PMC4317063_01
Orthopantamograph taken preoperatively showing maxillary sinus pneumatization in the extracted site 25 and 26 area.
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An orthopantomogram was taken (Figure 1), and after clinical and radiographic examination, a taper implant with a 4.0 mm width and a 10 mm length was selected for replacement of both teeth.
Temporary abutment with crown fabrication from composite filling for easy adjustment and modification. Fabrication, contouring, and polishing were performed outside the patient's mouth.
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The first molar implant was immediately loaded with a temporary plastic abutment, and a crown was fabricated from a light-cured composite resin material (Figure 2).
Temporary abutment and crown installed into the 26-position implant and torque before flap closure. Cover screw used for the 25-position implant, which was placed with the submerged technique and left to heal for 2 months before re-entry.
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At this stage, the crown was out of occlusion, with a narrow occlusal table and no interproximal contact (Figures 3 and 4).
Occlusion was checked before releasing the patient. The crown was left out of occlusion to prevent any occlusal loading during the early healing period.
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At this stage, the crown was out of occlusion, with a narrow occlusal table and no interproximal contact (Figures 3 and 4).
Occlusal view of the temporary abutment and crown issued on the day of surgery (implant placement); small occlusal table with no adjacent tooth contact. The flap was adapted around the crown (simultaneously covering the 25-position implant) and sutured with nylon sutures.
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The tissue flap was adapted to the temporary crown, and the gingiva was sutured around it (Figure 5).
An immediate postoperative periapical radiograph showing the 16-position implant penetrating the maxillary sinus by a few millimeters.
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A periapical radiograph was taken postoperatively for both implants and was considered a basic radiograph (Figure 6).
Second stage of temporary crown modification 1 month after implant placement. The crown now has contact with adjacent tooth 27, as it has a wider diameter but is still out of occlusion.
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The crown was modified (Figure 7) by increasing the width of the occlusal table and obtaining distal contact with the adjacent tooth (upper right second molar).
Third stage of temporary crown modification. After 2 months of implant placement, an increase in the diameter of the crown was done. The crown was contoured to resemble the natural tooth anatomy.
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The crown was modified by increasing the vertical height and obtaining occlusal contact with the opposing tooth in the axial direction only (Figure 8).
Temporary crown increased in size, and implant with light center occlusion. The implant in position 25 is now exposed, and the healing abutment is installed.
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A healing abutment was placed and left for 1 month to allow healing of the soft tissue (Figure 9).
Differences are seen in the gingival contour around temporary crown 26 and healing abutment in the 25-position implant. The emergence profile is achieved, and interdental papillae are growing around the temporary abutment.
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Three months after implant placement (Figure 10), the RFA measurement for the first molar was 75 ISQ in the mesiodistal, lingobuccal, and distomesial directions and 71 ISQ in the buccolingual direction.
Acrylic provisional crown received from the laboratory and issued with a customized abutment; only light and centric occlusion is allowed on the provisional crowns.
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Titanium hex abutments were placed using 30 Ncm of force for both implants, and provisional crowns were cemented with temporary cement (Figure 11). Occlusion was checked and adjusted, leaving only centric occlusal contacts and removing all contacts found during excursive movements (Figure 11).
Periapical radiograph after abutment installation does not reveal any bone resorption or radiolucencies around either implant, with a stable bone crest around the 26-position implant despite many abutment disconnections. There are no complications in the apical penetrating part of the 26-position implant.
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A periapical radiograph after abutment installation was taken (Figure 12).