The aim of this article is to present a case of single-tooth prosthetic restoration in the aesthetic zone step by step. The patient was referred to our clinic with a fractured root of tooth #11 (Fig. 1). The cone beam computed tomography (CBCT) analysis confirmed the fracture and revealed external resorption of the root from the vestibular side (Fig. 2). The tooth had to be extracted, and it was decided to follow immediate implant placement with a temporary aesthetic implant restoration. The immediate implant placement was planned with short-term non-occlusal loading.
With the use of the CEREC Omnicam scanner (Dentsply Sirona), scans were taken of both the maxillary and the mandibular full arches along with a buccal scan (Fig. 3). The scans, together with the DICOM files, were uploaded to the Simplant software (Dentsply Sirona; Figs. 4 & 5).
The optimal position was planned for an Ankylos C/X B 14 implant (Dentsply Sirona) in line with the 3A–2B rule.1 Using the Simplant software, a Simplant Guide, along with a patient-specific Atlantis CustomBase Solution (with a titanium nitride abutment surface; Dentsply Sirona) and digital files, were ordered using Atlantis Core File (Dentsply Sirona).
Fig. 1: Situation before treatment, which led to the decision to extract tooth #11.
Fig. 2: CBCT scan: the root of the tooth was visibly fractured, and there was clear external resorption of the root from the vestibular side.
Fig. 3: Buccal scan: information on the positioning of the maxilla relative to the mandible. This is absolutely necessary for designing a crown.
Fig. 4: Designing the guide in the Simplant software based on the planned implant position.
Fig. 5: Overlaying the CBCT and CEREC intra-oral scans, as well
as the planned implant position, in the Simplant software.
Fig. 6: Planning the shape and size of the future CAD/CAM full ceramic crown in cut-back technique in the inLab software (Dentsply Sirona) based on the Atlantis Core File received.
Fig. 7: Full ceramic crown milled in the CEREC CAD/CAM system before sintering. As can be seen in the image, the Atlantis abutment and
the crown would fit perfectly together.
Fig. 8: The completed screw-retained IPS e.max crown ready to be cemented extra-orally with the Atlantis abutment (titanium nitride abutment surface).
Fig. 9: Visible granulation tissue at the resorption and fracture area of tooth #11.
Fig. 10: Removal of the granulation tissue with an Er:YAG laser.
Fig. 11: Clean socket after atraumatic extraction of tooth #11.
Fig. 12: Tooth-supported Simplant Guide.
Fig. 13: The guide fitted flawlessly on the patient’s teeth.
Fig. 14: A sequence of implant drills with specific guide sleeves were used.
Fig. 15: Placement of the Ankylos implant using the Simplant Guide.
Fig. 16: Sub-crestal placement of the Ankylos implant. Attachment of the screw-retained
IPS e.max crown on to the Atlantis abutment (non-functional restoration).
Fig. 17: A follow-up CBCT scan demonstrated the perfectly executed positioning of the implant as it had been planned.
Fig. 18: There was perfect adaptation of the soft tissue around the implant restoration. In addition, a ceramic crown
was placed on tooth #12 (after root canal therapy) and ceramic veneers on teeth #21 and 22. Three years follow up shows stability of soft and hard tissue.
The digital files were used to design and manufacture a screw-retained Atlantis crown for implant #11 in the CEREC CAD/CAM system (Dentsply Sirona). All the components, the Simplant Guide, the Atlantis abutment and the temporary crown, using CEREC, were manufactured and delivered prior to the surgical procedure (Figs. 6–8).
After precise planning, the tooth was extracted. At the resorption and fracture area of tooth #11, granulation tissue was clearly visible (Fig. 9). The granulation tissue was removed with an Er:YAG laser (H14 handpiece, Fotona; Fig. 10). The extraction was atraumatic and the socket clean and ready for implant placement (Fig. 11).
The implant was placed sub-crestally using the Simplant Guide (Figs. 12–15), which assures precision and safety. The screw-retained full ceramic crown on the Atlantis abutment (non-functional restoration) was placed immediately after implantation (Fig. 16). A follow-up CBCT scan demonstrated the perfectly executed positioning of the implant as it had been planned in the Simplant software (Fig. 17).
The treatment was successful, and the final outcome was very satisfying. After three years, the soft tissue around the implant was well adapted and healthy (Fig. 18). In addition, a ceramic crown was placed on tooth #12 (after root canal therapy) and ceramic veneers on teeth #21 and 22.
Reference
1. Rojas-Vizcaya F. Biological aspects as a rule for single implant placement. The 3A-2B rule: a clinical report. J Prosthodont 2013;22(7):575-80
Editorial note: This article was published in digital―international magazine of digital dentistry Vol. 2, Issue 1/2021.
CAD/CAM
CBCT
Cerec
Digital dentistry
Immediate implant placement
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:sharpen(level=0):output(format=jpeg)/up/dt/2021/04/1_.jpg "Fig. 1: Situation before treatment, which led to the decision to extract tooth #11.")
:sharpen(level=0):output(format=jpeg)/up/dt/2021/04/2_-1.jpg "Fig. 2: CBCT scan: the root of the tooth was visibly fractured, and there was clear external resorption of the root from the vestibular side.")
:sharpen(level=0):output(format=jpeg)/up/dt/2021/04/3_-1.jpg "Fig. 3: Buccal scan: information on the positioning of the maxilla relative to the mandible. This is absolutely necessary for designing a crown.")
:sharpen(level=0):output(format=jpeg)/up/dt/2021/04/4_-1.jpg "Fig. 4: Designing the guide in the Simplant software based on the planned implant position.")
:sharpen(level=0):output(format=jpeg)/up/dt/2021/04/5_-1.jpg "Fig. 5: Overlaying the CBCT and CEREC intra-oral scans, as well
as the planned implant position, in the Simplant software.")
:sharpen(level=0):output(format=jpeg)/up/dt/2021/04/6_-1.jpg "Fig. 6: Planning the shape and size of the future CAD/CAM full ceramic crown in cut-back technique in the inLab software (Dentsply Sirona) based on the Atlantis Core File received.")
:sharpen(level=0):output(format=jpeg)/up/dt/2021/04/7_.jpg "Fig. 7: Full ceramic crown milled in the CEREC CAD/CAM system before sintering. As can be seen in the image, the Atlantis abutment and
the crown would fit perfectly together.")
:sharpen(level=0):output(format=jpeg)/up/dt/2021/04/8_-1.jpg "Fig. 8: The completed screw-retained IPS e.max crown ready to be cemented extra-orally with the Atlantis abutment (titanium nitride abutment surface).")
:sharpen(level=0):output(format=jpeg)/up/dt/2021/04/9_-1.jpg "Fig. 9: Visible granulation tissue at the resorption and fracture area of tooth #11.")
:sharpen(level=0):output(format=jpeg)/up/dt/2021/04/10_-1.jpg "Fig. 10: Removal of the granulation tissue with an Er:YAG laser.")
:sharpen(level=0):output(format=jpeg)/up/dt/2021/04/11_-1.jpg "Fig. 11: Clean socket after atraumatic extraction of tooth #11.")
:sharpen(level=0):output(format=jpeg)/up/dt/2021/04/12_-1.jpg "Fig. 12: Tooth-supported Simplant Guide.")
:sharpen(level=0):output(format=jpeg)/up/dt/2021/04/13_-1.jpg "Fig. 13: The guide fitted flawlessly on the patient’s teeth.")
:sharpen(level=0):output(format=jpeg)/up/dt/2021/04/14_-1.jpg "Fig. 14: A sequence of implant drills with specific guide sleeves were used.")
:sharpen(level=0):output(format=jpeg)/up/dt/2021/04/15_-1.jpg "Fig. 15: Placement of the Ankylos implant using the Simplant Guide.")
:sharpen(level=0):output(format=jpeg)/up/dt/2021/04/16_-1.jpg "Fig. 16: Sub-crestal placement of the Ankylos implant. Attachment of the screw-retained
IPS e.max crown on to the Atlantis abutment (non-functional restoration).")
:sharpen(level=0):output(format=jpeg)/up/dt/2021/04/17-1.jpg "Fig. 17: A follow-up CBCT scan demonstrated the perfectly executed positioning of the implant as it had been planned.")
:sharpen(level=0):output(format=jpeg)/up/dt/2021/04/18-1.jpg "Fig. 18: There was perfect adaptation of the soft tissue around the implant restoration. In addition, a ceramic crown
was placed on tooth #12 (after root canal therapy) and ceramic veneers on teeth #21 and 22. Three years follow up shows stability of soft and hard tissue.")
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