Initial situation

A 68-year-old male patient, a non-smoker, presented with controlled Type 2 diabetes. He had undergone previous dental implant treatments with positive results in the past. The patient presented to the office with tooth #36 in a non-restorable condition with indication for extraction. He requested a dental implant as the treatment choice.

Various treatment possibilities were discussed:

1. extraction, healing and conventional implant placement;
2. extraction and immediate placement with conventional healing and then a definitive prosthesis; or
3. extraction, implant placement and immediate functional loading of the implant.

In his previous treatments, the patient had experienced successful treatment outcomes with the one-tooth, one-time technique, which is a technique that provides the definitive crown to be produced and seated in immediate occlusal function right after the surgical procedure. For this particular case, given the systemic condition, it was suggested that a crown made of temporary material be put into immediate function during the healing phase to ensure that the systemic condition would not affect the soft-tissue healing and contours before starting the definitive crown. After full discussion, the patient opted for the third solution. All the parameters supported the chosen treatment.

Treatment planning

After careful assessment of the patient’s anatomical condition through a panoramic radiograph and CBCT scan (Figs. 1–3), it was possible to verify ideal interradicular bone availability, allowing the following treatment plan:

• minimally traumatic tooth extraction;
• immediate implant placement (Straumann TLX, 3.75 × 12.00 mm);
• intra-oral scanning;
• temporary crown design and chairside milling;
• immediate provisional crown in function; and
• after osseointegration and soft-tissue maturation, proceeding with the definitive crown.

Surgical procedure

The surgical procedure was carried out under conscious sedation with local anaesthetic, and routine sterile preparations for surgical procedures were followed. To preserve the gingival and surrounding walls as far as possible, a flapless minimally traumatic approach to the extraction was employed by splitting the roots in different directions (Fig. 4). Extra precautions were taken not to inflict any trauma, not even by the suction device on the papilla and any surrounding soft tissue. A simple orthodontic elastic was placed around the adjacent teeth to delimitate the buccal and lingual red zone margins that should not be encroached upon.

It was possible to verify solid interradicular bone availability (Fig. 5), extending further the limits of the root apices and allowing for a centrally oriented osteotomy. The implant bed preparation started with the use of a needle drill at 800 rpm, followed by the ⌀ 2.2 mm and ⌀ 2.8 mm drills (Figs. 6–10). The implant was placed with the use of ratchet and torque control, reaching the desired final position at a 50 N cm torque value (Figs. 11–13). The socket was then augmented with bovine-derived bone substitute impregnated with advanced platelet-rich fibrin (A-PRF) and finalised with sutures to keep the A-PRF application immobile, and a 3 mm healing abutment was placed (Figs. 14–17).

The patient also received an intra-operative antibiotic with 4 mg dexamethasone intravenously and received standard postoperative care with analgesics, chlorhexidine mouthwash and antibiotic for five days.

Prosthetic procedure

The patient was sent to the prosthodontist, and the immediate restoration technical work followed a digital workflow that included an intra-oral scanner (TRIOS Pod, 3Shape) and CAD/CAM processing using Straumann CARES Digital Solutions (Dental Wings). A PMMA crown was milled and cemented to a prefabricated titanium abutment (Variobase, Straumann; Fig. 18). A few hours later, the patient left the office having received an immediate implant and a functional provisional screw-retained restoration (Fig. 19 & 20).

In Taiwan to celebrate the Chinese New Year, the patient was caught up in the first COVID-19 restrictions, and his return to the office was compromised for a few days.

Upon the patient’s return, the definitive crown placement was initiated by another intra-oral scan to copy all the gingival contours after healing (Figs. 21 & 22). A full monolithic zirconia crown was milled and cemented to a Variobase abutment (diameter: 5 mm; height: 6 mm) and properly seated, occlusal and contact points checked. The screw access hole was properly closed with PTFE tape and light-polymerised composite (Fig. 23).

Treatment outcomes

From a clinical perspective, the immediate placement and function were very well indicated as they could be verified through the gingival margins and health, and bone levels throughout the healing phase, and final and one-year follow-up images (Figs. 24–29).

The patient was very satisfied with the result in relation to masticatory performance and aesthetics. In addition, given the time restrictions to undergoing several treatment appointments, the possibility of having a very close to final restoration immediately after the surgical procedure requiring only another session to finalise the treatment was, according to him, far more desirable than his earlier dental implant procedures.