Anatomically Driven Immediate Implant Placement in the Esthetic Zone: Two Case Reports as Proof of Principle
Achieving favorable and stable esthetic outcomes with immediate implants used to replace maxillary anterior teeth can be challenging. Osteotomies need to be initiated along the palatal socket wall, and it is often difficult to stabilize initial drilling. An immediate implant was planned for a hopeless maxillary incisor. Using a flapless surgery technique, the tooth was removed and decoronated, and an entry point was made in the root to guide the osteotomy drills. The root was reinserted and stabilized while a precision drill and 2-mm twist drill were used in sequence to drill through the tooth root, establishing the osteotomy location but stopping 3–4 mm short of final depth. The root was then removed, and the final implant bur for a 3.5 × 11.5-mm implant was drilled to depth, engaging the necessary native bone apically. The original tooth crown was then used to prepare and insert a transitional crown. Reinserting the extracted root of a maxillary anterior tooth and using it as a guide for osteotomy preparation is an excellent method to optimally position an immediate implant palatally in the socket wall.
(a) Flowchart for osteotomy initiation using the extracted but reinserted root for anatomical guidance. (b) Flowchart for initiating osteotomy preparation before root removal.
(a) The patient wished to have his maxillary left lateral incisor replaced with an immediate implant. (b) The periodontium of the adjacent teeth was healthy.
After restoring the tooth with flowable composite, a putty matrix was made to assist with later fabrication of a temporary restoration using the patient's tooth.
(a) After sectioning the crown from the root and removing the latter atraumatically without raising a flap, a starting hole was created in the cingulum and the root reinserted as a guide tool. (b) Bracing the root facially with a surgical elevator, the osteotomy was partially developed by drilling through the root structure. (c) The pilot bur was used to confirm that the osteotomy was correctly positioned for a screw-retained restoration. (d) An intraoperative radiograph confirmed the developing osteotomy to be well positioned.
(a) “Sticky bone” was prepared by combining allograft particles with platelet-rich fibrinogen isolated from the patient's venous blood. (b) The facial gap between implant and cortical plate was packed with the sticky bone.
A temporary prosthetic abutment was inserted and trimmed appropriately.
Teflon tape was placed in the screw access hole and over the graft material to allow finalization of the temporary in the mouth.
Luxatemp was injected around the abutment and into the putty matrix and allowed to set in the mouth.
The customized transitional crown was refined, connected to the implant with a retention screw, and confirmed to be free of incisal contact.
(a) The immediate postoperative radiograph confirmed ideal implant positioning and subcrestal placement. (b) At the 2-week postoperative visit, the site showed favorable soft tissue contour along with heavy stain from the chlorhexidine antibacterial mouth rinse regimen. (c) A clinical photograph of the final crown inserted after 4 months of site healing.
(a) This endodontically treated lateral incisor was deemed nonrestorable. (b) After removing the crown, initial drilling of the osteotomy was done after establishing the correct entry point in the cingulum. (c) After removing the root atraumatically, the osteotomy was completed to receive a 3.5-mm-diameter x 11.5-mm-long Nobel Active implant implant and a large-diameter healing abutment connected to help seal the grafted peri-implant gaps. Temporization was achieved using the modified original crown splinted with a Ribbond extra-coronal splint to the contiguous teeth See panel (d). (d) Instead of a transitional crown, the modified tooth crown was splinted to the contiguous 2 teeth.
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