Written by: Brian Jackson, DDS
The reconstruction of partially edentulous patients with dental implants has become a predictable approach in dentistry.1 The immediate implant placement with provisionalization (IIPP) concept has been utilized to maintain hard and soft tissue, as well as replace teeth with a hopeless prognosis.2,3 The incorporation of digital technology with IIPP principles can reduce surgical and restorative treatment time, streamline procedures, and establish enhanced outcomes.
Digital implant dentistry, including the synergy of intraoral scanning and cone beam computerized tomography (CBCT), is widely recognized as a predictable method to capture soft and hard tissue in a 3D manner.4 These technologies can reduce surgical and prosthetic treatment times via comprehensive preoperative planning. In addition, the surgical and restorative techniques, guides, and associated materials can be determined prior to clinical treatment, which can expedite the entire procedure and thus create an enhanced result.5
In this case report, a patient was treated after a hopeless diagnosis, and a poor prognosis was determined for a maxillary left central incisor (tooth No. 9). A comprehensive digital plan was utilized for the fabrication of a surgical guide which was based on the final restoration type, implant position, and specific implant system. In addition, the final zirconia abutment, provisional (PMMA), and final crown (IPS e.max [Ivoclar]) were virtually developed and fabricated before surgery. The IIPP digital approach was utilized to establish a seamless execution of the complete process. The approach will reduce chairside treatment time and consolidate the entire process into a total of 2 patient appointments.
CASE REPORT
A 69-year-old female presented to our office for the evaluation of a fractured maxillary central incisor at the gingival margin. After a clinical and radiographic evaluation, a diagnosis of horizontal root fracture was made, and a poor prognosis was determined (Figure 1). Implant therapy was recommended as the treatment of choice because the adjacent maxillary central incisor was a cement-retained implant restoration. The displaced crown was temporarily cemented to the residual root as an aesthetic resolution of the emergency situation (Figure 2).
A comprehensive medical history, intraoral scanning (iTero [Align Technology]), CBCT (Green X [Vatech America]), and a shade was taken prior to patient discharge.
The intraoral scan and CBCT files were sent to merge and reformat the digital information. A meeting with the design company (Implant Concierge) was set to discuss several aspects of the procedure, including the implant selection, final abutment, provisional, and final restoration. The agreed-upon treatment plan was a cement-retained restoration with a zirconia abutment (Ti base). The implant coronal/apical position was determined to be placed 4 mm subgingival to the ideal midfacial gingival margin, and the buccal, palatal implant position was located within the incisal edge and cingulum of the final restoration. The zirconia abutment facial finish line was designed 1.5 mm supra-implant abutment connection.
The digital design company was instructed to fabricate the surgical guide, zirconia abutment, and provisional crown. The information was sent to a commercial dental laboratory (Gardali Advanced Restorative & ImplantONE) for the fabrication of the final all-ceramic, lithium silicate crown (IPS e.max). After the digital information was ascertained and the fabrication of guides and associated components was received, the surgery date was made (Figures 3 to 5).
The patient was prepped, draped, and asked to rinse with a Chlorhexidine mouthwash for 30 sec. A blood pressure of 122/78 was recorded pre-surgery. A 20 ml blood draw from the median cubital vein utilizing a standard phlebotomy technique was performed to develop buffy coat platelet-rich plasma (PRP) and platelet-rich fibrin (PRF). A single spin centrifuge at 3200 rpm was utilized to harvest platelet concentrates. The patient was anesthetized with 3% (54 mg) Mepivacaine Hydrochloride without epinephrine and 2% (36mg) Lidocaine Hydrochloride with 1:000,000 epinephrine (Benco Dental).
An intrasulcular incision with a 15C blade, periotome 1, 2, and a universal forcep was used to atraumatically remove the tooth (Figure 6). A surgical guide was placed, followed by the osteotomy procedure, which was performed with a fully guided system (Implant Direct) (Figure 7). The final implant drill was 3.2 mm in diameter, followed by the placement of a 4.2- x 13-mm SBM (Legacy 1[Implant Direct]) implant placed to final depth through the guide with a hand driver (Figure 8). After ideal implant placement, a 2.5 mm hex tool was placed into the fixture, and a torque value of >35N/cm was recorded (Figures 9 and 10).
The restorative stage was initiated with the placement of the final zirconia abutment with a Ti base (Figure 11). A periapical radiograph was taken to confirm proper seating of the abutment, and a torque of 30N/cm was applied to the abutment screw 2x in a 5 min period (Figure 12).
The space between the implant fixture and bony walls of the socket, as well as the soft tissue sulcus, was grafted with a mineralized irradiated cancellous allograph (Fine [Rocky Mountain Tissue Bank]) of fine particle size mixed with PRP (Figure 13). The provisional restoration was evaluated to confirm zero contact during centric occlusion, excursions, and protrusion. The incisal edge was shortened from the ideal length. The provisional PMMA restoration was placed with permanent resin cement (Figure 14). The final implant restoration was placed 4 months post an osseointegration period (Figure 15).
DISCUSSION
Implant dentistry has become a widely accepted discipline for restoring missing teeth. Digital technology, including intraoral scanning and CBCT imaging, has altered the way implant therapy is approached and delivered to enhance outcomes.6 The IIPP approach for restoring a missing tooth has become a predictable means of streamlining a comprehensive process.7
Digital technology associated with implant dentistry incorporates intraoral scanning and CBCT imaging. The DICOM and STL files are merged to create a soft and hard tissue 3D image for treatment planning, fabrication of surgical guides, abutments, as well as a provisional and final restoration. The digital approach can be more accurate than freehand implant surgery or utilizing a conventional impression analog approach.8
The digital team and clinician discuss and design all aspects of the implant process. In this case, the determination of a cement-retained restoration initiates the discussion, followed by surgical placement in 3D. The buccal palatal position was designed palatal to the incisal edge. The coronal apical position was designed with the fixture platform placed 4 mm apical to the ideal mid-facial gingival margin. The final zirconia abutment facial finish line is designed to be 1.5 mm coronal to the fixture platform.
IIPP incorporates an array of surgical and restorative procedures.9 IIPP has exhibited enhanced outcomes in comparison to traditional staging approaches. The conventional IIPP approach includes extraction, implant placement, torque evaluation, impression or scanning, gap management, fabrication of a temporary abutment, and provisional restoration, chairside.10 After an osseointegration period, the provisional abutment and crown are removed and replaced with the final abutment and restoration. The IIPP conventional process streamlines the implant therapy for a missing tooth into only 2 appointments.
The digital IIPP approach alters the conventional process by developing a virtual treatment plan with fabrication of a surgical guide, final abutment, provisional, and final crown prior to surgery. This approach eliminates the need for the clinician to scan or impress implant position, as well as fabricate a temporary abutment and crown, chairside. More importantly, the final zirconia abutment is placed at implant surgery. This eliminates the need for an abutment disconnection after soft and hard tissue healing.11 A rigid fixation of the endosseous implant with a value of 35 N/cm or greater is required for nonocclusal immediate load principles. Implant placement is designed to place the fixture in a minimum of 3 mm of mature bone apical/palatal to the residual tooth socket. An implant that has a progressive thread design with a taper placed in an undersized osteotomy enhances fixation. A fully guided system assists the placement of the implant to its ideal position in 3D. The implant is placed 4 mm apical to the mid-facial gingival margin in a coronal apical dimension to facilitate a natural emergence profile.12
A limitation to the placement of the final abutment depends on achieving a fixation value of greater than 35 N/cm. If the value is achieved, then the final zirconia abutment is placed, the fixation screw is torqued down to 30 N/cm, and the provisional crown was cemented. The provisional restoration is designed with no contact in centric occlusion, lateral excursion, protrusion, and a shortened incisal edge. This is consistent with IPO principles for immediate load and provisionalisation. If the implant torque value is below 30 N/cm, then a healing collar and transitional removable prosthesis is placed.13
A fully guided system is recommended to reduce the likelihood of any discrepancy between the virtual design and the clinical execution at the surgical site. The process relies on an exactness in the timing of the implant rotation for the alignment of the final abutment. If the timing is inaccurate, then the 3D placement of the implant, zirconia abutment, provisional, and final crown will be incorrect. It is critical that the clinician stops inserting the implant when it is flush with the surgical guide. Otherwise, the hex position could be skewed from the desired position.14
The management of the space between the implant surface and bony walls, commonly referred to as the “GAP,” is critical for osseointegration and aesthetics. If all bony walls are present (Type 1 socket), then only a bone graft is needed.15 If the facial plate is missing (Type II socket), then a collagen membrane and bone graft is required.16 Allographs are the most commonly used type of bone graft in IIPP cases. In this case, a mineralized irradiated cancellous allograft of fine particle size was utilized. This particular allograph was harvested from the vertibular column of cadavers and irradiated with 50 Mrads.17,18 The allograft was mixed with PRP and PRF. Platelet concentrates have been shown to contain growth factors that promote healing, reduce pain, and are easy to develop chairside.19
The final restoration is fabricated by a commercial dental laboratory once the virtual design is complete. The final restoration will be designed and fabricated in accordance with IPO principles. The restoration will be void of contact in centric occlusion, excursions, or protrusion and exhibit an ideal incisal length. The final restoration is placed after the osseointegrative period has been completed.20
CONCLUSION
The rehabilitation of a missing tooth or teeth with endosseous implants is a predictable discipline in dentistry. The IIPP approach has been advocated for more than 30 years to preserve missing hard and soft tissue. The incorporation of digital technology with conventional techniques can streamline procedures, reduce morbidity, and enhance outcomes. The synergy of IIPP and digital technology for comprehensive case planning requires continual scientific studies.
ACKNOWLEDGMENTS
The author wishes to acknowledge Tatyana Lyubezhanina, DA, and LeeAnn Klotz, DA, for their assistance in the preparation of this article.
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ABOUT THE AUTHOR
Dr. Jackson received his DDS degree at State University of New York, Buffalo School of Dental Medicine, Buffalo, NY. He completed postgraduate training at St. Luke’s Memorial Hospital Center’s General Practice Residency Program. Dr. Jackson completed his implant training at New York University College of Dentistry. Dr. Jackson is board certified and a Diplomate of the American Board of Oral Implantology/Implant Dentistry and a Fellow of the American Academy of Implant Dentistry (AAID). Dr. Jackson is past president of the AAID. He is an attending staff dentist for Mohawk Valley Health System General Practice Residency Program. Dr. Jackson is the director of the AAID Boston Maxicourse in Oral Implantology and East Coast Implant Institute. He has published several articles in peer-reviewed journals on the topic of oral implantology and implant dentistry. He can be reached at bjjddsimplant@aol.com.
Disclosure: Dr. Jackson is a KOL for Implant Direct, Rocky Mountain Tissue Bank, and Adin Dental Implant Solutions. He did not receive compensation for writing this article.
