Case Presentation: Immediate Ceramic Implant

A patient presented with a failed root canal treatment in #30 [mandibular right first molar; 46].  I extracted #30 and immediately installed a zirconia implant fixture.  The implant diameter and implant pretty well matched the extraction socket dimensions.  Osseointegration progressed very well and healing of the bone and soft tissue was excellent.   I achieved adequate primary stability and later restored with a zirconia abutment and crown.  The aesthetics were excellent and the final restoration looked like a natural tooth and blended in quite well.  Do you have any comments or questions on the case?

Pre-op failed endo.
Pre-op failed endo.
CeraRoot 16 implant healed in place.
CeraRoot 16 implant healed in place.
3 months of healing.  Beautiful soft tissue.
3 months of healing. Beautiful soft tissue.
Final crown.
Final crown.

18 thoughts on: Case Presentation: Immediate Ceramic Implant

  1. Akash Akinwar says:

    Excellent management of failed RC treated tooth by immediate Implant placement.
    I have few doubts….3rd image showing 3 months of healing: also shows overgrown gingiva over mesial margin of abutment…Did you manage that soft tissue problem?? If yes, How did you manage that…? Was there any difficulty during impression taking ? Which method of impression did u follow??

  2. Dan Hagi

    You are correct the soft tissue did grow over the restorative platform. That is great thought as we have some excess soft tissue to play with. With titanium implant we often see tissues recede, with the zirconia surface we often get tissue overgrowth. In this case I did use a soft tissue laser to remove a little tissue and then used an iTero scanner to take a digital scan of the implant.

  3. Maite Moreno says:

    Please let me have the x ray where the implant without the abutment is, and after immediate extraction.
    Question 1, what did you use for tissue engineering, or you just let the socket healed as you comment that it was the same size.
    Question 2, it says, later restored with zirconia abutment…. please let me know the sistem name. Thank you!
    Best regards, and Happy new year… ! its a great case!!
    Maite Moreno DDS, MS

  4. Dan says:

    Hello Maite,

    This is a one piece zirconia implant. Only autogenous chips from the osteotomy where used around the implant as most of the socket was filled with implant body.
    Happy new year.

  5. dr M.P. says:

    Nice looking and well presented work. A couple of comments : Implant diameter could be smaller in order to preserve the buccal lamella – it is governing rules in the reconstruction of molars . New generation of titanium implants with conical connection allows smaller implant diameter and wide platform give good soft tissue profile , and i think they are still the best solution.
    Zirconia is a very brittle material , has low elasticity and very little resistance to twisting forces. Abutments in esthetics zone still are the best place for zirconia.
    Best regards, and Happy new 2014.

  6. Dan Hagi

    Great question guys.
    Implant size depends on available bone. In this case the molar implant CeraRoot 16 hard sufficient buccal lingual bone at 4.8mm apex and 6.5mm to the top of the threaded portion of the implant. Smaller diameter implants in the posterior are never a good idea as they have less surface area for fixation and are more prone to fracture under higher occlusal loads.
    As for zirconia. In terms of physical properties the static fracture strength of a 5mm external hex titanium implant is about 1955Ncm and dynamic is about 600+Ncm according to Misch and Boggan. For a smaller CeraRoot 21 the static is about >2100Ncm and dynamic at over 2000Ncm according to ISO angled off axis testing. So it appears to be a stronger material than hollow titanium alloy. Misch reports 1% implant fracture rates, 2% abutment screw complications and 4% prosthetic screw complications. I would rather have a one piece implant in light of this data.
    Zirconia abutments are aesthetic but they are hollow and the research shows higher fracture rates than titanium abutments because of the lack of bulk.
    The paradigm shift is that the one piece zirconia implant is the best solution for tooth replacement.
    Happy new year.

  7. CRS says:

    Very interesting, will follow. My feedback will be from the restoring doctors imput on working with a one piece zirconium abutment that is cemented. Like the idea for anterior esthetics, limitations due to one piece design and retrievability. Soft tissue if adequate and protected will grow over anything, Titanium or zirconium . Don’t like immediate placement, I like to have more live bone present at implant placement especially at buccal plate since implant unlike a tooth has no blood supply. Some mechanical questions for the engineering types for long term prognosis . What is very nice about this case is that the implant was protected by the adjacent teeth and no provisional was placed to squash the healing tissue. Remember that implant abutment screw failures are not always related to the material itself but placement, restoration and occlusion, many factors. Seems like a promising implant used appropriately, time will tell. Thank you for interesting post please advise how it works out in future. Happy 2014!

  8. Dan Hagi

    You are correct. Retrievability i always disagree with as I would want the crown on a natural tooth to be retrievable more than the crown on this implant. Soft tissue will usually grow over everything but how often do we see anterior implants with gums receding, partially due to placement, partially due to the dieback of some crestal bone… this does not happen with the one piece implants (Hermann study). Immediate placement is nice sometimes for soft tissue and papilla and when circumstances are ideal works well.
    Thank you for your comments I’ll post more cases!!

  9. Dr. Geoffrey Bataringaya BDS says:

    Dan,I am blown away by your case. A Dr.Brian Faure in South Africa used to place some zirconium implants. They were shaped like Southern implants, long and tapered. I don’t remember them being single body.
    Please keep posting periodic reviews.
    Happy New Year to all

  10. Cliff Leachman says:

    Great Post! Thanx for sharing, Nice finished case, but I think I’ll wait to see the failures come in case they are out of this world. Can’t imagine trying to remove a failed implant? Trephine????

  11. Dan Hagi

    Cliff. Thank you. Failures happen with everything we use. With titanium my concern is early failure to integrate or maintain tissue. Long term failures in maintaining the bone, mechanical breakage of components, and exposure of black metal. With CeraRoot early failures may occur but late failures are less likely. Fracture is less likely, tissue stability eclipses titanium, exposure of some white is not the end of the world. Regardless when a screw fails we reverse it out, if we can’t we cut it out of the bone. The removal torque required to get 95% of implants out is less than 150Ncm. Not a big deal with the right toolbox.

  12. Mark says:

    I just don’t see the advantage at this point of placing something this untested long term in patients . Inability to correct angulations. If anything I see it being practical in anterior cases for esthetics but even then you would need custom angulations at times and I would worry About the shear strength in excursions on a zirconia product . Thoughts? I would need to see 10 year follow up studies on these before the jury is out .

  13. dr M.P says:

    How to remove 6.5mm wide implant? It’s not that easy at all…
    Here is some advice for the young colleagues: if you come in a situation of treatment failure, as the Xray No1 shows, the best solution is to remove a mesial
    root / lat. hemisectio/ make a fiber post and core build up on a distal root
    and a crown over them. In this situation-full dental arch and good
    patients biotip , there is no failure , the solution lasts for decades.
    If you decide to do an implant in this situation , then you need to have 2
    to 3 mm of surrounding bone, especially in the buco-lingual space. For
    6.5 mm implants we need a bone minimum width from 11 to 12mm , which is a
    very rare case…
    Titanium implants of about 5mm diameter with a conical connection are an
    excellent solution . In narrow areas, even a 4mm conical
    connection implant can be used. Personally, I have had a good decade long experience using Nobel Replace but recently, all brand Implant companies are switching to conical connection and a smaller implant diametar..
    In my opinion, zirconium one-peice implants may have a future in the aestethic zone.. Maybe even starting in 2014. 🙂

  14. Dan Hagi

    Mark, there are many advantages to zirconia as a dental implant material. One the top of that list is the fact that we can use a one-piece implant. If we could use a one piece titanium implant with no connection, I think that most people in this forum would agree that would be ideal. But we know it is hard to make look good in the mouth. With zirconia this is easy. The zirconia is also healthier against tissue, oxidation products from titanium implants, which nowaday are alloys mixed with other non inert metals, accumulate in the tissue. Finally, simplicity, I would rather have simple solutions to solve simple problems.

    As for long term data, how long do you think the data on any new product that comes to market in our field is? How long was the data present for Nobel Replace implants before use? We rely on data from other products (machines titanium) to support our use of similar products. There is published 5 year data (PDF Link) that was published in 2010. The yet unpublished 10 year study will be coming soon, and having seen the results, you are going to be blown away. So the data is out there, we just need to open our eyes and see.
    What is the shear strength of a 1.5mm abutment screw compared to a 4mm+ zirconia, because this is what we should be comparing. If you have a lateral shear force on an implant, you have a problem, but I would trust CeraRoot over the little prosthetic abutment screws.

    M.P. Hemisection was an option, so was a three unit bridge, so was a flipper, so was no tooth at all, the patients usually want the longest lasting, most cost effective option. I don’t need 2-3mm of bone around my implants. IF i have 1-2mm I am quite happy, which means I need a 10mm ridge, not so hard in the posterior mandible. Lets take this further and assume I had buccal bone lost and some tissue recession, what is the consequence? With titanium, I would start to see threads maybe? with zirconia, am i going to see some white? maybe I will have to replace the crown, prep a little margin, what if it were a tooth??

    This is a little bit of a paradigm shift. Once the zirconia implant integrates it is a tooth, what do you do to a tooth in that situation, do teeth come with angled abutments?
    Great feedback guys, I’m going to post another case, an anterior… lets see what you guys think.

  15. LSDDDS says:

    Gordon reports that orthopedic surgeons are seeing zirconia deterioration at the seven year mark on joint replacements.
    Osteosarcoma is reported on very small percent titanium implants, also orthopedic bone screws.
    Branemark original osseointegration was a 17yr study on heavy mandible Swedish
    Men only lower cuspid to cuspid. Upon this only is what we have today.
    Fortunately seems to have worked but reports of issues with fifty percent implants by the ten year mark.
    Time and this forum will tell.

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