 case report
Fixed Restoration in the Shortest
Possible Time with Replace Select
Implants
INTRODUCTION: A 35-year-old patient visited our dental office with two teeth (21 and 11) that could
not be preserved. Because other bridge appliances had already failed, an implant solution
seemed to be the only reasonable option.
Dr. Georg Bayer, Dr. Frank Kistler and Dr. Steffen Kistler, Germany
❙ The clinical findings led us to assume that
the bone supply in the implantation region was
sufficient to make primarily stable implant insertion possible after extraction of the roots,
22
3 2003
even though we had to make allowances for
augmentative measures in the apical region.
We also planned to insert an immediate provisional appliance with no chewing function if
there was enough primary stability to stabilize
the soft tissue in this extremely esthetically sensitive area. Use of the existing long-term provisional appliance was part of this plan. Before
the operation we explained to the patient that
this procedure should only be performed under the aforementioned circumstances. In this
way, an immediate appliance could be dispensed with if there were any problems so as
not to endanger the success of the implantation.
The first step in the operation was to remove
teeth 21 and 11, with meticulous care being
taken of the surrounding bone structures, especially the vestibular bone plate in the coronal
region. We therefore carried out the extraction using only a microscalpel and periotome
in order to loosen the periodontal ligament
fibers right up to the apex. The remaining
fibers were removed after we took out the root
remnant. The axial direction and position of
the implants were selected to correspond with
those of the original teeth. Consequently, we
made sure that the pilot hole was angled
slightly in a palatal direction to prevent a
vestibular perforation in the apical region of
the alveolus. The greatest danger posed by this
kind of perforation is when surgery is performed through the alveolus because, if undetected, it can result in implant loss or severe
pain for the patient. A meticulous check must
therefore be made to ensure no perforation
has occurred before the implants are inserted.
The implant diameter was selected with a template. A distance to the adjacent teeth of two
millimeters was ensured during the selection
 case report
process to let normal interdental papillae
form. Two Replace Select tapered implants by
Nobel Biocare with a diameter of 5mm were
used. The implants do not have any contact
with the bone in the crestal region. The approximal space to the bone, the so-called
“jumping distance,” is bridged during postoperative healing without additional augmentation procedures and can be up to 1.2 mm
(according to Garber and Salama). Natural
bone from the drilling stages was nonetheless
inserted in the approximal spaces here.
The implants were lowered 3 mm under the
level of the gingiva to place the prosthetic table
at the exact level of the original alveolar bone.
During the insertion we made sure there was
sufficient primary stability because we had also
selected a root-shaped implant with screw configuration. A torque of at least 45 Ncm is recommended for adequate stability. This can be
checked with a torque wrench. Moreover, a
resonant frequency measurement (Osstell)
can be used to determine the strength of the
implant in the bone.
When we checked the drill hole, we found perforations in the buccal bone. For this reason we
exposed the vestibular bone plate and suspected fenestration of the alveolus by making
an angular incision in the mucogingival line.
This method, described by Kirsch et al., allows
an adequate overview of the esthetically significant gingival zone during augmentation
while keeping it intact. The augmentation
material chosen was BioOss (Geistlich) with a
collagen membrane (Bio-Gide, Geistlich).
Suturing was done with a monofil 6.0 suture
material.
Provisional abutments were seated after the
implants had been inserted. These were prepared to fit under the existing crowns. The
crowns were then adapted with cold-curing
polymer. Next, the provisional appliance was
removed from the mouth and finished and
polished in our own lab. The provisional abutments were also coated with opaquer in the lab
to prevent the plastic crowns causing a dark
translucency. The immediate restoration thus
produced was seated on the implants again,
and the static and dynamic occlusion meticulously checked. During this check we made
sure the restoration had no function at all during any movement and had a clearance of at
least 1mm to avoid improper loads. In this case,
the immediate loading took the form of a passive support function because the splinted adjacent teeth were performing the active retention.
Before and after the operation the patient was
given explicit instructions about the purely es-
3 2003
23
 case report
thetic role the restoration plays until the implants have been safely osseointegrated after
about six months. These instructions were repeated during each recall appointment because there is a risk that patients may load the
restoration prematurely due to carelessness or
habit. The provisional appliance was disconnected from the adjacent teeth after two
months. After six months, the final restoration
with single fused-to-porcelain crowns could be
carried out. We wait this long because during
this period there may be changes to the gingival level that settle down again. Shrinkage of
about 1mm can normally be expected.
 summary
The method shows a procedure that, when
there are adequate anatomical relationships on
the one hand and the best possible patient
compliance in each treatment phase on the
other, saves patients a post-operative healing
phase with a removable denture and gives
them an esthetically satisfying fixed restoration
in the shortest time possible. Because implants
are not loaded in the postoperative healing
phase to guarantee safe osseointegration, we
must stress the non-functional and purely esthetic character of this type of primary restoration. The restoration should instead be regarded as a modified tooth or bridge-shaped
postoperative healing aid with no functional
value for postoperative transgingival healing.
When we take these requirements into account, this procedure may be superior to any
other temporary appliance that might exert uncontrolled forces on implants or provide inadequate support for the soft tissue.
Even with this method, however, the higher risk
of loss compared to conventional methods
must not be overlooked. So when we selected
a case we ensured there was sufficient compliance and, moreover, decided to only carry out
an intraoperative immediate restoration after a
very thorough assessment of the risks. In our
view, the procedure described has no effect on
the period leading up to osseointegration. Consequently, we aim to insert a permanent appliance after a postoperative healing period of five
to six months.
 a u t h o r ’s a d d r e s s
Dr. Steffen Kistler
Postfach 11 62
86881 Landsberg am Lech, Germany
Phone: +49-8191-42251
Fax: +49-8191-33848
E-mail: [email protected]
24
3 2003