Immediate Load Same Day Procedure
Cracked Bicuspid
This 48 year old female presented with a chief complaint of a cracked tooth. Upon examination it was found that she had fractured the lingual (inside) cusp of her left upper first bicuspid.
It was fractured below the gum line to the crest of the bone. The main reason it fractured was the existence of a large amalgam filling which weakened the tooth. |
Treatment Options
The patient had two treatment choices. We could perform root canal therapy, place a post and core, and then do a crown lengthening procedure to expose more tooth structure. Doing so would have required removing some gum tissue and bone. Then place a crown on the tooth.
The other option would be to remove the tooth, place an implant and immediately place a temporary crown.
The patient opted for an implant and crown. |
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Immediate Load Implant Criteria
To do an immediate load implant, certain criteria have to be met. There has to be adequate bone, a large enough implant needs to be placed, and the implant once placed has to be able to resist at least 40 ncm of force.
The temporary crown has to be adjusted so that no forces are placed on it during function. Meeting these criteria allows the bone to grow around the implant (osseointegration). After a period of nine weeks a permanent crown can placed.
The following picture sequence demonstrates an ideal situation for an immediate load implant or what I call a Vanity Crown because the patient refused to go out in public with a missing tooth.
A template was made of the tooth prior to removing the fractured cusp so as to facilitate fabrication of a temporary crown.
An important factor in this procedure is to carefully remove the tooth without removing any bone in the process.
In this photo, we are using a periotome, a thin instrument, to separate the root from the bone.
Preparation of Implant Socket
The photo here shows successful removal of the broken bicuspid and all root material.
The remaining boney socket (darker eliptical area) can be seen after the tooth was removed.
Socket Drilling
The socket was prepared with sequentially sized bone drills to accept a Nobel Biocare Select 5.0mm x 13mm implant.
In this photo the final sized drill bit is being used.
Precision Implant Placement
The implant is placed and tested with a torque wrench to see if it can be displaced with a force of 40 ncm.
This implant was proven to be extremely stable.
Zirconium Abutment
Next we customized a zirconium abutment and attached it to the implant with a torque of 35 ncm.
One of the advantages of using a white zirconium abutment as opposed to the silver colored titanium is that there is no graying of the overlying gum tissue.
X-ray Confirmation: Successful Implant
This is an immediate post operative x-ray taken showing the implant, zirconium abutment and temporary crown. Note how well centered the implant is between the canine and 2nd bicuspid.
The size of the implant and surrounding bone give more than adequate anchorage to place an immediate abutment and temporary crown.
Temporary Crown
The last photo shows the fitting of the temporary crown (Vanity Crown) that enables the patient to avoid the "toothless look" she was fearful of.
After 9 weeks, osseointegration has been achieved (bone material has completely integrated the implant substance), the permanent porcelain crown will be placed.
The porcelain material will be matched precisely with the patient's existing teeth. Future cosmetic considerations for the patient include replacement of old amalgam fillings, all ceramic crowns, porcelain veneers and Zoom teeth whitening.
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Mitchell Pohl, DDS
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