Pretreatment

A  root  extractor  was  deployed  and  supported by the neighbouring teeth (Fig. 5) to allow atraumatic extraction to preserve the buccal bone. A  complete  and  healthy  alveolar  bone  is  a  prerequisite  for  a  securely  anchored  implant.  We  choose  an  atraumatic  extraction  protocol  that  created  favourable  conditions by preserving the bone volume and preparing the bone optimally for the placement  of  the  implant. 

The  three-dimensional  preservation  of  hard  and  soft  tissue after extraction is also important for flawless aesthetic and functional implants and restorations. The vestibular bone wall in particular is extremely important for the correct  three-dimensional  implant  placement  as  well  as  for  the  preservation  of  the  soft  tissue  under  the  superstructure,  particularly  in  the  anterior  region.  It  is  therefore essential to prevent or minimize resorptive remodelling processes. After local anaesthesia, the force vector of  the  extractor  was  applied  in  the  direction  of  the  central  axis  of  the  tooth.  The  remaining  root  was  removed  (Fig.  6).  The  extraction  socket  was  carefully  curetted,  removing all fibrous tissue.A silicone key was prepared to facilitate chairside fabrication   of the provisional crown.

Surgical procedure and Implant Placement

To prepare the osteotomy, drilling was performed on the palatal side of the extraction socket (Fig. 7) such as to preserve the buccal plate and to avoid putting too much pressure on it as the implant is inserted. Once  the  osteotomy  had  been  completed  using  the  dedicated  surgical  kit,  the  implant  was  placed  at  an  insertion  torque of 40 Ncm (Fig. 8). 

After the extraction, the wound had to be cleaned thoroughly with a sharp curette. It is  important  to treat the implant site  gently, and especially not to destroy the buccal bone lamella. Therefore, I marked the  site  palatally  with  a  round  burr  and  prepared  the  implant  bed  to  a  depth  of 13  mm  with  the  2-mm  pilot  drill.  Once  the pilot bore is in place, it is not difficult to extend the implant site to a diameter of 4.5 mm.The implant bed was checked with an appropriate  instrument  and  disinfected  with  ozone.  The  implant  can  be  placed  either  manually  with  a  ratchet  or  with  a suitable drill. In this case, primary stability was achieved at a torque of 40 Nm (Fig. 9).  A control radiograph was taken (Fig. 10), and the fiberglass post was prepared  –  at  chairside  but  extraorally.  To  facilitate  the  preparation,  a  dummy  implant  was  used  to  hold  it  (Fig. 11).  After  the  try-in,  the  fiberglass  post  was  cemented with RelyX Unicem.

Finally, the provisional crown was fab-ricated at chairside using the silicone key (8). The fiberglass post was isolated with vaseline oil and the crown was cemented with  temporary  cement  to  be  retrievable  later  (Fig.  12).  Control radiographs  showed that the bone was well preserved (Fig. 13)   and  that  the  temporary crown could be delivered (Fig. 14).

The  crown  had  no  contact  with  its  antagonists in either static or dynamic oc-clusion.  At  one  day  (Fig.  15)  and  at  two  weeks (Fig. 16), the soft tissue was healing nicely.

Prosthetic Reconstruction

After six weeks, the dental laboratory provided a second provisional crown (Fig. 17). We had some problems with the shade of the crown due to the transparency of the fiberglass post. Following deliberations with the dental technician, we concealed the die with white composite resin (Fig. 18). After four months of healing, the case was finalized by delivering the definitive crown (Figs. 19 and 20). The soft tissue had remained perfectly healthy [9, 10]. At the five-year follow-up, the marginal bone levels presented fully maintained (Fig. 21).