Imm

of c

rece

tube

den

José Carlos Mar

aDoctoral student, Department of ImbDoctoral student, Department of ImcPostgraduate student, DepartmentdFull Professor, São Leopoldo Mand

Rosa et al

ediate implant placement, reconstruction

ompromised sockets, andrepairofgingival

ssionwitha triplegraft fromthemaxillary

rosity: A variation of the immediate

toalveolar restoration technique

tins da Rosa,a

Ariádene Cristina Pértile de Oliveira Rosa,b

Marcos Alexandre Fadanelli,c andBruno Salles Sotto-Maior, PhDd

São Leopoldo Mandic Dental Research Center, Campinas,São Paulo, Brazil

Immediate implant placement into compromised sockets is challenging for clinicians. The 3-dimensional implantposition, status of the buccal bone wall, and regeneration of the soft tissue contours all affect adequate estheticand functional results. This clinical report presents a treatment protocol (a variation of the immediate dentoalveolarrestoration concept) consisting of immediate implantation and the reconstruction of the buccal bone wall and gingivalrecession in a single procedure with a triple graft (cancellous and cortical bone and soft tissue graft). (J Prosthet Dent2014;112:717-722)

1 Abscess in right central incisor and poor soft tissuequality.

The immediate placement of implantsafter tooth extraction is a common clinicalpractice, with a success rate similar to thatof implant placement in healed sites.1

However, immediate implant placementin the esthetic zone is a challenging andcomplex procedure.2 To achieve optimalesthetic and stability outcomes with theimmediate placement of implants in freshsockets, a meticulous protocol for thesurgical and prosthodontic proceduresis necessary.1,3 Surgical considerationsinclude the 3-dimensional (3D) posi-tioning of the implants, primary stability,the presence of the buccal bone wall, andthe soft tissue thickness.4 Prosthetic con-siderations necessary for soft tissuematuration include the correct design ofthe emergence profile, the harmony of theperiimplant soft tissues relative to theadjacent dentition, the restoration color,and the contouring and polishing steps.5,6

Reasons for tooth extraction andimmediate implant placement includeendodontic treatment failure, ad-vanced periodontal disease, trauma,and root fracture, all of which are

plantologplantolo

of Operatic Dental

frequently associated with severe alve-olar bone resorption and soft tissueloss5 (Figs. 1, 2). When the bonedamage is extensive, as indicated bychanges in the level of the gingivalmargin, the esthetic risk increases, andimmediate loading is commonly con-traindicated.7,8 To improve the es-thetics and clinical efficacy, as well asto shorten the treatment period, avariation of the immediate dentoal-veolar restoration (IDR) technique is

y.gy.ive Dentistry.Research Center.

proposed. This technique uses a boneand soft tissue reconstructive pro-cedure involving immediate implantplacement in sockets with severebuccal bone wall damage and gingivalrecession in a single clinical session.

PROCEDURE

1. After anesthesia, make an intra-sulcular incision around the tooth to beextracted.

2 Cone-beam computed tomographic image showed totalabsence of buccal bone wall.

3 Implant installed with palatine anchoring (Replace Select;Nobel Biocare).

4 Emergence profile with concavecontour established on interim crown.

718 Volume 112 Issue 4

2. Extract the tooth with a mini-mally invasive procedure by using aperiotome, a microlever, and atrau-matic forceps to preserve the integrityof the remaining bone wall.

3. Carefully curette the socket toremove the granulation tissue and theremaining periodontal connective tis-sue. The socket walls should be probedin the apicocoronal and mesiodistaldirections to assess the degree of bonedamage and confirm the anatomicshape of the defect.

4. Insert the implant into the ideal3D position, regardless of whether thegingival margin is not level. The implantplatform should be placed 3 mm apicalto the cementoenamel junction (CEJ) of

The Journal of Prosthetic Dentis

the contralateral tooth. Anchor theimplant to the palatal wall, to providecorrect space for buccal hard and softtissue reconstruction (Fig. 3).

5. Test the interim titanium abut-ment, occlusal adjustment, and opaci-fication of the metallic component witha composite opaque resin (AmelogenPlus OW; Ultradent Products Inc). Aninterim crown is made by using a pre-viously prepared esthetic veneer withlight-polymerizing composite resin. Theideal emergence profile with a concavecontour is established on the interimcrown (Fig. 4), allowing free space forbetter accommodation of the soft tis-sue and promoting a thicker and morestable gingival margin.

try

6. Evaluate the occlusion andexcursive movements after the interimcrown is screwed to the implant.

7. After finishing the prostheticprocedures, make a horizontal incisionin the gingival papillae at the CEJ.Divergent incisions must follow thegingival recession pattern (Fig. 5). Thepurpose of the divergent incisions is toreposition the gingival tissue coronally,therebyminimizing trauma to the tissuesand promoting scar-free, first-intentionhealing. Make an intrassulcular incisionjoining the incisions, and divide theflap above the divergent incisions. Amicroblade (69 WS; Swann-Morton)may be used for all incisions.

8. Remove the gingival tissue pedi-cles between the double incisions in theregion of the papillae with a microbladeor microscissors (Fig. 6).

9. Infiltrate the donor area withanesthetic at the base of the vestibuleand in the palatine portion of themaxillary tuberosity.

10. Make a mucoperiosteal incisionat the maxillary tuberosity by followingthe distal contour of the last molar, 2or 3 mm from its distal side. This inci-sion is followed by 2 mucoperiostealrelaxing incisions in the posterior di-rection, thus reproducing the shape of

Rosa et al

5 Four incisions in gingival papillae area. Two horizontalincisions in gingival papillae (in area corresponding tocementoenamel junction of adjacent tooth), followedby 2 divergent incisions corresponding to gingivalrecession pattern.

6 Removal of epithelial part of pedicles between 2 incisions.

7 Flap division at donor site. Division starts at buccal angleand continues to posterior area, keeping uniform thickness ofconnective tissue over bone.

8 A, B, Triple graft is removed with straight chisel. Three layers of graft (connectivare present.

October 2014 719

Rosa et al

the defect in the receptor region. Afterthose 3 first mucoperiosteal incisions,divide the flap starting at the buccalline angle, then, directing the bladeto the most posterior portion ofthe relaxing incisions, maintainingconnective tissue 1 to 2 mm in thick-ness to cover the bone tissue (Fig. 7).

11. Cut the bone with a straightchisel (Schwert IDR Kit; A. Schweick-hardt GmbH & Co KG) along therelaxing incisions to define the bonefracture line. Position the chisel initiallyperpendicular to the bone structure onthe incision line surrounding the distalpart of the last molar. After it has beeninserted 2 or 3 mm with a surgicalhammer, change the chisel’s angulationto be parallel to the outer surface of the

e tissue, cortical, and cancellous bone)

9 Absence of buccal bone wall.

720 Volume 112 Issue 4

connective tissue. Deepen the chiselgradually as far as the distal limit of therelaxing incisions to obtain a uniformbone/gingiva graft (Fig. 8). After thebone is fractured, an incision is madein the distal portion of the connective

10 A, B, Triple graft remodeled accordconnective portion turned to gingival mu

11 Stabilization of graft by suturing conpart on gingival flap of receptor area. Simon mesial and distal papillae region.

The Journal of Prosthetic Dentis

tissue to remove the triple graft (corticaland cancellous bone and soft tissuegraft), taking care to maintain an epi-thelial pedicle to ensure better nutri-tion for the flap that will cover thedonor site. Additional cancellous bone

ing to shape and size of defect and testedcosa and cancellous portion turned to pr

nective tissueple stitches

12 Occlusal view at

try

is harvested from the same donor sitewith a chisel to fill the gaps between thetriple graft and the exposed spirals ofthe implant. The graft is embedded insaline solution and transferred to thereceptor site as soon as possible.

12. Manipulate the triple graft toreproduce the shape of the socketdefect and then test to achieve betteradaptation.

13. Compact the bone marrow har-vested from the maxillary tuberosity inthe buccal surface of the implant tocover the exposed implant threads(Fig. 9). The stability of this graft can bedetermined by the use of bone compac-tors (Schwert IDR Kit; A. SchweickhardtGmbH & Co KG). This step is donebefore inserting the triple graft.

14. Insert the triple graft carefully,leaving the bone portion in contact with

in receptor site; graft positioned witheviously compacted particulate bone.

4-month follow-up.

Rosa et al

13 A, B, Customized zirconia abutment prepared with adequate emergence profile and evaluatingrelationship between soft tissue and abutment.

October 2014 721

the previously packed bone marrow andthe connective tissue portion in contactwith the internal portion of the gingivalflap (Fig. 10). The connective portion ofthe graft should be stabilized up to thelevel of the gingival margin that wasmoved coronally. The bone portion ofthe graft must be coincident with theimplant platform. The connective portion

14 A, B, Clinical image and soft tissueimmediate dentoalveolar restoration pro

Rosa et al

of the graft must always be beyond thelimits of the bone defect.

15. Stabilize the graft by suturing theconnective tissue portion of the graft onthe gingival flap. The definitive flapcoaptation is obtained by suturing thepapillae with simple stitches (Fig. 11).

16. Apply a torque of 20 Ncm on theattachment screw of the interim crown

enhancement cone-beam computed tomocedure.

and seal the palatine orifice with pro-visional filling material (Fermit; IvoclarVivadent).

17. Finally, suture the gingival flap inthe donor region with simple stitches.

18. Monitor every 2 days for the first2 weeks and every 15 days for the next 4months. After a period of 4 months,once the bone and gingival architecture

graphic scan made 2 years after

722 Volume 112 Issue 4

has been reestablished (Fig. 12), a zir-conia abutment (Fig. 13) and ceramiccrown is provided. The stability of thebuccal bone wall is monitored by peri-odic cone-beam computed tomographicsagittal sections (Fig. 14).

DISCUSSION

A buccal bone wall with sufficientdimensions is a prerequisite to achievingstability and esthetic soft tissue con-tours in the esthetic zone.9 A lack ofbuccal bone wall to support the facialmucosa may lead to recession and anincomplete papilla. Thus, implanttreatment goals must be expanded toinclude the reconstruction of these lostanatomic structures. The techniqueaims to restore the buccal bone walland soft tissue contours by using thesame procedure as for implant place-ment, thereby reestablishing estheticsand function. This technique is a varia-tion of the IDR technique, which isindicated for immediate implant place-ment in compromised sockets and forthe repair of soft tissue recessions. Thestabilization of a thick graft tissue ina localized buccal wall defect is themost challenging part of the treatmentin damaged sockets. Therefore, themanipulation of the triple graft with a

The Journal of Prosthetic Dentis

rongeur to reproduce the same shape asthe periimplant bone defect is funda-mental, given that the stabilization ofthe triple graft is achieved by juxta-posing the bone defect borders.

The limitations of this techniqueinclude difficulty of access to the donorsite, especially in patients with a smallmouth opening. Another limitation isthe low availability of tuberosity boneand soft tissue to restore large defectsor more than 1 tooth. Limitationsrelated to the receptor site includeinsufficient amounts of residual tomake the primary stability of theimplant feasible and gingival recessionextending above the mucogingival line.

REFERENCES

1. Del Fabbro M, Ceresoli V, Taschieri S, Ceci C,Testori T. Immediate loading of postextractionimplants in the esthetic area: systematic reviewof the literature [published online April 22,2013]. Clin Implant Dent Relat Res.http://dx.doi.org/10.1111/cid.12074.

2. Noelken R, Neffe BA, Kunkel M, Wagner W.Maintenance of marginal bone support andsoft tissue esthetics at immediately provision-alized OsseoSpeed implants placed intoextraction sites: 2-year results. Clin OralImplants Res 2013;14:214-20.

3. Cabello G, Rioboo M, Fábrega JG. Immediateplacement and restoration of implants in theaesthetic zone with a trimodal approach: softtissue alterations and its relation to gingival bio-type. Clin Oral Implants Res 2012;9:1094-100.

try

4. Wittneben JG, Buser D, Belser UC, Brägger U.Peri-implant soft tissue conditioning withprovisional restorations in the esthetic zone:the dynamic compression technique. Int JPeriodontics Restorative Dent 2013;33:447-55.

5. Da Rosa JC, Rosa AC, da Rosa DM,Zardo CM. Immediate dentoalveolar restora-tion of compromised sockets: a novel tech-nique. Eur J Esthet Dent 2013;8:432-43.

6. Petropoulou A, Pappa E, Pelekanos S. Estheticconsiderations when replacing missing maxil-lary incisors with implants: a clinical report.J Prosthet Dent 2013;109:140-4.

7. Bäumer D, Zuhr O, Rebele S, Schneider D,Schupbach P, Hürzeler M. The socket-shieldtechnique: first histological, clinical, andvolumetrical observations after separation ofthe buccal tooth segmentea pilot study. ClinImplant Dent Relat Res 2013;30:1-12.

8. Buser D, Martin W, Belser UC. Optimizingesthetics for implant restorations in the ante-rior maxilla: anatomic and surgical consider-ations. Int J Oral Maxillofac Implants 2004;19:43-61.

9. Belser U, Buser D, Higginbottom F. Consensusstatements and recommended clinical pro-cedures regarding esthetics in implantdentistry. Int J Oral Maxillofac Implants2004;19:73-4.

Corresponding author:Dr José Carlos Martins da RosaAvenida São Leopoldo 680Caxias do Sul, RS 95097-350BRAZILE-mail: josecarlos@rosaodontologia.com.br

Copyright ª 2014 by the Editorial Council forThe Journal of Prosthetic Dentistry.

Rosa et al