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A Case presentation on SINGLE TOOTH REPLACEMENT BY ENDOSSEOUS IMPLANT IN ESTHETIC ZONE :

A Case presentation on SINGLE TOOTH REPLACEMENT BY ENDOSSEOUS IMPLANT IN ESTHETIC ZONE Guided by :- Prof(Dr). Ardhendu Banerjee Professor and HOD PROF (Dr).Tapas Gupta Department of Prosthodontics Dr. Malay Kundu

Slide 2:

A 41 year old, female patient reported to the Department of Prosthetic Dentistry with missing left upper lateral incisor tooth due to caries , creating esthetic problem. Past Dental History:- Her past dental history revealed extraction of upper lateral incisor tooth due to caries one year back. PAST MEDICAL HISTORY:- Non-contributory

STEP BY STEP PROCEDURE:

STEP BY STEP PROCEDURE Clinical Examination Investigations Selection of an implant size Bucco -lingual Angulation of implant Flap design & Implant insertion. Postoperative care.

Slide 5:

Clinical Examination Extra oral examination- No asymmetry on the face was present. smile line was average without gingival margin exposure.

Slide 6:

Intra oral examination- Mucosa over edentulous area was normal Gingivae of adjacent teeth were normal in color and contour, Interdental papillae are depressed . Adjacent and opposing teeth are healthy –no mobility. Sufficient height and width of edentulous ridge is present Crown height space is adequate. Occlusion- Bilateral Canine guided occlusion, Class-I molar relation.

Investigations - required for Implant supported prosthesis :

Investigations - required for Implant supported prosthesis Radiographic Assessment - I.O.P.A. and O.P.G. Ridge mapping Routine blood examination

Slide 8:

The I.O.P.A. shows normal bone pattern with no abnormality detected in the Adjacent teeth. Edentulous ridge space (MESIO- DISTAL) is 8mm at crest and 9 mm at middle 3 rd, 10mm at apical 3 rd in relation to the adjacent central incisor.

Slide 9:

O.P.G. also shows normal bone pattern and no abnormality in adjacent teeth. Vertical Bone Height of >18mm is measured from crest of ridge to anterior nasal spine.

Slide 10:

Ridge mapping Study cast was sectioned in the mid- mesio distal position for ridge mapping. In this case 4.8mm Bucco -Lingual bone width is present at the crest, 5.5mm width present 1mm apically and it is gradually increasing apically . Blood examination including Hb , TLC ,DLC ,CT ,BT ,blood sugar examination done- which were found within normal values.

Slide 11:

Crown height space -it is measured from the crest of the ridge to incisal edge or occlusal plane. Crown height space dictates cervico-incisal length of the prosthesis. minimum crown height space should be 8mm for fixed prosthesis and 14mm for removable prosthesis. it is measured on I.O.P.A . or over the ridge mapping cast. It is 12mm in this case.

Slide 12:

Selection of an implant size (length & diameter) Factors responsible for Implant diameter selection Available bone length( mesio distal) Available bone width( bucco lingual) For Implant length selection- Available bone height (vertical)

CRITERIAS FOR SELECTION OF IMPLANT DIAMETER:

CRITERIAS FOR SELECTION OF IMPLANT DIAMETER Two mesio - distal parameters- No-1 width of the single-tooth implant should correspond/closely resemble to the width of the missing natural tooth, 2mm bellow the CEJ. Maxillary tooth Mesiodistal crown 2mm bellow CEJ Implant diameter Central incisor 8.6 mm 5.5 mm 4 -5.2 mm Lateral incisor 6.6 mm 4.3 mm 3 -3.5 mm canine 7.6 mm 4.6 mm 3.7 -4.2 mm

CRITERIAS FOR SELECTION OF IMPLANT DIAMETER:

CRITERIAS FOR SELECTION OF IMPLANT DIAMETER No 2 the implant diameter +3mm (1.5 mm on each side) ≤ the distance between the adjacent roots, at the crest of the ridge. Facio palatal dimention of bone- For implant placement minimum 1.5mm bone facially and 0.5 mm lingually is required.

Slide 15:

Available bone length - it is the mesio -distal dimension of the available bone, measured from I.O.P.A.xray of edentulous span in between adjacent roots of teeth. In this case it is 8mm at crest 9mm at middle 1/3d and 10mm at apical 1/3 rd . For 3.3mm implant diameter require maximum 3.3+1.5+1.5=6.3mm bone.

Slide 16:

Available bone width (from ridge mapping).- In this case, 4.8mm at the crest and 5.5mm width is present 1mm apically. Recommended implant diameter is 3 – 3.5 mm for lateral incisor. Implant available in 3.3mm diameter, so a minimum 3.3+1.5+0.5=5.3mm bone width is required. This width can be achieved after 1 mm of osteoplasty with sufficient bone height remaining.

Slide 17:

Implant length selection - from available bone height . In this case Vertical height > 18mm (from OPG) is measured from crest of ridge to anterior nasal spine. For implant, minimum height required is 8mm in dense bone and minimum 12mm in porous bone. In this implant system implants are available in 8mm,10mm,11.5mm,13mm,16mm in length. 11.5mm implant can be used for upper lateral incisor.

AVAILABLE BONE:

AVAILABLE BONE Bone WIDTH Bone HEIGHT MESIO-DISTAL bone LENGTH CROWN HEIGHT SPACE Available 5.5 (1 mm apically from crest) 18 8 12 B-type bone 2.5-6mm >12mm >6mm <15mm Requirement for 3.3mm x 11.5mm implant 1.5+3.3+.5=5.3 11.5 1.5+3.3+1.5= 6.3

So the case is diagnosed as Kennedy’s class–III partially edentulous upper arch with Division - B bone.:

So the case is diagnosed as Kennedy’s class–III partially edentulous upper arch with Division - B bone. Treatment plan- I nsertion of Two piece endo -osseous implant of following dimensions for restoration of missing left upper lateral incisor- Length = 11.5 mm Diameter= 3.3 mm Abutment type : straight

Bucco-lingual Angulation of implant A-implant position bellow the incisal edge. B-implant in the position of natural tooth root. C- implant position bellow the cingulam. :

Bucco -lingual Angulation of implant A-implant position bellow the incisal edge. B-implant in the position of natural tooth root. C- implant position bellow the cingulam .

Bucco-lingual Angulation of implant:

Bucco -lingual Angulation of implant

Treatment Sequence:

Treatment Sequence 1.Antibiotic prophylaxis. 2.Maintainance of surgical sterilization & asepsis. 3.Soft tissue incision. 4.Flap reflection. 5.Sequential Osteotomy 6.Implant insertion 7.Wound closure. 8.Postoperative care.

Antibiotic prophylaxis:

Antibiotic prophylaxis Amoxycillin 1 gm 1 hr. before surgery. Then 500 mg 3 times daily for next 5 days.

Slide 24:

Flap design In this case interdental papillae are depressed, the vertical release incisions will include the papillae in the edentulous site. Facial soft tissue and papillae over each adjacent tooth will be reflected. The crestal incision is given on the palatal incline on the ridge.

Slide 25:

Osteotomy sequence sequential drilling of bone is done using external and internal irrigation. Drilling is started with round drill. then pilot drill of 2mm is used. then large diameter drill is used up to 2.8mm size.

Wound closure:

Wound closure The flap will be closed with 4.0 black silk.

Postoperative:

Postoperative Patient will be on antibiotic and anti-inflammatory for 5 days . 0.2% chlorhexidine mouth wash -twice daily At the 7 th day suture will be removed. Recall visits are to be done after one month and 4 months.

Thank you:

Thank you

Bucco-lingual Angulation of implant :

Bucco -lingual Angulation of implant

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