TREATMENT PLAN 

• Diagnostic casts, wax patterns, fabrication of laboratory processed fixed provisional restoration tooth #’s 2-7
• Extraction of tooth #’s 3 and 5, alveolar preservation grafts and ridge expansion tooth #6
• Placement of provisional fixed partial denture tooth #’s 2-7
• Healing of osseous defects, maxillary right posterior quadrant
• Extraction and immediate implant placement tooth #4, placement of implants in tooth positions 3, 5 & 6
• Placement of CAD/CAM healing abutments and definitive impression
• Immediate loading with a screw-retained provisional restoration
• Placement of definitive abutments and prosthesis

SURGICAL TREATMENT

This case required maintenance of a tooth with a hopeless prognosis (#4) for use as a provisional bridge abutment while the future implant sites underwent osseous healing post extraction, grafting and ridge expansion. The extractions were done in sequence: tooth #’s 3 and 5 were extracted in conjunction with grafting and ridge splitting in the areas of tooth #’s 5 and 6, respectively. A provisional FPD was made, using tooth #’s 2, 4 and 7 as the posterior and anterior abutments. In order to minimize chairtime and future maintenance issues, a laboratory fabricated provisional restoration with metal reinforcement was fabricated by the restorative dentist prior to surgery.

Tooth #’s 3 and 5 were extracted. A Piezosurgery® device was used to split the ridge and the palatal alveolus was expanded. The expansion was maintained with a 1.5mm lag screw. All sites were grafted with mineralized cancellous allograft. In site #6, a slowly resorbable barrier collagen membrane was placed and primary closure was achieved. In site #3, additional fixed, keratinized, attached tissue was desired and a perforated 100% PTFE (polytetrafluoroethylene) membrane was used (Figure 3). The prefabricated provisional FPD was placed and the patient was allowed to function for the four months of bone maturation.

Four months post tooth extraction and grafting, the patient returned for the second surgical phase of treatment: implant placement and implant provisional restoration. The fixed provisional restoration was removed (Figure 4). Tooth #4 was extracted. A small incision was made to remove the lag screw. The surgical guide was indexed to the anterior tooth preparation #7. NanoTite PREVAIL Implants were placed into tooth sites 3, 4, 5 and 6 with a sinus elevation performed in site #3. Composite bone grafts were used to augment the sites. Insertion torque values >35Ncm were obtained in all sites except tooth #3, which had an insertion torque value of 20Ncm. The surgeon placed Encode Healing Abutments with emergence profiles consistent with the teeth being replaced (Figure 5) and placed intermittent sutures to close the soft-tissue flaps. The patient was then seen by the prosthodontist for restorative treatment.

Figure 3	Figure 4
Figure 5