CATEGORY 44 AUSTRALASIAN DENTIST CLINICAL u Periodontal: low risk u Biomechanical: moderate risk u Aesthetic: high risk u Treatment options discussed: Option 1: Extraction of both #12 and 11 and dental implants Option 2: Extraction of both teeth and dental bridge (with thorough explanation of the future risk of a long span bridge). Option 3: Extraction of both teeth and removable partial denture. In the absence of tooth/root mobility or active infection, immediate implant placement with SS to support screwretained restorations was planned. The main challenge was the horizontal root fracture of the upper right central incisor and how to carefully remove the apical one third of the broken root without affecting the remaining 5mm buccal root shield. R2GATE software from MegaGen was used to plan the digital guided surgery and fabricate the surgical guide. Instruments and materials required for SST: 1. PET kit from MegaGen (includes a complete set of burs to section and smooth the buccal shield). 2. Irrigated surgical motor 3. Contra-angled surgical fast handpiece 4. Periotomes 5. Forceps 6. Monoglycolic 4.0 sutures Following adequate anesthesia of the site planned for immediate implants placement, the crown of #12 was removed and the lack of ferrule became evident (Fig 4). Both teeth were decoronated to the gingival level. The roots of #12 and #11 were then sectioned as apically as possible in a mesio-distal direction using the no. 2 longshank root resection bur (MegaGen PET Kit, Korea) (Fig 5). Once the labial and palatal root halves were adequately separated, a periotome was inserted into the palatal PDL space, carefully displacing the palatal root section labially into the recess created by the sectioning bur. The goal was to leave the apical part of #11 to be reduced using the implant drilling burs. A mini facial flap was raised to expose the coronal portions of the roots (Fig 6) (Andoni Jones 2020). The remaining root sections were then reduced coronally to the same level as the alveolar crest and thinned to no less than 2mm using the no. 2 long-shank round diamond bur (MegaGen PET Kit, Korea). Part of the mesial and distal curvature of each root was left to support the inter-proximal bone (Fig 6). to #11 site during drilling and checked with magnification to confirm complete drilling removal of the fractured apical one third of the root. The implant stability quotient (ISQ) of the implants was adequate for healing abutments but inadequate for immediate provisionalization. The mini flap was then sutured with 4/0 Monoglycolic simple interrupted sutures (Fig 9) and an Essix retainer with adequate clearance of the implants was used to temporarily restore the edentulous space for the duration of the healing. The healing was uneventful with no signs of infection or other complications at the 1-week and 1-month follow-up (Fig 11). An integration assessment was completed at 4 months at which point the ISQ was in the high 70s for both implants. Zero Fig 4. Crown sectioning Fig 3a. Cross section of #11 Fig 3b. Cross section of #12 Fig 5. PET Kit from MegaGen Fig 7. Surgical guide from R2GATE guided system Fig 8. Two MegaGen AnyOne implants in their final position Fig 9. Suture Fig 11. One month post op Fig 6. The two finished Socket Shields with the mini flap released to finish them with the alveolar bone. Look at the mesio-distal curvature to preserve the inter-proximal bone. The socket apices were then carefully curetted under magnification to remove any remnants of infection and each SS was checked for stability. The internal parts of the roots were smoothed using the no.4 bur (MegaGen PET Kit, Korea). The R2GATE designed surgical guide (Fig 7) and guided surgery kit burs were all used in this case. Osteotomies were then sequentially prepared to place two MegaGen AnyOne implants, size 4.0/13, at each site (Fig 8). Special attention was given Fig 10. Immediate post op PA
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