Journal of Dental Implants
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Year : 2018  |  Volume : 8  |  Issue : 1  |  Page : 25-30

Immediate implant placement and loading using fractured lateral incisor and surgirest template

Aria Dental Specialist Centre, Perth, Western Australia, Australia

Date of Web Publication25-Jul-2018

Correspondence Address:
Dr. Michael Zaninovich
1002 Hay Street, Perth, Western Australia 6000
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdi.jdi_2_18

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This clinical case report presents a novel laboratory technique to place an angulated implant fixture and fabricate an immediate provisional-fixed implant prosthesis using the patient's own extracted tooth. Preservation of the local hard and soft dental tissues with the immediate prosthesis assists predictability when the clinical situation permits.

Keywords: Crown-root fracture, immediate implant placement, immediate interim prosthesis, anterior implant esthetics, own natural teeth

How to cite this article:
Petrucci C, Zaninovich M. Immediate implant placement and loading using fractured lateral incisor and surgirest template. J Dent Implant 2018;8:25-30

How to cite this URL:
Petrucci C, Zaninovich M. Immediate implant placement and loading using fractured lateral incisor and surgirest template. J Dent Implant [serial online] 2018 [cited 2019 Dec 9];8:25-30. Available from:

   Introduction Top

Optimizing anterior implant esthetics is one of the most challenging tasks in implant dentistry. Ideal soft-tissue gingival contours around single implant prosthetics are difficult for any clinician to achieve.[1] Replacement of an anterior tooth with an immediate implant fixture is a safe, accepted, and biologically conservative treatment modality with high survival rates [2],[3],[4] which facilitates preservation of the gingival architecture for optimal esthetics [5] and provides an opportunity for the fabrication of a fixed immediate implant-supported prosthesis.[6]

Immediate interim-fixed implant prostheses restoring the anterior dentition require optimal esthetics and ease of adjustability of the prosthesis contours to assist gingival esthetics, gingival health, and papilla formation.[7] Prosthetic materials including acrylic resin, composite resin, and synthetic glass matrix ceramic are advantageous due to favorable optical properties, rapid laboratory fabrication, favorable surface texture, and ease of adjustability of the supra and subgingival prosthesis contours postinsertion when required. Synthetic glass matrix ceramics present with limitations when additive modifications are required to prosthesis contours.

Use of the patients' own natural extracted tooth can satisfy the requirements of an interim fixed immediate prosthesis when the existing dental hard and soft-tissue architecture is desirable to duplicate and preserve.

This case report describes a laboratory technique for modification of a patient's natural maxillary single tooth for use as an immediate interim implant prosthesis. The technique overcomes the limitation of conventional interim prosthetic materials, assists in a predictable subgingival prosthesis profile to support and stabilization of soft tissues, provides optimal natural esthetics, and the elimination for the need of a removable provisional prosthesis.

   Case Report Top

A 45-year-old female was referred following trauma to the maxillary anterior dentition. A clinical and radiographic examination concluded an oblique subgingival crown-root fracture of the maxillary left lateral incisor [Figure 1]. Replacement of the maxillary left lateral incisor with an implant-supported prosthesis recommended. On the basis of the clinical and radiographic observations, an angulated Co-Axis implant fixture (Southern Implants) and immediate provisionalization using the fractured tooth was proposed.
Figure 1: Preoperative LHS image outlining crown root fracture of the left lateral incisor

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Workup phase

Preliminary impressions were made with irreversible hydrocolloid impression material (GC Aroma Fine Plus). The diagnostic casts of both arches were fabricated using Type III dental stone (Ainsworth Bluestone), duplicated and mounted. The cast obtained serves as the template and in the guidance toward minimizing the hard and soft-tissue esthetic change with the proposed prosthesis, assuming the existing esthetics is favorable and requires preservation and replication. Two vacuum formed templates were fabricated (Erkoflex82th, 1.00 mm; Erkodent). The first surgirest template was designed with a palatal 3 mm diameter access hole. The surgirest template allows verification of the implant depth, screw axis and implant fixture screw position in order for a screw-retained prosthesis to be fabricated with optimal esthetics. The final purpose of the surgirest template once the implant is placed is to serve as a special tray to pick up the implant impression coping or implant provisional, temporary cylinder using a light curing resin (Triad, Dentsply). This avoids the need for a silicone impression. The second duplicated restorative template aids the technical phase allowing the correct positioning of the extracted maxillary left lateral incisor tooth into the template and relative to the cast. The restorative template is identical to the surgirest template without the palatal access hole.

Surgical phase

A sulcular incision with transseptal fiberotomy was executed using a 15c scalpel blade (Hu-Friedy). The maxillary lateral left incisor was atraumatically removed. A periodontal probe was used postextraction to verify the integrity of the labial plate and the socket debrided.

The extracted tooth was disinfected with sterile saline then soaked in 10% sodium hypochlorite for 5 min. A 4.0 mm × 15 mm 24d external hex Co-Axis implant (Southern Implants) was placed into the socket, engaging the palatal alveolus bone. The implant was positioned based on established implant positioning guidelines.[8],[9]

Impression phase

A 3.25 mm external hex impression coping was hand tightened to the implant fixture. The surgirest template was adapted to the existing dentition accurately with the impression coping protruding passively through the palatal access hole of the surgical template [Figure 2]. Light cured resin (Triad, Dentsply) was applied to connect the impression coping to the surgirest template. Following polymerization, the impression coping and surgirest template was removed, disinfected, and delivered to the laboratory. A healing abutment was placed until the immediate provisional prosthesis was fabricated.
Figure 2: Occlusal view of implant impression coping and surgirest template positioned accurately

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Immediate provisional prosthesis fabrication

Model fabrication

The tooth being replaced is removed from the cast from the socket area to its base with an acrylic carbide bur (Carbide bur, Komet) without damaging the surrounding gingival margin on the master cast. For this clinical case, the maxillary left lateral incisor on the master cast was removed. It is essential the gingival margin is accurately preserved, and a hole is drilled into the ridge of the cast itself to allow physical space for an implant laboratory analog [Figure 3].
Figure 3: Occlusal view of master cast with die stone removed in area of proposed implant fixture

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The implant laboratory analog is then carefully adapted to implant impression coping [Figure 4]. The surgirest template along with the implant componentry is then passively adapted accurately to the master cast [Figure 5]. Care is required to ensure there is no contact between the entire titanium cylinder and implant laboratory analog with the surrounding dental stone.
Figure 4: Surgirest template with impression coping and implant laboratory analog connected

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Figure 5: Surgirest template with impression coping and implant laboratory analog connected passively fitted into cavity of master cast

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Light cured resin (Triad, Dentsply) or Type IV dental stone is then applied to the cast through the base of the master model to the base of the platform of the implant laboratory analog to stabilize the analog. Care is required to place the resin 1 mm cervical from the platform. After light curing, the resin or setting of die stone, the implant fixture has been accurately transferred without the need of an impression. The surgirest template is removed [Figure 6].
Figure 6: Implant laboratory analog correctly positioned in master cast with use of light cured acrylic resin

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Natural tooth positioning and gingival profiling

The extracted tooth may require adhesive repair before sectioning 1–2 mm below the cementoenamel junction with a diamond disc on a low-speed handpiece (Diamond disc 946/180 serrated. Diam. 1.8 cm Diamond coated [double sided] cutting discs with H. P. shafts, Dentsply). The more the natural cervical root profile is present the more accurately the subgingival contours can be preserved and replicated. The status of the tooth and position of a crown-root fracture may limit the extent of tooth structure available. For this case, the fracture was favorably repaired with flowable resin to determine the ideal subgingival contour of the prosthesis.

The coronally sectioned tooth is positioned accurately into the surgirest template with cyanoacrylate and then fitted on the master cast [Figure 7]. The position of the extracted natural tooth on the cast with the use of the surgirest template should be passive and without friction or binding interproximally or circumferentially around the socket of the master cast. Additional removal of stone and the replication of the soft tissues are required by trimming the inner surface of the socket in the cast until the subgingival contours of the natural tooth are not impeded by the stone or the silicone material mimicking the gum.
Figure 7: Coronally sectioned tooth positioned in surgirest template with cyanoacrylate and fitted on the master cast

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The coronally sectioned tooth is carefully stabilized to the master cast provisionally with wax or cyanoacrylate [Figure 8]. The laboratory putty key is then adapted to the master model and accurately replicates the position of the tooth in relation to the soft tissues. Once the putty is set, it is removed and the sectioned tooth is adapted into the key [Figure 9]. Additional plaster is removed from the master cast to allow physical space for the soft gingival tissue replica [Figure 10] and the titanium cylinder is shaped and modified. Soft-tissue silicone replica is applied into the laboratory putty key with the sectioned tooth in situ which is then positioned on the master cast [Figure 11]. Once set, the laboratory putty key is removed and access to the implant analog is achieved by removing excess soft-tissue silicone [Figure 12] and [Figure 13].
Figure 8: Removal of surgirest template once coronally sectioned tooth correctly positioned and stabilized to master cast with cyanoacrylate

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Figure 9: Laboratory putty key of master cast with sectioned extracted tooth

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Figure 10: Modified titanium cylinder on implant analog and additional plaster removal from master cast

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Figure 11: Application of soft-tissue silicone replica in laboratory putty on master cast

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Figure 12: Sectioned tooth and soft-tissue silicone replica adapted to master cast

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Figure 13: Master cast with excess soft-tissue silicone removed to gain access to titanium cylinder

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To encase the temporary cylinder and maximize retention, a 1–2 mm bevel covering >180° of the extracted natural tooth is shaped in the surgirest template. A 50 μm diamond bur in a high speed handpiece was used under water irrigation to avoid denaturing collagen fibers. Further adjustment to the coronal portion of the tooth may be required to adapt the extracted tooth to the surface of the provisional titanium cylinder. The subgingival contours of the extracted tooth are preserved as much as possible without interfering with the implant fixture platform or provisional peek abutment. A minimum distance of 1 mm is recommended between the subgingival natural tooth and the shoulder of the provisional titanium cylinder to allow adequate space for adhesive materials between the extracted tooth and provisional abutment [Figure 14]. Once the extracted tooth is seated passively on the master cast and neither impeding the implant fixture platform nor provisional abutment surface, the bonding phase may commence.
Figure 14: Sectioned natural tooth in surgiest template positioned on master cast

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The tooth surfaces are prepared for bonding using an appropriate enamel and dentine bonding protocol. The provisional titanium cylinder abutment surface is sandblasted with 50 μm aluminum oxide before the application of unfilled resin (Visiolink, Bredent). Flowable resin composite (flowable composite, 3 m ESPE) is injected into the access hole in the soft silicone to fill the gap between the provisional peek abutment and natural tooth and light cured [Figure 15].
Figure 15: Access hole on buccal and palatal surface of soft tissue silicone replica with sectioned tooth, modified titanium cylinder and modified surgirest template in situ

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After curing, the modified surgirest template is removed; the implant prosthesis is modified and finished to a low surface roughness with tungsten carbide burs, rubber wheels, and glazed (Pala seal denture lacquer, Heraeus Kulzer). The prosthesis is then delivered to the clinician for insertion [Figure 16].
Figure 16: Completed provisional screw retained prosthesis

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Restorative phase

The immediate nonfunctional implant supported screw retained prosthesis was adapted to the implant fixture. The prosthesis was tightened to 32 Ncm. The access cavity was covered with resin composite. The occlusion carefully adjusted to minimize direct functionality [Figure 17].
Figure 17: Postoperative view 24 h following insertion of immediate prosthesis

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   Discussion Top

This clinical case presents the immediate replacement of a fractured maxillary lateral left incisor with an angulated implant fixture using the original fractured crown and the surgirest template technique.

Immediate implant placement and immediate provisionalization has proved favorable in hard and soft-tissue preservation especially for patients with thin and scalloped periodontal form.[9] Reduced chair time, elimination of additional surgery, immediate nonocclusal loading, bone preservation, and esthetics are additional benefits achieved when the patient receives a customized provisional restoration on the day of implant surgery.[6] A fixed provisional restoration can further maintain the psychological health of the patient and eliminate the necessity of a removable provisional restoration.

The benefits of angulated implants for the immediate replacement of teeth in the anterior maxilla should be strongly considered as an alternative to conventional endosseous straight implant fixtures. The Co-Axis design (Southern Implants) assists placement of an implant fixture ideally in the palatal alveolus along with versatility in the fixture screw positioning to ensure the delivery of a favorably desired screw retained prosthesis as opposed to a cemented implant prosthesis. Various fixture angulations are available depending on the degree of anterior maxillary protrusion and angulation in relation to the palatal surface of the maxillary anterior dentition.

The surgirest template is a radiographic template, surgical guide, impression jig, and restorative template during technical prosthesis fabrication. The surgirest template technique eliminates the need for silicone impression and a new master model, effectively reducing fabrication time compared to conventional techniques. It allows the use of the patient's natural tooth or the fabrication of an acrylic prosthesis.

The exact shape of the preexisting emergence profile can be optimally maintained with the natural tooth provisional prosthesis and then replicated with the final abutment and prostheses.

   Conclusions Top

An angulated implant fixture allows the fabrication of a screw retained prosthesis. The use of the patients own coronal tooth structure promotes immediate esthetics and tissue preservation. The surgirest template technique improves the work flow and efficiency in the delivery of an immediate provisional implant supported prosthesis. It eliminates the clinical need for a silicone impression after implant placement and reduces the technical fabrication time frame required.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Steigmann M, Cooke J, Wang HL. Use of the natural tooth for soft tissue development: A case series. Int J Periodontics Restorative Dent 2007;27:603-8.  Back to cited text no. 1
Michalakis K, Kalpidis CD, Hirayama H. Conversion of an existing metal ceramic crown to an interim restoration and nonfunctional loading of a single implant in the maxillary esthetic zone: A clinical report. J Prosthet Dent 2014;111:6-10.  Back to cited text no. 2
Cornelini R, Cangini F, Covani U, Wilson TG Jr. Immediate restoration of implants placed into fresh extraction sockets for single-tooth replacement: A prospective clinical study. Int J Periodontics Restorative Dent 2005;25:439-47.  Back to cited text no. 3
Buser D, Chen ST, Weber HP, Belser UC. Early implant placement following single-tooth extraction in the esthetic zone: Biologic rationale and surgical procedures. Int J Periodontics Restorative Dent 2008;28:441-51.  Back to cited text no. 4
Jemt T. Regeneration of gingival papillae after single-implant treatment. Int J Periodontics Restorative Dent 1997;17:326-33.  Back to cited text no. 5
Buser D, Martin W, Belser UC. Optimizing esthetics for implant restorations in the anterior maxilla: anatomic and surgical considerations. Int J Oral Maxillofac Implants. 2004;19 Suppl:43-61.  Back to cited text no. 6
Ross SB, Pette GA. Immediate implant placement and provisionalization using a customized anatomic temporary abutment (CATA) to achieve gingival margin stability. Compend Contin Educ Dent 2013;34:344-50.  Back to cited text no. 7
Saadoun AP, LeGall M, Touati B. Selection and ideal tridimensional implant position for soft tissue aesthetics. Pract Periodontics Aesthet Dent 1999;11:1063-72.  Back to cited text no. 8
Kan JY, Rungcharassaeng K. Immediate placement and provisionalization of maxillary anterior single implants: A surgical and prosthodontic rationale. Pract Periodontics Aesthet Dent 2000;12:817-24.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17]


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