Implant Assessment

Patient Information

• David Chen, 46 yo male, DOB: 12/08/1978, Medicare: 3492 81726 1, Ph: 0412 345 678, Address: 42 Stirling Hwy, Nedlands WA 6009

Chief Complaint

• Requests fixed replacement for missing upper right first premolar (tooth 14), extracted 6 months ago. Reports aesthetic concern when smiling and reduced chewing efficiency on RHS.

Medical History

• Mild hypertension, well-controlled. Nil prior hospital admissions or major surgeries.
• Meds: perindopril (Coversyl®) 5 mg PO OD.
• Allergies: NKDA. No history of bisphosphonates, bleeding disorders, or diabetes.

Dental History

• Tooth 14 surgical extraction on 14/09/2024 due to vertical root fracture; uncomplicated healing. Regular 6-monthly scale and clean. No history of periodontitis.
• Nil history of facial or dental trauma. Reports mild nocturnal bruxism (wears occlusal splint intermittently).

Social History

• Non-smoker (never smoked). Social alcohol intake (2–3 standard drinks/week). Brushes BD with electric toothbrush and fluoridated toothpaste; uses interdental brushes daily.

Clinical Examination

Extra Oral Examination

• Facial Symmetry: Symmetrical, proportional facial thirds, average smile line exposing 2 mm of gingiva in the premolar region.
• TMJ Assessment: Normal ROM (MIO 48 mm), nil clicks, crepitus, tenderness, or deviation on opening. Mild hypertrophy of masseter muscles bilaterally.
• Lymph Node Examination: Submandibular, submental, and cervical chains non-palpable and non-tender.

Intra Oral Examination

Soft Tissue Assessment

• Mucosa: Buccal mucosa, tongue, hard/soft palate, floor of mouth, and vestibule WNL. Moist, pink, nil ulceration or pathology.
• Gingiva: Pink, firm, stippled, scalloped contour, nil spontaneous bleeding or oedema. Well-healed edentulous ridge at site 14.

Hard Tissue Assessment

• Teeth: 27 teeth present. Missing 14, 18, 28, 38, 48. Existing composite restorations in 16, 26, 36, 46 intact. Adjacent teeth (13, 15) vital to cold testing, nil caries or mobility.
• Occlusion: Class I molar and canine relationship. Overjet 2 mm, overbite 3 mm (30%). Canine guidance on lateral excursive movements. Adequate interocclusal space (7.5 mm) and mesio-distal space (7.2 mm) at site 14.

Implant Site Evaluation

Bone Quality and Quantity

• Clinical Assessment: Healed ridge at site 14 shows mild buccal concavity. Ridge width clinically estimated at 7 mm, adequate vertical height. Bone feels dense on palpation (Type II/III).
• Radiographic Assessment: Good trabecular density. Available bone height from crest to maxillary sinus floor is 13.5 mm. Divergent roots of 13 and 15 with 7.0 mm interradicular clearance.

Soft Tissue Considerations

• Keratinized Tissue: 4 mm band of attached keratinised mucosa present buccally and crestally at site 14.
• Soft Tissue Biotype: Thick gingival biotype; probe not visible through sulcus of adjacent teeth, favourable for peri-implant soft tissue stability and aesthetics.

Periodontal Examination

• Periodontal Pocket Depth: Generalised probing depths 1–3 mm throughout dentition. 13 and 15 probe ≤ 2 mm on all 6 points. Nil BOP.
• Clinical Attachment Loss: Nil significant CAL noted.
• Furcation Involvement: Nil furcation involvement on molars.
• Gingival Recession: Nil recession at adjacent teeth 13 and 15.
• Plaque Index: Low (12% O'Leary plaque score).

Radiographic Examination

• Panoramic Radiograph: Generalised horizontal bone levels WNL. Maxillary sinuses clear and well-pneumatised. Nil periapical pathology noted on remaining dentition.
• Cone Beam Computed Tomography (CBCT): Site 14 demonstrates 6.8 mm buccolingual ridge width at 2 mm apical to the crest, widening to 8.2 mm apically. Vertical height to sinus floor is 13.5 mm. Buccal plate intact, 1.5 mm thick. Bone density consistent with Lekholm & Zarb Type II/III.

Diagnostic Casts and Impressions

• Digital intraoral scan (Trios) completed. Virtual diagnostic wax-up of 14 confirms ideal prosthetic emergence profile and screw-access channel exiting centrally through the occlusal fossa.

Laboratory Investigations

• FBC, HbA1c (5.2%), and Vitamin D (82 nmol/L) completed on 01/03/2025; all WNL.

Risk Assessment

• Midfacial Bone Crest to Gingival Margin: Low
• Integrity of Facial Plate: Low
• Thickness of Facial Bone Plate: Medium
• Horizontal Defect Dimension: Low
• Gingival Phenotype: Low
• Primary Stability of Implant: Low
• Presence of Benign Pathology: Low
• Placement Timing: Low
• Patient Compliance: Low

Diagnosis

• Partial edentulism (missing tooth 14), Siebert Class I ridge deficiency (mild). Periodontally healthy dentition.

Treatment Plan

Treatment Options

• Option 1: Single endosseous dental implant at site 14 with screw-retained crown (Recommended: preserves adjacent intact teeth 13 and 15, maintains bone volume, high long-term success rate; Risks: surgical complications, infection, implant failure).
• Option 2: 3-unit fixed dental prosthesis (bridge) from 13 to 15 (Risks: requires destructive preparation of virgin/unrestored abutment teeth, potential pulp necrosis).
• Option 3: Removable partial denture (Risks: bulkiness, plaque retention, less aesthetic).
• Option 4: No treatment (Risks: supra-eruption of opposing tooth 44, tipping of adjacent teeth).

Surgical Plan

• Two-stage conventional protocol under LA (articaine 4% with 1:100,000 adrenaline). Mid-crestal incision with sulcular extensions at 13 and 15. Fully guided osteotomy using 3D-printed pilot/full surgical stent. Placement of Straumann Bone Level Tapered (BLT) implant 4.1 mm x 10 mm RC at site 14. Minor contour augmentation on buccal aspect using deproteinised bovine bone mineral (Bio-Oss) and resorbable collagen membrane (Bio-Gide) if buccal plate measures < 2 mm intraoperatively. Cover screw placement and primary tension-free closure.

Prosthetic Plan

• 12-week osseointegration phase (no provisional prosthesis required per patient preference). Stage 2 exposure and healing abutment placement at 12 weeks. Digital impression 2 weeks post-exposure. Final restoration: Screw-retained monolithic zirconia crown bonded to titanium base abutment. Fabricate new maxillary nocturnal occlusal splint post-restoration to protect against bruxism.

Postoperative Care

• Amoxicillin 500 mg PO TID for 5 days, ibuprofen 400 mg PO TID PRN, paracetamol (Panadol®) 1,000 mg PO QID PRN, and chlorhexidine gluconate 0.2% (Savacol®) mouthwash 10 mL BD for 14 days. Soft diet for 1 week, avoid chewing on RHS, no strenuous exercise for 72 hours, apply ice pack extraorally 20 mins on/off for first 24 hours.

Prognosis

• Good to excellent long-term prognosis given thick tissue biotype, adequate native bone volume, late placement timing, non-smoking status, and high oral hygiene compliance.

Review and Follow-up

• Surgical placement booked for 28/03/2025 at 09:00 AWST.
• Suture removal and surgical review at 2 weeks post-op (11/04/2025).
• Stage 2 uncovering and osseointegration check at 12 weeks post-op (20/06/2025).
• Prosthetic impressions at 14 weeks (04/07/2025) and crown insertion at 16 weeks (18/07/2025).