A 40-year-old male patient visited the practice reporting discomfort from the UL1 for several months and dissatisfaction with the appearance of his teeth.
During the initial appointment the patient reported he was medically fit and healthy. In terms of his dental health, his oral hygiene was poor. He presented with generalised chronic gingivitis and a fractured root of the UL1 with a chronic perio-endo lesion and alveolar bone loss. He had no caries present and minimal horizontal bone loss.
First he was provided with a routine perio-generalised supragingival scale and oral hygiene education, including flossing instruction. The patient was very compliant, and his oral health was greatly improved at the following extraction appointment.
Treatment options
Treatment options were focused on rectifying the problems posed by the UL1 and included extraction of the UL1 followed by immediate placement of a partial denture.
The patient was unhappy with the idea of a removable a prosthesis as a permanent solution. In the end, a socket graft procedure with MinerOss and placement of a BioHorizons TLR 4612 implant was the treatment of choice. This was because it would allow for a good final aesthetic result and ideal implant placement to be achieved. An implant-restored crown had a good prognosis.
Treating the patient
The first appointment consisted of a consultation, as well as taking radiographs and photographs. The patient’s dental problems were diagnosed and treatment options were discussed.
Two weeks later the patient returned. The treatment plan was discussed once again and the way forwards agreed.
Oral hygiene instruction and simple perio scaling was undertaken. Initial impressions, bite registration and shade were taken to construct an immediate denture.
At the third appointment, the patient’s oral health and perio response was assessed, and it was found that the patient had been compliant.
Surgical removal of the UL1 was undertaken; a full periosteal flap was raised from the UR1 to UL2 with no relieving incision. Chronic granulation tissue was removed and the site prepared for the MinerOss bone graft. 0.5cc of MinerOss was placed, as was Mem-Lok membrane (15mm x 20mm), and three Vicryl Rapide sutures were used to close the flap.
An immediate denture was then fitted, ensuring it was non-traumatic in conformative occlusion.
At a review appointment two weeks later, the patient was reminded of the importance of a good oral health regimen at home.
After another four months, the patient returned as requested. A radiograph was taken to assess bone height and the quality of the graft.
An impression was taken for a surgical stent. Consent was obtained for implant placement and continuation of the
treatment plan.
Two weeks later an implant was placed at the UL1 using sequential drill guide pins and a surgical stent. A full periosteal flap was raised from the UR1 to UL2 with no relieving incision. A radiograph confirmed the implant’s positioning was as expected, the cover screw was placed and the flap was replaced using Vicryl Rapide sutures. The patient returned two weeks later for a review appointment; all was going well.
Three months later a healing abutment was placed at 3mm in height to achieve regular emergence at the UL1. At the following appointment an impression of the upper was taken using a closed tray pick-up technique in a special
tray using Impregum. An impression of the partial denture was used as a guide to copy the morphology of the UL1. Alginate was used for the lower impression and silicone for the bite. The patient’s tooth shade was then recorded, and a photo and the shade emailed to the lab. Modification to a stock titanium abutment and porcelain-fused-to-metal (PFM) crown in precious metal was prescribed.
The next appointment was for the crown to be fitted, oral health instruction to be given and photographs taken. The abutment was torqued to 25nm, the crown bonded with TempBond, and the aesthetics and occlusion checked.
Case overview
Thankfully, there were no particular unforeseen challenges during the seven months of treatment. The patient was
very highly motivated and compliant.
The patient had good quality soft tissue and the MinerOss bone graft achieved D1 and D2 bone quality.
The patient was very happy with the result, both functionally and aesthetically.