Immediate implant & restoration in anterior region

Intoduction

Two-piece zirconia implants are increasingly becoming the focus of clinical application due to their biological and material properties. No metallic corrosion, less plaque adhesion, better biological compatibility of alumina-toughened zirconia (ATZ) compared to titanium and a tooth-like colour make ceramic implants a preferred treatment option for patients. The following case report shows selected steps in immediate implant placement for tooth no. 21, its prosthetic restoration as well as a treatment result achieved by Dr. Max Riemann using the Zeramex XT implant system.

Clinical situation

A 27-year-old female patient visited our clinic last year. The patient complained of pain in tooth no. 21. The tooth had undergone insufficient root canal treatment several years ago. The gingiva showed clear signs of inflammation.

Fig. 1: Clinical situation

Before treatment, the patient was particularly keen to select a material that was as neutral and biological as possible. After a thorough examination and patient information about possible treatment options and implant materials, the patient decided in favour of immediate implant placement of a two-piece ceramic implant (Zeramex XT, RB 4.2 mm) for tooth no. 21, a new all-ceramic restoration for tooth no.11 and composite fillings for tooth no. 12 as well as no. 22.

Surgical phase

After atraumatic extraction of tooth no. 21, immediate implant placement of Zeramex XT RB 4.2 x 12 mm was performed according to the drilling protocol. That worked without complications. The insertion depth of the implant is possible between 1.6 and 0.6 mm supracrestally.

Due to the receding gingival margin in no. 21, a connective tissue graft was taken from the palate at the end of the dental arch to repair the gum defect. 

The implant and tooth no. 11 were then restored with a temporary crown.

Fig. 2: After temporary restoration 

Prosthetic phase

The check-up after six months showed irritation-free mucosal conditions. In addition, the peri-implant bone structure was checked. The radiographs showed stable bone conditions after bone remodelling.

The impression was taken using an A-silicone.

Fig. 3: Impression taking using A-silicone 

A customised abutment and a definitive zirconia crown (Dentaltechnik Hedwig, Nuremberg) were fabricated for the prosthetic restoration. In the patient's mouth, the Vicarbo screw was then used with the prescribed torque of 25 Ncm to secure the implant-abutment connection.

The tooth no. 12 and tooth no. 22 were restored using a composite filling.

Fig. 4: Prosthetic restoration

Discussion

The literature shows clear biological and immunological advantages of zirconia implants. Zirconia exhibits lower plaque accumulation, lower bacterial adhesion (Scarano et al. 2004; Ichikawa et al. 1992) and a lower thickness of the deposited biofilm (Roehling et al. 2016). The blood circulation in the peri-implant soft tissue around zirconia is similar to that of natural teeth (Kajiwara et al. 2015). Better circular blood flow means a healthier gingiva, which not only leads to better aesthetic results (Tartsch 2018).

According to clinical observations, micro-rough zirconia implants have identical soft tissue integration capacity and faster maturation of epithelial and connective tissue compared to titanium implants (Roehling et al. 2019). In addition, the known surgical and prosthetic protocols can largely be adopted for zirconia implants (Tartsch 2022).

Systematic reviews of zirconia implants show high survival rates after 5 and 10 years: the average 5-year survival rate for one-piece and two-piece zirconia implants is 97.2% (Roehling et al. 2023); the cumulative 10-year survival rate is 95.1% (Mohseni et al. 2023).

Conclusion

Zeramex XT two-piece zirconium dioxide (ATZ) implants have proven their reliability. This anterior case shows that Zeramex XT can be used to achieve a highly aesthetic result in the anterior region, including in cases with immediate implant placement.

The two-piece design also provides the usual advantages such as unencumbered healing, augmentation procedures and surgical and prosthetic flexibility. The carbon fibre-reinforced Vicarbo screw made of biocompatible polyether ether ketone (PEEK) ensures a stable and secure abutment-implant connection. Reentry is also possible in the event of complications. For the use of zirconia implants, appropriate indications should be selected and the manufacturer's guidelines should be followed. It is also important to involve the patient in the decision-making process.

Fig. 5: Final result

About the author

Dr. Max Riemann is specialised in dental implantology and biological dentistry. Dr. Riemann is a certified sports dentist and an active member of the German Society for Aesthetic Dentistry. He has been running a private practice BIO-PHYSIO-DENT in Nuremberg since 2017.

References

Kajiwara Net al.: Soft tissue biological response to zirconia and metal implant abutments. Implant Dentistry 24 (1), (2015).

Mohseni P, Soufi A, Chrcanovic BR. Clinical outcomes of zirconia implants: a systematic review and meta-analysis. Clin Oral Investig. 2023 Dec 23;28(1):15. doi: 10.1007/s00784-023-05401-8. PMID: 38135804; PMCID: PMC10746607.

Roehling, S.; Schlegel, K.A.; Woelfler, H.; Gahlert, M. Performance and outcome of zirconia dental implants in clinical studies: A meta-analysis. Clin Oral Implants Res 2018, 29 Suppl 16, 135-153.

Roehling S et al.: In vitro biofilm formation on titanium and zirconia implant surfaces. | Periodontol 88 (3), 298-307 (2016).

Roehling S, Gahlert M, Bacevic M, Woelfler H, Laleman I. Clinical and radiographic outcomes of zirconia dental implants-A systematic review and meta-analysis. Clin Oral Implants Res. 2023 Sep;34 Suppl 26:112-124. doi: 10.1111/clr.14133. PMID: 3775052

Roehling S, Gahlert M, Janner S, Bo Meng, Woelfler H, Cochran DL: Ligature-induced peri-implant bone loss around loaded zirconia and titanium implants. International Journal of Oral & Maxillofacial Implants, Review process (2018).

Scarano A, Piattelli M, Caputi S, Favero GA, Piattelli A: Bacterial adhesion on commercially pure titanium and zirconium oxide disks: An in vivo human study. J Periodontol 75, 292-296 (2004).

Tartsch J: Keramikimplantate - Exoten oder sinnvolle Erweiterung des Behandlungsspektrums. ZMK 34-11 (2018).

Tartsch J, Blatz MB. Ceramic Dental Implants: An Overview of Materials, Characteristics, and Application Concepts. Compend Contin Educ Dent. 2022 Sep;43(8):482-488; quiz 489. PMID: 36170627.