A 34-year-old patient presented with a failing central incisor after a root fracture. The case was treated with immediate implant placement and a screw-retained provisional that shaped the soft tissue over four months.

Presentation

The patient reported mobility of the upper right central incisor three years after endodontic treatment. The radiograph showed a vertical root fracture with no bone loss on the buccal plate; the gingival margin was level with the neighbouring tooth, and the smile line was high.

The treatment options discussed were a bridge, a removable provisional with delayed placement, and immediate placement with a provisional. The patient chose immediate placement.

Clinical case

Treatment progression

The failing incisor
01 — Presentation
The implant in place
02 — Placement
The provisional
03 — Provisional
Treatment

From extraction to final crown

01

Atraumatic extraction

The root was removed in two parts with periotomes, without flap, to keep the buccal plate intact.

02

Immediate placement

The implant was placed palatally in the socket with a gap of two millimetres to the buccal plate, filled with a slowly resorbing graft.1

03

A provisional that shapes

A screw-retained provisional was fitted the same day, out of occlusion, with an emergence profile adjusted twice over four months.

04

The final crown

A zirconia abutment and a layered ceramic crown were fitted at four months, after the soft tissue had stabilised.

Clinical result

Before and after treatment

The final crown after treatment
The failing incisor before treatment
BeforeAfter
Radiographs

Day of placement and at one year

The radiograph at placement
Day of placement.
The radiograph at one year
At one year: stable crestal bone.

Outcome

At one year the papillae filled the embrasures completely and the gingival margin matched the neighbouring tooth within half a millimetre. The patient reported no sensitivity and no difference in function.2

The provisional did most of the work. A crown placed on an unshaped tissue would have needed a second surgery.

In practice

The provisional is the treatment.

Immediate placement only pays off when the provisional is fitted the same day and adjusted until the tissue says it is done.

Further reading

References

  1. Buser D, Chappuis V, Belser UC, Chen S. Implant placement post extraction in esthetic single tooth sites: when immediate, when early, when late? Periodontology 2000. 2017;73(1):84–102.
  2. Chen ST, Buser D. Esthetic outcomes following immediate and early implant placement in the anterior maxilla: a systematic review. International Journal of Oral & Maxillofacial Implants. 2014;29 Suppl:186–215.