Challenging anterior multidisciplinary rehabilitation using Nobel Biocare N1™ implant system
Dr. Giacomo Fabbri
Patient: Male, 44 years old
Clinical situation: Good systemic and oral health condition, light smoker with history of periodontal disease. He requires a restorative esthetic treatment of the upper anterior teeth. All the natural teeth in the posterior areas are healthy and they don‘t need any therapy. They provide a good occlusal support and function.
Surgical solution: Extraction of 12 and 21 with immediate placement of the N1 Implant, immediate loading and connective tissue graft. Orthodontic therapy finalized to correct the position of tooth 11 and extrude tooth 21.
Restorative solution: Final restoration with all-ceramic restorations on teeth 11 and 12 and 2 screw-retained crowns on implants placed in regions 12 and 21.
Surgery date: March 20, 2021
Total treatment time: 14 months
Case courtesy of Dr. Giacomo Fabbri.
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The upper incisors present unpleasant esthetics due to dental migration, there is a significant rotation of the tooth 21, absence of soft tissue on the papilla between the teeth 21 and 22. Moreover, gingival recession is present on elements 12, 21 and 22. X-ray analysis shows a moderate loss of periodontal support on the upper incisors and the presence of severe root lesions on elements 12 and 21. These two root lesions compromised irreversibly the maintenance of teeth 12 and 21 that will be replaced by dental implants. An orthodontic therapy is also required in order to idealize teeth position, re-equilibrate the restorative space and favor the re-establishment of a new papilla between 21 and 22.
In relation to the clinical and esthetic evaluation a digital wax-up was created with DTX Studio™ Implant in order to plan the implant placement and also the orthodontic therapy in relation to the final prosthetic plan. The DTX Studio Implant software enables ideal planning, including occlusal, prosthetic, bone and soft tissue evaluation.
The blue contour represents the digital planning and red represents the initial condition. The implant placement is planned in relation to the final restoration. N1 Implant RP 13 mm and NP 13 mm were selected for the positions 21 and 12 respectively. The restorative planning with DTX Studio Implant has selected to use N1 Base 2.5 mm height in order to optimize tissue integration and bone integration and will not disturb soft tissue and bone healing throughout the treatment.
Teeth 12 and 21 are extracted (top left).
Flap was elevated according to CAF (coronally advanced flap) technique (top right).
Pilot drill guided surgery in relation to the 3D digital planning (bottom images).
Initial implant site preparation with OsseoDirector™ instrument
OsseoDirector in site 12 (left).
OsseoDirector in site 21 (right).
The sharp design of the OsseoDirector tip supports bone engagement and the tapered body allows changes in direction while cutting the pilot osteotomy.
OsseoShaper™ 1 instrument to create the final osteotomy.
OsseoShaper 1 for N1 Implant RP 13 mm in site 12 (left).
OsseoShaper 1 for N1 Implant NP 13 mm in site 21 (right).
The OsseoShaper 1 creates a specific osteotomy for the co-packed N1 Implant. The torque measured during shaping guides the surgical procedure.
Placement of N1 system implants
N1 Implant NP 13 mm. The implant achieved final insertion torque of 33 Ncm (left).
N1 Implant RP 13 mm. The implant achieved final insertion torque of 56 Ncm (right).
Implant site after the use of the OsseoShaper 1 in site 21: Residual bone particles are visible (left).
Implant in site: Flat side of the trioval collar faces buccally (right).
The N1 Base 2.5 mm was placed and torqued at 20 Ncm (left).
The N1 Base 2.5 mm was placed and torqued at 20 Ncm (right).
Occlusal view of the bases in situ (top left).
creos™ xenogain bone grafting (top center).
creos xenogain bone grafting (top right).
Soft tissue management using connective tissue graft (CTG) (bottom left).
Soft tissue grafting (bottom right).
Temporary restorations at abutment level were placed (top center).
Temporary restorations from digital workflow were placed on the temporary abutments by using flowable composite (top right).
Screw-retained temporary abutments in situ (bottom left). Suture (bottom center).
Healing after 10 days (bottom right).
Healing after 10 weeks (top left).
After 11 weeks the orthodontic therapy (top center).
6 months after the orthodontic therapy (top right).
New temporary restoration: Teeth and abutments preparation (bottom left).
New temporary cement base restoration in situ (bottom right).
Soft tissue healing 4 weeks after the soft tissue surgery, intraoral evaluation (top left).
Extra-oral evaluation of the soft tissue healing 4 weeks after the soft tissue surgery (top right images).
Final impression was taken 6 weeks after the soft tissue surgery using N1 Base scan abutment (bottom left).
Occlusal view (bottom right).
Soft tissue healing 2 weeks post surgery.
Soft tissue graft to increase the papilla volume between 21 and 22. A connective tissue graft was harvested from the palate and placed in the papilla area using tunnel technique.
Final zirconia NobelProcera® restoration placed on the 3D printed model (left).
Final zirconia NobelProcera restoration: Bonded teeth supported zirconia restoration for 22 and 11 and screw-retained Zi restoration placed at the base level on N1 Implant RP at 21, and N1 system implant NP at 12 (right).
Screw-retained zirconia restorations: Detailed view of the morphology and surface refinement used in the sub-gingival portions.
Try-in of the final restorations before the cut-back and the layering procedures.
Soft tissue evaluation: The fully-integrated 3D multidisciplinary approach allows us to achieve an excellent pink esthetic with an ideal soft tissue contour and dental proportion (left).
X-ray evaluation: X-rays show excellent integration of the restoration and excellent bone stability 1 year after implant placement (right).
Final impression (right).
The white line represents the soft tissue outlines before and during the treatment.
The comparison of the soft tissue outline before and after the therapy shows the improvement in soft tissue morphology, particularly at papilla level between 21 and 22.
Delivery of the final restorations: 1 year after implant placement.
21 (left), 12 (right). NobelProcera full zirconia screw-retained crowns placed at base level.
Tooth 12. Delivery of the final restorations: 1 year after implant placement.
Before the therapy (left).
After the therapy (right).
Baseline (top images).
3-month follow-up (bottom images).
Final restorations: 1 year after implant placement.
Final restorations: 1 year after implant placement.
X-ray evaluation: X-rays show excellent integration of the restoration and an excellent bone stability.