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logo 50 | the Camlog Partner Magazine logo 50 | the Camlog Partner Magazine 20 | Case study Case study | 21 PRACTICE Otto Prandtner Master dental technician Dr. Michael Berthold Oral surgeon Transmucosal zone 1. Arian, a 26-year-old student, presented in the practice with pain in the area of the central incisor as well as a persistent fistula. Resulting from an anterior tooth trauma during childhood, multiple root canal treatments, two apicoectomies and restoration with a metal-ceramic crown followed. 2. Due to the apicoectomy, the root of tooth 21 was shortened. A further revision attempt had a poor long-term prognosis. As the tooth had to be extracted, an immediate restoration protocol was discussed by the interdisciplinary team. The cross-sectional image of the DVT revealed sufficient bone volume apical to the tooth for immediate implantation. Fenestration due to the fistula did not represent a contraindication. 6. The submucosal design of the temporary restoration is intended to support the existing gingival margin and papilla height. The anatomical emergence profile of the original clinical tooth crown should be preserved accurately here. The design areas of the transition zone are divided into the biological areas and geometric shaping. 4. Taking into account all the biological criteria for hard and soft tissue preservation, the implant was placed correctly three-dimensionally. Based on the defined temporary restoration, a drilling sleeve is positioned for the fully-guided drilling template. Attention must be paid here to ensure that the edges of the sleeve do not touch the soft tissue structures to avoid traumatization when inserting the drilling template. 3. Pre-surgical planning includes digital volume tomography (DVT), a facial scan and the digital wax-up. The exact tooth position, alignment and length can be defined with the aid of the superimposed data. This forms the basis for optimal implant positioning - slightly oriented towards palatal to ensure palatal screw-retention of the restoration and sufficient space for peri-implant augmentation. 5. The natural tooth root acts as a model for the submucosal design of the abutments/gingiva formers. The root of tooth 21 was extracted from the DVT data set by surface rendering, converted into an STL data set and merged with the data from the scan of the upper jaw. A reliable method to achieve the basis for an exact anatomical crown emergence profile which corresponds to the natural tooth. Success factor of an implant restoration - the Personalized Tissue Support Concept Using an immediate temporary prosthetic restoration which mirrors the submucosal contours of the extracted tooth at the time of implant placement is the basis for promoting peri-implant soft tissue healing. An anatomically shaped individual gingiva former or the temporary implant crown assume the function of the soft tissue wound closure during immediate implantation. Both forms stabilize the blood coagulum and thus contribute to tissue preservation during immediate implantation. In the Personalized Tissue Support Concept the focus is on the "transition zone" - the transition area from the circular implant shoulder to the emergence profile of the restoration from the gingiva. Information on the tooth root and the gingiva profile, which can be transferred from the DVT into an STL data set, is essential for the design of the individual gingiva former. Virtual implant positioning as well as the commissioning of a drilling template for guided implant surgery is performed on the basis of 3D X-ray diagnostics and the digital recording of the clinical oral situation. Taking biological criteria into account, the individual PEEK gingiva formers are designed on this basis and manufactured by DEDICAM. Impression posts for open or closed impression taking are manufactured from the same data set to be able to transfer the anatomically shaped soft tissue precisely to the master cast. The fact that the impression post is fabricated from the same data set is crucial for the controlled preservation of the gingival geometry. The gingival geometry as well as the undulating profile of the healed gingiva are thus optimally communicated between the dentist and the dental technician. An essential part of the concept is that the implant abutment is fabricated with the same submucosal contour to avoid an uncontrolled gingival change due to over- or under-contouring. Over-contouring of the "transition zone" generally leads to uncontrolled apical positioning of the gingival margin and thus to an optically extended crown. Under-contouring creates a gap into which the gingiva collapses, which also results in apical positioning of the gingival margin. When designing according to biological criteria, a zone is created in which the connective tissue can attach to the suprastructure - the connected tissue zone. The decisive factor here is the concave shape of the suprastructure from the implant shoulder in direction of the epithelial attachment, which creates sufficient space for the formation of a stable mucosa cuff. The exact copy of the root geometry is essential in the area of the epithelial attachment (approximately 1mm) of the so-called "critical contour" [2]. This promotes primary wound closure as well as stabilization of the blood coagulum. The sulcus influences the level of the gingival margin, gingival color and architecture of the facial emergence profile as well as papilla height and is controlled by the prosthetic structure. During the healing phase, manipulation in the sulcus region could negatively alter the undulating gingival profile. In nature, the gingiva is situated at the enamel-cement border. The design of this border zone should only be completed during the final restoration to be able to define the shape of the sulcus. Highly esthetic implant solutions have been fabricated for years with customized gingiva formers created in the laboratory. The shaped profiles are then transferred to impression posts, which in turn are used for the accurate transfer to the master cast. With the objective of optimizing surgical procedures as well as predictable esthetic and functional implant restorations, patient-specific gingiva formers and impression posts as well as temporary restorations with the same emergence profile can now be fabricated in collaboration with DEDICAM via digital planning based on backward planning and taking into account the biological criteria of soft tissue support. The following patient case describes an immediate implantation with a fully digital solution approach from fully-guided implantation, the use of the customized DEDICAM PEEK gingiva former to preserve the soft tissue contour up to the final restoration. » From the patient's point of view, the success of an implant restoration is evaluated by the appearance of the dental crown and, above all, by a harmonious profile of the peri-implant soft tissue as well as the natural color transition from the white to the red zone [1]. A natural clinical appearance of an implant restoration in the anterior tooth region can be realized predictably by virtue of digital preplanning during surgery using the Personalized Tissue Support Concept.