This clinical report describes the immediate loading of a dental implant with a provisional crown to replace a missing central incisor. After 3 months of healing and soft tissue maturation with the provisional crown, an impression was made using a customized post to capture the established soft tissue contours. Finally, a definitive screw-retained all-ceramic crown was placed, which has had good results over 18 months of follow up without complications.

1. 34

2. Presented by: Dr.Abbasi Begum M
Department of prosthodontics
Narayana dental college & hospital
The Future of Prosthodontics
33

3. Immediate loading and customized
restoration of a single implant in the
maxillary esthetic zone:
A clinical report
Laurens den Hartog et al
J Prosthet Dent 2009;vol:102:211-215
32

4. What is an Implant???
 A prosthetic device or alloplastic material
implanted into the oral tissue beneath the mucosal
or/and periosteal layer and/ or in the bone to
provide retention and support for the fixed and
removable prosthesis.
GPT-8
31

5. Single/multiple missing tooth/Teeth
What are the treatment options available ???????
30

6. ?
1. Removable Partial
Denture (R.P.D.)
2.Fixed Partial
Denture (F.P.D.)
3. Implant Prosthesis 29

7. DISADVANTAGES :-
1. do not maintain bone
- compromise the
esthetic result
2. bulk – need for
cross arch stabilization
3. food debris , plaque accumulation
4. movement
-speech
-function
28

8. DISADVANTAGES :-
1. caries and endodontic failure of abutment teeth is the
most common failure
2. increased plaque retention of pontic increases caries
and periodontal disease risk
3. damage to healthy teeth
4. fracture ( porcelain , tooth )
5. esthetics ( anterior region )
6. Uncemented restorations
27

9. • It is contra indicated in
1. Poor abutment teeth support
2. inadequate hard and soft tissue in esthetic
regions
3. patient desire
4. young patients with large pulp horns 26

10. ADVANTAGES :-
1.Adjacent teeth do not require splinted
restoration
- - less risk of caries
- Less risk of porcelain fracture
- Less risk of uncemented restoration
- Less fracture of tooth
2. Psychological need of patient
25

11. 3. Improved hygiene conditions
- less decay risk
- less pontic overhang
4. Decreased cold and contact
sensitivity
5. Improved esthetics
6. Maintains bone height
7. Decreases adjacent tooth loss
24

12. •The replacement of a single missing anterior
tooth with an implant-supported crown is a
demanding therapy
LOADING
•LOADING
IMMEDIATE LOADING
23

13. •The application of an implant supported crown for the
restoration of a missing single tooth in the anterior
dentition is challenging
•In the esthetic zone, both the appearance of
the implant crown and the soft tissue contribute to a
successful treatment outcome and should consequently
be in harmony with the surrounding dentition.
•Attention has been focused on immediate or early
loading protocols in which a provisional restoration is
placed soon after implant placement.
22

14. Immediate or early loading have
reported
•favorable treatment
outcomes in terms of
implant survival,
marginal bone resorption, soft tissue
level, and
 the incidence of complications
of treatment in which implants
were inserted in healed sites, as well as
treatment in which implants were
placed in fresh extraction sockets 21

15. Advantages
• a shorter overall treatment time
• avoidance of a second-stage surgery
• elimination of the need for a removable
prosthesis during the healing phase.
• Good primary implant stability is a
prerequisite, as is the development of a
protected occlusion to create a nonoccluding
provisional crown
20

16. Purpose
to demonstrate an immediate implant
loading protocol for restoration
of a missing central incisor.
After the provisional restoration phase, an
individually fabricated impression post was used
and, subsequently, a definitive screw-retained 1
piece all-ceramic crown was placed.
19

17. CLINICAL REPORT
CLINICAL PRESENTATION
The patient was healthy, did not smoke, and intraoral examination
revealed a healthy, well maintained dentition.
Clinically, adequate bone volume was present at the future implant
site.
In all dimensions, sufficient space was available for an
implant crown with an anatomical design.
 Radiographically, no pathology of the bone and adjacent teeth
was noted. 18

18. •Preoperatively, diagnostic casts
were made with a diagnostic arrangement
representing the future implant crown in an
ideal position.
•Transparent acrylic resin template
(Vertex Castapress; Vertex-Dental BV,
Zeist, the Netherlands) was fabricated,
and a guide channel was prepared
in the template to aid in proper implant
placement.
17

19. Care was taken with the surgical guide so that
the guide channel would direct the implant
sufficiently toward the palate to accommodate a
screw-retained restoration.
Antibiotic prophylaxis (amoxicillin
500 mg, 3 times daily for 7 days
used a 0.2% chlorhexidine mouthwash 16

20. Following the administering of local anesthesia
(Ultracaine D-S Forte; Aventis Pharma Deutschland
GmbH, Frankfurt am Main, Germany), a slightly
palatal crest incision was made with extensions
through the buccal and palatal sulcus of the adjacent
teeth.
Mucoperiosteal flap was elevated to expose only the
ridge crest.
An implant (NobelReplaceTapered RP, 16 mm; Nobel
Biocare AB, Goteborg, Sweden) was placed, guided by
the surgical template
15

21. 1. The shoulder of the implant was placed at a depth of 3
mm apical to the buccal and cervical aspect of the
prospective clinical crown to provide soft tissue to
develop an adequate emergence profile.
2. Good primary implant stability of >45 Ncm was
obtained, determined with a measurement device for
implant site preparation (Osseocare;Nobel Biocare AB).
3. Next, an open tray impression was made at the implant
level using a custom acrylic resin impression tray
and a polyether impression material (Impregum Penta;
3MESPE,St. Paul, Minn).
Finally, a healing abutment (NobelReplace; Nobel
Biocare AB) was placed, and the wound was closed with
sutures
14

22. •In the dental laboratory, a screwretained
provisional restoration was fabricated, consisting of an
engaging temporary abutment against which composite
resin was modeled
•The abutment was removed and the provisional
crown was placed and subsequently torqued to 32 Ncm
•Special care was taken to prevent any centric and
eccentric occlusion contacts with the antagonist teeth.
•Furthermore, the provisional restoration was
contoured so that the periimplant soft tissue was
optimally supported
13

23. The interproximal papillae were given enough
space to regenerate.
Patients instructions;
• A soft diet, to avoid exerting force on the provisional
restoration,
• Continue chlorhexidine Rinses for 7 days.
•
12

24. •For pain control, 600-mg
ibuprofen (Brufen Bruis 600; Abott
BV, Hoofddorp, the Netherlands) was
prescribed, to be taken 3 times daily
•the sutures were removed after 2 weeks
Follow up once in a month 3 months-implant mobility, oral
hygiene, and occlusion were evaluated
11

25. important objective was the
creation
of an ideal emergence profile
by removing the provisional
crown.
View of periimplant soft tissue after
provisional restoration
phase. Note established emergence profile
Three months later (6
months following implant
placement), an implant-
level impression was made
using an impression post
10

26. the provisional crown was assembled
with an implant analogue embedded in type
IV dentalstone .An addition silicone
impression of the cervical portion of the
crown was made . Next, the latter was
substituted for an impression
post and bis-acrylic composite resin was
added to the post.
9

27. Customized impression post.
.
post (Fig. 5), it was inserted
into the implant and an open tray
impression
was made with a polyether
impression material
In the dental laboratory, a soft
tissue cast was prepared. First, a
waxing of the definitive crown was
made on a temporary abutment 8

28. The screw access hole was located sufficiently near
the palate to create a screw-retained crown and to
prepare an appropriate abutment.
Therefore, the waxing was cut back to the desired
form and scanned for fabrication of an individual
zirconia abutment
Porcelain was added directly to the abutment to
create a screw-retained 1-piece definitive
restoration
7

29. Application of porcelain to individually
fabricated Procera (Nobel Biocare
AB) zirconia abutment to create 1-piece
screw-retained definitive crown 7
The restoration was placed and the abutment
screw was torqued to 32 Ncm. Finally, the screw
hole was filled with a cotton pellet and composite
resin (Clearfil AP-X; Kuraray Medical, Inc,
Okayama, Japan).The restoration has been in
service for 18 months without complication

30. DISCUSSION
•An immediate loading protocol finalized with the
placement of a screw-retained all ceramic restoration.
•A major prerequisite for immediate loading is a high
degree of primary stability in terms of high insertion
torque
•An initial insertion torque of atleast 45 Ncm was
reached.
A substantial maturation of the papillae occurred during
the provisional phase.
remodeling potential of the soft tissues to establish
a proper biological height after the surgical manipulation. 6

31. Finally, a screw-retained definitive restoration was fabricated.
Advantages :
•This type of restoration compared to a cement-retained
restoration include retrievability
•No risk of cement remnants, thereby eliminating the
possibility of irritation of the periimplant tissues by such
remnants.
DRAWBACKS
•the presence of a screw access opening decreases fracture
resistance of the porcelain.
•Furthermore, screw-retained restorations necessitate
precise implant positioning for a proper palatal position of
the screw access hole that does not
interfere with esthetics.
5

32. SUMMARY
This clinical report describes a treatment in which
a lost anterior tooth was replaced with a dental
implant that was immediately restored with a
provisional crown. After the provisional phase, an
impression was made with a customized
impression post for an accurate reproduction of
the established emergence profile.
Finally, a 1-piece screw-retained all ceramic
crown was placed.
4

33. Clinical view of definitive implant crown 18
months
after implant placement.
Radiographic view 18 months after implant
placement
3

34.  Contemporary implant dentistry- Carl Misch
1. Chang M, Wennstrom JL, Odman P, AnderssonB. Implant supported single-tooth
replacements compared to contralateral natural teeth. Crown and soft tissue dimensions.
Clin Oral Implants Res 1999;10:185-94.
2. Belser UC, Schmid B, Higginbottom F,Buser D. Outcome analysis of implant restorations
located in the anterior maxilla: a review of the recent literature. Int J Oral Maxillofac
Implants 2004;19 Suppl:30-42.
3. Palmer RM, Palmer PJ, Smith BJ. A 5-year prospective study of Astra singletooth
implants. Clin Oral Implants Res2000;11:179-82.
2

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