Initial situation

A 48-year-old female patient presented to the IUSD Center for Implant, Esthetic and Innovative Dentistry with an unrestorable maxillary first molar (Fig. 1). The patient had no significant medical history and was not a smoker. Her overall oral health was good, with good oral hygiene. Initial clinical evaluation showed adequate inter-occlusal and medio-distal prosthetic space (Fig. 2). No infection was present, and the soft tissues were of medium thickness, with no recession, and no signs of inflammation. She had a medium smile line and realistic esthetic expectations.

The radiographic assessment showed very divergent roots, no periapical lesions, >4 mm apical to the apexes of the roots, and the presence of a wide inter-septal bone. (Figs. 3,4)

Treatment planning

Intraoral scans of her remaining dentition and virtual occlusal records were taken with an intraoral scanner (Virtuo Vivo™; Institut Straumann AG). Digital Imaging and Communications in Medicine (DICOM) files from CBCT imaging and a Standard Tessellation Language (STL) file from the intraoral scan were imported into an implant planning software program (coDiagnostiX®; Institut Straumann AG). Diagnostic waxing was completed in the same software program (Fig. 5).

The surgical plan was developed using the coDiagnostiX® software, with the aim of simulating an immediate implant placement (TLX WT Ø 5.5 x 8 mm; Institut Straumann AG). After careful evaluation, all factors considered were positive for the indication of flapless tooth extraction, and immediate placement of a Straumann® TLX implant, with DBBM+C (deproteinized bovine bone mineral + collagen) graft on the remaining socket gaps (Figs. 6-9).

Following the completion of the surgical plan, the file was imported into a computer-aided design and computer-aided manufacturing (CADCAM) software program (CARES® Visual; Institut Straumann AG) to design a provisional restoration with prefabricated implant screw access. The provisional restoration was 3D-printed with ceramic filled hybrid material (Figs. 10-13).

Surgical procedure

The surgical procedure was performed under local anesthesia. A flapless extraction of the maxillary first molar was performed, sectioning the roots, and preserving buccal and interseptal bone. A surgical template was placed, and the implant site was prepared following the Straumann® TLX sequence. Bone density was considered to be medium. The 4.3 mm drill was the last one used before placement of the 5.5 diameter implant in order to provide better primary stability. Primary stability was achieved at 45 Ncm, and an ISQ measurement of 70 was obtained. The remaining gaps between the implant and the socket walls were filled completely with a DBBM+C material (Figs. 14-19).

Prosthetic procedure

After the implant placement, the temporary abutment (Temporary Abutment Crown; Institut Straumann AG) was secured on the implant with 15 Ncm torque. The 3D-printed provisional crown was adjusted to ensure the complete seating over the temporary abutment. Autopolymerizing resin was used to lute the provisional crown to the temporary abutment. The temporary crown was then removed from the implant. It was adjusted and polished in a dental laboratory. Light-polymerizing clear coating was used to protect the provisional crown (Figs. 20-24).

After two months of uneventful healing, the patient returned for the final impression with an intraoral scanner (Virtuo Vivo™; Institut Straumann AG). Scanbody (Mono Scanbody; Institut Straumann AG) was secured to the implant with 15 Ncm of torque. The intraoral scans and virtual occlusal record were exported in a polygon file format (PLY) and imported into a CADCAM software program (CARES® Visual; Institut Straumann AG) in order to design the definitive restoration on a prefabricated abutment (Variobase® Crown; Institut Straumann AG). The definitive crown was milled with a multi-layered ultra-high translucent zirconia (zerion® UTML; Institut Straumann AG). Surface characterization and glazing were completed on the definitive zirconia crown. The crown was luted to the prefabricated abutment with a resin luting agent. The patient returned to the clinic for the definitive crown delivery. After the conformation with esthetic and functional outcomes intraorally, the definitive crown was secured to the implant with 35 Ncm. Teflon and light-polymerizing composite resin were used to seal the screw access (Figs. 25-30).

Treatment outcomes

Overall, the immediate placement and loading approach was utilized for this clinical treatment with the aid of digital data recording, surgical planning, computer-guided surgery, and CADCAM provisional and definitive restorations. The newly designed Straumann® TLX Implant System with fully tapered Tissue Level implants (TLX) was used to achieve high primary stability and immediate placement procedures. The Roxolid® implant with the SLActive® surface provided the clinician with a predictable outcome with reduced healing time and shorter treatment time overall. The patient was satisfied with the immediate treatment approach and the esthetics and functional outcomes associated with this clinical treatment.