Objectives:In the aesthetic area, immediate implant placements are increasingly common. Using a 3-D custom-made guide for insertion is associated with less trauma and faster healing periods. Titanium implants may cause unfavourable soft tissue conditions or recession of gingiva in the area, and lead to compromised aesthetic outcomes. In this study, zirconia implants were chosen rather than titanium.. Methods:A 18-year-old woman, who had previously suffered serious trauma of frontal maxilla, was referred to our dental practice. Due to external root resorption, the central incisors were removed 15 months previously, and she had a fixed orthodontic retainer with two substitute acrylate teeth (#11 and #21) to preserve jaw line functionality and aesthetics. The patient was still adolescent, but thorough examination by cone beam CT established that her jaw development and growth was complete. We decided to insert two zirconia implants, with a comprehensive procedure because the bone loss at both positions was severe. The first step was horizontal augmentation of the alveolar ridge using a membrane technique in order to preserve necessary bone (BioResorb Macro Pore[tm]). Six months later, two zirconia implants (SDS, ATZ, 3.8x11.0mm, torque 35N/cm) were inserted using flapless surgery into predetermined positions using a 3-D custom-made guide. Two connected provisory acrylate crowns were inserted immediately, to stabilise the implants and give the patient functional teeth for the following five-month period. The crowns also aided the process of implant osteointegration, providing an ideal emergence profile and supporting the peri-implant soft tissue. Follow-up was uneventful. Three months after surgery, the final prosthetic restoration comprised of two connected ceramic, metal-free crowns. Results: The healing period was uneventful with no adversary reactions. Both procedures resulted in minimal trauma, due to the use of 3-D custom-made guides for both bone regeneration and implant insertion, which led to a good post-operative period. The first procedure (bone regeneration) gave satisfactory results, and the second (implant placement) gave excellent primary stability without radiographic bone loss or gingiva inflammation. Peri-implant soft tissue parameters showed promising results. Probing depth, clinical attachment level and modified bleeding index at the implant sites were all satisfactory. The restoration work showed a healthy gingival margin and no discoloration of the soft tissue. The most important patient feedback related to permanently improved perception of function, aesthetics, sense, speech and self-esteem (which is very important in adolescents). Conclusion: Use of 3-D custom-made guides for implant placement enables faster and better recovery because trauma is minimised. There is an increasing demand for metal-free implants because of the potential immunologic and aesthetic compromises associated with titanium implants entails. Unfavourable soft tissue conditions or gingival recession may lead to compromised aesthetics, which are particularly concerning when maxillary incisors are involved. Cervical bone loss and gingival recession associated with metal implants tend to cause bluish discoloration of the overlying gingiva, thus impairing aesthetic outcome. Zirconia implants are a good choice for the aesthetic zone. In our case, the gingival margin was healthy and there was no discoloration of the soft tissue. Zirconia implants are also suitable because they have a tooth-like colour, good mechanical properties (high strength, fracture toughness) and good biocompatability.

The old reconstructions have to be replaced. But how? A challenging case treated by Dr. Sven Mühlemann, University of Zurich.

The 1st EAO Consensus Conference (2006)