As already written in a previous article, the first molar is a tooth of primary importance in maintaining the stability of the stomatognathic system. Unfortunately, it is also often the first tooth to be lost and therefore requiring replacement.
Whenever possible, our first treatment option is immediate post-extraction implant placement with immediate provisionalization. Sometimes, for a variety of reasons, this option is not feasible, so we may decide to proceed with an immediate, but non-load-bearing, post extraction implant.
In this clinical case an immediate post extractive implant placement without immediate provisionalization in the first lower right molar is combined with a contemporary regenerative procedures to fill the gap between the fixture and the surrounding bone, in order to maintain and stabilize the root bump shape to achieve a future better esthetic result, and allow to the patient a better hygiene maintenance.
Fig.1
The patient presented to our clinic complaining of an ill defined pain during chewing on tooth 46.
At a first view every thing was fine without any problem.
Fig.2
When probing the tooth it was immediate clear that there was a root fracture with a characteristic point probing.
Fig.3
The X-ray shows a radiolucency at the tooth #46 in proximity to the distal root, that confirmed the presence of a root fracture.
It was also evident the ideal shape dimension of the bone septum to insert an implant immediately after the extraction, providing to don’t damage it during the extraction maneuvers.
Fig.4
The tooth has been separated in two portions along its furcation to facilitate the extraction, and to prevent damage to the bone septum.
Fig.5
A special drill was used to expand the septal bone and thus prepare an ideal site for an implant of at least 4.5mm in diameter.
Fig.6
At the end of the osteotomy it is evident how the bone septum has been expanded, optimising its shape to accommodate an implant and how the bone wall is missing in the mesial direction.
Fig.7
After the implant insertion, the residual socket has been filled with some bone substitute up to the gingival margin, with the objective to reduce the bone remodeling and to sustain the soft tissues. in order to preserve the root bump anatomy (root bump preservation).
Fig.8
To better maintain stable in situ the grafted bone it was decided to change the healing screw with a bigger one umbrella shaped.
Fig.9
A collagen sponge was applied over the grafted bone for protection and to reduce the possibility of dispersion of the material inside the oral cavity.
Fig.10
Everything was then stabilized with surgical cyanoacrylate.
Fig.11
The x-ray at the end of the surgery clearly shows the contact between the implant and the natural bone and the area grafted by the biomaterial.
Fig.12
At 6 weeks from the surgery the healing was going well, but it was decided to change the healing screw with a thinner one to allow a better space with less compression to the soft tissue in which to grow.
Fig.13
The X-ray immediately after the screw change.
Fig.14
After 4 months, clinical healing can be considered perfect and the final crown can be prepared.
Fig.15
The crown we received from the technician was slightly vertically undercontoured at the level of the gingival emergence profile. So it was decided to modify it.
Fig.16
To better fit the space some resin was added to the crown to show to the technician how to press the soft tissue.
Fig.17
The definitive zirconia-ceramic crown with the modified profile at 2 years from the surgery.
The crown now seems absolutely like a natural tooth, and the soft tissue are contouring its profile in a really natural way.
Fig.18
Control X-ray at 2 years. The implant is well integrated, and the natural bone together with the heterologous bone is correctly remodeled according our project.
Conclusions
The possibility to insert immediately an implant, just after the tooth extraction, gives not only the possibility to reduce the surgical sections, but in contemporary with the socket preservation, it gives the possibility to maintain the root bump prominence, and so, to reach a better esthetic result together with a better cleansing of this area.
Although the insertion of an immediate provisional restoration was not foreseen, optimal management of the soft and hard tissues allowed us to maintain an ideal anatomy, on which it was then possible to work by modifying the emergence profile of the prosthetic crown, so as to optimize both the functional and aesthetic result.
Bibliography
- Carvalho W, Ladeira Casado P, Caúla AL, Porto Barboza E: Implants for single first molar replacement: important treatment concerns. IMPLANT DENT 2004;13:328-335.
- Smith RB, Tarnow DP. Classification of molar extraction sites for immediate dental implant placement: technical note. Int J Oral Maxillofac Implants 2013;28: 911-6.
- Araújo MG, Hürzeler MB, Dias DR, Matarazzo F. Minimal invasiveness in the alveolar ridge preservation, with or without concomitant implant placement. Periodontol 2000. 2023 Feb;91(1):65-88. doi: 10.1111/prd.12441. Epub 2022 Aug 1. PMID: 35913046.
