The attempts to provide a better patient experience have led to the development of improved manufacturing technology, innovative techniques, and a better understanding of the biological aspects through clinical and pre-clinical studies. The immediate loading of implants has now become a reality, and these treatments are frequently used in the anterior maxillary area. However, the insertion of dental implants simultaneously with a provisional restoration can also provide benefits in the posterior areas, with a shorter time to the recovery of the masticatory function¹.

To this end, the estimation of the risk of the treatment result and effective treatment planning are crucial. It is essential to perform an analysis of the patient's medical condition, bone availability, soft tissues, and desired tooth shape, and take into consideration our patient’s needs and expectations.

The following case report describes the replacement of a single upper molar with the new Straumann® TLX implant in a fully healed site (Type 4, ITI implant placement) and the immediate rehabilitation with a provisional restoration.

Initial situation

A healthy, 40-year-old female non-smoker presented at our clinic with a missing maxillary molar. Her primary wish was to recover her masticatory function as soon as possible, because her condition prevented her from eating properly and was affecting her quality of life. Her dental history revealed that the tooth had been lost due to a vertical fracture a couple of months before. Since this incident happened during the Covid-19 lockdown, she had not been able to receive the complete treatment of the site.

The intraoral examination showed the missing upper right first molar. The patient's periodontal condition was healthy, and her oral hygiene was classified as good (Figs. 1,2).

The pre-operative CBCT revealed sufficient vertical and horizontal availability for an implant placement at site #16 and no risk of damage to the surrounding anatomic structures (Fig. 3).

Treatment planning

Prosthetic-driven planning was considered and close communication ensured between the patient, the prosthodontist (Dr. Cristiane Juchem), and the dental technician (Lisiane Merlin) . After the various treatment options were discussed with the patient, she opted for implant placement and provisional restoration at position #16. The clinical and radiographic evaluation showed adequate conditions for implant placement at the healed site. Furthermore, the CBCT for diagnosis revealed no need for a bone augmentation procedure. Therefore, a Straumann® TLX RT SP (Standard Plus) Roxolid® 3.75 x 10 mm with immediate provisionalization was planned only if the desired primary stability was achieved. The Straumann® TLX Implant System offers fully tapered tissue level implants (TLX) that are designed for high primary stability and immediate treatment procedures.

Surgical procedure

Local anesthesia was infiltrated using articaine (4%) with epinephrine. Mid-crestal and intrasulcular incisions were performed without a vertical release. The flap was raised to expose the bone in the area of tooth #16 (Fig. 4).

Following the manufacturer’s surgical protocol, a Straumann® TLX RT SP (Standard Plus) Roxolid® 3.75 x 10 mm was placed in a prosthetically driven position. A minimum gap of 1.5 mm from the implant shoulder to the adjacent tooth was taken into consideration. Due to the self-cutting properties of the TLX Implant, the implant bed was lightly underprepared. The drill bits were rotated clockwise, and an intermittent drilling technique with pre-cooled (5°C, 41°F) sterile saline solution was employed.

The 1.6 mm diameter needle drill was used first to mark the implant site, followed by the pilot drill (∅ 2.2 mm), which was drilled down to the full implant length (10 mm) (Fig. 5).

The bone density was then determined by drilling a pilot hole with drill # 2 (∅2.8 mm) (Fig. 6). Next, an alignment pin was placed to check the 3D position of the osteotomy and preparation depth (Figs. 7, 8). Additionally, since the placement of the implant was planned to be deeper than the shoulder mark on the mesial site, the corresponding profile drill was used (Fig. 9).

The Straumann® TLX implant was placed with a surgical ratchet with a torque setting >35 Ncm, and optimal primary stability was achieved (Figs. 10-12).

Prosthetic procedure

Since optimal primary stability was achieved, we were able to proceed with the preparation of the provisional restoration as requested initially by the patient.

For the provisionalization, a straight provisional titanium abutment and a pre-selected tooth based on the stone cast were used (Figs. 13-18). The provisional titanium abutment was reduced with a carborundum disc to avoid occlusal contact with the antagonist. The pre-selected tooth was prepared to be adapted to the abutment and bonded with flow composite. The final contouring and polishing were done chair-side by Dr. Cristiane Juchem.

Single nylon 5-0 sutures were placed around the implant. Analgesics were prescribed post-operatively, and a follow-up check and suture removal was planned one week later. The follow-up appointments were scheduled for 30 and 60 days post-surgery (Figs. 19, 20).

After two months of healing, a monotype scan body was screwed into the implant, and a digital impression was recorded using the Straumann® Virtuo Vivo™ Intraoral Scanner (Figs. 21, 22).

The coDiagnostiX® software was used for CAD processing, and a metal-free restoration (Zirconia) was cemented (Relyx™ U200, 3M) on top of the Variobase® (RT Variobase,  5 mm, AH 6 mm) for screw-retained rehabilitation. The height of the abutment was adjusted accordingly (Figs. 23, 24).

In accordance with the implant manufacturer’s recommendations, the restoration was screwed in with a torque of 35 Ncm (Figs. 27, 28).

And finally, the screw access hole was sealed with composite material (Fig. 29).

Treatment outcomes

Replacing one tooth in the posterior zone and loading it immediately can pose many challenges. Since the key is to identify who is eligible for this type of treatment, , the patient selection is crucial. In this case, we obtained good and predictable results in a short period of time as requested by the patient. The Straumann® TLX allows the implant to be loaded immediately, which in our case proved highly satisfactory in terms of health, esthetics, and function.

Author’s testimonial (optional)

My short-term experience with TLX has been amazing. I am a big fan of tissue level implants for the posterior region given all the benefits of this renowned design and the absence of the bone level connection, as also reported in the scientific literature. Allied to these advantages of the tissue level, we can now achieve better primary stability and greater confidence in immediate protocols with the new TLX. Therefore, I believe that the new body design and the predictability of the connection on the tissue level will be groundbreaking.