated resolution of inflammation, idealisation of the soft tissue drape and papillary re- generation (Fig 12). A radiograph illustrated preservation of inter- proximal and peri-implant bone (Fig 13). The patient was satisfied with the functional and aesthetic results (Fig 14). Post-Operative Instructions After each surgical procedure, the patient was instructed to take ibu- profen 600mg every 4-6 hours, hy- drocodone 7.5mg/acetaminophen 750mgevery4-6hoursprnpainand doxycycline 100mg as required for every day for 10 days. The pa- tient was instructed not to brush at or near the surgical site but in- stead to rinse with 0.12 per cent chlorhexidine or warm saline twice daily. The patient was also directed not to chew in the affect- ed area for at least two weeks. DT 1a. Initial facial view 1b. Smile view. Lack of papillae between 8 and 9 is evident. Patient also reveals gin- gival asymmetry, inflammation and excess gingiva around teeth 8 and 9 1c. Right lateral initial smile view 1d. Left lateral initial smile view. Teeth 8 and 9 appear to be on a different occlusal plane. Attention is drawn to them 1e. Initial radiograph. Teeth #8 and #9 are failing endodontically 2a. Contact points are broken and the crowns are removed. Trauma to the bone and adjacent teeth is to be avoided 2b. Following a sulcular incision piezosurgery is used to atraumatically remove the teeth 2c. Utilizing beaked serrated forceps and rotational apical pressure tooth #8 is removed without any destruction to the alveolar plate 3a. A surgical guide is used to ensure correct orientation during osteotomy preparation. A buccal view of the guide in place with orientation pins is shown 3b. Occlusal view of the surgical guide in place. Note that the osteotomy is located at the cingulum position, the preferred site for a screw-retained restoration. Notice to the occlu- sal wings on the guide that stabilise its position on adjacent teeth during surgical preparation 3c. Initial osteotomy orientation confirmed by radiograph 4. Occlusal view following placement of two 4 mm-diameter dental implants. Note the palatal position and the thickness of the buc- cal plate. A gap is present between the labial aspect of the implant and the facial plate. This will be grafted 5a.Temporary healing abutments in place. They prevent soft tissue and bony collapse while the provisional restoration is being fabricated extra-orally page 22DTà