Placement of Maxillary Right Central Incisor with Bovine Graft and Bicon Resorbable Collagen Membrane and Restoration with a Bicon Integrated Abutment Crown™

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1.

Pre-operative evaluation revealing a mid-facial probing of 8.0mm's and a fistula at the MGJ.

2.

Pre-operative radiograph.

3.

Post extraction site.

4.

Full thickness flap elevated on facial with mesial and distal vertical incisions placed one tooth away from graft site. If possible, these incisions are placed to avoid trauma to the interproximal aspect of the papillae. The graft site has been carefully curetted to remove granulation tissue and soft tissue tags.

5.

Allograft placed filling defect to the width of the buccal cortical plate, and to the height of the interproximal bone. Graft material can be bovine, porcine, human or inorganic.

6.

Bicon resorbable membrane cut to size and placed so that its margins extend onto surrounding bone on its mesial, distal, and apical borders. On the palatal aspect the membrane is tucked under the palatal tissue in direct contact with the palatal bone. The palatal tissue can usually be elevated with a periosteal elevator without using additional vertical incisions on the palatal aspect. However, if there is difficulty tucking the membrane under these tissues, small mesial and distal incisions can be made.

7.

Flap closure with vicryl sutures. In order to achieve primary closure, the facial flap was undermined by creating a split thickness flap and advancing the flap coronally.

8.

Flap closure with vicryl sutures. In order to achieve primary closure, the facial flap was undermined by creating a split thickness flap and advancing the flap coronally.

9.

Flap closure with vicryl sutures. In order to achieve primary closure, the facial flap was undermined by creating a split thickness flap and advancing the flap coronally.

10.

The transitional prosthesis was fabricated chairside and bonded in place.  Sutures should be positioned to facilitate their removal with a prosthesis in place.

11.

Post-operative radiograph.

12.

Five months later, full thickness access flap being made avoiding unnecessary papillary incisions.

13.

Exposure of firm graft site.

14.

A 2.0mm pilot bur preparing initial osteotomy at 1100RPM.

15.

Initial osteotomy being enlarged with a 2.5mm latch reamer bur rotating at 50RPM without water irrigation.

16.

Osteotomy being enlarged with a 3.0mm hand reamer bur which offers more control for the preparation of the osteotomy in the fragile graft site.

17.

Osteotomy being enlarged with a 4.0mm hand reamer.

18.

Osteotomy being enlarged with a 4.5mm hand reamer.

19.

A 4.5mm x 8.0mm HA coated implant being inserted into the osteotomy with implant inserter/retriever instrument.

20.

Implant in place revealing coronal graft material that was lost during the development of the osteotomy which will be replaced with bone harvested from the osteotomy preparation and then covered with a Bicon Resorbable Collagen Membrane.

21.

Using college pliers and a periodontal probe, the Bicon membrane is cut to the appropriate size.

22.

Using college pliers and a periodontal probe, the Bicon membrane is cut to the appropriate size.

23.

Harvested bone from the osteotomy is placed over the exposed buccal shoulder of the implant.

24.

Bicon membrane is adapted over the implant and graft. The palatal tissue is reflected from the bone with a periosteal elevator to allow the membrane to be tucked under the tissue.

25.

Radiograph seven months after implant placement.

26.

White 3.0mm plastic impression post being inserted into the 3.0mm well of the implant.

27.

White 3.0mm impression post receiving its mandatory seating tap.

28.

Impression material being injected around seated impression post for the making of an implant level transfer impression.

29.

Digital photograph is being taken to record the appropriate shade.

30.

After the uncovering of the integrated implant, a 5.0mm x 4.0mm stealth shouldered abutment is being inserted into the implant well with only finger pressure.

31.

A short 5.0mm wide acrylic sleeve being inserted onto the 5.0mm wide stealth shouldered abutment.

32.

A short acrylic sleeve is modified and its dimensions contoured with a vacuum formed clear acrylic template.

33.

Transitional composite material, “Integrity” by Dentsply, being added to the acrylic sleeve.

34.

Vacuum formed template is placed onto the core of transitional composite material to fabricate the transitional crown.

35.

Transitional crown being removed for polishing.

36.

Transitional crown in place.

37.

Integrated Abutment Crown™ on dental model with acrylic orientation jig.

38.

Mirror view of Integrated Abutment Crown™.

39.

View of transitional crown prior to its removal for the insertion of the Integrated Abutment Crown™.

40.

Shouldered stealth abutment after removal of transitional crown.

41.

View of implant well and soft tissue sulcus.

42.

Integrated Abutment Crown™ being inserted.

43.

Articulating paper being used to confirm interproximal contacts.

44.

Adjustment of interproximal contact. A too tight interproximal contact will prevent the engagement of the locking taper and possibly result in subsequent loosening of the Integrated Abutment Crown™.

45.

Plastic temporary abutment mounted on a straight driver to seat the Integrated Abutment Crown™ in the long axis of the abutment shaft and implant well to engage the locking taper.

46.

Incisal edge being marked to evaluate the need for aesthetic adjustment.

47.

Marked incisal edge evaluated against a black background.

48.

Incisal edge being reduced.

49.

Seated Integrated Abutment Crown™ after adjustment.

50.

Incisal contacts being evaluated in all extreme excursions while patient is clenching.

51.

Integrated Abutment Crown™ two weeks after insertion.

52.

Integrated Abutment Crown™ two weeks after insertion.

53.

Post-insertion radiograph.

54.

Smile with Integrated Abutment Crown™ in place.