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2-piece zirconia implant placement in the anterior area

2-piece zirconia implant in the anterior area with bone augmentation

Clinical situation and treatment planning

Below, the clinical case of a 41 years old male patient without any general diseases is described. In 2000, the patient suffered from a lateral luxation of tooth 21 and a total luxation of tooth 21. Both teeth have immediately been repositioned and splinted and subsequently endodontically treated.

Author

Dr. Stefan Röhling, GER

Vice President ESCI
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Figure 1: Initial clinical situation.
Figure 2: Radiographic controls: Initial situation (a), immediately after implant placement (b) and immediately after insertion of the screw-retained crowns.
Figures 3 and 4: Clinical Situation 8 weeks after extraction of teeth 11 and 21.

In 2017, the clinical investigation showed increased probing depths (12mm), bleeding on probing and mobility of grade II for both teeth and a fistula vestibular of teeth 21 (Figure 1). The radiographic investigation showed a root resorption and a vertical bone defect of tooth 21 (Figure 2). Based on the poor prognosis, both teeth were extracted and a temporary prosthesis was inserted. The patient was informed about an implant supported prosthetic reconstruction combined with a simultaneous bone augmentation. To achieve an optimal esthetic result, the insertion of 2 zirconia dental implants was recommended. For the planning of the implant placement, a “Backward-Planning” was used. After making a diagnostic Wax-Up, a drilling guide was fabricated as an intraoperative orientation. According to a delayed immediate implant placement, the implants were placed in local anesthesia 8 weeks after teeth extraction. At implant placement, the clinical situation showed sufficient horizontal and reduced vertical bone volume, especially in region 21 (Figures 3 and 4).

Figures 3 and 4: Clinical Situation 8 weeks after extraction of teeth 11 and 21.
Figure 5: Vertical bone deficiency in region 11 and 21.
Figure 6: Prosthetically driven implant placement using a drilling guide.
Figure 7: Placement of two 2-piece ceramic implants, bone deficiency especially in region of 21 (implant-type: Straumann® PURE Ceramic Implant, Straumann Group, Basel, CH).
Figures 8 and 9: Fixation of 2 autogenous bone blocks using 2 osteosynthesis screws.
Figures 8 and 9: Fixation of 2 autogenous bone blocks using 2 osteosynthesis screws.

Preoperatively, the patient was informed that implant placement had to be combined with a simultaneous bone augmentation.

Intraoperatively, a vestibular vertical bone deficiency was visible in region of teeth 11 and 21. Based on the fact, that the interdental bone lamella was still present (Figure 5), the bone augmentation was performed simultaneously with the implant placement. Using the prefabricated drilling guide, two 2-piece zirconia implants with a micro-rough surface topography were placed in a prosthetic optimal position (Figure 6, Straumann 2-piece PURE Implant, ZLA® Surface, Straumann Group, Basel, Switzerland). Both implants were inserted with good primary stability whereas especially the implant in region 21 showed a pronounced vestibular bone defect (Figure 7). For the reconstruction of the vestibular bone defects, 2 bone cortical bone blocks were harvested from the processus zygomaticus using Piezo-Surgery (Mectron Deutschland Vertriebs GmbH, Köln, Deutschland) and fixated with 2 osteosynthesis screws using to the allograft bone shell technique according to Prof. Khoury (Figures 8, 9, 2b).

Figure 10: Filling of the gap between implant surfaces and bone blocks with autog-enous bone chips.
Figure 11: Covering of the augmented area with a collagen membrane (Jason® membrane, Botiss Biomaterials GmbH, Zossen, Germany).
Figure 12: Unloaded transmucosal healing using metal healing caps. Surgery. PD Dr. Stefan Röhling, Munich, Germany.
Figure 13: Clinical situation 16 weeks after implant placement.
Figure 14: Clinical situation 16 weeks after implant placement. Small incisions to removal of the osteosynthesis screws.
Figure 15: Clinical situation 17 weeks after implant placement. Screw-retained, lab-fabricated provisional crowns to shape the peri-implant soft tissue conditions. Ane-mic peri-implant mucosa immediately after insertion of the crowns.

Subsequently, the gap between the implant surfaces and the bone blocks was filled with autogenous bone chips that were collected with a Safescraper ((Safescraper® Twist, Imtegra OHG, Rostock, Germany) and finally, the augmented bone was covered with a collagen membrane (Jason® membrane, Botiss Biomaterials GmbH, Zossen, Germany, Figures 10 and 11). Both implants healed in a unloaded, transmucosal position (Figure 12). Immediately after implant placement, the temporary prosthesis was adapted to the clinical situation and inserted (Surgery, PD. Dr. Stefan Röhling, Munich, Germany).

Figure 16: Clinical situation 24 weeks after implant placement and after shaping of the peri-implant mucosa.
Figure 17: Clinical situation 24 weeks after implant placement. Un-irritated soft tis-sue conditions.
Figure 18: Clinical situation 24 weeks after implant placement. Conventional im-pression taking using impression posts and an individual impression tray.
Figure 19: Inserted scan-bodies for digital impression taking.
Figure 20: Screw-retained ceramic crowns. Vestibular (a) and palatal view (b). Den-tal technician: Held Zahntechnik, Gossau, CH.

After 4 months of unloaded healing un-irritated per-implant conditions were visible (Figure 13). Using small incisions, the osteosynthesis screws were removed (Figure 14) and a conventional impression was taken. 1 week later, lab-fabricated screw-retained temporary crowns were inserted (Figure 15). Within the next 8 weeks, the temporary crowns were regularly removed and adapted using composite in order to shape the peri-implant soft tissue conditions (Figures 15, 16, 17). Following that, a final impression was taken using impression posts (Figure 18) and an individual impression tray, whereas a digital impression using scan-bodies would have been possible, too (Figure 19). 2 weeks later, 2 screw-retained crowns were inserted (Prosthetics: Dr. Thomas Borer, Basel, CH; Dental technician: Rolf Held, Gossau, CH, Figures 20, 21, 2c). Nine months after implant placement, the clinical situation showed un-irritated peri-implant conditions (Figure 22).

Figure 21: Inserted screw-retained ceramic crowns.
Figure 22: Clinical situation 9 months after implant placement and bone augmenta-tion. Ceramic crowns showing a natural translucency. Prosthetics: Dr. Thomas Bor-er, Basel, CH.

Conclusion

Zirconia implants with a Tissue-Level design are a reliable treatment option for complex anterior teeth reconstructions. However, an adequate preoperative planning and a consequent surgical transfer of the planned implant positions to the clinical situation are very important. The 2-piece implant design allows the insertion of reversible screw-retained prosthetic reconstructions. Based on the 2-piece implant design, an unplanned overloading of the implants during the early healing period can easily be avoided. This fact may be relevant in clinical situations, when implant placement has to be combined with complex bone augmentation procedures.

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1 Comment
  • Nico Kamosi
    Nico Kamosi
    Posted at 18:20h, 10 July Reply

    The veneering/ shell- technique using autogenous cortical plates was unequivocally performed as an state-of-art GBR technique.
    The implant position and abutment level are most compatible with the emergence profile.
    Thank you

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