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Case Report - Individualized Single Tooth
Dr Sebastian Horvath, Germany

Case report - Individualized Single Tooth

Dr. med. dent. Sebastian Horvath

Curriculum vitae

Dr. Sebastian Horvath specializes in esthetic-restorative treatments, as they combine many aspects of modern dentistry and have a positive impact on his patients. He works together with his wife and father in the group practice Dr. Horvath in Jestetten, Germany. Dr. Horvath is a native of Jestetten and studied dentistry at the University of Freiburg, Germany, from 2003-2008. In 2008, he received his doctorate (Dr. med. dent.) from the same university. From 2009-2012, he worked as a research assistant at the Department of Prosthodontics at the University Hospital of Freiburg, Germany, and completed training as a qualified advanced specialist in prosthodontics. As part of the specialization, he received in-depth training in fixed prosthodontics, esthetic dentistry, implantology, and all-ceramic materials. In 2012 he was awarded the "Young Esthetics Award" of the German Society for Esthetic Dentistry (DGÄZ).

Introduction

Growing health concerns of patients have led to an increas-ing demand of metal-free restorations. The same is true for dental implants. As dental professionals it is our goal to ful-fil this demand of our patients in the most predictable way. When  it  comes  to  implant  treatments  the  two  most  cru-cial aspects regarding a treatment success are the osse-ointegration of the implant and the prosthetic workflow. The Patent™ implant system features a novel zirconia implant design with an innovative prosthetic connection. In a pro-spective cohort study by Becker et al. 2017, the Patent™ implant system was evaluated for posterior single tooth ap-plications with good results. The survival rate was 95.8 % after  two  years.  A  very  positive  soft  tissue  response  was  also reported. This is in line with what was reported by Brüll et al. 2014, in a 3-year retrospective follow-up. The follow-ing  case  report  shows  the  replacement  of  a  lower  molar  using the Patent™ zirconia implant system.

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Dr. med. dent. Sebastian Horvath

Bahnhofstrasse 24 
79798 Jestetten, Deutschland 
https://www.drhorvath.de/

Telephone +49 7745 7211 kontakt@drhorvath.d

Initial Situation

A  54-year  old  female  patient  presented  at  the  author’s  office, asking for a general restoration of her teeth. As a part of this complex case the lower right quadrant was restored  (Figs.  1   &    2).  The  treatment  of  this  area  is  the  subject  of  this  case  report.  The  patient  reported  that  the old restoration was placed about 20 years ago after tooth #46 was lost due to endodontic complications. A few  years  after  the  placement  of  the  restoration  tooth  #45 was endodontically treated through the placed res-toration. Now the patient reported an increasing sensitiv-ity on tooth #47 due to ill-fitting margins. It was planned to restore the area with two all-ceramic crowns on teeth #45 & 47, and an implant-retained restoration in site #46. The implant-retained restoration was preferred to a new fixed dental prosthesis in order to reduce the load on the endodontically  treated  tooth  #45  and  to  reduce  future  risks by incorporating an endodontically treated tooth in a larger restoration. Initially, a CBCT was made in order to evaluate the bone volume in the edentulous areas and to evaluate existing root canal treatments.

Pretreatment

The CBCT revealed sufficient bone volume in site #46 to place an implant (Fig. 3). A custom implant was designed in order to get the optimal transgingival design for this individual case. The intrabony part of the implant had the di-mensions 4.5 x  9  mm. The old fixed dental prosthesis was removed and tooth #45 built-up with a post and core res-toration. Subsequently, a digitally planned provisional res-toration was fabricated and placed. The scan for the pro-visional restoration was further used for the fabrication of a surgical guide. For this, the scan was matched to the CBCT on the contralateral posterior teeth and the anterior teeth as they remained unchanged from the initial situation.

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Fig. 1:

Initial situation in the lower right quadrant. The patient reported about increasing  sensitivity  on  tooth  #47.

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Fig. 2:

Initial  radiograph  showing  the  lower right quadrant. Note the ill-fitting margin distal on tooth #47.

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Fig. 3:

A CBCT  revealed  sufficient  bone  volume  in  site  #46  to  place  an  implant.

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Fig. 4:

Clinical situation prior to the surgery.

Implant Placement

The  fit  of  the  surgical  guide  was  evaluated  prior  to  the  surgery (Fig. 5). Following local anaesthesia, a full-flap in site #46 was elevated to gain access to the bone (Fig. 6). The incision was performed centrally on the ridge in order to  evenly  space  out  the  attached  gingiva  on  the  lingual and buccal sides. Subsequently, a guided osteotomy was performed  according  to  the  manufacturers  recommen-dations  (Fig.  7).  The  drilling  protocol  for  hard  bone  was  used, which includes a cortical drill and a screw tap. The implant  was  placed  and  a  sufficient  primary  stability  of  30  Ncm  was  achieved  (Fig.  8).  The  insertion  torque  was  measured electronically during the placement of the im-plant. The incision was closed and the prosthetic connec-tion sealed using Teflon tape (Figs. 9–11). A new, digitally planned provisional restoration was fabricated (Fig. 12). In the area of the newly placed implant the provisional res-toration was planned as a flat pontic towards the implant with a distance of about .1 mm between the implant and the  provisional  restoration.  This  design  facilitated  good  cleaning in the following weeks and also ensured that the implant  was  unloaded  during  healing.  Sutures  were  re-moved ten days postsurgery. Healing was uneventful. 

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Fig. 5:

The placed surgical guide.

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Fig. 6:

A full-flap was elevated to gain access to the bone.

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Fig. 7:

The osteotomy was performed using the drilling protocol for hard bone.

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Fig. 8:

The custom-planned zirconia implant was placed and a sufficient primary stability of 30 Ncm achieved.

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Fig. 9:

Wound closure.

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Fig. 10:

The prosthetic connection was sealed using Teflon tape.

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Fig. 11:

Radiographic evaluation of the implant position.

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Fig. 12:

In the area of the newly placed implant the provisional restoration was planned as a flat pontic towards the implant with a distance of about .1 mm between the implant and the provisional restoration.

Prosthetic Reconstruction

The prosthetic phase was commenced three months after  implant  placement.  The  provisional  restoration  was  removed  and  final  preparations  performed  on  the  abutment  teeth.  Following  an  uneventful  healing  phase, the implant was stable and the periimplant soft tissue healthy (Figs. 13–15). For the prosthetic recon-struction  a  glass  fibre  post  and  core  assembly  was  adhesively  cemented  on  the  implant  (Figs.  16  &   17).  The  post  and  core  assembly  is  pre-fabricated  and  tightly  fits  into  the  implant  connection.  Following  this  build-up,  the  implant  was  prepared  for  a  full-crown  restoration  just  like  a  natural  tooth  (Figs.  18  &    19).  An  intra-oral  scan  was  performed  and  three   monolithic   zirconia   crowns   fabricated using a lab-side workflow (Figs. 20 &   21; Ceramics: MDT Claus- Peter Schulz). The final restorations were  cemented.  Figures  22  to  24  show the final treatment result.
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Fig. 13:

Clinical situation three months after implant placement. Healing was uneventful.

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Fig. 14:

The implant was stable and the soft tissue presented itself as healthy. 

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Fig. 15:

Occlusal view.

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Fig. 16:

For the prosthetic reconstruction a glass fibre post and core assembly was adhesively cemented on the implant.

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Fig. 17:

The post and core assembly is pre-fabricated and tightly fits into the implant connection.

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Fig. 18:

Following this build-up, the implant was prepared for  a  full-crown  restoration  just  like  a  natural  tooth.

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Fig. 19:

Occlusal  view.

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Fig. 20:

An  intra-oral  scan  was  performed  for  a  lab-side  prosthetic  workflow.

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Fig. 21:

Three monolithic zirconia crowns were fabricated (Ceramics: MDT Claus-Peter Schulz).

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Fig. 22:

Intra-oral view of the treatment result.

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Fig. 23:

Occlu-sal view.

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Fig. 24:

Radiographic evaluation of the treatment result.


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