hello everyone and welcome to chairside live I'm your host Megan strong in today's episode
inclusive magazine contributor dr. Timothy convinced key is discussing bone grafting an
immediate implant placement in the interior let's take a look I'm Timothy Kaczynski from Bingham
Farms Michigan here a 61 year old male exhibited slight perience around his maxillary right central
incisor the tooth which was previously restored with a conventional porcelain fused to metal crown
had become mobile an endodontist said determine that the root was fractured horizontally and
recommended extraction the patient had high blood pressure which was controlled with medication but
no other significant medical findings treatment options were discussed with the patient including
a conventional three unit and two your bridge a removable partial denture appliance or a
single dental implant reconstruction of the maxillary right central incisor the patient
elected to proceed with tooth extraction followed by dental implant restoration physics forceps from
golden dental solutions were used to remove the problematic tooth the beak of the instrument was
placed onto the palatal aspect of the root about three millimeters of gingival II the bumper or
fulcrum of the instrument was position as far up the vestibule as possible with a simple rotation
of the wrist towards the tip of the nose the tooth was lifted up and out of the socket the procedure
was a traumatic and no harm was done to the facial bone due to the aesthetic concerns involved with
working in the anterior maxilla an envelope flap was made avoiding the creation of any vertical
incisions the envelope flap allowed visualization of the facial bone contours evaluation of the
interdental papilla and observation of any dehiscence or defects in the facial bone
the facial wall had a slight defect that could be easily repaired and there was adequate bone apical
e to stabilize the implant it was determined that the site would be prepared for immediate
implant placement an osteotomy was created for a four point three millimeter by eleven point
five millimeter Han tapered implant a two point four millimeter pilot drill was used to create
the initial osteotomy about three millimeters palatal to the facial aspect of the adjacent
crowns in about three millimeters deeper than the cementoenamel junction of the adjacent roots
to avoid the risk of perforating the relatively thin facial bone the osteotomy was created without
following the path of the extraction socket and a 4.3 millimeter by 15 millimeter surgical drill
was used to create the final preparation extending beyond the apex of the socket
to maintain consistent bone volume demineralize allograph material composed of cortical cancellous
particles was mixed with sterile saline to create a paste for grafting allograft material
has osteoconductive elements that promote new bone growth while maintaining adequate volume
the graft material was packed firmly but not aggressively into the socket site because the
graft has various sized particles which vary in their rates of resorption and bone replacement
the operator should avoid condensing the particles too firmly in order to prevent crushing the larger
particles into smaller ones and elevating the rate of resorption a barrier membrane was then
placed to prevent in growth of the surrounding soft tissue and to permit osteogenic cells to
repopulate the bone defects a resorbable membrane was passively placed on the facial aspect of the
bone to act as a barrier when grafting a socket are attempting to repair a facial defect it can
be challenging to properly position the membrane and prevent it from dislodging prematurely because
the membrane must be retained passively in order to promote predictable bone growth it is important
to elevate the attached gingiva and mucosa to make sure the barrier engages the facial bone at least
at two millimeters apical two any defect this rule should also be followed on the palatal or lingual
side the gingiva can then be easily sutured and the membrane will not dislodge the hon tapered
implant was threaded into the osteotomy and then tightened to full seating with a torque wrench we
see that the prominent thread design of the implant allowed for precise straightforward
placement radiography confirmed proper positioning and full seating of the implant a flat cover screw
was hand tightened into the implant to minimize the pressure exerted on the implant during healing
and osseointegration the resorbable membrane was then tucked over the crest of the ridge and
engaged at least two millimeters of the palatal bone the flap was close with Villain plus sutures
from River Point medical which demonstrate the high tensile strength that is critical throughout
the healing period the maxillary flipper appliance was created to cover the palate protecting the
treatment site from excessive pressure figure thirteen shows the post-operative CB CT scanning
and illustrates that the implant was positioned optimally following seven days of healing the
sutures were removed and then the site was allowed to heal for approximately four additional months
and the patient returned for the final impression appointment a round tissue punch was used to
access the implant site the tissue punch caused little trauma allowing immediate final impressions
to be taken using an open tray transfer assembly a final impression was made using vinyl poly
siloxane materials as seen in Figure 17 to prevent the tissue from healing over the implant while a
temporary implant abutment and tranditional crown were fabricated a healing abutment was tightened
into place our lab Glidewell lab then fabricated a custom temporary abutment and provisional crown
to help establish optimal tissue contours in the aesthetic zone note that the margins of
the abutment were level with the height of the gingiva this prevented the possibility of cement
being forced beneath the soft tissue the patient was able to wear and evaluate the transitional
crown for about three weeks and the interdental contours improved over time following patient
approval of the provisional restoration our lab fabricated an inclusive zirconia custom abutment
with titanium base and an aesthetic Brooks er anterior crowned utilizing the latest dental CAD
CAM techniques the custom abutment and crown were produced with precision this allowed the final
restorative components to be seated with minimal adjustment the custom abutment was tightened to
full seating using a torque wrench and provided an esthetic substructure for the final all zirconia
crown because Brooks er anterior crowns exhibit translucency similar to natural dentition the
custom zirconia abutment help maintain the lifelike results so in conclusion excellent
function and aesthetic can be achieved with prosthetic ly driven implant treatment
modern implant techniques in design allow for outstanding initial stability and immediate
implant placement when indicated when properly executed grafting techniques help maintain bone
in this aesthetically demanding case the Hahn tapered implant provided an excellent foundation
for predictable and aesthetic tooth replacement provisional ization with the transitional abutment
and crown also played a key role in providing the patient with an aesthetic final restoration
in a challenging area of the mouth thank you for that dr. Kaczynski and if you'd like to
learn more about this case you can check out his article in the latest inclusive magazine
well that about wraps it up for this episode of chair side vibe on behalf of everyone here at
glial laboratories we thank you for watching and I'll meet you right back here next time
you