PI Dental Implant Center

Single Tooth Incisionless-Sutureless Surgery

TEETH IN A DAY

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Introduction

Immediate loading of titanium implants intended to become osseointegrated has peaked the interest of many clinicians and researchers. The evolution from the traditional 2-stage protocol, originally developed by Per Ingvar Brånemark, has provided exceptionally excellent results over the past two decades.

However, patients' desires and needs have also traditionally encouraged clinicians and researchers alike to find new solutions. Thus, acceleration of the treatment process has occurred as a result of perspective scientific studies. Much of the immediate loading research performed over the past nine years has focused on extensive partial and full arch restorations. Researchers have demonstrated the efficacy of immediate loading using the TEETH IN A DAY protocol in the fully edentulous maxilla and fully edentulous mandible as well as partially edentulous conditions. The results of these studies clearly indicate that immediate loading under specific protocols can work successfully.

There is a distinct difference between immediate loading of multiple implants and that of a single tooth. When functional loads are applied to a rigidly splinted multiple implant system, the majority, if not all the implants, absorb the load distribution in that system. However, any loading forces applied to a single tooth implant restoration are applied to the one implant. For this reason many clinicians believe that the initial restoration placed on the implant should be constructed in a manner that eliminates direct occlusal loading. After the implant has osseointegrated, the final prosthesis can be put into normal function. This is the procedure employed for the following patient.

Patient Treatment Review

The patient is a very lovely, energetic, athletic and highly motivated 26-year-old young woman who suffered a traumatic injury to her maxillary anterior teeth in adolescence. As a result of this injury the tooth eventually discolored from pulpal necrosis. Subsequent endodontic therapy was performed and the tooth remained clinically stable. In recent years the patient's family dentist identified external root resorption at the distal cervical region (Fig 1).

Clinical Evaluation
The patient presented with an intact dentition and significant discoloration of the maxillary right central incisor. Her smile line was graded Class IV smile line (gummy smile) making the dark coloration of the tooth obvious when she spoke and extremely evident upon smiling (Fig 2). Radiographic evaluation confirmed lateral root resorption and the position of proximal bone related to the resorptive process
(Fig 3). Considering the external root resorption, this tooth would have a very poor prognosis for long-term conventional restorative treatment, especially since an area of apical root resorption was also noted. Alternative forms of prosthetic intervention were discussed with the patient including the use of a 3-tooth fixed partial denture, a removable partial denture, and the possibility of a resin-bonded bridge. Ultimately, the removal of the tooth and insertion of a Brånemark implant using the TEETH IN A DAY protocol was offered. The patient felt quite strongly about maintaining the integrity of the adjacent teeth and was resistant to the thought of a removable prosthesis.

Therefore the treatment of choice to rectify this condition was an osseointegrated implant with an immediate loading protocol TEETH IN A DAY. Two weeks later the patient scheduled to begin this process.

TEETH IN A DAY Surgical Procedure

Local anesthesia was administered as follows: Marcaine 1:200,000 two carpules and Lignospan 1:100,000 2 carpules. The local anesthesia was tolerated well. Tooth # 8 was carefully removed using thin elevators to dissect the periodontal ligament to allow atraumatic removal of the tooth from the socket while maintaining all of the available bone surrounding the area (4a, b, c). Using finger palpation of the vestibular area, the labial anatomy of the premaxilla was digitally visualized. Clinical palpation and lateral cephalometric radiographs assisted in positioning the drills used to create the implant osteotomy site. Profuse saline irrigation was used throughout the drilling procedure, which was designed to orient the receptor site toward the palatal aspect of the socket to create an implant angulation similar to that of the natural root but extending far beyond the apex into the pre-maxillary basal bone (Fig 5a, b).

Following preparation of the socket, a 15 X 4 mm TiUnite MK4 Brånemark implant was placed with the shoulder of the implant 4 mm below the crest of the gingiva on the labial aspect. A bone guide was installed and the accompanying trephine used to remove peripheral bone from the proximal surfaces of the socket. Then a 1 mm CeraOne abutment was installed (Fig 6). The gold fastening screw was tightened with an electronic torque driver to 32 Ncm of torque force.

TEETH IN A DAY Prosthetic Procedures

With the abutment in place, a methylmethacrylate custom coping was fitted over the CeraOne abutment (Fig 7). A prefabricated acrylic crown was carefully connected to the plastic coping with a soft mix of acrylic resin (Fig 8a,b). One needs to be aware of the potential for acrylic engaging the interproximal undercuts during this phase of treatment. Once the acrylic polymerized to the coping, the crown was removed from the abutment and an abutment analogue was installed in the coping to preserve the integrity of the acrylic margins during the refinishing of the acrylic restoration. Small amounts of acrylic were added to any voids or thin areas that required reinforcement. Once set, recontouring and final polishing was accomplished (Fig 9).

Clinical treatment continued during this laboratory phase. Autogenous bone obtained from the osteotomy site was used to fill voids between the socket wall and the implant surface.

Cementation of the acrylic crown was accomplished with a carboxylate cement (Duralon, ESPE America Inc., Norristown). Only the thinnest amount of cement was required in order to avoid the extrusion of excess into the crevicular area of the fresh extraction site. The contours of this restoration were designed to mimic the original tooth and root form, sealing the socket and maintaining clot formation subgingivally. The morphology of this restoration also provided support of the labial gingiva (Fig 10a, b, c).

No sutures are required when sculpting the restoration in this fashion. This incisionless-sutureless procedure provides an exceptionally fast recovery with very little if any postoperative discomfort. Standard protocol for medications following implant surgery was given to the patient along with postoperative instructions cautioning premature function on the individual implant (Fig 11).

In many similar patients, the master impression can be made at the time of this one-stage procedure, just prior to cementation of the TEETH IN A DAY crown. In this instance, the patient returned four months after the TEETH IN A DAY procedure for the final impression followed a few days later by delivery of the porcelain fused to gold implant supported crown.