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Case Report - Immediate Placement and Loading
Dr. Harald Fahrenholz

Case Report - Immediate Placement and Loading

Dr. Harald Fahrenholz –  Zahnästhetik am Kohlmarkt

Curriculum vitae

Dr. Harald Fahrenholz was born in Königssee, Bavaria, at 19.11.1949 After his education at the University of Mainz he worked 25 years in his own office in Grünwald near Munich. Later he worked together with Prof. Rolf Ewers at the CMF Clinic in Vienna. Since 2007 he is working in his own office at the Zahnästhetik am Kohlmarkt. He was influenced by teachers like Dr. Peter  Kraus, P. K. Thomas, Charles Stewart, Dr. Axel Bauer, Dr. Alexander Gutowski and Lorenzo Vanini. Subsequently in implantology Dr. Axel Kirsch, Prof. Per-Ingvar Brånemark, Prof. Ulf Lekholm (CTC Courses at the Brånemark Clinic, Gothenburg), Prof. Rolf Ewers, Dr. Johan Feith and Dr. Ulrich Volz

His main emphasis is the metal-free and biologic dentistry in  implantology and prosthodontics.

Introduction

To  evaluate  the  clinical  performance  of  the  system,  I  performed  a  retrospective  evaluative study of my own patients be-tween 2009 and 2015, together with Dr Sofia  Karapataki  (Athens,  Greece).  The  follow-up included 114 Patent implants. Our  clinical  survival  rate  was  97.6%;  no  fractures  were  reported  for  this  period.  Any  cases  of  implant  loss  were  related  to bone augmentation, sinus floor eleva-tion or immediate implant placement. To date, I have placed 700 Patent implants and experienced only three fractures, all of  them  two-piece  implants.  By  hind-sight,  all  failures  were  caused  by  incor-rect  prosthetic  design.  Nor  did  we  see  any detachment or fracture of fiberglass abutments. These   results   correlate   well   with   the   reports  by  Becker  et  al.  (2017)  and  Brüll.et  al.  (2014)  [1,  2].  Both  confirm  the  fa-vourable    soft-tissue    response,    which    Brüll  et  al.  state  even  holds  when  com-pared to titanium implants. Our own re-sults confirm this: we have not seen any case  of  peri-implantitis  associated  with  these  implants.  The  retrospective  study  by Brüll et al. also reported good results with immediate implant placement.The  present  case  report  demonstrates  how  the  Patent  implant  system  can  be  applied   in   immediate   placement   and   loading situations.

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Dr. Harald Fahrenholz –  Zahnästhetik am Kohlmarkt

Kohlmarkt 7/1/34, 1010 Vienna, Austria www.zahnaesthetik-wien.at

Telephone +43 664 9127454 h.fahrenholz@zahnaesthetik-wien.at

4. April 2020

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Figure 1:

Initial situation, the fracture is not recognizable

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Figure 2:

Initial situation with the fractured tooth 21

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Figure 3:

Relined root extractor in situ

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Figure 4:

The extracted root



Initial Situation

A 30-year-old female patient presented for emergency treatment at our clinic with a fractured upper left central inci-sor (tooth 21). The fracture was not vis-ible (Fig. 1), but the crown soon chipped and splintered (Fig. 2).Based  on  a  conventional  radiograph,  we  decided,  together  with  the  patient, to extract the tooth and imme-diately place a two-piece Patent implant 13 mm in length and 4.5 mm in diameter (Fig. 4). We also decided that an immedi-ate-loading protocol was appropriate and a  provisional  crown  should  be  placed  in  the same session.

We  had  considered  three  alternative  courses of treatment:

• Extraction with no immediate other action besides provisionalization
• Extraction, augmentation with platelet-rich fibrin and bone-grafting material and subsequent provisionalization
• Extraction, immediate implant place-ment and, if possible, immediate restoration with a temporary crownIf immediate restoration had not been possible because of insufficient primary stability  of  the  implant,  another  fixed  prosthetic solution would have had to be found. The great advantage of immediate restoration is that all structures – including the gingiva (papillae) and the bone – are optimally preserved.

Pretreatment

A  root  extractor  was  deployed  and  supported by the neighbouring teeth (Fig. 3) to allow atraumatic extraction to preserve the buccal bone. A  complete  and  healthy  alveolar  bone  is  a  prerequisite  for  a  securely  anchored  implant.  We  choose  an  atraumatic  ex-traction  protocol  that  created  favourable  conditions by preserving the bone volume and preparing the bone optimally for the placement  of  the  implant. 

The  three-dimensional  preservation  of  hard  and  soft  tissue after extraction is also important for flawless aesthetic and functional implants and restorations. The vestibular bone wall in particular is extremely important for the correct  three-dimensional  implant  place-ment  as  well  as  for  the  preservation  of  the  soft  tissue  under  the  superstructure,  particularly  in  the  anterior  region.  It  is  therefore essential to prevent or minimize resorptive remodelling processes. After local anaesthesia, the force vector of  the  extractor  was  applied  in  the  direc-tion  of  the  central  axis  of  the  tooth.  The  remaining  root  was  removed  (Fig.  4).  The  extraction  socket  was  carefully  curetted,  removing all fibrous tissue.A silicone key was prepared to facilitate chairside   fabrication   of   the   provisional   crown.

Surgical procedure and Implant Placement

To prepare the osteotomy, drilling was performed on the palatal side of the extraction socket (Fig. 5) such as to preserve the buccal plate and to avoid putting too much pressure on it as the implant is inserted. Once  the  osteotomy  had  been  completed  using  the  dedicated  surgical  kit,  the  implant  was  placed  at  an  insertion  torque of 40 Ncm. 

After the extraction, the wound had to be cleaned thoroughly with a sharp curette.It  is  important  to  treat  the  implant  site  gently, and especially not to destroy the buccal bone lamella. Therefore, I marked the  site  palatally  with  a  round  burr  and  prepared  the  implant  bed  to  a  depth  of 13  mm  with  the  2-mm  pilot  drill.  Once  the pilot bore is in place, it is not difficult to extend the implant site to a diameter of 4.5 mm.The implant bed was checked with an appropriate  instrument  and  disinfected  with  ozone.  The  implant  can  be  placed  either  manually  with  a  ratchet  or  with  a suitable drill. In this case, primary stability was achieved at a torque of 40 Nm (Fig. 6).  The   fibreglass   post   was   prepared  –  at  chairside  but  extraorally.  To  facilitate  the  preparation,  a  dummy  implant  was  used  to  hold  it  (Fig. 7).  After  the  try-in,  the  fibreglass  post  was  cemented with RelyX Unicem.

Finally, the provisional crown was fab-ricated at chairside using the silicone key. The fibreglass post was isolated with vaseline oil and the crown was cemented with  temporary  cement  to  be  retrievable  later  (Fig.  8).  Control  radiographs  showed that the bone was well preserved  and  that  the  temporary  crown  could be delivered (Fig. 9).

The  crown  had  no  contact  with  its  antagonists in either static or dynamic oc-clusion.  At  one  day  (Fig.  10)  and  at  two  weeks (Fig. 11), the soft tissue was healing nicely.

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Figure 5:

Drilling the osteotomy in the palatal Wall of the extraction socket

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Figure 6:

Patent™ Implant in situ

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Figure 7:

Chairside preparation (extra-orally) of the glass fiber post

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Figure 8:

Glass fiber post cemented after try-in

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Figure 9:

The temporary crown immediately after surgery

 
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Figure 10:

Situation after one day

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Figure 11:

Two weeks later. You can see the perfect soft tissue healing.

Prosthetic Reconstruction

After six weeks, the dental laboratory provided a second provisional crown (Fig. 12).We had some problems with the shade of the crown due to the transparency of the  fibreglass  post.  Following  deliberations with the dental technician, we concealed the die with white composite resin (Fig. 13). After four months of healing, the case was finalized by delivering the definitive crown  (Figs.  13  and  14).  The  soft  tissue  had remained perfectly healthy. At the five-year follow-up, the marginal bone  levels  presented  fully  maintained  (Fig.17).

Conclusion

The Patent™ Dental Implant System is very conducive to immediate placement and restoration. The risk of implant loss is certainly higher than with a two-stage procedure, but after weighing up all the advantages and disadvantages, patient comfort and above all the preservation of the surrounding structures was deemed more important.

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Figure 12:

Provisional crown

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Figure 13:

Final crown

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Figure 14:

Final result

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Figure 15:

Before extraction

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Figure 16:

Situation at implant placement

Situation at implant placement
Situation at implant placement
Situation at implant placement

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Figure 17:

Situation 2 years implant placement years post-op. Note the wellpreserved marginal bone levels

References

Becker J, John G, Becker K, Mainusch S, Diedrichs G, Schwarz F. Clinical performance of two-piece zirconiumimplants in the posterior mandible and maxilla: a prospective cohort study over 2 years.Clin. Oral Impl. Res. 28, 2017, 29–35 doi: 10.1111/clr.12610 

Brüll F, van Winkelhoff AJ, CuneMSZirconia dental implants: a clinical, radiographic, and microbiologic evaluation up to 3 years. Int J Oral MaxillofacImplants. 2014 Jul-Aug;29(4):914-20. doi. 10.11607/jomi.3293


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