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A metal-free solution for restoring natural aesthetic

A metal-free solution for
restoration of natural aesthetics

Clinical situation and treatment planning

A 57-year-old female patient presented at our clinic in May 2018. She asked for restoration of her premolar and molar site following extraction. The tooth 45 had been extracted alio loco three months and the tooth 46 one year before visit (Fig 1). The radiographic examination showed a single lateral dehiscence defect at tooth site 45 and a fully healed situs at tooth site 46 (Fig 2). The patient was informed about ceramic implants as alternative to titanium implants and the Nobel Pear dental implant system as a metal-free solution. After a detailed enlightenment talk, the patient decided for this treatment option. Her main argument for her decision was the advantage of a less inflammation prognosis of the peri-implant tissue with ceramic implants, the disadvantage of still less long term evidence compared to titanium implants was tolerated. After an initial hygiene phase and the periodontal treatment of tooth 47 by root planning, the implant surgery was performed in July 2018.

Author

Dr. Jens Tartsch, CH

President ESCI
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Surgical phase

After cleaning of the alveolar bone, a suitable bone level for implant insertion in site 46 was established and a lateral defect at site 45 was observed (Fig. 3). NobelPearl tapered dental implants of 4.2 mm in diameter and 10.0 mm in length with NobelPearl Inter-X straight abutments were used in the clinical procedure (Fig. 4). Both implants were inserted 0.6 mm supra crestally at a torque of 30 Ncm. Primary stability was good. The implants were covered with the cover screws in situ (Fig. 5). The buccal surface of implant 45 remained within the bone contour (three-wall defect), thus the lateral defect could be easily augmented with deproteinised bovine bone (Bio- Oss, Geistlich) and a membrane (Bio-Guide, Geistlich) following the standard clinical procedure (Figs. 6). After smoothening a periosteal incision, primary wound closure could be achieved (Figs. 7).

Fig 1a. Healed sites after extraction of teeth 45 and 46 before surgery
Fig 1b. Healed sites after extraction of teeth 45 and 46 before surgery
Fig 2. A pre-op CBCT scan showed a lateral defect near site 45
Fig 3. Suitable bone for implant insertion at tooth position 46, and lateral defect at position 45.
Fig 4. Manual insertion of the implant following preparation of sites.
Fig 5. Cover Screw in situ.
Fig 6. Horizontal augmentation using deproteinized bovine bone.
Fig 7. With a two-piece implant system, primary wound closure is possible.

Restorative protocol

3 months after surgery, the restorative process (Fig 8 -10) started with the re-entry by small single roll-flaps at each implant site and by placing the 3mm Healing Abutments (Fig 8) . Soft-tissue was healthy and keratinize around the Healing Abutment (Fig 11) the open impression coping after 2 weeks was performed (Fig 9) . Monolithic zirconia crown was selected as prosthetic solution. For stability and because of the augmentation at position 45, the crowns were splinted in that case .

Fig 8. Healthy soft-tissue two weeks after re-entry.
Fig 9. NobelPearl™ Impression Coping Open Tray Inter-X placed on implants and fixed for precision.
Fig 10. Abutments placed on the master cast with gingiva mask.

After removal of the healing caps (Fig 11) and after try in of the Abutments, the screw channels were sealed with Teflon and are now ready  for cementation of the restoration (Fig 12). Fig 13 shows the restoration and abutments before connection, Fig 14 shows the final glued restoration.

Fig 11. Healthy and thick keratinized peri-implant mucosa seen following removal of the NobelPearl Healing Abutment Inter-X.
Fig 12. The screw channels were sealed with Teflon, and NobelPearl™ Abutments prepared for cementation.
Fig 13 & 14. Final restoration and abutments before insertion.

To reach a tension and bending free connection of the restoration and the implants, the Zirconia restorations were glued intraoral to the abutment in the standard procedure with RelyX Unicem (3M Espe). Teflon was removed through the screw channel and the whole restoration was removed again in toto. The cement can now be easily removed, and the final restorations polished according that procedure. After this cleaning, the restoration was reinserted and the carbon abutmentscrew was following the guidelines torqued at 25 Ncm. The screw channel is closed again using the Teflon band (Fig 15) and finally covered by composite. Fig 16 shows the final restoration in situ after screw channel closure and sealing with composite. Total treatment time was 4 months.

Clinical outcomes

The result was beautiful and the patient was highly satisfied at 1-year follow-up (Fig 17 & 19).  No inflammation or prosthetic problems occurred during the follow up periods. The result in this case is a metal- and cement-free, screw-retained and reversible restoration.

If problems such as chipping or subsequent color adjustments should become obvious, these can be easily corrected and revised – like with titanium implants

Fig 15. For the final installation of the restoration the screw is torqued at 25 Ncm and the screw channel is closed again with Teflon band.
Fig 16. Final restoration in situ after screw channel closure and sealing with composite.
Fig 17. Excellent aesthetics at the one-year follow-up. Note the healthy soft tissue and natural-looking restorations
Fig 18. Control radiograph after delivery of the restorations
Fig 19. 1-year follow-up shows stable bone level.

Conclusion

Ceramic implants are designed for broad range of indications, from single to multiple unit. It performed great in the presented case, carrying splined crown after bone augmentation in defected bone. The surgical and prosthetic protocols are nearly comparable to these of titanium implants. These are important factors for a successful integration of a new dental implant system in the daily dental practice.

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