Figures 1a, 1b: The patient presented with mobile maxillary central incisors resulting from avulsion and subsequent reimplantation during adolescence. Despite several endodontic procedures completed over the years, she was extremely anxious about the prognosis for these teeth.

Figures 2a, 2b: The position of the implant sites within the premaxilla required careful consideration as to whether we could obtain a predictably successful esthetic result. Using CBCT analysis, we evaluated the volume of vertical and horizontal bone, which indicated some facial bone loss that would require grafting.

Figures 3a, 3b: In treatment planning, it’s essential to visualize how the implants should be placed using a “crown-down” approach. Because the facial plate is very thin, positioning of the implant is paramount. CBCT analysis further indicated that this patient’s implants would need to be placed to follow the contour of available bone. This would result in a slightly facial angle to the implants, necessitating a cemented final restoration.

Figures 4a, 4b: The extraction procedure began with a periotome to release the soft tissue attachment and gain mobility of the root.

Figures 5a–5d: Forceps were used for final removal. Special care was taken to maintain the thin facial plate. The maxillary left central incisor had significant root resorption, and the associated facial bone loss required grafting.

Figures 6a, 6b: When evaluating the socket, it’s important to determine the condition of the facial plate and check for granulation tissue. Following any extraction, a radiograph should be taken to ensure that all the root structure has been removed. 

Figures 7a, 7b: An envelope reflection was made to further evaluate the facial plate area. Note that no vertical releasing incisions were made into mucosal tissue, reducing subsequent inflammation and release of prostaglandins and histamine. The sockets were then carefully curetted to remove any granulation tissue, and the flaps were repositioned. 

Figures 8a, 8b: A pilot bur from the Glidewell HT™ Implant Surgical Kit (Glidewell Direct; Irvine, Calif.) — formerly the Hahn™ Tapered Implant Surgical Kit — was used to create the initial osteotomy 3 mm palatal to the facial aspect of the adjacent teeth. Direction was determined by visualizing the apices of the adjacent root structure. The osteotomies were then widened using the recommended protocol of the Glidewell HT surgical kit. 

Figures 9a, 9b: In immediate implant placement, the implant shoulder should be positioned 1 mm subcrestal. 3.5-mm-diameter osteotomy burs were then used to widen the osteotomy. The final widening of the site was performed with a 4.3-mm-diameter osteotomy bur. Digital radiographs were used at every step to ensure proper angulation and depth.

Figures 10a–10c: Glidewell HT implants feature aggressive threads that create maximum primary stability and directional control during immediate implant placement. The implants were torqued into position at 45 Ncm, and digital radiographs were used to evaluate the implant positions. After confirming proper depth and angulation, cover screws were threaded onto each implant before grafting the facial defect.

Figures 11a–11d: Because there was more than 1 mm of space between the implant and the facial plate in the socket for tooth #9, grafting was required to minimize facial tissue loss that might otherwise occur. A Newport Biologics™ Resorbable Collagen Membrane (Glidewell Direct) was passively positioned to create facial stabilization for the graft material. Newport Biologics Mineralized Cortico/Cancellous Allograft Blend (Glidewell Direct) was then carefully placed onto the facial aspect of the site between the implant body and the membrane. The envelope reflection was easily repositioned to encapsulate the grafted socket and sutured to establish new interdental papilla.

Figures 12a, 12b: A removable flipper was placed immediately after surgical placement of the implants and allograft, with careful adjustments to be sure that the appliance did not impinge on the grafted area. After a healing period of seven days the sutures were removed, and the tissue was evaluated.

Figures 13a, 13b: After four months of integration, the implants were uncovered, and healing abutments were torqued to 25 Ncm to allow for an esthetic gingival cuff to form.

Figures 14a–14c: The technicians at Glidewell fabricated custom titanium abutments with margins that were equigingival or slightly subgingival to maintain periodontal health posttreatment. These were torqued into place at 35 Ncm.

Figures 15a, 15b: The final restorations were BruxZir^® Esthetic crowns placed over custom abutments on Glidewell HT Implants, fabricated by Glidewell technicians to achieve an esthetic and long-lasting result. The crowns were seated, restoring form, function and quality of life for the patient.