CATEGORY 54 AUSTRALASIAN DENTIST Introduction In the anterior region, creating of an immediate loading provisional restoration that respects biological principles has scientifically proven to be the preferred alternative to preserve papillae, gingival volume, prevent recessions, and quickly restore aesthetic and phonetic functions. A successful immediate implant placement in fresh extraction sockets can be achieved provided that certain criteria are met, such as optimal primary stability and correct position of the implant. A common treatment method involves the use of prefabricated acrylic resin teeth that are adapted to the oral situation and fixed to a provisional abutment during surgery. In this clinical case, however, the stump portion of the provisional hybrid abutment (referred to as the aesthetic substructure here) was fabricated from a highly filled CAD/CAM nano-hybrid composite. Due to the fact that the contralateral tooth 11 exhibited macro and micro textures, accompanied by colour nuances and chromatic effects on the incisal edge (halo effect), it was decided to design the aesthetic substructure in such a way that a direct composite veneer could be layered on it. The case shown here confirms that modern composites are also effective materials for achieving highly aesthetic restorations in the context of implant surgery. The immediate loaded implantretained provisional solution was made from composite materials (substructure and veneer) primarily indicated for definitive restorations without any restrictions. As such, it would also be suitable for long-term use in the mouth. Case description Case history A 31-year-old woman presented at our dental practice with an upper left central incisor (tooth 21) that was causing concern due to increased tooth mobility. The patient reported accidentally hitting after “falling against a piece of furniture five years ago”. Records The patient was apparently in good health. A thorough examination revealed no active caries nor gingivitis. No fistulae, nor signs of acute inflammatory processes were observed. The soft tissues showed no changes in colour, contour, shape or texture. Routine professional hygiene session was performed prior to treatment. The patient was concerned that the increased degree of tooth loosening would worsen over time and might lead to the loss of the compromised incisor. She wanted a solution that would provide stability for eating and speaking while maintaining an optimal aesthetic appearance. The records included periapical radiographs of tooth 21, a tomography (Fig. 1), 3D-printed dental study models and a pulp vitality test. u The various imaging showed a negative crown-root ratio due to the obvious root resorption. u A bone concavity in the vestibular apical region as well absence of bone substance and thin gingival phenotype were recorded. u The tooth did not show any sensitivity to the cold test. There was clinical evidence of the tooth loosening reported by the patient. Diagnosis u Post-traumatic root resorption in tooth 21 with loss of vitality u Grade 3 tooth mobility on tooth 21 Therapy Treatment plan Based on the diagnosis, the only treatment option was a minimally traumatic extraction of tooth 21, followed by an alveolar curettage with preservation of the healthy soft tissues. The plan was for an implantation immediately after extraction with additional use of a temporary gingiva former, bone regeneration with a xenograft, and an immediate loading restoration. A milled substructure from nano-hybrid composite (Grandio disc, VOCO) was to be fixed and to be layered clinically with a direct composite veneer. Timeline of treatment steps u After assessment of vestibular morphology and texture (Fig. 2) as well as detailed impression taking, physical and virtual models of the teeth were created in the laboratory. The diagnostic wax-up was used as a guide for the fabrication of the provisional mock-up and of the substructure. u Accordingly, a diagnostic crown mockup from micro-filled composite for temporary restorations was milled (Structur CAD, VOCO) and placed in the patient’s mouth next to the Aesthetic dentistry following guided implant placement and immediate loading utilizing CAD/CAM nano-hybrid composite Authors: Amilkar Rocha DDS, MSc, PhD (Specialist in dental prosthetics; MSc and PhD in implantology) amilkarrocha@yahoo.com Oscar Arauco Urzagaste DDS (Specialist in implantology) Kevin Cavero DDS (Specialist in oral rehabilitation and esthetic dentistry) Luis Eduardo Marques Padovan DDS, MSc, PhD Geninho Thomé DDS, MSc, PhD CLINICAL Keywords Immediate implant loading, Dental implant, Guided surgery, Single-tooth replacement, CAD/CAM, Grandio disc, Composite resin matrix, Tissue graft Amilkar Rocha
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