Eimear O’Connell walks us through treatment for a patient who recently required an implant on his LR6.

Patient attended the clinic for a routine check up on 25 April 2017 and had assessment both clinically and radiographically. It was determined that the lower LR6 had a hopeless prognosis. The tooth had been previously root treated and had fractured through the furcation.

The treatment options were given for the site post-extraction:

  1. Leave the space
  2. Replace the missing tooth with a three-unit fixed bridge
  3. Place an immediate guided implant.

The patient had previously had an implant placed at his LL6 site and wanted to proceed with the same treatment on the right-hand side.

Creating a guide

On 2 May 2017 the patient returned and as he wanted the implant placement we carried out an intra-oral scan with the Omnicam, and at the same visit we took a 3D scan (small volume) bone scan of the lower right quadrant, which we took with the Orthophos SL. This allows immediate integration of these scans using Galaxis software.

We plan a replacement crown for the site, by virtually extracting the tooth on the software and designing a crown in the space.

This data is exported into the laptop, to merge with the CBCT data. We can then plan the best position for the implant in relation to the planned position of the crown. Once the length, diameter and orientation of the implant is determined we create a design for the surgical guide, which we export into the Omnicam. Before the surgical visit we make a surgical guide that is milled in-house.

Placing the implant

On the day of extraction, we place an immediate guided implant in to the extraction socket. A Piezomed is used to clean the site after extraction and before osteotomy to ensure no remnants of granulation tissue are left in situ.

We used the guide with keys for Astra EV to place an immediate 5.4 diameter 11mm implant.

This allows maximum bone to implant contact. It also allows us to achieve good primary stability.

The implant was torqued into place at 40Ncm, then there is still space where the tooth roots have been extracted. I used Eth-Oss to graft around the implant, packing it tightly into the remaining bony void. I then use some collagen plugs and place sutures to close the wound.

The procedure is carried out with just a small crestal incision.

This surgery was carried out one month after the initial assessment.

The patient gets the sutures out four days later and then six weeks later we place the final screw retained crown.

I made an slight error at the time of surgery and placed a uni healing abutment. This meant that at the restorative stage I had to make a small incision in the buccal mucosa as it had healed so tightly around this narrower healing abutment.

The photos below are at the one-year review and you can see slight staining in the composite access cavity, but good marginal gingival tissue and very good bone levels around the ti-base.

The patient was very happy with the outcome.

Figure 1: Initial radiograph of LR6
Figure 2: Intra-oral scan with Omnicam
Figure 3: 3D scan to show the bone of the lower right quadrant
Figure 4: Using the software we can plan the best position and implant to fit
Figure 5: We placed an immediate guided implant in the extraction socket
Figure 6: We can make sure of a perfect fit
Figure 7: Final radiography
Figure 8: A small incision was required as it had healed so tightly around the abutment
Figure 9: Crown in place
Figure 10: One-year review with slight staining on the access cavity
Figure 11: One-year review radiograph