This case report describes the treatment of a fractured left maxillary first bicuspid, followed by immediate placement of a dental implant and a personalized healing abutment to preserve the gingival contour. The tooth was extracted with minimal trauma, the osteotomy was prepared to the required depth and a Straumann Bone Level Implant was inserted, followed later by placement of a personalized healing abutment.

An impression was made three months after implant placement. Then a full contour provisional restoration was fabricated. Once the occlusion, contours and esthetics were approved, a definitive screw-retained E-Max CAD was milled, bonded to a titanium Variobase and delivered to the patient. A periapical, CT Scan and clinical evaluation at one year post-insertion exhibited no clinical or radiologic complications.

Clinical case of a fractured maxillary first bicuspid

A 58-year-old male patient presented with a chief complaint of crown fracture at the cervical area of tooth #24. Clinical and radiological evaluation revealed that the tooth had root canal treatment with adequate alveolar bone, absence of periapical pathology and a fracture line that was at the gingival margin (Fig.1).

restoration single tooth implant

Comprehensive treatment, including the replacement of the restoration in the adjacent tooth (#25) was discussed with the patient, and it was decided to carry on with treatment of the aforementioned tooth in a phased approach (Fig. 1).

So it was decided to extract and place an endosseous implant immediately after extraction. After administering local anesthesia, the extraction of the tooth was carried out using periotomes and small periosteal elevators in order to preserve the surrounding bone as much as possible. The socket was debrided with curettes and a Straumann Bone Level implant was placed (3.3 x 14 mm), primary stability was achieved and a DBBM (BIO-OSS) bone graft was placed between the implant and buccal wall. A personalized healing abutment was created utilizing composite and a temporary abutment cylinder to preserve the emergence profile. One week after placement, the patient was recalled for post-surgery follow-up (Fig. 2).

bone graft implant

The patient was recalled after three months and a full contour provisional implant-supported restoration was fabricated following the emergence profile maintained with the personalized healing abutment (Fig. 3 and Fig. 4).

emergence profile
full center provisional implant supported restoration

The patient road-tested the provisional for three weeks. Once occlusion, contours and esthetics were approved, a new digital scan was performed utilizing a scan body and an Omnicam to capture the 3D position of the implant. Then the digital design was performed and the definitive crown was milled from an E-Max Cad block for CEREC. After it was crystallized and stained, the crown was bonded to the titanium Variobase and delivered to the patient.

Once the accuracy of the fit was confirmed radiographically, recommended torque value was delivered to the definitive abutment screw, and the screw access hole was then obliterated utilizing a PTFE tape followed by a direct composite restoration (Fig. 5, Fig. 6, Fig. 7, Fig. 8).  

radiographic implant placement
clinical implant restoration
abutment screw implant placement
implant restoration single tooth

The clinical and radiographic appearances at one year after insertion show acceptable esthetics and maintenance of bone around the implant (Fig. 9).

single tooth cerec

(Click this link for more dentistry articles by Dr. Ricardo Mitrani.)

Ricardo Mitrani, D.D.S., M.S.D., Spear Faculty and Contributing Author


Commenter's Profile Image Angelos S.
May 28th, 2018
Thanks for posting this interesting case Dr. Mitrani. Just wondering- what is the thickness of your ceramic at the crown-abutment interface? My understanding is that e.max needs a minimum 0.8-1mm thickness of ceramic at the margin for adequate strength. On the radiograph the marginal ceramic appears much thinner. Would you care to elaborate on this point? 2) Are you routinely using narrow diameter Roxolid implants in premolar sites or did you decide to do this as a compromise in this situation due to the narrow ridge? Warmest regards, Dr. Angelos Sourial, Melbourne, Australia