Soft Tissues and Pink Esthetics in Implant Therapy [1 ed.] 0867158158, 9780867158151

Table of contents :
Soft Tissues & Pink Esthetics in Implant Therapy
Frontmatter
Dedication
Library of Congress Cataloging-in-Publication Data
Contents
Forewords
Preface
Acknowledgments
Chapter One: Quality and Quantity of Peri-implant Soft Tissue
1. What is the biologic significance of peri-implant softtissue?
2. How does soft tissue heal around an implant?
3. What are the histologic characteristics of peri-implantsoft tissues?
4. What are the main differences between a natural toothand an implant at the supracrestal level?
5. Is biologic width present around implants?
6. What are the clinical implications of forming biologic width around implants?
7. What is meant by platform switching and what is its biologic significance?
8. What are the dynamics of soft tissue healing around immediate implants?
9. What is the role of keratinized tissues around implants?
References
Recommended Reading
Chapter Two: Spontaneous Healing of the Socket After Extraction and Alveolar Ridge Remodeling
1. What are the dynamics of socket healing after extraction?
2. Why does the ridge undergo extra-alveolar remodeling after extraction?
3. Can alveolar ridge remodeling after extraction influence implant placement?
4. Can the extraction technique influence site healing after extraction?
References
Recommended Reading
Chapter Three: Decision-Making Criteriain Socket Management After Extraction
1. How are extraction sites classified?
2. What are the main therapeutic options when treating a postextraction socket?
3. What are the indications, advantages, and limitations of immediate implant placement after extraction?
4. What are the indications, advantages, and limitations of delaying implant placement after extraction?
5. What are the indications, advantages, and limitations of ridge preservation techniques?
6. What are the indications, advantages, and limitations of ridge augmentation techniques?
7. What are the final recommendations for treating a socket after extraction?
References
Chapter Four: Immediate Postextraction Implant Placement
1. What are the key surgical factors in immediate postextraction implant placement?
2. When is immediate prosthetic restoration following immediate postextraction implant placement advisable?
3. When is soft tissue augmentation of an immediate postextraction implant site advisable?
4. Is immediate postextraction implant placement possible in a molar site?
5. What is the required waiting period before definitive prosthetic restoration of an implant placed immediate lypostextraction?
References
Recommended Reading
Chapter Five: Alveolar Ridge Preservation and Augmentation
1. What are the criteria for choosing between ridge preservation and ridge augmentation techniques?
2. What is the biologic rationale for ridge preservation?
3. What are the key surgical factors in ridge preservation?
4. Can ridge preservation be used in maxillary molar sites?
5. Are ridge preservation techniques supported by the scientific literature?
6. What are the key surgical factors in ridge augmentation?
7. What are the healing times for subsequent implant placement after ridge preservation and ridge augmentation?
Clinical Case Studies
References
Recommended Reading
Chapter Six: Periodontal Plastic Surgery to Optimize Soft Tissues at Peri-implant Sites
1. What is meant by gingival recession?
2. What are the main etiologic factors in the development of gingival recession?
3. Apart from the main causal factors, what predisposingfactors have been identified for gingival recession?
4. What are the therapeutic options for treating gingival recession?
5. Is it possible to predict the potential outcome of root coverage using periodontal plastic surgery techniques?
6. What are the main periodontal plastic surgery procedures?
7. What techniques are used to harvest gingival tissue during periodontal plastic surgery?
8. Can biomaterials be used to replace connective tissue?
9. Given current scientific findings and the techniques described previously, what treatment guidelines can be suggested for different recession types?
References
Recommended Reading
Chapter Seven: Peri-implant Keratinized Tissue Augmentation
1. What is the role of keratinized tissues around implants?
2. Can keratinized tissue be preserved?
3. What surgical techniques are used to reconstruct keratinized tissue around implants?
4. What is the timing of keratinized tissue augmentation techniques?
Clinical Case Studies
References
Chapter Eight: Esthetic Augmentation of Peri-implant Soft Tissue
1. What is meant by esthetic augmentation of peri-implantsoft tissue?
2. What are the indications for soft tissue augmentation inthe esthetic zone?
3. What is the timing of esthetic soft tissue augmentation?
4. Do peri-implant soft tissue augmentation techniques offer predictable outcomes?
5. What are the main soft tissue harvesting sites andtechniques?
6. Are there biomaterials that can mimic the behavior of autogenous connective tissue?
Clinical Case Studies
References
Chapter Nine: Peri-implant Soft Tissue Conditioning Using Restorations
1. What is meant by peri-implant soft tissue conditioning using restorations?
2. What are the main soft tissue conditioning techniques, and what is the time frame for using them?
3. How can the conditioned tissue architecture be transferred to the dental laboratory?
Clinical Case Studies
References
Chapter Ten: Orthodontic Development for Implant Sites
1. What are the characteristics of orthodontic movement, and what is its role in multidisciplinary treatment plans?
2. In what clinical situations and time frames canorthodontic therapy be used to develop an implant site?
3. What are the options for managing tooth agenesis in the esthetic zone?
Clinical Case Studies
Reference
Recommended Reading
Chapter Eleven: Treatment of Esthetic Failures in Implant Dentistry
1. What is meant by esthetic failure in implant dentistry?
2. Why should esthetic failures be considered a serious complication of implant dentistry?
3. What are the most common causes of esthetic failure in implant dentistry?
4. What is important to assess when choosing a strategy for treating esthetic failures?
5. What are the main techniques for treating esthetic failures?
6. Which cases cannot be re-treated or offer expectations of only partial success?
Clinical Case Studies
References
About the Authors

Citation preview

Cardaropoli Casentini

About the Authors

Soft Tissues & Pink Esthetics

Paolo Casentini, dds, earned his degree in dentistry from the University of Milan and subsequently attended the oral surgery and implantology program at San Paolo University Centre in Milan. He currently maintains a private practice in Milan, with a particular interest in regenerative surgery and esthetic treatment. Dr Casentini is the author of numerous journal articles in the fields of implantology and regenerative surgery as well as the online education channel. He is also the co-author of nine books on oral surgery, implant surgery and prosthetics, and advanced implantology. He has lectured in more than 40 countries and is a fellow and president of the Italian Section of the International Team for Implantology (ITI), director of the ITI Milan 1 Study Group, and an active member of the IAO and the SIdP.

Paolo Casentini,

in Implant Therapy

Daniele Cardaropoli, dds, graduated with honors with a degree in dentistry and dental prosthetics and subsequently pursued postgraduate studies in periodontology at the University of Turin. He obtained postgraduate diplomas in periodontology and implantology from the Harvard School of Dental Medicine and in biomechanics from the University of Siena in Italy. In addition to his private practice in Turin, Dr Cardaropoli is the scientific director of the Institute for Professional Education in Dentistry (ProEd) and head of oral implantology at the Sedes Sapientiae Clinic. He is a member of the editorial board of The International Journal of Periodontics & Restorative Dentistry and a reviewer for several journals. Dr Cardaropoli lectures widely and is also the author of numerous publications. He is the recipient of both the Henry M. Goldman Prize for clinical research from the Italian Society of Periodontology and Implantology (SIdP) as well as the Italian Society of Orthodontics (SIDO) National Award in Clinical Orthodontics. Dr Cardaropoli is an active member of the SIdP, the European Federation of Periodontology (EFP), the Italian Academy of Osseointegration (IAO), and the Academy of Osseointegration (AO) and an international member of the American Academy of Periodontology (AAP).

Daniele Cardaropoli,

DDS

DDS

Soft Tissues & Pink Esthetics

in Implant Therapy

ISBN 978-0-86715-815-1

90000>

9 780867 158151

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Soft Tissues and Pink Esthetics in Implant Therapy

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Soft Tissues & Pink Esthetics

in Implant Therapy Daniele Cardaropoli, dds Scientific Director Institute for Professional Education in Dentistry Private Practice Turin, Italy

Paolo Casentini, dds Lecturer Postgraduate Oral Surgery and Implantology University of Milan Private Practice Milan, Italy

Berlin, Barcelona, Chicago, Istanbul, London, Mexico City, Milan, Moscow, Paris, Prague, São Paulo, Seoul, Tokyo, Warsaw

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This book is dedicated to the memory of Giuseppe Cardaropoli: a brother, friend, and colleague; a person who always believed in the importance of scientific research; and an author whose publications are an international benchmark in the implant literature.

First published as Testo Atlante: Parodontologia e Terapia Implantare in Italian in 2017 by Quintessenza Edizioni Srl in Milan, Italy.

Library of Congress Cataloging-in-Publication Data Names: Cardaropoli, Daniele, author. | Casentini, Paolo, author. Title: Soft tissues and pink esthetics in implant therapy / Daniele Cardaropoli, Paolo Casentini. Description: Batavia, IL : Quintessence Publishing Co., Inc., [2019] | Includes bibliographical references and index. | Summary: “Illustrates the surgical techniques to preserve peri-implant soft tissues during implant therapy”-- Provided by publisher. Identifiers: LCCN 2019020501 | ISBN 9780867158151 (hardcover) Subjects: MESH: Dental Implantation--methods | Esthetics, Dental | Gingiva | Gingivoplasty--methods Classification: LCC RK667.I45 | NLM WU 640 | DDC 617.6/93--dc23 LC record available at https://lccn.loc.gov/2019020501

© 2020 Quintessence Publishing Co, Inc Quintessence Publishing Co Inc 411 N Raddant Road Batavia, IL 60510 www.quintpub.com 5 4 3 2 1  ll rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any A form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher. Editor: Bryn Grisham Design: Sue Zubek Production: Sarah Minor Printed in China

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Contents Forewords xi Preface xii Acknowledgments

xiii

1

Quality and Quantity of Peri-implant Soft Tissue 1 1. What is the biologic significance of peri-implant soft tissue? 2. How does soft tissue heal around an implant? 3. What are the histologic characteristics of peri-implant soft tissues? 4. What are the main differences between a natural tooth and an implant at the supracrestal level? 5. Is biologic width present around implants? 6. What are the clinical implications of forming biologic width around implants? 7. What is meant by platform switching and what is its biologic significance? 8. What are the dynamics of soft tissue healing around immediate implants? 9. What is the role of keratinized tissues around implants?

2

Spontaneous Healing of the Socket After Extraction and Alveolar Ridge Remodeling 29 1. What are the dynamics of socket healing after extraction? 2. Why does the ridge undergo extra-alveolar remodeling after extraction? 3. Can alveolar ridge remodeling after extraction influence implant placement? 4. Can the extraction technique influence site healing after extraction?

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Decision-Making Criteria in Socket Management After Extraction 57 1. How are extraction sites classified? 2. What are the main therapeutic options when treating a postextraction socket? 3. What are the indications, advantages, and limitations of immediate implant placement after extraction? 4. What are the indications, advantages, and limitations of delaying implant placement after extraction? 5. What are the indications, advantages, and limitations of ridge preservation techniques? 6. What are the indications, advantages, and limitations of ridge augmentation techniques? 7. What are the final recommendations for treating a socket after extraction?

4

Immediate Postextraction Implant Placement 83 1. What are the key surgical factors in immediate postextraction implant placement? 2. When is immediate prosthetic restoration following immediate postextraction implant placement advisable? 3. When is soft tissue augmentation of an immediate postextraction implant site advisable? 4. Is immediate postextraction implant placement possible in a molar site? 5. What is the required waiting period before definitive prosthetic restoration of an implant placed immediately postextraction? Clinical Case Studies

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Alveolar Ridge Preservation and Augmentation 135 1. What are the criteria for choosing between ridge preservation and ridge augmentation techniques? 2. What is the biologic rationale for ridge preservation? 3. What are the key surgical factors in ridge preservation? 4. Can ridge preservation be used in maxillary molar sites? 5. Are ridge preservation techniques supported by the scientific literature? 6. What are the key surgical factors in ridge augmentation? 7. What are the healing times for subsequent implant placement after ridge preservation and ridge augmentation? Clinical Case Studies

6

Periodontal Plastic Surgery to Optimize Soft Tissues at Peri-implant Sites 193 1. What is meant by gingival recession? 2. What are the main etiologic factors in the development of gingival recession? 3. Apart from the main causal factors, what predisposing factors have been identified for gingival recession? 4. What are the therapeutic options for treating gingival recession? 5. Is it possible to predict the potential outcome of root coverage using periodontal plastic surgery tehniques? 6. What are the main periodontal plastic surgery procedures? 7. What techniques are used to harvest gingival tissue during periodontal plastic surgery? 8. Can biomaterials be used to replace connective tissue? 9. Given current scientific findings and the techniques described previously, what treatment guidelines can be suggested for different recession types? Clinical Case Studies

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Peri-implant Keratinized Tissue Augmentation 253 1. What is the role of keratinized tissues around implants? 2. Can keratinized tissue be preserved? 3. What surgical techniques are used to reconstruct keratinized tissue around implants? 4. What is the timing of keratinized tissue augmentation techniques? Clinical Case Studies

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Esthetic Augmentation of Peri-implant Soft Tissue 285 1. What is meant by esthetic augmentation of peri-implant soft tissue? 2. What are the indications for soft tissue augmentation in the esthetic zone? 3. What is the timing of esthetic soft tissue augmentation? 4. Do peri-implant soft tissue augmentation techniques offer predictable outcomes? 5. What are the main soft tissue harvesting sites and techniques? 6. Are there biomaterials that can mimic the behavior of autogenous connective tissue? Clinical Case Studies

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Peri-implant Soft Tissue Conditioning Using Restorations 343 1. What is meant by peri-implant soft tissue conditioning using restorations? 2. What are the main soft tissue conditioning techniques, and what is the time frame for using them? 3. How can the conditioned tissue architecture be transferred to the dental laboratory? Clinical Case Studies

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Orthodontic Development for Implant Sites 397 1. What are the characteristics of orthodontic movement, and what is its role in multidisciplinary treatment plans? 2. In what clinical situations and time frames can orthodontic therapy be used to develop an implant site? 3. What are the options for managing tooth agenesis in the esthetic zone? Clinical Case Studies

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Treatment of Esthetic Failures in Implant Dentistry 453 1. What is meant by esthetic failure in implant dentistry? 2. Why should esthetic failures be considered a serious complication of implant dentistry? 3. What are the most common causes of esthetic failure in implant dentistry? 4. What is important to assess when choosing a strategy for treating esthetic failures? 5. What are the main techniques for treating esthetic failures? 6. Which cases cannot be re-treated or offer expectations of only partial success? Clinical Case Studies

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Forewords This work reflects the surgical and treatment procedures employed by two highly experienced clinicians. Each chapter provides readers with information on how and why to treat their patients in order to achieve and maintain an optimum esthetic outcome with implant therapy. The diagnosis and assessment of the quantity and quality of hard and soft tissues suitable for implant placement are discussed with particular attention to the expected outcome of therapy. Placement of implants immediately after extraction can be challenging because the socket healing process is always critical. In such situations, it is crucial to assess buccal cortical bone integrity and soft tissue thickness and consider alternative options if acute infections are present. Other considerations include the use of a grafting technique to fill the gap between bone and implant and the choice of suitable biomaterials. When specifically indicated, socket preservation techniques can be applied at the same time. This means selecting the most appropriate biomaterials, barrier membranes, and surgical techniques. In addition, soft tissue augmentation procedures are crucial when deficiencies have to be managed during implant placement to build up the site or when conditioning peri-implant tissue to receive a prosthesis. On these specific topics, Dr Cardaropoli—whom I have known since he was a university student—has made a substantial contribution to the international literature, and his works are referred to throughout the book. This work is a must for anyone performing implant dentistry. The book offers a clear, multidisciplinary approach to dealing with implants in the esthetic zone and a thorough description of the procedures necessary for a successful long-term outcome. Every dental practice should make room on its bookshelves for this volume.

Myron Nevins, DDS Associate Professor Harvard School of Dental Medicine

I read this book with great interest and even some pride. I used to teach Dr Casentini, and he has achieved more in his career than any of my other students. After studying oral surgery under my guidance, he expanded his knowledge into periodontology, implant dentistry, and prosthetics. His approach is extremely constructive, and he has always combined intellectual curiosity with indubitable clinical skills and great natural talent. Last but not least, he is a remarkable teacher who is invited all over the world to share his knowledge. The subject of this book, peri-implant soft tissue management, is very topical and has grown considerably in recent years to become the main pillar of successful prosthetic rehabilitation using implants. Both authors are expert and creative clinicians who have contributed to the development of peri-implant soft tissue management techniques and built up 20 years of experience in the field. I was particularly struck by the book’s innovative structure: Each chapter is dedicated to a specific topic with an opening question-and-answer section that serves the twofold purpose of providing the scientific bases and answering clinicians’ frequently asked questions. A long series of lavishly illustrated case studies in the second part of each chapter explores the different clinical ramifications of the topic in question, showing various clinical situations in which readers will be able to identify cases that are similar to ones they have personally encountered. Some of the cases Dr Casentini discusses stem from our own partnership, which dates back more than 20 years, and I am happy to have been able to contribute our joint case histories to the book. Although I was his teacher, I am proud to say that he has been a source of ongoing professional enrichment for me and has expanded my dental outlook in the broadest sense. I am sure this book breaks new ground in terms of its structure and content. It is destined to continue providing clinicians with a very useful reference in the long term. I think it is indispensable reading for the modern dental practitioner, and I am certain that it will not disappoint its many readers. Matteo Chiapasco, DDS, MD Professor, Head of Oral Surgery University of Milan Visiting Associate Professor Loma Linda University School of Dentistry

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Preface Why a guide to soft tissues and pink esthetics in implant therapy? Osseointegration, ie, direct contact between the implant and surrounding bone tissue, must still be considered a basic requirement of implant therapy but is no longer the only objective to be achieved in oral implantology. Today, optimal integration of the prosthetic restoration with the surrounding soft tissues must be considered a main criterion for successful implant treatment. “Pink esthetics” has become the holy grail of modern implant therapy. Once

sufficient hard tissue volume has been built up, a series of techniques must be implemented to maintain, augment, condition, and replicate the soft tissues that will surround the future implant-supported restorations. Only in this way will it be possible to achieve satisfactory esthetic integration of hard issues with their surrounding soft tissues, ie, crowns that look like natural teeth and are not immediately recognizable as crowns on implants.

Why a book with questions, answers, and clinical case studies? Over many years of training, during innumerable courses and lectures, we realized that the most important part of contemporary teaching is responding to our colleagues’ questions and needs and explaining treatment strategies by presenting clinical case examples. This book, which can be considered a distillation of 20 years of clinical and teaching experience, is based on this principle. Each chapter begins with strategically chosen frequently asked questions and their answers, providing a framework for the topic covered, describing current scientific findings, and setting out guidelines for a given technique. The next section offers step-by-step analysis of clinical cases, providing detailed examples of surgical techniques applied to specific treatment options. When selecting clinical cases, we tried to represent the different ramifications of a topic, explaining the surgical and prosthetic procedures applied to a wide range of different therapeutic needs. The range of clinical situations explored is sufficiently broad to allow readers to identify clinical cases similar to those they deal with routinely. Our clinical activities have continued along parallel tracks for many years and find a natural

meeting point in our common quest for the best therapeutic option, always making the patient the focus of our decision making. Each of us contributed our own personal clinical and professional experiences to the text, but they are framed by a common working philosophy designed to enhance the reader’s learning experience. We are sure that the systematic organization of the topics covered, the wealth of photographs, and the clear descriptions will help generate a general picture and be a useful training tool for our colleagues. We hope we will see more clinical cases treated in a predictable manner. The true value of our professional lives is not reflected by a single action, whose success can depend on chance, but by the sum of all our actions. Randomness and chance are not equal to routine practice. It is wrong to claim success based on a chance positive result, because predictability means knowing how to achieve that result systematically. The only way to do this is to know exactly how and why this result was achieved. Without evidence-based scientific and objective knowledge, we cannot formulate proper treatment plans and achieve optimal, stable results over time.

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Acknowledgments First and foremost, my sincere thanks go to my wife, Lorena. She is my life partner; without her advice, support, and understanding, I would not be what I am or be able to do what I do. Thank you to my children, Luca and Alessia. They are my life and my strength. Special thanks to my parents—Annamaria and Tito. I am grateful for the way they brought me up and what they taught me and passed on to me: honesty and fairness, first and foremost. Thank you to my grandparents. They are my roots. They have passed on, but I am sure that they are watching me from above. Thank you to all the practice staff: Linda, Francesca, Melissa, and Sonia. I am bound to thank my mentor, Ron Nevins, who has always been a point of reference and source of inspiration. He is an unparalleled clinician and researcher. Thanks to all the friends and colleagues who have supported and appreciated my teaching activities over the years. They are the reason for my ongoing quest for improvement. Thanks to the Dentalanze dental laboratory in Castagnole delle Lanze, Italy. Unless otherwise specified, the cases I treated surgically were managed on an interdisciplinary basis by the PRoEd—Institute for Professional Education in Dentistry—team, and I would like to thank them all: Drs Alessandro Roffredo, Lorenzo Tamagnone, Andrea De Maria, Lorena Gaveglio, and Monica Ravera.

First of all, I would like to thank my family—my wife, Irene, and my children, Zeno and Sveva—for the great support they give me every day. I inevitably stole time from them to write this book, and I hope they will understand. Thank you to my father, Augusto Casentini, and my mother, Silvana De Luca: parents, colleagues, and teachers by profession and above all by their professional ethics. Thank you for teaching me to strive to do my best for my patients every day. Thanks to Nicolò Gruden, who is practically my second father and a very experienced clinician. Heartfelt thanks to my teacher, Matteo Chiapasco, the most experienced, sophisticated, and creative surgeon that I’ve ever met and one of the most cultured people I have had the good fortune to know. Thank you for our fruitful partnership and for igniting my passion for teaching. Thanks to Claudio Gatti for launching me as a speaker nearly 25 years ago. Thanks to the team at my practice and the Narcodont Centre, who help me pursue excellence every day; thanks in particular to Nicola Balduzzi, Fabio Quarta, and Luca Pizzoni, who are fantastic colleagues and friends. Thanks to my dental technician friends for everything they have taught me and for the outstanding results we have achieved together over the years. A special mention to all the colleagues and dental technicians who contributed to each case in the case study section: warm thanks for all your hard work!

Daniele Cardaropoli Paolo Casentini

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We are what we repeatedly do. Excellence, then, is not an act, but a habit. Aristotle

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one Quality and Quantity of Peri-implant Soft Tissue

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Questions: 1. What is the biologic significance of peri-implant soft tissue? 2. How does soft tissue heal around an implant? 3. What are the histologic characteristics of peri-implant soft tissues? 4. What are the main differences between a natural tooth and an implant at the supracrestal level? 5. Is biologic width present around implants? 6. What are the clinical implications of forming biologic width around implants? 7. What is meant by platform switching and what is its biologic significance? 8. What are the dynamics of soft tissue healing around immediate implants? 9. What is the role of keratinized tissues around implants?

1

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What is the biologic significance of peri-implant soft tissue?

The creation of a soft tissue barrier around a dental implant at the point where it emerges into the oral cavity is an important stage in the process of rendering the implant functional and ensuring the esthetic integration of the implantsupported prosthetic restoration (Fig 1-1). Maintaining this

seal in a condition of health is critical to the function and long-term prognosis of the implant. The ultimate purpose of the peri-implant soft tissue seal is to protect the underlying bond between the implant and bone tissue created through the osseointegration process.

a

b

c

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Fig 1-1 Physiologic appearance of peri-implant soft tissues around different implant types. (a and b) Bone-level titanium implants. In these cases the depth of the peri-implant mucosal tunnel, ie, the distance from the gingival margin to the implant connection, is greater. (c) Tissue-level titanium implant. In these cases the peri-implant mucosal tunnel is more shallow. (d) Single-component zirconia implant. With tissue-level implants, the implant prosthetic platform is located closer to the surface in a juxtagingival or slightly subgingival position.

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How does soft tissue heal around an implant?

Formation of a transmucosal or peri-implant attachment begins with the implant placement for single-component implants (Fig 1-2). The epithelial cells at the margin of the surgical flap adapted to the implant or abutment neck proliferate and migrate to cover the underlying connective tissue and adhere to the implant or abutment surface, forming a

junctional epithelium. Apical migration of the epithelial cells ends at a band characterized by dense connective tissue and located immediately above the bone ridge, which also comes into contact with the implant surface (Fig 1-3). For two-piece implants, formation of the peri-implant attachment begins at surgical reopening and abutment attachment (Fig 1-4).

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How does soft tissue heal around an implant?

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Fig 1-2  (a to d) The peri-implant mucosal seal around transgingival or single-component implants begins to form immediately after implant insertion, when the soft tissues are adjusted to fit the smooth implant neck by means of sutures.

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Fig 1-3  Histologic evaluation of peri-implant hard and soft tissue healing in a dog model 12 weeks after insertion. (a) With submerged healing, the implant achieves secondary stability through the osseointegration process. The soft tissues above the implant, consisting of epithelium and connective tissue, completely cover the head of the fixture. (b) After reopening and abutment connection, the soft tissues adapt around the abutment and heal by creating a mucosal tunnel consisting of an epithelial attachment and connective tissue attachment up to the first contact between bone and implant. (Courtesy of Prof J. L. Calvo Guirado, Murcia, Spain.)

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one  Quality and Quantity of Peri-implant Soft Tissue

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Fig 1-4 (a to h) For two-component bone-level implants, submerged healing is used, and the inner implant cavity is initially sealed by means of a surgical screw. On reopening, transmucosal healing screws are then positioned. In these cases, a peri-implant soft tissue seal is therefore formed after the second surgical stage.

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What are the histologic characteristics of peri-implant soft tissues?

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What are the histologic characteristics of peri-implant soft tissues?

Various histologic studies on animal and human models1–7 have allowed detailed description of the interface between soft tissues and titanium implants. This is characterized by: • Junctional epithelium: Epithelial cells adhere to the implant surface through a basal lamina less than 200 nm thick through the formation of hemidesmosomes, as occurs with natural teeth. The apicocoronal extension of the junctional epithelium is 2 mm on average. Histologic examination of human biopsies has often detected the presence of an inflammatory infiltrate dominated by T lymphocytes below the junctional epithelium,8,9 although in the absence of clinical signs of soft tissue inflammation and bone resorption. The composition of this inflammatory infiltrate, which acts as a physiologic barrier against external antigenic stimuli, is very similar to that present in periodontal soft tissues in natural teeth.

a

• Supracrestal connective tissue: The supracrestal connective tissue, which is approximately 1.5 mm high, seems to be the most important component of the peri-implant seal. The formation of this connective tissue layer (50 to 100 µm in thickness) adhering to the implant surface, which is packed with collagen fibers, is poorly vascularized, contains hardly any cells, and has characteristics similar to those of scar tissue, limits the apical migration of the overlying epithelium. Unlike the tooth connective tissue attachment, where the connective tissue fibers mainly grow at right angles to the root surface so they can insert into the root cement, peri-implant connective tissue fibers usually run parallel to the implant surface and can adopt a circular pattern. In the remaining connective tissue portion (excluding the layer adhering to the implant), connective tissue fibers run in different directions, and the cellular and vascular components are higher (Fig 1-5).

b

Fig 1-5  Histologic evaluation in a beagle model at the interface between the implant and supracrestal soft tissues 6 weeks after implant placement. (a) The junctional epithelium extends from the sulcus in an apical direction, where it is delimited by the connective tissue attachment, which ends apically at the point of first contact between bone and implant (original magnification ×10). (b) Polarized light clearly shows the direction of the collagen fibers within the supracrestal connective tissue and at the point of connective tissue attachment (original magnification ×40). (Courtesy of Prof G. Cardaropoli, Turin, Italy.)

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What are the main differences between a natural tooth and an implant at the supracrestal level?

The soft tissues around implants and teeth is very similar and in both cases is more or less keratinized (depending on the presence or absence of keratinized gingiva). The subgingival interface between the soft tissues and the tooth or implant is represented by a junctional epithelium in the coronal component (approximately 2 mm wide) and supracrestal connective tissue in the apical direction (approximately 1 to 1.5 mm wide). In both cases, the connection with the junctional epithelium takes place through basal lamina and a layer of hemidesmosomes. In natural teeth, the apical limit of the junctional epithelium is the cementoenamel junction. In the soft tissue–implant interface, the epithelium stops about 1.5 mm short of the bone crest at the supracrestal connective tissue band. In natural teeth, the connective tissue fibers are predominantly horizontal and insert into the root cement (Fig 1-6). Because implants lack a periodontal ligament, connective tissue fibers appear to originate from the bone crest periosteum, and their growth pattern is parallel to the implant surface. In the supracrestal area, the connective tissue seems

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to adhere closely to the thin layer of titanium oxide covering the implant surface. Connective tissue fibers growing with a circular pattern around the implant have been identified. Peri-implant supracrestal connective tissue is richer in collagen fibers, but its cell population (fibroblasts) and vascularization are lower than those of natural teeth, having the properties of scar tissue. Any fibroblasts at this level perform the function of maintaining and, if necessary, restoring cohesion between the connective tissue and implant surface. The lower vascularization of the implant connective tissue is explained by the fact that the natural teeth have a twofold source of vascularization, from the supraperiosteal vessels and the periodontal ligament vascular plexus, while the latter source is not present in implants. The connective tissue attachment and supracrestal connective tissue both perform a barrier function in natural teeth and implants. The early response to a buildup of bacterial plaque, ie, the composition of the inflammatory infiltrate and the type of lesions from a histologic viewpoint, is entirely similar in periodontal and peri-implant soft tissues (Fig 1-7).

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Fig 1-6  Illustrations of supracrestal tissues around a natural tooth (a) and a titanium implant (b).

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Is biologic width present around implants?

In natural teeth, the supracrestal soft tissues perform the function of protecting the periodontium (made up of root cementum, periodontal ligament, and alveolar bone) from external attack. From an anatomical viewpoint, supracrestal tissues consist of the sulcular epithelium, junctional epithelium, and connective tissue attachment. Together, the junctional epithelium and connective tissue attachment make up the biologic width, which tends to have constant dimensions. There is evidence of the presence of soft tissue biologic width around osseointegrated implants (Figs 1-8 and 1-9). The average biologic width is approximately 3.0 to 3.5 mm, of which 2 mm is the junctional epithelium and about 1.0 to 1.5 mm is supracrestal connective tissue. In an experimental animal model6 it has been shown that if supracrestal soft tissue thickness is reduced to less than 3 mm, the healing process will still tend to re-create a biologic width of 3 mm,

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which in this case will involve some bone ridge resorption, with the formation of an angular bony defect near the implant platform. Formation of this soft tissue band will subsequently protect the underlying bond between the implant and bone tissue, which is known as osseointegration. Whether the implant positioning involves one or two surgical stages does not seem to affect biologic width.10,11 The type of implant system used (ie, two component, bone level versus single component, tissue level) does not appear to have any impact either.12 It can therefore be concluded that, as with the interface between soft tissues and natural teeth, a biologic width has been identified around implants (Fig 1-10). It measures approximately 3 mm and tends to be re-created by reduction of the bone ridge if the soft tissue height is insufficient.

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Fig 1-7 Histologic appearance of periodontal tissues around a natural tooth (a) and peri-implant soft tissues around a transmucosal singlecomponent implant (b). (Courtesy of Prof F. Schwarz, Frankfurt, Germany.)

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Fig 1-8  Biologic width is absent when the implant is still submerged (a), forming after connection of the prosthetic components and loading (b).

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Fig 1-9 Histologic image of peri-implant soft tissues contributing to biologic width formation. The image shows oral epithelium (A), sulcular epithelium (B), epithelial attachment (C), and connective tissue attachment in the supracrestal portion (D). (Courtesy of Prof G. Cardaropoli, Turin, Italy.)

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Is biologic width present around implants?

clinical case 1 Formation of a peri-implant mucosal seal around an implant positioned using a single-stage protocol

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Fig 1-10  (a) A titanium implant is inserted at bone level in a mandibular first molar site by detaching a full-thickness flap. (b) A healing abutment is immediately screwed onto the implant head, and the soft tissues are fitted and sutured around it. (c) An intraoral radiograph shows the correct implant position in relation to the marginal bone level. (d) Twelve weeks later, after osseointegration, a newly created peri-implant mucosal seal is evident after removing the healing abutment. (e) Enlarged image of the peri-implant mucosal tunnel shows that these tissues are perfectly healthy, without any sign of superficial inflammation or bleeding. (f) Follow-up photograph 5 years after loading. Osseointegration of the implant and mucosal seal quality help to maintain the peri-implant tissues in perfect health with a sufficiently thick band of keratinized gingiva. (g) A radiograph taken 5 years after loading shows the stability of the marginal bone level.

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What are the clinical implications of forming biologic width around implants?

The need for a peri-implant soft tissue seal with predominantly consistent dimensions obviously has clinical implications. Limited initial soft tissue thickness correlates to greater marginal bone loss around the coronal aspect of the implant, which could represent a potential risk for the subsequent development of peri-implant problems. A controlled clinical study on humans13 confirmed results found in animal models: when peri-implant soft tissue thickness is limited, ie, less than 2 mm, peri-implant bone resorption is greater (1.38 mm) than that recorded when initial soft tissue thickness is greater (0.25 mm). A subsequent clinical study conducted by the same authors14 to assess the behavior of bone-level implants inserted in posterior mandibular sectors

using a single-stage protocol examined the possibility of preventing bone resorption in the presence of thin tissues by inserting an allogeneic dermal membrane to increase tissue thickness. Peri-implant bone resorption was similar around implants with thick tissues and those with initially thin soft tissues (< 2 mm) increased by the insertion of an allogeneic dermal membrane. If the initially thin tissues (< 2 mm) were not increased, greater initial bone resorption was recorded. Therefore, the clinical recommendation is to increase the thickness of peri-implant soft tissues surgically if they are initially thin.15 Soft tissue thickness can be increased by an autologous connective tissue graft or the use of biomaterials such as collagen matrices (Figs 1-11 to 1-14).

Fig 1-11  Initial soft tissue thickness can be easily assessed using a periodontal probe marked in millimeters after detaching a full-thickness buccal access flap.

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Fig 1-12  (a) An edentulous area around the mandibular first molar has an atrophic ridge with thin gingival tissue. (b and c) An osseointegrated implant is placed, and a porcine collagen matrix (Fibro-Gide, Geistlich) is grafted to increase gingival thickness. (d) The gingival tissue is then sutured around the healing abutment. (e) Three months later, the implant is osseointegrated and the soft tissues have matured. (f) Removal of the healing abutment reveals a healthy transmucosal tunnel of well over 2 mm, without signs of inflammation and ready for impression procedures.

clinical case 2 Soft tissue augmentation simultaneous with implant placement in a guided bone regeneration site. At sites that have undergone previous bone augmentation, soft tissues may be thinner as they have been stretched to cover the reconstructed area.

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Fig 1-13  (a and b) In this case, in which an implant was being inserted in an area that had previously undergone guided bone regeneration, measurement of soft tissues after crestal incision showed reduced thickness (approximately 2 mm).

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clinical case 2 (cont)

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g Fig 1-13  (cont) (c to f) Once the implant was placed, soft tissue thickness was increased by means of a connective tissue graft that was harvested from the palate, de-epithelialized, and fixed to the site by trailing suspended sutures. (g) Passive flap advancement for complete graft coverage. (Surgery by Dr P. Casentini.)

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clinical case 3 Soft tissue augmentation using a 3D collagen matrix simultaneous with implant placement

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Fig 1-14  (a) Edentulous mandibular left first molar site with ridge atrophy coinciding with a soft tissue deficiency. The treatment plan involves insertion of a single implant. (b) After lifting a full-thickness flap, the implant site is prepared for insertion of a 4.8-mm-diameter, 12-mm-long tapered implant (SLActive Bone Level Tapered, Straumann). (c to e) After implant placement, a distobuccal peri-implant bone defect remains, which is managed with the use of a biomaterial with added collagen (Bio-Oss Collagen, Geistlich) and a resorbable membrane (Bio-Gide, Geistlich). (f) A 6-mm-thick porcine collagen matrix (Fibro-Gide, Geistlich) is selected to augment the supracrestal soft tissue thickness. (g and h) The matrix is trimmed to fit the site anatomy while maintaining the original thickness. The matrix absorbs the blood from the surgical site within a few seconds. The process of soft tissue regeneration begins as soon as the clot is stabilized.

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clinical case 3 (cont)

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Fig 1-14  (cont) (i) The flap is advanced passively over the matrix in order to obtain healing by first intention and closed using a combination of horizontal mattress and simple interrupted sutures. (j) Radiograph taken at the end of stage-one surgery. (k to n) Clinical images after 1, 2, 4, and 8 weeks, respectively, showing good progression of wound healing with maintenance of the augmented volume. (o) After 3 months, stage-two surgery can be initiated. (p) After incision, the increased soft tissue thickness can be observed.

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clinical case 3 (cont)

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Fig 1-14 (cont) (q and r) A healing cap is placed on the implant to allow tissue healing and the creation of biologic width. (s and t) Six weeks later, the mucosal tunnel is thick and healthy, measuring 4 mm in height. It creates a seal around the implant and limits marginal bone remodeling. (u) Follow-up clinical image showing formation of a stable mucosal tunnel after the screw-retained ceramic crown has been placed. (v) The radiograph also reveals stable marginal bone levels.

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What is meant by platform switching and what is its biologic significance?

Another potential factor in peri-implant bone remodeling that occurs at an early stage, in addition to adequate biologic width, is the presence of a microgap between the implant and prosthetic abutment in two-component implants. Some authors have demonstrated the presence of predominantly anaerobic bacteria (cocci and a smaller percentage of rods) in two-component systems and the consequent presence of an inflammatory infiltrate in the microgap. This gives rise to vertical bone remodeling up to the level of the first implant thread16,17 (Fig 1-15). The problem is significantly reduced by using the platformswitching technique18–20: Abutments of a smaller diameter than the implant platform are used to create a bone-level

implant-abutment junction that is shifted inward (Fig 1-16). The change in the horizontal relationship between the external border of the implant and the prosthetic abutment creates a dimensional mismatch that moves the cellular inflammatory infiltrate away from the crestal bone because the microgap is no longer located on the external implant profile. This significantly reduces physiologic peri-implant bone remodeling after abutment or healing screw connection (Figs 1-17 to 1-23). However, the mechanism of preserving crestal bone through platform switching does not seem to work when the tissues are very thin21; the need to have sufficient biologic width therefore seems to play a predominant role.

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Fig 1-15  Sequence of radiographs showing the way that peri-implant bone remodeling typically evolves with a two-component or bone-level implant after transmucosal component connection. Bone remodeling, absent when the implant is submerged and a screw cap is present (a), begins after connection of the healing screw (b) and stabilizes at the first implant thread after connection of the implant abutment (c) and definitive prosthetic loading (d).

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What is meant by platform switching and what is its biologic significance?

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Fig 1-16  (a) Connection between implant and abutment according to the concept of platform switching. Scanning electron microscope image of (b) a standard implant-abutment connection and (c) a connection made by means of platform switching.

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Fig 1-17 (a) Standard implant-abutment connection: The presence of a microgap, and thus an inflammatory infiltrate, gives rise to marginal bone remodeling. (b) Implant-abutment connection according to the concept of platform switching: Inward horizontal displacement of the microgap prevents marginal bone remodeling.

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Fig 1-18  Six-month radiographic and histologic follow-up assessment of an implant positioned in human bone using platform switching. The implant threads show close contact with the surrounding bone, indicating a successful osseointegration. (a) The microcomputed tomography image shows a good level of bone-implant contact. (b and c) Histologic evaluation reveals the absence of apical migration of the junctional epithelium around the implant threads. The bone-implant contact consists of a combination of newly formed bone and native bone. The buccal and lingual bone levels match the original platform position at the time of insertion, without subsequent resorption. (Courtesy of Dr M. Nevins, Boston, Massachusetts.)

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Fig 1-19  Eighteen-week follow-up assessment of two implants positioned in a dog mandible using platform switching. (a) Radiographic view. (b) The histologic images reveal circular collagen fibers at the level of the implant platform. Mature connective tissue and vessels can be observed near the titanium surface. The collagen fibers grow at right angles, emerging from the peripheral soft tissue area. This set of radial fibers changes course near the implant surface and grows in a circular pattern to create continuity. (c) The polarized light image shows the presence of fibers above the interimplant bone septum. These fibers seem to connect the two adjacent titanium surfaces. (Courtesy of Prof X. Rodriguez, Barcelona, Spain.)

Fig 1-20  (a and b) Clinical and radiographic images of a maxillary central incisor implant prosthetically treated by means of a zirconia abutment with a platform-switched connection. Note that the peri-implant bone level has been maintained.

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Fig 1-21  (a and b) Comparison between postoperative radiograph and follow-up radiograph taken 5 years after prosthetic loading with use of the platform-switching concept, revealing the absence of peri-implant bone resorption.

clinical case 4 Platform switching: Stability of the mucosal seal and peri-implant bone level in the esthetic zone 5 years after prosthetic loading

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Fig 1-22  (a to c) Six months after extraction and simultaneous ridge preservation procedures (see chapter 5), an implant (bone-level 3.3 × 10 mm, Straumann) is inserted in the maxillary right central incisor site using a prosthetically guided technique.

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clinical case 4 (cont)

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g Fig 1-22  (cont) (d to f) Peri-implant bone volume is further augmented by means of guided bone regeneration using autologous bone mixed with deproteinized bovine bone (Bio-Oss) and a collagen membrane (Bio-Gide). (g and h) After conditioning with a screw-retained provisional crown, the peri-implant soft tissues are ready for placement of the definitive restoration. Buccal and occlusal views reveal favorable tissue architecture and the complete absence of inflammation. This soft tissue seal performs the task of protecting the underlying implant-bone connection without any inflammation. (i and j) Clinical and radiographic images after placement of the definitive crown.

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What is meant by platform switching and what is its biologic significance?

clinical case 4 (cont)

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Fig 1-22 (cont) (k to m) Clinical and radiographic images after 5 years. The precise, stable implant-crown connection achieved through platform switching made it possible to maintain a stable peri-implant bone level. The stability of the soft tissue seal and profile can also be appreciated. (n and o) The ultimate goal of any prosthetic rehabilitation using implants must always be favorable integration of the implant-supported restoration with the surrounding tissues, smile, and the patient’s facial appearance. (Implant surgery and prosthetic rehabilitation by Dr P. Casentini; prostheses by Mr A. Schoenenberger.)

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clinical case 5 Platform switching: Stability of peri-implant mucosal seal and bone level 10 years after prosthetic loading in the posterior mandible

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Fig 1-23  Clinical (a) and radiographic (b) views of an edentulous mandibular right first molar site. Following the lifting of a full-thickness flap (c), a tapered titanium implant (Osseotite Certain Tapered, 5 × 13 mm, Zimmer Biomet) is inserted at the bone ridge level (d). (e and f) After inserting a screw cap, the implant is left to heal in a completely submerged position. (g) Three months after placement, when osseointegration is complete, the stage-two surgery commences with the raising of a full-thickness flap. (h) A healing abutment with a diameter (4 mm) smaller than that of the implant (5 mm) is screwed onto the implant head, applying the concept of platform switching.

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clinical case 5 (cont)

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Fig 1-23  (cont) (i) Six weeks later the soft tissues are healed, and a transfer impression can be taken of the newly created mucosal tunnel. (j) The implant undergoes prosthetic loading after inserting a 4-mm-diameter titanium abutment (GingiHue, Zimmer Biomet) and cementing a provisional resin crown. (k) A radiograph shows that the implant and abutment are out of horizontal alignment with the marginal bone level at the time of loading. (l) When the definitive ceramic crown is cemented in place, the peri-implant soft tissues are optimally shaped and show an acceptable band of keratinized tissue. (m) The radiograph shows the marginal bone level 1 year after loading. (n) Clinical image 5 years after loading, highlighting the health of the peri-implant soft tissues. (o) A radiograph taken 5 years after loading shows that the marginal bone level has moved in a coronal direction. (p) A radiograph taken 10 years after loading shows that platform switching has helped to gain bone. The marginal bone level has moved in a coronal direction to the level of the implant-abutment connection.

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What are the dynamics of soft tissue healing around immediate implants?

Immediately after extraction, soft tissue healing at the site inevitably leads to the formation of a mucosal barrier consisting of junctional epithelium and connective tissue attachment. This occurs regardless of whether implant placement is carried out using a flapless or a flap technique and whether the implant undergoes transmucosal healing through the use of a healing abutment or is treated using an immediate prosthetic loading technique. The structural and histologic characteristics of the original biologic width, intended to protect the natural tooth, undergo changes during the first

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few weeks following tooth extraction and implant placement.22 Four weeks after surgery, the keratinized oral epithelium is continuous with the junctional epithelium. The connective tissue apical to the epithelial cells has a dense network of collagen fibers with few vascular structures and inflammatory cells. In the innermost area, the connective tissue fibers are already lined up parallel to the implant axis. There is also nearly a total absence of blood vessels, making the tissue scarlike (Figs 1-24 and 1-25).

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Fig 1-24  (a) Maxillary premolar site prepared for implant placement immediately after extraction. (b) After implant placement, the bone-implant gap is filled with biomaterial and protected with a resorbable membrane. (c) A healing abutment is immediately screwed onto the implant head to achieve transgingival healing. (d and e) Healing of peri-implant soft tissues after 6 weeks, with re-establishment of biologic width.

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Fig 1-25  (a and b) Histologic evaluation of biologic width formation in implants positioned immediately after extraction in a beagle dog model. Eight weeks after transmucosal implant placement, the peri-implant mucosa is covered by a well-keratinized oral epithelium continuous with the long junctional epithelium and in contact with the abutment and the smooth portion of the implant collar. Connective tissue is interposed between the apical cells of the barrier epithelium and the bone ridge. It is free of inflammatory cells but rich in mesenchymal cells, with a collagen fiber network organized circularly around the implant. Collagen fibers close to the titanium surface tend to be aligned obliquely or parallel to the implant, while fibers located some distance away tend to be at right angles to the titanium surface. (Courtesy of Prof J. L. Calvo Guirado, Murcia, Spain.)

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What is the role of keratinized tissues around implants?

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What is the role of keratinized tissues around implants?

There is no absolute consensus in the scientific literature about the role played by keratinized tissue in maintaining healthy conditions in peri-implant tissues.23 Nevertheless, a growing number of clinical studies support the idea that a band of peri-implant keratinized tissue measuring at least 2 mm may promote healthy conditions and a favorable longterm outcome. In particular: • When a peri-implant keratinized tissue band is absent or measures < 2 mm, patients report discomfort during brushing, particularly for mandibular rehabilitations.24 • Under the same anatomical conditions (keratinized tissue < 2 mm), higher levels of plaque and bleeding on probing were recorded (Fig 1-26).

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• With no keratinized tissue, the peri-implant soft tissues showed a higher incidence of recession and biologic complications.25 • Implant sites with a band of keratinized tissue measuring less than 2 mm showed a higher incidence of periimplantitis.26 In general, it is therefore recommendable to achieve a band of keratinized tissue measuring at least 2 mm around the implants. Chapter 7 analyzes the different surgical techniques and time frames for increasing the peri-implant keratinized tissue band.

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Fig 1-26  (a to e) Pain on brushing and greater plaque buildup with bleeding on probing and a tendency toward recession were noted around the implant inserted in the mandibular right first premolar site, which lacked peri-implant keratinized tissue. An absence of keratinized tissue represents a risk factor for the development of peri-implant biologic complications.

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References 1. Schroeder A, van der Zypen E, Stich H, Sutter F. The reactions of bone, connective tissue, and epithelium to endosteal implants with titanium-sprayed surfaces. J Maxillofac Surg 1981;9:15–25. 2. Berglundh T, Lindhe J, Ericsson I, Marinello CP, Liljenberg B, Thomsen P. The soft tissue barrier at implant and teeth. Clin Oral Implants Res 1991;2(2):81–90. 3. Buser D, Weber HP, Donath K, Fiorellini JP, Paquette DW, Williams RC. Soft tissue reactions to nonsubmerged unloaded titanium implants in beagle dogs. J Periodontol 1992;63:225–235. 4. Albrektsson T, Eriksson AR, Friberg B, et al. Histologic investigation on 33 retrieved Nobelpharma implants. Clin Mater 1993;12:1–9. 5. Berglundh T, Lindhe J, Jonsson K, Ericsson I. The topography of the vascular systems in the periodontal and peri-implant tissues in the dog. J Clin Periodontol 1994;21:189–193. 6. Berglundh T, Lindhe J. Dimension of the peri-implant mucosa. Biological width revisited. J Clin Periodontol 1996;23:971–973. 7. Cochran DL, Hermann JS, Schenk RK, Higginbottom FL, Buser D. Biologic width around titanium implants. A histometric analysis of the implanto-gingival junction around unloaded and loaded nonsubmerged implants in the canine mandible. J Periodontol 1997;68:186– 198. 8. Adell R, Leckholm U, Rockler B, et al. Marginal tissue reactions at osseointegrated titanium fixtures (I). A 3-year longitudinal prospective study. Int J Oral Maxillofac Surg 1986;15:39–52. 9. Tonetti MS, Imboden M, Gerber L, Lang NP. Compartmentalization of inflammatory cell phenotypes in normal gingiva and peri-implant keratinized mucosa. J Clin Periodontol 1995;22:735–742. 10. Ericsson I, Nilner K, Klinge B, Glantz PO. Radiographical and histological characteristics of submerged and nonsubmerged titanium implants. An experimental study in the Labrador dog. Clin Oral Implants Res 1996;7:20–26. 11. Abrahamsson I, Berglundh T, Moon IS, Lindhe J. Peri-implant tissues at submerged and nonsubmerged titanium implants. J Clin Periodontol 1999;26:600–607. 12. Abrahamsson I, Berglundh T, Wennstrom J, Lindhe J. The periimplant hard and soft tissues at different implant systems. A comparative study in the dog. Clin Oral Implants Res 1996;7:212–219. 13. Linkevicius T, Apse P, Grybauskas S, Puisys A. The influence of soft tissue thickness on crestal bone changes around implants: A 1-year prospective controlled clinical trial. Int J Oral Maxillofac Implants 2009;24:712–719. 14. Puisys A, Linkevicius T. The influence of mucosal tissue thickening on crestal bone stability around bone-level implants. A prospective controlled clinical trial. Clin Oral Implants Res 2015;26:123–129.

15. Suarez-Lopez Del Amo F, Lin GH, Monje A, GalindoMoreno P, Wang HL. Influence of soft tissue thickness on peri-implant marginal bone loss: A systematic review and meta-analysis. J Periodontol 2016;87:690–699. 16. Ericsson I, Persson LG, Berglundh T, Marinello CP, Linde J, Klinge B. Different types of inflammatory reactions in peri-implant soft tissues. J Clin Periodontol 1995;22:255–261. 17. Persson LG, Lekholm U, Leonhardt A, Dahlen G, Lindhe J. Bacterial colonization on internal surfaces of Brånemark system implant components. Clin Oral Implants Res 1996;7:90–95. 18. Lazzara RJ, Porter SS. Platform switching: A new concept in implant dentistry for controlling postrestorative crestal bone levels. Int J Periodontics Restorative Dent 2006;26:9–17. 19. Al-Nsour MM, Chan HL, Wang HL. Effect of the platform-switching technique on preservation of peri-implant marginal bone: A systematic review. Int J Oral Maxillofac Implants 2012;27:138–145. 20. Atieh MA, Ibrahim HM, Atieh AH. Platform switching for marginal bone preservation around dental implants: A systematic review and meta-analysis. J Periodontol 2010;81:1350–1366. 21. Linkevicius T, Apse P, Grybauskas S, Puisys A. Influence of thin mucosal tissues on crestal bone stability around implants with platform switching: A 1-year pilot study. J Oral Maxillofac Surg 2010;68:2272–2277. 22. Negri B, López Marí M, Maté Sánchez de Val JE, Iezzi G, Bravo González LA, Calvo Guirado JL. Biological width formation to immediate implants placed at different level in relation to the crestal bone: An experimental study in dogs. Clin Oral Implants Res 2015;26:788–798. 23. Wennström JL, Derks J. Is there a need for keratinized mucosa around implants to maintain health and tissue stability? Clin Oral Implants Res 2012;23(suppl 6):136–146. 24. Souza AB, Tormena M, Matarazzo F, Araújo MG. The influence of peri-implant keratinized mucosa on brushing discomfort and periimplant tissue health. Clin Oral Implants Res 2016;27:650–655. 25. Roccuzzo M, Grasso G, Dalmasso P. Keratinized mucosa around implants in partially edentulous posterior mandible: 10-year results of a prospective comparative study. Clin Oral Implants Res 2016;27:491–496. 26. Canullo L, Peñarrocha-Oltra D, Covani U, Botticelli D, Serino G, Penarrocha M. Clinical and microbiological findings in patients with peri-implantitis: A cross-sectional study. Clin Oral Implants Res 2016;27:376–382.

Recommended Reading Calvo-Guirado JL, López-López PJ, Maté Sánchez de val JE, Mareque-Bueno J, Delgado-Ruiz RA, Romanos GE. Influence of collar design on peri-implant tissue healing around

immediate implants: A pilot study in Foxhound dogs. Clin Oral Implants Res 2015;26:851–857.

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Questions: 1. What are the dynamics of socket healing after extraction? 2. Why does the ridge undergo extra-alveolar remodeling after extraction? 3. Can alveolar ridge remodeling after extraction influence implant placement? 4. Can the extraction technique influence site healing after extraction?

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What are the dynamics of socket healing after extraction?

Socket healing after extraction comprises a series of biologic effects that have been widely documented by scientific research1–5 (Figs 2-1 to 2-3). Tooth extraction creates a wound in the socket that bleeds immediately and spontaneously. The first sequence of events in the healing mechanism is blood clot formation, stabilization, and maturation. The marginal portion of the clot is covered by a layer of inflammatory cells comprising mainly neutrophil granulocytes. The clot is principally made up of red blood cells and platelets incorporated in a fibrin network. Over the ensuing days, the clot is partially replaced by richly vascularized granulation tissue. Fibroblasts infiltrate the clot and deposit a temporary connective tissue matrix. Subsequently, an initial form of mineralized tissue made up of woven bone containing a particularly high

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number of cells is deposited. Later, this mineralized tissue fully matures to completely occupy the socket and create continuity with the preexisting bone lining the socket walls. This bone tissue contains a large number of primary osteons. Simultaneously, the marginal soft tissue compartment creates a well-organized fibrous connective tissue that is covered by keratinized epithelium. This marginal mucosal layer will then be separated from the underlying tissue by the creation of a hard tissue bridge, primarily formed of woven bone. Apical to this bone bridge, part of the woven bone will be replaced by bone marrow containing blood vessels, inflammatory cells, and adipocytes. Most of the socket will be made up of lamellar bone in the final stages of the healing process.6

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Fig 2-1  Histologic cross sections showing socket healing in an animal model (original magnification ×10). (a) Twenty-four hours after extraction. The socket is occupied by a blood clot containing a large number of red blood cells and platelets within a fibrin network. Inflammatory cells are present in the coronal marginal portion. The clot is in contact with the periodontal ligament at the peripheral edges of the socket. (b) Third day of healing. Note the neutrophils and macrophages engaged in cleaning the wound and breaking down the blood clot. Osteoclast activity can also be seen on the surface of the bone walls that delineated the socket. (c) Healing after 7 days. Highly vascularized early granulation tissue can be seen in the coronal part of the socket, and a large number of inflammatory response cells are present. The tissue present in the more apical areas includes fibroblast-like cells that make up late granulation tissue. Periodontal ligament cells have migrated into the clot. (d) Healing after 14 days. In marginal wound portions, a provisional connective tissue has formed that is rich in fibroblast-like cells. Woven bone formation has already begun in the most apical regions of the bony defect. (e) Healing after 30 days. The socket is filled with woven bone and contains a high number of cells and primary osteons. Lamellar bone can be seen forming around them. (Courtesy of Prof G. Cardaropoli, Turin, Italy.)

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What are the dynamics of socket healing after extraction?

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Fig 2-2  Histologic cross sections showing socket healing in humans. (a) Spontaneous socket healing 4 months after extraction, showing supracrestal soft tissue. An epithelial tissue layer covers the connective tissue layer, both of which are separate from the lamina propria. There are no inflammatory processes (original magnification ×50). (b) Spontaneous socket healing 4 months after extraction, showing hard tissue. Immature woven bone can be seen surrounding the mature lamellar bone, with abundant blood vessels and adipocytes (original magnification ×100). (c) Socket bone healing 4 months after extraction. Newly formed vital bone consisting of lamellar bone and woven bone is present together with a nonmineralized component with large marrow spaces, adipose cells, and blood vessels (original magnification ×200).

clinical case 1 Clinical dynamics of socket healing after extraction

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Fig 2-3 (a) Initial clinical presentation of a case requiring extraction of a maxillary second premolar for periodontal reasons. An atraumatic extraction is always recommended in order to interfere as little as possible with the physiologic healing processes. (b) A few seconds after tooth extraction, spontaneous bleeding occurs within the socket with activation of the platelet stage and subsequent completion of the coagulation cascade. (c) Clinical situation after 24 hours. Completion of the physiologic clotting process gives rise to formation of a fibrin clot that completely fills the socket. The stabilized clot forms an initial tissue frame for subsequent healing. Red blood cells and platelets are present within the fibrin network. These will release growth factors responsible for attracting the cells that will lay down new tissue. (d) Clinical situation after 1 week. The clot has been degraded through a process of fibrinolysis so that it can be replaced by a provisional connective tissue matrix. An initial soft tissue healing stage can be observed in the most coronal part of the socket, with re-epithelialization by second intention.

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clinical case 1 (cont)

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Fig 2-3  (cont) (e) Clinical situation after 2 weeks. Socket healing is progressing. The apical, central, and coronal parts are made up of osteoid tissue, which will subsequently be mineralized. The socket opening now consists of newly formed soft tissue undergoing the final stages of keratinization. (f) Situation after 6 weeks. The socket is filled with the first form of mineralized bone: woven bone. The socket opening is completely sealed off by a new keratinized epithelium. (g) Healing is complete after 16 weeks. The preexisting socket anatomy is no longer recognizable. A band of keratinized tissue fully covers the soft tissue portion coronal to the mucogingival line. (h) At 16 weeks, the bone ridge is visible following flap opening. The socket interior is completely filled with newly formed bone tissue. Note the formation of a cortical bone bridge.

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Why does the ridge undergo extra-alveolar remodeling after extraction?

The alveolar process is a structure directly related to the presence of teeth. It is formed when the teeth erupt. Agenesis of one or more teeth gives rise to an underdeveloped or missing alveolar process (Fig 2-4). The volume and shape of the alveolar process are determined by the shape of the teeth and their eruption axis. Following extraction of one or more teeth, the alveolar process will therefore atrophy to different degrees. From an anatomical viewpoint, the inner side of the tooth socket walls is covered by bundle bone (Fig 2-5), a portion of cortical bone that receives nutriment directly from the periodontal ligament.4 In the weeks following tooth extraction, the bundle bone in crestal portions of the buccal and lingual bone walls is reabsorbed and partially replaced by woven bone (Figs 2-6 and 2-7). This heightened osteoclast activity results in resorption of crestal regions of both buccal and lingual cortical bone. The reduction in cortical bone height is usually much

more pronounced on the buccal side than on the lingual side because cortical bone on the buccal side very often consists only of bone, while the cortical bone on the lingual side is made up of bundle bone and cortical bone forming part of the alveolar process.7 The reduction in bone height is accompanied by inevitable horizontal resorption, which is much more pronounced on the buccal side (Figs 2-8 and 2-9). In terms of figures, the alveolar ridge can display average horizontal reabsorption of 50% during the 12 months following extraction of a single tooth, which creates considerable difficulties during implant placement surgery.8 From a clinical viewpoint, the most recent systematic literature reviews reveal that the ridge can undergo median resorption of 3.8 mm in a horizontal direction and 1.24 mm in a vertical direction during the 6 months following extraction.9 Clinical case examples of socket healing following extraction are shown in Figs 2-10 to 2-14.

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Why does the ridge undergo extra-alveolar remodeling after extraction?

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Fig 2-4  (a to c) An underdeveloped maxillary process in a case of agenesis of a maxillary lateral incisor. Agenesis of a permanent tooth that had failed to undergo its natural eruption process leads to lack of development of the alveolar process, creating a hollow ridge deficit on the buccal side. Ideally, this is treated by a regenerative technique if an implant is placed. (d) Histologic evaluation of socket side walls after extraction. Blood clot, periodontal ligament, and bundle bone can be observed. The periodontal ligament separated from the root surface contains a high number of mesenchymal cells, fibers, and many apparently dilated vascular units. The main fibers are Sharpey fibers that are in direct contact with the bundle bone. (Courtesy of Prof G. Cardaropoli).

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Fig 2-5  (a) Anatomical image of a dry skull in mesiodistal cross section and the corresponding radiograph. The tooth root is separated from the bone tissue by the periodontal ligament. The bone tissue portion in direct contact with the periodontal ligament is bundle bone, made up of cortical bone. (b) On a radiograph, the bundle bone corresponds to the lamina dura, a mineralized structure contrasting with the nonmineralized periodontal ligament.

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Fig 2-6  Resorption of bundle bone and disappearance of the lamina dura. (a) An initial radiograph of a maxillary second premolar reveals the presence of the lamina dura. This takes the form of a thin radiopaque structure surrounding the periodontal ligament, which is evident as a fine radiolucent layer in direct contact with the root surface. (b) Immediately following root extraction, the lamina dura is still visible, while the periodontal ligament can no longer be seen. (c) Four months later, the socket has been filled with newly formed bone, and the lamina dura is no longer recognizable as the bundle bone has been reabsorbed.

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Fig 2-7  Socket after extraction of maxillary central incisor. (a) The socket inner walls consist of a thin wall of cortical bone—the bundle bone—in direct contact with the periodontal ligament. This bone unit is associated with the presence of a tooth. (b) The cortical bone on the buccal and palatal side is made up of actual cortical bone (belonging to the alveolar process) and bundle bone. The alveolar process is considerably thicker on the palatal side than on the buccal side. (c) Occlusal view after detachment of a full-thickness flap, highlighting the different alveolar ridge thicknesses. The inner socket wall is made up of bundle bone, which is surrounded circumferentially by alveolar bone. On the mesial and distal sides, this forms the interradicular bone septum, while on the buccal and palatal sides it forms the cortical bone proper.

Fig 2-8  (a) A 3D digital rendering of an occlusal CBCT scan of a maxillary arch. (b) Virtual tooth extraction reveals the anatomical relationships between the sockets and cortical bone. The buccal cortical bone thickness is limited and much thinner than the palatal cortical bone.

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Why does the ridge undergo extra-alveolar remodeling after extraction?

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Fig 2-9  (a) A mandibular second premolar with evident caries involvement is beyond saving and planned for extraction. (b) An occlusal view highlights the thinness of the soft tissues horizontally, to a greater degree on the buccal side than on the lingual side. (c) The root is extracted atraumatically with an open flap. The narrow buccal cortical bone has lost its characteristic yellow texture in the central portion, taking on a grayish appearance. This bundle bone is not covered by alveolar cortical bone. (d) An occlusal view with the open flap shows that the bundle bone is covered by alveolar cortical bone on the lingual side. This does not occur on the buccal side. (e and f) A titanium implant can be inserted into the socket after extraction, but it is clear biologically that the implant cannot alter physiologic resorption of the bundle bone and alveolar ridge remodeling.

clinical case 2 Spontaneous healing of a single socket after extraction of a maxillary premolar

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Fig 2-10  (a to b) Endodontically and prosthetically compromised maxillary second premolar with vertical root fracture, which is a candidate for avulsion. (c) An atraumatic extraction is performed without raising a flap to preserve soft tissue anatomy and leave the cortical bone intact, with spontaneous blood clot stabilization. (d) Four months later, horizontal ridge size has contracted, particularly on the buccal side.

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clinical case 3 Spontaneous healing of a single socket after extraction of a mandibular molar

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f Fig 2-11  (a and b) The mandibular left first molar is untreatable following failed endodontic treatment. (c) The extraction is performed using a flapless approach after separation of both roots and subsequent spontaneous clot stabilization. (d) Stripping of the distal root’s mesial surface. (e) Four months later, the socket has undergone complete healing. (f) When implant surgery is performed, a full-thickness flap is raised, showing significant horizontal resorption of the bone ridge. (g) In volumetric terms, the horizontal dimension of the socket, occupying the width of the ridge, has been remodeled to approximately 50% of its original size.

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Why does the ridge undergo extra-alveolar remodeling after extraction?

clinical case 4 Spontaneous healing of multiple sockets after extraction in the maxillary anterior region

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Fig 2-12  (a and b) Multiple sockets after extraction of maxillary incisors, viewed from buccal and occlusal angles. (c and d) Healing after 4 weeks shows that the alveolar ridge has already undergone some contraction in the apicocoronal and buccopalatal directions. (e and f) Healing after 8 weeks shows further contraction of the alveolar profile. Because implant placement is not required in this case, alveolar ridge contraction is critical to achieving an optimum emergence profile for pontic teeth on the future fixed prosthesis.

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clinical case 5 Socket healing after extraction of a maxillary central incisor with immediate implant placement

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Fig 2-13  (a and b) Maxillary central incisor with deep crown-root vertical fracture following trauma. (c) After raising a full-thickness flap, the tooth was extracted, respecting the hard tissue anatomy. (d and e) The thinness of the buccal bone is highlighted by photographs taken during surgery, suggesting that the cortical bone could be made up almost entirely of bundle bone. (f) An osseointegrated implant is inserted into the socket after extraction, respecting the anatomy of the buccal cortical bone. (g and h) Four months later, during stage-two surgery, intraoperative photographs show bone resorption with complete loss of buccal cortical bone in the coronal area of the implant. The implant, which is osseointegrated, is unable to prevent the natural remodeling of the socket after extraction.

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Can alveolar ridge remodeling after extraction influence implant placement?

clinical case 6 Socket healing after extraction of a maxillary canine with immediate implant placement. Healing of bone in an extraction site.

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Fig 2-14  (a) Flap detachment reveals thin buccal cortical bone made up mainly of bundle bone. (b) Immediate implant placement in the extraction socket. (c) A photograph taken a few months later shows bone remodeling and resorption of cortical bone. The fact that the implant has been inserted a few millimeters away from the buccal cortical bone prevents exposure of the implant surface and allows a good esthetic outcome. (Surgery by Dr P. Casentini.)

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3|

Can alveolar ridge remodeling after extraction influence implant placement?

When an implant is inserted in a type 3 or 4 site,10 ie, when the socket has mostly or completely healed, typically 12 to 16 weeks or more after extraction, it may sometimes be necessary to use a bone regeneration technique at implant placement if too much bone has been resorbed (Figs 2-15 to

2-18). A recent controlled randomized study11 showed that if implant placement is delayed and spontaneous socket healing occurs, 58% of sites require the use of an additional bone regeneration procedure at the time of implant surgery.

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two  Spontaneous Healing of the Socket After Extraction and Alveolar Ridge Remodeling

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Fig 2-15  (a to d) These diagrams show horizontal resorption of a postextraction site and the consequent need to use bone regeneration at the time of implant insertion.

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Fig 2-16 (a and b) A maxillary premolar is extracted atraumatically using a flapless approach, leaving the soft tissues and cortical bone intact. (c) However at 4 months, remodeling of the soft tissue profile is observed. (d) After raising a mucoperiosteal flap, significant horizontal resorption of the alveolar ridge is evident.

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Can alveolar ridge remodeling after extraction influence implant placement?

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Fig 2-17  (a and b) Spontaneous bleeding takes place inside the socket after extraction. Within a few moments, a blood clot forms, and its subsequent stabilization represents the first stage of tissue healing. (c) The fibrin network acts as a framework for the new cells, leaving room for granulation tissue followed by a temporary connective tissue matrix. (d) The socket is now completely filled with nonmineralized connective tissue, and the osteoblastmediated mineralization stage begins in the most apical area with new bone formation. At the same time, the soft tissues have almost completed their healing stage. (e) Most of the socket has been filled with new woven bone. Soft tissues have completely sealed off the socket opening. (f) Healing is complete. The socket has been completely filled with new bone and the bundle bone has been fully resorbed. The outer ridge walls also show vertical and horizontal volumetric resorption. (g) Superimposed view showing dimensions of the socket before extraction and once healing is complete. Note that the ridge has been resorbed both vertically and horizontally and resorption is greater buccally than lingually.

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clinical case 7 Delayed implant placement with the need for bone regeneration

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Fig 2-18 (a) Mandibular premolar showing endodontic and prosthetic involvement. (b) An extraction was carried out using a flapless approach with spontaneous healing. (c) Four months later, perfect healing of the soft tissues was evident but with simultaneous remodeling of the tissue profile. (d) At the time of implant surgery, after full-thickness flap elevation and prosthetically guided implant placement, a deep bone dehiscence is evident with exposure of the implant threads on the buccal face. (e and f) Guided bone regeneration is performed using deproteinized bovine bone mixed with fibrin glue and protected by a resorbable collagen membrane.

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Can the extraction technique influence site healing after extraction?

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Can the extraction technique influence site healing after extraction?

From a surgical viewpoint, the tooth extraction stage fulfills an essential role in ensuring optimal healing for proper socket management after extraction. Hard and soft tissue management is therefore vital. The importance of using an atraumatic avulsion technique is revealed by the severe loss of socket volume observed when avulsion takes place during trauma (Fig 2-19). To optimize the results when the socket is intact, it is advisable to extract the tooth without raising a flap because the latter procedure triggers a series of biologic effects, including a transitory phase of cortical hypoxia, which activates the osteoclasts with consequent bone resorption12 (Fig 2-20). Similarly, close attention must be paid to the root luxation and extraction stage, which should be performed using appropriate desmotomes and elevators. After extraction, the socket must be thoroughly washed with saline solution to decontaminate the site.

roots into several fragments using thin fissure burs mounted on a straight or contra-angle handpiece. Separation of the various root fragments is then completed using fine elevators or periotomes. The space created by removing the first fragment facilitates subsequent luxation of the remaining fragments, while allowing the surrounding bone walls to be preserved (Figs 2-25 to 2-27).

Atraumatic extraction techniques

Avulsion of ankylosed teeth with root resorption, which is a frequent late outcome of trauma, may be particularly demanding due to the lack of any real cleavage plane between the tooth root and the surrounding tissues. In such cases, often there are also residues of root canal-filling materials such as gutta-percha and endodontic cement, which must be removed as the extraction is carried out. Any of the instruments examined previously (periotomes, desmotomes, piezoelectric instruments, and burs) may prove useful for avulsion in this case. It may also be useful to finish the socket after extraction with a round diamond bur that can be used to grind away any root residues (Figs 2-30 and 2-31).

When the tooth is intact, the use of desmotomes, periotomes, elevators, and endodontic instruments may be indicated in order to preserve soft tissues and bone, particularly buccal cortical bone (Figs 2-21 to 2-24).

Extraction after root separation using rotating instruments If residual roots cannot be gripped with normal extraction pliers, one effective technique is to separate the residual

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Extraction by means of piezoelectric surgery If a tooth is fractured, with the coronal root margin positioned adjacent to the bone or under the ridge, or if ankylotic root residue is present, it may be advisable to use piezoelectric surgery with specially designed inserts (Figs 2-28 and 2-29).

Avulsion of ankylosed teeth

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Fig 2-19 (a) Traumatic avulsion of two maxillary incisors following a motor vehicle accident with loss of large buccal cortical bone fragments that remained attached to the root surface. (b) The superficial position of the retro-incisal papilla, which currently occupies a position in the center of the alveolar process (arrow), reveals pronounced horizontal contraction of the alveolar process that occurred during the healing process.

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Fig 2-20  Extractions of maxillary second premolars by detaching a full-thickness flap (a) or using a minimally invasive approach without flap opening to preserve the soft tissue contour (b).

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Fig 2-21 Demonstration of the use of desmotomes and elevators for atraumatic tooth extraction on a model. (a and b) A straight desmotome is inserted parallel to the tooth’s long axis, preferably at the buccal and interproximal surface level. (c and d) An angled desmotome is used on the palatal and lingual surfaces.

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Can the extraction technique influence site healing after extraction?

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Fig 2-21 (cont)  (e and f) The luxation maneuver is performed by inserting the small, compact straight elevator alternately (the order is unimportant) into the mesial and distal surfaces of the periodontal space parallel to the tooth’s long axis. (g) After luxation, the tooth can be extracted with the aid of extraction forceps.

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c Fig 2-22 (a) A straight desmotome is indicated for working on the mesial, distal, and buccal surfaces. (b) An angled desmotome is indicated for working on the palatal/lingual surfaces. (c) A straight elevator is indicated at the luxation stage.

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two  Spontaneous Healing of the Socket After Extraction and Alveolar Ridge Remodeling

clinical case 8 Flapless extraction technique for a maxillary premolar

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Fig 2-23  Extraction of a maxillary first premolar for periodontal reasons. (a to c) After anesthetizing the area, a straight periotome is inserted into the sulcus, initially at the interproximal mesial and distal levels and then buccally. The periotome penetrates the superficial periodontal tissues and passes the gingival sulcus before detaching the epithelial and connective tissue attachment from the root surface up to the bone ridge at the periodontal ligament level. (d) This elevation is easily performed on the palatal side using an angled periotome. (e and f) At this point, a straight, compact elevator is used for the luxation stage, seeking to apply leverage between the root surface and the marginal bone ridge to preserve the soft tissues. (g) This maneuver tears the periodontal ligament, mobilizing the tooth horizontally and vertically. (h and i) Once the extraction is complete, the soft tissues and the alveolar walls remain intact.

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Can the extraction technique influence site healing after extraction?

clinical case 9 Extracting a root fragment using an endodontic instrument

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Fig 2-24 (a to c) If a tooth is fractured horizontally, the crown of the fractured tooth can easily be removed. (d to f) The barely accessible remaining apical portion can be removed through synergistic action between a thin desmotome and an endodontic instrument engaged in the fragment’s canal system. Also in this case, the avulsion is as minimally traumatic as possible. (Surgery by Dr P. Casentini.)

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two  Spontaneous Healing of the Socket After Extraction and Alveolar Ridge Remodeling

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Fig 2-25  (a and b) Thin fissure burs can be fitted on a surgical multiplier handpiece or straight handpiece for root separation.

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d Fig 2-26 (a to e) Atraumatic avulsion by separating the root into two fragments, mesial and distal, using a thin fissure bur. When separating the root, it is important not to damage the buccal cortical bone. It may be prudent to leave a thin septum of buccal root tissue and complete the separation by fracture. Both fragments can then be luxated with periotomes and extracted separately. Usually, avulsion of the first fragment creates a useful space for luxation and subsequent avulsion of the second fragment. (Surgery by Dr P. Casentini.)

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Can the extraction technique influence site healing after extraction?

clinical case 10 Extraction after root separation using rotating instruments

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Fig 2-27  (a to d) Root separation by means of rotating instruments can be very useful if the roots being avulsed are very curved. In this case, the separation line (red line in b) allowed removal of the distal portion of the maxillary second premolar root. The remaining root could then be luxated (luxation pathway is shown by the green line in b), allowing for the accentuated distal curvature. (Surgery by Dr P. Casentini.)

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Fig 2-28  Piezosurgery (Mectron) extraction inserts. (a) EX1: main extraction scalpel able to create a thin periradicular osteotomy, even with ankylotic roots. (b) EX2: left-angled extraction scalpel for osteotomies in posterior areas. (c) EX3: right-angled extraction scalpel for osteotomies in posterior areas.

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clinical case 11 Extraction by means of piezoelectric surgery

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Fig 2-29  (a) Presence of a mandibular second premolar root fractured at the juxtagingival level. (b) After anesthesia, an intrasulcular incision is performed, followed by elevation of a full-thickness mucoperiosteal flap. (c to d) Three extraction inserts are normally provided (buccolingual, mesial, and distal). These are inserted at the periodontal ligament level for slow and controlled root luxation. The inserts are inserted deep into the periodontal space, parallel to the root surface, starting from the interproximal surfaces and then moving to the mesial and distal surfaces, if necessary. (e to f) Once the root has been luxated, it can be extracted easily, preserving the intact bony walls. This particularly applies to the buccal cortical bone, which may be very thin.

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Can the extraction technique influence site healing after extraction?

clinical case 12 Extraction of an ankylosed maxillary central incisor

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Fig 2-30  (a to d) A maxillary right central incisor with advanced resorption and ankylosis is initially avulsed using normal extraction forceps, followed by desmotomes and microelevators to remove the remaining root portion, which is partially fused with the surrounding alveolar bone. (e to h) The socket is finished after extraction by grinding with a round diamond bur mounted on a straight handpiece. This removes any residual root wall and endodontic filling material. (Surgery by Dr P. Casentini.)

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clinical case 13 Extraction of a maxillary central incisor with ankylosis and external resorption followed by implant placement

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Fig 2-31  (a and b) A 29-year-old patient presented with ankylosis of the maxillary right central incisor. The tooth crown previously was inappropriately reconstructed using composite material. (c) A radiograph shows tooth ankylosis without the presence of a periodontal ligament. (d to f) A 3D CBCT assessment shows the degree of root resorption, with fusion between the root and buccal cortical bone, and endodontic material present within the cortical bone and directly in contact with the buccal gingival connective tissue. (g and h) Removal of the clinical crown reveals discontinuity between the crown and root. (i and j) Because of the close contact between the root canal filling material and the buccal soft tissue, it is necessary to raise a full-thickness mucoperiosteal flap only on the buccal side, with a releasing incision distal to the lateral incisor without elevating the two interproximal papillae. The ideal treatment plan was to conduct a ridge augmentation procedure followed by fixed orthodontic treatment to redistribute the spaces in a mesiodistal direction, followed by insertion of an osseointegrated implant. However, the patient rejected this plan and demanded an immediate fixed provisional rehabilitation.

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Can the extraction technique influence site healing after extraction?

clinical case 13 (cont)

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Fig 2-31  (cont) (k) A 4 × 13–mm tapered implant (T3 Certain, Zimmer Biomet) was inserted immediately after extraction. (l) The defective bone ridge was reconstructed by means of a horizontal augmentation procedure using deproteinized bovine bone (Bio-Oss, Geistlich) mixed with homologous fibrin glue (Tisseel, Baxter). (m) A 3D collagen matrix (Mucograft, Geistlich) was applied to protect the bone graft and simultaneously regenerate the buccal soft tissues, increasing their thickness. (n) The flap was then repositioned and sutured by closing the fenestration that had arisen at the mucogingival level using resorbable 6-0 polyglycolic acid sutures. (o) A provisional screw-retained crown was delivered immediately. (p) The sutures were removed 2 weeks later.

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clinical case 13 (cont)

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r Fig 2-31  (cont) (q and r) Six months later, definitive rehabilitation was performed using a zirconia abutment and full-ceramic crown. Two porcelain veneers were applied to the maxillary right lateral incisor and left central incisor at the same time to achieve the best esthetic outcome. The clinical crown was lengthened on the right lateral incisor to harmonize the gingival profile. (s) A radiograph shows the marginal bone level 1 year after loading. (t) A 3D CBCT assessment, also performed 1 year after loading, shows regeneration of bone buccal to the implant. (u) The patient’s smile is now wellproportioned and very pleasing esthetically.

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Recommended Reading

References 1. Amler MH, Johnson PL, Salman I. Histological and histochemical investigation of human alveolar socket healing in undisturbed extraction wounds. J Am Dent Assoc 1960;61:32–44. 2. Amler MH. The time sequence of tissue regeneration in human extraction wounds. Oral Surg Oral Med Oral Pathol 1969;27:309–318. 3. Pietrokovski J, Massler M. Alveolar ridge resorption following tooth extraction. J Prosthet Dent 1967;17:21–27. 4. Cardaropoli G, Araújo, M, Lindhe J. Dynamics of bone tissue formation in tooth extraction sites. An experimental study in dogs. J Clin Periodontol 2003;30:809–818. 5. Trombelli L, Farina R, Marzola A, Bozzi L, Liljenberg B, Lindhe J. Modeling and remodeling of human extraction sockets. J Clin Periodontol 2008;35:630–639. 6. Cardaropoli D, Roffredo A, Tamagnone L, Gaveglio L, Cardaropoli G. Socket preservation using bovine bone mineral and collagen membrane: A randomized controlled clinical trial with histologic analysis. Int J Periodontics Restorative Dent 2012;32:421–430. 7. Araújo MG, Lindhe J. Dimensional ridge alterations following tooth extraction. An experimental study in the dog. J Clin Periodontol 2005;32:212–218.

8. Schropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft tissue contour changes following single-tooth extraction: A clinical and radiographic 12-month prospective study. Int J Periodontics Restorative Dent 2003;23:313–323. 9. Hämmerle CH, Araújo MG, Simion M, Osteology Consensus Group 2011. Evidence-based knowledge on the biology and treatment of extraction sockets. Clin Oral Implants Res 2012;23:80–82. 10. Hämmerle CH, Chen ST, Wilson TG Jr. Consensus statements and recommended clinical procedures regarding the placement of implants in extraction sockets. Int J Oral Maxillofac Implants 2004;19:26–28. 11. Cardaropoli D, Tamagnone L, Roffredo A, Gaveglio L. Evaluation of dental implants placed in preserved and nonpreserved postextraction ridges: A 12-month postloading study. Int J Periodontics Restorative Dent 2015;35:677–685. 12. Nobuto T, Suwa F, Kono T, et al. Microvascular response in the periosteum following mucoperiosteal flap surgery in dogs: Angiogenesis and bone resorption and formation. J Periodontol 2005;76:1346–1353.

Recommended Reading Boyne PJ. Osseous repair of the postextraction alveolus in man. Oral Surg Oral Med Oral Pathol 1966;21:805–813. Cardaropoli D, Cardaropoli G. Preservation of the postextraction alveolar ridge: A clinical and histologic study. Int J Periodontics Restorative Dent 2008;28:469–477. Cardaropoli D, Debernardi C, Cardaropoli G. Immediate placement of implant into impacted maxillary canine extraction socket. Int J Periodontics Restorative Dent 2007;27:71–77. Cardaropoli D, Tamagnone L, Roffredo A, Gaveglio L. Relationship between the buccal bone plate thickness and the healing of post-extraction sockets with/without ridge preservation. Int J Periodontics Restorative Dent 2014;34:211–217.

de Souza RF, Travess H, Newton T, Marchesan MA. Interventions for treating traumatised ankylosed permanent front teeth. Cochrane Database Syst Rev 2015;16:CD007820. Devlin H, Sloan P. Early bone healing events in the human extraction socket. Int J Oral Maxillofac Surg 2002;31:641–645. Jang Y, Hong HT, Chun HJ, Roh BD. Influence of dentoalveolar ankylosis on the biomechanical response of a singlerooted tooth and surrounding alveolar bone: A 3-dimensional finite element analysis. J Endod 2016;42:1687–1692.

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Questions: 1. How are extraction sites classified? 2. What are the main therapeutic options when treating a postextraction socket? 3. What are the indications, advantages, and limitations of immediate implant placement after extraction? 4. What are the indications, advantages, and limitations of delaying implant placement after extraction? 5. What are the indications, advantages, and limitations of ridge preservation techniques? 6. What are the indications, advantages, and limitations of ridge augmentation techniques? 7. What are the final recommendations for treating a socket after extraction?

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1|

How are extraction sites classified?

The Wilson and Weber1 system classifies extraction sites based on the stage of the socket healing process at which implant placement occurs following tooth extraction as immediate, recent, delayed, and mature.

A second classification system subdivides extraction sites in a more structured manner based on time elapsed from the moment of extraction. Types 1 to 4 are defined,2 with the advantages and disadvantages shown in Table 3-1.

Table 3-1  | Protocols for implant placement in extraction sockets and their advantages and disadvantages* Classification

Definition

Advantages

Disadvantages

Type 1

Implant placement immediately following tooth extraction and as part of the same surgical procedure

• Reduced number of surgical procedures. • Reduced overall treatment time. • Optimal availability of existing bone.

• Site morphology may complicate optimal placement and anchorage. • Thin tissue biotype may compromise optimal outcome. • Potential lack of keratinized mucosa for flap adaptation. • Adjunctive surgical procedures may be required. • Procedure is technique-sensitive.

Type 2

Complete soft tissue coverage of the socket (typically 4 to 8 weeks)

• Increased soft tissue area and volume facilitates soft tissue flap management. • Resolution of local pathology can be assessed.

• Site morphology may complicate optimal placement and anchorage. • Treatment time is increased. • Socket walls exhibit varying amounts of resorption. • Adjunctive surgical procedures may be required. • Procedure is technique-sensitive.

Type 3

Substantial clinical and/or radiographic bone fill of the socket (typically 12 to 16 weeks)

• Substantial bone fill of the socket facilitates implant placement. • Mature soft tissues facilitate flap management.

• Treatment time is increased. • Adjunctive surgical procedures may be required. • Socket walls exhibit varying amounts of resorption.

Type 4

Healed site (typically more than 16 weeks)

• Clinically healed ridge. • Mature soft tissues facilitate flap management.

• Treatment time is increased. • Adjunctive surgical procedures may be required. • Large variations are present in available bone volume.

*Reprinted from Hämmerle et al2 with permission.

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What are the main therapeutic options when treating a postextraction socket?

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What are the main therapeutic options when treating a postextraction socket?

Given the current knowledge of socket healing dynamics, the most common surgical approaches for managing extraction sites are as follows (Fig 3-1): • Immediate implant placement in an extraction socket. In this case, the implant site can be prepared immediately after tooth avulsion, and the implant is placed in the extraction socket. • Deferred implant placement in extraction socket. After avulsion, the socket is left to heal for a few weeks in order to achieve soft tissue healing and partial healing of bone tissue. The implant is then inserted at the same time as regenerative techniques are performed at stage-two surgery. The category of deferred implant placement in extraction sockets can be subdivided as follows: early, in which the implant is inserted 4 to 8 weeks after extraction when only the soft tissues have healed and/or localized disease has been resolved; and delayed, in which the implant is placed 3 to 4 months later when hard tissue healing has taken place, with remineralization of the socket. • Implementation of a site preservation technique (ridge preservation). In this case, avulsion is followed by socket

filling with an osteoconductive biomaterial, which may be accompanied by socket sealing using various techniques. Implant placement is deferred for a few months. • Use of a site augmentation technique (ridge augmentation). As previously, the socket is filled using an osteoconductive biomaterial. In this situation, however, the severely damaged socket wall is treated by means of a regenerative technique that may involve mucoperiosteal flap elevation and membrane positioning. Every technique has its own specific indications, advantages, and limitations, which are analyzed in the following sections. Some extraction sockets can be treated with any of the techniques described, based on the clinician’s preferences. However, a series of case-specific factors may guide the clinician’s choice toward one of the various techniques. Extraction site treatment must always be preceded by a thorough clinical and radiographic presurgical analysis, using 3D imaging techniques if necessary. The treatment method should be decided prior to extraction. This is advantageous from an ergonomic viewpoint for preparation of surgical instruments and ensuring availability of the necessary biomaterials.

Fig 3-1 Various options for managing a fresh extraction site. (a) Immediate implant placement after extraction. (b) Ridge preservation. (c) Ridge augmentation. (d) Delayed implant placement after extraction.

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What are the indications, advantages, and limitations of immediate implant placement after extraction?

The indications, advantages, and limitations of immediate postextraction implant placement can be accurately defined based on many years of using this technique, backed by a significant amount of scientific data from clinical studies on animals and humans as well as systematic reviews of the relevant literature.

Indications • Intact socket walls. To reduce the incidence of complications, it is only advisable to place implants in extraction sockets when local conditions are favorable, ie, in the presence of intact socket walls (Fig 3-2). The importance of carrying out avulsion using a technique that is as atraumatic as possible was discussed in the previous chapter. The presence of sufficiently intact socket walls is undoubtedly an important requirement for implant placement in an extraction socket because significant destruction of the socket walls could affect the implant’s primary stability. In this case, the treatment would also be more complicated because implant positioning would have to be combined with a regenerative technique involving flap elevation and placement of a biomaterial and membrane. As already discussed, this could have a negative impact on extraction socket healing. • Absence of active infection and suppuration in the extraction socket. In agreement with the literature, the authors consider the presence of active infection and suppuration a contraindication to implant placement immediately after extraction (Fig 3-3). • Favorable anatomy of the tooth to be extracted and its residual socket. The presence of a thin or resorbed root or the loss of periodontal support usually allows good primary stability for postextraction implant placement (Figs 3-4 and 3-5). Conversely, the presence of a large

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root or the complex anatomy typical of a molar is often a contraindication to postextraction implant placement. • Absence of sturdy anatomical structures near the extraction socket. If the socket base is located at least a few millimeters away from the sinus floor and nasal cavity in the maxilla or from the mandibular canal in the mandible, it will be possible to use the alveolar bone apical to the socket to stabilize the implant. This means that immediate implant placement in the extraction socket is possible. • Favorable anatomy of soft tissue surrounding the extraction socket. If there are soft tissue defects, such as asymmetries, perforations, or very thin tissues, immediate implant placement in an extraction socket would lead to a risk of esthetic complications because the healing process would be less predictable (Fig 3-6). • Possibility of prosthetically guided implant insertion. The fundamental premise must be optimal 3D implant positioning from a prosthetic viewpoint. If the anatomy of the extraction socket does not allow this, it is preferable to regenerate sufficient bone volume to allow more effective implant positioning. One common mistake in this situation is placing the implant at an excessive buccopalatal angle in an attempt to achieve sufficient primary stability in the bone at the palatal aspect of the extraction socket (Fig 3-7).

Advantages Immediate postextraction implant placement offers some undeniable advantages: • Shorter treatment duration. Treatment time is shorter than with other techniques (ie, deferred placement in extraction socket and ridge preservation) because in theory a definitive prosthesis can be fitted a few weeks after implant placement.

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Fig 3-2  (a to c) Presence of intact socket walls, established by probing the walls using a periodontal probe, suggested that the best clinical choice was implant placement immediately after extraction. In this case, other parameters were also extremely favorable, such as the quantity and quality of surrounding soft tissues (eg, a broad band of keratinized tissue and a coronally positioned soft tissue margin) and bone volume.

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Fig 3-3  (a to c) After avulsion of the mandibular right first premolar due to an endodontic defect that led to a buccal fistula and suppuration, implant placement immediately after extraction was ruled out.

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Fig 3-4  (a to d) The presence of a short root or large bone volume apical to the root to be extracted represents a favorable indication for immediate implant placement in an extraction socket.

Fig 3-5 (a to e) Insignificant roots with little to no residual periodontal attachment are an indication for immediate postextraction implant placement, which will be able to achieve satisfactory anchorage in the basal bone. (Surgery and prosthetic rehabilitation by Dr P. Casentini.)

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• Psychologic advantage for patients. With immediate placement of a prosthesis, the patient does not have to live with the unsightly gap caused by the loss of a tooth. This is particularly important when the extracted teeth are in the esthetic zone. • Ergonomic advantage. Immediate placement of an implant in an extraction site also offers an undeniable ergonomic advantage for clinicians because it allows an unprofitable procedure such as tooth extraction to be combined with a more remunerative procedure, namely implant placement.

experience. As is discussed in chapter 4, it must also be combined with regenerative techniques. • Risk of esthetic complications. Various scientific reports and systematic reviews of the literature on the subject3–6 have highlighted the risk of soft tissue recession around implants placed in extraction sockets, particularly on the buccal aspect, leading to esthetic complications. Hard tissue augmentation techniques and accurate 3D implant positioning in a socket, as described in chapter 4, can effectively minimize this risk. Careful case selection following the guidelines described above allows such complications to be reduced. • One chance for success. Unlike other techniques that require several steps, with immediate postextraction positioning, the final result is essentially determined by a single surgical operation involving extraction and immediate implant positioning. With deferred implant positioning in an extraction socket and ridge preservation, on the other hand, corrections can be made at a later stage.

Limitations Countering these advantages are certain limitations and risks associated with immediate postextraction implant placement: • Operator-dependent technique. Prosthetically guided immediate implant positioning in an extraction socket is a delicate surgical technique requiring a high level of

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Fig 3-6  (a to c) Favorable anatomy of soft tissue surrounding the maxillary left lateral incisor, which is planned for extraction. This is a good indication for immediate implant placement in the extraction socket (see chapter 4 for a full description of this clinical case).

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Fig 3-7  A desire to place an implant in the extraction socket at all costs, even under unfavorable conditions, led to the implant being placed in an excessively apical position. The resulting excessive buccopalatal angle meant a poor outcome for the implantsupported prosthetic treatment.

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What are the indications, advantages, and limitations of delaying implant placement after extraction?

4|

What are the indications, advantages, and limitations of delaying implant placement after extraction?

To overcome problems that may arise with immediate implant placement in extraction sockets, some authors7,8 suggested deferring postextraction placement by 6 to 12 weeks (Figs 3-8 and 3-9). The advantage of this technique is that soft tissue healing facilitates surgical tissue handling and partial healing of socket bone facilitates accurate prosthetically guided implant positioning. Bone remodeling, ie, partial resorption of buccal cortical bone, that occurs in the meantime (see chapter 2) must be corrected by means of a guided bone regeneration (GBR) technique performed at the same time as implant placement.

to be created with a crestal incision and makes it easier to perform a regenerative technique. • Esthetically guided implant positioning. Partial healing of alveolar bone facilitates accurate 3D positioning of the implant. • Shorter treatment time than with ridge preservation protocols. Because implant positioning is deferred by only 6 to 8 weeks, treatment time is shorter than with ridge preservation techniques, which are typically associated with a delay of 4 to 6 months.

Indications

Limitations

In theory, the technique can be applied to all extraction sites. However, the clinical reality is that in sites with thin, scalloped periodontal biotypes and significant involvement of buccal cortical bone, simple extraction that is not combined with any other preservation or regeneration technique can lead to widespread tissue collapse that is more difficult to correct at a later stage. In such cases, it appears that ridge preservation and/or augmentation are advisable.

• Increased treatment time. There is a longer treatment time than with immediate postextraction implant placement. • Risk of uncontrolled tissue collapse. There is a risk of uncontrolled tissue collapse in cases with a thin, scalloped biotype and/or partial or complete absence of buccal cortical bone. In such cases, the most indicated and recommended protocols are ridge preservation or augmentation. • More complicated surgery. Deferred postextraction implant placement always requires a regenerative technique and therefore a high degree of surgical experience. • More invasive surgical technique. Any regenerative technique requiring mucoperiosteal flap elevation and passive advancement usually involves greater postoperative morbidity and the need to keep the patient well informed.

Advantages The advantages of deferred postextraction implant placement can be summarized as follows: • Facilitated soft tissue management. Full healing of soft tissues above the extraction socket allows an access flap

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Fig 3-8 (a and b) Deferred implant placement in an extraction socket was planned after traumatic avulsion of the maxillary left central incisor. (c) Eight weeks later, a radiograph reveals partial healing of the alveolar bone. (d) The soft tissues had healed, and horizontal ridge resorption had taken place.

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clinical case 1 Delayed postextraction implant placement in a maxillary incisor site

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Fig 3-9  Delayed postextraction implant placement in a maxillary incisor site (a and b) Eight weeks after extraction of a maxillary left central incisor, a full-thickness mucoperiosteal flap is raised, showing partial resorption of the buccal cortical bone and filling of the socket. (c and d) An implant (Bone Level Tapered, 4.1 × 12 mm, Straumann) is then inserted. (e and f) A GBR technique is performed using bone of bovine origin (Bio-Oss, Geistlich), and a collagen membrane (Bio-Gide, Geistlich) is stabilized with titanium pins (SuperTack, MC Bio). (g and h) The flap is then passively advanced, and the wound is sutured for healing by first intention. (Surgery and prosthetic rehabilitation by Dr P. Casentini.)

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What are the indications, advantages, and limitations of ridge preservation techniques?

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What are the indications, advantages, and limitations of ridge preservation techniques?

Indications There is a broad range of indications for extraction socket preservation techniques, and they particularly apply to clinical situations in which implant placement in extraction sockets is contraindicated. • Presence of damaged socket walls. Buccal cortical bone may be damaged by a preexisting condition (eg, root fracture or periapical infection) or as a consequence of an extraction that was not sufficiently atraumatic. With damaged socket walls, it is prudent to preserve ridge volume by means of ridge preservation and defer implant positioning (Fig 3-10). • Unfavorable residual socket anatomy. If the root of the tooth to be extracted is large in size or surrounded by a broad osteolytic area, the socket anatomy is unlikely to be compatible with immediate implant placement in the extraction socket because the fundamental premises for achieving satisfactory primary stability are missing (Fig 3-11). • Presence of important anatomical structures near the extraction socket. If the socket floor is adjacent to the maxillary sinus or mandibular canal, implant placement in the extraction socket is not indicated because the fundamental requirement for achieving sufficient primary stability is lacking (Figs 3-12 and 3-13). Therefore, it is often advisable to carry out a ridge preservation procedure. • Unfavorable anatomy of soft tissues surrounding the extraction socket. Immediate implant placement after extraction is contraindicated if the soft tissues around the tooth to be extracted recede or the soft tissues are asymmetric due to ankylosis (Figs 3-14 and 3-15). In such cases, a ridge preservation technique allows bone volume to be maintained and simultaneously improves soft tissue morphology. • Treatment of a future pontic area. Ridge preservation techniques are indicated not only in future implant sites but also in sockets that will be fitted with a pontic positioned on an implant- or tooth-supported prosthesis (Fig 3-16). In these sites, maintenance of the original alveolar ridge shape will allow a more natural appearance and improve the appearance of the definitive prosthesis.

• Need to defer implant treatment. In many cases, extraction is required, but it is not possible to carry out implant treatment immediately or in the short term. In many complex cases, the treatment plan involves carrying out preliminary procedures, with implants placed at a later stage. For example, time-consuming periodontal or orthodontic treatments might be required before implant treatment. In other cases, implant placement must be deferred due to the patient’s personal situation (eg, moving or spending time abroad). In all these situatons, site preservation techniques provide a great advantage in terms of simplification of the overall treatment plan and maintenance of bone volume for implant placement.

Advantages Ridge preservation techniques offer many advantages: • Wide range of clinical indications. Unlike implant placement immediately after extraction, which can only be performed under specific clinical conditions, ridge preservation techniques are indicated in a wide range of clinical situations. • Simpler surgical technique. Compared with immediate and deferred postextraction implant placement, which require a higher degree of surgical experience, site preservation techniques are less dependent on the clinician’s experience. • Opportunity for corrections. Because implant placement is deferred, further corrections (eg, hard and soft tissue augmentation) can be implemented during subsequent treatment steps. The primary advantage is a reduced risk of esthetic complications. • Treatment simplification. Compared with deferring implant placement by a few months, which may result in extensive resorption of the alveolar ridge and the need for more complex and extensive reconstruction techniques, preservation techniques reduce the use of reconstructive techniques in subsequent steps.

Limitations Treatment lasts longer than with immediate and deferred postextraction insertion. However, this is a minor disadvantage when compared with the many advantages of the technique.

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Fig 3-10  (a to d) After avulsion of a maxillary central incisor affected by complications from endodontic treatment, it is established that the buccal bone wall is completely absent. This was suspected at the presurgical probing stage. In this clinical situation, immediate implant positioning is contraindicated, and a ridge preservation technique should be performed. (e and f) Before positioning an osteoconductive biomaterial (Bio-Oss Collagen, Geistlich), the buccal wall is repaired by positioning a collagen membrane (Bio-Gide).

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Fig 3-10 (cont) (g and h) The extraction socket is then sealed using a collagen matrix (Mucograft Seal, Geistlich) sutured to the surrounding soft tissues by means of interrupted sutures. (i and j) Six months later, the CBCT scan shows well-maintained extraction site volume and satisfactory graft osseointegration. (Surgery by Dr P. Casentini.)

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Fig 3-11  (a to c) In the clinical situations revealed by these intraoral radiographs, it would not be possible to use an immediate or deferred postextraction implant because of a lack of the necessary primary stability. Ridge preservation or augmentation techniques might be valid alternative options because they allow greater bone volume to be maintained compared with spontaneous site healing.

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Fig 3-12  (a to c) Continuity between the socket floor of the tooth to be extracted and the maxillary sinus floor as well as the fracture of the buccal wall represent contraindications to immediate implant placement in this case. (d to f) Instead, a ridge preservation technique is indicated. (Surgery by Dr P. Casentini.)

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What are the indications, advantages, and limitations of ridge preservation techniques?

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Fig 3-13 (a and b) The treatment plan for this patient involved the avulsion of the mandibular right premolars and subsequent implant-supported prosthetic rehabilitation of this sector. The use of postextraction implant placement was ruled out because the root apices were too close to the mental foramen. (c to f) After using a piezoelectric surgical instrument with a periotome-type extraction tip for atraumatic avulsion of the teeth, the site was treated by means of ridge preservation. (g) A CBCT cross section of the same site 6 months later shows a perfectly maintained ridge profile compatible with implant placement. (Regenerative surgery by Dr P. Casentini.)

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d Fig 3-14  (a and b) The maxillary left central incisor, which had been fitted with a prosthesis following soft tissue recession and affected by a chronic infection that caused resorption of the buccal cortical bone, needed to be extracted. An immediate implant was ruled out due to the conditions of the socket walls and the more apical position of the soft tissue margin in relation to the affected tooth, leading to asymmetry between the two central incisors. (c) The extraction site was therefore treated by means of ridge preservation with insertion of an osteoconductive biomaterial and positioning of a collagen membrane. The socket was sealed with a connective tissue graft taken from the palate to improve soft tissue quality. (d) Six months later, before implant insertion, the improvement in soft tissue morphology was noticeable.

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clinical case 2 Multidisciplinary approach to ridge preservation for ankylosed maxillary central incisors

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Fig 3-15  Ridge preservation technique for ankylosed maxillary central incisors using a multidisciplinary approach. (a to d) The maxillary central incisors were planned for extraction. The presence of noticeable asymmetry of the soft tissues between these and the adjacent teeth, caused by ankylosis of the central incisors, contraindicated immediate implant placement in the extraction socket. (e to h) In this case, the treatment plan involved preliminary orthodontic treatment with the aim of aligning both arches, increasing the mesiodistal space, improving the lateral incisor position, and aligning and intruding the mandibular incisors. The orthodontic treatment therefore required extraction of both maxillary central incisors, and ridge preservation was performed by inserting an osteoconductive biomaterial of bovine origin (Bio-Oss Collagen). Collagen sponges were used to seal the sockets after extraction.

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clinical case 2 (cont)

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Fig 3-15  (cont) (i and j) After orthodontic treatment, both arches were optimally aligned, and the appearance of the soft tissues was satisfactory, which meant that implant treatment could be planned. (k and l) A CBCT scan carried out using a radiopaque diagnostic template was used to create a 3D digital plan for the placement of two implants and a computer-guided surgical template. (m to p) The implant site was prepared with the aid of a computer-guided template. Elevation of a full-thickness flap made it possible to improve implant site morphology using a GBR technique (Bio-Oss and Bio-Gide).

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clinical case 2 (cont)

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Fig 3-15 (cont) (q to t) After submerged healing of implants, the site was uncovered by making small slits using the same computerguided template. It was thus possible to avoid excessive traumatic damage to the tissues, which were subsequently conditioned by a provisional screw-retained prosthesis. (u to x) Once soft tissue conditioning was complete, two screw-retained zirconia-ceramic crowns were made.

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clinical case 2 (cont)

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Fig 3-15  (cont) (y to bb) Clinical follow-up 4 years after the end of prosthetic rehabilitation. The clinical and radiographic follow-up images demonstrate favorable integration of the implant-supported prostheses with the surrounding tissue and the patient’s pleasing smile. (cc and dd) Comparison between the pre- and posttreatment situations shows a considerable overall improvement in terms of esthetics and function. (Preliminary orthodontic treatment by Dr S. De Luca; prostheses by Mr A. Schoenenberger.)

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Fig 3-16  (a and b) Failure of a crown on the maxillary right canine due to secondary caries led to a need to replace this tooth. Because two implants were previously placed and restored in the adjacent premolar positions, it was decided to modify the existing implant-supported prosthesis by adding a pontic in the form of a mesial cantilever. (c to f) A ridge preservation technique was used to prevent collapse of the ridge profile at the extraction site with the aim of achieving optimal esthetics in the definitive prosthesis. The socket was filled with an osteoconductive biomaterial (Bio-Oss Collagen) and sealed using a collagen membrane (Bio-Gide). (g and h) A provisional prosthesis with an ovate mesial pontic was then positioned.

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l Fig 3-16  (cont) (i to l) Four months later, the ridge profile had been well maintained, and it was therefore possible to place a definitive prosthetic rehabilitation that also featured a mesial cantilever with an ovate pontic. (Regenerative surgery and prosthetic rehabilitation by Dr P. Casentini; prosthesis by Mr Alessandro Giacometti).

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What are the indications, advantages, and limitations of ridge augmentation techniques?

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What are the indications, advantages, and limitations of ridge augmentation techniques?

Indications Ridge augmentation techniques, which involve flap detachment and a regenerative technique, can essentially be defined as a GBR technique performed immediately after tooth extraction. Such techniques are indicated if socket walls are severely compromised, in which case simple extraction would lead to formation of a defect that would be subsequently difficult to correct or correctable only by means of complex regenerative techniques (Fig 3-17). Detachment of a full-thickness flap also allows complete removal of all periradicular inflammatory tissue, even if the defect anatomy is complex. While ridge preservation is performed using a flapless technique when damage is contained to the socket walls, ridge augmentation is indicated in cases of severely damaged walls and extensive radiotransparent periradicular lesions and involves raising a full-thickness flap.

Advantages With ridge augmentation techniques, treatment is simpler than with spontaneous healing. The advantage of using this

technique increases in direct proportion to the extraction socket defect size. If the socket walls are severely damaged, spontaneous healing would cause the formation of a large bony defect that would require a more complex reconstructive technique to correct.

Limitations • More complex surgical technique. Compared with ridge preservation, which involves a flapless technique, ridge augmentation requires elevation and passive advancement of a full-thickness flap as well as a regenerative technique. The operator therefore must be more surgically experienced. • More invasive surgical technique. Like any regenerative techniques, elevation and passive advancement of a full-thickness flap usually involves a greater degree of postoperative pain and swelling for the patient, who must be properly informed of this before surgery. • Longer treatment duration. With large defects, regeneration times can also be longer than with ridge preservation techniques, taking up to 9 months.

clinical case 3 Ridge augmentation after avulsion of a mandibular incisor with abnormal anatomy and complete loss of the buccal socket wall

Fig 3-17  (a and b) The treatment plan for this patient involved extraction of the maxillary left lateral incisor, which was characterized by abnormal anatomy and had been previously treated by orthograde and retrograde endodontic treatment. Deep buccal probing was another feature. The size of the roots make the site unsuitable for an immediate or deferred postextraction implant placement. a

b

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three  Decision-Making Criteria in Socket Management After Extraction

clinical case 3 (cont)

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h Fig 3-17  (cont) (c and d) After extraction, socket probing confirmed that the buccal socket wall was severely compromised. A full-thickness flap was therefore raised, and the extraction socket was completely decontaminated. (e to i) The defect is then treated by means of a ridge augmentation protocol. After positioning a collagen membrane and osteoconductive material (Bio-Oss and Bio-Gide), the flap was passively advanced and sutured.

i

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What are the indications, advantages, and limitations of ridge augmentation techniques?

clinical case 3 (cont)

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Fig 3-17 (cont) (j) The small area of crestal membrane exposure is protected by a provisional resinbonded prosthesis (k to p) Six months later, after a successful soft tissue healing process, it was possible to position an implant (Bone Level Tapered, 3.3 × 12 mm, Straumann) in the reconstructed bone volume without having to perform further regenerative procedures. (Regenerative and implant surgery by Dr P. Casentini.)

p

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7|

What are the final recommendations for treating a socket after extraction?

Based on the previous discussion, the authors suggest classifying extraction sockets into four different categories according to the anatomical situation (Fig 3-18). There are one or more preferred surgical techniques for each category.

Class I: Extraction site with favorable anatomical conditions Specific characteristics • Buccal cortical bone that is intact or affected by damage not exceeding 20% of the wall’s extent • Optimum soft tissue level • Possibility of achieving satisfactory primary stability

Surgical techniques • First choice: Immediate implant placement in extraction socket with a flapless technique, potentially combined with immediate placement of a prosthesis if primary stability is > 35 Ncm • Second choice: Ridge preservation and implant insertion after 4 to 6 months • Third choice: Early implant placement (6 to 8 weeks after extraction) with GBR

Class II: Extraction site with favorable anatomical conditions Specific characteristics • Buccal cortical bone that is intact or affected by damage not exceeding 20% of the wall’s extent • Optimal soft tissue level • Difficulty in achieving satisfactory primary stability and/or presence of anatomical structures limiting postextraction placement (eg, maxillary sinus floor, mandibular canal)

Class III: Partially compromised extraction site Specific characteristics • Resorption of the buccal cortical bone amounting to between 20% and 50% of the wall • Suboptimal soft tissue level and/or thin, scalloped periodontal biotype

Surgical techniques • First choice: Ridge augmentation, possibly with soft tissue augmentation, and implant placement after 6 months • Second choice: Delayed implant placement (3 to 4 months after extraction) with GBR

Class IV: Severely compromised extraction site Specific characteristics • Severely compromised socket walls, particularly when buccal wall loss exceeds 50% • Suboptimal soft tissue level and/or scalloped periodontal biotype • Presence of periradicular osteolytic lesions, periodontal lesions, and/or a large quantity of granulation tissue

Surgical techniques • First choice: Ridge augmentation, possibly with a soft tissue augmentation procedure, and implant placement after 6 to 8 months • Second choice: Extraction with possible soft tissue augmentation procedure and deferred implant placement (6 to 8 weeks) accompanied by GBR

Surgical techniques • First choice: Ridge preservation and implant placement after 4 to 6 months • Second choice: Delayed implant placement (3 to 4 months after extraction) with GBR

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References

Fig 3-18  The four extraction site treatment classes: Class I (a), Class II (b), Class III (c), and Class IV (d).

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References 1. Wilson TG Jr, Weber HP. Classification of and therapy for areas of deficient bony housing prior to dental implant placement. Int J Periodontics Restorative Dent 1993;13:451–459. 2. Hämmerle CH, Chen ST, Wilson TG Jr. Consensus statements and recommended clinical procedures regarding the placement of implants in extraction sockets. Int J Oral Maxillofac Implants 2004;19:26–28. 3. Chen ST, Buser D. Clinical and esthetic outcomes of implants placed in postextraction sites. Int J Oral Maxillofac Implants 2009;24(Suppl):186–217. 4. Esposito M, Grusovin MG, Polyzos IP, Felice P, Worthington HV. Timing of implant placement after tooth extraction: Immediate, immediate-delayed or delayed implants? A Cochrane systematic review. Eur J Oral Implantol 2010;3(3):189–205.

5. Hämmerle CH, Araújo MG, Simion M; Osteology Consensus Group 2011. Evidence-based knowledge on the biology and treatment of extraction sockets. Clin Oral Implants Res 2012;23(Suppl 5):80–82. 6. Lang NP, Pun L, Lau KY, Li KY, Wong MC. A systematic review on survival and success rates of implants placed immediately into fresh extraction sockets after at least 1 year. Clin Oral Implants Res 2012;23(Suppl 5):39–66. 7. Buser D, Chappuis V, Belser UC, Chen S. Implant placement post extraction in esthetic single tooth sites: When immediate, when early, when late? Periodontol 2000 2017;73:84–102. 8. Chen ST, Wilson TG Jr, Hämmerle CH. Immediate or early placement of implants following tooth extraction: Review of biologic basis, clinical procedures, and outcomes. Int J Oral Maxillofac Implants 2004;19(Suppl):12–25.

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Questions: 1. What are the key surgical factors in immediate postextraction implant placement? 2. When is immediate prosthetic restoration following immediate postextraction implant placement advisable? 3. When is soft tissue augmentation of an immediate postextraction implant site advisable? 4. Is immediate postextraction implant placement possible in a molar site? 5. What is the required waiting period before definitive prosthetic restoration of an implant placed immediately postextraction?

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What are the key surgical factors in immediate postextraction implant placement?

Certain factors common to all immediate postextraction implant placement procedures must be met to achieve clinical success: • Atraumatic tooth avulsion. See chapter 2 for an analysis of less traumatic avulsion techniques. • Esthetically guided implant placement taking into consideration the anatomy of the extraction socket. When an implant is placed immediately, accurate 3D positioning in relation to the prosthetic axis of the future restoration must be combined with consideration of the specific anatomical conditions of the socket after extraction. In particular in the maxillary area, it is necessary to avoid positioning the implant along the original axis of the extracted tooth because in many cases this would lead to fenestration

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Yes

of the apical portion of the thin buccal bone wall. Even positioning with a significantly more palatal axis, which would appear to be the ideal solution to achieve good primary stability, should be avoided to prevent later problems with the prosthesis and unsightly soft tissue recession. The ideal axis is an intermediate buccopalatal inclination, which takes advantage of the increased bone volume on the palatal side but also allows an optimal prosthetic axis to be achieved (Figs 4-1a to 4-1d). This option also allows a screw-retained restoration. To achieve this axis, it is useful to carry out the initial pilot drilling at the palatal socket wall using a spear-point bur, which unlike a round rose-head bur does not tend to slip on the palatal wall. Implant site preparation can then continue using successive conventional burs (Figs 4-1e to 4-1g).

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e Fig 4-1 (a to c) Excessive palatal or buccal inclination of the implant insertion axis in an immediate postextraction socket can be a source of later problems. (d) Optimal implant axis in an immediate postextraction socket. (e and f) Pilot drilling on the palatal wall using a spear-point bur. (g) After the pilot drilling, implant site preparation continues as usual using twist drills.

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What are the key surgical factors in immediate postextraction implant placement?

Achieving satisfactory primary stability Achieving sufficient primary stability is crucial for obtaining implant osseointegration. In an extraction site, an implant whose diameter and length perfectly fits the internal socket anatomy, contacting the internal cortical bone, should never be chosen because when the bundle bone is reabsorbed a few weeks after extraction, the implant could lose stability and any micromovements could impair its integration (Fig 4-2a). Instead, primary stability must be achieved by inserting the apical third of the implant into a triangle of preexisting bone located apically and palatally to the root apex, seeking to achieve an effective implant depth of at least 3 mm in preexisting bone (Figs 4-2b to 4-2d).

Buccopalatal position of the implant Buccopalatal positioning of the implant must consider the buccal cortical bone resorption pattern of the extraction socket (see chapter 2). In particular, several clinical and animal studies have shown that: • The average thickness of buccal cortical bone in sockets after extraction is less than or equal to 1 mm in most cases.1

• The buccal cortical bone of extraction sockets is mainly made up of bundle bone, into which periodontal ligament fibers are inserted. This thin bone plate will be reabsorbed after extraction.2 It is therefore advisable to maintain a certain distance between the buccal cortical bone (which is certain to be reabsorbed) and the implant platform (Fig 4-3).

Apicocoronal position of the implant The apicocoronal positioning must consider subsequent buccal cortical bone remodeling. Placing the implant prosthetic platform approximately 1 mm below the cortical bone compensates for partial vertical reabsorption of buccal cortical bone3 (see Fig 4-3). This parameter is effective only if the buccal wall is intact. Because immediate postextraction implants are often placed using a flapless technique, ie, without raising an access flap, probing of the bony ridge before and after extraction, known as bone sounding, identifies the position of the buccal cortical bone, which will represent the guiding parameter when choosing an apicocoronal implant position (Fig 4-4). Buccal bone wall integrity is also one of the main decision-making factors when choosing between immediate postextraction implant placement and ridge preservation (see chapter 3).

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Fig 4-2 (a) Postextraction implant engaging only the inner socket walls. (b to d) The surgical site must be prepared to include a triangle bone located apically and palatally to the natural socket apex. The implant will be able to achieve sufficient primary stability with a minimum depth of 3 mm in preexisting bone.

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Fig 4-3 Ideal buccopalatal and apicocoronal position of an implant in an immediate postextraction socket.

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Fig 4-4  (a and b) Assessing the bone ridge by means of bone sounding carried out after administering local anesthetic.

Filling the gap using a slow-resorbing osteoconductive material It is advisable to fill the gap between the implant and the cortical bone, keeping in mind the fate of the thin buccal cortical bone (Figs 4-5 to 4-8). Many clinical studies have confirmed that the alveolar ridge dimensions are more stable when the gap is filled, which compensates for remodeling of the alveolar ridge after extraction and maintains the horizontal component of bone volume. This step has a similar effect to a ridge preservation technique performed to coincide with implant insertion.4,5 To date, the most widely used biomaterial that is best supported by scientific evidence in this clinical situation is deproteinized bovine bone mineral (DBBM). The concept of bone-implant gap management has been reappraised in the light of recent findings from controlled randomized studies. It is now known that the gap must not be filled with the aim of achieving or improving immediate postextraction implant osseointegration. Instead it must be filled to maintain bony ridge volume and minimize contraction after extraction. With this in mind, gap filling performs

a role similar to that of ridge reservation techniques but with simultaneous implant placement. It therefore becomes very important to fill the gap as effectively as possible 360 degrees around the implant, avoiding the creation of underfilled areas.

Filling the gap before implant placement Filling the gap prior to implant placement is a further development of the socket-implant gap management technique. After implant placement, gap filling can sometimes be difficult, particularly in the more apical regions, because of the anatomy of the socket and the surgical site as well as the presence of implant threads (Fig 4-9). The option of filling the gap in advance is a very effective alternative from a clinical viewpoint. The biomaterial is packed into the gap, after which an implant analog is inserted to ensure that there has been no accidental penetration of the biomaterial into the apical portion of the site. This technique makes it possible to optimize filling of the apical component of the gap (Figs 4-10 and 4-11).

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Fig 4-5 (a and b) Horizontal bone remodeling follows immediate implant placement after extraction. If the gap is allowed to heal spontaneously by clot stabilization alone, the alveolar ridge will contract in a horizontal direction, particularly on the buccal side. (c to e) If the gap between bone and implant is filled with a biomaterial, particularly a slowly reabsorbed xenograft, this compensates for marginal bone remodeling to preserve the horizontal ridge volume.

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Fig 4-6  (a and b) After implant placement, the gap between the bone and the implant is filled to make up for remodeling of the socket walls after extraction.

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Fig 4-7  (a and b) The gap between the implant and buccal cortical bone is filled with a collagenated form of DBBM (Bio-Oss Collagen, Geistlich) that facilitates biomaterial handling and packing into the gap.

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Fig 4-8  (a and b) Immediate postextraction implant placement in the maxillary first premolar position. (c) The gap is filled with DBBM. (d) Four months later, newly formed bone is observed in contact with the implant, and horizontal ridge volume has been maintained.

Fig 4-9 Underfilling of the middle and apical portions of the gap.

Fig 4-10 The Cardaropoli compactor is a surgical instrument specially designed for boneimplant gap filling and ridge preservation techniques. It consists of two working parts. The hollow portion of the scoop on one side can be used to carry biomaterial to the surgical site, while the convex portion can be used to shape the biomaterial. A truncated cone-shaped compactor on the other side features a rounded tip that is 2.0 mm in diameter with three black reference notches spaced 5 mm apart. The specific truncated cone shape creates two force vectors when biomaterial is pressed into the extraction site, one in a apicocoronal direction and another in a lateral direction.

Choice of diameter and length of the implant to be inserted The sizes of the implant to be inserted in the extraction socket should always be defined with a certain amount of accuracy before surgery, based on local anatomical conditions. From an ergonomic viewpoint, it is nevertheless always useful to have alternative options regarding the diameter and length of the implant to be inserted. The simplest method for deciding on the implant to be inserted is superimposing a normal intraoral radiograph and the 1:1 projection film provided by implant manufacturers. Intraoral radiographs performed

using a digital technique allow precision measurements to be taken in order to choose the most appropriate implant (Fig 4-12). The software sometimes comes with a library of implants of varying diameters and lengths. Lastly, when there is some doubt about local anatomy or if the site is located near delicate anatomical structures (eg, the maxillary sinus or mandibular alveolar canal), a 3D CBCT scan can be requested (Fig 4-13). Although CBCT examinations should be reserved for selected cases in order to minimize the radiation dose to which patients are exposed, the information obtained allows implant surgery to be planned very thoroughly.

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What are the key surgical factors in immediate postextraction implant placement?

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Fig 4-11  Technique for preliminary filling of the gap between the implant site and the socket wall. (a) The tooth is extracted. (b) The implant site is prepared. (c) An implant analog instrument is used to check the axis and preparation depth. (d and e) The clinician begins to transfer biomaterial into the surgical site. (f to h) It is packed apically and laterally into the surgical site to prevent the anticipated gap between the bone and implant. (i) In this way, the gap is accurately filled, and the clinician can use the implant analog to check that no biomaterial granules have been left in the apical portion of the implant preparation site. (j) The implant is then placed, partially in contact with the biomaterial.

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Fig 4-12  (a to c) In most cases, normal radiographs carried out using a centering device, analog, and digital parallelism technique are sufficient for choosing the size of a postextraction implant.

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Fig 4-13  A CBCT examination shows the area in question in three spatial dimensions. In the case shown here, a maxillary second premolar needs to be extracted due to failure of a prosthetic reconstruction. (a) The radiograph makes it impossible to perform an accurate presurgical diagnosis, leaving many uncertainties over actual site anatomy and the consequent possibility of placing an immediate postextraction implant. (b) A CBCT scan is therefore performed with volume of 5 × 5 cm and isotropic resolution of 0.09 mm using a CS 9300 device (Carestream). (c) The 3D images show that the root apex is positioned in the vicinity of the buccal cortical bone with a notch in the maxillary sinus located palatally to the apex. (d) A more mesial section highlights the presence of a bone septum with the sinus floor migrated to a more apical position to allow immediate implant placement. (e and f) Presurgical virtual planning reveals the possibility of inserting an implant measuring 4 mm in diameter and 13 mm in length with its long axis displaced in relation to the natural tooth and the apex mesially displaced. (g and h) A follow-up CBCT scan performed 12 months after loading shows that the implant is correctly positioned in relation to the virtual planning.

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When is immediate prosthetic restoration following immediate postextraction implant placement advisable?

2|

When is immediate prosthetic restoration following immediate postextraction implant placement advisable?

The option of immediate prosthetic treatment for an implant placed immediately postextraction is very beneficial for patients, who have the satisfaction of seeing a missing tooth immediately repaired, albeit provisionally. For clinicians, immediate prosthetic treatment of an implant is also advantageous because the provisional prosthesis performs the task of conditioning the soft tissues immediately, maintaining their shape while allowing the gap between the implant and soft tissues to be protected and sealed.6 From a scientific viewpoint, this procedure is now supported by enough evidence7–9 to allow its recommendation in certain clinical situations. The basic elements that clinicians must assess before deciding to carry out immediate prosthetic treatment are described below.

Sufficient primary implant stability Primary implant stability remains the main parameter for choosing this clinical option. Primary stability can easily be assessed by means of implant insertion torque, which in turn can be assessed by the implant motor or a torque wrench, depending on whether the implant is inserted by means of a handpiece or manually (Fig 4-14). The minimum recommended torque for immediate prosthetic treatment is 35 Ncm. Some state-of-the-art implant motors with a control display can show the torque trend and quantify torque in relation to time and rpm. This type of dynamic display makes it possible to check the torque trend throughout the implant placement stage and not merely the final placement torque (Fig 4-15).

Implant primary stability can also be evaluated using an electronic instrument that carries out a resonance frequency analysis (RFA). This instrument (Osstell) displays a number reflecting the implant stability quotient (ISQ). Minimum resonance frequency value for the purposes of immediate prosthetic treatment is usually acknowledged to be 70 ISQ (Fig 4-16).

Implant axis compatible with creation of a screw-retained provisional restoration Irrespective of the clinical choice of permanent restoration type, a direct screw-retained provisional prosthetic restoration offers undeniable advantages. The most important of these is the possibility of avoiding the use of cement, which at this stage could be left below the abutment and may invade the coronal aspect of the fresh socket. Another advantage is the possibility of achieving better control of the provisional restoration emergence profile. In order to be able to fit a screw-retained immediate provisional prosthesis, the implant axis must fall within the occlusal surface in posterior areas and remain at the palatal surface level (if possible, between the incisor margin and the cingulum) in anterior areas. For this reason, when immediate prosthetic treatment is planned, it is advisable to use a surgical template containing the provisional crown shell. The template will make it possible to establish an axis compatible with a screw-retained restoration from the early stages of implant site preparation (Fig 4-17). Implant placement will thus be prosthetically guided.

Fig 4-14  Checking placement torque and implant primary stability using a torque wrench.

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a Fig 4-15  Graph showing torque plot in relation to rpm and implant insertion time for an implant achieving an insertion torque of 50 Ncm. The graph shown on the iChiropro (Bien-Air) surgical motor display shows the torque increasing gradually during implant placement, which means that the implant is in direct contact with bone from the early stages of placement.

b Fig 4-16  (a and b) Checking primary stability by electronic RFA.

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Fig 4-17  (a to f) A thermoformed surgical template facilitates prosthetically guided implant placement in a maxillary lateral incisor extraction socket with the aim of creating a screw-retained restoration.

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When is soft tissue augmentation of an immediate postextraction implant site advisable?

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When is soft tissue augmentation of an immediate postextraction implant site advisable?

Some clinical studies have highlighted the possibility of counteracting soft tissue contraction and improving the definitive esthetic outcome in immediate postextraction sites by means of connective tissue grafts10,11 (Figs 4-18 and 4-19). From a

clinical viewpoint, the use of a connective tissue graft cannot always be justified; however, this technique may be advisable in certain situations (eg, with a thin gingival biotype).

Fig 4-18 Example of connective tissue graft positioning technique performed at the same time as immediate implant placement. The graft is positioned between the connective tissue and buccal cortical bone, if possible in a supraperiosteal position, using a flapless approach or by raising a flap. This graft does not obviate the need to pack the gap between bone and implant with a biomaterial.

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Fig 4-19  (a to d) In this case, inserting a connective tissue graft at the same time as an immediate postextraction implant leads to the formation of a thick layer of dense connective tissue that guarantees the stability of the peri-implant soft tissues.

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Is immediate postextraction implant placement possible in a molar site?

Maxillary and mandibular molar root anatomy can contraindicate immediate postextraction implant placement. The interradicular septum often does not allow sufficient primary implant stability to be achieved. A large area of the implant surface is also out of contact with the surrounding bone tissue. If the implant is inserted into one of the root sockets, however, the implant position would be asymmetric in relation to the crown that it would eventually support. The criterion

for prosthetically guided implant placement would therefore not be met. However, in some cases, when anatomical conditions are favorable and particularly when the septum is well represented, it is possible to prepare a molar implant site in a prosthetically guided position (Fig 4-20). In such cases, it will then be possible to place the implant and compensate for any discrepancy between the extraction socket and implant morphology using a regenerative technique.

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Fig 4-20  (a to d) Presurgical evaluation of implant placement in the interradicular septum of a maxillary first molar. The root anatomy allows placement of an implant with a diameter of 5 mm and length of 10 mm in a prosthetically favorable position. (See Fig 4-27 for the complete case presentation.)

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Clinical Case Studies

5|

 hat is the required waiting period before definitive W prosthetic restoration of an implant placed immediately postextraction?

If an immediate postextraction implant is restored with an immediate provisional prosthesis (normally using a flapless technique), the definitive prosthesis may be fitted after only 3 months once osseointegration has taken place. If the implant has undergone transmucosal healing but is not immediately fitted with a prosthesis (eg, because of insufficient primary stability), after a period of 3 to 4 months prosthetic loading can usually be started with a provisional crown. The definitive

prosthesis can be fitted after an additional 2 months, once favorable soft tissue conditioning has taken place. In cases where the implant is submerged because it is combined with more complex reconstructive techniques that usually involve raising of a flap, after 4 to 6 months the second surgical step of connecting a healing screw can be carried out along with subsequent provisional prosthetic treatment, followed by the definitive prosthesis 2 months later (Fig 4-21).

Flap

Submerged/ transmucosal healing

Provisional restoration at 3 to 4 months

Definitive restoration at 5 to 6 months

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Definitive restoration at 6 months

Provisional restoration at 2 to 3 months

Definitive restoration at 3 to 4 months

Definitive restoration at 3 to 4 months

Fig 4-21  Various stages of prosthetic treatment with immediate postextraction implant placement.

Clinical Case Studies Figures 4-22 to 4-31 present clinical cases demonstrating different applications of immediate postextraction implant placement.

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clinical case 1 Immediate postextraction implant placement with submerged healing

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Fig 4-22  (a and b) Initial clinical and radiographic status. A maxillary second premolar shows destruction of the crown with a periapical lesion and caries infiltration near the alveolar bone margin. Clinical crown lengthening is contraindicated as it would require an osteotomy to be performed on the distal surface of the first premolar. (c to e) The treatment plan involves root extraction and immediate implant placement. The root is extracted atraumatically, preserving soft tissue integrity by means of a flapless approach. (f to h) The implant insertion axis is modified in relation to the natural root axis, preparing the implant site in the socket by exploiting the interradicular bone septum volume. After inserting a tapered fixture measuring 5 mm in diameter and 13 mm in length, the gap between bone and implant is packed with bovine bone substitute.

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Clinical Case Studies

clinical case 1 (cont)

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Fig 4-22  (cont) (i and j) The implant is protected by a porcine collagen membrane trimmed to the size of the socket and stabilized with a crossed horizontal mattress suture in 5-0 silk. Three months later, the implant is completely covered by newly formed soft tissue. (k to n) Three months after placement, the implant site is reopened by making a slit. The prosthetic loading stage starts with the seating of a titanium pin and cementing of a provisional resin crown. The definitive ceramic crown is cemented in place 2 months later. (o to p) At the 1-year follow-up visit, the initial soft tissue profile, papilla height, and buccopalatal contour have been fully preserved.

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clinical case 2 Immediate postextraction implant placement with transmucosal healing

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Fig 4-23  (a to c) Initial images. A maxillary second premolar is affected by a crown-root fracture. The fracture line located below the alveolar bone margin suggests an unfavorable prognosis. The indicated treatment is tooth extraction and replacement by an implant. The radiograph shows that the root apex is near the maxillary sinus floor. The implant will establish primary stability in the maxillary sinus cortical bone laterally through a crestal lift procedure and also in the middle and apical third through the use of an implant with a diameter larger than that of the natural root. (d to f) The extraction is carried out using a flapless technique, preserving soft tissue integrity. The osteotome is positioned in the socket, and the sinus floor fracture is repaired by inserting a biomaterial (ie, Modified Summers technique). (g to j) After implant insertion (3i Tapered 5 × 13 mm, Zimmer Biomet), the gap is filled with biomaterial (Bio-Oss Collagen) and protected with an appropriately trimmed resorbable collagen membrane (Bio-Gide, Geistlich). A healing abutment is tightened onto the implant head.

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Clinical Case Studies

clinical case 2 (cont)

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Fig 4-23  (cont) (k and l) Three months later, when osseointegration has taken place and the soft tissues have matured, prosthetic loading can proceed. (m and n) A provisional resin prosthesis is cemented in place 3 months after implant placement. Following a further 2 months, a definitive ceramic crown is positioned. (o and p) The 1-year follow-up shows that the soft tissues have maintained their original configuration, both vertically (height of the interdental papillae and buccal gingival margin) and horizontally (buccopalatal width).

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clinical case 3 Immediate postextraction implant placement with immediate prosthetic treatment in the esthetic region

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Fig 4-24  (a to d) The initial clinical status reveals a crown-root fracture affecting the maxillary left central incisor, extending 3 mm subginivally. The soft tissues are substantially intact, with a sufficient band of keratinized tissue and the gingival margin slightly coronal in relation to the contralateral central incisor. (e to h) Following extraction performed using a flapless method, the implant site is prepared, moving the implant axis to a palatal position in relation to the center of the extraction socket. After tightening the implant (Certain Tapered 5 × 15 mm, Zimmer Biomet) in place, the remaining gap of at least 2 mm is packed with biomaterial (Bio-Oss Collagen).

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Clinical Case Studies

clinical case 3 (cont)

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Fig 4-24  (cont) (i and j) Following extraction using a flapless method, the implant site is prepared, moving the implant axis palatally in relation to the center of the extraction socket. After tightening the implant (Certain Tapered 5 × 15 mm) in place, the remaining gap of at least 2 mm is packed with biomaterial (Bio-Oss Collagen). (k and l) Proper spatial positioning requires the implant axis to be more palatal than the natural root axis. This leaves a bone-implant gap around the circumference of the implant. If this is packed with slow-resorbing biomaterial, alveolar ridge volume can be preserved. At the same time, the implant axis emerges occlusally, between the incisal margin and the cingulum, to allow a screw-retained prosthesis to be placed immediately. When a prosthesis is fitted immediately after extraction, screw-retained crowns are preferable to a cemented option. (m and n) A provisional polytetrafluoroethylene pin is tightened to the implant head, and a provisional resin crown is secured to the pin using acrylic resin.

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clinical case 3 (cont)

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Fig 4-24  (cont) (o to s) The composite transmucosal portion is made chairside. The provisional crown is tightened in place, avoiding any contact occlusally and in protrusive and lateral movements. The 4- (r) and 12-week (s) follow-up views show soft tissue healing. (t to w) The contour of the soft tissues, which have completely matured 3 months after implant placement, follows the profile created by the provisional prosthesis. Now an impression can be taken for the definitive crown without any inflammation. A zirconia abutment is prepared, and a full ceramic crown is made, replicating the soft tissue anatomy.

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Clinical Case Studies

clinical case 3 (cont)

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Fig 4-24  (cont) (x and y) Vertical papilla height has been maintained. Buccal soft tissue thickness has also been maintained horizontally at the crown margin. (z to bb) Five-year clinical and radiographic follow-up. The long-term follow-up demonstrates the possibility of maintaining an excellent esthetic and functional result even in a case of immediate implant placement with immediate prosthetic treatment. The soft tissue contour is still well shaped, providing the crown with satisfactory support because immediate placement of the prosthesis allowed the original profile to be maintained. A radiograph shows that the mesial and distal bone margins are stable at the implant-abutment connection level as a result of the platform-switching technique.

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clinical case 4 Gap filling prior to immediate postextraction implant placement with immediate application of a prosthesis

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Fig 4-25 (a to f) The initial radiographic status shows root resorption inside the root of a maxillary central incisor in a 43-year-old patient. This is confirmed by the postextraction image of the tooth. Initial clinical evaluation highlights the esthetic status, with the papillae fully present, well-contoured gingival profiles, and the absence of gingival recession. (g to l) The tooth is extracted using a flapless technique, preserving the anatomical integrity of the soft tissues and the thin buccal septum. Implant site preparation is prosthetically guided, and the implant is placed using a surgical template to ensure that the implant axis is palatal to the axis of the natural socket.

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Clinical Case Studies

clinical case 4 (cont)

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Fig 4-25  (cont) (m to p) The socket is packed with bone substitute biomaterial (Bio-Oss Collagen). A specially designed truncated, coneshaped, bone-compacting instrument (Cardaropoli instrument, Omnia) is used to fit the biomaterial to the walls of the socket to fill the gap between bone and implant before implant insertion. A similar implant tool is used to check that the implant preparation site is free of biomaterial granules to allow proper seating of the implant. (q and r) This technique of managing the bone-implant gap before implant placement allows the gap to be filled perfectly, avoiding the formation of underfilled areas in the middle and apical thirds. After implant insertion, the biomaterial can be seen to fit perfectly between the titanium implant and extraction socket bone walls. (s to v) A provisional polytetrafluoroethylene pin is then seated chairside. A provisional acrylic resin crown is secured to this pin. The fit is facilitated by two palatal positioning tabs that are subsequently removed at the finishing stage.

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clinical case 4 (cont)

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Fig 4-25  (cont) (w and x) A cotton pellet is used to prevent acrylic resin from invading the path of the retaining screw. The provisional crown portion that will remain below the free gingival margin has been remodeled in composite material for better polishing and biocompatibility. (y to z) After finishing and polishing, the provisional crown provides ideal support for the soft tissues, maintaining them in exactly the same position as prior to surgery in both the vertical and horizontal dimensions. (aa to cc) Follow-up radiographs and a CBCT assessment show the ideal 3D positioning of the implant following prosthetic guidance. The cross-sectional view also demonstrates that the gap between the bone and implant has been sufficiently packed with biomaterial. (dd to gg) Once osseointegration has been achieved three months later, a final impression can be taken. The soft tissues have maintained their initial morphology, and the peri-implant transmucosal path is wide and well shaped.

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Clinical Case Studies

clinical case 4 (cont)

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Fig 4-25 (cont) (ff and gg) TThe soft tissue anatomy is replicated using a custom impression transfer. This is used to prepare a zirconia abutment that will effectively support the soft tissues. (hh to jj) Follow-up carried out 12 months later shows that the prosthesis perfectly fits the soft tissues, which have maintained their initial vertical contour (papilla height and buccal profile) and horizontal contour (buccal thickness of the mucosa). Platform switching has minimized peri-implant bone remodeling, optimizing the marginal bone level 1 year later.

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clinical case 5 Gap filling prior to immediate postextraction implant placement

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Fig 4-26  (a to d) When a tooth has a poor prognosis and the treatment plan requires immediate implant placement, the authors recommend atraumatic, flapless extraction to safeguard soft tissue integrity and buccal cortical bone thickness. The implant site is then prepared to allow the implant to achieve satisfactory primary stability in a prosthetically guided position. (e) Positioning of the implant analog reveals the gap that will exist between the bone and implant. (f to i) The biomaterial is transferred to the socket entrance and gently pushed inside, fitting it to the socket walls circumferentially, carefully preventing any granules from settling in the apical area of the implant site. In this manner, small successive amounts of biomaterial are added, leaving space for implant placement.

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Clinical Case Studies

clinical case 5 (cont)

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Fig 4-26 (cont) (j to m) To ensure that the socket is properly filled with biomaterial, the implant analog is inserted, confirming that it reaches the bottom of the prepared implant site. Only at this point is the implant tightened. The gap between bone and implant is therefore perfectly filled, leaving no empty spaces at the middle and apical thirds. (n to s) The implant is immediately fitted with a prosthesis, using an acrylic resin crown secured to a provisional abutment screwed directly into the implant. Three months later, the soft tissue contour has been completely preserved horizontally and vertically at the interdental papilla level. This makes it possible to fit a definitive ceramic crown that perfectly matches the soft tissue profile, replicating the initial esthetic situation.

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clinical case 6 Immediate postextraction implant placement in a maxillary molar site

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Fig 4-27  (a and b) The patient presented for treatment of caries infiltration of a maxillary first molar with a large amalgam filling. The radiograph shows that the limit of the healthy tooth tissue on the mesial portion of the tooth is positioned at the bone ridge level. To preserve the tooth, it would be necessary to lengthen the clinical crown with an ostectomy with inevitable loss of attachment on the adjacent premolar root. There is also evidence of failed root canal treatment, with a periapical lesion at the mesial root apex. Clinical and radiographic information therefore suggests tooth extraction and subsequent replacement with an implant. (c and d) CBCT reveals an extensive interradicular bone septum in both horizontal and vertical directions. Immediate postextraction implant placement is therefore considered. (e and f) After clinical crown removal, the three roots are separated and extracted individually to keep the buccal cortical bone intact. (g and h) The interradicular bone septum is very evident, and the implant site is prepared precisely in its center. To increase the available bone in a vertical direction, a maxillary sinus elevation procedure is performed with access via the ridge, using biomaterial (Bio-Oss Collagen) and a Modified Summers technique.

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Clinical Case Studies

clinical case 6 (cont)

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Fig 4-27  (cont) (i) An implant measuring 5 mm in diameter and 11.5 mm in length is then placed. (j and k) The peri-implant gap and root socket are filled with slowly resorbing biomaterial (0.25- to 1-mm granules of Bio-Oss) and protected by a resorbable collagen membrane (BioGide) that is shaped around the implant healing screw. The soft tissues are sutured at the interproximal papilla level. (l to n) Radiographic and CBCT images show that the implant has been properly placed, with a dome of perfectly adapted biomaterial below the sinus membrane. (o and p) Four months later, the implant has integrated, and the soft tissues are perfectly healed and mature.

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clinical case 6 (cont)

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Fig 4-27  (cont) (q and r) A check-up 12 months after loading shows that the ceramic crown is well adapted with the soft tissues well supported and healthy. (s to u) Radiographic and CBCT images taken 12 months after loading show a physiologic marginal bone level, maintenance of horizontal bone volume, and new cortical bone in the maxillary sinus.

clinical case 7 Immediate postextraction placement of multiple implants in a mandibular posterior area

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Fig 4-28  (a and b) A mandibular second premolar and first molar are judged to be unrecoverable following endodontic, reconstructive, and prosthetic assessments.

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Clinical Case Studies

clinical case 7 (cont)

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Fig 4-28  (cont) (c to e) CBCT images show available bone height in relation to the inferior alveolar nerve canal to be 5.7 mm apical to the premolar, 5.8 mm apical to the molar roots, and 9.6 mm at the molar furcation. It is therefore decided to carry out immediate postextraction implant placement. (f and g) After removing the ceramic crowns, the molar roots are separated, and a small flap is raised to reveal the thin buccal cortical bone. (h to k) Two implants are inserted, with diameters of 4 mm in the premolar site and 5 mm in the molar site. Both are positioned 1.5 mm below ridge level. The gap is filled with a biomaterial (Bio-Oss Collagen), and at the same time biomaterial is also positioned to cover the implant heads and on the buccal aspect of the cortical bone. A porcine collagen matrix (Mucograft Seal, Geistlich) is then positioned for protection. The soft tissues are sutured at the interproximal level, while the collagen matrix is sutured at the sulcus level to achieve open healing rather than healing by first intention.

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clinical case 7 (cont)

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Fig 4-28  (cont) (l) Open healing of the collagen matrix allows epithelial migration by second intention; epithelial cells act as a scaffold to support soft tissue regeneration. Three weeks after surgery, the soft tissues are almost fully healed. (m) After 4 months, the tissues have matured with optimal coverage of the implant heads. (n and o) The stage-two surgery is performed by raising a flap, which reveals bone regeneration that has partially covered the implant tightening screws. The gap between bone and implant is perfectly filled with new tissue, and the buccal and lingual cortical bone is thick enough to maintain long-term peri-implant support. (p and q) The final clinical and radiographic images show how well the prosthesis and implants are integrated. The prosthesis is protected by a band of keratinized tissue that is broad enough to guarantee peri-implant tissue health.

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Clinical Case Studies

clinical case 8 Immediate postextraction implant placement in a mandibular premolar site combined with a connective tissue graft

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Fig 4-29  (a and b) The initial clinical and radiographic status reveals the presence of a mandibular premolar that has previously undergone a displaced root fracture following an accident. Because the soft tissues around the tooth to be extracted are thin, the treatment plan involves immediate postextraction implant placement combined with gap filling and a dense connective tissue graft taken from the maxillary tuberosity. (c to e) The two root fragments are gently luxated using periotomes and extracted, attempting not to damage the residual socket walls.

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clinical case 8 (cont)

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Fig 4-29  (cont) (f to i) After avulsion, the implant site is prepared using a prosthetically guided technique with the aim of placing a screwretained restoration. The gap is then filled with successive layers of deproteinized bovine bone in a collagen matrix (Bio-Oss Collagen). The biomaterial is compacted in the direction of the buccal wall using an appropriate compacting device (Cardaropoli Instrument) prior to implant placement. When the gap is narrow and deep, it is more difficult to fill after implant placement. (j and k) The next step is to insert the implant (Bone Level Tapered 4.1 × 12 mm, Straumann), connect a healing screw, and further compact the biomaterial. If the biomaterial also occupies the supracrestal portion of the gap, it will be more difficult to prepare a tunnel for subsequent connective tissue graft insertion.

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Clinical Case Studies

clinical case 8 (cont)

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Fig 4-29 (cont) (l to o) A special tunneling instrument is therefore used to create a tunnel between the buccal cortical bone and superficial soft tissues. A dense connective tissue graft taken from the maxillary tuberosity area is then positioned inside this. Before placement, the graft is de-epithelialized and shaped to fit the host site. (p to r) The connective tissue graft is left partially exposed coronally and secured to the surrounding soft tissues by means of a reduced-diameter resorbable suture (Vycril 6-0, Ethicon) to prevent the graft from moving.

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clinical case 8 (cont)

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x Fig 4-29  (cont) (s to x) Provisional prosthesis stage. After 2 months of healing, the healing screw is removed, and an impression is taken with precision material. A screw-retained provisional crown allows satisfactory conditioning of the surrounding soft tissues.

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Clinical Case Studies

clinical case 8 (cont)

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Fig 4-29  (cont) (y to bb) Taking an impression for the definitive restoration. After 2 months of soft tissue conditioning, the peri-implant tissues look well contoured and free of inflammation. The transmucosal part of the provisional prosthesis is then replicated by means of a custom impression transfer technique, and a final polyether impression is taken (Permadyne and Impregum, 3M ESPE). (cc to ff) Definitive prosthetic restoration. A screw-retained restoration was possible because of the favorable prosthetic axis, which was selected from the outset. In particular, a zirconia-ceramic crown was bonded to a titanium base (Variobase, Straumann). (Prosthesis by Mr A. Giacometti.)

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clinical case 8 (cont)

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Fig 4-29  (cont) (gg to ii) Final clinical and radiographic follow-ups show that the crown has integrated well with the surrounding hard and soft tissues. A buccal view of the restoration highlights a natural emergence profile in line with the profile of the adjacent teeth. (Implant surgery and prosthetic rehabilitation by Dr P. Casentini)

clinical case 9 Immediate postextraction implant placement associated with a connective tissue graft in the esthetic zone

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Fig 4-30  (a and b) Initial clinical status: the root of the maxillary left lateral incisor offers insufficient residual dental structure. It is planned to extract the root and perform immediate postextraction implant placement. (c) Preliminary measurement reveals the presence of a thin layer of buccal soft tissue. (d and e) After atraumatic avulsion, the next step is to prepare the implant site and then insert a reduced-diameter cylindrical implant (Bone Level implant 3.3 × 12mm, Straumann). Note that the implant axis is compatible with a screw-retained restoration.

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Clinical Case Studies

clinical case 9 (cont)

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Fig 4-30 (cont) (f to h) The desired gap between the implant and buccal cortical bone, achieved by shifting the implant position palatally, is filled using a slow-resorbing biomaterial (Bio-Oss Collagen). (i and j) A special instrument is used to create a tunnel between the superficial soft tissues and the buccal cortical bone. (k to n) A fragment of connective tissue is taken from the maxillary tuberosity area, deepithelialized, and then inserted into the previously created tunnel, where it is stabilized by means of sutures.

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clinical case 9 (cont)

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w Fig 4-30  (cont) (o) Radiographic followup shows correct positioning of the implant. (p) Buccal view after suturing. (q and r) Comparison of soft tissue thickness before and after treatment. (s to u) Proper planning of the implant axis made it possible to achieve a screw-retained zirconia-ceramic prosthetic restoration. In this case, the ceramic veneer was layered directly above the CAD/ CAM zirconia mesostructure. (Prosthesis made by Mr C. Pedrinazzi and Mr R. Colli.) (v) A final clinical follow-up shows that the crown is well integrated into the surrounding hard and soft tissues. (w) A long-term follow-up radiograph shows the stability of the peri-implant bone level. (x) The end result is pleasing.

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Clinical Case Studies

clinical case 10 Implant placement in extraction and healed sites with subsequent immediate loading in the maxilla

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Fig 4-31 (a to i) Initial clinical and radiographic status. The prognosis of the residual tooth structure of the maxillary left central incisor to first premolar is unfavorable because of the presence of subgingival caries lesions. The low smile line, the good quality of the residual soft tissues that show no signs of inflammation, and the presence of sufficient bone volume apical to the residual roots are favorable factors for immediate postextraction implant placement. (j) A lateral view also shows the presence of a favorable maxillomandibular relationship. Given the clinical and radiographic status, this patient’s treatment plan involves placing six implants in the maxillary central incisor, canine, and first premolar sites bilaterally and subsequent placement of a provisional prosthesis with immediate loading, to be replaced a few months later by a screw-retained metal-ceramic prosthesis. The fixed partial denture in the maxillary left posterior region will be maintained.

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clinical case 10 (cont)

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Fig 4-31  (cont) (k and l) The dental laboratory prepares a provisional prosthesis based on preliminary interocclusal impressions and records. This provisional prosthesis includes a palatal stabilization plate and a tooth-mounted support that will be kept to allow accurate positioning during surgery. Large holes have also been prepared at the planned implant sites. The provisional prosthesis serves the dual purpose of a surgical template to achieve prosthetically guided implant placement and a screw-retained prosthesis. (m to p) The implants (SLActive Bone Level, Straumann) are placed in extraction sites in the left maxilla and healed sites in the right maxilla. The provisional prosthesis facilitates prosthetically guided placement.

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Clinical Case Studies

clinical case 10 (cont)

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Fig 4-31 (cont) (q and r) After placing the implants, the gaps between the extraction sockets and the implants are filled using particulate bovine bone (Bio-Oss). (s and t) Provisional titanium prosthetic abutments are connected to the implants, and the flap is sutured. The soft tissues are protected by a perforated sheet of rubber dam. (u and v) The provisional prosthesis is re-seated. After checking that the position is accurate using the palatal plate supported on the residual teeth in the maxillary left posterior region, an indexing procedure is performed to secure the provisional abutments to the provisional prosthesis using self-curing resin. (w and x) Delivery of the provisional prosthesis 24 hours after implant placement. The healing screws that were positioned after the indexing procedure are removed, and the provisional prosthesis is treated with chlorhexidine gel prior to placement.

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clinical case 10 (cont)

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ee Fig 4-31  (cont) (y to cc) Clinical and radiographic follow-up after positioning the provisional prosthesis 24 hours after implant surgery. The prosthetic load is distributed as evenly as possible, and the patient is advised to eat a soft diet during the first month of loading. (dd) The patient’s smile after immediate loading of the prosthesis shows satisfactory restoration of the esthetic appearance. (ee and ff) After a 3-month period, implant osseointegration is confirmed, and the healed periimplant soft tissues are free of inflammation.

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Clinical Case Studies

clinical case 10 (cont)

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Fig 4-31 (cont) (gg to kk) It is now possible to take the final impressions using a polyether material (Impregum and Permadyne, 3M ESPE). In the same session, the maxillomandibular relationships are recorded. In this case, this was facilitated by the presence of some residual teeth in occlusion (in the left posterior region). The records are taken by means of special press-fitted plastic components, adjusted to the correct maxillomandibular height and relined with self-curing resin.

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clinical case 10 (cont)

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qq Fig 4-31  (cont) (ll to rr) Overall view and detail of the prosthesis prior to delivery. A cantilever with two premolar teeth has been formed on the right side. Given the favorable distribution of the implants, ensuring a satisfactory anteroposterior spread, this is considered to be a reliable long-term solution. Prosthetically guided implant positioning allowed the prosthesis to be seated directly on the implants.

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Clinical Case Studies

clinical case 10 (cont)

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vv Fig 4-31  (cont) (ss to vv) Delivery of definitive implant-supported prosthesis. The internal aspect of the implants and the prosthetic device are disinfected with chlorhexidine gel. The retaining screws are activated with a torque of 35 Ncm, and the access holes are sealed with polytetrafluoroethylene tape and composite. (Implant surgery and prosthetic rehabilitation by Dr P. Casentini; prostheses by Mr A. Schoenenberger.)

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clinical case 10 (cont)

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Fig 4-31  (cont) (ww to bbb) Final clinical views and the patient’s smile after rehabilitation. Color adjustment by the dental technician made it possible to match the rehabilitation very naturally with the face of the patient, who is elderly.

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Clinical Case Studies

clinical case 10 (cont)

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Fig 4-31 (cont) (ccc and ddd) Clinical and radiographic follow-up after 4 years. Note the favorable soft tissue conditions and substantial maintenance of the peri-implant bone levels. (eee to ggg) Removal of the implant-supported prosthesis at a later stage. Note how the peri-implant soft tissues have been further conditioned by the presence of the prosthesis and are free of inflammation.

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References 1. Huynh-Ba G, Pjetursson BE, Sanz M, et al. Analysis of the socket bone wall dimensions in the upper maxilla in relation to immediate implant placement. Clin Oral Implants Res 2010;21:37–42. 2. Araújo MG, Sukekava F, Wennström JL, Lindhe J. Ridge alterations following implant placement in fresh extraction sockets: An experimental study in the dog. J Clin Periodontol 2005;32:645–652. 3. Caneva M, Botticelli D, Morelli F, Cesaretti G, Beolchini M, Lang NP. Alveolar process preservation at implants installed immediately into extraction sockets using deproteinized bovine bone mineral–An experimental study in dogs. Clin Oral Implants Res 2012;23:789– 796. 4. Araújo MG, Linder E, Lindhe J. Bio-Oss collagen in the buccal gap at immediate implants: A 6-month study in the dog. Clin Oral Implants Res 2011;22:1–8. 5. Cardaropoli D, Gaveglio L, Gherlone E, Cardaropoli G. Soft tissue contour changes at immediate implants: A randomized controlled clinical study. Int J Periodontics Restorative Dent 2014;34:631–637. 6. Cardaropoli D, Tamagnone L, Roffredo A, Gaveglio L, Cardaropoli G. Socket preservation using bovine bone mineral and collagen membrane: A randomized controlled clinical trial with histologic analysis. Int J Periodontics Restorative Dent 2012;32:421–430.

7. Kan JY, Rungcharassaeng K, Lozada J. Immediate placement and provisionalization of maxillary anterior single implants: 1-year prospective study. Int J Oral Maxillofac Implants 2003;18:31–39. 8. Lang NP, Lui P, Lau KY, Li KY, Wong MCM. A systematic review on survival and success rates of implants placed immediately into fresh extraction sockets after at least 1 year. Clin Oral Implants Res 2012;23:39–66. 9. Chu SJ, Hochman MN, Tan-Chu JH, Mieleszko AJ, Tarnow DP. A novel prosthetic device and method for guided tissue preservation of immediate postextraction socket implants. Int J Periodontics Restorative Dent 2014;34(suppl 3):s9–s17. 10. Grunder U. Crestal ridge width changes when placing implants at the time of tooth extraction with and without soft tissue augmentation after a healing period of 6 months: Report of 24 consecutive cases. Int J Periodontics Restorative Dent 2011;31:9–17. 11. Yoshino S, Kan JY, Rungcharassaeng K, Roe P, Lozada JL. Effects of connective tissue grafting on the facial gingival level following single immediate implant placement and provisionalization in the esthetic zone: A 1-year randomized controlled prospective study. Int J Oral Maxillofac Implants 2014;29:432–440.

Recommended Reading Araújo MG, Lindhe J. Dimensional ridge alterations following tooth extraction. An experimental study in the dog. J Clin Periodontol 2005;32:212–218. Araújo MG, Lindhe J. Ridge preservation with the use of Bio-Oss collagen: A 6-month study in the dog. Clin Oral Implants Res 2009;20:433–440. Becker BE, Becker W, Ricci A, Geurs N. A prospective clinical trial of endosseous screw-shaped implants placed at the time of tooth extraction without augmentation. J Periodontol 1998;69:920–926. Botticelli D, Berglundh T, Lindhe J. Hard-tissue alterations following immediate implant placement in extraction sites. J Clin Periodontol 2004;31:820–828. Botticelli D, Renzi A, Lindhe J, Berglundh T. Implants in fresh extraction sockets: A prospective 5-year follow-up clinical study. Clin Oral Implants Res 2008;19:1226–1232. Canullo L, Iurlaro G, Iannello G. Double-blind randomized controlled trial study on post-extraction immediately restored implants using the switching platform concept: Soft tissue response. Preliminary report. Clin Oral Implants Res 2009;20:414–420. Cardaropoli G, Araújo M, Lindhe J. Dynamics of bone tissue formation in tooth extraction sites. An experimental study in dogs. J Clin Periodontol 2003;30:809–818.

Cardaropoli D, Tamagnone L, Roffredo A, Gaveglio L. Relationship between the buccal bone plate thickness and the healing of post-extraction sockets with/without ridge preservation. Int J Periodontics Restorative Dent 2014;34:211–217. Cooper LF, Raes F, Reside GJ, et al. Comparison of radiographic and clinical outcomes following immediate provisionalization of single-tooth dental implants placed in healed alveolar ridges and extraction sockets. Int J Oral Maxillofac Implants 2010;25:1222–1232. De Rouck T, Collys K, Cosyn J. Immediate single-tooth implants in the anterior maxilla: A 1-year case cohort study on hard and soft tissue response. J Clin Periodontol 2008;35:649–657. De Rouck T, Collys K, Wyn I, Cosyn J. Instant provisionalization of immediate single-tooth implants is essential to optimize esthetic treatment outcome. Clin Oral Implants Res 2009;20:566–570. El-Chaar ES. Immediate placement and provisionalization of implant-supported, single-tooth restorations: A retrospective study. Int J Periodontics Restorative Dent 2011;31:409–419. Furhauser R, Florescu D, Benesch T, Haas R, Mailath G, Watzek G. Evaluation of soft tissue around single-tooth implant crowns: The pink esthetic score. Clin Oral Implants Res 2005;16:639–644.

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Recommended Reading

Hinds KF. Custom impression coping for an exact registration of the healed tissue in the esthetic implant restoration. Int J Periodontics Restorative Dent 1997;17:584–591. Lazzara RJ, Porter SS. Platform switching: A new concept in implant dentistry for controlling postrestorative crestal bone levels. Int J Periodontics Restorative Dent 2006;26:9–17. Nevins M, Camelo M, De Paoli S, et al. A study of the fate of the buccal wall of extraction sockets of teeth with prominent roots. Int J Periodontics Restorative Dent 2006;26:19–29. Nobuto T, Suwa F, Kono T, et al. Microvascular response in the periosteum following mucoperiosteal flap surgery in dogs: Angiogenesis and bone resorption and formation. J Periodontol 2005;76:1346–1353. Ottoni JM, Oliveira ZF, Mansini R, Cabral AM. Correlation between placement torque and survival of single-tooth implants. Int J Oral Maxillofac Implants 2005;20:769–776. Polyzois I, Renvert S, Bosshardt DD, Lang NP, Claffey N. Effect of Bio-Oss on osseointegration of dental implants surrounded by circumferential bone defects of different dimensions: An experimental study in the dog. Clin Oral Implants Res 2007;18:304–310. Sanz M, Cecchinato D, Ferrus J, Pjetursson EB, Lang NP, Lindhe J. A prospective, randomized controlled clinical trial

to evaluate bone preservation using implants with different geometry placed into extraction sockets in the maxilla. Clin Oral Implants Res 2010;21:13–21. Schropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft tissue contour changes following single-tooth extraction: A clinical and radiographic 12-month prospective study. Int J Periodontics Restorative Dent 2003;23:313–323. Tan WL, Wong TL, Wong MC, Lang NP. A systematic review of post-extractional alveolar bone dimensional changes in humans. Clin Oral Implants Res 2012;23:1–21. Vandamme K, Naert I, Geris L, Vander SJ, Puers R, Duyck J. Influence of controlled immediate loading and implant design on peri-implant bone formation. J Clin Periodontol 2007;34:172–181. Vignoletti F, Matesanz P, Rodrigo D, Figuero E, Martin C, Sanz M. Surgical protocols for ridge preservation after tooth extraction. A systematic review. Clin Oral Implants Res 2012;23:22–38. Wadhwani C, Piñeyro A. Technique for controlling the cement for an implant crown. J Prosthet Dent 2009;102:57–58.

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Questions: 1. What are the criteria for choosing between ridge preservation and ridge augmentation techniques? 2. What is the biologic rationale for ridge preservation? 3. What are the key surgical factors in ridge preservation? 4. Can ridge preservation be used in maxillary molar sites? 5. Are ridge preservation techniques supported by the scientific literature? 6. What are the key surgical factors in ridge augmentation? 7. What are the healing times for subsequent implant placement after ridge preservation and ridge augmentation?

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1|

What are the criteria for choosing between ridge preservation and ridge augmentation techniques?

Specific indications for each extraction socket management therapeutic option have already been described in chapter 3, but it may be useful to summarize the different characteristics of both techniques. Ridge preservation can be defined as the set of techniques designed to preserve ridge volume within the existing anatomy at the time of extraction.1 Ridge preservation techniques will be used when the socket is essentially intact, ie, three

a

walls are 100% preserved, while the fourth wall is at least 80% preserved.2 Technically, a small dehiscence of buccal cortical bone no greater than 1.5 mm is acceptable (Fig 5-1a). Ridge augmentation involves techniques designed to increase ridge volume beyond the anatomy existing at the time of extraction. Ridge augmentation techniques are generally used if buccal cortical bone is partially or complete absent at the time of extraction (Fig 5-1b).

b

Fig 5-1 (a) Extraction socket with all four bone walls intact that is eligible for treatment with a ridge preservation technique. (b) Extraction socket showing almost complete loss of buccal cortical bone. This should be treated with a ridge augmentation technique because there are no indications for the use of ridge preservation techniques.

2|

What is the biologic rationale for ridge preservation?

Filling and covering an extraction socket with bone substitutes and barrier membranes cannot prevent the physiologic process of site remodeling due to bundle bone resorption with consequent volume loss. Clinically, however, ridge preservation techniques seem able to preserve bony ridge volume in a predictable manner. From a biologic viewpoint, bone volume preservation is achieved by a mechanism of compensating for marginal contraction through a bone regeneration process within the extraction socket to promote bone remodeling.3 To simplify, with ridge preservation, physiologic resorption of bundle bone and possible loss of the original buccal cortical bone cannot be avoided, but the bone regeneration occurring inside the socket can create new ridge volume very similar to that present before extraction. Biologically, therefore, ridge preservation does not preserve the socket but preserves alveolar ridge volume through a compensatory mechanism (Figs 5-2 and 5-3).

a

b

Fig 5-2  CBCT scans of an extraction site before and after ridge preservation. (a) The initial image shows the presence of thin buccal cortical bone and biomaterial inside the socket. (b) Four months later, the buccal cortical bone has been resorbed, but the biomaterial has led to bone regeneration that has made up for the marginal remodeling.

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What are the key surgical factors in ridge preservation?

a

b

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Fig 5-3  Clinical example of the benefits offered by ridge preservation techniques. (a and b) Extraction of a maxillary premolar and socket filling with biomaterial and membrane. (c and d) Four months later, the volume has been maintained, allowing implant placement with ideal ridge conditions.

3|

What are the key surgical factors in ridge preservation?

Atraumatic tooth avulsion and flapless technique Atraumatic avulsion is always the fundamental prerequisite for proper treatment of an extraction socket. The technical details of atraumatic avulsion techniques are discussed in chapter 2. In particular, if the socket is intact or its walls are minimally compromised, flapless extraction without flap elevation is advisable because mucoperiosteal flap elevation triggers a series of biologic effects that include a transient cortical bone hypoxia stage, which activates osteoclasts and causes bone resorption.4

Extraction socket decontamination After extraction, the socket must undergo curettage to remove all inflammatory tissue and undergo abundant cleansing with saline solution. Some authors5 also recommend removing the epithelium to expose the underlying connective tissue on the soft superficial walls of the socket. This procedure

promotes superficial re-epithelization of the socket and revascularization of an epithelial–connective tissue punch or a collagen matrix positioned to seal the socket (Fig 5-4).

Placing osteoconductive biomaterial in an extraction socket The ideal biomaterial for use in ridge preservation must be biocompatible, osteoconductive, and slowly resorbed in order to compensate for the inevitable bundle bone remodeling. Slow-resorbing biomaterials of bovine origin appear to be the best performing in terms of maintaining the initial 3D ridge volume.6 Deproteinized bone mineral of bovine origin succeeds in preserving 93% of the initial ridge volume on average after 4 months, by which time the socket has practically healed (Fig 5-5). From a histologic viewpoint, on average it is made up of approximately 26% newly formed bone and 18% of residual bovine bone granules.2 This histologic situation is fully compatible with implant placement.7,8

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a

b

Fig 5-4 The inner surfaces of the socket can be de-epithelialized using a diamond bur mounted on a red ring handpiece (a) or a no. 15c scalpel blade (b).

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Fig 5-5  (a) Extraction site that has undergone ridge preservation. (b and c) Four months later, a biopsy is taken from the future implant site. (d) Histologic evaluation reveals new bone formation with woven bone and areas of lamellar bone with abundant presence of cells and vascular spaces (basic fuchsin; original magnification ×100).

Socket sealing After the socket is filled with osteoconductive material, the coronal part of the socket requires sealing. From a biologic viewpoint, this seal seems to be required to promote healing of superficial soft tissues while also protecting and promoting healing of the underlying bone graft. Commonly used methods proposed in the literature for sealing the socket surface are positioning of an autogenous soft tissue graft, collagen membrane, or collagen matrix.

Positioning of an autogenous soft tissue graft (punch or pocket-seal technique) This technique, which was widely used in the past,9 has gradually fallen out of use because collagen matrices guarantee similar results but are less invasive. The technique may still be indicated if soft tissues are very thin and an increase in tissue thickness is required (Fig 5-6).

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What are the key surgical factors in ridge preservation?

a

b

Fig 5-6  (a) Two extraction sockets after removal of two poorly positioned implants are treated by filling the sockets with slow-resorbing osteoconductive material (Bio-Oss Collagen, Geistlich) and sealing them by means of two epithelial–connective tissue grafts taken from the palate and fixed using 6-0 resorbable sutures. (b) Two weeks later, when the sutures are removed, favorable early graft integration can be seen. (See Fig 11-22 for a full analysis of this case.)

Collagen membrane positioning

Collagen matrix positioning

Positioning of a collagen membrane, appropriately shaped and stabilized above the socket by means of horizontal cross mattress sutures, has proved to be effective in protecting the underlying bone graft and promoting soft tissue healing by second intention without risk of infection. Open healing does not therefore represent a contraindication or even a risk factor. The authors prefer to use a double-layer native collagen membrane of porcine origin. Bacteria find it difficult to attack the smooth surface layer, which provides an ideal substrate for epithelial cell migration during healing by second intention. Full soft tissue closure usually takes place between the third and fourth week after extraction (Fig 5-7).

This is a development of a previously described technique (collagen membrane positioning), made possible by the availability of collagen matrices with specific properties. In particular, collagen matrices are thicker (approximately 3 mm) than a conventional membrane. The outermost layer (making up approximately 10% of the total matrix thickness) consists of very compact collagen fibers that can create a smooth surface suitable for open healing and be sutured to the surrounding soft tissue. The innermost layer (which represents 90% of the total thickness) is made up of very sparse collagen fibers that can absorb blood from the surgical site to promote satisfactory clot stabilization with subsequent revascularization of the matrix and soft tissue regeneration (Fig 5-8).

a

b

c

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Fig 5-7 (a) The extraction socket is filled using a slow-resorbing osteoconductive biomaterial (Bio-Oss Collagen). (b) The socket is sealed using a collagen membrane (Bio-Gide, Geistlich). (c) When these sutures are removed after 2 weeks, partial re-epithelization of the site is evident. (d) The process is complete after 4 weeks.

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Fig 5-8  (a and b) The extraction socket is filled using a slowly resorbed osteoconductive biomaterial (Bio-Oss Collagen). (c and d) The socket is sealed using a collagen matrix (Mucograft Seal, Geistlich). (e and f) The more consistent outer layer can be used to secure the matrix to the socket edges by means of interrupted sutures.

4|

Can ridge preservation be used in maxillary molar sites?

In posterior regions of the maxilla, bone ridge vertical height is kept constant by the presence of premolar and molar roots, with the inferior wall of the maxillary sinus situated between them (Fig 5-9). Extraction of these teeth can result in reshaping of the alveolar ridge horizontally and vertically as well further pneumatization (increase in internal air volume)

a

of the maxillary sinus. In this case, implant placement must be combined with a sinus elevation technique, increasing the morbidity of the procedure. Ridge preservation techniques are able to maintain vertical socket height, limiting pneumatization of the maxillary sinus and therefore avoiding the use of more invasive sinus elevation techniques10 (Fig 5-10).

b

Fig 5-9  (a and b) Anatomical and radiographic images showing the relationship between the inferior maxillary sinus wall, the alveolar bone process, and the roots of the second premolar and the first and second molars.

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Are ridge preservation techniques supported by the scientific literature?

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b

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Fig 5-10  (a and b) Maxillary first molar with crown-root fracture. (c) An initial radiograph highlights the levels of the marginal bone and the maxillary sinus floor. (d) Follow-up radiograph performed immediately after extraction and ridge preservation. (e) Clinical image after 6 months, showing maintenance of the horizontal ridge dimension. (f) A radiograph after 6 months shows good vertical bone availability and stability of the maxillary sinus floor height compared with the initial situation.

5|

Are ridge preservation techniques supported by the scientific literature?

Various systematic reviews of the literature generally support the effectiveness of ridge preservation techniques in safeguarding ridge volume.1,6,11 The results obtained by different authors vary according to the surgical technique and biomaterials used. The range of reliable results obtained with the procedure can vary from an average gain in vertical ridge dimension of 1.3 mm to an average loss of 2.48 mm and from an average gain in horizontal ridge dimension of 3.25 mm to an average loss of 2.5 mm.11 As already mentioned, the results are dependent on the surgical approach used (extraction performed with or without flap elevation), the type of filling material used (autogenous, allogeneic, xenogeneic, or alloplastic graft), and whether a membrane is used (Fig 5-11). Slow-resorbing biomaterials of bovine origin appear to be the best performing in terms of initial 3D ridge volume maintenance.6

1

3 2 4

3

Fig 5-11 Dimensional changes and new bone formation following ridge preservation compared with spontaneous healing. 1, bone without preservation; 2, new bone formation; 3, horizontal effect of ridge preservation; 4, vertical effect of ridge preservation.

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6|

What are the key surgical factors in ridge augmentation?

As stated previously, ridge augmentation techniques and ridge preservation techniques have different indications (badly damaged socket versus substantially intact extraction socket) and surgical techniques (flap elevation versus flapless technique).

must be slowly resorbed. Bone of bovine origin is therefore considered the gold standard for both ridge preservation and ridge augmentation (Fig 5-13a).

Atraumatic tooth avulsion

The collagen membrane is applied following guided bone regeneration technique principles. Resorbable collagen membranes are usually used. The membrane must fully cover the bony defect caused by the fracture of the socket walls, and a few millimeters should rest on the surrounding bone tissue (Figs 5-13b and 5-13c). Unlike with the customary guided bone regeneration technique, the membrane can be partially healed by second intention in the socket because it is an extraction site. As with ridge preservation techniques, partial exposure of the collagen membrane does not involve any particular risks and prevents excessive misalignment of the mucogingival junction, which could lead to a deficit of keratinized gingiva.

Avulsion usually can easily be carried out atraumatically when the socket is badly damaged.

Access flap incision and detachment Full-thickness flap detachment is necessary for complete removal of granulation tissue, which would be much more difficult with a compromised socket. Accurate fitting of the collagen membrane to a large bony defect would also be difficult or impossible without detachment of a flap, which makes it possible to view the borders of the bony defect perfectly (Fig 5-12).

Extraction socket decontamination The principles of ridge preservation generally apply.

Placing osteoconductive biomaterial in an extraction socket The characteristics of the preferred biomaterial in these situations are the same as for ridge preservation. The material must have properties favorable for osteoconduction, and it

a

b

Collagen membrane positioning

Passive advancement of the flap Before the flap is sutured, passive advancement by incision of the periosteum is usually indicated. Passive advancement of the flap is usually necessary to compensate for slight overfilling of the bony defect, which is normal in guided bone regeneration techniques (Figs 5-13d and 5-13e). Detachment and subsequent passive advancement of the access flap affects the morbidity of the procedure, leading to more postoperative swelling than with flapless ridge preservation techniques. The patient must therefore be properly informed about the extent of postsurgical symptoms prior to surgery.

c

Fig 5-12  (a) The maxillary right first premolar is affected by a buccal fistula and must be extracted. (b) Endodontic material left over from previous treatment on the extracted first molar must also be removed. This material seems to be surrounded by a radiolucent halo. (c) The quadrant will subsequently undergo implant treatment, and ridge augmentation has been planned with the extraction to allow formation of sufficient bone volume. Detachment of a full-thickness flap reveals the area to be treated and confirms complete removal of all inflammatory tissue, including around the buccal cortical bone margins.

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What are the healing times for subsequent implant placement after ridge preservation and ridge augmentation?

a

b

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e

d

Fig 5-13  Continuation of the case shown in Fig 5-12. (a) After removing all inflammatory tissue and abundant irrigation with sterile saline solution, the defect is filled using bone of bovine origin (Bio-Oss). The defect is slightly overfilled in relation to the original bone ridge profile. (b) The next step is shaping and positioning a collagen membrane (Bio-Gide) to stabilize the biomaterial and allow the bone regeneration process to take place based on the principle of guided bone regeneration. The membrane is stabilized using titanium pins (SuperTack, MC Bio). (c) The augmented ridge profile. (d) Flap suturing by first intention is performed after passive advancement of the flap, achieved by incision of the periosteum. (e) A final radiograph shows filling of the bony defect with biomaterial. (Surgery by Dr P. Casentini.)

7|

 hat are the healing times for subsequent implant W placement after ridge preservation and ridge augmentation?

For ridge preservation with a flapless technique, implant placement can take place after 4 to 6 months.12 This timing is sufficient to guarantee adequate osseointegration of the osteoconductive biomaterial with deposition of a sufficient quantity of newly formed bone to allow good primary stability at the time of implant placement.

With ridge augmentation, and particularly when the initial postextraction bony defect is of significant size, it could be advisable to wait for 6 to 9 months.13 The bone regeneration process takes place centripetally, starting from the surrounding bone walls, and it may therefore take longer for vital bone tissue to form in the central part of the defect in such situations (Fig 5-14).

Fig 5-14 Continuation of the case shown in Figs 5-12 and 5-13. (a and b) Nine months later, after complete consolidation of the area treated by ridge augmentation as evidenced by the increased radiopacity of the graft, there is sufficient bone volume for implant placement.

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c

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Fig 5-14  (cont) (c and d) Three implants are inserted in the first and second premolar and first molar positions. The implants will be prosthetically restored after 8 weeks of osseointegration. (e) Clinical and radiographic follow-up 1 year later shows healthy soft tissues and marginal bone stability. (Surgery and prosthetic rehabilitation by Dr P. Casentini.)

Clinical Case Studies Figures 5-15 to 5-27 present clinical cases demonstrating different applications of alveolar ridge preservation and augmentation techniques.

clinical case 1 Ridge preservation with deproteinized bovine bone graft and collagen membrane (open healing)

a

b Fig 5-15 (a) The patient presented with a deeply infiltrating caries lesion of the maxillary right second premolar root, but the horizontal soft tissue contour was intact. (b) A buccal view also shows that the soft tissue volume and contour have been preserved. The tooth is considered hopeless and is therefore extracted. (c) Extraction without flap elevation is atraumatic for the soft tissues. Once buccal cortical bone integrity has been established, the socket undergoes curettage and is washed with saline solution, and the sulcular and junctional epithelia are removed using a no. 15c blade.

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clinical case 1 (cont)

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Fig 5-15 (cont) (d) The socket is filled with deproteinized bovine bone together with porcine collagen (Bio-Oss Collagen). The biomaterial was previously rehydrated with saline solution until it was the consistency of wet sand. (e) A porcine-based membrane (Bio-Gide) is trimmed to the exact size of the socket, positioning the rough part in contact with the biomaterial and the smooth part facing the oral cavity. (f) The membrane is gently inserted into the socket and held in place by applying a main horizontal cross mattress suture and an accessory suture bridge composed of simple interrupted sutures. (g) Two weeks after extraction, the membrane has created a substrate where epithelial cells migrate to heal the wound by second intention. (h) Four weeks after extraction, re-epithelialization is complete and the grafted biomaterial is perfectly protected. (i) Four months after extraction, the hard and soft tissues are fully healed. Alveolar ridge volume has been preserved and the implant can be placed. (j and k) On the day of surgery, a biopsy is taken from the implant placement site to check the bone quality.

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clinical case 1 (cont)

l

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s

Fig 5-15 (cont) (l) Biopsy specimen comprising soft tissues (epithelium and connective tissue) and hard tissue corresponding to the previously grafted area of the socket. (m) Histologic section through the biopsy showing soft tissue in blue and mineralized tissues in red (basic fuchsin). (n) Histologic image of soft tissues showing the lamina propria separating connective tissue from the epithelium. No inflammation is identified throughout the thickness of the soft tissue. This is the area where the collagen membrane was left exposed (basic fuchsin; original magnification ×50). (o) Histologic image of hard tissues showing presence of a deproteinized bovine bone granule in direct contact with newly formed woven bone and almost completely surrounded by it (basic fuchsin; original magnification ×100). (p) Histologic image showing the presence of some Bio-Oss granules surrounded by osteoid tissue with woven bone portions (basic fuchsin; original magnification ×100). (q) A tapered osseointegrated implant measuring 4 mm in diameter and 13 mm in length (Osseotite Tapered, Zimmer Biomet) is inserted in the bony ridge. (r) Clinical view 4 months after implant surgery showing the titanium healing abutment tightened onto the implant head to allow transmucosal healing. (s) An impression is taken for the provisional prosthesis 6 weeks following placement. The clinical image shows a well-configured transmucosal pathway without any signs of inflammation.

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clinical case 1 (cont)

t

u

v

w

x

aa

bb

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Fig 5-15  (cont) (t) Occlusal image performed after tightening the titanium prosthetic abutment and cementing the acrylic resin provisional prosthesis. (u) Lateral view of definitive ceramic crown 12 months after prosthetic loading, showing that the original soft tissue contour has been maintained at the interproximal papillae and buccal gingival margin level. (v) Occlusal image 12 months after prosthetic loading with ceramic crown in place, showing maintenance of the horizontal dimension of the alveolar ridge. (w to bb) Intraoral radiographic sequence. (w) Initial status, prior to extraction. (x) Immediately after extraction, with the socket packed with biomaterial. (y) Four months after extraction. (z) Immediately after implant placement. (aa) At the time of prosthetic loading, with tightening of the titanium abutment. (bb) Twelve months after loading, showing marginal bone level stability. (cc) CBCT scan taken 12 months after prosthetic loading, showing maintenance of transverse bone volume with 3.5 mm of buccal cortical bone.

cc

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clinical case 2 Ridge preservation of a mandibular molar site with open healing

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Fig 5-16  (a) The patient presented for treatment complaining of symptoms and reporting a slight swelling of the gingival tissue around the mandibular left first molar. A probing depth of 9 mm was measured at the buccal furcation, ruling out a periodontal lesion. (b) The suspected diagnosis of an endodontic lesion is confirmed by a radiograph, which shows resorption at the furcation level corresponding to the post inserted in the distal root. (c) The tooth is judged to be hopeless, and extraction is performed by separating the roots. (d and e) Intraoperative images show complete loss of the interradicular bone septum with the presence of abundant granulation tissue. (f and g) Inspection of the extracted roots shows stripping of the mesial aspect of the distal root. (h) After thorough debridement of the socket, it is packed with demineralized bovine bone granules (Bio-Oss) and protected by a porcine collagen membrane (Bio-Gide). (i) The membrane is gently fitted inside the gingival sulcus and held in place by two horizontal cross mattress sutures. (j) Despite the considerable initial horizontal socket dimension (14 mm), the gingival tissue is able to heal by second intention without any infectious process, as an image taken 3 weeks later shows.

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clinical case 2 (cont)

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Fig 5-16 (cont) (k) Four weeks after extraction, the soft tissues are completely healed. (l) Six months after extraction, an occlusal image shows that the soft tissue contour has only undergone slight remodeling, and abundant keratinized tissue is present occlusally. (m) The surgical stage of implant placement is carried out 6 months after extraction. Elevation of a full-thickness flap reveals that the vertical and horizontal dimensions of the bone ridge have been maintained. (n) This makes it possible to insert an implant measuring 5 mm in diameter and 13 mm in length (Osseotite Tapered), with a residual buccal cortical bone thickness of 3 mm. (o) After placing a 4-mm-diameter healing abutment to carry out platform switching at the implant-abutment interface, the soft tissues are sutured, taking care not to interrupt the mucogingival junction and leaving a band of keratinized tissue measuring at least 2 mm. (p) A definitive titanium prosthetic abutment and provisional crown are positioned 12 weeks after implant placement (shown), while the definitive ceramic crown is positioned after a further 8 weeks. (q) Clinical follow-up image 12 months after loading shows the prosthesis perfectly adapted to the soft tissues. The interdental papillae fill the interproximal spaces, and an adherent band of gingiva is present to guarantee the health of the peri-implant issues. (r) A radiograph, also taken 12 months after loading, shows stability of the mesial and distal marginal bone levels.

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clinical case 3 Ridge preservation of a maxillary molar site with a flapless approach

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Fig 5-17  (a and b) The patient presented with a mesiodistal fracture of the pulp chamber floor of a maxillary first molar that had been previously treated endodontically. (c) A flapless extraction is performed with separation of the three roots. (d and e) The three sockets are packed with deproteinized bovine bone (Bio-Oss) protected by a resorbable collagen membrane held in position by two horizontal mattress sutures. (f) A radiograph shows packing of the biomaterial to the level of the interproximal bone peaks.

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clinical case 3 (cont)

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Fig 5-17 (cont) (g) Four months later, the occlusal view shows that the soft tissues are completely mature, the buccopalatal contour has been maintained, and there is abundant keratinized tissue. (h to j) Flap elevation shows bone healing, which makes it possible to place an implant measuring 5 mm in diameter and 10 mm in length (Osseotite Tapered). The ridge preservation proved effective in compensating for bone remodeling and preventing pneumatization of the maxillary sinus, allowing implant placement without having to resort to sinus elevation techniques. (k) The implant is prosthetically restored after a 3-month healing period. This clinical image, taken when the definitive ceramic crown was cemented, shows good adaptation of soft tissues with a well-supported, healthy emergence profile. (l) A follow-up radiograph taken 1 year after loading shows the stability of the marginal bone level.

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five  Alveolar Ridge Preservation and Augmentations

clinical case 4 Ridge preservation with deproteinized bovine bone graft and epithelial–connective tissue punch

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Fig 5-18  (a to f) Initial clinical situation and treatment plan. The patient’s esthetic demands are high, and she is requesting replacement of the maxillary right central incisor, which has been affected by external root resorption due to previous trauma. An initial analysis shows a high smile line and a thin, strongly scalloped periodontal biotype. The shape of the two central incisors is asymmetric and the incisal line lacks convexity, with the incisal margins of the incisors forming a straight line. The occlusal view reveals the slightly buccally displaced position of the right central incisor, which further reduces the thickness of the buccal soft tissues. Given the initial clinical situation, particularly the delicacy of the soft tissues and the radiographic status that shows that the extraction socket is asymmetrically positioned, the site is not considered suitable for immediate implant placement following extraction. It is therefore decided to use ridge preservation techniques to maintain and, if possible, improve local hard and soft tissue conditions. (g) The tooth is extracted. (h) The socket is prepared and packed with bone of bovine origin in a collagen matrix (Bio-Oss Collagen). The collagenated form of this biomaterial facilitates handling: After the biomaterial has been hydrated with saline solution, it can be trimmed to the required shape and adapted optimally to the morphology of the socket, whereas granules tend to disperse. The resorbable collagen component also leaves more room for autologous bone formation.

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Clinical Case Studies

clinical case 4 (cont)

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Fig 5-18 (cont) (i) In view of the very limited soft tissue thickness, it was considered important to increase its volume using a palatal fibromucosal tissue punch. The pre-shaped graft is fixed to the walls of the socket by small-diameter resorbable interrupted sutures (Vycril 6-0, Ethicon). The donor site is protected with a resorbable hemostatic material (Spongostan, Ethicon) stabilized using a cross suture in the same material. (j and k) A provisional metal-resin Maryland bridge is placed at the site, providing an accurate fit without creating compression of the tissues. (l and m) Six months later, buccal and occlusal views show favorable integration of the soft tissue graft and good maintenance of the site dimensions. (n) Biomaterial integration is also evidenced by a characteristic increase in local radiopacity. (o and p) After flap elevation, the appearance of the bone ridge reveals a favorable outcome of the ridge preservation technique.

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clinical case 4 (cont)

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Fig 5-18  (cont) (q and r) It is now possible to prepare the site for implant placement (SLActive Bone Level 3.3 × 10 mm, Straumann), guided by a surgical template for accuracy. The patient’s preference for a screw-retained restoration in the esthetic zone was considered when choosing the implant axis. (s and t) To compensate for slight horizontal contraction of the site and to increase the buccal cortical bone thickness, thus improving esthetics, a guided bone regeneration technique was performed using bovine bone granules (Bio-Oss) and a collagen membrane (Bio-Gide). (u) The flap is then sutured without tension following incision of the periosteum. (v and w) Tissue appearance after conditioning by a screw-retained provisional prosthesis with successive increments of additional flowable composite. An indirect composite restoration has been placed on the adjacent central incisor to lengthen its incisal margin by approximately 1 mm. (x and y) Prosthesis on working cast prior to delivery. It is important to create surface texture in the ceramic to give the restoration a biomimetic appearance.

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Clinical Case Studies

clinical case 4 (cont)

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Fig 5-18 (cont) (z to bb) Note also the gradual emergence profile from the implant-prosthetic connection to the supragingival portion of the restoration by means of platform switching. With thin soft tissues, forming a harmonious emergence profile without steps and excessive tissue compression is considered an important factor for long-term stability of the soft tissue profile. (cc) Appearance of the implant-supported crown after delivery. The restoration appears to be well integrated into the surrounding soft tissues. The incisal margins form a convex line that is more pleasing than the original straight line, and the symmetric shape of the central incisors is favorable. (dd) A radiograph shows the marginal bone levels. (Surgery and prosthetic rehabilitation by Dr P. Casentini; laboratory stages by Mr A. Schoenenberger.) (ee to ff) The 5-year follow-up images show favorable medium-term prognosis of this implant-supported prosthetic rehabilitation and the stability of hard and soft tissues.

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clinical case 4 (cont)

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hh Fig 5-18 (cont) (gg to ii) This implant-supported prosthetic rehabilitation provides excellent integration with the surrounding soft tissues and the patient’s smile.

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Clinical Case Studies

clinical case 5 Ridge preservation with deproteinized bovine bone graft and 3D collagen matrix (open healing)

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Fig 5-19 (a to c) The patient presented with a periapical lesion and external root resorption of a maxillary central incisor. The patient has moderate generalized chronic periodontitis with horizontal bone resorption in the maxillary anterior region. She has undergone causal therapy. The tooth’s poor prognosis suggests a treatment plan involving extraction, ridge preservation, and delayed implant placement. (d and e) An atraumatic extraction is performed using straight and curved desmotomes to incise the biologic width of the tooth. (f and g) The tooth is then gently luxated and removed without injuring the soft tissues. (h) The socket then undergoes curettage and abundant cleansing with saline solution. (i) An occlusal view shows the four bony walls to be intact.

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clinical case 5 (cont)

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Fig 5-19  (cont) (j) The socket is thoroughly packed with deproteinized bovine bone mixed with 10% porcine collagen (Bio-Oss Collagen). (k) The biomaterial is protected by a 3D collagen matrix of porcine origin measuring 8 mm in diameter and 2.5 to 3 mm in height (Mucograft Seal). (l) The collagen matrix is gently fitted to the socket entrance without prior rehydration, taking particular care to ensure it rests perfectly on the biomaterial and is in close contact with the soft tissues peripherally. (m) The matrix is sutured to the gingival sulcus by means of six simple interrupted sutures using a nonresorbable material (polytetrafluoroethylene 5-0). (n and o) A radiograph and 3D CBCT scan show that the socket is perfectly packed with biomaterial, which has been positioned in a slightly supracrestal position. The combined use of Bio-Oss Collagen and Mucograft Seal is based on a symbiotic principle. The biomaterial supports the matrix, which would otherwise collapse into the socket, while the matrix protects the biomaterial and allows soft tissue regeneration. For this reason, the biomaterial is positioned 2.5 mm from the gingival margin, independently of the underlying bone ridge position, while the matrix is positioned at the free gingival margin level. (p) Three weeks later, the soft tissues show excellent healing due to migration of epithelial cells by second intention over the collagen matrix and integration of connective tissue cells inside the spongy matrix.

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Clinical Case Studies

clinical case 5 (cont)

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Fig 5-19  (cont) (q) Complete maturation is confirmed by a clinical image taken 4 months later. (r and s) A radiograph and 3D CBCT scan show that the ridge volume is sufficient for implant placement without the need to use additional bone regeneration techniques. The ridge preservation procedure proved effective in compensating for physiologic remodeling of the extraction socket. (t) Four months after extraction, full-thickness flap elevation reveals that the ridge profile has been maintained on the buccal aspect and the horizontal dimension is sufficient. (u) In order to assess the quality of the newly formed tissue, a biopsy is taken from the implant insertion area. (v) A histologic assessment shows the presence of new vital bone with woven bone and extensive areas of lamellar bone at a very advanced stage of maturation as well as residual biomaterial granules undergoing resorption.

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clinical case 5 (cont)

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Fig 5-19  (cont) (w to z) A surgical template is used to place the implant (T3 Prevail Tapered implant 4 × 13 mm, Zimmer Biomet) in a prosthetically guided manner, achieving an implant stability quotient of 83 (Mentor, Osstell). (aa to cc) An immediate prosthetic treatment protocol is carried out by placing a provisional polyether ether ketone (PEEK) abutment and then securing a provisional acrylic resin crown to it. (dd) The retaining screw axis remains on the palatal surface of the provisional prosthesis. (ee) A radiograph at the end of surgery shows the implant with the direct screw-retained provisional prosthesis.

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Clinical Case Studies

clinical case 5 (cont)

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Fig 5-19  (cont) (ff and gg) Three months after implant placement, the provisional prosthesis is disconnected, showing healthy soft tissues with good morphology. (hh and ii) Frontal and occlusal clinical images of the definitive ceramic crown 1 year after prosthetic loading show the vertical and horizontal stability of the soft tissues. (jj and kk) A radiograph and 3D CBCT scan, also taken 1 year later, show the stability of the mesial, distal, and buccal bone levels.

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clinical case 6 Ridge preservation with deproteinized bovine bone graft for intermediate pontic sites in an implant-supported full-arch rehabilitation

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Fig 5-20  (a to c) The patient has a mandibular implant-supported fixed rehabilitation and a maxillary fixed prosthesis from the right second premolar to the left canine, supported by five teeth. (d) Lateroposterior sectors are rehabilitated with removable partial dentures retained by distal precision attachments. The rehabilitation is no longer acceptable to the patient, who wants it to be replaced with a fixed prosthesis. (e to i) The prognosis of the residual natural abutments is doubtful, as evidenced by radiographs, and will have to be reassessed after removal of the current prosthetic device. The treatment plan involves removing the old prosthesis and positioning a milled provisional prosthesis with metal reinforcement extending from the right second premolar to the left canine. This method makes it possible to reappraise the residual dental abutments and create a definitive treatment plan.

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Clinical Case Studies

clinical case 6 (cont)

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l Fig 5-20  (cont) (j to l) After removing the old prosthesis, an evaluation is performed to ensure the absence of secondary caries and sufficient tooth structure to allow the ferrule effect on the remaining abutments. The abutments are re-prepared and provisionally reconstructed with composite, and a milled provisional prosthesis with metal reinforcement is applied. Now it is possible to draw up a definitive treatment plan, considering the situation of the remaining abutments, the patient’s preference for a fixed solution extending to the molars, and the patient’s budget. The definitive treatment plan includes placement of five implants in the intermediate edentulous sites (both lateral incisor and the right first premolar sites) and the distal edentulous saddles (right first molar and left second premolar sites). All implants sites have sufficient bone volume except the maxillary right first molar site, which will require a maxillary sinus floor elevation. Once the implants have been osseointegrated, a definitive titanium-composite prosthesis will be delivered to coincide with extraction of the remaining teeth. The extraction sockets, which will become pontic sites in the implant-supported rehabilitation, will be treated by means of a ridge preservation protocol to maintain ridge volume, ensuring the definitive rehabilitation meets high esthetic standards. The small number of implants used, the use of complex regenerative techniques only at one site, the selected prosthetic materials, and the small number of steps required keeps the rehabilitation costs down, meeting the patient’s expectations within his budget.

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clinical case 6 (cont)

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Fig 5-20  (cont) (m and n) The implants (SLActive Bone Level Tapered, Straumann) were inserted in a single session. After this, the provisional prosthesis was reapplied using the metal reinforcement made previously. No regenerative techniques were performed at four of the five sites because the bone volume was sufficient for implant placement. (o and p) However, at the right first molar site, the implant was inserted after maxillary sinus floor elevation with lateral access. (q) The implant in the left second premolar site was tilted distally to achieve a more distal emergence and avoid the anterior maxillary sinus wall. (r) The soft tissues were sutured to obtain healing by first intention.

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Clinical Case Studies

clinical case 6 (cont)

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Fig 5-20  (cont) (s to u) Construction of the definitive titanium-composite implant-supported prosthesis. The dental technician now has all the information required to produce a definitive prosthesis that will be delivered when the remaining teeth are extracted. The possibility of producing a screw-retained, and therefore easily removable, rehabilitation for subsequent evaluation is considered a very important requirement in full-arch rehabilitations. The connection between the implants and the prosthesis will be via specific screw-retained titanium abutments that allow the prosthetic axis to be corrected up to 30 degrees. The natural abutments are eliminated on the plaster cast, and the dental technician produces an ovate pontic shape for the intermediate sites. To improve esthetic integration of the rehabilitation, it is important to combine a ridge preservation protocol at the extraction sites with preparation of ovate pontics to allow maintenance of gingival scalloping. (v and w) After extraction of the residual teeth and before placing the definitive rehabilitation, the sockets are filled with a slowly resorbing osteoconductive biomaterial of bovine origin (Bio-Oss). In this case, the purpose of ridge preservation is not subsequent implant placement but the maintenance of gingival scalloping around the intermediate teeth on an implant-supported prosthesis.

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clinical case 6 (cont)

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Fig 5-20  (cont) (x and y) The definitive screw-retained rehabilitation is tightened in place, carefully checking the occlusal ratios. (z and aa) The final appearance of the rehabilitation shows favorable esthetic integration of the prosthesis with the surrounding tissues, and the patient’s smile is pleasing. (bb) A follow-up radiograph shows an accurate prosthetic fit and the absence of peri-implant bone resorption. (cc and dd) After 1 year, when the prosthetic device is removed, the gingival architecture is shown to be perfectly maintained in the areas where ridge preservation was performed. (ee) In ovate pontic areas, note the presence of some superficial biomaterial granules, which have not caused any tissue inflammation. The most superficial granules can, however, be easily removed without the patient experiencing pain. (Surgery and prosthetic rehabilitation by Dr P. Casentini; laboratory work by Mr A. Giacometti.)

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Clinical Case Studies

clinical case 7 Flapless ridge augmentation with “ice cream cone” technique in mandibular premolar site with buccal cortical bone loss

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Fig 5-21  (a and b) The mandibular right first premolar must be extracted because of endodontic problems. The presence of a buccal fistula indicates at least partial loss of the buccal cortical bone. Periodontal probing distal to the canine is reduced and suggests limited attachment loss despite the radiographic appearance. However, the site characteristics are not favorable for implant placement immediately after extraction. A site preservation technique has therefore been planned so that an implant can subsequently be placed under more favorable conditions. (c and d) After extraction, the pathway of the fistula is checked by means of a periodontal probe. (e to h) Thorough curettage of the extraction socket is then performed. Granulation tissue is removed using a sharp surgical scoop and small rongeur. The socket is then abundantly irrigated with sterile saline solution.

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clinical case 7 (cont)

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Fig 5-21 (cont) (i) A flapless ridge augmentation is then performed. This technique differs from the classic ridge augmentation because no flap is raised even though the buccal cortical bone is extensively compromised. The technique involves shaping a resorbable membrane (Bio-Gide) to look like an ice cream cone. (j) The narrow end of the ice cream cone is placed inside the socket and fitted to the buccal wall to repair the fracture in the buccal cortical bone. (k) The socket is then fully packed with bovine bone in a collagen matrix (Bio-Oss Collagen). The technique is similar to a ridge augmentation technique because the aim is to slightly overfill the socket horizontally to compensate for the buccal cortical bone loss. (l and m) The wide, rounded end of the membrane is folded to seal the occlusal surface of the socket. (n and o) Single sutures using a fine material (Vycril 6-0, Ethicon) slightly compress the membrane to adapt it accurately to the underlying tissues. (p) The radiograph shows overfilling of the defect. (q) Two weeks later, the site shows good healing.

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Clinical Case Studies

clinical case 7 (cont)

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Fig 5-21 (cont) (r) Complete re-epithelialization occurs after 4 weeks. (s and t) At 6 months, the site is fully healed, with normal probing depth distal to the canine. (u) At this time, a periosteal flap is elevated without involving the interdental papillae. This reveals sufficient bone volume for implant placement. (v to x) An implant (TissueLevel Regular Neck Standard Plus 3.3 × 10 mm, Straumann) is placed with a transmucosal healing technique. (y) The final appearance of the rehabilitation shows favorable esthetic integration of the implant-supported prosthetic restoration. (z) A follow-up radiograph shows a well-adapted crown and the absence of peri-implant bone resorption. (Surgery and prosthetic rehabilitation by Dr P. Casentini; laboratory stages by Mr R. Colli and Mr C. Pedrinazzi.)

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clinical case 8 Ridge augmentation with flapless technique and specially shaped membrane to treat gingival recession and buccal bone loss

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Fig 5-22  (a) Maxillary lateral incisor with vertical fracture. (b and c) An radiograph shows interproximal bone levels, while a 3D CBCT scan shows almost total loss of buccal cortical bone. (d and e) The tooth is extracted using an atraumatic flapless approach to preserve soft tissue integrity and contour. (f) A scalpel blade is used to remove the endothelial layer internal to the soft tissues to expose the connective tissue. (g) A ridge augmentation procedure will be performed using a specially shaped porcine collagen membrane (Bio-Gide Shape). (h) The membrane is positioned inside the socket with the long side in contact with the buccal surface. (i to k) The socket is filled with consecutive additions of collagenated deproteinized bovine bone (Bio-Oss Collagen) to the soft tissue level.

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Clinical Case Studies

clinical case 8 (cont)

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Fig 5-22  (cont) (l) Both wings of the membrane are then folded in to protect the bone graft and sutured circumferentially to the soft tissues by means of six simple interrupted stitches (polytetrafluoroethylene 6-0). (m) The membrane is left exposed to achieve healing by secondary intention. (n and o) Because this is an area with a high esthetic impact, a removable provisional prosthesis has been made out of thermoplastic nylon (Valplast) with two cosmetic hooks on the adjacent central incisor and canine. (p) This provisional removable partial prosthesis has no vertical movement and therefore does not compress the surgical site. (q) Two weeks later, good healing is observed, with regeneration of soft tissues over the membrane and no inflammation or infection. (r) The healing process continues until complete re-epithelialization has taken place, which occurs 4 weeks after extraction. (s) Four months later, good soft tissue maturation is observed, and keratinized tissue has been gained as a result of the flapless extraction technique and open healing.

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clinical case 8 (cont)

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y Fig 5-22 (cont) (t) The horizontal ridge dimension has been perfectly preserved. (u and v) The surgical stage of implant placement is carried out 4 months after the ridge augmentation. After full-thickness flap elevation, complete regeneration of buccal cortical bone is observed. (w and x) There is sufficient bone to allow preparation of a prosthetically guided implant site through the use of a surgical template, followed by implant placement (SLActive Bone Level Tapered 3.3 × 10 mm). (y) The definitive prosthetic rehabilitation integrates well with the soft tissues, which are properly supported by a sufficient band of keratinized tissue. (z) A radiograph taken 1 year after loading shows marginal bone level stability.

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Clinical Case Studies

clinical case 9 Ridge augmenation using flap elevation and collagen membrane with open healing

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Fig 5-23  (a) The maxillary left canine, a prosthetic abutment for a fixed partial denture that extends to the first molar with pontic elements in the premolar positions, shows swelling of the buccal soft tissues at middle third of the root. (b) A radiograph reveals no abnormality. (c) When an exploratory flap is elevated by intrasulcular incision connected to a vertical releasing incision distal to the canine, a buccal bone dehiscence with abundant granulation tissue is identified. (d) Debridement of the lesion shows a complete greenstick root fracture. (e and f) The metal-ceramic bridge is separated mesial to the first molar to extract the fractured root. (g) After extraction, considerable resorption of buccal cortical bone is evident. (h) Intra- and extra-alveolar components of the defect are packed with bovine bone granules (Bio-Oss), overfilling in the area of the lost cortical bone. (i) The filling material is protected by a resorbable collagen membrane (Bio-Gide).

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clinical case 9 (cont)

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Fig 5-23  (cont) (j) The flap is then repositioned above the membrane and sutured with simple interrupted sutures for the vertical releasing incision and horizontal cross mattress suture in the coronal portion, leaving the membrane exposed for healing by secondary intention. (k) An image taken 2 weeks after extraction shows good soft tissue healing. (l) This is confirmed by an image taken after 4 weeks, showing almost complete re-epithelialization over the membrane. (m) Six months later, the soft tissue contour is good; there is a broad band of keratinized tissue due to the fact that the mucogingival junction was not advanced during surgery. (n) Flap elevation shows good buccopalatal bone thickness with complete regeneration of the missing buccal cortical bone. (o) The regenerated bone volume allows placement of an implant measuring 5 mm in diameter and 13 mm in length (3i Certain Tapered, Zimmer Biomet). An implant is simultaneously placed at the site of the second premolar. (p) Definitive prosthetic rehabilitation is carried out by constructing a metal-ceramic partial denture using the implants in the canine and second premolar sites as abutments. (q) A follow-up radiograph taken 1 year after loading shows peri-implant marginal bone level stability.

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Clinical Case Studies

clinical case 10 Ridge augmentation and amelogenin treatment of an adjacent tooth in a maxillary premolar site

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Fig 5-24  (a to d) The patient, who has chronic periodontitis, is affected by abnormal probing depths and mobility in certain isolated molar sites. In particular, the maxillary left second premolar and second molar show grade 3 mobility and deep interproximal probing. The maxillary left first molar also has increased probing depths but displays no apparent furcation involvement and grade 2 mobility. The area had previously undergone regenerative surgery with flap elevation at another clinic. Given the clinical situation and radiographic status, the second premolar and second molar are considered hopeless and scheduled for extraction. The aims of this procedure, to be performed after causal therapy, are to: (1) perform avulsion of the second premolar and second molar; (2) completely remove periradicular granulation tissue; (3) establish the periodontal condition of the first molar with the site exposed, carry out root planing, and if possible, use guided tissue regeneration to improve long-term periodontal prognosis; (4) achieve ridge augmentation at the second premolar site by means of guided bone regeneration with the aim of subsequently placing an implant in this site. (e and f) After flap elevation and avulsion of the second premolar and second molar, the complexity of the local bony defect as well as the importance of performing immediate regeneration is confirmed. In such cases, waiting until after extraction will exacerbate the situation, and the lesion will become chronic with the disappearance of bone ridges and the socket’s potential for healing, which are still present at this stage. Ridge augmentation therefore offers the possibility of exploiting and enhancing the spontaneous healing potential that is now still present but will disappear with time, making subsequent treatment more complex and invasive. (g) After complete removal of granulation tissue and root planing of the first molar, 24% ethylenediaminetetraacetic acid (EDTA) gel (PrefGel, Straumann) is applied to the tooth. This neutral pH chelator removes the dentinal smear layer from the root surface and exposes the collagen fibers inside the dentinal tubules.

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clinical case 10 (cont)

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Fig 5-24  (cont) (h) The EDTA is left in situ for 2 minutes and then abundantly rinsed and removed with saline solution. This chemical conditioning of the root surface improves the clot’s stabilization potential and sets the stage for subsequent amelogenin application. Amelogenins (Emdogain, Straumann) are then applied to the root to induce periodontal regeneration at the first molar. (i and j) The extraction defect, which also involves the mesial surface of the first molar, is then filled with deproteinized bovine bone (Bio-Oss) and protected with a dual-layer collagen membrane (Bio-Gide). (k) The flap is then sutured by first intention, sliding it in a mesial and coronal direction to cover the root recession at the site of the first premolar. (l) A radiograph shows filling of the bony defect. (m to p) Clinical and radiographic follow-up 9 months later shows filling of the bony defect with a notable increase in radiopacity and favorable periodontal healing, together with the disappearance of the abnormal probing depth at the first molar. In the meantime, the other sites with periodontal problems have also been successfully treated, and the patient has been attending routine appointments every 4 months. Placement of an implant in the second premolar site can now be scheduled.

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Clinical Case Studies

clinical case 10 (cont)

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u Fig 5-24  (cont) (q and r) Implant placement (SLActive Bone Level 4.1 × 10 mm) takes place in accordance with a standard protocol after flap elevation, which confirms favorable bone and periodontal healing at the site. (s and t) Another 2 months later, the site can be reopened. This is performed using a circular mucotome, given the extensive amount of keratinized tissue present locally. (u) A healing abutment is then placed on the implant.

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five  Alveolar Ridge Preservation and Augmentations

clinical case 10 (cont)

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aa Fig 5-24  (cont) (v) The final posttreatment clinical view shows that the case has been favorably concluded with the restoration of satisfactory esthetics and function. (w) A radiographic follow-up shows a well-adapted crown and the absence of peri-implant bone resorption. (x to z) Periodontal probing also demonstrates the absence of pathology associated with the first molar. (Surgery and prosthetic rehabilitation by Dr P. Casentini; laboratory stages by Mr. R. Colli and Mr C. Pedrinazzi.) (aa and bb) The clinical and radiographic 5-year follow-up images show recovery of the papilla between the second premolar and first molar as well as stable bone levels.

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Clinical Case Studies

clinical case 11 Ridge augmentation and coronally displaced flap corresponding to a maxillary central incisor affected by ankylosis

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Fig 5-25  (a to d) The patient requires a permanent solution to an unsightly infraocclusion and ankylosis of the maxillary right central incisor. The current clinical situation is the consequence of an accident that occurred some years previously. (e) A side effect of subsequent orthodontic treatment was partial root resorption of the other teeth, as can be seen on the radiograph. (f) A 3D CBCT reconstruction shows apparent “fusion” between the dental tissues and the alveolar process; the root appears to have been completely resorbed, and the previous endodontic treatment material seems to be in direct contact with the surrounding bone tissue and partly protrudes beyond the bone structure to create a pronounced buccal concavity. It is clear that simple extraction would not allow all the tooth tissue mixed with socket tissue to be removed with certainty, while also making it difficult to remove the endodontic material outside the bone structure. It is therefore decided to perform ridge augmentation to coincide with extraction, involving access flap elevation, which would permit the following results: (1) complete avulsion of the ankylosed tooth, (2) removal of all endodontic material, (3) increase in the bone volume with the aim of subsequent implant placement, and (4) realignment of soft tissues, particularly the mucogingival junction.

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five  Alveolar Ridge Preservation and Augmentations

clinical case 11 (cont)

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Fig 5-25  (cont) (g) The planned flap design creates suitable access to the area using a releasing incision. This flap design also ensures the possibility of coronally repositioning the flap to improve mucogingival junction symmetry and position at the extraction site. For this reason, part of the papillae between the right central incisor and lateral incisor and between the central incisors will be left in situ and de-epithelialized to act as a receiving bed for the coronally displaced flap. (h and i) Ridge augmentation: after full-thickness flap elevation, the ankylosed tooth and all endodontic material are removed. (j) The next step is to fill the alveolar defect and apical concavity with deproteinized bovine bone (BioOss). (k) Subsequent application of a porcine collagen membrane (Bio-Gide) allows the biomaterial to be properly stabilized and maintained in situ, simultaneously separating it from the superficial soft tissues. (l) After an incision is made in the periosteum and the residual papillae is deepithelialized mesial to the right lateral and left central incisors, the flap is passively advanced coronally to more effectively align the mucogingival junction. (m) At the ridge, the membrane is allowed to heal in an exposed position. As has already been demonstrated, this does not have a negative impact on the healing process. In fact in this case, healing by first intention would have the opposite effect of excessively misaligning the mucogingival junction.

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Clinical Case Studies

clinical case 11 (cont)

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Fig 5-25  (cont) (n) Provisional prosthetic treatment uses a Maryland bridge that also protects the extraction socket and the area where the membrane was left exposed. The Maryland bridge is the preferred provisional option because it ensures greater comfort and quality of life for the patient. (o) A radiograph shows effective filling of the defect. (p) Clinical follow-up after 2 weeks shows favorable healing and improved esthetics. (q and r) The clinical follow-up after 8 months shows that the shape of the alveolar process is satisfactory in terms of height and width, and the mucogingival junction is correctly aligned. Implant placement can now be planned. (s) A full-thickness flap is elevated by means of a central ridge incision and a releasing incision in the same position as the first surgery. (t) The volume of the regenerated area is satisfactory, and the biomaterial is well integrated and difficult to distinguish from the surrounding bone tissue. (u and v) Implant site preparation takes place under the guidance of a surgical template; its use allows better control of the implant axis, particularly the buccopalatal axis, which will make it possible to produce a screw-retained restoration.

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five  Alveolar Ridge Preservation and Augmentations

clinical case 11 (cont)

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Fig 5-25  (cont) (w to y) An implant is then inserted (SLActive Bone Level 4.1 × 12 mm) with a correct insertion axis. (z) The site is then sutured for first intention healing. (aa) Two months later, the site is reopened by making a small linear incision in a mesiodistal direction, leading to the center of the ridge without involving the adjacent papillae. (bb) The authors prefer to use a small healing screw to avoid excessive compression on surrounding soft tissues. (cc and dd) The implant axis, planned from the surgical stage, makes it possible to produce a screw-retained provisional restoration to achieve soft tissue conditioning. (ee) It is important to ensure that the provisional prosthesis and the healing screw do not compress the soft tissues excessively.

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Clinical Case Studies

clinical case 11 (cont)

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Fig 5-25 (cont) (ff) The impression transfer is customized with light-cured resin in order to duplicate the transmucosal pathway. (gg) The final impression is then taken with an open tray and polyether material (Impregum and Permadyne, 3M ESPE). (hh and ii) The definitive crown obtained by direct ceramic coating of a customized zirconia abutment (CARES CADCAM System, Straumann) is also screw-retained and essentially represents a replica of the provisional crown, adapting perfectly to the preexisting transmucosal pathway. (jj) The clinical appearance of the definitive rehabilitation shows favorable integration of the implant-supported crown in the context of the surrounding hard and soft tissues. (kk) A radiograph reveals stable marginal bone levels. (ll and mm) Extraoral views also show the patient’s pleasing smile; he was very satisfied with the final result. (Surgery and prosthetic rehabilitation by Dr P. Casentini; laboratory stages by Mr A. Schoenenberger).

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clinical case 12 Ridge augmentation of maxillary anterior region and subsequent computer-guided implant placement in patient with periodontal disease

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Fig 5-26  (a and b) In a 33-year-old man diagnosed with severe generalized aggressive periodontitis, the maxillary anterior teeth show attachment loss with abnormal tooth migration and grade 3 mobility combined with extreme horizontal bone resorption. (c to f) CBCT cross sections show the severity of bone resorption, with involvement of periapical areas. (g) Extractions were performed from the right first premolar to the left canine. (h) After removal of granulation tissue and the epithelium internal to the periodontal pockets, a regenerative procedure is performed on the intra- and supra-alveolar components. A graft is created by mixing deproteinized bovine bone granules (Bio-Oss) with homologous fibrin glue (Tisseel, Baxter). (i) The graft is protected by a resorbable collagen membrane of porcine origin (Bio-Gide), positioning the smooth side toward the oral cavity and the rough side toward the bone graft. (j) The soft tissue is sutured at the interproximal papilla level without seeking closure by first intention, leaving the membrane intentionally exposed at extraction socket level in order not to avoid displacing the mucogingival junction.

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Clinical Case Studies

clinical case 12 (cont)

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Fig 5-26 (cont) (k to n) CBCT images show the bone graft positioning within the socket and in a supra-alveolar position to achieve ridge augmentation. (o) Healing after 2 weeks shows partial epithelialization of the wound, with some membrane portions still exposed and covered by a fibrin layer. (p) Four weeks later, soft tissue maturation is observed with complete re-epithelialization. (q) Six months after extraction, the alveolar ridge contour is maintained together with a broad band of keratinized gingiva. (r to u) A CBCT scan shows the available bone volume, which has increased horizontally and vertically.

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clinical case 12 (cont)

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Fig 5-26  (cont) (v and w) CBCT images are used for computer-guided implant surgery planning using dedicated software (Simplant, Dentsply Sirona). In the maxillary anterior region, the available bone volume allows the insertion of four implants in the canine and central incisor sites without the need for additional bone grafts. Flapless implant surgery therefore is scheduled with immediate loading. (x) A surgical template (SurgiGuide, Dentsply Sirona) is used to obtain the implant positioning on a master working cast, on which the implant analogs will be positioned. (y to aa) The same cast is used when milling the titanium posts, on which a reinforced resin provisional prosthesis is constructed from the right first premolar to the left canine. (bb) The surgical template supported by teeth and mucosa is positioned centrally and stabilized. (cc) The implants are then placed using the dedicated surgical kit (Navigator, Zimmer Biomet) and a flapless technique.

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Clinical Case Studies

clinical case 12 (cont)

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Fig 5-26 (cont) (dd) The implants (T3 Certain Prevail, Zimmer Biomet) are inserted in accordance with the digital planning, surrounded by abundant keratinized tissue. (ee) The definitive titanium abutments, whose diameter is smaller than that of the implant platform, are immediately positioned in accordance with platform-switching. (ff) Acrylic resin crowns are positioned on the abutments for immediate prosthetic loading of the implants. In this specific case, it was possible to use a cemented provisional prosthesis because the surgery was performed without raising a flap and there was therefore no risk of the cement penetrating the surgical site. (gg) The radiographs show correct implant placement at the bone level and platform switching between the implants and abutments. (hh) Clinical image of definitive ceramic crowns 12 months after loading. (ii) Radiographs reveal stable marginal bone levels after 1 year. (jj and kk) Profile images 12 months after loading show perfect integration between the soft tissues and the implant-supported ceramic crowns, with the soft tissues providing excellent support.

jj

kk

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clinical case 13 Ridge augmentation on two maxillary central incisors with periodontal defects using a 3D collagen matrix

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Fig 5-27  (a) Initial situation of maxillary central incisors with severe periodontal involvement, presence of etiologic factors on root surfaces, and soft tissue retraction with loss of papilla between the right central and lateral incisors. (b) A radiograph shows external root resorption at the apex of the right central incisor and horizontal bone resorption exacerbated by infrabony defects on both central incisors. (c) The negative prognosis leads to extraction of both central incisors, which is carried out using a flapless approach. (d) After granulation tissue removal and de-epithelialization of the internal part of the periodontal pocket, the left central incisor socket is packed with collagenated bovine bone (BioOss Collagen) to a distance of 2.5 mm from the soft tissue margin. (e and f) The graft is protected by a 3D collagen matrix (Mucograft Seal), which will occupy the remaining distance between the bone graft and the soft tissue margin. (g) The matrix is then sutured to the surrounding tissue by means of four simple interrupted sutures in a nonresorbable material (polytetrafluoroethylene [PTFE] 5-0). (h) The right central incisor socket is overfilled with biomaterial, pushing the soft tissue buccally. (i) Both matrices are left exposed to the oral cavity in order to achieve open healing.

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Clinical Case Studies

clinical case 13 (cont)

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Fig 5-27  (cont) (j) Two weeks later, the collagen matrices are still partly exposed, covered by fibrin but without signs of infection. (k). The soft tissues appear to be completely healed after 4 weeks with re-epithelialization of the coronal part of the sockets over the collagen matrices and a consequent increase in keratinized bone volume. (l and m) A CBCT examination carried out after 6 months shows the presence of regenerated bone volume vertically and horizontally, with newly formed buccal cortical bone at both the right (l) and left (m) central incisor sites. The biomaterial has compensated for socket remodeling. (n) Full-thickness flap elevation shows bone ridge thickness in a buccopalatal direction. (o and p) Two titanium implants are placed with a diameter of 4 mm and length of 13 mm (T3 Certain Prevail). They are in a prosthetically guided position and three-dimensionally accurate in both the horizontal and vertical directions. (q) To ensure sufficient support by hard tissues, a vertical and horizontal bone regeneration procedure is used with a mixture of bovine bone (Bio-Oss) and homologous fibrin glue (Tisseel). (r) The graft is protected by a resorbable collagen membrane (Bio-Gide). The fibrin glue stabilizes the clot, improving the quality of the physiologic fibrin mesh and slowing fibrinolysis. When used together with a slowly resorbed biomaterial acting as a scaffold, this creates a 3D graft that maintains volume.

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clinical case 13 (cont)

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x Fig 5-27 (cont) (s) The flap is made to slide in a coronal direction and sutured using a double layer technique (horizontal mattress sutures and simple interrupted sutures) using nonresorbable material (PTFE 5-0). A frenulotomy is carried out on the median frenulum at the same time. (t) Four months after GBR, excellent soft tissue healing and abundant keratinized gingiva are observed. (u) The implants are reopened with a minimal single incision in order to move the keratinized tissue buccally. (v) Clinical images of the definitive crowns show that the end result is very satisfactory from an esthetic viewpoint, with good soft tissue scalloping and partial recovery of the papilla between the right central and lateral incisors. (w) A radiograph taken 12 months after loading shows marginal bone level stability. (x and y) A comparison between the pre- and posttreatment soft tissue profiles shows excellent recovery of the baseline deficit through good surgical and prosthetic planning to achieve a well-proportioned gingival structure.

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Recommended Reading

References 1. Hämmerle CH, Araújo MG, Simion M; Osteology Consensus Group 2011. Evidence-based knowledge on the biology and treatment of extraction sockets. Clin Oral Implants Res 2012;23(suppl 5):80–82. 2. Cardaropoli D, Tamagnone L, Roffredo A, Gaveglio L, Cardaropoli G. Socket preservation using bovine bone mineral and collagen membrane: A randomized controlled clinical trial with histologic analysis. Int J Periodontics Restorative Dent 2012;32:421–430. 3. Araújo M, Linder E, Wennström J, Lindhe J. The influence of Bio-Oss Collagen on healing of an extraction socket: An experimental study in the dog. Int J Periodontics Restorative Dent 2008;28:123–135. 4. Nobuto T, Suwa F, Kono T, et al. Microvascular response in the periosteum following mucoperiosteal flap surgery in dogs: Angiogenesis and bone resorption and formation. J Periodontol 2005;76:1346–1353. 5. Jung RE, Philipp A, Annen BM, et al. Radiographic evaluation of different techniques for ridge preservation after tooth extraction: A randomized controlled clinical trial. J Clin Periodontol 2013;40:90–98. 6. Avila-Ortiz G, Elangovan S, Kramer KW, Blanchette D, Dawson DV. Effect of alveolar ridge preservation after tooth extraction: A systematic review and meta-analysis. J Dent Res 2014;93:950–958.

7. Haas R, Mailath G, Dörtbudak O, Watzek G. Bovine hydroxyapatite for maxillary sinus augmentation: Analysis of interfacial bond strength of dental implants using pull-out tests. Clin Oral Implants Res 1998;9:117–122. 8. Zitzmann NU, Schärer P, Marinello CP, Schüpbach P, Berglundh T. Alveolar ridge augmentation with Bio-Oss: A histologic study in humans. Int J Periodontics Restorative Dent 2001;21:288–295. 9. Landsberg CJ. Socket seal surgery combined with immediate implant placement: A novel approach for single-tooth replacement. Int J Periodontics Restorative Dent 1997;17:140–149. 10. Rasperini G, Canullo L, Dellavia C, Pellegrini G, Simion M. Socket grafting in the posterior maxilla reduces the need for sinus augmentation. Int J Periodontics Restorative Dent 2010;30:265–273. 11. Vignoletti F, Matesanz P, Rodrigo D, Figuero E, Martin C, Sanz M. Surgical protocols for ridge preservation after tooth extraction. A systematic review. Clin Oral Implants Res 2012;23:22–38. 12. Cardaropoli D, Tamagnone L, Roffredo A, Gaveglio L. Evaluation of dental implants placed in preserved and nonpreserved postextraction ridges: A 12-month postloading study. Int J Periodontics Restorative Dent 2015;35:677–685. 13. Scheyer ET, Heard R, Janakievski J, et al. A randomized, controlled, multicentre clinical trial of post-extraction alveolar ridge preservation. J Clin Periodontol 2016;43:1188–1199.

Recommended Reading Araújo MG, Liljenberg B, Lindhe J. Dynamics of BioOss Collagen incorporation in fresh extraction wounds: An experimental study in the dog. Clin Oral Implants Res 2010;21:55–64. Araújo MG, Lindhe J. Ridge preservation with the use of Bio-Oss collagen: A 6-month study in the dog. Clin Oral Implants Res 2009;20:433–440. Barone A, Aldini NN, Fini M, Giardino R, Calvo Guirado JL, Covani U. Xenograft versus extraction alone for ridge preservation after tooth removal: A clinical and histomorphometric study. J Periodontol 2008;79:1370–1377. Cardaropoli G, Araújo M, Hayacibara R, Sukekava F, Lindhe J. Healing of extraction sockets and surgically produced— augmented and nonaugmented—defects in the alveolar ridge. An experimental study in the dog. J Clin Periodontol 2005;32:435–440.

Cardaropoli D, Tamagnone L, Roffredo A, Gaveglio L. Relationship between the buccal bone plate thickness and the healing of postextraction sockets with/without ridge preservation. Int J Periodontics Restorative Dent 2014;34:211–217. Engler-Hamm D, Cheung WS, Yen A, Stark PC, Griffin T. Ridge preservation using a composite bone graft and a resorbable membrane with and without primary wound closure: A comparative clinical trial. J Periodontol 2011;82:377–387. Iasella JM, Greenwell H, Miller RL, et al. Ridge preservation with freeze-dried bone allograft and a collagen membrane compared to extraction alone for implant site development: A clinical and histologic study in humans. J Periodontol 2003;74:990–999. Nevins M, Camelo M, De Paoli S, et al. A study of the fate of the buccal wall of extraction sockets of teeth with prominent roots. Int J Periodontics Restorative Dent 2006;26:19–29.

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Questions: 1. What is meant by gingival recession? 2. What are the main etiologic factors in the development of gingival recession? 3. Apart from the main causal factors, what predisposing factors have been identified for gingival recession? 4. What are the therapeutic options for treating gingival recession? 5. Is it possible to predict the potential outcome of root coverage using periodontal plastic surgery tehniques? 6. What are the main periodontal plastic surgery procedures? 7. What techniques are used to harvest gingival tissue during periodontal plastic surgery? 8. Can biomaterials be used to replace connective tissue? 9. Given current scientific findings and the techniques described previously, what treatment guidelines can be suggested for different recession types?

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The aim of this chapter is to demonstrate that periodontal plastic surgery or mucogingival surgery techniques can be combined and used synergistically with implant surgery to optimize the final result. Teeth adjacent to implant sites are very often affected by mucogingival problems such as gingival recession. The chapter begins with analysis of the causes and

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prognosis of gingival recession and the most common therapeutic approaches, particularly periodontal plastic surgery techniques. In the second part of the chapter, clinical cases are presented to demonstrate how these techniques can be combined with implant surgery in different clinical situations.

What is meant by gingival recession?

Gingival recession refers to movement of the soft tissue margin apical to the cementoenamel junction (CEJ) with exposure of the root surface (Fig 6-1).

GM GM

CEJ

CEJ

Fig 6-1  Gingival recession. GM, gingival margin.

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What are the main etiologic factors in the development of gingival recession?

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What are the main etiologic factors in the development of gingival recession?

The main causal factors of gingival recession can be summarized as follows (Fig 6-2):

2. Localized inflammatory lesions due to bacterial plaque buildup 3. Generalized forms of destructive periodontal disease

1. Mechanical factors (damage caused by brushing, use of dental floss, or piercings)

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Fig 6-2 Clinical examples of gingival recession associated with brushing damage (arrows indicate erythematous areas caused by recent brushing injuries) (a), bacterial plaque buildup (b), and advanced chronic periodontitis (c).

Mechanical factors Brushing damage Incorrect brushing technique is undoubtedly the etiologic factor most commonly associated with the development of

a

gingival recessions (Fig 6-3). A direct correlation has been demonstrated between applied brushing force and the onset of gingival recessions. Correction of harmful brushing techniques is one of the fundamental principles of mucogingival therapy.

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Fig 6-3 (a and b) Multiple gingival recessions associated with brushing damage in the lateral regions of the maxilla in young adult patients. (c) A 32-year-old left-handed man with multiple recessions. The recessions, associated with a traumatic brushing technique, are more serious on the right side of the mouth, ie, sites contralateral to the hand that he uses to brush his teeth.

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six  Periodontal Plastic Surgery to Optimize Soft Tissues at Peri-implant Sites

Damaging use of dental floss Incorrect use of dental floss by pushing it into excessively apical positions can cause gingival recession (Fig 6-4).

Injuries caused by piercings Increasingly popular extra- and intraoral piercings often create a chronic trauma mechanism that can give rise to gingival recessions (Fig 6-5).

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Fig 6-4  (a and b) Palatal gingival recession at the second molar, linked to incorrect use of dental floss.

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Fig 6-5  (a to c) Nineteen-year-old woman with a pierced lower lip. The metal plate on the inside of the lip caused chronic injury to the gingiva of the mandibular right central incisor and development of recession.

Localized inflammatory lesions Localized inflammatory lesions are due to bacterial plaque buildup (Fig 6-6). Localized accumulation of bacterial plaque and consequent tissue inflammation may result in gingival margin recession. In some cases, gingival margin recession begins with a traumatic mechanism that subsequently causes

a

bacterial plaque buildup because the transition zone between the gingival margin and the tooth surface has become more difficult to clean. In addition, the presence of incorrect prosthetic margins, representing an iatrogenic factor, can lead to gingival recession (Fig 6-7).

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Fig 6-6  (a and b) Gingival recession caused by bacterial plaque buildup.

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What are the main etiologic factors in the development of gingival recession?

Fig 6-7  The presence of prosthetic margins that are incorrect or infringe on the biologic width can cause apical soft tissue recession.

Gingival recessions associated with generalized forms of periodontal disease Advanced loss of periodontal support associated with severe forms of periodontitis causes soft tissue recession as a side effect (Fig 6-8). Unlike recessions caused by localized me-

chanical or inflammatory factors, which usually affect only the buccal surface, recessions caused by advanced forms of periodontal disease involve circumferential abnormal root surface exposure. This type of recession cannot be treated by mucogingival therapy; therefore, it is mentioned merely in passing here.

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Fig 6-8  (a to e) In these patients, there is gingival recession associated with generalized chronic periodontitis.

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six  Periodontal Plastic Surgery to Optimize Soft Tissues at Peri-implant Sites

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Apart from the main causal factors, what predisposing factors have been identified for gingival recession?

The main mechanical and inflammatory etiologic factors often act on conditions that are already predisposed to gingival recession. A series of local predisposing factors for the development of gingival recession can be identified, including: bone dehiscence; presence of tension on the frenulum (pull syndrome); keratinized tissue band reduced or absent; tooth malposition; previous orthodontic treatment; and thin, scalloped gingival biotype.

Bone dehiscence Dehiscence is an anatomical anomaly of bone most frequently associated with the development of gingival recession. It is an anatomopathologic condition characterized by loss of margin and cortical bone above the root surface (Fig 6-9).

Tension on the frenulum An insufficiently deep fornix, often associated with tension on the frenulum (or pull syndrome), is another common predisposing factor for recession (Fig 6-10).

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Fig 6-9 (a) Buccal cortical bone dehiscence evident at the mandibular right canine on a dry skull, which represents a predisposing factor for soft tissue recession. (b) Deep gingival recession on a maxillary canine. (c) Flap elevation reveals the corresponding buccal bone dehiscence.

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Fig 6-10  Examples of tension on the frenulum as a predisposing factor for soft tissue recession, affecting the mandibular (a) and maxillary (b) central incisors.

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Apart from the main causal factors, what predisposing factors have been identified for gingival recession?

Keratinized tissue band reduced or absent The need for a minimal band of adherent gingiva is still a current topic of discussion in mucogingival treatment. However, scientific evidence has shown that in patients who are able to maintain appropriate plaque control, the lack of a sufficient quantity of adherent gingiva (1 mm) does not result in an increased incidence of soft tissue recession.1 From a clinical viewpoint, however, absence of adherent gingiva undoubtedly creates unfavorable conditions for proper plaque control with consequent inflammation of the marginal soft tissues and possible development of recession (Fig 6-11).

a

Tooth malposition Incorrect tooth alignment, particularly buccal tooth displacement outside the ideal arch curvature, is a predisposing factor in gingival recession (Fig 6-12).

Previous orthodontic treatment Expansion therapy, especially if associated with heavy orthodontic forces, drives the teeth in a buccal direction through the bone, often with the development of bone dehiscence. Subsequent brushing damage or gingival inflammation associated with plaque will then lead to soft tissue recession (Figs 6-13 and 6-14). Improper prosthetic treatment may also predispose gingival tissues to recession (Fig 6-15).

b

Fig 6-11  (a and b) In these patients, a reduced band of keratinized tissue represents the main predisposing factor for recession, which is caused by the associated bacterial plaque accumulation.

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Fig 6-12  (a) This patient’s multiple gingival recessions seem to be more accentuated at the malpositioned teeth, such as the maxillary and mandibular left canines, which are buccally displaced and lie outside the normal curvature of the arch. (b) Rotation of a tooth, in this case the mandibular left canine, causes the mesiobuccal tooth surface to be positioned outside the normal curvature of the arch and is a predisposing factor for gingival recession.

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Fig 6-13  (a) Multiple gingival recessions that occurred at the end of (mandible) and during (maxilla) orthodontic treatment. (b) Excessive buccal displacement causes bone dehiscence and subsequent gingival recession.

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Fig 6-14  (a and b) Recession affecting the mandibular lateral incisor. The patient, a 22-year-old woman, has previously undergone orthodontic treatment and had extracoronal splinting with braided wire. The lateral incisor root has undergone excessive buccal torque with displacement of the root outside the alveolar arch and the subsequent development of recession.

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Figs 6-15  (a and b) Multiple areas of recession in the anterior maxilla, associated with improper prosthetic and implant-supported prosthetic treatment that led to misalignment of the free gingival margin at the buccal and interproximal levels and apical displacement of papillae.

Thin, scalloped gingival biotype Marginal gingival tissue anatomy (shape and volume) is undoubtedly a factor that can influence the development of gingival recession. A study on humans2 showed how superficial characteristics of the periodontal tissue relate to maxillary central incisor shape. Measuring the ratio between the width (CW) and length (CL) of the clinical crown of maxillary central incisors, a CW/CL ratio > 0.66 indicates short, wide teeth with a square shape. A CW/CL ratio of < 0.66 indicates tall, narrow teeth with a triangular shape.

Gingival tissues can be subdivided into two types based on the CW/CL ratio: thick gingival biotype, characterized by short teeth and minimally scalloped gingival structure (Figs 6-16a and 6-16b), and thin gingival biotype, characterized by long teeth and a highly scalloped gingival structure (Figs 6-16c and 6-16d). Observations reported in the literature confirm the hypothesis that individuals with long, narrow teeth have a thin gingival biotype and are more susceptible to developing gingival recession.

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What are the therapeutic options for treating gingival recession?

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Fig 6-16  (a and b) Thick gingival biotype, with square teeth and short clinical crowns. (c and d) Thin gingival biotype, with triangular teeth and long clinical crowns.

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What are the therapeutic options for treating gingival recession?

Mucogingival therapy, ie, the surgical and nonsurgical procedures for correcting periodontal soft tissue defects, includes three options that can be combined based on the clinical situation: 1. Causal therapy and patient motivation: Treatment of gingival recession always starts with causal therapy for local removal of bacterial plaque combined with guidelines for correct oral hygiene. Visiting a dental hygienist and performing oral hygiene at home allow the removal of bacterial plaque, which represents one of the etiologic factors for recession. If a damaging brushing technique is identified, this must also be corrected before embarking on any other treatment. This causal therapy combined with educating and encouraging the patient in the use of a proper brushing technique can allow coverage of

the exposed root through a creeping attachment effect in certain situations (Fig 6-17). 2. Orthodontic treatment: Orthodontic realignment by moving teeth within the arches and cortical bone using light, continuous forces can cause coronal migration of the free gingival margin. This can also happen using an intrusive movement in the case of abnormal tooth migration (Fig 6-18). 3. Periodontal plastic surgery: This is a set of surgical techniques designed to correct soft tissue defects. Gingival grafts (free flap), pedicle flaps (coronally and laterally displaced flaps), and bilaminar techniques (a combination of repositioned flaps associated with a connective tissue graft) or tunneling techniques can be used to treat gingival recessions. Periodontal plastic surgery also includes subtractive surgical techniques to correct a gummy smile.

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Fig 6-17  Causal therapy combined with the use of proper oral hygiene at home is an option for managing gingival recessions. (a) In this case, the presence of two Stillman clefts is noted on the buccal aspect of two maxillary premolars. Careful diagnosis reveals that the inner part of both Stillman clefts has not yet fully epithelialized, and both lesions therefore can still be healed. (b) After an appropriate session of causal therapy with thorough removal of bacterial plaque supra- and subgingivally, the periodontal fibers are stimulated using a curette. This procedure is repeated at 2-week intervals. (c) The patient is then encouraged to use a soft brush with a rolling brushing motion. (d) Sixty days later, the Stillman clefts are completely healed, and there is a sufficient band of keratinized tissue on both free gingival margins.

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e

c

Fig 6-18  Abnormal tooth migration is often associated with advanced forms of periodontal disease. The teeth can migrate because of attachment loss and bone tissue resorption through a combination of buccal displacement and extrusion. At the same time, the free gingival margin retracts at the buccal and interproximal level, with the development of gingival recession. (a to c) In the case shown here, a 45-year-old man with generalized chronic periodontitis is affected by migration of the maxillary anterior teeth and Miller Class III gingival recessions on the right central and lateral incisors. (d) The patient undergoes nonsurgical periodontal treatment. Three months after assessment, fixed orthodontic treatment begins for realignment of the teeth with closure of gaps, retroclination, and intrusion. (e) A checkup 12 months after the end of orthodontic treatment shows almost total elimination of recession on both incisors, with simultaneous recovery of the interdental papillae.

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Is it possible to predict the potential outcome of root coverage using periodontal plastic surgery techniques?

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Is it possible to predict the potential outcome of root coverage using periodontal plastic surgery techniques?

Regardless of the size of the recession and the surgical techniques used, the potential for covering the exposed root surface is dependent on the integrity of interproximal periodontal support. In 1985, Preston Miller suggested classifying gingival recessions by subdividing them into four classes and anticipating the possibility of achieving root coverage in each case.3 • Class I. Marginal tissue recession that does not extend to the mucogingival junction; there is no interproximal periodontal attachment loss (bone peaks intact and papillae fully present); 100% root coverage can be anticipated (Fig 6-19a). • Class II. Marginal tissue recession that extends to or beyond the mucogingival junction; there is no interproximal

periodontal attachment loss (bone peaks intact and papillae fully present); 100% root coverage can be anticipated (Fig 6-19b). • Class III. Marginal tissue recession that extends to or beyond the mucogingival junction; loss of interproximal periodontal attachment (bone peaks reabsorbed and papillae not fully present) or malpositioning of the teeth; only partial root coverage can be anticipated (Fig 6-19c). • Class IV. Marginal tissue recession that extends to or beyond the mucogingival junction; absorption of bone or papillae in the interproximal area and/or severe malpositioning of the teeth; root coverage cannot be anticipated (Fig 6-19d).

a

b

c

d

Fig 6-19  Clinical examples of Miller Class I (a), II (b), III (c), and IV (d) recessions.

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What are the main periodontal plastic surgery procedures?

Free gingival graft Previously, a free gingival graft (Fig 6-20) was the primary technique used to treat gingival recessions. Nowadays, it is rarely used with natural teeth because other techniques

such as flap repositioning guarantee better esthetic results. As discussed in chapter 7, the gingival graft technique is still used to augment or re-create a band of keratinized tissue around implants.

a

b

c

d

e

f

Fig 6-20  (a and b) The epithelial–connective tissue gingival graft technique involves creating a partial-thickness recipient bed followed by mechanical treatment of the previously exposed root surface. (c) The recipient bed is then measured, and a thin band of epithelial tissue of appropriate size is taken from the palate. (d) The graft is then stabilized with single sutures and suspension sutures with periosteal anchorage. For the graft to revascularize, it is essential for it to remain completely immobile during the healing period. (e and f) One of the main limitations of this technique and the reason it has been almost entirely abandoned for the treatment of gingival recessions is the lack of color matching between the graft tissue and the surrounding tissue. However, the gingival grafting technique is still effective for creating a keratinized tissue band where this was previously absent. (Surgery by Dr P. Casentini.)

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What are the main periodontal plastic surgery procedures?

Coronally repositioned flap to treat a single recession The coronally repositioned flap technique (Fig 6-21) is based on the surgical principle of free gingival margin displace-

Recession

ment coronally to the CEJ. This entails creation of a flap that includes the design of two new papillae adjacent to the recession, known as surgical papillae. These must be positioned exactly over the existing interdental papillae, which are known as anatomical papillae.

Surgical papilla

Surgical papilla

CEJ

Anatomical papilla Anatomical papilla b

a

c

Partial thickness Total thickness

De-epithelialization of the papillae Mucogingival line

Recession line

De-epithelialization of the papillae

Partial thickness d

e

f

g

Fig 6-21  (a) The coronally repositioned flap technique is used for a single recession by displacing the free gingival margin coronally to the CEJ. (b) The flap includes two surgical (new) papillae that are positioned over the anatomical (existing) papillae. (c) Because the dental arches are curved, the coronal displacement of the surgical papillae requires a complex movement that is not purely vertical. (d) The pedicle flap is created through an intrasulcular incision at the buccal recession joined on both sides by a broad vertical releasing incision in the vestibule (to increase the size of the vascular bed) that tapers off toward the underlying bone surface (to reduce the risk of residual scarring). The flap is partially detached: half thickness up to the recession line, full thickness from the recession line to the mucogingival junction, and half thickness again apical to the mucogingival junction. (e) The anatomical papillae are de-epithelialized to allow adhesion to the connective tissue on the inner surface of the surgical papillae. (f) Once passive advancement of the flap has been achieved, it is sutured by positioning each surgical papilla over the corresponding anatomical papilla using a double-loop suspension suture. The needle is inserted into the surgical papilla from the external surface inward and then into the corresponding anatomical papilla in a buccopalatal direction. The suture thread emerges at the tooth’s palatal surface and then is drawn out by the needle under the contact point on the other side of the teeth, where it again enters the surgical papilla from the external surface inward and enters the corresponding anatomical papilla in a buccopalatal direction. The thread, again on the palatal surface of the tooth, is drawn out by the needle below the contact point to tie a knot. In this way, the surgical papillae are anchored to the corresponding anatomical papillae, and the mesial and distal papillae are connected by a single suture. The vertical incision lines are sutured with simple O-shaped interrupted sutures. (g) After 12 months, the recession is fully covered.

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six  Periodontal Plastic Surgery to Optimize Soft Tissues at Peri-implant Sites

Coronally repositioned flap without releasing incisions to treat multiple recessions If multiple recessions are present (Fig 6-22), two vertical releasing incisions can be made at both ends of the flap in order to slide the flap coronally. However, this would mean

making two angled incisions well beyond the mucogingival junction, which could involve the midline in the anterior region. Because the recessions are multiple, flap elasticity can be conferred by extending the flap. Consequently, surgical papillae that all converge toward the flap’s center of rotation can be created.

Recession

Surgical papilla Surgical papilla

CEJ

Surgical papilla Center of rotation a

b

Mucogingival line Recession line

Center of rotation

Center of rotation

c

d

e

f Fig 6-22 (a) Multiple recessions are present. (b) The flap is extended beyond the area of the recessions, and surgical papillae that all converge toward the flap’s center of rotation are created. (c) The flap is partially detached: partial thickness up to the recession line, full thickness from the recession line to the mucogingival junction, and partial thickness apical to the mucogingival junction in the alveolar mucosa. (d) The surgical papillae are advanced in a coronal direction with an added rotation. The mesial surgical papillae are rotated clockwise at their center of rotation, while the distal surgical papillae are rotated counterclockwise at their center of rotation. (e) The anatomical papillae are de-epithelialized. (f) Sling sutures are used to secure each surgical papilla over the corresponding anatomical papilla. (g) Twelve months later, full root coverage has been maintained.

g

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What are the main periodontal plastic surgery procedures?

Laterally repositioned flap A laterally repositioned flap is another option for treating gingival recessions. The main indication for this flap is the

presence of a broad band of keratinized tissue at the site of the tooth adjacent to the recession (Fig 6-23).

a

b

c

d

e

f

g

h

Fig 6-23 (a) Recessions on the maxillary left canine and first premolar are planned for treatment with a laterally repositioned double flap. (b) This involves: A releasing incision (1) angled in the direction that the flap will be displaced and extending beyond the gingival line. An arched paramarginal incision (2) applied within the keratinized tissue band of the tooth adjacent to the recession. The mesiodistal extension of this incision is key to cover the recession and must therefore match its mesiodistal width plus a few millimeters to fit the recipient bed created mesially and distally to the recession. The third incision line delimiting the pedicle flap (3) coincides with the gingival margin of the tooth affected by the recession and continues in an apical direction beyond the mucogingival junction. A recipient bed (4) is obtained for the laterally displaced flap by de-epithelializing the anatomical papillae adjacent to the recession. (c to h) The recessions at the canine and first premolar have been treated with a laterally displaced double flap, mobilizing part of the keratinized tissue apical to the lateral incisor and second premolar. The broad papilla between both teeth affected by recession has been used as a recipient bed. In particular, the flap rotated from the second to the first premolar has been anchored to the distal half of the papilla, while the mesial half of the de-epithelialized anatomical papilla houses the flap displaced laterally from the lateral incisor.

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six  Periodontal Plastic Surgery to Optimize Soft Tissues at Peri-implant Sites

i

j

Fig 6-23  (cont) (i and j) Tissue healing upon removal of sutures and long-term healing demonstrate that complete root coverage has been achieved. (Surgery by Dr P. Casentini.)

Bilaminar techniques Bilaminar techniques involve combining a coronally repositioned flap with a connective tissue graft, which is completely covered by the primary flap (Figs 6-24 to 6-26). Several systematic reviews of the literature on root coverage techniques have shown that this is the most predictable approach in terms of percentage of root coverage and long-term stability of results. To date, bilaminar techniques are therefore the gold standard for gingival recession treatment. The use of bilaminar techniques seems to be particularly indicated in cases where residual keratinized tissue is scarce or absent apical to the recession and in cases where erosion of the exposed root surface is associated with the recession. Adding a connective tissue graft increases gingival

a

b

tissue thickness in the marginal area, reducing coronally displaced contraction. Connective tissue is usually taken from the palate by epithelial–connective tissue harvesting or by harvesting connective tissue alone using an envelope technique.

Tunneling techniques Tunneling techniques may be an alternative to pedicle flaps for the treatment of gingival recessions. The tunneling techniques essentially involve detaching a partial-thickness envelope flap, tunneling into the anatomical papillae instead of making incisions (Fig 6-27). This approach can be advantageous in cases with a shallow vestibule, where coronally repositioned flaps are not a good solution.

c Fig 6-24  (a to c) Gingival recession on a maxillary canine treated with a bilaminar technique consisting of a connective tissue graft covered by a coronally advanced flap. (d) Twelve months later, full root coverage is observed. (e) Root coverage is confirmed at a 10-year follow-up.

d

e

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What are the main periodontal plastic surgery procedures?

a

b

c

d

e

f

g

h

i

Fig 6-25  (a) Gingival recession on a maxillary left canine. (b) The exposed root area shows a caries lesion with hard tissue loss and a buccopalatal hollow with preservation of the CEJ. (c and d) The root surface is planed using diamond-coated ultrasonic inserts (DPL3, EMS) to expose healthy tissue. (e) A partial-thickness flap is created, with two vertical releasing incisions and subsequent de-epithelialization of the papillae. (f) A connective tissue graft taken from the palate is sutured to the anatomical papillae, and the periosteum is positioned slightly coronal to the CEJ. (g) The flap is coronally advanced until it fully covers the connective tissue and then sutured with a combination of sling sutures at the papillae and simple sutures on the releasing incisions. (h and i) Twelve months later, complete root coverage is observed, and gingival tissue thickness has increased.

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a

b

c

d

e

f

Fig 6-26  (a and b) Treatment of multiple recessions by means of a coronal repositioning flap without releasing incisions combined with a connective tissue graft and application of amelogenins. In this case, a multiple-flap approach was used to treat recessions affecting the maxillary right first molar to lateral incisor. The use of a bilaminar technique is indicated in this case by the almost complete absence of keratinized tissue apical to the deep recessions. A coronally repositioned flap alone would not therefore be sufficient to ensure a stable long-term result. (c) As mentioned previously, a center of rotation must be identified: the canine in this case. The surgical papillae (identified by incision lines) that lie mesial to the center of rotation will rotate in a coronal and mesial direction, while those distal to the center of rotation will rotate in a distal and coronal direction. (d to f) The previously exposed roots are planed mechanically and then chemically treated with 24% ethylenediaminetetraacetic acid (EDTA) and amelogenins. Applying EDTA (PrefGel, Straumann), a chelator with a neutral pH, for 2 minutes removes planing debris from the dentinal tubules, leaving a decontaminated, microporous surface. Subsequent application of enamel organ proteins (Emdogain, Straumann), which are deposited on the root for 2 minutes, induces the differentiation of clot cells into cementoblasts. Application of amelogenins to the root surface during periodontal plastic surgery therefore improves the quality of the attachment between soft tissues and exposed root surface.

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What are the main periodontal plastic surgery procedures?

g

h

i

j

k

l

Fig 6-26  (cont) (g and h) De-epithelialization of the anatomical papillae. (i) A connective tissue graft is applied to the deepest recessions on the canine and both premolars and sutured in place. (j) The graft is completely covered by the coronally repositioned flap, which is stabilized in its new position by suspension sutures anchored to the anatomical papillae. A horizontal compressive suture anchored mesially and distally to the treated area completes flap stabilization. (k and l) Long-term follow-up showing full coverage of the gingival recessions and an improvement in periodontal tissue quality, with an increase in thickness and the keratinized tissue band. (Surgery by Dr P. Casentini.)

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six  Periodontal Plastic Surgery to Optimize Soft Tissues at Peri-implant Sites

a

b

c

d

e

f

g

h

Fig 6-27  Treatment of gingival asymmetry in the anterior maxilla using a tunneling technique and connective tissue graft. (a to c) The preliminary step is to remove the root component of the provisional composite restorations on the maxillary left central and lateral incisors and canine. Partial-thickness detachment is usually performed using appropriate microblades and periosteal elevators and extended beyond the mucogingival junction to allow mobilization of a flap in a coronal direction. (d and e) A connective tissue graft taken from the palate is then introduced inside the tunnel. (f) As with all periodontal plastic surgery techniques, the root surface must be treated mechanically and, if necessary, chemically. (g) The flap is then coronally mobilized and stabilized with suspension sutures that exploit the interdental contacts, reinforced with composite if needed. (h) After completing the case with ceramic veneers, the long-term clinical follow-up shows improved gingival levels in the treated area. Also note the complete absence of scarring, which is an advantage of tunneling techniques. (Surgery and prosthetic rehabilitation by Dr P. Casentini.)

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What are the main periodontal plastic surgery procedures?

Clinical crown lengthening techniques to correct altered passive eruption Resective techniques to correct clinical situations of altered passive eruption are usually listed among periodontal plastic surgery techniques. In such cases, the position of the gingival margin is excessively coronal in relation to the CEJ. From an esthetic viewpoint, such situations are often associated with unsightly gummy smiles (Figs 6-28 and 6-29). Unlike

a

root coverage techniques, in this case the desired result is apical (and not coronal) repositioning of the tissues, which must realign correctly in relation to the CEJ. Because excessively coronal position of the gingival margin is often associated with the presence of buccal cortical bone, the situation is corrected by apical repositioning techniques combined with bone remodeling. In less severe cases, it is sufficient to remove excess gingival tissue by internal bevel gingivectomy.

b

Fig 6-28  (a and b) A case of altered passive eruption in which the gingival margin, instead of being physiologically positioned 1 to 1.5 mm coronal to the CEJ, has a more coronal position, giving rise to an unsightly gummy smile. (c) This clinical situation can be diagnosed by comparing the length of the clinical crown (distance between the gingival margin [GM] and the incisal margin [IM]) with the radiographic crown length (distance between the CEJ and the IM) measured on a radiograph.

c

a

b

Fig 6-29  (a and b) Also in this case, altered passive eruption has given rise to an unsightly gummy smile. (c and d) The diagnosis can be confirmed by comparing the sizes and proportions of the clinical crowns with those measured on radiographs.

c

d

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e

f

g

h

i

j

k

l

m Fig 6-29 (cont) (e and f) To correct this situation, clinical crown lengthening is planned, in which buccal paramarginal flap elevation makes it possible to redesign the mucogingival architecture. (g to j) After elevating the flap and removing excess gingival tissue, bone remodeling by means of osteoplasty and ostectomy is necessary to expose the CEJ. (k and l) The flap is then sutured in an apical position by means of resorbable sutures (polyglycolic acid 6-0). (m and n) Long-term intra- and extraoral clinical follow-up shows improved tooth proportions and smile esthetics. (Surgery by Dr P. Casentini.)

n

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What techniques are used to harvest gingival tissue during periodontal plastic surgery?

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What techniques are used to harvest gingival tissue during periodontal plastic surgery?

As has been shown, periodontal plastic surgery techniques often involve transplanting an epithelialized or nonepithelialized gingival (ie, connective tissue) graft that is taken from the palate. The two techniques used are epithelial–connective tissue harvesting and the envelope technique.

Epithelial–connective tissue harvesting The advantages of this technique are the possibility of obtaining good quantities of tissue (Fig 6-30) and the fact that tissues can be harvested from the same site again after a certain time interval. However, there are disadvantages, mainly the difficulty of the surgical technique, the increased risk of bleeding, and greater postoperative discomfort for the patient. Postoperative discomfort can be significantly reduced by using a thermoformed plate to protect the donor site (Fig 6-31). The plate should be thin in order not to alter the patient’s bite. Patients treated with a plate report

a

a significant reduction in symptoms during the first week postsurgery. The plate is also a useful device for controlling postsurgical bleeding.

De-epithelialization of an epithelial– connective tissue graft With the exception of gingival graft techniques, harvested epithelial–connective tissue is usually used as a connective tissue graft and must therefore be stripped of the epithelial layer, which would hinder graft attachment and could promote exposure during healing. The epithelial layer can be removed before detaching the sample from the palate by means of a bur (Fig 6-32) or, at a later stage, using a scalpel blade (Fig 6-33). In both cases, this maneuver should be performed using a magnification system to be certain of removing the entire epithelial layer.

b

Fig 6-30 (a and b) Harvesting epithelial–connective tissue from the palate. In the superficial layer, connective tissue quality is favorable and the amount of adipose tissue is minimal.

a

b

c

Fig 6-31  Step-by-step technique for harvesting epithelial–connective tissue from the palate. (a) The blade initially defines the perimeter of the graft by working at right angles to the palatal vault and penetrating approximately 2 mm. The area usually used for harvesting is located posterior to the palatal rugae, between the second premolar and the second molar. (b and c) The blade then works tangentially to the mucosal plane, separating the harvested tissue from the underlying surface.

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six  Periodontal Plastic Surgery to Optimize Soft Tissues at Peri-implant Sites

d

e

f Fig 6-31 (cont) (d and e) If the graft is harvested from the superficial layer only, it is essentially devoid of adipose tissue, and intraoperative bleeding is usually reduced. (f and g) The harvesting site is then protected with collagen stabilized by cross sutures. (h) The use of a thermoformed plate to protect the donor site considerably reduces the patient’s postoperative discomfort and facilitates control of postoperative bleeding.

g

h

a

b

c

Fig 6-32  De-epithelialization of the harvested tissue before detaching from the palate. (a) After delimiting the harvest area using a no. 15c scalpel, staying at least 1 mm away from the sulcus of the corresponding teeth, a superficial epithelial layer is removed from an area distal to the palatal rugae, using a diamond-coated round bur fitted to a turbine handpiece. (b) The scalpel blade is then tilted in order to position it parallel to the palate, separating the connective tissue layer. The periosteum covered by a residual layer of connective tissue remains on the palate. (c) The harvested tissue is thus made up of connective tissue alone and is ready to be grafted.

a

b

c

Fig 6-33  (a) The harvested graft is de-epithelialized by means of a no. 15c blade passed tangentially over the harvested tissue surface. (b) The maneuver is facilitated by immobilizing the tissue, resting it on a rough surface such as a sterile cloth, and holding it in place with surgical forceps. (c) Graft de-epithelialization should be limited to removal of the most superficial layer alone in order to avoid thinning the connective tissue graft component excessively.

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What techniques are used to harvest gingival tissue during periodontal plastic surgery?

Harvesting from the palate using the envelope technique This technique (Fig 6-34) offers some advantages over epithelial–connective tissue harvesting. For example, tissue collection can be extended to include the area of the palatal rugae. In addition, hemostasis is more easily achieved because the harvesting site is closed by first intention, and this theoretically promotes better postoperative healing.

However, there are also some disadvantages. If the palatal fibromucosa is thin, harvestable tissue quantity and quality are reduced. Though healing theoretically occurs by first intention, in practice the thin superficial epithelial layer often becomes necrotic, and healing takes place by second intention. Lastly, the technique requires good manual skills and an experienced operator. In this case, too, the use of a protective thermoformed plate can improve postoperative healing.

a

b

c

d

e

f

Fig 6-34 In the envelope harvesting technique, a single incision line is made, through which connective tissue is removed, leaving epithelial tissue in situ. This makes it possible to work even in the area of the palatal rugae. (a) After anaesthetizing the patient with adrenaline 1:50,000, a horizontal incision is made from a point distal to the canine to a point mesial to the first molar at least 1 mm from the adjacent tooth sulci, remaining above the periosteum. (b) A periosteal elevator is used to gently open the incision line to insert a no. 15c scalpel blade. (c) The blade is inserted parallel to the bone surface throughout its length, remaining at the superficial level to separate the epithelium from the connective tissue. (d) The scalpel blade is then inserted deeper to separate the connective tissue from the periosteum. (e) Two vertical incisions, one mesial and one distal, allow the connective tissue to be detached on four sides and taken out of the envelope with the aid of tweezers. (f) The incision line on the palate can be closed with simple interrupted sutures to promote healing by first intention. (g) Freshly harvested connective tissue graft measuring 12 mm in length and 5 mm in width.

g

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Can biomaterials be used to replace connective tissue?

A connective tissue graft taken from the palate, as used in bilaminar techniques, is the gold standard for treating gingival recessions, even though it inevitably increases the morbidity of the entire surgical procedure. Negative aspects of this approach are: • Need for a second surgical harvesting site • Difficult surgical harvesting technique • Increase in intraoperative bleeding and risk of postoperative hemorrhage • Longer surgical session • Limited availability of graft tissue • Postoperative pain • Risk of palatal tissue necrosis For these reasons, over the years, scientific research has been aimed at selecting biomaterials that can be used as connective tissue graft substitutes in the various mucogingival surgery procedures. One possibility is a 3D matrix in native porcine collagen (Mucograft, Geistlich). This matrix consists of two layers: a superficial layer accounting for 10% of the

a

total thickness, made up of very thick collagen fibers that can create a smooth, compact structure for suturing that can be left exposed in the oral cavity, and a deep layer, accounting for about 90% of total thickness, consisting of very sparse collagen fibers that can create a porous, spongy structure to stabilize the blood clot and initiate the biologic stages of soft tissue regeneration (Fig 6-35). The total thickness of the matrix is approximately 2.5 to 3 mm, and it is sold in two sizes (15 × 20 mm and 20 × 30 mm). A controlled randomized study4 found that comparable results could be achieved using connective tissue and a collagen matrix when combined with a coronally repositioned flap for the treatment of gingival recessions. For this indication, the matrix must be completely covered by a pedicle flap and well stabilized to the underlying periosteum. The introduction of collagen matrices has increased the use of primary periodontal plastic surgery techniques. Shown here are examples of coronally repositioned flaps combined with collagen matrix placement for single (Fig 6-36) and multiple (Fig 6-37) recessions.

b

Fig 6-35  (a) Mucograft collagen matrix, with the superficial layer facing upward. (b) Lateral view showing the matrix thickness.

a

b

c

d

e

Fig 6-36  Single coronally repositioned flap combined with collagen matrix placement. (a) Recession on a maxillary lateral incisor with a lesion on the cervical third of the tooth due to abrasion. (b) This lesion has caused a buccopalatal tissue deficit. (c) The first step is conservative reconstruction of the CEJ to promote effective soft tissue adaptation during postsurgical healing. (d and e) A coronally repositioned flap is then created with two vertical releasing incisions, using partial-thickness detachment and de-epithelialization of the anatomical papillae.

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Can biomaterials be used to replace connective tissue?

f

g

h

i

j

Fig 6-36 (cont) (f) The next step is to cut a 3D collagen matrix (Mucograft) to the width of the surgical bed in order to achieve the best possible blood flow and the largest possible support base to increase mechanical stability. (g) The collagen matrix is sutured to the anatomical papillae and, apically, to the periosteum. The matrix begins to stabilize the blood clot due to spontaneous bleeding from the surgical wound. (h) The pedicle flap is repositioned over the matrix to cover it completely, coronally advanced, and sutured with sling sutures and simple sutures (polytetrafluoroethylene 5-0). (i and j) Clinical images taken 1 year later show complete root coverage and a gain in tissue when viewed laterally, with satisfactory support at the CEJ.

a

b

c

d

Fig 6-37  Coronally repositioned flap with collagen matrix placement for the treatment of multiple recessions in a patient with high esthetic expectations. (a and b) Treatment of the patient, who has a broad smile line, involves the use of a coronal repositioning flap without releasing incisions, extending from the first molar to the central incisor. The procedure is usually carried out separately on each side, but in this case it was carried out simultaneously at the patient’s request. (c) After creating and elevating both mixed-thickness flaps, considering the canines to be the center of rotation on both sides, the exposed roots were thoroughly planed and treated with EDTA, and the anatomical papillae were de-epithelialized. (d and e) A trimmed collagen matrix (Mucograft) was then applied and sutured using resorbable sutures (polyglycolic acid 7-0). Application of a bilaminar technique with a connective tissue graft substitute seems to be particularly indicated in this case because intraoperative removal of overextensive preexisting cervical restorations had led to a step at the CEJ. The collagen matrix is able to offer mechanical support for the flap.

e

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f

g

h

i Fig 6-37 (cont) (f) A second collagen matrix was applied and sutured. (g) Lastly, the flaps are sutured in a coronal position. (h and i) Long-term intra- and extraoral clinical follow-up demonstrates favorable results, with complete coverage of the gingival recessions and a clear esthetic improvement. (Surgery by Dr P. Casentini.)

9|

 iven current scientific findings and the techniques G described previously, what treatment guidelines can be suggested for different recession types?

Based on anatomical, biologic, and clinical considerations regarding factors such as the presence and quantity of residual keratinized tissue and periodontal tissue thickness, the author’s proposed treatment guidelines subdivide recessions into three different types. The common denominator shared by the different therapeutic approaches is a clinical need to guarantee the presence of marginal keratinized tissue after healing and sufficient gingival thickness to allow the result to be maintained long term.

• Type 1: Single or multiple gingival recessions with the presence of adherent marginal gingiva and thick biotype (Fig 6-38). Treatment: Coronally repositioned flap with or without releasing incisions. • Type 2: Gingival recessions with adherent marginal gingiva but thin biotype and/or lack of tooth root structure (Fig 6-39). Treatment: Coronally repositioned flap with connective tissue graft or collagen matrix. • Type 3: Gingival recessions without adherent marginal gingiva (Fig 6-40). Treatment: Coronally repositioned flap with connective tissue graft.

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Clinical Case Studies

a

b

Fig 6-38  Type 1 recessions. Presence of a sufficient band of adherent tissue, laterally (a) and apically (b) to the recession, to be advanced to cover the exposed root portion.

a

b

Fig 6-39  Type 2 recessions. Presence of recessions with adherent tissue apical to the free gingival margin but with a thin gingival biotype (a) and a deficiency of crown and root hard tissue (b). Both of these situations require tissue augmentation.

a

b

Figs 6-40  Type 3 recessions. Absence of a sufficient band of adherent gingiva. Both of these situations (a and b) require a connective tissue graft to re-create keratinized gingiva at the CEJ.

Clinical Case Studies Figures 6-41 to 6-49 present clinical cases demonstrating different applications of periodontal plastic surgery techniques.

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clinical case 1

Implant placement in premolar site and treatment of gingival recession at the canine by means of a coronally repositioned flap

a

b

c

d

e

De-epithelialized anatomical papilla

f Fig 6-41  (a to e) In this 40-year-old woman, an initial clinical and radiographic examination revealed edentulism at the first premolar site and gingival recession affecting the adjacent canine and second premolar. The recessions can be classified as Miller Class II and III, considering the mesial and distal bone peaks. The extraoral view also reveals that the recessions detract from the esthetic aspect of the patient’s smile. A buccolingual defect can also be observed at the edentulous site in the occlusal and frontal views. (f) A flap is therefore created, allowing access to the edentulous site, which will be treated by implant placement and simultaneous guided bone regeneration (GBR). The flap can then be coronally repositioned to treat the recessions.

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Clinical Case Studies

clinical case 1 (cont)

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Fig 6-41 (cont) (g) After detaching and elevating an access flap, the implant site is prepared, and an implant is placed (Bone Level 4.1 × 10 mm, Straumann). (h and i) The root surfaces of both teeth affected by recessions are then planed and treated with EDTA gel (PrefGel) for 2 minutes. (j and k) The next step in the procedure is to perform a GBR technique using hydroxyapatite of bovine origin and a collagen membrane (Bio-Oss and Bio-Gide, Geistlich) to correct the buccal cosmetic defect. (l) The flap is then made passive by means of a partial-thickness detachment of the apical portion and repositioned coronally after de-epithelializing the anatomical papilla between the canine and lateral incisor using a no. 15c blade. (m and n) The oblique sutures, applied in an apicocoronal direction to the releasing incision, contribute to flap coronal repositioning.

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six  Periodontal Plastic Surgery to Optimize Soft Tissues at Peri-implant Sites

clinical case 1 (cont)

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Fig 6-41 (cont) (o and p) After 4 months, complete coverage is observed at the canine site. Mesial and distal bone peak reabsorption at the second premolar prevented a greater degree of root coverage. (q and r) Reopening for healing screw connection is performed with a small trapezoid flap, which should avoid the need to involve the adjacent papillae and serve the secondary purpose of properly realigning the mucogingival junction at the implant site. (s to v) A final clinical and radiographic follow-up highlights favorable esthetic integration of the implant-supported prosthetic device and absence of peri-implant bone resorption. Correction of the gingival recession improved the intra- and extraoral appearance of the treated area, with a significant esthetic improvement in the smile. (Surgery and prosthetic rehabilitation by Dr P. Casentini; laboratory procedures by Mr R. Colli and Mr C. Pedrinazzi.)

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Clinical Case Studies

clinical case 2

Implant placement and simultaneous treatment of gingival recessions in the esthetic zone

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Fig 6-42  (a and b) A man came for treatment with an old gold and resin maxillary partial denture with a pontic tooth in the left central incisor site. The device shows evident signs of wear on the buccal surface of the acrylic resin, and the two natural teeth supporting the partial denture show free gingival margin recession. (c) A radiograph shows abundant availability of bone in a vertical direction. (d) The treatment plan involves removing the partial denture and placing an implant in site the left central incisor site with subsequent construction of three individual crowns. Implant placement is planned by means of a diagnostic wax-up and subsequent creation of a surgical template to carry out prosthetically guided placement. (e) A mixed partial and full-thickness mucoperiosteal flap is elevated with the creation of three surgical papillae mesial to the right central incisor, left lateral incisor, and left canine, converging toward the flap’s center of rotation, ie, the left central incisor site. (f and g) The elevated flap is full thickness at the implant site and partial thickness around the natural teeth. The implant site is prepared with the aid of a surgical template, which makes it possible to place the implant (T3 Certain Tapered 5 × 13 mm, Zimmer Biomet) in the correct 3D position. (h) The flap is then sutured, obtaining closure by first intention at the ridge incision in the maxillary left central incisor site and coronal advancement of the free gingival margin on the right central incisor and left lateral incisor by means of a suspension suture. (i) It is preferable to carry out submerged implant healing in order to facilitate fitting of the flap to the natural teeth. (j) Twelve weeks later, a sufficient keratinized tissue band is present.

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six  Periodontal Plastic Surgery to Optimize Soft Tissues at Peri-implant Sites

clinical case 2 (cont)

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Fig 6-42  (cont) (l to n) After a few minutes, an impression transfer is positioned on the implant head, and 2 weeks later, a zirconia prosthetic abutment is placed. (o) A radiograph shows that the post is perfectly positioned, and platform switching has taken place with the implant platform. (p) Three individual provisional crowns are then cemented in place to condition the soft tissues by compression and create the correct tooth and gingival architecture. (q) Three months later, the provisional crowns have conditioned the tissues to create a perfectly scalloped gingival architecture with the papillae properly supported, even around the implant. (r and s) The three individual full-ceramic crowns.

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Clinical Case Studies

clinical case 2 (cont)

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Fig 6-42  (cont) (t and u) The crowns have been manufactured to fit perfectly to the soft tissue architecture, which was properly modulated during the provisional stage. (v) One year later, a clinical image confirms esthetic stability of the final result, with correct proportions between teeth and gingiva. (w) A radiograph reveals stable marginal bone levels. (x and y) Comparison between the initial and final situations.

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six  Periodontal Plastic Surgery to Optimize Soft Tissues at Peri-implant Sites

clinical case 3 Implant placement with simultaneous buccal bone augmentation and treatment of two adjacent gingival recessions

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Fig 6-43  (a) The patient presented with a metal-ceramic partial denture from the first premolar to the first molar in the right maxilla, with a pontic tooth at the site of the second premolar. Initial clinical analysis shows recession of the free gingival margin on both abutments and inconsistent prosthetic margins. (b) A radiograph shows the absence of periapical lesions and good vertical bone availability in the second premolar site. (c) The treatment plan involves placing an implant in the second premolar site and new prosthetic treatment with three individual ceramic crowns. (d) A full-thickness flap is detached in the edentulous area with the aim of preparing the implant site, and a partial-thickness flap is detached buccal to the natural teeth. An osseointegrated implant is inserted measuring 4 mm in diameter and 11.5 mm in length (Osseotite Tapered, Zimmer Biomet). The implant is fully inserted in the cortical bone, but there is a concavity in the buccal cortical bone. (e) The concavity is augmented using slowly resorbing biomaterial (Bio-Oss Collagen). (f) The flap is coronally repositioned to achieve closure by first intention at the implant site and coverage of the recessions on the natural teeth by means of a suspension suture. (g) A radiograph shows that the implant placement is consistent with preexisting bone availability. (h) Healing after 4 months shows excellent soft tissue stability.

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Clinical Case Studies

clinical case 3 (cont)

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Fig 6-43 (cont) (i) Given the abundant amount of keratinized tissue, the second stage of implant surgery is performed through a slit, then a titanium prosthetic abutment is attached to the implant. (j) Three individual provisional crowns in acrylic resin are cemented in place, with a slightly supragingival seal on the natural teeth. (k) The radiograph also reveals stable bone tissues. (l) A radiograph taken a year later shows stable marginal bone levels at the peri-implant level and no periapical lesions. (m) A clinical image shows an excellent fit between the prosthesis and the gingiva. m

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six  Periodontal Plastic Surgery to Optimize Soft Tissues at Peri-implant Sites

clinical case 4 Implant placement in a maxillary premolar site combined with a bilaminar technique at the adjacent canine site

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Fig 6-44  (a to f) Rehabilitation of the first quadrant was required for this 69-year-old patient. Implant-supported prosthetic rehabilitation cannot be considered in the molar region because of a prior maxillary sinus infection treated by surgical revision of the maxillary sinus, which has since resolved. The volume available for implant placement is therefore limited to the premolar sector in the mesiodistal direction. It will also be necessary to replace the provisional restorations on the maxillary right lateral incisor and canine with definitive restorations. An analysis of the mucogingival situation shows a distinct misalignment of gingival margins between the maxillary right lateral incisor and canine. Given this situation and the length of the clinical crown of the left canine, it is reasonable to suspect the presence of a gingival recession at the right canine, even though the CEJ is unidentifiable because of the prosthetic preparation. An almost complete lack of keratinized tissue also can be observed at the right canine, which is a critical factor for definitive prosthetic treatment. The treatment plan therefore involved placing two implants in the first and second premolar sites and the simultaneous performance of a bilaminar technique at the canine to improve the mucogingival conditions. (g and h) After elevating a partial-thickness flap on the mesial side and a full-thickness flap on the distal side of the implants and after mechanical treatment of the canine using a diamond bur, two reduced-diameter (3.3 mm) implants (Bone Level) are positioned in the first (10-mm length) and second (8-mm length) premolar sites. The choice of implant diameter is not dictated by the horizontal alveolar ridge volume, which is adequate, but by the small amount of available mesiodistal space.

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Clinical Case Studies

clinical case 4 (cont)

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Fig 6-44  (cont) (i) To improve the canine’s mucogingival conditions, a bilaminar technique is therefore performed by means of a connective tissue graft taken from the palate and coronal flap repositioning with complete graft coverage. (j) The connective tissue graft is then stabilized to the recipient bed by means of single sutures at the anatomical papillae and a compressive cross suture anchored to the apical periosteum and suspended around the prosthetic abutment. (k and l) From an occlusal view, a comparison between the preoperative situation and the situation prior to delivery of the definitive restoration shows a considerable increase in soft tissue buccal to the canine and reconstruction of a sufficient band of keratinized tissue. (m to q) Upon delivery, the definitive prosthetic devices (individual metal-ceramic crowns on the right lateral incisor and canine and a screw-retained metal-ceramic partial denture on the right premolars with a distal cantilever) are clearly well-integrated with a precise margins and good symmetry between the two sides of the maxilla. (Surgery by Prof M. Chiapasco and Dr P. Casentini; prosthetic rehabilitation by Dr P. Casentini; laboratory procedures by Mr A. Giacometti.)

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six  Periodontal Plastic Surgery to Optimize Soft Tissues at Peri-implant Sites

clinical case 4 (cont)

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Fig 6-44 (cont) (r and s) Two years later, the tissues have clearly matured, and the papillae have reformed between the tooth- and implant-supported crowns.

clinical case 5 Implant placement in maxillary premolar site and simultaneous tunneling technique with a connective tissue graft to treat recessions on adjacent teeth

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Fig 6-45  (a to d) An initial clinical and radiographic examination revealed edentulism at the maxillary right second premolar site and gingival recessions affecting the adjacent first premolar and first molar. The recessions are classified as Miller Class III because periodontal support has been lost at the interproximal level. The band of keratinized tissue present apical to the recessions is nearly absent. An occlusal view also shows the presence of a slight buccopalatal defect at the edentulous site. Given that the missing tooth is to be replaced by an implant, the plan involves a simultaneous connective tissue graft taken from the palatal aspect of the flap and inserted buccally after tunneling.

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Clinical Case Studies

clinical case 5 (cont)

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Fig 6-45  (cont) (e and f) The access flap used in this context involves a simple incision in the center of the ridge, extending into the sulcus of the teeth adjacent to the edentulous space. After preparing the implant site, an implant is positioned (Bone Level 4.1 × 10 mm). No hard tissue augmentation technique is performed because the implant is surrounded by sufficient bone volume. (g to j) In the mucogingival stage of the procedure, after root surface planing with curettes, the papillae mesial and distal to the edentulous site are tunneled with a micro-elevator, and flap detachment is extended to partial thickness with a no. 15c blade in an apical direction to mobilize the flap in a coronal direction. (k and l) On the palatal aspect, the incision is then extended mesially in order to harvest a connective tissue graft from the internal side of the flap.

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six  Periodontal Plastic Surgery to Optimize Soft Tissues at Peri-implant Sites

clinical case 5 (cont)

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Fig 6-45  (cont) (m and n) The graft is then pulled inside the previously created tunnel and stabilized by mesial and distal sutures. (o and p) The flap is then sutured without tension to fully cover the graft and obtain closure by first intention in the harvest site. (q to s) Final clinical and radiographic follow-up: Comparison of occlusal views before and after treatment shows correction of the slight horizontal atrophy present at the edentulous site and an increase in soft tissue thickness around the adjacent first premolar and first molar. In this case, the esthetic correction is achieved solely using a connective tissue graft.

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Clinical Case Studies

clinical case 5 (cont)

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Fig 6-45  (cont) (t) The gold-ceramic implant-supported prosthesis is well integrated into the surrounding tissues. There has clearly been a distinct improvement in mucogingival architecture with almost complete coverage of the gingival recessions and a significant increase in the keratinized tissue band. (u) Posttreatment radiograph showing the osseointegrated implant. (Surgery and prosthetic rehabilitation by Dr P. Casentini; laboratory procedures by Mr A. Schoenenberger.)

clinical case 6 Implant placement in a mandibular molar site combined with a bilaminar technique at the adjacent premolar sites

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Fig 6-46  (a to d) The treatment plan for this 58-year-old patient previously treated for periodontitis involves rehabilitation of the edentulous mandibular left first and second molar sites by placing an implant in the first molar site. The mesially inclined third molar, which has grade 3 mobility and lacks an antagonist, will be extracted at the time of implant placement. The paraxial computed tomography section shows adequate bone volume at the first molar site. The patient also complains of pain when brushing the adjacent premolars, which are clearly affected by Miller Class III gingival recessions due to partial loss of mesial and distal bone peaks and almost complete absence of residual keratinized tissue. Given the mucogingival conditions of the teeth adjacent to the site, a bilaminar technique is planned to coincide with implant placement. (e and f) An access flap is detached, partial thickness in the mesial part of the flap relating to the mucogingival area, which will act as a recipient bed for the connective tissue graft, and full thickness in the distal part relating to the implant.

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six  Periodontal Plastic Surgery to Optimize Soft Tissues at Peri-implant Sites

clinical case 6 (cont)

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Fig 6-46  (cont) (g to j) After implant placement in the first molar site (Straumann Wide Neck SP, 4.8 × 8 mm) and mechanical preparation of the root surfaces, a connective tissue graft taken from the palate is stabilized to the recipient bed by means of resorbable sutures (polyglycolic acid 6-0) and then covered by a coronally repositioned flap. A transmucosal healing procedure, whereby the soft tissues are fitted around the healing screw by means of single sutures, is used at the implant placement site. (k to o) The clinical situation before and after delivery of the definitive restoration reveals an increase in the keratinized tissue band and good coverage of recessions on the premolars, for which the probing depth is normal. A sufficient quantity of keratinized tissue and reduced probing depth are also present at the implant site. (p) A radiographic follow-up shows the absence of peri-implant bone resorption. (Surgery and prosthetic rehabilitation by Dr P. Casentini; laboratory procedures by Mr R. Colli and Mr C. Pedrinazzi.) p

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Clinical Case Studies

clinical case 7

Maxillary sinus elevation with simultaneous bilaminar technique involving collagen matrix placement

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Fig 6-47  (a to g) Rehabilitating the maxillary right quadrant of this 62-year-old woman involves replacing her preexisting tooth-supported partial denture (the distal abutment of which has an uncertain prognosis) with an implant-supported prosthetic rehabilitation. The first rehabilitation step will be a maxillary sinus floor elevation, which will allow the subsequent placement of two implants in the first premolar and first molar sites. A computed tomography scan carried out before the surgery does not reveal any local contraindications to this procedure. A new crown for the canine site as well as a partial denture supported by the implants in the first premolar and first molar sites will be made. After removing the partial denture, an assessment of the mucogingival condition of the canine abutment tooth shows the presence of very thin, poorly keratinized tissue. It would be advantageous to thicken and improve the apicocoronal position of the soft tissues in this site with a view to making a new restoration with a subgingival margin that will cover the discolored root. For this reason, coronal flap repositioning and collagen matrix placement are planned to coincide with the maxillary sinus surgery.

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six  Periodontal Plastic Surgery to Optimize Soft Tissues at Peri-implant Sites

clinical case 7 (cont)

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Detached full-thickness flap j

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Detached partial-thickness flap

Fig 6-47  (cont) (h to k) The access flap is detached partial thickness in the mesial part of the flap relating to the mucogingival area, which will act as a recipient bed for the collagen matrix, and full thickness in the distal part, where access to the maxillary sinus will be created. (l to o) Maxillary sinus surgery begins by delineating an osteotomy line using piezoelectric instruments (Piezosurgery, Mectron). The root surfaces of the adjacent abutment are decontaminated using the same diamond tip. Once the bony wall of the maxillary sinus has been worn down, a piezoelectric instrument is used to start detaching the membrane, and the operation is then completed manually using an elevator.

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Clinical Case Studies

clinical case 7 (cont)

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Fig 6-47  (cont) (p) After achieving a good degree of elevation for the bony flap, the space obtained is filled using deproteinized bovine bone (Bio-Oss). (q and r) The decision to use a collagen matrix (Mucograft) is determined by a desire to improve the quality of soft tissues around the mesial abutment of the partial denture while avoiding the need to harvest connective tissue, which would increase the morbidity of an invasive procedure like maxillary sinus surgery. The mucogingival stage of surgery begins with de-epithelialization of the anatomical papillae, which will act as a recipient bed for the coronal repositioning flap. (s and t) The collagen matrix is shaped with the scalpel blade, thus avoiding compression and a change in thickness. The matrix is then applied dry to the defect so that it will gradually soak up blood and then secured in the same way as a connective tissue graft, ie, using resorbable sutures (polyglycolic acid 6-0). (u and v) The remaining part of the collagen matrix is used as a membrane to seal the maxillary sinus window.

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six  Periodontal Plastic Surgery to Optimize Soft Tissues at Peri-implant Sites

clinical case 7 (cont)

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Fig 6-47  (cont) (w) After passively advancing the flap, it is sutured without tension in a coronal position to fully cover the matrix. (x to bb) Nine months later, after establishing that the graft is properly mineralized in the maxillary sinus, Bone Level implants can be placed in the first premolar (3.3 × 10 mm) and first molar (4.1 × 10 mm) sites.

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Clinical Case Studies

clinical case 7 (cont)

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Fig 6-47 (cont) (cc to hh) After conditioning the peri-implant and periodontal soft tissues at the canine site, the definitive metal-ceramic prostheses can be delivered. The soft tissues around the canine appear to be sufficiently thick and in good condition, and the rehabilitation appears to be well integrated with the surrounding tissues. (ii) A radiographic follow-up shows the absence of peri-implant resorption. (Surgery and prosthetic rehabilitation by Dr P. Casentini; laboratory procedures by Mr A. Schoenenberger.)

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clinical case 8 Ridge preservation combined with tunneling technique and tissue grafting in a case with high esthetic impact

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e Fig 6-48  (a) This 42-year-old woman has high esthetic expectations and says she is very dissatisfied with the appearance of her smile. She also reports discomfort in the anterior maxilla. Her smile line, which may be classified as middle to high, shows asymmetry. (b) At the intraoral level, a frontal view reveals asymmetry between the central and lateral incisors. The contralateral teeth have different clinical crown lengths, and volume loss and retraction of the papilla between the left central and lateral incisors are also evident. The left central incisor has undergone multiple reconstructive and endodontic treatments and is very mobile. The left lateral incisor has been treated with a provisional crown. Gingival recession is also present at the right central incisor. (c and d) The radiograph and computed tomography scan also reveal complete loss of the buccal cortical bone around the left central incisor and partial loss of the bone peak between the left central and lateral incisors. To improve the harmonious proportions of the maxillary anterior teeth, it is necessary to realign the gingival margins, improve the alignment of the incisal margins and the tooth axes, redistribute the mesiodistal spaces (the left lateral incisor looks bulkier than the right lateral incisor), and improve tooth color, which does not look uniform. (e) The left central incisor is considered compromised and is planned for extraction. The main risk attached to extracting a tooth with complete buccal cortical bone loss and a thin, scalloped biotype is severe soft tissue collapse with further compromise of the bone peaks and soft tissue recession around adjacent teeth. For this reason, it is decided to carry out a series of corrective maneuvers to prevent this risk of collapse. First, a provisional prosthesis will be prepared for the left lateral incisor with a pontic for the central incisor to ensure the patient sufficient comfort with a fixed provisional prosthesis. Then, the left central incisor will be extracted with careful removal of inflammatory tissue. A simultaneous flapless extraction site preservation technique will be implemented. Although flap elevation is the treatment of choice when cortical bone is completely lost because of the high risk of tissue collapse, flap detachment is contraindicated in this case. In addition, a mucogingival tunneling procedure will be performed at the left lateral incisor at the same stage to improve the shape and volume of the soft tissues around this tooth and make it more symmetric with the right lateral incisor. A few months later, an implant will be inserted in the left central incisor site, most likely combined with a regenerative technique because the ridge preservation technique has not been carried out under ideal conditions. On this occasion, it will also be possible to treat the gingival recession at the right central incisor. Provisional prosthetic treatment will then be carried out to condition the peri-implant soft tissues. The rehabilitation will be concluded with definitive restorations at the implant site and on the left lateral incisor and an additive veneer on the right central incisor, with the intention of improving most of the esthetic parameters.

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Clinical Case Studies

clinical case 8 (cont)

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Fig 6-48 (cont) (f to i) After avulsion and careful removal of inflammatory tissue using alveolar curettes, the soft tissues between the left central and lateral incisors and apical to the lateral incisor are tunneled with a microblade (Micro Blade Tunnel, Keydent). (j and k) A connective tissue graft taken from the palate is then inserted in the tunnel, placed under traction with a suture apical to the left lateral incisor, and left slightly exposed on the cervical area of that tooth. The connective tissue graft is secured by means of a pair of sutures passing through the superficial soft tissues and the graft. (l) An extraction site preservation technique is then performed; a specially shaped porcine collagen membrane (BioGide) is used to create a barrier between the superficial soft tissues and the socket, given the severely impaired condition of the buccal bone wall. The membrane is inserted, folded into the socket, and then stretched and bonded to the buccal tissues. (m) The socket is then packed with collagenated bovine bone (Bio-Oss Collagen), layer by layer. (n and o) Lastly, the socket is sealed with the most coronal part of the membrane, and a connective tissue graft, also taken from the palate, is secured by means of reduced-diameter resorbable sutures (polyglycolic acid 6-0). (p and q) The palatal donor sites are protected with a fine, transparent, thermoformed plate, and the new provisional prosthesis (crown on the left lateral incisor abutment with a pontic extension at the left central incisor site) is cemented in place, carefully avoiding excessive compression of the underlying tissues.

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clinical case 8 (cont)

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z Fig 6-48 (cont) (r and s) The appearance of the soft tissue is greatly improved 6 months later. The periodontal plastic surgery procedure achieved good symmetry in the gingival levels of the lateral incisors, and the ridge preservation technique achieved the expected effect, avoiding tissue collapse and maintaining volume horizontally and vertically. (t to w) Six months later, a 3D radiographic follow-up shows that the biomaterial inserted at the time of extraction is not uniformly integrated. The mesial part of the biomaterial appears to be well integrated, while a residual defect seems to be present distally. The simulated implant placement shows sufficient primary stability. However, the main aim of the ridge preservation technique in this case is to maintain volume and prevent tissue collapse. Given the radiographic situation, implant placement is planned with simultaneous GBR. (x and y) After soft tissue conditioning is achieved through progressive adjustment of the provisional restorations (see chapter 9), the transmucosal path of the provisional restorations is duplicated, and a custom polyphenol siloxane transfer is prepared that is used to take an impression of the implant and the adjacent abutments. (z) The definitive reconstruction involved preparing two full-ceramic crowns (lithium disilicate) for the left central and lateral incisor sites. The left central incisor crown is cemented on an individual zirconia abutment.

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Clinical Case Studies

clinical case 8 (cont)

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Fig 6-48 (cont) (aa) The right central incisor received a mesial additive veneer in feldspathic ceramic to harmonize the shapes of the two central incisors, redistributing the available mesiodistal space. The clinical follow-up shows good esthetic integration of the restorations with the surrounding hard and soft tissues. (bb) The radiograph shows well-adapted restorations and the absence of peri-implant bone resorption. (Surgery by Dr P. Casentini and Prof M. Chiapasco; prosthetic rehabilitation by Dr P. Casentini; laboratory procedures by Mr A. Schoenenberger.) (cc and dd) The posttreatment situation shows a significant improvement in soft tissue architecture, restoration of appropriate morphologic and color symmetry, and a distinct improvement in the esthetic appearance of the smile, which is well integrated in the patient’s face.

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clinical case 9 Implant treatment for agenesis of a maxillary lateral incisor and altered passive eruption affecting adjacent teeth

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f Fig 6-49 (a and b) A man presented with a request for an implant to replace his missing maxillary right lateral incisor. A physical examination and medical history revealed that this was a case of permanent tooth agenesis. The contralateral tooth is present in the arch but displays characteristics of a conoid tooth. (c) A radiograph shows good vertical bone availability, and the central incisor and canine roots are somewhat parallel to one another. (d and e) A fullthickness flap is raised by means of a ridge incision connected to two intrasulcular incisions, revealing abundant horizontal bone volume. (f and g) A surgical template is prepared to insert the implant in a prosthetically guided position.

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Clinical Case Studies

clinical case 9 (cont)

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Fig 6-49  (cont) (h to j) The same template is used to prepare the implant site, which will allow positioning of a tapered implant measuring 3.25 mm in diameter and 13 mm in length (Osseotite Tapered, Zimmer Biomet). (k and l) Intrasurgical images showing excellent 3D implant positioning with buccal cortical bone width greater than 2 mm. (m and n) An impression transfer is screwed to the implant head to record the intrasurgical implant position. The surgical template is then positioned on the arch, and the impression transfer is secured to the template by means of red acrylic resin. (o) The flap is then sutured with simple interrupted stitches to allow submerged healing. (p) A radiograph reveals ideal implant placement.

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clinical case 9 (cont)

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Fig 6-49  (cont) (q to s) The template with the impression transfer is then positioned in the right lateral incisor site on the master cast to place an implant analog that will faithfully replicate the implant position. This intrasurgical technique for recording implant position avoids having to use a conventional impression tray with the risk of bringing nonsterile impression material into contact with the implant site when the flap is open. (t to v) A titanium abutment is then milled, and an acrylic resin provisional prosthesis is prepared. (w and x) Three months later, the second stage of surgery is carried out, when the implant site is reopened by means of a ridge incision. (y and z) A titanium post is then positioned, and a screw-retained provisional crown is placed for soft tissue conditioning. (aa) A radiograph shows bone tissue stability and perfect housing of the prosthetic component.

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clinical case 9 (cont)

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Fig 6-49  (cont) (bb and cc) Careful esthetic analysis shows altered passive eruption affecting the central incisors and the conoid left lateral incisor. It is decided to take the initial step of prosthetically treating the conoid tooth by preparing a resin provisional prosthesis with the aim of achieving an optimum esthetic result. (dd) Once the provisional prosthesis has been inserted on the right lateral incisor implant, it is decided to adjust the gingival margin of the central incisors and the conoid tooth to the level of the CEJ to create harmony with the right lateral incisor by means of an external bevel gingivectomy. (ee and ff) Three months later, the gingival tissues are considered stable, and therefore a definitive prosthesis can be placed on the lateral incisors. (gg) An esthetic analysis shows perfect harmony of the gingival scalloping on a vertical plane, with the free gingival margin of the lateral incisors slightly coronal in relation to the central incisors on the frontal plane. (hh) The occlusal view shows that a midline shift to the right, caused by agenesis of the right lateral incisor, has led to a smaller mesiodistal space in that site compared with the left lateral incisor site. Only orthodontic treatment could compensate for this difference.

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clinical case 9 (cont)

ii

jj Fig 6-49  (cont) (ii and jj) The posttreatment clinical images show optimum harmonization of the gingival scalloping of the anterior teeth, with perfect integration of the ceramic crowns on the lateral incisors. The gingivectomy apically repositioned the free gingival margin of the central incisors at the CEJ. In particular, the implant-supported definitive crown on the right lateral incisor is well adapted within the new, harmonious gingival scalloping. (kk) A radiograph reveals stable marginal bone levels.

kk

References 1. Wennström JL. Lack of association between width of attached gingiva and development of soft tissue recession. A 5-year longitudinal study. J Clin Periodontol 1987;14:181–184. 2. Olsson M, Lindhe J. Periodontal characteristics in individuals with varying form of the upper central incisors. J Clin Periodontol 1991;18:78–82.

3. Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985;5:8–13. 4. Cardaropoli D, Tamagnone L, Roffredo A, Gaveglio L. Treatment of gingival recession defects using coronally advanced flap with a porcine collagen matrix compared to coronally advanced flap with connective tissue graft: A randomized controlled clinical trial. J Periodontol 2012;83:321–328.

Recommended Reading Aroca S, Molnár B, Windisch P, et al. Treatment of multiple adjacent Miller class I and II gingival recessions with a modified coronally advanced tunnel (MCAT) technique and a col-

lagen matrix or palatal connective tissue graft: A randomized, controlled clinical trial. J Clin Periodontol 2013;40:713–720.

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Recommended Reading

Bruno JF. Connective tissue graft technique assuring wide root coverage. Int J Periodontics Restorative Dent 1994;14:126–137. Cairo F, Pagliaro U, Nieri M. Treatment of gingival recession with coronally advanced flap procedures: A systematic review. J Clin Periodontol 2008;35:136–162. Cardaropoli D, Cardaropoli G. Healing of gingival recessions using a collagen membrane with a demineralized xenograft: A randomized controlled clinical trial. Int J Periodontics Restorative Dent 2009;29:59–67. Cardaropoli D, Tamagnone L, Roffredo A, Gaveglio L. Coronally advanced flap with and without a xenogenic collagen matrix in the treatment of multiple recessions: A randomized controlled clinical study. Int J Periodontics Restorative Dent 2014;34:s97–s102. Chambrone L, Sukekava F, Araújo MG, Pustiglioni FE, Chambrone LA, Lima LA. Root-coverage procedures for the treatment of localized recession type defects: A Cochrane systematic review. J Periodontol 2010;81:452–478. Chambrone L, Tatakis DN. Periodontal soft tissue root coverage procedures: A systematic review from the AAP Regeneration Workshop. J Periodontol 2015;86:S8–S51. Del Pizzo M, Modica F, Bethaz N, Priotto P, Romagnoli R. The connective tissue graft: A comparative clinical evaluation of wound healing at the palatal donor site. A preliminary study. J Clin Periodontol 2002;29:848–854. Harris RJ. A comparison of two techniques for obtaining a connective tissue graft from the palate. Int J Periodontics Restorative Dent 1997;17:260–271. Harris RJ. The connective tissue and partial thickness double pedicle graft: A predictable method of obtaining root coverage. J Periodontol 1992;63:477–486. Hürzeler MB, Weng D. A single-incision technique to harvest subepithelial connective tissue grafts from the palate. Int J Periodontics Restorative Dent 1999;19:279–287. Jepsen K, Jepsen S, Zucchelli G, et al. Treatment of gingival recession defects with a coronally advanced flap and a xenogeneic collagen matrix: A multicenter randomized clinical trial. J Clin Periodontol 2013;40:82–89. Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol 1985;56:715–720. Matter J, Cimasoni G. Creeping attachment after free gingival grafts. J Periodontol 1976;47:574–579. McGuire MK, Nunn M. Evaluation of human recession defects treated with coronally advanced flaps and either enamel

matrix derivative or connective tissue. Part 1: Comparison of clinical parameters. J Periodontol 2003;74:1110–1125. McGuire MK, Scheyer ET. Xenogeneic collagen matrix with coronally advanced flap compared to connective tissue with coronally advanced flap for the treatment of dehiscence-type recession defects. J Periodontol 2010;81:1108–1117. Molnár B, Aroca S, Keglevich T, et al. Treatment of multiple adjacent Miller Class I and II gingival recessions with collagen matrix and the modified coronally advanced tunnel technique. Quintessence Int 2013;44:17–24. Müller HP, Eger T. Gingival phenotypes in young male adults. J Clin Periodontol 1997;24:65–71. Olsson M, Lindhe J, Marinello CP. On the relationship between crown form and clinical features of the gingiva in adolescents. J Clin Periodontol 1993;20:570–577. Pandit N, Khasa M, Gugnani S, Malik R, Bali D. Comparison of two techniques of harvesting connective tissue and its effects on healing pattern at palate and recession coverage at recipient site. Contemp Clin Dent 2016;7:3–10. Pini-Prato GP, Cairo F, Nieri M, Franceschi D, Rotundo R, Cortellini P. Coronally advanced flap versus connective tissue graft in the treatment of multiple gingival recessions: A split-mouth study with a 5-year follow-up. J Clin Periodontol 2010;37:644–650. Roccuzzo M, Bunino M, Needleman I, Sanz M. Periodontal plastic surgery for treatment of localized gingival recessions: A systematic review. J Clin Periodontal 2002;29:178–194. Sanz M, Lorenzo R, Aranda JJ, Martin C, Orsini M. Clinical evaluation of a new collagen matrix (Mucograft prototype) to enhance the width of keratinized tissue in patients with fixed prosthetic restorations: A randomized prospective clinical trial. J Clin Periodontal 2009;36:868–876. Tatakis DN, Chambrone L, Allen EP, et al. Periodontal soft tissue root coverage procedures: A consensus report from the AAP Regeneration Workshop. J Periodontol 2015;86:S52– S55. Wennstrom J, Pini Prato G. Mucogingival therapy: Periodontal plastic surgery. In: Lindhe J, Karring T, Lang N (eds). Clinical Periodontology and Implant Dentistry, ed 4. Copenhagen: Munksgaard, 2003:576–649. Zucchelli G, Mele M, Mazzotti C, Marzadori M, Montebugnoli L, De Sanctis M. Coronally advanced flap with and without vertical releasing incisions for the treatment of multiple gingival recessions: A comparative controlled randomized clinical trial. J Periodontol 2009;80:1083–1094.

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Questions: 1. What is the role of keratinized tissues around implants? 2. Can keratinized tissue be preserved? 3. What surgical techniques are used to reconstruct keratinized tissue around implants? 4. What is the timing of keratinized tissue augmentation techniques?

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1|

What is the role of keratinized tissues around implants?

Although there is no absolute scientific consensus on the role of peri-implant keratinized tissue, a growing number of clinical trials support the idea that a band of at least 2 mm of peri-implant keratinized tissue can encourage healthy conditions and promote a favorable long-term implant prognosis.1 In particular, it has been found: • When a peri-implant keratinized tissue band is absent or measures < 2 mm, patients report discomfort during brushing, particularly for mandibular rehabilitations.2 • When keratinized tissue measured < 2 mm, increased levels of plaque and bleeding on probing were recorded.

a

• With no keratinized tissue, peri-implant soft tissues show a greater incidence of recession and biologic complications.3 • Implant sites with a keratinized tissue band of < 2 mm show a higher incidence of peri-implantitis.4 Based on the available evidence and the authors’ experience, they recommend a keratinized tissue band of at least 2 mm around implants (Fig 7-1). Therefore, this chapter presents techniques allowing the reconstruction of peri-implant keratinized tissue.

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Fig 7-1  (a and b) A band of keratinized tissue around implants is an important prerequisite for maintaining a soft tissue seal and thus promoting a good long-term prognosis.

2|

Can keratinized tissue be preserved?

Before examining techniques for rebuilding of lost peri-implant keratinized tissue, it is important to clarify that in many cases keratinized tissue can be first and foremost preserved or even augmented by simply guiding the spontaneous healing pro-

a

cess of an extraction socket (Fig 7-2). The ridge preservation techniques presented in chapter 5 are a good demonstration of this possibility.

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Fig 7-2  (a and b) Ridge preservation techniques facilitate keratinized tissue maintenance, particularly in lateral and posterior sectors of the mandible where the tissue may initially be reduced in quantity or absent altogether. Poor extraction socket management can lead to almost complete loss of the keratinized tissue band. When a mandibular molar is extracted, socket preservation requires collagenated bovine bone (Bio-Oss Collagen, Geistlich) and a collagen sponge.

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What surgical techniques are used to reconstruct keratinized tissue around implants?

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Fig 7-2  (cont) (c to e) This technique maintains a good band of keratinized tissue.

3|

What surgical techniques are used to reconstruct keratinized tissue around implants?

To date, the most documented and effective technique for peri-implant keratinized tissue reconstruction is an autologous epithelial–connective tissue graft taken from the palate. In the past, this technique was widely used around teeth in mucogingival surgery5–8 (Fig 7-3). The epithelial–connective tissue graft technique used with implants is essentially identical to that used for natural teeth (Fig 7-4), although there are some differences with regard to timing, and thus there is the possibility of performing this procedure at different stages of treatment (see next question). The palate as a donor site involves obvious disadvantages, although patient discomfort can be reduced by protecting the donor site with a thermoformed plate (see chapter 6). Collagen matrices offer interesting prospects for reconstructing peri-implant keratinized tissue. They mimic the characteristics of autologous tissue and rule out the need

for autologous tissue harvesting. A procedure involving insertion of a collagen matrix to increase keratinized tissue is very similar to that used for an epithelial–connective tissue graft (Fig 7-5). Also in this case, a partial-thickness recipient bed is prepared, and the collagen matrix is secured using the same type of sutures used to stabilize autologous tissue (see the clinical case studies section). Unlike with autologous tissue, the presence of a keratinized tissue band, however slight (2 mm), seems to be essential for guaranteeing the success of the procedure. The biologic mechanism of the collagen matrix appears to act by maintaining a space available for the epithelial cells to migrate from the surrounding keratinized mucosa. Preliminary results with collagen matrices are very promising; however, it cannot yet be claimed that these biomaterials can completely replace autologous tissues.9–11

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Fig 7-3 (a to d) The epithelial–connective tissue graft requires the creation of a partial-thickness recipient bed, above which a band of epithelized tissue taken from the palate is positioned and then stabilized. The main reason for partially abandoning this technique around natural teeth is the poor color match between the grafted tissue and the surrounding tissues. (Surgery by Dr P. Casentini.)

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Fig 7-4  (a to d) The epithelial–connective tissue graft technique is used around implants in a similar way to around natural teeth. (Surgery by Dr P. Casentini; prosthetic rehabilitation by Dr S. Storelli.)

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d Fig 7-5  (a to e) The use of collagen matrices offers new prospects for reconstructing peri-implant keratinized tissue. After vestibuloplasty with partialthickness detachment, a porcine collagen matrix (Mucograft, Geistlich) is positioned and secured to the recipient site in order to increase the keratinized tissue depth.

e

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What is the timing of keratinized tissue augmentation techniques?

4|

What is the timing of keratinized tissue augmentation techniques?

There are several opportunities to augment/reconstruct the peri-implant keratinized tissue band. The choice of timing is mainly linked to two factors: the need to use bone augmentation techniques and the anatomical site involved. The use of hard tissue augmentation techniques, particularly if the volume increase to be implemented is significant, often determines the need to reconstruct the keratinized tissue at a late stage after positioning the implants. Bone volume augmentation techniques involve passive flap advancement, which usually results in the loss of keratinized tissue. Keratinized tissue reconstruction can then be performed later or to coincide with implant reopening, when the residual tissue volume is known. The anatomical treatment site can also influence the timing. In the posterior region of a mandible with an atrophic alveolar ridge, if the basal bone increase is primarily horizontal, it may be best to augment keratinized tissue after positioning the provisional restorations, which facilitate graft stabilization.

The various stages at which keratinized tissue augmentation can be performed are summarized in the following sections.

Reconstruction of keratinized tissue prior to implant placement This indication usually arises in the posterior sector of the mandible, where the amount of keratinized tissue is usually reduced. If the implant treatment does not involve significant bone volume augmentation, the best time to augment a thin band of keratinized tissue is prior to implant placement (Fig 7-6). The keratinized tissue band will be equally divided between the buccal and lingual aspects of the flap upon subsequent implant surgery, which may take place after a few weeks.

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Fig 7-6  (a to c) In a mandible where keratinized tissue is completely or nearly absent, an epithelial–connective tissue graft is carried out prior to implant placement. (d) The implants are placed approximately 2 months after mucogingival surgery. (e and f) Clinical and radiographic views of subsequent implant-supported prosthetic reconstruction of the two regular-length implants (Straumann RN SP 4.1 × 10 mm) and two short implants (Regular Neck Standard Plus 4.8 × 6 mm, Straumann) reveal that the peri-implant soft tissues are in favorable condition. (Surgery by Dr P. Casentini; prosthetic rehabilitation by Dr N. Gruden.)

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Keratinized tissue reconstruction combined with vestibuloplasty to coincide with reopening After extensive bone volume reconstruction, usually combined with extended loss of fornix depth as a consequence of passive flap advancement during the reconstructive stage, a need arises to reconstruct keratinized tissue as well as the buccal fornix. After implant placement, at the reopening stage, a combination of vestibuloplasty with partial-thickness soft tissue detachment and an epithelial–connective tissue graft allows both objectives to be achieved (Fig 7-7).

Keratinized tissue reconstruction after provisional prosthetic treatment In some cases, it may be advantageous to proceed with keratinized tissue reconstruction after the implants have been fitted with a provisional restoration (Fig 7-8). This can be an advantage from the viewpoint of patient motivation because he or she will have experienced the discomfort and inconveniences associated with a lack of keratinized tissue. The presence of a provisional prosthesis can also help stabilize the epithelial–connective tissue graft.

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Fig 7-7  (a) After extensive 3D reconstruction of the maxilla, there is a total lack of correspondence between the position of the reconstructed alveolar process and the keratinized tissue position, which has shifted palatally. (b and c) To re-create a normal fornix depth and a sufficient keratinized tissue band, vestibuloplasty has been performed upon implant reopening, grafting two extensive epithelial–connective tissue grafts taken from the palate into the resulting recipient bed. (d) After healing, an occlusal view shows the wide band of keratinized tissue that was rebuilt buccally at the implants. (Surgery by Dr P. Casentini.)

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Fig 7-8 (a) After provisional prostheses were placed on two osseointegrated zirconia implants, the patient reports discomfort during brushing. (b) From a clinical viewpoint, the lack of keratinized tissue is associated with inflammation.

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Clinical Case Studies

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Fig 7-8  (cont) (c to f) Before fitting the definitive prostheses, a sufficient band of keratinized tissue is re-created by means of an epithelial–connective tissue graft. (Surgery by Dr P. Casentini.)

Reconstruction of keratinized tissue as a late corrective procedure Lastly, in some cases, keratinized tissue reconstruction is performed at a late stage after the definitive implantsupported restoration is complete, as a final corrective measure (Fig 7-9). This is a compromise solution because late

a

b

soft tissue reconstruction can lead to a lack of harmony between the contours of the definitive restoration and those of the soft tissues. This means that keratinized tissue band reconstruction ideally should take place before fabricating the definitive restoration, which should take into account the stable shape of the surrounding soft tissues.

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Fig 7-9 (a) After fitting definitive prostheses on the implants in the lateroposterior sector of the mandible, the patient complains of difficulty and discomfort during brushing. (b and c) It is therefore decided to reconstruct the keratinized tissue by means of an epithelial–connective tissue graft. (Surgery by Dr P. Casentini.)

Clinical Case Studies Figures 7-10 to 7-16 present clinical cases demonstrating different applications of peri-implant keratinized tissue augmentation techniques.

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clinical case 1 Increasing keratinized tissue by means of an epithelial–connective tissue graft prior to implant placement in the posterior mandible

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Fig 7-10  (a to c) Preliminary assessment of the mandibular right first molar site for implant placement reveals an almost complete absence of buccal keratinized tissue. In addition, the mesial tooth is completely lacking in adherent gingiva and is affected by gingival recession. The bone volume is sufficient to allow implant placement in a prosthetically guided position. To ensure the presence of sufficient peri-implant keratinized tissue, it is decided to reconstruct the soft tissues as a preliminary step by means of an epithelial–connective tissue graft taken from the palate. Implant placement will be deferred for 2 months. (d) Recipient bed preparation involves making an incision line at the border between the alveolar mucosa and residual keratinized tissue. (e and f) The alveolar mucosa is then separated from the periosteal plane by inserting a scalpel blade tangentially to the bone surface. (g) Microsurgery scissors are used to complete recipient bed preparation by removing any residual adherent muscle tissue from the periosteal plane. In this anatomical sector, partial-thickness detachment should not be extended too far apically to maintain a safe distance from the mental foramen, which must be identified radiographically.

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Clinical Case Studies

clinical case 1 (cont)

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Fig 7-10  (cont) (h) Once the recipient bed has been prepared and root planing has been carried out on the adjacent tooth, the recipient bed is measured, and an epithelial–connective tissue graft of corresponding size is taken from the palate. When establishing graft dimensions, graft contraction during the healing stage (which can be up to 50%) also must be considered. (i) The graft is stabilized by means of single sutures and compression sutures anchored to the periosteum. Graft thickness should be reduced (1 to 1.5 mm) and made uniform. (j and k) When the sutures are removed after 2 weeks, early graft attachment and re-epithelialization of the palatal harvesting site are evident. (l) Two months later, reconstruction of a sufficient band of keratinized tissue on the edentulous ridge and around the adjacent tooth is evident. (m) A transmucosal implant (Wide Neck 4.8 × 10 mm, Straumann) can now be positioned using a prosthetically guided technique. (n and o) The keratinized tissue is divided into two parts of equal width buccolingually and then fitted around the transmucosal healing screw.

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clinical case 1 (cont)

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Fig 7-10  (cont) (p) Eight weeks later, an impression can be taken, and prosthetic loading can begin once implant osseointegration has been confirmed. The peri-implant soft tissues appear to be perfectly healed. (q and r) The definitive prosthetic reconstruction involves cementing a metal-ceramic crown on the implant and a feldspathic ceramic overlay on the second molar. Producing an all-ceramic restoration made it possible to improve the occlusal plane, treat secondary caries, and improve the contact point with the implant-supported restoration. (s) The posttreatment radiograph shows the accurate fit of the restorations and the uniform bone level. (Surgery and prosthetic rehabilitation by Dr P. Casentini; fabrication of prostheses by Mr A. Schoenenberger.) (t) Clinical view after treatment shows a restoration with satisfactory esthetics and function.

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Clinical Case Studies

clinical case 2 Increasing keratinized tissue using a collagen matrix prior to implant placement in the posterior mandible

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Fig 7-11 (a to c) A preliminary assessment reveals almost complete absence of keratinized tissue on the buccal aspect of the edentulous mandibular left first molar site. As in clinical case 1, bone volume is sufficient to allow implant placement in a prosthetically guided position, and it was decided to carry out preliminary soft tissue reconstruction, re-creating a sufficient band of keratinized tissue. In this case, the keratinized soft tissue was reconstructed using a collagen matrix. The prospect of avoiding tissue harvest from the palate is very appealing and a great benefit to the patient, and the end result is very favorable. It must be emphasized that the use of collagen matrices always requires a residual keratinized tissue band of at least 2 mm in surrounding areas. In this case, implant placement will be deferred for 4 months after soft tissue reconstruction. (d) Recipient bed preparation involves making an incision line at the border between the alveolar mucosa and the residual keratinized tissue. The recipient bed is prepared in exactly the same way as in the previous case. However, instead of an epithelial–connective tissue graft, a collagen matrix is positioned in this case (Mucograft). (e) The matrix is secured by means of interrupted sutures and compression sutures anchored to the periosteum in exactly the same way as an epithelial–connective tissue graft. An open healing technique is used in this case. (f) Clinical follow-up after 1 week. Healing takes place without complications and with very few symptoms. The patient rinses with a chlorhexidine-based mouthwash for 3 weeks after surgery. (g) The sutures are removed after 2 weeks.

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clinical case 2 (cont)

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m Fig 7-11  (cont) (h to k) A comparison between the initial situation and the 4-month follow-up, at which time a significant increase in the keratinized tissue band is evident. Implant surgery can now be planned. (l and m) A transmucosal implant (Wide Neck 4.8 × 8mm) is positioned using a prosthetically guided technique. The keratinized tissue is divided into two parts of equal width buccolingually and then fitted around the transmucosal healing screw.

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Clinical Case Studies

clinical case 2 (cont)

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Fig 7-11  (cont) (n and o) A comparison of occlusal views before treatment and immediately prior to definitive restoration of the implant clearly shows the favorable change in ridge morphology and the augmented peri-implant keratinized tissue volume. (p to r) Posttreatment clinical and radiographic follow-up. The cemented zirconia-ceramic crown appears to be well integrated in the surrounding hard and soft tissues. (Surgery and prosthetic rehabilitation by Dr P. Casentini; fabrication of prostheses by Mr G. Voce and Mr A. Schoenenberger.)

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clinical case 3 Epithelial–connective tissue graft and vestibuloplasty to increase keratinized tissue at implant site reopening following maxillary reconstruction

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Fig 7-12  (a to c) The initial clinical status of this patient with a maxillary complete denture shows severe vertical and horizontal atrophy of the maxilla. The patient is strongly motivated to carry out a fixed prosthetic rehabilitation. The mandible, treated with fixed prostheses, does not require urgent treatment. An ideal dental display is created by a wax-up prepared to check the residual bone volumes with a view to prosthetically guided implant rehabilitation. This allows a radiopaque diagnostic template to be created to carry out a 3D radiographic examination. (d and e) A CBCT scan confirms the severe atrophy and insufficient bone volumes for implant placement at any of the sites evaluated. It is suggested that the patient should undergo 3D reconstruction of the maxilla with autologous bone grafts taken from extraoral sites to create sufficient bone volume to enable osseointegratable implants and subsequent placement of an implant-supported fixed prosthesis. (f and g) The aim of the bone reconstruction is to restore enough vertical and horizontal bone volume to allow subsequent implant placement. Reconstructive surgery is performed under general anesthesia and involves fixing autologous iliac and calvarial bone blocks after a bilateral sinus elevation. (h) Despite the significant volume increase, it is possible to achieve full passive advancement of the flaps and suture without tension for healing by first intention. This will involve significant loss of the buccal fornix and palatal displacement of the keratinized tissue. (i) A postsurgical radiograph shows the large amount of bone that has been reconstructed. (Reconstructive surgery by Dr M. Chiapasco.)

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clinical case 3 (cont)

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Fig 7-12  (cont) (j) The implants can be placed after 6 months. For this surgery, an incision is made at the border between the alveolar mucosa and the keratinized tissue, which (as already mentioned) is displaced palatally. Lifting of an access flap reveals the good degree of bone graft integration and minimal resorption. (k to n) Eight implants (SLActive Bone Level, Straumann) are placed in the reconstructed maxilla using a surgical template as a guide. (o) The postsurgical radiograph shows good parallelism between the implants. (Implant surgery by Dr P. Casentini.) (p) Tissue healing after bone reconstruction and implant surgery. The normal soft tissue anatomy looks radically altered and requires correction. The fornix has been lost, and there is no correspondence between the position of the new, more buccally located ridge and the keratinized tissue, which was displaced palatally when the flap was passively advanced after bone reconstruction. To re-create a more normal anatomical situation, it will be necessary to perform vestibuloplasty, deepen the fornix, and apply epithelial–connective tissue grafts taken from the palate. (q) After deepening the fornix by means of a partial-thickness dissection, the vestibuloplasty surgery provides for the fixation of the alveolar in a more apical position using resorbable sutures. The flap is secured by means of several sutures spaced equidistant from one another and anchored to the periosteum. The suture is initially passed from the outside of the flap to the inside.

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clinical case 3 (cont)

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Fig 7-12  (cont) (r) The second step is to pass the thread through the periosteum in a mesiodistal direction. (s) The third and final step involves passing the needle from the inside of the flap to the outside. The suture can then be tied off, stabilizing the flap in an apical position. (t) At the end of this stage of surgery, a new fornix depth has been re-created by applying several apical sutures with periosteal anchorage. The space created between the palatal keratinized tissue and the apically fixed alveolar mucosa can now act as a recipient bed for epithelial–connective tissue grafts taken from the palate. (u and v) After connecting three healing screws to the implants, three epithelial–connective tissue grafts taken from the palate are used to reconstruct a sufficient band of keratinized tissue. The grafts are initially secured by means of discontinuous sutures and then stabilized by means of compression sutures anchored to the periosteum. The long healing screws connected to the implants help stabilize the grafts. (w to y) Given the extent of the grafts harvested from the palate, donor sites are protected with hemostatic material, and a palatal plate rebased with soft material is positioned and secured to the palatal vault by means of two osteosynthesis screws. (Surgery by Dr P. Casentini.)

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clinical case 3 (cont)

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bb Fig 7-12 (cont) (z) Definitive zirconia-ceramic screw-retained fixed prosthesis prior to delivery. The prosthesis is screw-retained to intermediate abutments (Multi-Base, Straumann), which in turn are tightened to the implants. Despite the impressive bone reconstruction achieved, the prosthesis needs to include a certain amount of pink ceramic to achieve full esthetic and functional restoration and support the perioral soft tissues satisfactorily. (Preparation of prostheses by Mr R. Colli and Mr C. Pedrinazzi.) (aa and bb) Occlusal views before and after delivery of the definitive prosthesis, demonstrating successful reconstruction of a broad band of peri-implant keratinized tissue. (cc to ee) Clinical and radiographic follow-up showing that the definitive prosthetic reconstruction allows full esthetic and functional recovery and is well integrated into the surrounding soft and hard tissues. (Prosthetic rehabilitation by Dr P. Casentini.)

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clinical case 4 Increasing keratinized tissue in the maxilla using a collagen matrix at implant reopening

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Fig 7-13  (a to d) A 39-year-old man came for treatment due to an accidental shotgun injury while hunting. The pellets entered his mouth, striking five teeth on the right side of the maxilla (from the lateral incisor to the first molar), damaging the tooth structure and gingival tissues. This impact nevertheless slowed down the pellets, which lodged in his cheek. A few months after the accident, general and reconstructive plastic surgery are complete, and the patient requires dental rehabilitation. Intraoral photographs and a panoramic radiograph show destruction of the clinical crowns on the affected teeth, and buccal probing reveals gingival recession. (e) Multiple tooth extractions are performed. Intrasurgical assessment shows posttraumatic loss of buccal cortical bone. (f) To compensate for the soft tissue deficiency, a connective tissue graft is removed from the palate and positioned supracrestally. (g and h) The tissues are sutured using simple interrupted sutures at the interdental papillae in order to stabilize the connective tissue graft above the interproximal peaks. The flap is not advanced buccally because this would misalign the mucogingival junction. Healing by second intention is planned.

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clinical case 4 (cont)

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Fig 7-13  (cont) (i and j) Eight weeks later, excellent soft tissue healing is observed on both vertically and horizontally. (k) A CBCT scan allows implant placement to be planned. (l) A 3D rendering shows loss of buccal cortical bone in the postextraction sites. (m and n) Transverse cuts in the lateral incisor and canine areas, respectively, show the available bone volume and loss of buccal cortical bone. (o) Following a crestal incision, a full-thickness flap is detached up to the mucogingival junction, followed by a half-thickness flap in the alveolar mucosa, with subsequent denudation of the bone plate to highlight the residual defects. (p and q) The implant sites are prepared from the lateral incisor to the first molar using a surgical template prepared from a diagnostic guide.

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clinical case 4 (cont)

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Fig 7-13  (cont) (r and s) The implants are then placed in a prosthetically guided manner. They are all tapered, with a diameter of 3.25 mm for the lateral incisor, 4 mm from canine to second premolar, and 5 mm for the first molar (T3 Tapered, Zimmer Biomet). After placement, periimplant bone defects of various sizes and anatomical characteristics remain. Dehiscence and fenestrations are evident, as is a need for vertical regeneration on the lateral incisor, canine, and first premolar. (t and u) A vertical bone regeneration technique is used, involving the creation of a graft made up of 30% autologous bone chips and 70% deproteinized bovine bone (Bio-Oss, Geistlich) mixed with homologous fibrin glue (Tisseel, Baxter). (v) The graft is then protected by a resorbable collagen membrane (Bio-Gide, Geistlich). (w) The flap is advanced, with inevitable mucogingival junction misalignment, and sutured with a double row of sutures, horizontal mattress sutures in an apical direction and simple interrupted sutures in a coronal direction, using a nonresorbable material (polytetrafluoroethylene 5-0). (x) The radiograph shows that implants have been accurately placed. (y) Six months later (the time required to achieve complete bone healing), even the soft tissues appear to have matured, albeit with inevitable loss of keratinized tissue.

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clinical case 4 (cont)

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aa

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Fig 7-13  (cont) (z) Stage-two surgery is performed by means of a crestal incision and half-thickness detachment to move a portion of the keratinized gingival band buccally. (aa and bb) Healing abutments are then connected, seeking to achieve healing by second intention at the interproximal level, where the periosteum has not been detached from the underlying bone. (cc) To increase the band of adherent gingiva, a paramarginal incision is made along the mucogingival junction. This is half-thickness in order not to affect the periosteum. (dd) The flap is raised, apically displaced, and sutured at the fornix. (ee) The periosteal bed is protected by applying a 3D porcine collagen matrix (Mucograft), which is sutured coronally to the papillae and apically to the periosteum. (ff) Within a few minutes, the spongy inner part of the matrix absorbs blood from the surgical bed, stabilizing the clot, and soft tissue regeneration begins. The matrix is left uncovered to achieve open healing. (gg) Three weeks later, good soft tissue regeneratio is evident. (hh) Four weeks after reopening, the gingival tissue is ready for impression taking.

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clinical case 4 (cont)

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Fig 7-13 (cont) (hh) Four weeks after reopening, the gingival tissue is ready for impression taking. (ii) Another 2 weeks later, the titanium abutments can be connected. (jj) Buccal view of the definitive ceramic crowns, showing good soft tissue adaptation with a sufficient band of keratinized tissue. (kk and ll) Posttreatment radiographs reveal stable marginal bone levels.

clinical case 5 Keratinized tissue augmentation with an epithelial–connective tissue graft after guided bone regeneration (GBR), implant placement, and provisional prosthetic treatment in the mandible

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Fig 7-14  (a) Treatment of the distal mandibular edentulism involved placement of three small-diameter implants (Bone Level 3.3 × 10 or 8 mm, Straumann) combined with GBR. (b) Perforations are made in the mandibular cortical bone to facilitate migration of osteogenic cells from the marrow spaces.

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clinical case 5 (cont)

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Fig 7-14  (cont) (c) A layer of particulate autologous bone recovered during implant site preparation is positioned. (d) A deproteinized bovine bone graft (Bio-Oss) is then placed. (e) This is protected and stabilized by means of a porcine collagen membrane (Bio-Gide) secured with titanium pins (Frios, Dentsply). (f) After passive advancement of the flap, it is sutured passively using expanded polytetrafluoroethylene sutures (W. L. Gore). These procedures inevitably involve reducing the band of keratinized tissue, which in this case was not very thick at the outset. (g to j) During reopening and connection of the healing abutments, a buccal incision is carried out, deliberately leaving a small amount of keratinized tissue on the lingual side. Lingual reconstruction of keratinized tissue is much more difficult to achieve. Tissues will then heal in the absence of buccal keratinized tissue.

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clinical case 5 (cont)

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Fig 7-14  (cont) (k) After placement of a provisional screw-retained restoration, initial peri-implant soft tissue conditioning and a sufficient band of lingual keratinized tissue are evident. The next step is to reconstruct the buccal keratinized tissue by means of an epithelial–connective tissue graft. (l) The recipient bed is prepared after making a linear incision along the boundary between the keratinized tissue and alveolar mucosa. (m) Making a small mesial releasing incision facilitates detachment of a partial-thickness flap, which allows creation of a recipient bed for the graft. (n) After measuring the recipient bed, a thin graft of corresponding size is taken from the palate. (o and p) The donor site is then protected using hemostatic material stabilized by compression cross sutures.

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clinical case 5 (cont)

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v Fig 7-14  (cont) (q and r) The graft is then positioned in the recipient site with interrupted sutures and compression sutures anchored to the periosteum. (s) Subsequent repositioning of the provisional prosthesis helps stabilize the graft. (t and u) Two weeks later, upon suture removal, the graft already appears to be revascularized, and the donor site seems to be re-epithelialized. Removing a thin tissue layer encourages re-epithelialization and considerably reduces postsurgical symptoms. (v to x) Prosthetic reconstruction is carried out using a screw-retained zirconia-ceramic restoration on a prefabricated titanium base (Variobase, Straumann),which appears to be well integrated into the surrounding soft and hard tissues. Despite graft contraction, a stable band of keratinized tissue is evident around the implants. (Surgery by Dr P. Casentini; prosthetic rehabilitation by Dr M. Tschurtschenthaler; laboratory procedures by Mr A. Mairunteregger.)

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clinical case 6 Reconstruction of peri-implant keratinized tissue with an epithelial–connective tissue graft after prosthetic loading of an implant-supported overdenture in an edentulous mandible

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Fig 7-15  (a to d) After placement of an implant-supported overdenture in an edentulous mandible, the patient noticed a certain amount of peri-implant soft tissue recession and complained of pain during brushing. Physical examination confirmed peri-implant soft tissue recession and the exposure of 2 to 3 mm of the rough implant neck to the oral environment. The almost complete absence of keratinized tissue is noticeable on three of the four implants. The implant sites do not show significant probing depth or bleeding on probing. The radiographs show no signs of peri-implantitis. Peri-implant bone resorption seems to be associated with the trauma of the various implant stages (implant surgery, reopening, and impressions) and consequent bone remodeling. The absence of keratinized tissue is an aggravating factor and potentially a predisposing factor for peri-implantitis because it makes cleaning more difficult and uncomfortable. The treatment plan therefore provides for reconstruction of a sufficient band of peri-implant keratinized tissue in two steps (two implants at a time) by means of epithelial–connective tissue grafts. (e to h) After detaching a trapezoid flap by making two small mesial and distal releasing incisions, a partial-thickness flap is raised, leaving the periosteum adhering to the bone surface. Implantoplasty is then performed with the aim of removing the implant’s superficial microthreads and achieving a smooth implant surface using diamond burs, Arkansas stone burs, and silicone polishers.

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Clinical Case Studies

clinical case 6 (cont)

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Fig 7-15 (cont) (i to l) After harvest of the graft, adipose tissue is removed from the inner side of the flap. A circular mucotome is also used to remove two small semicircles for better adaptation around the implant abutments. (m and n) The graft is fitted to the recipient bed and initially fixed with single sutures. (o) The next step is to compress the graft onto the recipient bed by means of a mesiodistal suture anchored mesially and distally, exploiting the arch curvature.

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clinical case 6 (cont)

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t Fig 7-15  (cont) (p and q) Graft stabilization is finalized by sutures that are anchored to the periosteum and crossed and suspended around the implants. (r and s) A couple of months after the first surgery, the left mandible is treated in the same manner. (t) Following soft tissue reconstruction, a broad band of peri-implant keratinized tissue has been restored. The soft tissues have crept to almost completely cover the most coronal aspect of the implants, which was previously exposed. (Surgery by Dr P. Casentini and Dr P. Fusari.)

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clinical case 7 Increasing keratinized tissue using a connective tissue graft years after placement of implants and a definitive prosthesis in the mandible

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Fig 7-16  (a) The patient presented with a fixed rehabilitation supported by three implants, placed 9 years previously. The two mesial implants have no keratinized tissue at the free gingival margin, with exposure of part of the titanium abutment and implant neck. The most distal implant is protected by a sufficient band of adherent gingiva, and there is no soft tissue recession. (b) A radiograph shows implant osseointegration without any sign of peri-implantitis. (c) The exposed part of the two implants is decontaminated with an ultrasonic instrument with a dedicated polytetrafluoroethylene tip and glycine-based prophylactic powder. (d) An intrasulcular marginal flap is then shaped by means of two small mesial and distal releasing incisions. (e) A partial-thickness flap is detached, leaving a generous periosteal bed, and the marginal tissue is apically displaced. (f) The connective tissue is positioned at the recipient site, seeking the best spontaneous stability. (g) The graft is stabilized on the papillae by means of three combined sutures in resorbable material (polyglycolic acid 5-0). The suture technique involves inserting the needle buccally into the connective tissue to create a simple interrupted suture and securing it to the corresponding papilla by means of a vertical mattress stitch. The marginal tissue of the primary flap is secured apically with two sutures anchored to the periosteum. (h) To improve healing potential, the wound is protected with a gel containing a high content of hyaluronic acid and amino acids (Aminogam, Errekappa).

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clinical case 7 (cont)

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j Fig 7-16 (cont) (i) An image taken 1 week later shows optimum healing with good graft revitalization. (j) Ten days after surgery. (k) After 6 months, complete tissue maturation can be observed, with the creation of a sufficient band of adherent keratinized tissue to safeguard peri-implant health.

k

References 1. Wennström JL, Derks J. Is there a need for keratinized mucosa around implants to maintain health and tissue stability? Clin Oral Implants Res 2012;23:136–146. 2. Souza AB, Tormena M, Matarazzo F, Araújo MG. The influence of peri-implant keratinized mucosa on brushing discomfort and periimplant tissue health. Clin Oral Implants Res 2016;27:650–655. 3. Roccuzzo M, Grasso G, Dalmasso P. Keratinized mucosa around implants in partially edentulous posterior mandible: 10-year results of a prospective comparative study. Clin Oral Implants Res 2016;27:491–496. 4. Canullo L, Peñarrocha-Oltra D, Covani U, Botticelli D, Serino G, Penarrocha M. Clinical and microbiological findings in patients with periimplantitis: A cross-sectional study. Clin Oral Implants Res 2016;27:376–382. 5. Miller PD Jr. Root coverage using a free soft tissue autograft following citric acid application. Part 1: Technique. Int J Periodontics Restorative Dent 1982;2:65–70. 6. Miller PD Jr. Root coverage using the free soft tissue autograft following citric acid application. III. A successful and predictable procedure in areas of deep-wide recession. Int J Periodontics Restorative Dent 1985;5:14–37.

7. Agudio G, Nieri M, Rotundo R, Cortellini P, Pini Prato G. Free gingival grafts to increase keratinized tissue: A retrospective long-term evaluation (10 to 25 years) of outcomes. J Periodontol 2008;79:587– 594. 8. Zucchelli G. Mucoingival Esthetic Surgery. Chicago: Quintessence, 2012. 9. Sanz M, Lorenzo R, Aranda JJ, Martin C, Orsini M. Clinical evaluation of a new collagen matrix (Mucograft prototype) to enhance the width of keratinized tissue in patients with fixed prosthetic restorations: A randomized prospective clinical trial. J Clin Periodontol 2009;36:868– 876. 10. Lorenzo R, García V, Orsini M, Martin C, Sanz M. Clinical efficacy of a xenogeneic collagen matrix in augmenting keratinized mucosa around implants: A randomized controlled prospective clinical trial. Clin Oral Implants Res 2012;23:316–324. 11. Schmitt CM, Moest T, Lutz R, Wehrhan F, Neukam FW, Schlegel KA. Long-term outcomes after vestibuloplasty with a porcine collagen matrix (Mucograft) versus the free gingival graft: A comparative prospective clinical trial. Clin Oral Implants Res 2016;27:125–133.

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Questions: 1. What is meant by esthetic augmentation of peri-implant soft tissue? 2. What are the indications for soft tissue augmentation in the esthetic zone? 3. What is the timing of esthetic soft tissue augmentation? 4. Do peri-implant soft tissue augmentation techniques offer predictable outcomes? 5. What are the main soft tissue harvesting sites and techniques? 6. Are there biomaterials that can mimic the behavior of autogenous connective tissue?

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1|

What is meant by esthetic augmentation of peri-implant soft tissue?

This chapter specifically refers to soft tissue augmentation techniques that allow a better final esthetic outcome (Fig 8-1). Such techniques are usually not intended for peri-

a

b

implant keratinized tissue band creation or augmentation as discussed in chapter 7.

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Fig 8-1  (a to c) A combination of hard tissue augmentation techniques (guided bone regeneration [GBR]) and soft tissue augmentation techniques (connective tissue grafting) allows an optimum outcome with long-term stability.

2|

What are the indications for soft tissue augmentation in the esthetic zone?

The main indications for peri-implant soft tissue augmentation techniques can be summarized as follows.

Improving the final esthetic outcome

beneath the gingiva. In other cases, when hard tissue augmentation techniques have been used, soft tissue thickening can complete residual defect filling and achieve a better esthetic result (Fig 8-2).

In the esthetic zone, soft tissue augmentation techniques can allow the simulation of the contour of natural tooth roots

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c Fig 8-2 (a and b) Upon reopening following hard tissue augmentation via GBR, peri-implant soft tissue is augmented using connective tissue grafts. These are secured to the inside of the flap. (c to e) This procedure increases the thickness of the soft tissues, which are subsequently conditioned with a provisional prostheses before the case is finalized. (Surgery and prosthetic rehabilitation by Dr P. Casentini; prostheses by Mr A. Schoenenberger.)

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What are the indications for soft tissue augmentation in the esthetic zone?

More stable long-term esthetic results In implant-supported prosthetic treatment of the esthetic zone, every effort should be made to guarantee the best longterm prognosis and most stable tissue morphology possible.

a

In some cases, particularly with a thin periodontal biotype, over time the gray color of the implant or prosthetic abutment can unfortunately become evident through the tissue. This effect can occur even after many years but can be prevented easily by increasing the initial soft tissue thickness (Fig 8-3).

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Fig 8-3  (a to d) Upon delivery of the crown on the implant in the maxillary right lateral incisor site, the shape and thickness of the soft tissues appear adequate, and all the conditions seem favorable for a good long-term prognosis. In this case, treatment did not include a peri-implant soft tissue augmentation technique. (Prosthetic surgery and rehabilitation by Dr P. Casentini; prosthesis by Mr R. Colli and Mr C. Pedrinazzi.) (e to h) After 12 years, osseointegration appears to be very stable, with a complete absence of peri-implant bone resorption. However, the appearance of the soft tissues has changed, with significant retraction of the gingival margin associated with the appearance of a concavity and altered color of the tissues with respect to the contralateral side. The photographs with a polarizing filter (f and g) highlight the gingival color change at the implant site. An initial increase in soft tissue thickness would have prevented this problem.

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Preventing and treating esthetic complications

implant soft tissue recession and consequent unsightly results (Fig 8-4). As is shown in chapter 11, these techniques can also treat some peri-implant esthetic complications.

When coupled with accurate 3D implant positioning, periimplant soft tissue augmentation techniques prevent peri-

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Fig 8-4  (a and b) Failure to augment peri-implant soft tissues has resulted in an esthetic problem some years later, with exposure of the titanium abutment and the appearance of a grayish halo in the most coronal aspect of the peri-implant soft tissues. (c and d) The case is treated by mucogingival techniques to increase the thickness of the peri-implant soft tissues by means of connective tissue grafts (see Fig 11-16 for a full analysis of this case).

3|

What is the timing of esthetic soft tissue augmentation?

Tissues can be augmented at various stages of implant treatment; in most cases, the earlier the soft tissue augmentation is carried out, the greater the possibility of achieving correct implant site morphology and potentially carrying out further corrections at a later stage of treatment. Soft tissues generally can be augmented: • Prior to implant insertion. Tissue augmentation prior to implant placement is a relatively rare clinical reality. However, in some cases, eg, when combined with ridge preservation techniques (see chapter 5), soft tissues can be augmented by sealing the extraction socket using an epithelial–connective tissue punch. This technique is currently reserved for tissues that are very thin or damaged by previous complications (Fig 8-5).

• At the same time as implant placement. As demonstrated in chapters 4 and 5, soft tissue augmentation techniques can sometimes be combined with postextraction implant placement and ridge preservation techniques. Healed implant sites are often affected by a horizontal deficit when such techniques are not used. Defect correction may be carried out to coincide with implant placement by means of a guided bone regeneration (GBR) technique if bone volume is insufficient. If bone volume is sufficient to ensure a favorable long-term implant prognosis (buccal bone thickness of at least 2 mm), the defect can be corrected by soft tissue augmentation (Fig 8-6). • At the time of stage-two surgery, involving reopening and healing screw connection. In some cases, when ideal implant site morphology cannot be achieved during stage-

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What is the timing of esthetic soft tissue augmentation?

one implant surgery, potentially combined with hard tissue augmentation, site reopening represents an additional opportunity for further correction. The approach in this

case is usually a tunneling technique with placement of a connective tissue graft (Fig 8-7).

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Fig 8-5  (a to d) Incorrect 3D positioning of the implant in the maxillary right lateral incisor position has caused severe peri-implant soft tissue recession. Because the implant will have to be removed, the very thin peri-implant soft tissues could contribute to severe tissue collapse. (e to j) Implant removal, performed after a buccal osteotomy using a piezoelectric insert (Mectron), is immediately followed by a ridge preservation technique using bovine bone in a collagen matrix (Bio-Oss Collagen, Geistlich) and bone flap relocation. Because the soft tissues are thin, their thickness is increased, and the extraction socket is sealed using a connective tissue graft taken from the palate.

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Fig 8-5  (cont) (k and l) Long-term healing shows a favorable outcome for the hard and soft tissue augmentation. It will therefore be possible to place a new implant in a prosthetically guided position. (Surgery by Dr P. Casentini.)

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Fig 8-6  (a to g) Treating partial edentulism in the maxillary left quadrant involves placing two implants in the first premolar and first molar sites. Because there is sufficient bone volume at the first premolar site, the horizontal esthetic defect is treated using a connective tissue graft taken from the maxillary tuberosity and secured by a horizontal mattress suture to the buccal flap. (Surgery by Dr P. Casentini.)

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What is the timing of esthetic soft tissue augmentation?

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Fig 8-6 (cont) (h and i) Occlusal views prior to and after placing the definitive crowns show correction of the horizontal defect. (j) The buccal view reveals favorable integration of the implant-supported zirconiaceramic crowns with the surrounding tissues. (Prosthetic rehabilitation by Dr P. Casentini; prostheses by Mr A. Mairunteregger.)

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Fig 8-7  (a and b) When an implant previously placed with GBR in the maxillary right first premolar site is reopened, a small residual defect can be corrected using a connective tissue graft. (c and d) After making a linear incision that does not involve the adjacent papillae and creating a vestibular tunnel, the graft is inserted.

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h Fig 8-7 (cont) (e) The graft is secured to the tissues by means of a horizontal mattress suture. (f) Positioning of a healing screw helps to correct the defect. (Surgery by Dr P. Casentini.) (g to i) Peri-implant soft tissue augmentation has made it possible to achieve a natural emergence profile for the implant-supported crown, which appears to be well integrated. (Prosthetic rehabilitation by Dr P. Casentini; prosthesis by Mr R. Colli and Mr C. Pedrinazzi.)

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4|

Do peri-implant soft tissue augmentation techniques offer predictable outcomes?

Several recent systematic reviews of the literature have highlighted the effectiveness of peri-implant soft tissue augmentation techniques in providing a stable increase in tissue thickness and allowing a better esthetic outcome.1–4 Among the various augmentation techniques in these systematic reviews, the use of connective tissue grafts placed below existing soft tissues seems to be the best documented and most effective method. To date there is no evidence sup-

porting the superiority of a specific surgical technique or flap design. In this book, the authors describe their own experience and the surgical techniques they prefer for soft tissue augmentation. Their clinical experience suggests that soft tissue thickness augmentation is reliably stable, and they are beginning to see scientific reports in the literature that confirm this finding.5

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What are the main soft tissue harvesting sites and techniques?

5|

What are the main soft tissue harvesting sites and techniques?

The main harvesting sites for esthetic peri-implant soft tissue augmentation are the palate and the maxillary tuberosity.

Harvesting from the palate The palate is the most common harvest site, as extensively described in chapter 6. The advantages of this site are the possibility of obtaining a good amount of tissue and the fact that the same site can be harvested again at a later stage. The disadvantages are that it is a more difficult surgical technique due to the greater risk of bleeding and greater postoperative discomfort for the patient. The quality of the connective tissue harvested is often only good in the superficial layers. Deeper layers of the graft are often made up solely of adipose tissue, which is much less stable over time (Fig 8-8). Postoperative discomfort in the harvest site can, however, be considerably reduced by protecting it with a thermoformed plate. The plate should be thin to avoid changing the patient’s bite. Patients treated using this method report much fewer symptoms in the first week after surgery. The plate is also a useful device for the control of postsurgical bleeding.

Harvesting from the maxillary tuberosity This harvest site offers the main disadvantage of not always being available (for example, if patients have maxillary third

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Fig 8-8  The amount of adipose tissue in the epithelial–connective tissue graft increases in direct proportion to its thickness.

molars). When the maxillary tuberosity is available, it is an excellent source of dense connective tissue with no risk of bleeding and very little postoperative discomfort. Harvesting techniques vary depending on the quantity and shape of connective tissue to be removed. The first option is to harvest the tissue in a cylindrical shape. This technique is indicated when the harvested connective tissue will be used to seal extraction sockets in ridge preservation techniques (Fig 8-9). A second option involves taking a tissue wedge using a technique similar to the distal wedge technique used in periodontal resection surgery (Fig 8-10). The third option is to thin the connective tissue component of the maxillary tuberosity by making a horizontal incision with a no. 15c blade or, better yet, a curved no. 12 blade, in a distal to mesial direction (Figs 8-11 and 8-12). This technique is easily performed even by less-experienced surgeons.

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Fig 8-9  (a to e) Harvesting from the maxillary tuberosity to perform a preservation technique in an extraction site. In this case, the maxillary tuberosity characteristics are so favorable that a 5-mm-thick cylinder of dense connective tissue can be harvested.

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Fig 8-10 (a to c) Harvesting connective tissue from the tuberosity using the distal wedge technique. In this case, connective tissue is harvested by making two slightly converging incisions in a distal direction.

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Fig 8-11 (a to c) Harvesting connective tissue from the tuberosity by making a horizontal incision with a no. 15c blade, cutting in a distal to mesial direction.

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c Fig 8-12 (a and b) As can be seen on the radiograph (arrow), the maxillary tuberosity shape and thickness are extremely favorable. Upon extraction of the premolars, the connective tissue graft obtained from the tuberosity will be used to increase soft tissue thickness at both extraction sites. Simultaneously, implants will be placed in the first premolar and first molar sites and immediately fitted with prostheses. (c and d) The simplified harvesting technique from the tuberosity involves making a horizontal incision with a no. 12 blade. The curved blade simply cuts from distal to mesial and defines the connective tissue layer to be removed. (e) The follow-up radiograph shows the reduction in tuberosity thickness after graft harvesting. (Surgery by Dr P. Casentini.)

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What are the main soft tissue harvesting sites and techniques?

Palatal flap thinning This surgical technique can be used in combination with implant placement in the maxilla when the palatal flap is sufficiently thick. The inner part of the palatal flap is separated from the superficial flap component by a partial-thickness incision and then used as a connective tissue graft to increase

the flap’s buccal thickness, thus improving the esthetic appearance of the implant-supported rehabilitation (Fig 8-13). The main advantage of this technique is the absence of a second surgical harvesting site. The limitation of the technique is that it can only be used when the palatal flap is sufficiently thick. If the residual component of the palatal flap is too thin, it could become necrotic.

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Fig 8-13 (a and b) When implants are placed in the maxillary left premolar and second molar sites, the inner part of the palatal flap is separated from the rest of the flap by a partial-thickness incision. (c and d) The resulting connective tissue graft is joined with mattress sutures horizontal to the buccal flap in order to increase its thickness and thus improve the final esthetic appearance of the implant-supported rehabilitation. (Surgery by Dr P. Casentini.)

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6|

Are there biomaterials that can mimic the behavior of autogenous connective tissue?

Autogenous connected tissue is certainly the gold standard for peri-implant soft tissue thickness augmentation. However, to overcome the inevitable disadvantages of graft harvesting, porcine collagen matrices, which could potentially replace autogenous tissue, recently have been introduced. From a biologic viewpoint, the purpose of these matrices, when positioned beneath a flap exactly as we have seen for connective tissue grafts, is to maintain a space that can then be colonized by fibroblasts from surrounding soft tissues (Fig 8-14). The matrix should then be gradually reabsorbed and replaced by autogenous soft tissue. The actual quantity of newly formed tissue is not yet clear, and

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there is variability in the results, probably linked to the properties of the recipient tissue. Although preliminary clinical results are promising, it is not yet possible to recommend routine use of these biomaterials because there is insufficient scientific information on their long-term performance in a large patient group. The clinical case section of this chapter includes some pilot clinical cases in which collagen matrices have been used to increase soft tissue thickness. As demonstrated in chapters 6 and 7, further clinical applications for collagen matrices include mucogingival surgical techniques for root coverage and augmentation of the keratinized tissue band.

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Fig 8-14 (a and b) The use of biomaterials to replace autogenous soft tissues is an attractive proposition for clinicians wishing to reduce patient morbidity.

Clinical Case Studies Figures 8-15 to 8-27 present clinical cases demonstrating different applications of esthetic techniques for augmenting peri-implant soft tissue.

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Clinical Case Studies

clinical case 1 Connective tissue graft with simultaneous immediate postextraction implant placement

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Fig 8-15  (a and b) Initial clinical status of a young adult patient with agenesis of both maxillary right premolars and retention of the primary second molar, which shows signs of mobility. The buccal free gingival margin is so apically retracted that it is causing gingival recession, with root exposure, contraction of the soft tissues in a buccopalatal direction, and very little keratinized gingiva. (c) A radiograph shows root resorption of the primary tooth and abundant vertical bone availability in the site, with maintenance of the interproximal bone peaks. (d) Careful clinical evaluation shows that the gingival margin of the primary tooth is positioned more apically than that of the adjacent teeth, and for this reason an additional mucogingival correction procedure will be required. (e and f) The implant site is prepared after extracting the primary tooth. The available bone volume allows a site to be prepared fully within the ridge, without any gaps or residual defects. (g) The site is large enough to accommodate an implant 4 mm in diameter and 13 mm in length with integrated platform switching (T3 Prevail Tapered, Zimmer Biomet). (h and i) After tightening a healing abutment in place, a connective tissue graft is harvested from the palate and placed as an envelope between the buccal gingival tissue and healing abutment and sutured to the soft tissue with resorbable sutures (polyglycolic acid 6-0). The wound is then protected with a gel with a high content of amino acids and hyaluronic acid (Aminogam, Errekappa) to facilitate soft tissue healing. The connective tissue graft serves to cover the recession and increase support in a horizontal direction.

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eight  Esthetic Augmentation of Peri-implant Soft Tissue

clinical case 1 (cont)

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Fig 8-15  (cont) (j and k) After 24 hours, a provisional resin crown is screwed in place to mark the start of functional implant loading and create proper support for the soft tissues to adapt and mature. (l) Three months later, once osseointegration is complete, the soft tissues have healed and matured around the profile created by the provisional crown. Their level on the gingival zenith and interdental papillae is optimal. (m) A radiograph also reveals perfectly stable marginal bone levels. (n) When the provisional crown is disconnected, a healthy, stable mucosal tunnel is revealed, and biologic width has also been partially created on the horizontal plane. (o and p) A titanium post is then tightened in place, onto which the definitive ceramic crown is cemented, perfectly adapting to the soft tissue contours both vertically and horizontally. (q) A 12-month follow-up shows stable soft tissues and a sufficiently broad keratinized tissue band to guarantee peri-implant tissue health. (r) Radiographic examination reveals stable bone levels. (s) The gingival profile is now optimally positioned for a maxillary premolar, ie, slightly coronal to that of the canine and first molar.

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Clinical Case Studies

clinical case 2 Peri-implant soft tissue augmentation with a collagen matrix combined with GBR and immediate prosthetic restoration a mandibular incisor site

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Fig 8-16  (a to e) Delayed placement of an implant is planned a few weeks after extraction of the mandibular right central incisor due to fracture. In the meantime, a Valplast removable partial denture is used. The increased mesiodistal gap will be managed by means of two composite veneers to be bonded to the adjacent teeth. Delayed postextraction positioning is usually combined with hard tissue augmentation techniques using GBR to compensate for intervening alveolar ridge contraction (see chapter 3). Peri-implant soft tissue thickness augmentation is also planned by means of a collagen matrix and immediate placement of a prosthesis without functional loading. The optimal primary stability usually found in the anterior mandible facilitates the implementation of immediate prosthetic restoration techniques. (f to k) After reducing the excessive mesiodistal gap using composite veneers, a full-thickness flap is elevated, and an implant site is prepared with an axis compatible with a screw-retained restoration. After placing a small-diameter implant (Bone Level 3.3 × 12 mm, Straumann), the next step is a GBR technique involving positioning of deproteinized bovine bone and a porcine collagen membrane (Bio-Oss and Bio-Gide, Geistlich). The residual buccal bone thickness of less than 1 mm would be insufficient to guarantee good medium-and long-term implant prognosis.

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eight  Esthetic Augmentation of Peri-implant Soft Tissue

clinical case 2 (cont)

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Fig 8-16  (cont) (l to n) A 3-mm-thick collagen matrix is inserted to increase the soft tissue thickness, which is normally extremely reduced in this area (Mucograft, Geistlich). The matrix is stabilized by means of resorbable sutures anchored laterally to the releasing incisions. (o) After the access flap is sutured, an immediate provisional crown is placed and tightened to the implant. The crown, which was prepared prior to surgery with lingual access and used as a surgical template, is connected to a provisional titanium abutment by means of flowable composite and finished outside the oral cavity. The final occlusal check verifies the absence of any contact with the opposing arch. (p) A radiograph highlights correct implant placement in relation to the adjacent tooth roots. (q and r) After a few months, the provisional crown can be removed and an impression taken for the definitive restoration. The occlusal view shows complete correction of the horizontal defect and good symmetry between the implant site and adjacent teeth in the buccal soft tissue scalloping. (s and t) A prosthetic axis compatible with a screw-retained restoration allows optimum management of space around the definitive gold-ceramic restoration.

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Clinical Case Studies

clinical case 2 (cont)

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Fig 8-16  (cont) (u to w) The definitive restoration exhibits good biomimetic qualities, and the extraoral view shows that it is well integrated with surrounding tissues. (x) The radiographic follow-up reveals correct osseointegration without any signs of peri-implant resorption. (Surgery and prosthetic rehabilitation by Dr P. Casentini; laboratory stages by Mr A. Schoenenberger.)

clinical case 3

Implant placement with simultaneous GBR and connective tissue grafting in an esthetic site with significant horizontal atrophy

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Fig 8-17  (a to d) The patient requires replacement of the maxillary left lateral incisor, which has been extracted due to endodontic complications. An initial clinical examination clearly shows a horizontal ridge defect. The existing bone volume is verified with a radiograph and CBCT with a radiopaque marker. Although there is sufficient bone to allow implant placement, clinical success can only be achieved if the horizontal defect is also corrected. This will be done at the same time as implant placement through a combination of hard tissue augmentation (GBR) and soft tissue augmentation (connective tissue graft) to stabilize peri-implant bone volume and ensure an esthetic outcome.

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clinical case 3 (cont)

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Fig 8-17  (cont) (e and f) Once the implant site has been prepared, the reduced residual buccal cortical bone thickness is evident. A transmucosal implant (Standard Plus Regular Neck 3.3 × 12 mm, Straumann) is placed in a prosthetically guided manner. (g and h) A hard tissue augmentation technique using deproteinized bovine bone (Bio-Oss) and a double-layer collagen membrane (Bio-Gide) allows buccal bone thickness to be stably augmented.6 (i and j) The connective tissue graft is harvested from the palate using the envelope technique. (k and l) The flap is advanced without tension after volume augmentation through dissection and interruption of the periosteal layer.

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Clinical Case Studies

clinical case 3 (cont)

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Fig 8-17  (cont) (m to p) The connective tissue graft is secured to the recipient site flap by means of a horizontal mattress suture tied off with a buccal knot. Partially submerged healing is used. (q and r) Eight weeks later, after implant osseointegration, peri-implant soft tissue conditioning is initiated with a screw-retained provisional crown.

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eight  Esthetic Augmentation of Peri-implant Soft Tissue

clinical case 3 (cont)

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Fig 8-17 (cont) (s to u) Clinical and radiographic follow-up after definitive prosthetic restoration. Clinical follow-up demonstrates correct esthetic integration of the implant-supported crown within the surrounding tissues. An occlusal view shows that the horizontal defect has been fully corrected. The follow-up radiograph reveals the physiologic bone remodeling process at the neck of the implant, which allows bone peaks to be maintained at adjacent tooth sites. (Implant surgery and tissue augmentation by Dr P. Casentini; prosthetic rehabilitation by Dr A. Ghedini; prosthetic fabrication by Mr D. Viera.) (v to x) Clinical follow-up after 7 years. Soft tissue thickness seems to have increased. This is a common finding in medium- to long-term follow-up of soft tissue augmentation techniques, ie, the result is stable and even improves over time. (y and z) Clinical and radiographic follow-up after 14 years shows maintenance of peri-implant hard and soft tissue volume. Dental wear is also evident on the maxillary left central incisor, resulting from bruxism.

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Clinical Case Studies

clinical case 4 Placement of a submerged implant in the esthetic zone with GBR and connective tissue grafting

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Fig 8-18  (a to c) When the maxillary right central incisor was extracted, a ridge preservation technique involving placement of osteoconductive biomaterial (Bio-Oss Collagen) was performed. Despite the ridge preservation technique, the ridge showed some signs of horizontal resorption. According to the treatment plan, when the implant is placed, a soft tissue augmentation technique will be performed using a connective tissue graft and GBR, if necessary. In this chapter, the surgical stages of this case are analyzed. See Fig 9-14 for an analysis of the prosthetic stages, particularly soft tissue conditioning through the use of a provisional crown. (d and e) After elevating an access flap by making a single distal releasing incision at the adjacent lateral incisor, it can be seen that the biomaterial used during the preservation technique has integrated well. The implant is placed using a prosthetically guided technique, and its axis is compatible with a screw-retained restoration. (f and g) Despite the successful outcome of the preservation technique, it is decided to even out the ridge shape by performing additional GBR using bovine bone and a collagen membrane (Bio-Oss and Bio-Gide).

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clinical case 4 (cont)

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Fig 8-18  (cont) (h and i) A connective tissue graft taken from the palate is fixed to the inner surface of the flap using a horizontal mattress suture. (j) The flap is then passively advanced and sutured by first intention using interrupted sutures. Creating a thicker soft tissue layer will promote subsequent soft tissue conditioning by means of a provisional crown. (k to n) A definitive zirconia-ceramic crown is directly screwretained on the implant, and a feldspathic ceramic veneer is fabricated on the left central incisor. Note the creation of favorable peri-implant soft tissue scalloping and complete reconstruction of the papillae. (Implant surgery, tissue augmentation, and prosthetic rehabilitation by Dr P. Casentini; prosthetic fabrication by Mr A. Schoenenberger.) (o and p) Clinical and radiographic follow-up after 5 years shows stable soft tissue morphology and peri-implant bone level.

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Clinical Case Studies

clinical case 5 Augmentation of gingival thickness using a 3D collagen matrix followed by extraction of an impacted tooth and implant placement

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Fig 8-19 (a and b) A 39-year-old man presented with a large destructive lesion affecting the retained primary maxillary right canine. The permanent canine is impacted. (c) A radiograph confirms the clinical symptoms. It is impossible to save and restore the primary tooth. Radiographic examination also reveals the position of the permanent canine, which is rotated 90 degrees on its long axis and impacted between the roots of the lateral and first premolar. The first treatment suggested to the patient was orthodontic, aimed at bringing the impacted tooth back into the arch, but the patient decided against this approach. As an alternative, it was decided to extract both teeth, (ie, the primary and permanent canines), and place an osseointegrated implant. (d and e) A flap is therefore designed with intrasulcular incisions connected to a distal releasing incision at the first premolar, followed by extraction of the primary canine and subsequent full-thickness flap detachment. (f and g) An insert mounted on a Piezosurgery device (Mectron) is used to design a rectangle in the buccal cortical bone to gain access to the underlying surface and expose the impacted canine. Desmotomes are used to luxate the tooth, and it is extracted with the aid of levers and forceps. (h) The image of the extracted tooth shows the particular anatomical shape of the root apex. (i and j) Vertical and horizontal bony defects remain because of the large size of the crown and root of the impacted canine.

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clinical case 5 (cont)

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Fig 8-19  (cont) (k and l) A ridge augmentation technique is applied using deproteinized bone granules (Bio-Oss), first filling the intra-alveolar component and then reconstructing the bony defect more coronally. (m) The buccal cortical bone detached previously is repositioned above the graft in order to encourage the formation of new cortical bone. (n and o) The site is covered with a resorbable collagen membrane (BioGide). After repositioning and suturing the flap, the occlusal portion of the membrane is left partially exposed to encourage open healing, which will prevent misalignment of the mucogingival junction with the attendant risk of losing keratinized tissue width. (p and q) Six months after extraction, the soft tissues are fully mature, and the radiograph shows that bone healing is complete. (r) A final implant-supported prosthetic treatment plan can now be made. A diagnostic wax-up allows a surgical template to be constructed so that the implant can be positioned in a prosthetically guided manner. (s) A full-thickness flap is then detached, which reveals the formation of new buccal cortical bone. (t) The implant site is prepared in accordance with the axis provided by the surgical template.

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Clinical Case Studies

clinical case 5 (cont)

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Fig 8-19  (cont) (u) A tapered implant measuring 5 mm in diameter and 13 mm in length with integrated platform switching (T3 Prevail Tapered) is placed. The occlusal image shows 2 mm of horizontal bone buccal to the implant, as suggested by the literature, to ensure long-term stability and allow biologic width to form naturally. (v) For purely esthetic reasons, ie, to re-create an appropriate canine shape, the tissue thickness is augmented buccally by applying a layer of bovine bone substitute (Bio-Oss) mixed with homologous glue (Tisseel, Baxter). (w) The graft is covered by a 3D collagen matrix (Mucograft), with the smooth side facing out. (x) The radiograph shows accurate implant placement. (y) The flap is then repositioned and sutured by first intention. (z and aa) Three months later, which is the time required to achieve implant integration, stage-two surgery is performed by making a single linear incision in the ridge, with spreading of the soft tissues and placement of a titanium healing abutment. (bb) Two weeks later, a definitive titanium prosthetic abutment is placed, creating a healthy emergence profile with abundant keratinized tissue. (cc and dd) Buccal and occlusal clinical images show the definitive ceramic crown 1 year after implant placement, confirming soft tissue stability and an excellent esthetic outcome. (ee) A radiograph reveals maintenance of marginal bone levels.

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eight  Esthetic Augmentation of Peri-implant Soft Tissue

clinical case 6 Increasing gingival thickness in an area of high esthetic impact using a 3D collagen matrix

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Fig 8-20  (a) Initial clinical situation with two joined metal-ceramic crowns on the maxillary central incisors. (b and c) The left central incisor crown is on an implant, whereas the right central incisor crown is supported by a natural tooth. Both crowns have migrated buccally. A peri-implant infection has caused implant osseointegration to fail completely, and the natural tooth has a root fracture. (d) A radiograph shows peri-implant bone loss and compromise of the natural tooth structure. (e and f) Both crowns are removed, and then the implant and tooth root are removed using a flapless approach. (g) The implant surface has almost no contact with the bone, while the root shows two fracture lines, one transverse and one longitudinal. (h) Transmucosal probing of the sockets shows complete buccal cortical bone loss. The sockets are sealed using a 3D collagen matrix (Mucograft Seal), which will allow gingival tissue regeneration without loss of keratinized gingiva. At the same time, the median frenulum is removed. (i) Clinical view 2 weeks after extraction shows excellent recovery with almost complete re-epithelialization over the collagen matrix. (j) Six weeks later, soft tissue healing is complete. (k) A CBCT scan is performed using a 5 × 5–cm field of view with 90 mm (CS 9300, Carestream) in order to diagnose the exact amount of bone volume available.

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Clinical Case Studies

clinical case 6 (cont)

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Fig 8-20  (cont) (l) A 3D rendering highlights the severe horizontal and vertical hard tissue deficiency, with partial loss of palatal cortical bone in the maxillary right central incisor region, as confirmed by a frontal section. (m and n) The two transverse images highlight the bone loss caused by infection affecting both incisor sites. (o) Surgery is thus approached in a delayed fashion, 6 weeks following extraction (type 2 site according to Hämmerle7), ie, once soft tissue healing is achieved. A mucoperiosteal flap is prepared by means of a crestal incision and two vertical releasing incisions distal to the lateral incisors. Detachment is performed full thickness up to the mucogingival junction and partial thickness apical to the mucogingival junction, with subsequent bone surface denudation. When the flap is elevated, severe bone deficiency is evident, with loss of buccal cortical bone and partial resorption of the palatal cortical bone in the right incisor area. (p) A titanium-reinforced polytetrafluoroethylene (PTFE) membrane is cut (Cytoplast, Osteogenics) and secured first to the palatal cortical bone by means of two retaining screws (Pro-Fix, De Ore). (q) A bone graft is then applied, consisting of deproteinized bovine bone granules (Bio-Oss) mixed with fibrin glue (Tisseel) to shape the new alveolar ridge. (r) The membrane is then folded over onto the occlusal side and fitted on the buccal side.

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eight  Esthetic Augmentation of Peri-implant Soft Tissue

clinical case 6 (cont)

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Fig 8-20  (cont) (s) The membrane is secured to the cortical bone with two additional screws. (t) Flap closure is achieved by first intention and sutured with a combination of horizontal mattress sutures and simple interrupted sutures positioned on two different rows (PTFE 5-0). (u and v) Six months later, the soft tissues have healed optimally above the nonresorbable membrane. (w to z) Follow-up CBCT imaging shows that the membrane fits perfectly over the bone graft, with a gain in volume both horizontally and vertically. (aa and bb) During stage-two surgery, a full-thickness flap is elevated to expose the PTFE membrane, which is removed by taking out the fixing screws and elevating it first palatally and then buccally.

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Clinical Case Studies

clinical case 6 (cont)

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Fig 8-20 (cont) (cc and dd) Regenerated bone volume is present horizontally and vertically below the membrane, sufficient to allow the positioning of two implants measuring 4 mm in diameter and 13 mm in length (T3 Certain Prevail Tapered, Zimmer Biomet) in a prosthetically guided position. (ee) Residual horizontal buccal cortical bone thickness exceeds 4 mm. (ff and gg) To thicken the soft tissues and increase the proportion of keratinized tissue, a 3D collagen matrix (Mucograft) is applied on the buccal aspect, with the smooth side facing out and the rough side in contact with the bone surface. (hh) The soft tissues are repositioned and sutured with nonresorbable material (PTFE 5-0). (ii and jj) Twelve weeks later, the implant sites are opened by tracing two horizontal 4-mm-wide incisions and then positioning two titanium healing abutments with the keratinized tissue displaced in a buccally.

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clinical case 6 (cont)

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Fig 8-20  (cont) (kk and ll) Prosthetic rehabilitation is performed using two zirconia abutments and two individual full-ceramic crowns. (mm) A radiograph taken 1 year after loading shows stable marginal bone levels with platform switching. (nn to pp) Follow-up CBCT imaging 1 year after loading shows stability of the buccally regenerated bone volume on the horizontal and transverse planes.

clinical case 7 Augmenting peri-implant soft tissues to optimize esthetic outcome after hard tissue augmentation in a case of severe maxillary atrophy

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b Fig 8-21  (a to c) The initial clinical symptoms demonstrated by this 39-year-old patient include a severely atrophied maxilla, in which only the canines, the right first premolar, and the left second premolar are still present. This severe atrophy is probably linked to premature avulsion of the other teeth many years previously, mainly due to caries. At the time of the first visit, the patient wears a maxillary removable partial prosthesis that is esthetically substandard and mandibular removable prostheses distal to the second premolars. The remaining teeth are free of caries and periodontal disease.

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Clinical Case Studies

clinical case 7 (cont)

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Fig 8-21  (cont) (d to h) Prosthetic case planning is carried out according to a prosthetically guided regeneration protocol.8 In the event of significant bony defects, as in this case, the authors’ protocol first requires the development of a comprehensive prosthetic mock-up. Plaster casts are mounted onto an articulator after registering the facebow in centric relation, and a diagnostic wax-up is made and tested in the patient’s oral cavity to ensure it is satisfactory from esthetic and phonetic points of view. (i to l) After the in vivo check, the prosthetic mockup is duplicated on a diagnostic template in which the missing teeth are reproduced with a resin and barium mixture. Each tooth on the prosthetic mock-up features a 2-mm-diameter hole corresponding to the ideal implant axis. The diagnostic template is then tested in the oral cavity. l

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eight  Esthetic Augmentation of Peri-implant Soft Tissue

clinical case 7 (cont)

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Fig 8-21  (cont) (m to o) Only at this point is 3D radiographic examination required. This accurately quantifies the extent of bone deficiency in relation to the planned position of the teeth to be replaced and future implant sites. This diagnostic approach also makes it possible to choose the most appropriate reconstructive technique following accurate quantitative and qualitative definition of the bony defects. In this case, given the severe bone atrophy present, none of the sites analyzed (central and lateral incisor and both premolar sites bilaterally) offer an opportunity to place implants in positions that match the prosthetic mock-up. Therefore, prosthetically guided regeneration will precede implant placement. (p to t) Bone reconstruction is performed during a single surgery under general anesthesia. Autogenous bone blocks taken bilaterally from the mandibular ramus are used to reconstruct the anterior maxilla and combined with maxillary sinus elevation on the right side. Bone reconstruction is performed using a diagnostic template and then the prosthetic mock-up as a guide.

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Clinical Case Studies

clinical case 7 (cont)

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Fig 8-21 (cont) (u to w) On the left side, maxillary sinus elevation is combined with GBR using particulate autogenous bone mixed with deproteinized bovine bone (Bio-Oss) and stabilized with a collagen membrane (Bio-Gide). (x) Areas treated with autogenous bone blocks are subsequently covered with a layer of deproteinized bovine bone (Bio-Oss) and collagen membrane (Bio-Gide) with the aim of reducing resorption.9 (y) The flaps are then activated by cutting the periosteal layer and sutured without tension by first intention. (z) A follow-up panoramic radiograph shows bone reconstruction and harvesting areas. (Reconstructive surgery by Dr P. Casentini and Prof M. Chiapasco.)

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clinical case 7 (cont)

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Fig 8-21  (cont) (aa to dd) After reconstructive surgery, provisional prosthetic treatment is provided by a chrome and resin full-arch bonded prosthesis fabricated using CAD/CAM (CARES System, Straumann). After this type of reconstructive surgery, it is important to avoid compressing the reconstructed areas as much as possible. (ee and ff) Comparison between pre- and postreconstruction maxillary occlusal views demonstrates the extent of the bone reconstruction performed.

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Clinical Case Studies

clinical case 7 (cont)

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Fig 8-21 (cont) (gg to mm) Implants (SLActive Bone Level, Straumann) are placed in the reconstructed maxilla after 6 months. The same template used during the planning and prosthetically guided regeneration stages is modified and used to guide implant placement. (Implant surgery by Dr P. Casentini.)

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clinical case 7 (cont)

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Fig 8-21  (cont) (nn to qq) After reopening and connection of healing screws, a tunneling technique is performed in the anterior maxilla using special surgical instruments, and dense connective tissue grafts taken from the maxillary tuberosity are positioned. After extensive bone reconstruction, as in this case, soft tissue thickening is often carried out to coincide with implant placement or reopening to facilitate subsequent tissue conditioning and help achieve a better esthetic outcome. Bone reconstruction techniques and subsequent soft tissue mobilization involve tissue thinning that must be compensated for and corrected during subsequent treatment stages. (rr to uu) The implants are fitted with provisional screw-retained prostheses that meet the patient’s esthetic and functional expectations. After a 3-month soft tissue conditioning period, the tissue morphology is still not considered satisfactory at the left central incisor pontic site. The next step is to carry out a second soft tissue augmentation procedure.

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Clinical Case Studies

clinical case 7 (cont)

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Fig 8-21  (cont) (vv to zz) A palatal incision is made at the left central incisor site, a tunnel is created, and a dense connective tissue graft taken from the maxillary tuberosity is inserted. The provisional prosthesis is slightly loosened in the pontic area and immediately repositioned. (aaa) After another 3 months of use and additional modifications to the provisional prostheses (see chapter 9), the soft tissue conditioning is considered satisfactory. (bbb to ddd) Definitive rehabilitation is carried out by means of a screw-retained metal-ceramic prosthesis directly attached to the implants. Metallic mesostructures are produced using a CAD/CAM technique (CARES System). (Prostheses fabricated by Mr R. Colli and Mr C. Pedrinazzi.)

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clinical case 7 (cont)

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fff Fig 8-21 (cont) (eee to ggg) The implantsupported prostheses are well integrated into the surrounding hard and soft tissues. The rehabilitation, completed by bilateral implant placement and prosthetic treatment in the mandibular first molar sites, allows significant improvement in the patient’s quality of life, esthetic appearance, and self-esteem. (Prosthetic rehabilitation by Dr N. Balduzzi and Dr P. Casentini.)

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clinical case 8 Connective tissue graft from palatal side of a flap to correct an esthetic defect caused by a single missing maxillary premolar

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Fig 8-22 (a to d) Implant placement and subsequent restoration with a single crown is planned to replace a maxillary right first premolar. Additional implants will also be placed in the left posterior maxilla. Case planning involves a diagnostic wax-up and production of a radiopaque template. The computed tomography scan performed with the diagnostic template shows adequate bone volume and sufficiently thick palatal soft tissues. It is therefore planned to place the implant without bone volume augmentation and correct the slight hollow in the buccal ridge using soft tissue augmentation alone. In this case, the connective tissue can be taken from the very thick inner side of the flap without having to resort to another harvest site.

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Clinical Case Studies

clinical case 8 (cont)

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Fig 8-22  (cont) (e) A transmucosal implant (Standard Plus Regluar Neck 4.8 × 8 mm) is inserted with the guidance of the diagnostic template modified to serve as a surgical template. (f) After inserting the implant, the hollow in the buccal cortical bone is evident. (g) A buccal view reveals considerable flap thickness (approximately 6 mm) on the palatal side. (h and i) The innermost part of the palatal flap is then detached by means of a partial-thickness incision and fixed to the inner side of the buccal flap by means of a horizontal mattress suture. (j) The final step is semi-submerged healing. (Implant surgery by Dr P. Casentini.) (k and l) Appearance of peri-implant soft tissues prior to placement of the definitive prosthesis. The favorable peri-implant tissue morphology can be appreciated from both buccal and occlusal views.

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clinical case 8 (cont)

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Fig 8-22 (cont) (m) The treatment was finalized with a cemented metal-ceramic crown. (n and o) The clinical and radiographic follow-up reveal good crown integration and adaptation. (Surgery and prosthetic rehabilitation by Dr P. Casentini; prostheses fabricated by Mr R. Colli and Mr. C. Pedrinazzi.)

clinical case 9 Connective tissue graft from the maxillary tuberosity placed using a tunneling technique upon reopening of a maxillary central incisor implant site

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Fig 8-23  (a to d) After complete avulsion of the maxillary right central incisor due to an accident, for a few months the patient wore a removable provisional prosthesis (made by another dentist) in the form of a transparent retainer with a resin crown. The accident also involved partial fracture of the left central incisor, which was treated with a composite restoration. At the time of examination, the mesiodistal restorative space associated with the right central incisor site, which was planned for implant placement, was considered insufficient, and the occlusion was problematic, with unsatisfactory incisor and canine guidance. Given the situation, the treatment plan involved preliminary orthodontic treatment with the aim of improving dental alignment, creating sufficient restorative space for the right central incisor crown, and improving occlusion by implementing appropriate protrusion and lateral guidance. Subsequently, an implant was to be placed, combined with hard and soft tissue augmentation techniques, and the central incisors were to be prosthetically treated by placing a crown on the implant and a porcelain veneer on the left central incisor.

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Clinical Case Studies

clinical case 9 (cont)

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Fig 8-23 (cont)  (e to g) Once orthodontic treatment had achieved the established objectives, implant-supported prosthetic treatment could begin. The clinical and radiographic examinations indicate slight atrophy. (Orthodontic treatment by Dr S. De Luca.) (h and i) Prosthetically guided implant placement and GBR. After elevating a flap with a single releasing incision distal to the canine, an implant (Bone Level 4.1 × 12 mm) is inserted, and GBR is performed using Bio-Oss and Bio-Gide to increase the thickness of the buccal cortical bone. (Surgery by Prof M. Chiapasco and Dr P. Casentini.) (j and k) Despite the GBR treatment, a slight horizontal defect is still noticeable, particularly when the contour of the implant site is compared with that of the adjacent central incisor site. It is therefore decided to use the second surgical stage of site reopening to increase soft tissue thickness.

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eight  Esthetic Augmentation of Peri-implant Soft Tissue

clinical case 9 (cont)

l

m

Mucogingival junction

5 mm

Tunnel area

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Linear incision avoiding the papillae

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Fig 8-23  (cont) (l to n) After making a small linear incision in the center of the ridge, without affecting the adjacent papillae, a tunnel is created under the buccal soft tissues with a special rounded, semi-sharp instrument. Tunneling takes place in an intermediate plane between the periosteal and superficial surfaces and extends for approximately 5 mm beyond the mucogingival junction. (o and p) Illustration of a connective tissue graft being pulled into a previously created tunnel by means of a suture anchored to the external surface of the soft tissue. (q and r) A dense connective tissue graft taken from the maxillary tuberosity is pulled into the previously created tunnel and sutured to the superficial soft tissues. Positioning of a transmucosal healing screw applies pressure in a buccal direction and allows peri-implant soft tissue volume to be optimized. (Surgery by Dr P. Casentini.)

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Clinical Case Studies

clinical case 9 (cont)

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Fig 8-23 (cont) (s) The case will be finalized by means of a screw-retained crown on the implant and a porcelain veneer on the adjacent tooth. After conditioning the soft tissues, a definitive impression is taken with a screw-retained transfer customized to fit the implant emergence profile (see chapter 9) and a retraction cord that highlights the veneer preparation finish line. (t and u) A zirconia-ceramic crown bonded in the laboratory to a titanium abutment (Variobase, Straumann) was prepared for the implant, and the veneer was made using feldspathic ceramic. (Prostheses fabricated by Mr A. Mairunteregger.) (v) The treatment goals have been achieved. Favorable integration of the implant-supported crown and ceramic veneer allowed the edentulism to be resolved with an optimal esthetic and functional outcome. Orthodontic treatment also allowed functional improvement with restoration of incisal and canine guidance. (w) The radiograph reveals normal peri-implant bone levels. (x) The patient’s smile at the 4-year follow-up shows favorable esthetic integration of the prosthetic reconstruction. (y and z) The 4-year clinical and radiographic follow-up reveals complete stability of peri-implant soft tissue and bone levels.

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clinical case 10 Connective tissue graft at implant placement and upon reopening in mandibular incisor region

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Fig 8-24  (a and b) The initial clinical situation reveals absence of the mandibular central incisors and right lateral incisor, previously extracted due to endodontic complications. The patient was treated with a removable partial prosthesis. Note the clear horizontal alveolar ridge reduction, combined with a reduction in the keratinized tissue band. (c) A prosthetically guided regeneration protocol requires the production of a prosthetic mock-up before any other step. The mock-up for this case envisaged replacing only two mandibular incisors, given that insufficient mesiodistal space is available for positioning three incisors. An additional disilicate veneer will be positioned on the adjacent canine for more effective management of the mesiodistal space. (d) The diagnostic wax-up is duplicated and converted to a radiopaque diagnostic template that is used to perform a 3D radiographic examination. A CBCT image reveals that sufficient bone volume is present for implant placement. However, to achieve clinical success, soft tissue augmentation techniques will have to be carried out to increase ridge volume. (e) At the time of first surgery, an implant (Bone Level Roxolid 3.3 × 10 mm, Straumann) is placed in the mandibular right central incisor site using a prosthetically guided technique. When replacing two adjacent mandibular incisors, the preferred option is often to place one implant and create a cantilever. This solution avoids the need to place two implants too close together. (f and g) GBR is then performed to increase the thickness of the thin buccal cortical bone. Deproteinized bovine bone stabilized by means of a collagen membrane (Bio-Oss and Bio-Gide) is positioned for this purpose. (h and i) The surgery is completed by inserting a connective tissue graft taken from the palate using an envelope technique and fixed to the recipient site by means of resorbable sutures.

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Clinical Case Studies

clinical case 10 (cont)

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Fig 8-24  (cont) (j) The flap is then sutured by first intention. (k and l) The site was reassessed before stage-two surgery for site reopening and healing screw connection. There has been a clear improvement in the edentulous ridge shape, but it is still not optimal. (m and n) A second soft tissue augmentation technique is therefore performed using a dense connective tissue graft taken from the maxillary tuberosity region and positioned using a tunneling technique after de-epithelialization. (o) The clinical follow-up shows favorable esthetic integration of the implant-supported prosthetic device and a pleasing soft tissue appearance after conditioning. In accordance with the initial prosthetic treatment plan, the right canine has been fitted with a ceramic veneer to harmonize the mesiodistal spaces. (p) A radiographic follow-up 3 years after prosthetic loading demonstrates the absence of peri-implant bone resorption. (Surgery by Dr P. Casentini; prosthetic rehabilitation by Dr M. Tschurtschenthaler; laboratory procedures by Mr A. Mairunteregger.)

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clinical case 11 Connective tissue graft placed at the time of implant reopening in a site previously treated with GBR

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Fig 8-25  (a and b) Initial clinical images of a mandibular first molar site 6 months after extraction with vertical and horizontal soft tissue deficiency severe enough to warrant bone volume regeneration prior to implant surgery. (c and d) CBCT documents the presence of an atrophic ridge. The transverse view shows the clearly coronal course of the mandibular alveolar canal, while a 3D rendering shows bone resorption in the extraction area. (e) Mucoperiosteal flap elevation shows a bone ridge with a broad base and an alveolar process that is very tapered in the coronal third. (f and g) An implant site is created in the middle of the edentulous gap in a prosthetically guided manner, and holes are created in the bone cortex with the aim of opening marrow spaces and promoting bleeding. (h and i) A tapered implant measuring 5 mm in diameter and 10 mm in length (T3 Certain Tapered, Zimmer Biomet) is positioned, surrounded by a residual coronal bony defect.

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Clinical Case Studies

clinical case 11 (cont)

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Fig 8-25  (cont) (j to l) The bone volume deficiency is reconstructed by means of a deproteinized bovine bone graft (Bio-Oss) mixed with homologous fibrin glue (Tisseel) and protected by means of a resorbable collagen membrane (Bio-Gide). (m) The flap is sutured to achieve closure by first intention with a double line of sutures consisting of simple interrupted stitches and horizontal mattress sutures using a nonresorbable material (PTFE 5-0). (n) The posttreatment radiograph shows correct implant placement and bone grafting. (o and p) Six months later, the second stage of surgery takes place with elevation of a half-thickness flap and healing screw connection. (q) To increase soft tissue thickness, connective tissue is harvested from the palate.

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clinical case 11 (cont)

r

s Fig 8-25 (cont) (r) The connective tissue is grafted buccally and secured to the underlying periosteal bed by means of resorbable sutures (polyglycolic acid 5-0). (s) The primary flap is then sutured above the connective tissue graft. (t) A clinical view of the ceramic crown in position reveals that the peri-implant tissues are well adapted.

t

clinical case 12 Gingival tissue augmentation with a collagen matrix at mandibular implant site following GBR

a

b Fig 8-26  (a and b) Initial clinical situation in a case of unilateral distal edentulism in a mandible with an atrophic ridge. Intraoral examination shows the vertical and horizontal of the ridge. (c) The preoperative computed tomography (CT) scan documents the very coronal position of the mental foramen in the premolar area, accompanied by a somewhat superior alveolar canal route.

c

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Clinical Case Studies

clinical case 12 (cont)

d

e

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j

Fig 8-26  (cont) (d) CT cross sections demonstrate the reduced vertical dimension of the ridge in the coronal third. (e) The surgical approach involves a ridge incision dividing the remaining keratinized tissue into two portions. (f) Distally, the incision is clearly moved to the buccal aspect to avoid damaging major anatomical structures. (g) Mesially, a buccal releasing incision is performed beginning from the mesiobuccal limit of the distalmost natural tooth. (h) A hockey stick–shaped vertical releasing incision is performed on the lingual side. (i and j) Buccally, a full-thickness flap is detached up to the mucogingival junction, switching to half thickness beyond the mucogingival junction.

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clinical case 12 (cont)

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Fig 8-26  (cont) (k) In the retromolar trigone, the tissues are detached at full thickness using a Molt periosteal elevator, again with a view to leaving major anatomical structures unharmed. (l to n) The lingual flap is advanced by detaching connective tissue above the plane made up of myeloid muscle fibers, thus pushing the flap lingually and coronally until it has advanced 15 mm in a vertical direction. (o) Holes are made above the cortical bone in order to open marrow spaces and promote bleeding. (p) Two tapered osseointegrated implants (T3 Certain Tapered) are then positioned, 4 × 11.5 mm in the second premolar position and 5 × 11.5 mm in the second molar position. (q and r) An autogenous bone graft is prepared by harvesting bone from the retromolar area using a bone scraper, blending it with other autogenous bone taken from burs during the implant preparation stage, and mixing it with deproteinized bovine bone (Bio-Oss) in a ratio of 30:70.

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Clinical Case Studies

clinical case 12 (cont)

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x

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Fig 8-26 (cont) (s) The blend of autogenous and animal bone is mixed with fibrin glue (Tisseel). (t and u) The bone graft is positioned to reconstruct the horizontal and vertical components of the atrophic ridge and protected by a porcine collagen resorbable membrane (Bio-Gide). (v) The flap is passively advanced and closed by first intention with a horizontal line of mattress sutures and a line of simple interrupted sutures in nonresorbable material (PTFE 5-0). (w) Six months later, the soft tissues appear to be perfectly healed. (x) An incision is made in the ridge, and tissue is detached to full thickness, revealing grafted bone healing with full coverage of the implant heads. (y) Newly formed bone tissue must be removed in order to connect the healing abutments. (z) A periosteal bed fixed with resorbable sutures (polyglycolic acid 6-0) is then created.

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eight  Esthetic Augmentation of Peri-implant Soft Tissue

clinical case 12 (cont)

aa

bb

cc

dd

ee

ff

Fig 8-26  (cont) (aa) A 3D matrix in porcine collagen (Mucograft) is applied to increase soft tissue thickness. (bb) The flap is then sutured over the collagen matrix and around the healing abutments. (cc) Three weeks later, the soft tissues fit snugly around the healing abutments. (dd) Two definitive titanium abutments and provisional resin crowns are then positioned to further condition the soft tissues. (ee) Follow-up clinical view of definitive ceramic crowns highlighting the excellent functional and esthetic outcome. Tissue thickness and the keratinized gingival band are sufficient to maintain peri-implant health. (ff) A follow-up intraoral radiograph shows stable marginal bone levels. (Prosthetic rehabilitation by Dr F. Cattoni.)

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Clinical Case Studies

clinical case 13 Peri-implant soft tissue augmentation using a collagen matrix in a mandibular site previously treated with bone augmentation

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b

c

d

e

Fig 8-27  (a to c) A 3D CBCT examination is required to treat edentulism involving the two mandibular central incisors with evident horizontal alveolar ridge atrophy. A CBCT scan performed with a radiopaque radiographic template confirms marked horizontal atrophy of the alveolar process that is incompatible with prosthetically guided implant placement. 3D bone reconstruction surgery is then planned using an autogenous bone block taken from the chin symphysis. Using the symphysis (which is favorably shaped, according to the CBCT scan) as a donor site offers the advantage of a single surgical harvesting and grafting site. Placement of a single implant to support a crown with a cantilever will thus be deferred for 6 months to allow graft healing. (d and e) The atrophic bone ridge with initial thickness of less than 3 mm is reconstructed using an autogenous bone block taken from the chin symphysis apical to the bony defect. The harvesting osteotomy is performed using a large-diameter trephine bur.

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clinical case 13 (cont)

f

g

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Fig 8-27 (cont) (f) The block is fixed to the recipient site with an osteosynthesis screw (Modus System, Straumann). (g) Osteoconductive biomaterial is then positioned on the donor site and in areas surrounding the graft for a well-proportioned shape.10 Positioning biomaterial above the graft also inhibits resorption.9 (h) Positioning a double layer of collagen membrane (Bio-Gide) prevents biomaterial dispersion. (i) After incision of the periosteum, the flap is sutured without tension. (j and k) Six months later, optimum graft integration is evident.

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Clinical Case Studies

clinical case 13 (cont)

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n

o

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q

Fig 8-27  (cont) (l and m) A small-diameter implant can be positioned (Bone Level 3.3 × 10 mm). The implant placement axis is compatible with a screw-retained restoration, which is considered the best choice in this region. (n to p) A collagen matrix (Mucograft) is inserted to increase soft tissue thickness and the keratinized tissue band. The access flap is not tightly closed in order to achieve healing partially by second intention and increase the keratinized tissue band. (q) The shape of the edentulous alveolar ridge after implant placement reveals the increase in soft tissue thickness and the morphologic improvement.

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eight  Esthetic Augmentation of Peri-implant Soft Tissue

clinical case 13 (cont)

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s

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v

Fig 8-27 (cont) (r) Three months after implant placement, a healing screw is placed after making a limited mesiodistal incision that does not involve the adjacent papillae. (s and t) Prosthetic reconstruction is carried out using a screw-retained zirconia-ceramic restoration on a prefabricated titanium base (Variobase). A single implant with a cantilever is the first choice in this sector, where the available mesiodistal space is nearly always limited. Reconstruction of the papilla between the two incisors using pink porcelain improves the final biomimetic appearance of the restoration, which appears to be well integrated into the surrounding hard and soft tissues. (u and v) Extraoral views confirm that the implant-supported prosthetic rehabilitation is well integrated. (Surgery by Dr P. Casentini; prosthetic rehabilitation by Dr M. Tschurtschenthaler; laboratory procedures by Mr A. Mairunteregger.)

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References

References 1. Esposito M, Maghaireh H, Grusovin MG, Ziounas I, Worthington HV. Soft tissue management for dental implants: What are the most effective techniques? A Cochrane systematic review. Eur J Oral Implantol 2012;5:221–238. 2. Thoma DS, Buranawat B, Hämmerle CH, Held U, Jung RE. Efficacy of soft tissue augmentation around dental implants and in partially edentulous areas: A systematic review. J Clin Periodontol 2014;41:S77–S91. 3. Bassetti RG, Stähli A, Bassetti MA, Sculean A. Soft tissue augmentation procedures at second-stage surgery: A systematic review. Clin Oral Investig 2016;20:1369–1387. 4. Bassetti RG, Stähli A, Bassetti MA, Sculean A. Soft tissue augmentation around osseointegrated and uncovered dental implants: A systematic review. Clin Oral Investig 2017;21:53–70. 5. De Bruyckere T, Eghbali A, Younes F, De Bruyn H, Cosyn J. Horizontal stability of connective tissue grafts at the buccal aspect of single implants: A 1-year prospective case series. J Clin Periodontol 2015;42:876–882.

6. Buser D, Chappuis V, Kuchler U, et al. Long-term stability of early implant placement with contour augmentation. J Dent Res 2013;92:176–182. 7. Hämmerle CH, Chen ST, Wilson TG Jr. Consensus statements and recommended clinical procedures regarding the placement of implants in extraction sockets. Int J Oral Maxillofac Implants 2004;19:26–28. 8. Chiapasco M, Casentini P. Horizontal bone-augmentation procedures in implant dentistry: Prosthetically guided regeneration. Periodontol 2000 2018;77:213–240. 9. Cordaro L, Torsello F, Morcavallo S, di Torresanto VM. Effect of bovine bone and collagen membranes on healing of mandibular bone blocks: A prospective randomized controlled study. Clin Oral Implants Res 2011;22:1145–1150. 10. Von Arx T, Buser D. Horizontal ridge augmentation using autogenous block grafts and the guided bone regeneration technique with collagen membranes: A clinical study with 42 patients. Clin Oral Implants Res 2006;17:359–366.

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nine Peri-implant Soft Tissue Conditioning Using Restorations

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Questions: 1. What is meant by peri-implant soft tissue conditioning using restorations? 2. What are the main soft tissue conditioning techniques, and what is the time frame for using them? 3. How can the conditioned tissue architecture be transferred to the dental laboratory?

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1|

What is meant by peri-implant soft tissue conditioning using restorations?

Peri-implant soft tissue conditioning using restorations describes the set of prosthetic operations, usually performed at the provisional prosthesis stage, used to create an appropriate tissue morphology. An implant-supported prosthetic

restoration is an esthetic success if the restoration blends in attractively and symmetrically with the surrounding hard and soft tissues (Fig 9-1).

a

b

c

d

e

f

Fig 9-1 (a to f) Replacing a maxillary central incisor with an implant-supported single crown. After site reopening and healing screw connection, peri-implant soft tissue conditioning with a provisional crown allows the ideal tissue architecture to be achieved. This is a fundamental requirement for satisfactory esthetic integration of an implant-supported prosthetic restoration. (See case 7 [Fig 9-14] in the clinical case studies section for a full analysis of this case.)

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What are the main soft tissue conditioning techniques, and what is the time frame for using them?

2|

What are the main soft tissue conditioning techniques, and what is the time frame for using them?

Esthetic conditioning of peri-implant soft tissues can be achieved with different techniques and time frames, depending on the chosen treatment procedure. Different techniques can often be combined and used synergistically.

Immediate provisional restoration Immediate application of a provisional restoration is one of the most commonly used soft tissue conditioning techniques. With postextraction implants, immediate restoration of positioned implants makes it possible to seal the socket margins

while also providing the adjacent papillae with mechanical support so that they maintain their shape. This method is also advantageous from an ergonomic viewpoint because soft tissue conditioning takes place at the same time as the osseointegration process and, in many cases, additional soft tissue conditioning sessions are not required1–4 (Figs 9-2 and 9-3). Of course, to carry out risk-free immediate prosthetic treatment, certain requirements must be met: first and foremost, satisfactory primary implant stability (see chapter 4).

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b

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d

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Fig 9-2 Immediate prosthetic treatment of a single postextraction implant. (a) After extracting a fractured maxillary left first premolar, an immediate postextraction implant is inserted. (b) The peri-implant gap is filled with deproteinized bovine bone (Bio-Oss Collagen, Geistlich). (c) A provisional titanium abutment is then positioned, and the soft tissues are isolated by means of a rubber dam fragment. (d) The provisional crown, retained by a positioning template, is then joined to the titanium abutment with composite resin. (e and f) Outside the oral cavity, more composite resin is added before finishing and polishing until the screw-retained provisional crown emergence profile is correct. (g) The provisional crown is then retightened to the implant. (h) For single restorations, it is important to remove any contact with the opposing arch to rule out the risk of micromovements that could affect osseointegration. The provisional crown provides the adjacent papillae with appropriate mechanical support and improves the patient’s appearance.

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h

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nine  Peri-implant Soft Tissue Conditioning Using Restorations

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Fig 9-2  (cont) (i to l) After some time, it is evident that a provisional crown represents the best option for preparing a definitive restoration that blends in well with the surrounding tissues because it leaves the soft tissue anatomy unchanged. (Surgery and prostheses by Dr P. Casentini; laboratory procedures by Mr R. Colli and Mr C. Pedrinazzi.)

a

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c

d

Fig 9-3  (a to d) Immediate prosthetic treatment of multiple implants. The principle of immediately conditioning soft tissue with a provisional restoration immediately connected to implants can be applied to multiple extraction sites as well as a single site. (Surgery and prostheses by Dr P. Casentini; laboratory procedures by Mr R. Colli and Mr C. Pedrinazzi.)

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What are the main soft tissue conditioning techniques, and what is the time frame for using them?

Customized healing screw When the primary stability of a postextraction implant does not allow immediate prosthetic treatment or when this step is not considered necessary, another option is available for achieving immediate soft tissue conditioning without losing

a

the anatomy present at the time of extraction. This involves preparing a customized healing screw that performs the same function as an immediate provisional prosthesis, sealing the socket and providing immediate support for soft tissues without any risk of mechanical overload5 (Fig 9-4).

b

Fig 9-4  (a to c) Extraction socket tissue conditioning can also be achieved by preparing a customized healing screw. (See case 6 [Fig 9-13] in the clinical case studies section for a full analysis of this case.)

Deferred provisional restoration This is the main peri-implant soft tissue conditioning technique used in cases without immediate postextraction implant placement in conjunction with immediate conditioning techniques.

a

c

This technique is used, for example, when implant placement takes place in conjunction with regenerative techniques that require submerged healing. In such cases, peri-implant soft tissue conditioning takes place gradually using a provisional restoration with a progressively modified profile6,7 (Fig 9-5).

b

Fig 9-5  (a and b) After reopening a site with a submerged implant placed in conjunction with a ridge augmentation technique, the soft tissues must be conditioned because the buccolingual and apicocoronal morphology is unsatisfactory.

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nine  Peri-implant Soft Tissue Conditioning Using Restorations

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Fig 9-5  (cont) (c to k) The provisional restoration is prepared with the aim of achieving a buccal morphology reflecting that of the adjacent teeth while avoiding excessive soft tissue compression. For this reason, the provisional restoration initially has a buccal overlap that will be successively filled with incremental additions of flowable composite until an appropriate emergence profile is achieved. (Prosthetic rehabilitation by Dr P. Casentini; prosthetic fabrication by Mr A. Giacometti.)

Soft tissue ridge-splitting techniques This technique is usually used to condition areas planned for intermediate pontic teeth on implant-supported prosthetic rehabilitations. When the morphology of such sites is sub-

a

b

optimal, placement of the provisional or definitive restoration can be combined with a ridge-splitting technique limited to the soft tissue component. The ovate pontic shape of the intermediate tooth will allow the desired conditioning to be achieved (Fig 9-6).

c

Fig 9-6  Conditioning of a pontic site using a soft tissue ridge-splitting technique. (a to c) This technique is performed to improve the soft tissue morphology around the intermediate element and involves making a linear incision in the center of the ridge, within the keratinized tissue, combined with small releasing incisions that allow the two sections of tissue to be mobilized. The flap, usually supraperiosteal, is gently elevated to create a space within which the ovate pontic is positioned.

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How can the conditioned tissue architecture be transferred to the dental laboratory?

d

e

f

Fig 9-6 (cont) (d to f) The shape of the intermediate element is traced after preliminarily correcting the ridge shape on the plaster cast to create an ideal profile. (g and h) A few weeks later, it is evident that the defect has been corrected and the implant-supported prosthetic restoration is well integrated. (Prosthetic rehabilitation by Dr P. Casentini; prosthetic fabrication by Mr A. Giacometti.) g

3|

h

How can the conditioned tissue architecture be transferred to the dental laboratory?

After the peri-implant soft tissues have been conditioned by provisional restorations and an ideal tissue profile has been obtained, it is important to accurately transfer tissue anatomy information to the dental laboratory. The technique of constructing a transfer from a custom impression was

a

introduced to overcome the drawback of rapid tissue collapse after provisional restoration removal, which prevents the shape from being accurately transferred. This effectively replicates the juxtagingival and subgingival component of the provisional restoration8,9 (Fig 9-7).

b

c

Fig 9-7 (a to e) Prosthetic rehabilitation of this single implant positioned in the maxillary right central incisor site begins with placement of a provisional restoration designed with an overlap. This is filled incrementally with flowable composite until the desired soft tissue morphology and crown emergence profile are achieved.

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e

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nine  Peri-implant Soft Tissue Conditioning Using Restorations

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Fig 9-7 (cont) (f) To transfer the soft tissue morphology determined by the provisional restoration, the restoration is removed from the oral cavity, tightened to a laboratory analog, and then embedded in a small amount of silicone mixture for impressions. (g) Once the silicone has set, the provisional prosthesis is removed, leaving an impression of the subgingival component of the provisional restoration in the silicone. (h to n) At this point, a transfer taken from the impression is connected to the laboratory analog; the gap present between the transfer and provisional restoration impression is filled using a lightcuring material. This means that the transfer profile will be identical to that of the provisional restoration, and this will be faithfully reproduced on the plaster cast. In this case, the prosthetic plan also involves preparing a veneer to be applied to the contralateral central incisor (see Fig 8-23).

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Clinical Case Studies Figures 9-8 to 9-16 present clinical cases demonstrating different applications of peri-implant soft tissue conditioning techniques using restorations.

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Clinical Case Studies

clinical case 1 Immediate soft tissue conditioning using a provisional restoration on an immediate postextraction implant in a maxillary central incisor site

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Fig 9-8  (a and b) Clinical situation when the patient first presented for treatment because of an old metal-ceramic crown on her maxillary right central incisor. (c) The initial radiograph reveals root resorption external to the apex with a periapical lesion. An area with an unsatisfactory seal can be noted at the prosthetic margin. (d) The tooth prognosis is unfavorable due to the negative root–crown ratio that would arise following the necessary clinical crown elongation. The ideal contour of the interdental papillae and buccal gingival profile, together with the absence of deep periodontal probing, suggest that immediate postextraction implant placement with immediate provisional restoration is the optimal therapeutic solution. The natural tooth is therefore extracted by means of a flapless procedure, taking particular care to keep the soft tissues intact. The buccal cortical bone is also intact. (e) The implant is positioned in a prosthetically guided manner using a surgical template. (f) A tapered implant measuring 5 mm in diameter and 13 mm in length with integrated platform switching is positioned (T3 Certain Prevail Tapered, Zimmer Biomet). (g) The bone-implant gap is filled with biomaterial mixed with collagen (Bio-Oss Collagen) to compensate for socket resorption. (h) A polyether ether ketone (PEEK) provisional abutment (PreFormance, Zimmer Biomet) is then positioned. (i) A provisional acrylic resin crown is then connected to the abutment and rebased in order to achieve direct screw retention.

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nine  Peri-implant Soft Tissue Conditioning Using Restorations

clinical case 1 (cont)

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Fig 9-8  (cont) (j and k) Transmucosal pathways from the provisional abutment shoulder to the free gingival margin are modeled in composite material. (l) The provisional crown is then positioned and tightened in place, thus offering ideal support to the original soft tissue anatomy. The immediate provisional restoration replicates the original crown emergence profiles, offering appropriate support to the interproximal papillae and buccal gingiva. (m) A radiograph shows the implant and provisional crown positioning. The radiopaque material shows a transmucosal pathway made of composite to provide the interdental papillae with effective support. (n) Three months later, the time allowed for implant osseointegration when using a flapless technique, the soft tissues reach maturity and can be considered stable enough to perform the definitive restoration. The clinical image shows very good fit at the border between the provisional crown and the soft tissues. (o and p) Removal of the provisional post and crown reveals the quality of the peri-implant mucosa, which faithfully reflects the original anatomy of the interdental papillae from a frontal view and of the buccal tissue from an occlusal view. (q) An impression is taken of the implant head that faithfully replicates the soft tissue profile. A definitive zirconia prosthetic post is prepared with a conventional shoulder. The finishing margin is displaced coronally because the definitive crown will be cemented. (r) An occlusal view shows perfect positioning of the zirconia post in relation to the surrounding soft tissues.

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Clinical Case Studies

clinical case 1 (cont)

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Fig 9-8 (cont) (s and t) The definitive all-ceramic crown. (u and v) Once cemented in place, the definitive crown effectively supports the interdental papillae and the buccal soft tissue. (w and x) Clinical images after 1 year show tissue stability. (y) A radiograph reveals a stable mesial and distal marginal bone level.

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clinical case 2 Immediate soft tissue conditioning using a provisional restoration on an immediate postextraction implant in a maxillary second premolar site

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Fig 9-9  (a and b) Clinical situation of a patient who presented for treatment because of an old metal-ceramic crown placed approximately 15 years previously, which had become unseated twice during the previous 2 weeks. The soft tissues look perfectly harmonious, with interdental papillae filling the interproximal spaces, a satisfactory band of keratinized tissue, and good buccal tissue support. (c) A radiograph shows infiltration of the prosthetic reconstruction, a post that is misaligned with the root canal axis, and ineffective root canal treatment. At the same time, available bone can be seen apical to the root apex. (d and e) In view of the tooth’s poor prognosis, soft tissue integrity, physiologic sulcus without periodontal attachment loss, and the possibility of achieving satisfactory primary stability in the available bone between the root apex and the maxillary sinus, it is decided to extract the tooth and replace it immediately with an implant. A provisional crown will be connected to this to maintain the soft tissue architecture. A flapless extraction is performed, preserving the integrity of the papillae and gingival margin buccally and palatally. (f) The implant site is then prepared by grinding the bone beyond the root apex with burs. (g and h) The space remaining between the implant threads and socket walls (bone-implant gap) is filled with deproteinized bovine bone mixed with collagen (Bio-Oss Collagen).

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Clinical Case Studies

clinical case 2 (cont)

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Fig 9-9  (cont) (i and j) At this point, a tapered titanium implant measuring 5 mm in diameter and 11.5 mm in length with integrated platform switching (T3 Certain Prevail Tapered) is placed. (k) A directly screw-retained immediate provisional crown is prepared, using a provisional abutment measuring 4 mm in diameter in order to create platform switching. (l and m) The provisional crown is tightened directly to the head of the implant in order to support the preexisting gingival profile buccally and at the interdental papillae. (n) A radiograph taken after surgery shows correct positioning of the implant. (o) Three months later, when the implant is osseointegrated, clinical analysis reveals that the peri-implant mucosal tissue is well integrated. The papillae completely fill the interproximal embrasures, and the buccal soft tissue has remained stable in its position. (p) An occlusal view reveals that the horizontal dimension of the ridge profile has been maintained.

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nine  Peri-implant Soft Tissue Conditioning Using Restorations

clinical case 2 (cont)

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Fig 9-9  (cont) (q and r) Disconnection of the provisional crown reveals that the peri-implant tissues are in perfect condition and have adapted to the emergence profiles created by the provisional crown. (s) All that remains to be done is to replicate these profiles when preparing the definitive titanium post and metal-ceramic crown. (t and u) A clinical follow-up 1 year after surgery reveals satisfactory peri-implant tissue stability in all three dimensions, with the papillae perfectly shaped and the horizontal ridge contour maintained. (v) A follow-up radiograph shows stable marginal bone levels.

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Clinical Case Studies

clinical case 3 Immediate and deferred peri-implant soft tissue conditioning in a case of immediate prosthetic treatment of postextraction implants in the esthetic zone

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Fig 9-10 (a to h) The patient underwent surgery and orthodontic treatment as a child for left-sided labiopalatoschisis and subsequently underwent rehabilitation with a mixed tooth- and implant-supported partial denture in the maxillary left incisor and canine area. Fourteen years after this rehabilitation, which is still in good condition, it has become necessary to treat the maxillary right incisor and canine area, where the teeth are affected by advanced root resorption. Given the available bone volume, evaluated in 3D by means of a CBCT scan, immediate postextraction placement of two implants in the maxillary right central incisor and canine sites is planned, followed by immediate prosthetic treatment of the same sector. The advantage of immediate soft tissue conditioning is the possibility of preserving the soft tissue scalloping around the teeth to be extracted. (i and j) A diagnostic wax-up allows the shape of the restoration to increase symmetry with the left side of the arch. (k) A provisional restoration to be rebased with palatal access holes is then obtained from the diagnostic wax-up. (l) The provisional restoration will also be used as a surgical template, and its accurate repositioning will be facilitated by a thermoformed template.

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clinical case 3 (cont)

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Fig 9-10  (cont) (m to p) Implant sites are prepared in the extraction sockets of central incisor and canine, following a prosthetically guided axis that allows a screw-retained restoration to be prepared. After inserting the implants (SLActive Bone Level Tapered 4.1 × 14 mm, Straumann) with a torque greater than 35 Ncm, two titanium provisional abutments are connected and joined to the provisional restoration with self-curing composite resin. After the resin has cured, the provisional restoration is removed from the oral cavity. (q to s) The provisional restoration is finished by adding composite resin to create a perfect transition line between the titanium abutment and the resin provisional restoration. The aim of the provisional restoration is to seal the extraction sockets, providing mechanical support to the papillae and allowing immediate peri-implant soft tissue conditioning. (t and u) While the dental technician is finishing the provisional restoration, the gap between the implants and socket walls is filled with deproteinized bovine bone in a collagen matrix (Bio-Oss Collagen) to facilitate tissue volume maintenance. The socket of the maxillary right lateral incisor is also filled with the same biomaterial.

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Clinical Case Studies

clinical case 3 (cont)

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Fig 9-10  (cont) (v to x) The provisional restoration is then screwed to the implants and tightened to a torque of 35 Ncm. Clinical and radiographic follow-ups show that the provisional restoration is an accurate fit. (y to aa) Eight weeks later, further provisional restoration rebasing is carried out after slightly increasing the gingival scalloping using a rounded diamond bur. (bb) The freshly abraded soft tissues are isolated with polytetrafluoroethylene (PTFE) tape so that the composite resin can be applied in a dryer environment. (cc) Slight swelling caused by soft tissue compression is evident after repositioning the provisional restoration. (dd) It is useful to create a partial model in order to create customized impression transfers. Binding with dental floss helps position the material.

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clinical case 3 (cont)

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Fig 9-10  (cont) (ee and ff) Preparation of the partial model does not require a full impression but simply an index created by connecting two impression transfers to the implants and joining them using rigid occlusal registration material (Ramitec, 3M ESPE). (gg to ii) The provisional partial denture is screwed to the previously prepared model, and the provisional restoration emergence profile is recorded by injecting silicone. After removing the provisional restoration, the impression transfers are connected and rebased with light-cured flowable composite. (jj to ll) The resulting customized transfers are then used to take a final impression, which records soft tissue conditioning at the implant and intermediate pontic sites.

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Clinical Case Studies

clinical case 3 (cont)

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Fig 9-10  (cont) (mm and nn) A definitive metal-ceramic partial denture is produced by adding a ceramic coating to a chrome-cobalt structure produced using CAD/CAM technology (CARES System, Straumann). The prosthetically guided implant placement approach adopted from the initial planning stage means that a screw-retained prosthetic mesostructure can easily be prepared. (oo to rr) Modeling of the prosthetic device allows for diastemata to match the original dentition and the contralateral prosthesis. The emergence profiles at the implant abutment and intermediate tooth sites provide the soft tissues with satisfactory support. (ss and tt) The soft tissues have been well conditioned, and the prosthesis is decontaminated with chlorhexidine gel in preparation for placement.

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nine  Peri-implant Soft Tissue Conditioning Using Restorations

clinical case 3 (cont)

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yy Fig 9-10 (cont) (uu to zz) The prosthesis is connected to the implants and tightened to a torque of 35 Ncm. The access holes are sealed with PTFE tape and flowable composite. Clinical and radiographic follow-ups show that the partial denture is a good fit. (Surgery and prosthetic rehabilitation by Dr P. Casentini; laboratory procedures by Mr A. Giacometti.)

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Clinical Case Studies

clinical case 4 Immediate and deferred conditioning of peri-implant soft tissues in a case of immediate full-arch loading in the maxilla

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Fig 9-11  (a to h) The patient requires treatment because she is not happy with the appearance of her 15-year-old metal-ceramic maxillary rehabilitation. The prosthetic abutments show gingival recessions, secondary caries, periapical lesions, reconstructions with large cast posts, and previous apicectomies. The right first molar, disconnected from the previous rehabilitation, has already been extracted because it shows signs of mobility and is affected by endodontic and periodontal problems. The residual maxillary tooth abutments were not considered reliable enough for a new tooth-supported rehabilitation, except for the left first molar, which was kept. The more recent tooth- and implant-supported mandibular restorations do not require any type of intervention. In order to offer the patient a new rehabilitation that will improve her appearance and offer long-term reliability, a fixed rehabilitation is planned, supported by four implants evenly distributed throughout the arch. Given the favorable bone volume and CBCT results, the option of immediate implant loading with a fixed provisional restoration is suggested. The advantages of this method are that it allows immediate soft tissue conditioning by a provisional restoration and meets with the patient’s approval. (i to k) A 3D volumetric CBCT scan confirms the feasibility of placing implants in both lateral incisor sites as well as two angled implants in the right second premolar and left first premolar sites. The examination reveals that implants of appropriate length (14 mm) can be inserted in bone tissue of normal density that presumably offers good primary stability. This information also confirmed the possibility of performing an immediate implant loading procedure.

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clinical case 4 (cont)

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Fig 9-11  (cont) (l to n) Presentation software was used to outline the potential arrangement of the anterior maxillary teeth to improve their shape and reduce the patient’s gummy smile. The digitally designed smile was used as a basis for a diagnostic wax-up and for modeling of the prosthetic restoration teeth by the dental technician. (o to s) After extraction of the remaining teeth with the exclusion of the left first molar, four implant sites are prepared using a flapless approach. The implants (Bone Level Tapered, Straumann) in the lateral incisor sites (3.3 × 14 mm) are placed at a normal angle, while those in the right second premolar and left first premolar sites (4.1 × 14 mm) are angled distally by 30 degrees. All the implants show satisfactory primary stability with an insertion torque greater than 35 Ncm. Straight and angled permanent abutments (Screw-retained Abutment, Straumann) are then connected to the implants and tightened to 35 Ncm. Titanium copings are then connected to the abutments and joined to the provisional restoration using a self-curing resin, preserving the correct occlusal arrangement. The extraction sockets are then filled with Bio-Oss Collagen to prevent soft tissue collapse.

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Clinical Case Studies

clinical case 4 (cont)

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Fig 9-11  (cont) (t to x) Twenty-four hours later, once the provisional restoration has been finished by the dental laboratory, it is connected to the implants by means of four screws tightened to 15 Ncm. Occlusal balancing allowed uniform contacts to be achieved, maintaining the previous vertical dimension demonstrated by the presence of the maxillary right first molar. The clinical follow-up shows a good relationship between the restoration and soft tissues and a better-looking smile. The postsurgical swelling has gone down, and the soft tissues have healed quickly because the surgery was performed without access flap elevation. (y to aa) Eight weeks later, the provisional restoration is further rebased with the aim of increasing gingival scalloping and improving the morphology of the anterior teeth. After removing the provisional restoration, gingival scalloping is enhanced by removing tissue using a rounded diamond bur.

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nine  Peri-implant Soft Tissue Conditioning Using Restorations

clinical case 4 (cont)

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Fig 9-11  (cont) (bb) Flowable composite is added after isolating the tissues with PTFE tape. (cc) Rebasing is performed in two steps, reconditioning first the right side of the provisional restoration and then the left side. (dd and ee) Four weeks after rebasing the provisional restoration, a final impression is taken using a customized impression tray. The transfers are connected to the permanent abutments, which remain in place after implant positioning. The impression is therefore taken from the abutments and not the implants. (ff and gg) The impression transfers are connected by dental floss and then joined together using a rigid polyether material used for occlusal registration (Ramitec, 3M ESPE). (hh and ii) This procedure can reduce the risk of the impression, which is taken with another polyether (Impregum, 3M ESPE), being inaccurate.10

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Clinical Case Studies

clinical case 4 (cont)

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Fig 9-11  (cont) (jj to oo) After recording the occlusion and facebow, the provisional restoration is removed from the oral cavity and connected to the master cast to allow accurate mounting on the articulator.

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nine  Peri-implant Soft Tissue Conditioning Using Restorations

clinical case 4 (cont)

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Fig 9-11  (cont) (pp to ww) Before delivering the provisional restoration to the patient, several silicone templates are prepared, including a gingival template to reproduce the soft tissue conditioning obtained using the provisional restoration. This template allows the technician to accurately reproduce the transition area between the restoration and soft tissues.

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Clinical Case Studies

clinical case 4 (cont)

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Fig 9-11  (cont) (xx and yy) The prosthesis is then connected to the implants and tightened to a torque of 35 Ncm after decontamination with chlorhexidine gel. The access holes are sealed with PTFE tape and flowable composite. (zz and aaa) Intraoral and radiographic follow-up views shows that the partial denture is well adapted. (bbb to ddd) Extraoral views show the esthetic appearance of the implant-supported prosthetic rehabilitation. (Surgery and prosthetic rehabilitation by Dr P. Casentini; laboratory procedures by Mr A. Giacometti.)

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clinical case 5 Immediate soft tissue conditioning in the mandibular anterior region following immediate postextraction computer-guided placement and loading of multiple implants

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Fig 9-12  (a) A patient presented for treatment complaining of dental mobility and gingival bleeding in the mandibular anterior region. (b) The teeth show periodontal attachment loss and grade 2 mobility with severe horizontal bone resorption. (c and d) A 3D CBCT scan is performed with a view to computer-aided diagnostic and therapeutic procedures. A 3D volumetric rendering shows six teeth in the anterior region (yellow) and their corresponding marginal bone levels, with horizontal resorption exacerbated by a vertical component at the canines. Two buccal cortical bone fenestrations are evident on the left lateral incisors and canines. (e and f) The six teeth are extracted virtually, revealing the size of the sockets and the thinness of the cortical bone. (g and h) A prosthetic mock-up is then created with a view to resolving the crowding of the natural teeth by simulating six aligned crowns.

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Clinical Case Studies

clinical case 5 (cont)

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Fig 9-12  (cont) (i and j) It is planned to support the prosthetic rehabilitation by placing implants in both canine, the right central incisor, and the left lateral incisor sites, using implants with diameters measuring 4 mm on the canines and 3.25 mm on the incisors and lengths of 13 mm in all sites, with an internal hexagon-shaped connection (T3 Certain Tapered, Zimmer Biomet). (k to n) Dedicated implant surgery planning software (Simplant, Dentsply Sirona) simulates prosthetically guided positioning, with the implant axes emerging between the incisal margin and the lingual surface of the crowns. (o and p) The software uses this as a basis for simulating a surgical template (SurgiGuide, Dentsply Sirona) that is tooth-supported in the posterior sectors, with surgical preparation sleeves at the implant sites. (q and r) Once the treatment plan has been approved, a surgical template is prepared, faithfully replicating the setup planned on the computer.

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clinical case 5 (cont)

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Fig 9-12 (cont) (s to u) In the laboratory, the six anterior teeth, canine to canine, are extracted on the master cast, and then a surgical template is positioned to allow laboratory analogs of the implants to be positioned by inserting implant mounts in the sleeves. (v to x) This will make it possible to mill titanium posts and prepare an acrylic resin provisional restoration. A provisional restoration will also be fabricated to replace the left first premolar, which will be extracted during surgery; an immediate postextraction implant with gradual loading will be placed in its site. The reference planes for this provisional restoration are the buccal gingival margin of the natural teeth as the crown margin and 3 mm apical to the buccal gingival margin as the titanium abutment shoulder position. (y) After performing local anesthesia by means of a plexus block with 4% articaine and adrenaline 1:100,000, the teeth are luxated and extracted, taking special care to safeguard cortical bone integrity. (z) A SurgiGuide template is then positioned, and the implants are placed following a computer-guided implant site preparation protocol using dedicated equipment (Navigator, Zimmer Biomet).

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Clinical Case Studies

clinical case 5 (cont)

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Fig 9-12  (cont) (aa) To allow accurate housing of the titanium abutments, a full-thickness flap is elevated within the structure of the adherent gingiva without crossing the mucogingival junction. (bb) The residual bone-implant gaps and sockets not planned for implant placement are filled with bovine-derived bone (Bio-Oss), with the aim of preserving ridge volume. (cc) Provisional resin crowns are then positioned, and the soft tissues are sutured using resorbable material (polyglycolic acid 5-0) to promote healing and soft tissue maturation guided by the prosthetic emergence profiles. (dd) Radiographs taken after surgery show accurate implant positioning, perfect fit of the titanium abutments, and filling of the extraction sockets with biomaterial. (ee) Clinical view 4 months after surgery. Good intraoperative management of the soft tissues, with maintenance of all of the keratinized tissue and maturation guided by immediate provisional restorations, as well as bone-implant gap filling combined with ridge preservation procedures have produced a well-proportioned, scalloped gingival profile and interdental papillae that perfectly fit the prosthetic margins. The papillae completely fill the interproximal embrasures, and stable alveolar ridge volume has been maintained both horizontally and vertically. (ff) When an impression is taken to prepare a definitive restoration, the titanium abutments are surrounded by an ample band of keratinized tissue that will ensure long-term peri-implant tissue health.

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nine  Peri-implant Soft Tissue Conditioning Using Restorations

clinical case 5 (cont)

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hh Fig 9-12  (cont) (gg) A metal-ceramic prosthesis is then prepared with seven teeth, extending from the left first premolar to the right canine. (hh) A final clinical view shows ideal adaptation of the soft tissues to the definitive crowns and an excellent functional and esthetic outcome. (ii) A final radiograph shows stable marginal bone levels, with maintenance of the interimplant bone volume and biomaterial still partially present within the socket to compensate for physiologic postextraction remodeling.

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clinical case 6 Immediate conditioning of peri-implant soft tissues with a customized healing screw in an immediate postextraction implant

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b Fig 9-13 (a to c) The first premolar has a vertical root fracture and must be extracted. Tooth avulsion and simultaneous placement of an immediate postextraction implant are planned. Because the patient does not have any esthetic requirements, the soft tissue profile will be maintained by means of a customized healing screw in this case.

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Clinical Case Studies

clinical case 6 (cont)

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Fig 9-13  (cont) (d and e) After atraumatic tooth avulsion, an implant site is prepared, and an implant (Bone Level Tapered 4.1 × 12 mm) is immediately placed. (f and g) The implant is positioned centrally in the socket, and the gaps between the implant and socket wall are filled with a heterogenous graft (Bio-Oss Collagen). (h) After the gaps are filled, a temporary titanium abutment is connected to the implant. (i to m) Positioning of PTFE tape fragments separates the provisional abutment from the soft tissues and controls bleeding. Adding flowable composite around the provisional abutment creates a customized healing screw that can be finalized outside the oral cavity and faithfully reproduces the extraction socket contour.

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clinical case 6 (cont)

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Fig 9-13  (cont) (n and o) Clinical follow-up 12 weeks later, when osseointegration is complete, shows good maintenance of gingival scalloping and socket profile. (p and q) The mucosal tunnel and successfully maintained gingival contour are accurately transferred to the laboratory using a customized transfer. (r) The dental technician can then prepare a screw-retained crown using a prefabricated titanium base (Variobase, Straumann), to which a zirconia-ceramic crown is bonded. (s to u) Different views of the prosthesis show the accurate emergence profile and the well-positioned screw access.

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Clinical Case Studies

clinical case 6 (cont)

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Fig 9-13  (cont) (v to y) The final clinical and radiographic follow-up shows that the prosthesis is well integrated in the surrounding tissues, and the extraoral appearance is favorable. (Surgery and prosthetic rehabilitation by Dr P. Casentini; laboratory procedures by Mr A. Giacometti.)

clinical case 7 Deferred peri-implant soft tissue conditioning with a screw-retained provisional restoration

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Fig 9-14  (a to c) It is not always possible to perform immediate conditioning using a provisional crown. In this case, the implant has been placed in a submerged position to await guided bone regeneration (GBR) and soft tissue augmentation by means of a connective tissue graft (see Fig 8-18 for the surgical stages of the case). When a preliminary impression is taken not long after reopening by means of a small mesiodistal linear incision, the tissues are not conditioned, except by the presence of the healing screw.

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clinical case 7 (cont)

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Fig 9-14  (cont) (d to f) In this case, in addition to the soft tissue conditioning, the mesiodistal gap between the two central incisors had to be redistributed. This goal was achieved by making an additive feldspathic ceramic veneer on the mesial aspect of the left central incisor. (g and h) Provisional restoration contouring must consider two different, apparently conflicting needs: The provisional restoration must not compress the surrounding soft tissues excessively; and the provisional restoration should have the same buccal dimensions as the adjacent tooth and therefore the same cervical emergence profile. These objectives are achieved in the following two ways: (1) In the deepest area, ie, the first few millimeters above the implant platform, the provisional restoration displays a cylindrical profile. This prevents the deep peri-implant connective tissue from being overly compressed. (2) In more superficial areas, a correct buccal shape is achieved for the provisional restoration (with a view to achieving good symmetry with the adjacent tooth) by means of a buccal overlap that will subsequently be filled incrementally with successive applications of flowable composite at 2-week intervals. A screw-retained provisional restoration certainly facilitates soft tissue conditioning and provisional restoration management in general. For example, it would be difficult to remove the cement from the overlap with a cemented restoration. Another advantage of screw-retained restorations is the opportunity to perform progressive tightening during placement. It is therefore essential to plan an implant axis that is compatible with a screw-retained restoration at the implant planning and positioning stages. (i to l) After isolating the field using rubber dam, adhesive cementation of a thin additive veneer is completed on the left central incisor. A provisional screw-retained crown is then placed on the implant in the right central incisor site.

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Clinical Case Studies

clinical case 7 (cont)

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Fig 9-14  (cont) (m to p) A couple of weeks after placing the provisional crown, the active stage of peri-implant soft tissue conditioning begins. After removing the crown, the implant internal cavity is decontaminated with chlorhexidine gel, and a healing screw is positioned to prevent tissue collapse. Airborne-particle abrasion is performed on the crown, followed by application of a bonding agent and addition of light-cured flowable composite. This procedure is repeated two to three times at 2-week intervals until the desired profile is achieved. (q and r) The aim of peri-implant soft tissue conditioning is to gradually compress the soft tissues to achieve a gingival morphology that is symmetric with that of the contralateral side from both buccal and occlusal viewpoints. (s to u) After making additional changes to the provisional restoration, it is important to transfer the exact tissue shape to the laboratory on the master cast. This is achieved by customizing the impression transfer. The provisional crown is connected to a laboratory analog and embedded in a small amount of impression material. After curing, the shape of the provisional restoration remains impressed in the material. A laboratory analog is connected, and flowable composite is injected and light cured.

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clinical case 7 (cont)

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bb Fig 9-14 (cont) (v to y) The subgingival aspect of the impression transfer is now the same shape as the provisional prosthesis and allows accurate reproduction of the peri-implant mucosa in the final impression and thus on the master cast on which the definitive crown will be prepared. (z and aa) Comparing the initial profile of the provisional crown with that of the definitive crown, which is a replica of the modified provisional crown, clearly demonstrates the significant soft tissue conditioning achieved. (bb and cc) The case is finalized by means of a zirconia-ceramic crown screwed directly onto the implant. The crown is produced by direct ceramic coating of a custom zirconia abutment produced using CAD/CAM.

cc

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Clinical Case Studies

clinical case 7 (cont)

dd

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Fig 9-14  (cont) (dd and ee) The restoration blends in well with the surrounding hard and soft tissues as well as the patient’s smile. Note the symmetric gingival scalloping between the central incisors (see Fig 8-18 for additional posttreatment photographs of this case). (Surgery and prosthetic rehabilitation by Dr P. Casentini; prosthesis by Mr A. Schoenenberger and Mr G. Voce.)

clinical case 8 Conditioning interdental papillae when treating agenesis of a maxillary lateral incisor

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Fig 9-15  (a and b) A 20-year-old man with unilateral agenesis of the maxillary right lateral incisor underwent fixed orthodontic treatment during adolescence with the aim of opening the space. A canine-to-canine reinforced composite Maryland bridge was used for orthodontic retention and prosthetic rehabilitation. At the time of examination, the Maryland bridge is showing evident signs of wear. The patient requires a definitive prosthetic solution and simultaneous removal of the Maryland bridge. The possibility of placing an implant is therefore considered. (c and d) Clinical examination reveals limited mesiodistal space at the lateral incisor site and a horizontal ridge deficiency that is evident upon removal of the Maryland bridge.

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clinical case 8 (cont)

5.06 mm e

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Fig 9-15  (cont) (e) A concavity is evident in the ridge at the mucogingival junction. (f) Radiography shows an extremely reduced mesiodistal gap due to the proximity of the central incisor and canine root surfaces, which are approximately 5 mm apart at ridge level. (g and h) A surgical template is created on the plaster working cast to guide the implant placement axis buccopalatally and mesiodistally. (i) Due to the reduced mesiodistal space caused by the natural teeth being too close together, there is a definite possibility of interproximal bone resorption because it is not possible to respect the rule of leaving at least 1.5 to 2 mm between tooth and implant. This bone resorption would cause the interdental papillae to lose height. A flap is therefore designed that does not require a ridge or intrasulcular incision to ensure the papillae are not detached. A palatal marginal incision is made, connected by two vertical releasing incisions that diverge to the mucogingival junction and then run parallel in the alveolar mucosa. The resulting flap is raised at full thickness up to the mucogingival junction and then half thickness, and then the bone plate is denuded. (j) The implant site is created, following the axis indicated by the surgical template, which leads to a bone fenestration in the apical third due to the buccopalatal concavity in the ridge. (k) Placement of a tapered titanium implant measuring 3.25 mm in diameter and 13 mm in length (Osseotite Certain Tapered, Zimmer Biomet) reveals that the threads are exposed at the bone fenestration site.

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Clinical Case Studies

clinical case 8 (cont)

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Fig 9-15  (cont) (l and m) The ridge deficiency is managed using a biomaterial (Bio-Oss) mixed with homologous fibrin glue (Tisseel, Baxter) and protected by a resorbable collagen membrane (Bio-Gide, Geistlich). (n and o) The flap is then passively repositioned and sutured with a horizontal mattress suture on the ridge and a set of simple interrupted sutures on the releasing incisions using polyvinylidene fluoride 5-0 (Resopren, Resorba). (p) A radiograph taken after surgery shows perfect implant positioning with no impact on the lamina dura of the two adjacent teeth and preservation of the interproximal bone peaks. (q and r) Three months later, the second stage of surgery is performed by making a small incision that does not involve the papillae to allow a healing abutment to be screwed in place while preserving the gingival anatomy in terms of horizontal thickness and vertical height. A healing abutment that has the correct diameter for the implant and does not compress the interproximal tissues is chosen. (s and t) After taking an impression 2 weeks later, the first step is to tighten a definitive titanium post in place and then cement a provisional resin crown, seeking to move the interdental papillae coronally by applying a small amount of compression. (u) A follow-up radiograph shows stable marginal bone levels. (v) A frontal view shows excellent integration of the prosthesis with the gingival anatomy.

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clinical case 8 (cont)

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Fig 9-15 (cont) (w) Posttreatment view of the definitive ceramic crown, showing perfect integration with the soft tissues, presence of the interdental papillae, and an ample band of keratinized tissue. (x) A radiograph shows bone stability at the interproximal peaks. (y) A follow-up image 3 years after loading reveals stable soft tissues. (z and aa) Clinical and radiographic 9-year follow-up images show a stable outcome in terms of esthetics and function. Good flap design and accurate 3D implant positioning made it possible to maintain soft tissue integrity. In particular, the interdental papillae are present and have been maintained in the long term, supported by intact interproximal bone peaks despite the reduced mesiodistal space.

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Clinical Case Studies

clinical case 9

Deferred peri-implant soft tissue conditioning using different techniques in a case of multiple missing maxillary teeth

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g Fig 9-16  (a to f) In this case, the patient wishes to rehabilitate the left side of the maxilla, which is currently fitted with a very old metal-ceramic fixed prosthesis supported by the canine, first premolar, and second molar. The first premolar needs to be extracted because of a fracture, and the long-term prognosis of the canine and second molar is doubtful. The patient’s smile line can be classified as medium-high, with full exposure of the surrounding teeth and soft tissues when she smiles broadly. The preliminary treatment plan includes removal of the partial denture, extraction of the fractured premolar root, and temporary reuse of the old partial denture as a provisional prosthesis. At this point, it will be possible to more accurately assess the condition of the canine and second molar, take a 3D radiograph, and draw up a definitive treatment plan. (g) From an esthetic viewpoint, the parameters to be corrected to achieve optimum esthetic characteristics can be summarized as follows: (1) Lengthening the incisal margins of the central incisors in accordance with the patient’s occlusion to improve the clinical crown width-length ratio to nearly 80%. This would also make it possible to restore the proper degree of convexity to the incisal margins, which are too straight. (2) Correcting the gingival margin position at the left lateral incisor site. The emergence profile at this site, which corresponds to the mesial cantilever of the metal-ceramic fixed prosthesis, is more apical than that of the contralateral lateral incisor. (3) Correcting the horizontal esthetic defect in the root area of the left lateral incisor (white dotted lines). The presence of a concavity in the alveolar ridge at the left lateral incisor site, linked to the long-standing edentulism, is probably the cause of the elongated clinical crown. (4) Lengthening of the clinical crown of the left first premolar, which currently looks very reduced.

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clinical case 9 (cont)

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Fig 9-16  (cont) (h and i) The first treatment step, as already mentioned, is to extract the fractured left first premolar and reposition the old partial denture as a provisional prosthesis. Prosthesis removal also makes it possible to establish the absence of prosthetic stability around the canine, which was previously treated with a cast post. The second molar lacks an opposing tooth and is affected by a periapical endodontic lesion. (j) The lateral incisor (LI), first premolar (FP), and first molar (FM) sites were selected as implant sites based on a 3D radiographic examination following extraction of the first premolar. (k and l) At the lateral incisor site, affected by long-standing edentulism, the bone volume is sufficient for prosthetically guided placement of a small-diameter implant. This must be combined with GBR to correct the horizontal esthetic defect. (m and n) Buccal cortical bone is still identifiable in the first premolar site approximately 4 weeks after extraction. The site is compatible with deferred postextraction placement of a standard-diameter implant and filling of the gap between the implant and buccal cortical bone. (o and p) Significant ridge width is present in the first molar site, compatible with placement of a large-diameter implant, but the bone height is low (6 mm) inferior to the maxillary sinus. A probable mucus retention cyst is present in the maxillary sinus. The plan for this site is to place an implant and at the same time elevate the maxillary sinus floor via the ridge and remove the cyst.

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Clinical Case Studies

clinical case 9 (cont)

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Fig 9-16  (cont) (q) Following clinical and radiographic evaluations, the following treatment sequence is defined: (1) Maintenance of the old partial denture as an initial provisional prosthesis. (2) Placement of implants in sites the canine, first premolar, and first molar sites using a submerged technique while also performing hard and soft tissue augmentation techniques. (3) Reopening the site and taking an impression to make an implant-supported provisional restoration. (4) Extracting the remaining canine and second molar and simultaneously placing an implant-supported provisional prosthesis with preliminary peri-implant soft tissue conditioning. (5) Modifying the provisional prosthesis for secondary conditioning of the peri-implant tissues and taking impressions for preparation of a definitive implant-supported prosthesis. (6) Fitting the definitive screw-retained implant-supported prosthesis. (r to t) At the lateral incisor site, placement of an implant (Bone Level Tapered 3.3 × 12 mm) is combined with a GBR technique using a collagen membrane (Bio-Gide) secured with titanium pins (SuperTack, MC Bio), which is used to stabilize a deproteinized bovine bone graft (Bio-Oss). Soft tissue thickness is also increased by applying a connective tissue graft taken from the palate. (u) A deferred postextraction implant (Bone Level Tapered 4.1 × 12 mm) is positioned in the first premolar site, and the gap is filled using the same biomaterial.

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clinical case 9 (cont)

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Fig 9-16  (cont) (v) At the first premolar site, after preparing an implant site 1 mm shorter than the cortical bone height, the maxillary sinus floor is fractured using a hollow-headed cylindrical osteotome as a depth stop (Straumann). (w) The implant is then placed (Bone Level 4.8 × 8 mm, Straumann), and the maxillary sinus cyst is aspirated by creating a small secondary access at the most apical point. The flap is then passively advanced and sutured. The old partial denture is relieved to avoid applying excessive pressure to the tissues and re-cemented. (x and y) Six months after the implant placement, the site is reopened by making small linear incisions. (z and aa) After another week, impressions can be taken to make a provisional implant-supported prosthesis. (bb and cc) The shape of the contralateral teeth is digitally re-created using a photograph and the Keynote computer program. This graphic reference is useful during communication with the dental technician, who will create a wax-up of the edentulous sector. The digital design reveals a need to extend the length of the clinical crowns in relation to the current soft tissue position. The dental technician will take this need into account when preparing the provisional restoration, which will be obtained after removing plaster on the cast.

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Clinical Case Studies

clinical case 9 (cont)

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Fig 9-16  (cont) (dd) The cast prepared using the preliminary impression represents the baseline for peri-implant soft tissue conditioning because until that point the tissues have not been conditioned in any way. Conditioning must be carried out with a view to the following requirements: (1) Conditioning of the implant sites (green arrows). As stated previously, these crowns must be elongated so that they are the same length as the contralateral teeth. To achieve this desired effect, the dental technician will have to perform subtractive scalloping on the plaster cast, and the provisional restoration will feature a slight overlap in this area. (2) Avoiding excessive tissue compression (blue arrows). As mentioned in case 7 (Fig 9-14), excessive compression must be avoided. To this end, no changes will be made to the shape in the most apical portion of the peri-implant tissues, which will maintain their cylindrical shape. (3) Conditioning of the canine site. The canine tooth root will be extracted immediately prior to fitting the provisional restoration. At this site, the provisional restoration must be shaped to include a buccal overlap on one side to achieve the correct crown morphology. At the same time, the provisional restoration will be ovate at the root extraction site in order to create an ovate pontic. (4) Conditioning of the second premolar pontic site (pink arrows). In this site, the shape of the edentulous ridge is deficient, but this can be remedied by conditioning with the provisional restoration. Combining soft tissue ridge splitting (inset, black dotted line) with an ovate provisional restoration is the ideal technique for making additional changes to the edentulous ridge shape at this site. (ee and ff) The provisional prosthesis therefore includes a combination of areas of overlap, ovate pontics, and a cylindrical profile near the implants.

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clinical case 9 (cont)

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Fig 9-16  (cont) (gg and hh) To correct the edentulous second premolar site, a soft tissue ridge-splitting technique will be performed by making a midcrestal incision and two releasing incisions that will allow the buccal and palatal sites to be separated. An ovate pontic will be placed in the resulting space. (ii and jj) After extraction of the two tooth abutments supporting the old partial denture, the canine extraction socket is filled with a low-resorption biomaterial (Bio-Oss). It is advisable to maintain crestal bone volume at this site to achieve a natural emergence profile for the intermediate ovate pontic on the provisional restoration, which will seal the socket. At the second premolar pontic site, a combination of a soft tissue ridge-splitting technique and an ovate provisional restoration is used to improve the ridge shape. (kk to mm) At the 4-week clinical follow-up, removal of the provisional restoration reveals successful initial conditioning of the peri-implant soft tissues. An occlusal view reveals that the volume has been maintained at the canine site, which underwent ridge preservation, and there has been a favorable change in ridge profile at the second premolar site, which was treated by soft tissue ridge splitting. (nn to pp) The second stage of soft tissue conditioning involves filling the buccal overlaps that were used initially to avoid overcompressing the soft tissues. After airborne-particle abrasion and bonding treatment, the subgingival portion of the provisional prosthesis is adapted with the addition of light-cured flowable composite. Before reconnection with the implants, the provisional restoration is polished and decontaminated with chlorhexidine gel.

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Clinical Case Studies

clinical case 9 (cont)

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Fig 9-16  (cont) (qq to tt) Once peri-implant tissue conditioning is complete, it is reproduced in the final impression using the custom transfer technique. For accurate replication of the tissues, the custom transfers must reproduce the pontic as well as the peri-implant tissues.

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clinical case 9 (cont)

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yy Fig 9-16  (cont) (uu to yy) Prosthetically guided implant placement is used in preparation for a screw-retained metal-ceramic partial denture with well-positioned screw access holes, produced using CAD/CAM (CARES System). Peri-implant soft tissue conditioning achieved using the provisional prosthesis allowed a favorable relationship between the soft tissues and the restoration.

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clinical case 9 (cont)

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Fig 9-16  (cont) (zz to ccc) Clinical and radiographic follow-up reveals good integration between the implant-supported restoration and the surrounding hard and soft tissues, including natural emergence profiles. (Surgery and prosthetic rehabilitation by Dr P. Casentini; laboratory procedures by Mr A. Schoenenberger.) (ddd) An esthetic analysis repeated after rehabilitation shows that the previous deficiencies have been corrected (compare with Fig 9-16g). (eee and fff) Favorable esthetic integration of the prosthetic rehabilitation is also evident in extraoral views.

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References 1. 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– 824. 2. De Rouck T, Collys K, Cosyn J. Single-tooth replacement in the anterior maxilla by means of immediate implantation and provisionalization: A review. Int J Oral Maxillofac Implants 2008;23:897–904. 3. Kan JY, Rungcharassaeng K, Lozada JL, Zimmerman G. Facial gingival tissue stability following immediate placement and provisionalization of maxillary anterior single implants: A 2- to 8-year follow-up. Int J Oral Maxillofac Implants 2011;26:179–187. 4. Ross SB, Pette GA, Parker WB, Hardigan P. Gingival margin changes in maxillary anterior sites after single immediate implant placement and provisionalization: A 5-year retrospective study of 47 patients. Int J Oral Maxillofac Implants 2014;29:127–134. 5. Finelle G, Lee SJ. Guided immediate implant placement with wound closure by computer-aided design/computer-assisted manufacture sealing socket abutment: Case report. Int J Oral Maxillofac Implants 2017;32:e63–e67.

6. Wittneben JG, Buser D, Belser UC, Brägger U. Peri-implant soft tissue conditioning with provisional restorations in the esthetic zone: The dynamic compression technique. Int J Periodontics Restorative Dent 2013;33:447–455. 7. Furze D, Byrne A, Alam S, Wittneben JG. Esthetic outcome of implant supported crowns with and without peri-implant conditioning using provisional fixed prosthesis: A randomized controlled clinical trial. Clin Implant Dent Relat Res 2016;18:1153–1162. 8. Hinds KF. Custom impression coping for an exact registration of the healed tissue in the esthetic implant restoration. Int J Periodontics Restorative Dent 1997;17:584–591. 9. Elian N, Tabourian G, Jalbout ZN, et al. Accurate transfer of periimplant soft tissue emergence profile from the provisional crown to the final prosthesis using an emergence profile cast. J Esthet Restor Dent 2007;19:306–314. 10. Hariharan R, Shankar C, Rajan M, Baig MR, Azhagarasan NS. Evaluation of accuracy of multiple dental implant impressions using various splinting materials. Int J Oral Maxillofac Implants 2010;25:38–44.

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Questions: 1. What are the characteristics of orthodontic movement, and what is its role in multidisciplinary treatment plans? 2. In what clinical situations and time frames can orthodontic therapy be used to develop an implant site? 3. What are the options for managing tooth agenesis in the esthetic zone?

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1|

 hat are the characteristics of orthodontic movement, W and what is its role in multidisciplinary treatment plans?

Orthodontic movement allows teeth to be moved in three spatial planes through forces applied to the clinical crowns that act on the periodontal ligament. Movements can be on a vertical plane (intrusion or extrusion) or lateral plane (translation, which may take the form of mesialization or distalization) when the orthodontic force passes through the tooth center of resistance. When the force passes through a point other than the tooth’s center of resistance, the resulting movements have a rotating component known as tipping (root or crown). The most reliable theory for explaining orthodontic movement is pressure-tension theory, according to which the system of forces brings about a change in cellular activity induced by chemical messengers. Pressure exerted on the periodontal ligament brings about a change in blood flow, resulting in the synthesis and release of chemical messages and activation of specialized cells. When gentle forces are used, osteoclasts are recruited on the pressure side with consequent bone resorption, while osteoblasts are recruited on the tension side, with consequent bone apposition (Fig 10-1). With this direct reabsorption pattern, the tooth moves with the bone rather than through the bone, which is what happens when heavy forces are applied, creating an area of hyalinization due to ischemia and aseptic necrosis.

a

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Due to its characteristics, orthodontic movement can also be used to improve the periodontal condition of the teeth. A wealth of literature is available on the orthodontic treatment of periodontally compromised teeth. Once periodontal infection has been controlled by appropriate causal therapy and satisfactory patient compliance has been achieved, orthodontic movement can be used to address the intrabony defects adjacent to abnormally migrated teeth (Fig 10-2). More specifically, there is no contraindication to moving a tooth within an intrabony defect that has undergone bone regeneration techniques. The option of achieving simultaneous tooth and bone movement may be useful in specific clinical situations in order to overcome anatomical issues. For example, an appropriate system of forces can be used to distalize a maxillary premolar in an edentulous area with extensive maxillary sinus pneumatization, in the process developing enough alveolar bone for implant insertion. In such situations, the tooth does not penetrate the maxillary sinus but moves together with its periodontal ligament and bundle bone, adapting the mesial wall of the sinus. No damage occurs to the tooth’s vascular and nerve bundle, which remains vital. At the same time, a site with enough bone volume for implant placement is created on the mesial aspect (Fig 10-3).

c Fig 10-1 Area of tension with bone apposition during orthodontic movement. (a and b) In a patient with agenesis of a maxillary canine, the lateral incisor is subjected to a mesial translation movement to open the necessary space. Pressure forces are created on the mesial surface of the root, while tension forces are created on the distal surface. On a radiograph, these appear as thickening and hypermineralization of alveolar bone in contact with the periodontal ligament. (c and d) In this case, there is insufficient space following extraction of a maxillary second premolar, so the first premolar is moved by translation in a mesial direction. Traction forces built up on the root surface, with consequent alveolar bone thickening. (Orthodontic treatment by Dr L. Gaveglio.)

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What are the characteristics of orthodontic movement, and what is its role in multidisciplinary treatment plans?

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Fig 10-2  (a) Patient with a 14-mm-deep periodontal pocket on the mesial aspect of the maxillary left central incisor and simultaneous abnormal tooth migration with opening of a diastema. (b) A radiograph reveals the severity of the intrabony defect. (c and d) After causal therapy and reassessment, regenerative periodontal surgery is performed through flap elevation with preservation of the papilla and grafting of bovine bone mixed with collagen (Bio-Oss Collagen, Geistlich). (e) Orthodontic treatment begins just 14 days after surgery, to intrude and mesialize the incisor. (f) One year after the end of interdisciplinary therapy, probing depths are normal, and the tooth is perfectly realigned and maintained in position by a resin-bonded splint. (g) A follow-up radiograph shows filling of the bony defect. (Orthodontic treatment by Dr L. Gaveglio.)

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Fig 10-3  Patient with distal edentulism of the left maxilla and extensive maxillary sinus pneumatization. (a and b) An initial stage of orthodontic movement involving distalization of the second premolar is followed by placement of an implant near the tuberosity for anchorage. (c) This allows the root to be translated in a distal direction, changing the sinus anatomy. (d and e) The original second premolar site retains sufficient mineralized bone tissue for placement of an implant, which is prosthetically loaded after 12 weeks. (f) Sufficient space was created to place a ceramic crown. (g) A follow-up radiograph taken 12 months after loading shows the stability of marginal bone levels. (Orthodontic treatment by Dr W. Manuzzi.) g

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2|

In what clinical situations and time frames can orthodontic therapy be used to develop an implant site?

Orthodontic treatment is an effective tool in a multidisciplinary treatment plan; in particular, combining orthodontic treatment with implant-supported prosthetic treatment is often essential to achieving a satisfactory end result. Orthodontic treatment can be included in the implant-supported prosthetic workflow within different time frames, depending on the clinical situation.

Orthodontic treatment in young patients who need implant therapy restoration when growth is complete

ment plays an essential role in maintaining enough space in the arch. Once growth is complete, it will then be possible to place an implant. The alveolar bone volume may have to be reconstructed because it usually undergoes a process of atrophy due to underdevelopment following non-eruption of permanent teeth (Fig 10-4). Another typical situation is early loss of teeth at a young age due to injury; also in such cases, orthodontic treatment performs the task of maintaining space in the arch (Fig 10-5).

Patients affected by agenesis are a typical example of this clinical situation. In this case, preliminary orthodontic treat-

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Fig 10-4  (a to d) Orthodontic treatment for agenesis of both maxillary lateral incisors. Interceptive treatment is performed when the patient is 11 years old. A functional mobile device is initially used to expand the arches and open the bite. A fixed orthodontic device is then used to align the teeth and guide the eruption of the two maxillary canines.

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Fig 10-4  (cont) (e and f) The treatment is put on hold to allow completion of growth when the patient reaches the age of 16, keeping the primary lateral incisors and using a resin-bonded splint to maintain space. (g to i) The patient is reexamined at the age of 20 years, and the space created by orthodontic treatment has been maintained. (j and k) Radiographs reveal that the roots of the central incisors and canines are parallel. (l to n) The resin-bonded splint is removed, and the two primary incisors are extracted to proceed with implant placement.

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Fig 10-4 (cont) (o to s) Clinical and radiographic images taken after treatment reveal an excellent esthetic and functional outcome. (Orthodontic treatment by Dr L. Gaveglio.)

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Fig 10-5  Interceptive orthodontic treatment while awaiting completion of growth. (a to d) This young patient lost the maxillary right central and lateral incisors due to injury, so orthodontic treatment is used to guide subsequent dental changes, restoring the correct mesiodistal space.

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In what clinical situations and time frames can orthodontic therapy be used to develop an implant site?

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Fig 10-5  (cont) (e and f) With orthodontic treatment complete, a resin-bonded prosthesis is constructed pending completion of growth, when implantsupported prosthetic restoration will commence. (Orthodontic treatment by Dr F. Verdecchia.)

Orthodontic treatment preliminary to implant placement in adults In patients who have finished growing and are therefore considered to be adults, orthodontic treatment often allows the creation of conditions that are more favorable to implant placement. A typical example is mesiodistal movement with the aim of increasing the available prosthetic space for a future implant-supported restoration (Fig 10-6). In other cases, there is sufficient space in the arch for the prosthesis, but there is not enough mesiodistal bone volume to place an implant. In this case, the goal of orthodontic therapy is mainly root movement in order to obtain enough space for implant placement (Fig 10-7). Conversely, orthodontic treatment is sometimes necessary to reduce an overly wide mesiodistal space (Fig 10-8). The result achievable through a combination of orthodontic treatment and implant placement should always be previewed at the treatment planning and preparation stage. The preview can be achieved traditionally using an orthodontic setup combined with a diagnostic wax-up (Fig 10-9) or by means

of digital techniques (Fig 10-10). Preview techniques optimize communication within the team and are also an excellent method of communicating with the patient. Preliminary orthodontic treatment is also indicated for realignment of the teeth adjacent to the implant site for esthetic purposes and to improve occlusion, which allows a better outcome for the entire implant-supported prosthetic rehabilitation (Fig 10-11).

Orthodontic treatment following implant placement In some cases, previously placed implants can be used as an orthodontic anchor for moving adjacent teeth. The purpose of these movements may be to optimize the mesiodistal space, which may be too large or too small, or improve the occlusion or esthetic alignment of adjacent teeth by extrusion and intrusion movements. In some cases, orthodontic movement subsequent to implant placement using an implantsupported prosthesis as an anchor may represent the final finishing stage of earlier orthodontic treatment.

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Fig 10-6  Preliminary orthodontic treatment to increase the mesiodistal prosthetic space. (a to d) Loss of mesiodistal space after traumatic avulsion of the maxillary right central incisor requires use of orthodontic treatment with a view to subsequent implant-supported prosthetic restoration. (e and f) Orthodontic treatment also made it possible to improve the occlusion, increasing contacts and restoring the correct incisal and lateral guidance. (See Fig 8-23 for full details of treatment of this patient. Orthodontic treatment by Dr S. De Luca.)

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In what clinical situations and time frames can orthodontic therapy be used to develop an implant site?

b

a

c

Fig 10-7  Preliminary orthodontic treatment to increase mesiodistal root space. (a to c) In this case, orthodontic treatment is indicated because the root space is insufficient (4 mm) to allow placement of implants in the maxillary lateral incisor sites, which were affected by agenesis. (See Fig 10-18 in the clinical case studies section for a full analysis of this case.)

a

b

c

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Fig 10-8 Orthodontic treatment to reduce mesiodistal space. (a to d) After poorly executed clinical crown lengthening to repair a fracture of the maxillary left lateral incisor, that tooth along with the adjacent teeth migrated to form a large and unsightly diastema between the left central and lateral incisors. Orthodontic diagnosis also revealed a tooth size discrepancy according to the Bolton analysis, with inconsistency between the dimensions of the arch and the teeth.

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ten  Orthodontic Development for Implant Sites

a

c

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d

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Fig 10-9 Traditional method of previewing treatment outcome of case shown in Fig 10-8. (a to e) The orthodontic setup allows the case to be planned in detail in terms of orthodontic treatment and implant-supported prosthetic restoration. To achieve a favorable outcome and compensate for the tooth-size discrepancy, it will be necessary to combine different treatments: orthodontic treatment to achieve accurate mesiodistal alignment; replacement of the maxillary left lateral incisor with an implant-supported prosthetic restoration; and additive veneers or direct composite restorations on the other incisors.

a

b

c

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Fig 10-10  (a to d) Digital preview of orthodontic and implant treatment by means of the Invisalign method. The proprietary ClinCheck system (Align Technology) predetermines and displays the mesiodistal prosthetic space to be occupied by the future implant-supported prosthetic restoration.

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What are the options for managing tooth agenesis in the esthetic zone?

a

b

Fig 10-11  Orthodontic and implant treatment plan. (a and b) Posttraumatic ankylosis of the maxillary central incisors has impaired the normal vertical and sagittal development of the incisive bone, with an impact on the alignment of adjacent teeth. A certain degree of extrusion and crowding can also be noted in the mandibular incisors. Before replacing the central incisors with osseointegrated implants, it is essential to carry out preliminary orthodontic treatment with the following goals: mesiodistal expansion of the incisive bone to make more space for restoration of the maxillary central incisors; extrusion and realignment of the maxillary lateral incisors; and intrusion and realignment of the mandibular incisors. (See Fig 3-15 for a full description of the case.)

3|

What are the options for managing tooth agenesis in the esthetic zone?

Agenesis is a dental anomaly characterized by the failure to form one or more primary or permanent teeth. The most frequently affected teeth, excluding the third molars, are the mandibular second premolars and the maxillary lateral incisors. The agenesis of the latter, which has a relatively high incidence, presents the clinician with various therapeutic

choices: (1) orthodontic treatment to maintain the space (Fig 10-12); (2) orthodontic treatment to open the space (Fig 10-13); (3) orthodontic treatment to create a prosthetic space (Fig 10-14); or (4) orthodontic treatment to close the space (Fig 10-15).

a

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Fig 10-12  Orthodontic treatment to maintain the space. (a) Young patient with bilateral agenesis of the maxillary lateral incisors. Orthodontic treatment with a fixed device creates dental alignment and maintains space in both sites affected by agenesis. (b and c) After orthodontic treatment, a resinbonded prosthesis is created with pontic teeth at the lateral incisor sites and adhesive tabs on the palatal surfaces of the central incisors and canines. (d) The resin-bonded prosthesis is cemented to simultaneously maintain orthodontic space and provide provisional rehabilitation.

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ten  Orthodontic Development for Implant Sites

e

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l Fig 10-12 (cont) (e) When the patient has finished growing, the case is reassessed. The resin-bonded prosthesis has performed its function to perfection, maintaining appropriate space for implant placement. Lack of development of the alveolar process has caused buccal concavity of the ridge at both of the future implant sites. (f to m) Horizontal bone regeneration is thus carried out using deproteinized bovine bone (Bio-Oss, Geistlich), homologous fibrin glue (Tisseel, Baxter), and a resorbable collagen membrane (Bio-Gide, Geistlich).

m

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What are the options for managing tooth agenesis in the esthetic zone?

n

o

p

Fig 10-12  (cont) (n and o) Six months later, two 3.25-mm-diameter, 14-mm-long titanium implants (T3 Tapered, Zimmer Biomet) can be placed in sufficient bone volume using a prosthetically guided procedure. (p) Intraoral image of the result with the implant-supported fixed prosthetic rehabilitation in place. (Orthodontic treatment by Dr W. Manuzzi.)

a

d

g

b

c

e

f

h

Fig 10-13  Orthodontic treatment to open the space. (a) Young adult patient with unilateral agenesis of the maxillary left lateral incisor. Eruption of the permanent teeth has partly closed the space between the central incisor and canine, and the mesiodistal diameter is now insufficient for implant placement, particularly at the apical level. The patient requires a single implant-supported rehabilitation. (b and c) Fixed orthodontic treatment is started to induce root tipping—mesial for the central incisor and distal for the canine—to open up the space and move the root apices apart. (d and e) Once a satisfactory degree of root parallelism has been achieved, implant surgery is performed. (f) Transmucosal healing. (g and h) Intraoral images showing the good esthetic integration of the implant-supported crown. (Orthodontic treatment by Dr W. Manuzzi.)

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ten  Orthodontic Development for Implant Sites

a

b

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e

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g

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Fig 10-14 Orthodontic treatment to create a prosthetic space. (a to d) Young adult patient with unilateral agenesis of the left lateral incisor. The mesiodistal space is insufficient for implant placement; the spatial dimensions are not the same as at the contralateral site, even at the occlusal level. (e to h) The purpose of orthodontic treatment is to create a space in the arch similar to that present at the right lateral incisor site, thereby creating symmetry and esthetic harmony. (i to k) At this point, a resin-bonded prosthesis is constructed with five adhesive tabs and a pontic tooth at the left lateral incisor site.

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What are the options for managing tooth agenesis in the esthetic zone?

l

m

n

Fig 10-14 (cont) (l) Paletal view of the resin-bonded prosthesis. (m and n) The posttreatment images show the excellent esthetic outcome, with perfect symmetry and well-proportioned gingival scallops. (Orthodontic treatment by Dr S. Re.)

a

b

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e

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Fig 10-15 Orthodontic treatment to close the space. (a and b) Patient with unilateral agenesis of the right lateral incisor, deep bite, and multiple gingival recessions. The multidisciplinary treatment plan requires a combination of periodontal plastic surgery, orthodontics, and prosthetic restoration. (c to h) During the first stage, multiple recessions are treated bilaterally in the mandible by means of coronal repositioning flaps and 3D collagen matrices (Mucograft, Geistlich).

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ten  Orthodontic Development for Implant Sites

i

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Fig 10-15 (cont) (i and j) Results on the right and left sides, respectively. (k to n) During the first stage of orthodontics, minimally traumatic corticotomies are carried out by means of the Piezocision procedure1 in both arches to speed up tooth movements. (o and p) Orthodontic movements are accelerated by an induced transient osteopenic state known as the regional acceleratory phenomenon. This is followed by active orthodontic treatment with opening of the bite, closure of spaces, movement of the maxillary right canine into the lateral incisor site, and remodeling of the canine into the shape of the lateral incisor.

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Clinical Case Studies

q

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Fig 10-15  (cont) (q to u) Once the spaces have been closed, periodontal plastic surgery is performed in order to move the free gingival margin of the right canine (in the lateral incisor site) coronally and thicken the gingival tissue of the entire maxillary anterior region by means of a 3D collagen matrix graft (Mucograft). (v to x) Treatment concludes with the creation of four ceramic veneers for the maxillary central and lateral incisor sites. The final clinical images and radiograph reveal the excellent esthetic and functional outcome. (Orthodontic treatment by Dr L. Gaveglio.)

Clinical Case Studies Figures 10-16 to 10-22 present clinical cases demonstrating orthodontic development techniques for implant sites.

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ten  Implant Site Orthodontic Development Techniques

clinical case 1 Interdisciplinary management of a growing patient with agenesis of the maxillary lateral incisors

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Fig 10-16  (a to c) Initial clinical and radiographic documentation for a 14-year-old patient. Note the bilateral agenesis of the permanent maxillary lateral incisors, delayed eruption of the permanent maxillary canines, and retention of the primary maxillary lateral incisors and canines. (d and e) The maxillary frenal pull is addressed prior to initiating orthodontic treatment. A frenotomy is performed by making a V incision, which is partially closed in the apical portion by means of a resorbable 5-0 suture (Resopren, Resorba), leaving the coronal portion to heal by second intention. (f) After 2 weeks, tissue healing is observed. (g) Further maturation takes place over the next 2 weeks. (h) The frenum disappears altogether after 8 weeks.

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Clinical Case Studies

clinical case 1 (cont)

i

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Fig 10-16 (cont) (i) Over the next 2 years, orthodontic treatment begins to bring the partially retained maxillary canines into the arch and simultaneously create space for the lateral incisors. (j and k) A resin-bonded prosthesis made of reinforced composite material with tabs on the palatal surfaces of the central incisors and canines is chosen to maintain the space. (l) A panoramic radiograph taken at the end of orthodontic treatment, when the patient is 17 years old, shows a satisfactory level of parallelism between the roots of the central incisors and canines and more than enough room to place implants in the edentulous sites. Implant surgery will be carried out when the patient has finished growing. (m and n) Clinical images of the maxillary anterior region after removal of the resin-bonded prosthesis when the patient is 19 years of age. (o and p) Tomographic images confirm the conspicuous buccopalatal ridge deficiency. Tooth agenesis leads to underdevelopment of the alveolar process because the eruption process fails to take place. Bone deficit at the maxillary lateral incisor sites is more pronounced on the buccal aspect given the presence of the palatal vault. Ridge augmentation is planned, with implant placement to follow 6 months later. (q) At the right lateral incisor site, a flap is created without involving the papillae by making two vertical releasing incisions, connected by a crestal incision.

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ten  Implant Site Orthodontic Development Techniques

clinical case 1 (cont)

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Fig 10-16  (cont) (r) The flap is detached, full thickness up to the mucogingival line and partial thickness apical to the line, with releasing incisions at the periosteal level to passively advance the flap. The bone surface is denuded, revealing insufficient horizontal thickness with a deep hollow in the alveolar mucosa. (s) A bovine-derived block graft (Bio-Oss Block, Geistlich) is shaped, soaked with recombinant platelet-derived growth factors (GEM 21S, Lynch Biologics), and then fixed to the buccal cortical bone with a retaining screw. (t) The graft is covered with bovine bone granules (Bio-Oss) mixed with homologous fibrin glue (Tisseel) to close all gaps with the recipient cortical bone. (u) The flap is passively repositioned and sutured with interrupted sutures at the releasing incisions and mattress sutures at the crestal incision (Resopren). (v and w) Radiograph and tomographic image showing the bone graft after surgery. (x to z) The same procedure is performed at the contralateral site (where the horizontal ridge deficiency is even more evident).

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Clinical Case Studies

clinical case 1 (cont)

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ii

Fig 10-16  (cont) (aa to dd) The same techniques and biomaterials are used. (ee to gg) Clinical image at the end of the surgical session, after 24 hours, and after 2 weeks, respectively. (hh and ii) Occlusal views at 2 weeks show that the soft tissues have healed perfectly.

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ten  Implant Site Orthodontic Development Techniques

clinical case 1 (cont)

jj

kk

ll

mm

nn

oo

pp

qq

Fig 10-16  (cont) (jj) Six months after surgery, the volume of the alveolar process has increased at both edentulous sites. (kk) At the time of implant placement, clinical images show an increased ridge profile with horizontal augmentation. (ll) A flap is elevated, following the same design used during the first surgery, to check the outcome of bone regeneration. (mm) The retaining screw head is exposed to remove the screw. (nn and oo) A titanium implant, 3.25 mm in diameter and 13 mm in length (T3 Certain Tapered, Zimmer Biomet), is placed using a surgical template to ensure accurate positioning. (pp) The flap is sutured in order to achieve healing by first intention. (qq) A radiograph shows that the implant is well positioned.

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Clinical Case Studies

clinical case 1 (cont)

rr

ss

tt

uu

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xx

yy

Fig 10-16  (cont) (rr to uu) The same procedure is performed simultaneously on the contralateral site, inserting an implant of similar size. (vv) Frontal view 4 months after implant placement. (ww and xx) Once osseointegration is achieved, the wound is reopened by making a minimal horizontal incision, tightening a healing abutment in place, and buccally displacing the keratinized tissue. (yy) Three weeks later, permanent titanium abutments and provisional resin crowns are positioned to begin functional loading of the implants and create appropriate soft tissue emergence profiles.

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ten  Implant Site Orthodontic Development Techniques

clinical case 1 (cont)

zz

aaa

bbb

eee

ccc

ddd

fff

Fig 10-16  (cont) (zz and aaa) During provisional restoration, the gingival scalloping is contoured and made uniform. The clinical crowns of the central incisors are elongated by means of an external bevel gingivectomy and placement of additive composite material on the distal surfaces. (bbb) The definitive ceramic crowns are cemented in place 3 months later. (ccc and ddd) Radiographs show that the marginal bone levels are perfectly stable. (eee and fff) Follow-up 1 year after cementing the definitive crowns. The intraoral clinical and radiographic images show an excellent esthetic and functional outcome for this case of extreme bone atrophy associated with agenesis of the lateral incisors. Effective bone regeneration made it possible to accurately place two implants for prosthetic restoration, which undoubtedly facilitated the good outcome. The soft tissues are stable at the buccal zeniths and interdental papillae. (Orthodontic treatment by Dr S. Re.)

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Clinical Case Studies

clinical case 2 Interdisciplinary orthodontic and implant treatment in a case of bilateral agenesis of the maxillary lateral incisors

a

b

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i

j

Fig 10-17  (a) A 23-year-old patient presented for clinical examination with a removable partial prosthesis replacing two maxillary lateral incisors. (b) Physical examination, medical history, and radiographs revealed agenesis of both maxillary lateral incisors together with agenesis of the mandibular second premolars and a missing mandibular right first molar. (c and d) The clinical view of the maxillary lateral incisor sites indicates that there is sufficient restorative space; however, radiographic assessment shows converging central incisor and canine roots bilaterally, meaning that implant placement is not possible due to lack of space in the apical third. (e and f) Fixed orthodontic treatment is therefore necessary to straighten the roots of the central incisors and canines, creating root parallelism and sufficient bone volume for implant placement. Orthodontic treatment is also carried out in the mandible to optimize occlusion and open spaces in the posterior sectors so that implants can be placed at the missing tooth sites. (g and h) Opening spaces through orthodontic movement on both sides allows implant placement because the roots of the central incisors and canines are now parallel to one another. (i and j) Radiographs show the excellent degree of root parallelism that has been achieved through orthodontic movement involving mesial tipping of the incisor apices and distal tipping of the canine apices. New bone apposition can also be noted in areas of tension on the distal root surfaces of the central incisors and mesial surfaces of the canines.

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ten  Implant Site Orthodontic Development Techniques

clinical case 2 (cont)

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Fig 10-17  (cont) (k) A surgical template is formed on a plaster working cast to create an accurate prosthetically guided implant placement axis, passing between the incisal margin and the cingulum. (l) The surgical template also allows prosthetic restoration to be assessed on the buccal aspect. (m and n) Prior to surgery, template precision and stability are checked. (o and p) A full-thickness incision is made in the center of the ridge and connected by means of an intrasulcular incision up to the buccal zenith of both adjacent teeth. After elevating a full-thickness flap, titanium implants measuring 3 mm in diameter and 15 mm in length (Astra Tech, Dentsply Sirona) are inserted. (q and r) Residual dehiscence of the threads in the coronal third of the right implant is managed by grafting bovine bone mixed with collagen (Bio-Oss Collagen).

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Clinical Case Studies

clinical case 2 (cont)

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Fig 10-17  (cont) (s to v) After surgery, an impression is taken at the implant level to develop a cast that can be used to mill permanent titanium abutments and prepare provisional resin crowns. (w to z) Twenty-four hours after surgery, the titanium abutments are connected to the implant heads, and the provisional crowns are placed to encourage successful soft tissue healing.

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ten  Implant Site Orthodontic Development Techniques

clinical case 2 (cont)

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ii Fig 10-17  (cont) (aa and bb) Radiographs reveal perfect adaptation of the titanium abutments to the implants, which feature platform switching at the crestal level. (cc and dd) Four weeks after implant surgery, soft tissue healing is apparent, with the creation of new interproximal papillae. (ee and ff) Eight weeks after surgery, the implants undergo orthodontic loading for anchorage purposes. Two brackets are bonded to the buccal surfaces of the provisional resin crowns so that the orthodontic wire can be inserted into the slots. The interproximal surfaces of the provisional crowns are stripped mesially and distally to encourage maturation of the papillae. Subsequent closure of the spaces using a metal ligature creates pressure on the papillae, which migrate coronally toward the available space, filling the interproximal embrasure to a greater extent. Because of their flexible collagen fiber content, the interdental papillae tend to behave like a spring: When they are crushed, they compress and tend to occupy the empty spaces. (gg and hh) Four months after surgery, the soft tissues have matured. It is evident that the papillae are fully healed and well shaped. (ii) A frontal view shows that a harmonious balance has been achieved between teeth and gingiva, and the soft tissues display physiologic scalloping in keeping with the patient’s gingival biotype.

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Clinical Case Studies

clinical case 2 (cont)

jj

kk

ll

mm

pp

nn

qq

rr

oo

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Fig 10-17  (cont) (jj and kk) Radiographs show stable marginal bone levels, confirming that osseointegrated implants can be used successfully for orthodontic anchorage purposes. (ll) Clinical image at the end of orthodontic treatment, with creation of second provisional restorations on implants in the lateral incisor sites. The spaces have been redistributed harmoniously to ensure a satisfactory esthetic and functional outcome. (mm to oo) Frontal and radiographic views after placing definitive ceramic crowns. (pp to ss) One-year follow-up. The peri-implant soft tissue outline is stable and perfectly healthy, as are the bone levels. (Orthodontic treatment by Dr D. D’Alessio.)

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ten  Implant Site Orthodontic Development Techniques

clinical case 3 Orthodontic movement to correct a Class II malocclusion and obtain sufficient mesiodistal root space for implant placement in a case of bilateral agenesis of maxillary lateral incisors

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b

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g Fig 10-18 (a to e) The patient has bilateral agenesis of the maxillary lateral incisors previously treated by provisional composite restorations. She also has Class II malocclusion, which has a negative impact on her smile and occlusal function. The multidisciplinary orthodontic and implant treatment plan involves: orthodontic correction of Class II malocclusion by extraction of the maxillary third molars and distal movement of the other maxillary teeth; closing the interincisal diastema and increasing the root space at the maxillary lateral incisor sites, which is currently insufficient to allow implant placement; and placement and subsequent prosthetic restoration of implants at the maxillary lateral incisor sites. (f) After extraction of the maxillary third molars, the maxillary teeth are retracted, using the mandibular teeth as anchorage. (g and h) Final stage of orthodontic treatment. Elastic bands are used to increase the overbite, which was reduced when the maxillary teeth were moved distally.

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Clinical Case Studies

clinical case 3 (cont)

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Fig 10-18  (cont) (i to k) The following parameters have been achieved following orthodontic treatment: correction of Class II malocclusion to Class I occlusion; satisfactory overjet and overbite; closure of interincisal diastema; alignment of maxillomandibular midlines; and satisfactory mesiodistal space, both coronally and apically, at the edentulous maxillary lateral incisor sites. (l and m) A 3D radiographic assessment confirms the sufficient bone volume. Because the soft tissues are also sufficiently thick, implant placement can take place without having to resort to hard and soft tissue augmentation. Such circumstances are somewhat rare in esthetic dentistry, where hard and soft tissue augmentation are routinely used in most cases. (n to q) Implants are placed in accordance with a prosthetically guided axis, compatible with screw-retained crowns.

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ten  Implant Site Orthodontic Development Techniques

clinical case 3 (cont)

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Fig 10-18 (cont) (r and s) After suturing the implant sites for healing by first intention, provisional adhesive restorations are constructed directly using fiber-reinforced composite materials. (t and u) The submerged implants are exposed by making small mesiodistal ridge incisions without involving the adjacent papillae. Placement of healing screws allows the soft tissues to be gently pushed buccally. (v and w) One week later, polyether impressions (Impregum and Permadyne, 3M Espe) can be taken to make provisional restorations. (x and y) Two provisional resin crowns enable gradual conditioning of the peri-implant soft tissues.

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Clinical Case Studies

clinical case 3 (cont)

z

aa

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Fig 10-18 (cont) (z to bb) Clinical follow-up once rehabilitation is complete reveals a highly favorable occlusal situation and effective integration of the screw-retained zirconia-ceramic crowns into the surrounding soft tissue. (cc and dd) Radiographic follow-up shows well-fitting crowns, absence of peri-implant bone resorption, and respect for the roots of adjacent teeth. (Orthodontic treatment by Dr S. De Luca; surgery and prosthetic rehabilitation by Dr P. Casentini; laboratory procedures by Mr R. Colli and Mr C. Pedrinazzi.) (ee and ff) Extraoral views show that the smile has improved compared to the initial clinical situation and the implant-supported prosthetic rehabilitation is well integrated.

ff

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ten  Implant Site Orthodontic Development Techniques

clinical case 4 Implant site development in an adult with agenesis and insufficient space

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Fig 10-19  (a and b) Initial study cast for a 35-year-old woman reveals missing maxillary lateral incisors with impaired space distribution and discrepancy in the occlusal dimension. (c and d) Panoramic and cephalometric radiographic investigations confirm that two incisors are missing as a result of agenesis. The treatment plan involves placement of two implants for a fixed rehabilitation, preceded by orthodontic treatment to redistribute the spaces properly. (e and f) Orthodontic treatment requires tipping of the right canine and right central incisor roots to move their root apices apart and allow implant placement.

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Clinical Case Studies

clinical case 4 (cont)

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Fig 10-19  (cont) (g to i) At the same time, both central incisors are shifted to the left to even out the mesiodistal space at both lateral incisor sites. (j to l) A panoramic radiograph shows root movements, and radiographs reveal that root parallelism has been achieved. Note the new bone apposition along the distal root surface of the right central incisor and mesial surface of the right canine, corresponding to the zone of tension during orthodontic movement. (m to p) Once occlusal spaces are properly distributed and root surfaces are parallel, approximately 12 months following the start of orthodontic treatment, implant surgery is planned. A 3D CBCT scan is performed. This analysis assesses the significant ridge deficiency given the underdevelopment of the alveolar process resulting from the agenesis. The horizontal and buccopalatal bone dimensions are insufficient to allow correct implant placement. In anatomical terms, there is a significant hollow in the alveolar process. Therefore, the next step is a two-stage procedure involving bone regeneration followed by implant placement.

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ten  Implant Site Orthodontic Development Techniques

clinical case 4 (cont)

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Fig 10-19  (cont) (q to s) When managing single missing teeth in tight spaces, it is essential to maintain the periodontium of adjacent teeth intact. Flap design therefore does not involve the papillae: two vertical incisions are created, connected by a small crestal incision. (t) A flap is detached, full thickness in the keratinized tissue area and partial thickness in the alveolar mucosa area, with horizontal cuts above the periosteum to passively advance the flap. (u) The cortical bone is then denuded and drilled to open the marrow spaces and promote bleeding at the site. (v) A bovine-derived block graft (Bio-Oss Block) soaked in platelet-derived recombinant growth factors (GEM 21S) is secured in the deepest part of the buccal concavity. (w) The graft is then covered with granules of biomaterial (Bio-Oss) mixed with homologous fibrin glue (Tisseel) for an optimum fit between the graft and recipient site. (x) The graft is then passively repositioned and sutured with simple interrupted stitches over the vertical cuts and mattress stitches over the crestal incision (polytetrafluoroethylene 5-0). (y to dd) The same flap design and biomaterials are used to perform surgery at the left lateral incisor site.

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Clinical Case Studies

clinical case 4 (cont)

ee

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mm

Fig 10-19 (cont) (ee and ff) Two weeks later, the tissues have healed without signs of inflammation, and the surgical wound margins are perfectly re-epithelialized. (gg to jj) Clinical images taken 6 months later show that the alveolar ridge volume has been satisfactorily augmented, as confirmed by CBCT scans. The bone graft has integrated perfectly with the underlying buccal cortical bone. (kk to mm) To plan a prosthetically guided and minimally invasive surgery that respects the delicate soft tissue anatomy, a computer-assisted simulation (Simplant, Dentsply Sirona) is created for placing two implants in the maxillary lateral incisor sites without elevating a flap. The regenerated bone volume makes it possible to insert implants measuring 3.25 mm in diameter and 13 mm in length (T3 Certain Tapered).

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ten  Implant Site Orthodontic Development Techniques

clinical case 4 (cont)

nn

oo

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uu

Fig 10-19 (cont) (nn and oo) The patient’s maxillomandibular ratio and skeletal class, together with the inclination of the anterior teeth in relation to the alveolar process, require the prosthetic abutment to be angled by 15 degrees in relation to the implants. (pp and qq) A toothsupported surgical template (SurgiGuide, Dentsply Sirona) is created based on this plan. (rr and ss) Its accuracy is confirmed at the beginning of the surgical session. (tt and uu) After carrying out plexus anesthesia with 4% articaine plus 1:100,000 adrenaline at the maxillary right lateral incisor site, a small horizontal incision is made at the mucogingival junction to expose and remove the screw retaining the block graft.

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Clinical Case Studies

clinical case 4 (cont)

vv

ww

xx

yy

zz

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aaa

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Fig 10-19 (cont) (vv) The surgical template is now positioned, and the implant site is prepared according to the milling sequence programmed by the computer-guided surgery system (Navigator, Zimmer Biomet). (ww) The implant is placed using an implant mount to be aligned with one of the reference notches present on the template sleeve. (xx) When the template is removed, it is observed that the titanium implant has been placed exactly in the digitally preplanned position. (yy) Pending osseointegration, a titanium abutment is screwed in place to achieve transmucosal healing. (zz) A radiograph captured at the end of surgery shows that the implant has been perfectly placed within the mesiodistal and vertical parameters. (aaa to ccc) The same procedure for implant placement is performed at the left lateral incisor site.

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ten  Implant Site Orthodontic Development Techniques

clinical case 4 (cont)

ddd

eee

fff

ggg

hhh

iii

jjj

kkk

Fig 10-19  (cont) (ddd to fff) Connective tissue is harvested from the palate to overcome the slight residual tissue deficiency on the buccal surface. (ggg) The connective tissue is then placed in a tissue envelope between the keratinized gingiva and the periosteum. (hhh) Occlusal view at the end of surgery demonstrating the significant gingival tissue augmentation for esthetic purposes. (iii) A radiograph taken at the end of surgery also shows perfect implant placement in the left lateral incisor site. (jjj and kkk) Six weeks after placement, both implants are fitted with a definitive titanium abutment with a shoulderless finishing margin.

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Clinical Case Studies

clinical case 4 (cont)

lll

mmm

nnn

ooo

ppp

ttt

qqq

rrr

sss

uuu

Fig 10-19  (cont) (lll and mmm) Both implants are then fitted with an initial provisional crown in acrylic resin that is relieved in the area of the interdental papillae to encourage maturation and filling of the interproximal embrasure. (nnn and ooo) Definitive ceramic crowns positioned. The final esthetic outcome is excellent given the accurate redistribution of spaces achieved through orthodontic movement and an increase in volume through regenerative surgery. The papillae are fully intact and at the same level as the papillae of the natural teeth, while the line passing through the gingival zenith is coronal to the line connecting the zeniths of the central incisor and the canine. (ppp and qqq) The soft tissues of both sites also appear well supported when viewed laterally. (rrr and sss) Radiographs show the stability of marginal bone levels and the adaptation of the crowns to the titanium abutments with vertical finishing margins. (ttt and uuu) Images taken 1 year after cementing the definitive crowns show maintenance of peri-implant tissue health and the esthetic outcome. (Orthodontic treatment by Dr L. Gaveglio.)

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ten  Implant Site Orthodontic Development Techniques

clinical case 5 Multidisciplinary orthodontic-implant-veneer treatment in a case of dental ankylosis and anterior open bite

a

c

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f Fig 10-20 (a to e) The patient requests replacement of the maxillary right central incisor and an improvement in her smile. The tooth is affected by ankylosis and advanced root resorption as the result of an accident that occurred 7 years earlier. This ankylosis has altered the development of the entire anterior maxilla, giving rise to an anterior open bite. The multidisciplinary treatment plan for this patient involves: orthodontic correction of the malocclusion including extrusion of the maxillary anterior teeth with the exception of the anklyosed right central incisor and redistribution of the mesiodistal spaces; replacing the right central incisor with an implant after extraction and simultaneous alveolar preservation technique (because of the defect present at the right central incisor site, it is expected that additional hard and soft tissue augmentation techniques will have to be performed); and bonding of veneers to the other maxillary anterior teeth to harmonizie and improve tooth morphology and the patient’s appearance. (f) From an esthetic viewpoint, the treatment plan aims to correct the following impairments: (1) Misaligned gingival and incisal margins. Because of ankylosis of the right central incisor, the gingival and incisal margins of the right incisors are more apical than those of the left incisors. This impairment makes the smile asymmetric. The gingival margins are to be repositioned by orthodontic extrusion of the right lateral incisor, and hard and soft tissue augmentation techniques will be performed at the extraction site of the right central incisor. (2) Asymmetry in the shape and size of the two central incisors. Both incisors are asymmetric, with the right incisor predominating in terms of length and mesiodistal dimensions. (3) The teeth are small, given the extent of the patient’s smile, and it should be possible to improve the width-length ratio of the teeth. This is achieved by treating the left central incisor and the lateral incisors and canines with ceramic bonded restorations (veneers), preceded by a mock-up to allow a preview of the outcome.

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Clinical Case Studies

clinical case 5 (cont)

g

h

i

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Fig 10-20 (cont) (g) The orthodontic movement, initially aimed at extruding the right lateral incisor, begins immediately after extraction of the right central incisor combined with an alveolar preservation technique (placement of Bio-Oss Collagen and socket sealing with an epithelial–connective tissue punch). The orthodontic device also allows a provisional prosthetic restoration to be created using a provisional resin crown to which a bracket is bonded. (h) Some time later, the alveolar preservation technique has brought about a noticeable improvement in soft tissue volume at the site of the right central incisor. (i to l) In addition to the alveolar preservation technique, a guided bone regeneration (GBR) with Bio-Oss and Bio-Gide collagen membrane fixed with titanium pins and a connective tissue graft are also performed to coincide with implant placement (Bone Level Tapered implant 3.3 × 12 mm, Straumann) to optimize edentulous site volume and promote subsequent peri-implant conditioning.

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ten  Implant Site Orthodontic Development Techniques

clinical case 5 (cont)

m

n

o

p

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Fig 10-20  (cont) (m to o) After isolating the brackets with blue wax, polyether impressions are taken (Impregum) to produce a screw-retained resin provisional crown. After the provisional crown is fitted to the implant, a bracket is placed on it, and it is used as anchorage in order to finalize orthodontic movement of the adjacent teeth. (p and q) Once the orthodontic devices are removed, accurate realignment of the gingival and incisal margins and redistribution of the mesiodistal spaces can be observed.

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Clinical Case Studies

clinical case 5 (cont)

r

s

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Fig 10-20  (cont) (r to t) The dental technician produces a diagnostic wax-up and a corresponding clear silicone template based on the digitally planned anterior tooth morphology. The mock-up, produced by pouring light-cured flowable composite into the template, will preview the possible outcome, which can be adapted to the patient’s requests. (u and v) Comparison of the current smile to the smile with the diagnostic mock-up shows a clear improvement, to the patient’s great satisfaction.

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ten  Implant Site Orthodontic Development Techniques

clinical case 5 (cont)

w

x

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aa

Fig 10-20 (cont) (w to y) After removing the diagnostic mock-up, tooth preparation is limited to removal of a small amount of material to round off the edges. The bonded restorations will therefore take the form of additive veneers without a precise finish line. The customized impression transfer technique (see chapter 9) allows accurate transfer of the shape obtained by conditioning the soft tissues around the implant. The definitive restorations take the form of five lithium disilicate veneers and a screw-retained zirconia-ceramic crown bonded to the original titanium base (Variobase, Straumann). (z and aa) The final clinical and radiographic follow-ups reveal that the prosthetic devices are well integrated with the surrounding tissues for a good esthetic outcome. (Orthodontic procedures by Dr L. Pizzoni; implant surgery and prosthetic restorations by Dr P. Casentini; laboratory procedures by Mr A. Giacometti.)

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Clinical Case Studies

clinical case 5 (cont)

bb

cc

dd

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Fig 10-20  (cont) (bb to gg) Comparison between the initial clinical situation and the posttreatment situation shows the considerable improvement achieved and the correction of anomalies and imperfections.

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ten  Implant Site Orthodontic Development Techniques

clinical case 6 Multidisciplinary orthodontic-implant-composite bonding treatment in a case of malpractice leading to Bolton discrepancy

a

b

c

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e

f

g

Fig 10-21  (a to c) The patient presented with an unsightly diastema between the maxillary left central and lateral incisors. After fracture of the lateral incisor crown as a result of an accident, the patient underwent a procedure to lengthen the clinical crown of that tooth with considerable irreversible sacrifice of periodontal support for the adjacent central incisor and canine. The lateral incisor also received inadequate endodontic treatment and reconstruction of the abutment with a fiber post. A more rational treatment plan involving, for example, extrusion of the fractured tooth root or extraction combined with a preservation technique would have prevented irreversible damage to the adjacent teeth. In any case, given the discrepancy between the size of the arch and the size of the teeth (Bolton discrepancy), the treatment plan cannot be limited to replacing the missing tooth. (Other images related to the initial situation and the treatment plan adopted in this case are presented in Figs 10-8 and 10-9.) An interdisciplinary orthodontic-implant-veneer treatment plan is therefore drawn up involving the following steps: (1) orthodontic treatment to realign the maxillary teeth mesiodistally, evenly distributing the interdental spaces; (2) extraction of the left lateral incisor and alveolar preservation technique to avoid further volume loss; (3) bonding of the other anterior teeth to close the interdental spaces (note that the original plan was to apply direct composite restorations and then later apply ceramic veneers; however, the patient decided to forego the second stage of treatment for financial reasons); and (4) implant placement with an implant-supported prostheses at the left lateral incisor site. (d to g) After applying orthodontic brackets, extraction of the left lateral incisor is followed by an alveolar preservation technique. A slow-resorbing osteoconductive material (Bio-Oss Collagen) is placed in the extraction socket, and the socket is sealed by means of an epithelial–connective tissue graft taken from the palate. Immediately after placing the orthodontic wire, a provisional crown is placed in the left lateral incisor site, retained by the same wire, and orthodontic traction begins.

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Clinical Case Studies

clinical case 6 (cont)

h

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Fig 10-21 (cont) (h to k) Even distribution of the mesiodistal spaces can be observed at the end of orthodontic treatment. (l to o) After completing orthodontic treatment and reconstructing the anterior teeth with composite restorations, an implant (Bone Level 3.3 × 10 mm, Straumann) is inserted in the left lateral incisor site. Although the bone volume is sufficient for implant placement, it is further augmented for esthetic purposes by means of GBR with bone substitute and collagen membrane (Bio-Oss and Bio-Gide).

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ten  Implant Site Orthodontic Development Techniques

clinical case 6 (cont)

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q

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Fig 10-21 (cont) (p to s) After implant osseointegration and site reopening, a provisional prosthesis is attached to the implant. It is not possible to reconstruct the papillae due to the severe loss of periodontal support occurring after elongation of the clinical crown distal to the left central incisor and mesial to left canine. For this reason, it is decided to incorporate artificial pink ceramic papillae in the design of the definitive prosthesis to meet the patient’s esthetic requirements. (t to v) The definitive restoration includes a zirconia-ceramic structure made on a prefabricated titanium base (Variobase). The structure includes the construction of two pink ceramic papillae. A lithium disilicate crown is then cemented to the mesostructure.

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Clinical Case Studies

clinical case 6 (cont)

w

x

y

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aa

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Fig 10-21  (cont) (w to z) The final clinical follow-up shows favorable integration of the implant-supported prosthetic restoration. The use of pink ceramic, which is the only option for closing the black triangles between the teeth in this case, requires appropriate hygiene maintenance using dental floss (Super Floss, Oral-B). A final radiographic follow-up is carried out to check osseointegration and the absence of peri-implant root reabsorption. (Orthodontic procedures by Dr S. De Luca; implant surgery and prosthesis by Dr P. Casentini; bonding procedures by Dr N. Balduzzi; laboratory procedures by Mr A. Schoenenberger.) (aa to cc) Extraoral views show the patient’s attractive smile and favorable integration of the dental and pink components of the implant-supported prosthetic restoration.

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ten  Implant Site Orthodontic Development Techniques

clinical case 7 Implant placement followed by orthodontic movement achieved using elastic spacers and progressive modification of the provisional restoration

a

b

c

d

e

g

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i

Fig 10-22  (a and b) The treatment plan for this patient’s left maxilla involves replacing the first molar with an implant; increasing the mesiodistal prosthetic space through orthodontic movement, which should also make it possible to re-create a contact point between the second and third molars; and finalization of the prosthetic restoration by replacing the existing amalgam restorations on the adjacent teeth. In this case, orthodontic movement will be performed with the aid of an implant-supported provisional prosthetic restoration once osseointegration has occurred. (c to f) Implant placement (Wide Neck 4.8 × 8 mm, Straumann) takes place after an osteotome-mediated transcrestal sinus elevation procedure. Eight weeks later, peri-implant soft tissue healing is complete, and osseointegration is sufficient to start prosthetic loading. (g to i) The orthodontic distalization of the first and second molars is obtained by applying an elastic separator between the provisional implant crown and the adjacent tooth. After a few days, the elastic separator has created a space of about 1 mm.

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Clinical Case Studies

clinical case 7 (cont)

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j

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Fig 10-22  (cont) (j and k) At this point, composite resin is added to the provisional implant crown, filling the space thus created. (l to n) To further increase the mesiodistal prosthetic space for the definitive crown, the application of the elastic separator and the subsequent relining procedure is repeated. (o to r) Once enough mesiodistal space has been achieved to allow restoration and the diastema between the second and third molar is closed, impressions can be taken to finalize the prosthetic restoration. In this case, the definitive restorations take the form of lithium disilicate inlays on the premolars and second molar and a crown, also disilicate, bonded to a prefabricated titanium base (Variobase) and then screw-retained to the implant.

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clinical case 7 (cont)

s

t

Fig 10-22  (cont) (s and t) The final clinical and radiographic follow-ups show favorable integration of the rehabilitation. (Surgery, orthodontic procedures, and prosthetic rehabilitation by Dr P. Casentini; laboratory procedures by Mr A. Giacometti.)

Reference 1. Dibart S, Yee C, Surmenian J, et al. Tissue response during Piezocision-assisted tooth movement: A histological study in rats. Eur J Orthod 2014;36:457–464.

Recommended Reading Argyropoulos E, Payne G. Techniques for improving orthodontic results in the treatment of missing maxillary lateral incisors. A case report with literature review. Am J Orthod Dentofacial Orthop 1988;94:150–165. Belser UC, Buser D, Hess D, Schmid B, Bernard JP, Lang NP. Aesthetic implant restorations in partially edentulous patients—A critical appraisal. Periodontol 2000 1998;17:132– 150. Bidra AS, Uribe F. Preprosthetic orthodontic intervention for management of a partially edentulous patient with generalized wear and malocclusion. J Esthet Restor Dent 2012;24:88–100. Biggs J, Beagle JR. Pre-implant orthodontics: Achieving vertical bone height without osseous grafts. J Indiana Dent Assoc 2004;83:18–19. Cardaropoli D. Orthodontics for the adult periodontal patient: First or second choice treatment? Prog Orthod 2009;10:88–96.

Cardaropoli D, Gaveglio L. The influence of orthodontic movement on periodontal tissues level. Semin Orthod 2007;13:234–245. Cardaropoli D, Gaveglio L, Ramzi VA. Orthodontic movement and periodontal bone defects: Rationale, timing, and clinical implications. Semin Orthod 2014;20:177–187. Cardaropoli D, Re S, Corrente G, Abundo R. Reconstruction of the maxillary midline papilla following a combined orthodontic-periodontic treatment in adult periodontal patients. J Clin Periodontol 2004;31:79–84. Cardaropoli D, Re S, Manuzzi W, Gaveglio L, Cardaropoli G. Bio-Oss Collagen and orthodontic movement for the treatment of infrabony defects in the esthetic zone. Int J Periodontics Restorative Dent 2006;26:553–559. Cardaropoli D, Re S, Manuzzi W, Gaveglio L, Cardaropoli G. Orthodontic movement into infrabony defects augmented with a composite bovine xenograft: Clinical and radiological results. J Clin Periodontol 2006;33(suppl 7):52.

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Recommended Reading

Cheng YM. Dynamics of dental implants and orthodontics in today’s periodontal prosthesis. Compend Contin Educ Dent 2000;21:191–206. Chiu GS, Chang CH, Roberts WE. Bimaxillary protrusion with an atrophic alveolar defect: Orthodontics, autogenous chin-block graft, soft tissue augmentation, and an implant. Am J Orthod Dentofacial Orthop 2015;147:97–113. Danesh-Meyer MJ, Brice DM. Implant site development using orthodontic extrusion: A case report. N Z Dent J 2000;96:18–22. Drago CJ. Use of osseointegrated implants in adult orthodontic treatment: A clinical report. J Prosthet Dent 1999;82:504–509. Gündüz E, Rodríguez-Torres C, Gahleitner A, Heissenberger G, Bantleon HP. Bone regeneration by bodily tooth movement: Dental computed tomography examination of a patient. Am J Orthod Dentofacial Orthop 2004;125:100–106. Jamilian A, Perillo L, Rosa M. Missing upper incisors: A retrospective study of orthodontic space closure versus implant. Prog Orthod 2015;16:2. Knabe C, Schendel KU. The use of implant-supported titanium prostheses for treatment of periodontally compromised patients including functional and orthodontic therapy. Report of 2 cases. Clin Oral Implants Res 1997;8:332–338. Kokich V. Esthetics and anterior tooth position: An orthodontic perspective. Part II: Vertical position. J Esthet Dent 1993;5:174–178. Kokich VG. Esthetics: The orthodontic-periodontic restorative connection. Semin Orthod 1996;2:21–30. Makhmalbaf A, Chee W. Soft-and hard-tissue augmentation by orthodontic treatment in the esthetic zone. Compend Contin Educ Dent 2012;33:302–306. Marks MH, Rosen PS. Adult orthodontics: Periodontic and cosmetic enhancements. Compendium 1991;12:584,586,588. Mayer T, Basdra EK, Komposch G, Staehle HJ. Localized alveolar ridge augmentation before orthodontic treatment. A case report. Int J Oral Maxillofac Surg 1994;23:226–228. Millar BJ, Taylor NG. Lateral thinking: The management of missing upper lateral incisors. Br Dent J 1995;179:99–106. Mirabella AD, Kokich VG, Rosa M. Analysis of crown widths in subjects with congenitally missing maxillary lateral incisors. Eur J Orthod 2012;34:783–787. Nevins M, Jovanovic SA. Localized bone reconstruction as an adjunct to dental implant placement. Curr Opin Periodontol 1997;4:109–118.

Robertsson S, Mohlin B. The congenitally missing upper lateral incisor. A retrospective study of orthodontic space closure versus restorative treatment. Eur J Orthod 2000;22:697–710. Rosa M, Lucchi P, Ferrari S, Zachrisson BU, Caprioglio A. Congenitally missing maxillary lateral incisors: Long-term periodontal and functional evaluation after orthodontic space closure with first premolar intrusion and canine extrusion. Am J Orthod Dentofacial Orthop 2016;149:339–348. Rosa M, Olimpo A, Fastuca R, Caprioglio A. Perceptions of dental professionals and laypeople to altered dental esthetics in cases with congenitally missing maxillary lateral incisors. Prog Orthod 2013;14:34. Rubinov L. Prerestorative ortho to maximize esthetics and function. Dent Today 2011;30:74,76–77. Sabri R. Management of missing maxillary lateral incisors. J Am Dent Assoc 1999;130:80–84. Salama H, Garber DA, Salama MA, Adar P, Rosenberg ES. Fifty years of interdisciplinary site development: Lessons and guidelines from periodontal prosthesis. J Esthet Dent 1998;10:149–156. Salama H, Salama M. The role of orthodontic extrusive remodeling in the enhancement of soft and hard tissue profiles prior to implant placement: A systematic approach to the management of extraction site defects. Int J Periodontics Restorative Dent 1993;13:312–333. Salama H, Salama MA, Garber D, Adar P. The interproximal height of bone: A guidepost to predictable esthetic strategies and soft tissue contours in anterior tooth replacement. Pract Periodontics Aesthet Dent 1998;10:1131–1141. Salama H, Salama M, Kelly J. The orthodontic-periodontal connection in implant site development. Pract Periodontics Aesthet Dent 1996;8:923–932. Savarrio L, McIntyre GT. To open or to close space—That is the missing lateral incisor question. Dent Update 2005;32:16– 18,20–22,24–25. Silveira GS, de Almeida NV, Pereira DM, Mattos CT, Mucha JN. Prosthetic replacement vs space closure for maxillary lateral incisor agenesis: A systematic review. Am J Orthod Dentofacial Orthop 2016;150:228–237. Uribe F, Taylor T, Shafer D, Nanda R. A novel approach for implant site development through root tipping. Am J Orthod Dentofacial Orthop 2010;138:649–655. Zachrisson BU, Rosa M, Toreskog S. Congenitally missing maxillary lateral incisors: Canine substitution. Point. Am J Orthod Dentofacial Orthop 2011;139:434,436.

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eleven Treatment of Esthetic Failures in Implant Dentistry

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Questions: 1. What is meant by esthetic failure in implant dentistry? 2. Why should esthetic failures be considered a serious complication of implant dentistry? 3. What are the most common causes of esthetic failure in implant dentistry? 4. What is important to assess when choosing a strategy for treating esthetic failures? 5. What are the main techniques for treating esthetic failures? 6. Which cases cannot be re-treated or offer expectations of only partial success?

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eleven  Treatment of Esthetic Failures in Implant Dentistry

1|

What is meant by esthetic failure in implant dentistry?

Implant esthetic failures are clinical situations in which one or more implants placed in the esthetic sector fail to meet the criteria for successful esthetic integration in the surrounding tissues. The problem in such cases is usually soft tissue recession, giving rise to clinically visible asymmetry. The

a

esthetic failure will be even more evident if the patient has a high smile line, causing extensive exposure of the teeth (Fig 11-1). This chapter does not consider cases where the failure can be attributed exclusively to an unsatisfactory aspect of the restoration despite satisfactory soft tissue architecture.

b

Fig 11-1  (a) Implant esthetic failures can severely impair a patient’s smile and be very detrimental to quality of life. (b) If the patient has a high smile line, as in this case, the consequences of implant failure are particularly evident.

2|

Why should esthetic failures be considered a serious complication of implant dentistry?

There are several reasons that esthetic failures in implant dentistry should be taken seriously, including: 1. The clinical consequences of such failures can have an extremely negative influence on the patient’s quality of life. 2. Such failures often lead to a medicolegal dispute between the patient and the clinician involved. The patient can hardly be expected to accept the result when it falls seriously short of expectations and clearly impairs the

3|

smile from an esthetic viewpoint. Clinicians cannot provide many arguments in their defense when faced with a clear esthetic failure. 3. Treatment of implant esthetic failures is very complex, often requiring the use of hard and soft tissue reconstruction techniques; even then, the outcome is often a compromise. Because of this, such failures must be considered at least partially irreversible in some cases.

What are the most common causes of esthetic failure in implant dentistry?

Given the severe impact such failures have on the patient’s quality of life, the causes must be thoroughly understood in order to prevent their occurrence. In nearly all cases, im-

plant esthetic failures are due to clinical error. For example, mistakes are often made when choosing the 3D position or size of the implant.

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What are the most common causes of esthetic failure in implant dentistry?

Excessive buccal angulation of the implant

Excessive buccal positioning of the implant

This mistake is often associated with immediate postextraction placement. Occasionally, clinicians mistakenly over-angle the implant to establish optimum primary stability (Fig 11-2). If the angle is excessive, usually greater than 20 degrees, the only solution may be to remove the implant, perform regenerative techniques, and place a new implant.

Excessively buccal positioning often lies at the root of periimplant soft tissue recession, leading to esthetic failure1,2 (Fig 11-3).

a

b

Fig 11-2 (a and b) Severe esthetic failure associated with excessive buccal angulation of the implant, clearly illustrated by the clinical image and computed tomography scan.

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b

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Fig 11-3 (a to c) Excessively buccal implant placement almost always gives rise to soft tissue recession and esthetic failure, which is particularly striking in this case due to the high smile line.

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eleven  Treatment of Esthetic Failures in Implant Dentistry

Improper mesiodistal implant positioning

Incorrect choice of implant diameter

Lack of mesiodistal correspondence between the position of the implant and that of the restoration can also result in esthetic failure (Fig 11-4).

a

The use of large-diameter implants should be avoided in the esthetic sector. If implant dimensions are excessive, the implant position will be overly buccal, and this almost always leads to failure (Fig 11-5). In addition, if there are adjacent implants, choosing a large-diameter implant leaves too little space for an interimplant papilla.

b Fig 11-4  (a to c) Placement of two implants excessively mesial to the prosthetically guided position affects the emergence profile of the implant-supported restoration, negatively impacting the final appearance.

c

b

a

Fig 11-5 (a to d) Esthetic failure due to use of implants with an overly large diameter. In this case, incorrect choice of diameter is exacerbated by an overly buccal position and a buccally angled axis.

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d

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What are the most common causes of esthetic failure in implant dentistry?

Defective peri-implant soft tissue management The presence of soft tissues shaped to ensure symmetry with adjacent teeth and appropriate thickness is one of the most important requirements to ensure the success of an implant-supported prosthetic restoration in the esthetic sector (Fig 11-6).

a

Failed regenerative technique Failure of regenerative techniques in the esthetic sector performed at the same time as or prior to implant placement can considerably exacerbate an already compromised clinical situation, giving rise to even more extensive bony and soft tissue defects with scarring that is difficult to correct and irreversible loss of periodontal support for adjacent teeth (Fig 11-7). It is often not possible to completely remedy the situation when the clinical situation is so problematic.

b

Fig 11-6  (a and b) This patient’s high smile line highlights the lack of symmetry in the peri-implant soft tissues of the maxillary incisors. The soft tissues are so thin that they also reveal the presence of the subgingival titanium abutments, which are clearly visible as a gray halo.

a

c

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Fig 11-7  (a and d) Failure of an implant placed to coincide with a regenerative technique performed on the maxillary left central incisor leads to serious esthetic failure with irreversible attachment loss at the right central and left lateral incisors.

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eleven  Treatment of Esthetic Failures in Implant Dentistry

Implant placement at an excessively early age

Use of poor-quality implant materials In some cases, implant esthetic failure can be related to the poor quality of materials used. Some implant types have little likelihood of adapting favorably to local anatomical conditions (Fig 11-9).

Placing an implant when the patient is too young, ie, before the jaws have finished growing, leads to visible asymmetry between implant-supported restorations on an ankylosed prosthetic abutment and the adjacent teeth, which will undergo further eruption and coronal migration (Fig 11-8).

a

c

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Fig 11-8 (a and c) Esthetic failure caused by implant placement at an early age followed by further eruption and migration of adjacent teeth over subsequent years.

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Fig 11-9  (a and b) Implant esthetic failure caused by an overly large implant of insufficient quality. The size of the implant platform has reduced the adjacent tooth root area.

Presence of multiple failure factors When several potential causes of esthetic failure coexist, the negative effects add up to a very poor outcome (Fig 11-10).

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Fig 11-10  (a and b) The result can be truly detrimental when several mistakes are made in the same case.

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What is important to assess when choosing a strategy for treating esthetic failures?

c

d

Fig 11-10  (cont) (c and d) Removal of the provisional partial denture reveals overly buccal and apical and faulty mesiodistal positioning of the implants.

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What is important to assess when choosing a strategy for treating esthetic failures?

Esthetic failures can be re-treated using different techniques, including implant recovery combined with soft tissue defect correction by mucogingival surgery, implant removal, or use of a pink porcelain to compensate for hard and soft tissue defects. The choice between different treatment strategies is determined by personal preferences, the practitioner’s technical skills, and the clinical conditions. The main factors to be considered are angle and buccopalatal position of the implant (Fig 11-11), possibility of accessing the implant platform and replacing prosthetic components, and patient preferences.

Angle and buccopalatal position of the implant If the implant is placed in an overly buccal position, particularly if it is outside the ideal arch curvature, no mucogingival technique will be able to improve the clinical situation. An

a

unfavorable angle, usually greater than 25 degrees, is also unlikely to be compatible with esthetic recovery. The prognosis is particularly bad if a combination of both factors is present. Excessive buccopalatal angling may not represent a problem if the implant platform is in a more palatal position.

Possibility of accessing the implant platform and replacing prosthetic components In some cases, peri-implant soft tissue recession can be promoted by a poorly designed abutment that takes up space that should be occupied by soft tissues. Knowledge of the implant system used and therefore the possibility of connecting an abutment of different material and/or shape to the implant, allowing a new impression to be taken with the original components, greatly influences the possibility of re-treatment.

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Fig 11-11  (a and b) Implant buccopalatal position and angle are the main prognostic factors when evaluating the possibility of implant recovery.

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eleven  Treatment of Esthetic Failures in Implant Dentistry

Patient preferences If a patient who has experienced implant failure refuses to undergo a long therapeutic procedure involving the use of

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regenerative techniques, this can affect the choice of treatment. The patient may prefer traditional prosthetic solutions (eg, a tooth-supported partial denture).

What are the main techniques for treating esthetic failures?

The different treatment options can be summarized as follows.

Implant maintenance and peri-implant soft tissue treatment by means of mucogingival surgery The aim of these procedures is to cover any peri-implant dehiscences and create a thicker and more stable soft tissue layer. For this reason, mucogingival treatment of periimplant defects involves the use of bilaminar procedures with a connective tissue graft combined with a flap that is usually coronally displaced. In many cases, it is also necessary to replace or modify the implant abutment and position a new restoration that considers the new mucogingival architecture. This therapeutic option, which is the least invasive because it does not involve removing the implant, is usually the one preferred by patients and should always be the first choice. Some clinical studies have provided scientific support for the use of such procedures, demonstrating the possibility of obtaining repeatable results.3–8 Unfortunately, mucogingival correction is not always feasible. It represents an option only when conditions are favorable, particularly when the implant position is not excessively buccal and when it is possible to remove and replace the implant abutment, ie, when the type of implant used is known and the dedicated prosthetic components can be found.

Selective implant maintenance and removal combined with mucogingival surgery and bone regeneration This option can be considered if multiple implants have been placed in the esthetic sector. Implant removal might be limited to implants displaying the most unfavorable conditions, while other implants are maintained and treated by mucogingival surgery techniques. Any bone defects remaining after implant removal can be treated by bone regeneration procedures.

Implant removal, hard and soft tissue augmentation, and new implant placement In many cases, this is the only treatment strategy when the implant is unfavorably positioned. Implant removal must take place in the least invasive way possible in an attempt to avoid further reduction of the available bone volume. Currently, special removal kits are often used for this purpose. These allow a high counter-torque to be applied to the implant in order to break the bond between the implant and surrounding bone. Piezoelectric inserts are another means of reducing bone tissue sacrifice. Once the implant has been removed, in some cases ridge preservation techniques can be applied that are similar to those used to treat an extraction socket. Alternatively, residual bone volume can be assessed after some time, and a new implant can be placed, possibly combined with or preceded by hard and soft tissue augmentation procedures.

Implant- or tooth-supported fixed prostheses with pink porcelain In some cases, peri-implant soft tissue reconstruction is not technically feasible after implant failure because of anatomical limitations. For example, there may be irreversible attachment loss at adjacent teeth that cannot be corrected even after augmenting the hard and soft tissues of the adjacent implant site. In other cases, the patient refuses new implant treatment. In such cases, a good compromise may be an implant- or tooth-supported prosthesis that incorporates a certain amount of pink porcelain to compensate for any ridge profile defects. However, restorations with pink porcelain are always more difficult for the patient to clean and disinfect. It is essential to design the pink component properly to ensure satisfactory hygiene, avoiding the creation of any concave areas that are difficult to access.

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Which cases cannot be re-treated or offer expectations of only partial success?

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Which cases cannot be re-treated or offer expectations of only partial success?

In theory, no case can be considered untreatable unless systemic health problems or psychologic factors discourage repeat surgery. For example, if the failure is due to implant positioning that is bad enough to require implant removal but

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the patient refuses this procedure, corrective plastic surgery can allow partial improvement (Fig 11-12).

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Fig 11-12 (a and b) Implant in maxillary lateral incisor area; positioning of the implant apex in a palatal direction caused overly buccal and apical implant head positioning, with consequent soft tissue recession and creation of a long clinical crown. (c) The implant is perfectly osseointegrated, and a radiograph shows stable marginal bone levels. In this case, the only solution that would ensure an optimum esthetic outcome is to remove the malpositioned implant and place a new one. However, the patient refuses this solution for psychologic reasons and will only agree to mucogingival treatment to improve the soft tissue situation, knowing that this will achieve only partial success. (d) During surgery, the crown and titanium abutment are removed. (e and f) After this, a flap is elevated without involving the anatomical papillae by means of partial-thickness detachment.

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eleven  Treatment of Esthetic Failures in Implant Dentistry

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Fig 11-12 (cont) (g) A provisional abutment is then positioned to reduce buccal protrusion, and a connective tissue graft taken from the palate is sutured in place. (h) After placement of a new provisional crown, the flap is advanced and coronally repositioned. After surgery, the outcome seems more than satisfactory, but unfortunately the anatomical parameters lead to unsatisfactory healing. (i) After 1 year, the marginal soft tissue levels have again receded, and the position is still apical. The mucogingival surgery procedure has at least succeeded in increasing the band of keratinized tissue and gingival thickness, providing more stable soft tissues to ensure peri-implant health. (j) A radiograph confirms the excellent marginal bone level stability. (k) Fortunately, a low smile line makes this single implant-supported prosthetic rehabilitation acceptable.

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Clinical Case Studies Figures 11-13 to 11-24 present clinical cases demonstrating treatment of esthetic failures associated with implant placement.

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Clinical Case Studies

clinical case 1 Treatment of a peri-implant esthetic defect with periodontal plastic surgery

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Fig 11-13 (a) View of a single implant-supported prosthetic rehabilitation with soft tissue recession at the maxillary left canine site. (b) A radiograph shows no signs of peri-implantitis. (c and d) Intraoral and smile images show somewhat uneven positioning of the ceramic crown, which fails to mirror the position of the contralateral natural tooth and protrudes too far buccally. The patient refuses to have the prosthetic work redone for financial reasons. Treatment therefore focuses on the mucogingival aspects to eliminate the recession and improve soft tissue quality and quantity. (e) A flap is created to deal with recession at the single site. (f) This is elevated at partial thickness. (g) The exposed implant surface is decontaminated with abrasive powder (Perio Plus, EMS) and treated with an 890-nm diode laser using pulsed frequency (Raffaello, DMT). (h) Connective tissue is taken from the palate, positioned, and bonded with homologous fibrin glue (Tisseel, Baxter).

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eleven  Treatment of Esthetic Failures in Implant Dentistry

clinical case 1 (cont)

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Fig 11-13  (cont) (i) The flap is then coronally repositioned and sutured with nonresorbable material (polytetrafluoroethylene [PTFE] 5-0). (j) After 1 year, prosthetic restoration can also be carried out. The original titanium post is re-prepared to adjust the axis, moving it as far as possible in a palatal direction. (k) Following tooth whitening treatment, the new ceramic crown is blended in with the new color and shaped to match the other teeth more effectively than the original. The peri-implant gingival tissues are well scalloped and healthy. (l and m) The final intraoral and the smile images reveal an excellent esthetic outcome. (n) A follow-up radiograph also reveals stable marginal bone levels.

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Clinical Case Studies

clinical case 2 Treating a peri-implant soft tissue deficiency by means of a combined periodontal and prosthetic approach

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Fig 11-14 (a and b) Initial clinical situation showing evident peri-implant soft tissue deficiency on a maxillary premolar. The gingival tissue shows buccal recession and evident contraction of the horizontal dimension as well as an insufficient keratinized tissue band with marginal inflammation. (c) A radiograph reveals an inconsistency between the titanium prosthetic abutment and the metal-ceramic crown. The treatment plan involves replacing the crown and improving the soft tissues. (d and e) The first step is to re-prepare the titanium abutment using finishing procedures to reduce its diameter and move the axis as far as possible in a palatal direction. (f) The ceramic crown is provisionally modified, moving the finish line significantly coronal to the free gingival margin. (g) A triangular flap is created with two large horizontal surgical papillae. (h) A flap is fully detached at half thickness up to the fornix.

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eleven  Treatment of Esthetic Failures in Implant Dentistry

clinical case 2 (cont)

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n Fig 11-14  (cont) (i to l) An epithelial–connective tissue graft is taken from the palate and de-epithelialized on the surgical table. (m and n) The graft is positioned over the periosteal bed and secured using a combination of periosteal sutures and cross mattress sutures using resorbable thread (polyglycolic acid [PGA] 6-0). (o) The crown is repositioned, and the flap is advanced to a coronal position in order to cover the connective tissue graft, which is sutured using a combination of suspended sutures at the papillae and simple sutures over the vertical releasing incisions (PTFE 5-0).

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Clinical Case Studies

clinical case 2 (cont)

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Fig 11-14 (cont) (p and q) Excellent wound healing is observed after 3 and 8 weeks, respectively. (r and s) Sixteen weeks after surgery, good soft tissue maturation is observed, with coronal repositioning of the free gingival margin and a considerable increase in horizontal tissue thickness. (t to w) A new metal-ceramic crown is made, blending in perfectly with the new 3D soft tissue anatomy.

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eleven  Treatment of Esthetic Failures in Implant Dentistry

clinical case 2 (cont)

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Fig 11-14  (cont) (x) A radiograph taken after 12 months shows the good adaptation of the crown to the titanium abutment and stable bone levels. (y and z) A comparison between the initial and final clinical situations reveals a considerable esthetic improvement with coverage of the previously exposed portion of the implant.

clinical case 3 Mucogingival plastic surgery for correction of a peri-implant defect and maxillary central incisor root coverage

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Fig 11-15 (a to d) A provisional crown with artificial pink tissue has been placed to compensate for a buccal dehiscence at the maxillary right central incisor implant site. The solution is not acceptable given the patient’s high smile line. Note also the attachment loss at the adjacent tooth site. The treatment plan includes a bilaminar procedure to treat the dehiscence. A connective tissue graft will be positioned over the peri-implant defect and the adjacent tooth recession. The recession at the adjacent tooth site can be classified as Class III according to Miller’s classification.9 This indicates at the outset that full coverage will not be possible. It is also planned to reduce the buccal aspect of the implant abutment as well as the length of the provisional implant crown, removing the pink component.

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Clinical Case Studies

clinical case 3 (cont)

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Fig 11-15  (cont) (e and f) Flap design. The incision will allow surgical papillae to be designed within the anatomical papillae. The flap will be detached at partial thickness within the papillae and full thickness apical to the implant dehiscence, then again at partial thickness apically to allow coronal mobilization of the flap. The most coronal part of the anatomical papillae will then be de-epithelialized to act as a recipient bed for the coronally repositioned flap. A connective tissue graft will allow the flap to be stabilized in a coronal direction and increase tissue thickness in the region. The connective tissue graft will be completely covered by the coronally displaced flap. (g and h) After making an incision and detaching the flap at the thicknesses described in parts e and f, root planing is carried out on the left central incisor using a curette, and the thickness of the titanium abutment is reduced using a diamond bur. (i and j) After de-epithelialization of the anatomical papillae, a connective tissue graft taken from the palate is stabilized at the recipient site using a resorbable suture and then completely covered by the coronally displaced flap, which is stabilized in its final position by means of nonresorbable monofilament sutures. The provisional crown is reduced in length and re-cemented.

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eleven  Treatment of Esthetic Failures in Implant Dentistry

clinical case 3 (cont)

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n Fig 11-15  (cont) (k) The treated area shows good recovery when the sutures are removed 2 weeks after surgery. (l) After 4 months of healing. Some tissue has crept coronally, and much of the recession on the left central incisor has been covered. (m and n) Intraoral and smile views after completion of the restoration shows overall improvement in the mucogingival architecture and harmonious stabilization of the dental composition. (Mucogingival surgery by Dr P. Casentini; prosthetic rehabilitation by Dr E. Cerchione.)

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Clinical Case Studies

clinical case 4 Mucogingival plastic surgery to correct a peri-implant defect affecting a maxillary lateral incisor

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Fig 11-16  (a to d) The patient is dissatisfied with the unsightly implant-supported maxillary lateral incisor restorations and wishes to improve her smile. The implants were placed and prosthetically restored some years previously. The patient has a high smile line. Radiographic examination reveals satisfactory implant osseointegration without significant bone resorption, and the implants appear to be properly positioned. The esthetic failure in this case is caused by asymmetric restorations that have different clinical lengths, exposure of part of the titanium abutment, and a grayish halo because the soft tissues are so thin that the underlying titanium abutment is apparent. (e) The grayish halo is particularly evident on a photograph taken with a polarized filter (polar_eyes, PhotoMed). (f and g) After removing the restorations, an occlusal view shows that the implant position is excessively buccal, particularly at the left lateral incisor site. The original causes of esthetic failure are therefore excessively buccal implant placement, failure to use peri-implant soft tissue augmentation procedures, and choosing an abutment profile with a finish line (chamfer) that takes additional space from soft tissues.

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clinical case 4 (cont)

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Fig 11-16  (cont) (h) Preliminary esthetic analysis highlights an inconsistency in the lateral incisor tooth axes, which appear to be diverging instead of slightly converging toward the midline. The incisal edges of the central incisors are not aligned, and the position of neighboring teeth could be improved for better tooth alignment. Orthodontic treatment is therefore suggested to improve the position and alignment of the other teeth, but the patient is only interested in correcting the lateral incisor imperfection. Soft tissue analysis at the lateral incisors shows a different situation on each side. On the right side, the position of the gingival zenith of the lateral incisor is accurate in relation to those of the central incisor and canine. Therefore, there is no need to coronally reposition the soft tissue margin on this side; the soft tissue simply needs to be thickened to stabilize it and eliminate the grayish halo. On the left side, it will be necessary to increase soft tissues thickness and coronally reposition the tissues to better distribute the gingival scalloping of the incisors and canine. Mucogingival surgery procedures to modify the tissue thickness and position will be preceded by removal of the existing restorations and placement of undersized provisional restorations to allow spontaneous soft tissue maturation. A tunneling procedure will be used at the right lateral incisor site, where soft tissue thickness augmentation is required. A bilaminar procedure will be used at the left lateral incisor site, combining a coronally repositioned flap with a connective tissue graft. (i to m) To facilitate surgical tissue handling, the first step is to remove the previous restorations and apply provisional restorations that are undersized in the mesiodistal dimension. This will improve tissue growth prior to the procedures, particularly in interproximal areas that will be used as an anchorage for tissue repositioning. Where possible, it is equally important to change the abutment profile: the chamfered finish line is converted into a vertical finishing line. This will also simplify prosthetic management of the new definitive crowns.

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Clinical Case Studies

clinical case 4 (cont)

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Fig 11-16  (cont) (n and o) Because it is not necessary to substantially change the apicocoronal position of the gingival margin of the right lateral incisor, in this area it is decided to not elevate a flap and carry out tunneling instead; the tissues are tunneled out using a microblade (Omnia) with only one cutting edge. This is turned toward the inner side of the tissues to reduce the risk of perforation. The microblade is used to tunnel into the peri-implant area and create a tunnel connecting the gingival sulcus of the adjacent central incisor and canine with this area. (p and q) A rectangular fragment of dense connective tissue taken from the tuberosity region and stripped of its epithelial layer is then placed in the tunnel. (r to u) Sequence of threading the suture used to pull the graft into the tunnel.

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eleven  Treatment of Esthetic Failures in Implant Dentistry

clinical case 4 (cont)

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Fig 11-16 (cont) (v and w) Once inserted in the tunnel, the connective tissue graft must be stabilized by an intramural suture threaded through the graft and the superficial soft tissues. After cementing a provisional crown, the suture used to pull the graft into place is secured to the provisional crown using a drop of flowable composite to help maintain the graft in a stable position. (x and y) Occlusal view of the area at the end of the procedure and frontal view of healing after 1 month, immediately before treating the defect at the left lateral incisor site. (z to bb) To treat the implant in the left lateral incisor site, a trapezoid flap is elevated to partial thickness except in the implant neck area, where it is elevated to full thickness. The first exposed implant thread is treated with increasingly fine-grade diamond burs to obtain a perfectly smooth surface. The peri-implant anatomical papillae are de-epithelialized because they will act as the recipient bed for the coronally displaced flap. (cc) A connective tissue graft taken from the maxillary tuberosity area is secured with a few periosteally anchored single resorbable 7-0 sutures.

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Clinical Case Studies

clinical case 4 (cont)

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Fig 11-16  (cont) (dd to ff) A lateral view shows how the connective tissue graft can simulate the convex contour of a root. The connective tissue graft is completely covered with the coronally displaced flap, which is secured by means of single resorbable 6-0 sutures. (gg and hh) Occlusal view of the area prior to and 6 months after mucogingival surgery. Note the significant change in tissue thickness, which will enable long-term maintenance of a stable result. (ii) Before taking a final impression, the access holes for the abutment retaining screws are sealed with composite. (jj) Horizontal and vertical tissue displacement is then carried out using a braided impression thread. The thread is gently positioned in the peri-implant sulcus, and tissue displacement is activated by putting slight pressure on the provisional crowns, which have a subgingival closure margin. (kk) A polyether impression (Impregum and Permadyne, 3M ESPE) is then taken after a few minutes of displacement, which allows the subgingival shape of the implant abutments to be identified.

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eleven  Treatment of Esthetic Failures in Implant Dentistry

clinical case 4 (cont)

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Fig 11-16 (cont) (ll to oo) Definitive metal-ceramic restorations prior to placement. (pp to tt) Intra- and extraoral views after placement of the definitive crowns show successful esthetic integration of the prosthetic rehabilitation, and long-term radiographic follow-up shows a stable peri-implant bone level. (Mucogingival surgery and prosthetic rehabilitation by Dr P. Casentini; prosthetic devices by Mr A. Schoenenberger.)

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Clinical Case Studies

clinical case 5 Mucogingival plastic surgery to correct a peri-implant defect affecting the maxillary premolars

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Fig 11-17 (a) The patient, who has a high smile line, complains that the soft tissues around the implants in the maxillary left premolar sites are asymmetric, but no other problems are present. It is decided to treat the defect by placing a connective tissue graft in an envelope flap. (b to d) A linear incision is used to create an envelope flap detached at partial thickness using a tunneling microblade. A 2.5-mm-thick connective tissue graft harvested from the palate is placed inside the envelope flap. The graft is stabilized at the soft tissue surface layer by means of two mesial and distal sutures and an intermediate intramural suture. The implant restoration is reduced in the cervical area of the first premolar then re-cemented and used as anchorage for pulling the flap-graft complex coronally. The resorbable sutures (PGA 6-0) will be removed after 3 weeks. (e to g) A final clinical follow-up reveals an appreciable improvement in mucogingival architecture, with gingival scallops aligned at both premolar sites. The extraoral view is also pleasing. (Mucogingival surgery and prosthetic rehabilitation by Dr P. Casentini; prosthetic devices by Mr C. Pedrinazzi and Mr R. Colli.)

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eleven  Treatment of Esthetic Failures in Implant Dentistry

clinical case 6 Treatment of a recession in the peri-implant mucosa combined with a bone dehiscence in the esthetic zone

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Fig 11-18  (a and b) Initial situation showing implant positioned in the maxillary lateral incisor area. After connecting a titanium abutment and provisional resin crown, buccal soft tissue recession is apparent, while a radiograph shows stable interproximal bone levels. (c and d) Mucoperiosteal flap elevation reveals the presence of a peri-implant bone dehiscence with exposure of buccal threads. (e and f) The defect is covered with bovine bone mixed with collagen (Bio-Oss Collagen, Geistlich) and protected with a connective tissue graft. (g) The flap is then coronally repositioned. (h) One year later, the definitive ceramic crown shows an excellent esthetic outcome, with thickened soft tissues protecting the peri-implant region. (i) A radiograph also shows stable marginal bone levels.

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Clinical Case Studies

clinical case 7 Treatment of esthetic failure by removing an implant and maintaining adjacent implants combined with hard and soft tissue augmentation procedures

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Fig 11-19  (a to d) Severe esthetic impairment after implant-supported rehabilitation in the esthetic zone. The patient reported placement of three immediate postextraction implants following extraction of the maxillary central incisors and left lateral incisor, which had been assessed as hopeless. The severity of the failure is accentuated by the patient’s high smile line. Such patients often complain of psychologic difficulties and tend to develop a series of protective reflexes (eg, placing a hand in front of their mouth or smiling only minimally) to reduce the visibility of the imperfection when they speak or smile. (e and f) After removing the provisional restoration, the overly buccal position and axis of the left central incisor implant are evident as well as the overly apical implant emergence profile.

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eleven  Treatment of Esthetic Failures in Implant Dentistry

clinical case 7 (cont)

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Fig 11-19  (cont) (g) An initial esthetic analysis reveals several abnormalities. The most striking factor is the different apicocoronal level of soft tissues at the left incisors compared with the right incisors. The different soft tissue level has greatly influenced the shape of the clinical crowns of left incisors, where the presence of a false root makes for a considerable difference in clinical crown length. Part of the implant abutment is exposed at the neck area of both central incisors, while the left central incisor is affected by a lack of keratinized tissue. The papilla layout and shape are also very asymmetric: the papilla between the left central and lateral incisors is not well formed and is in a much more apical position than the papilla between the right central and lateral incisors. Another factor contributing to the asymmetry is marked convergence of the axes of teeth the left incisors, which has also come about because of the impaired soft tissue levels. Lastly, the incisal margins of the two central incisors are not aligned. The treatment plan first considers the patient’s requirements, which are to improve the esthetic situation but, if possible, without removing all the implants. Whereas the clinical situation of the implants in the right central incisor and left lateral incisor sites can be improved by mucogingival procedures, the implant in site left central incisor site is considered unrecoverable and will inevitably have to be removed. The treatment plan therefore involves removing the implant at the left central incisor site and managing the residual bone defect by means of guided bone regeneration (GBR). A simultaneous connective tissue graft will improve the mucogingival architecture at the right central incisor and left lateral incisor implant sites. After corrective surgery, the peri-implant soft tissues and pontic area at the left central incisor must be conditioned by means of a new provisional restoration that will precede the definitive metal-ceramic prosthetic restoration. (h to k) After detaching a canine-to-canine flap, the implant at the left central incisor site, markedly deviated in terms of its axis as well as its apicocoronal and buccopalatal position, is removed. The implants at the right central incisor and left lateral incisor sites undergo implantoplasty to smooth the exposed rough implant surface and make room for soft tissue augmentation. The lateral views clearly show the overly buccal axis of all implants.

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Clinical Case Studies

clinical case 7 (cont)

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Fig 11-19  (cont) (l to o) The bony defect left after removing the implant is treated by a GBR with placement of deproteinized bovine-derived bone (Bio-Oss, Geistlich) and a collagen membrane (Bio-Gide, Geistlich). (p to s) An extensive connective tissue graft with a thickness of approximately 3 mm, taken from the palate by means of an envelope procedure, is positioned over the implant dehiscences and the site of the removed implant. The coronal graft component is stabilized with single sutures. Sutures suspended from the implant abutments and anchored to the apical part of the periosteum, where the flap has been elevated to partial thickness, ensure the graft adapts perfectly to the recipient bed.

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clinical case 7 (cont)

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Fig 11-19  (cont) (t to v) After a 4-month recovery period and placement of a new provisional restoration, the appearance of the treated area has clearly improved. (w to bb) A second connective tissue graft is placed below a trapezoidal flap, which is detached at partial thickness, to bring about further improvement in soft tissue volume, particularly in the left central incisor pontic site. (cc) After a further 4-month period to allow soft tissue maturation and conditioning, an impression can be taken to make a definitive prosthesis. The tissues are slightly displaced horizontally and vertically by means of a braided thread positioned in the peri-implant sulci.

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Clinical Case Studies

clinical case 7 (cont)

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Fig 11-19 (cont) (dd) An impression is taken using polyether material. (ee to ii) This is a compromise solution to maintain the implants at the maxillary right central incisor and left lateral incisor sites. The result nevertheless satisfies the patient’s requirements, and the resulting smile is now pleasing. (Mucogingival surgery and prosthetic rehabilitation by Dr P. Casentini; prosthetic devices by Mr C. Pedrinazzi and Mr R. Colli.) (jj) A 7-year clinical follow-up shows a stable outcome that represents a considerable improvement over the initial clinical situation.

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clinical case 8 Treatment of esthetic failure by implant removal, hard and soft tissue augmentation, and placement of a new implant

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e Fig 11-20  (a to d) Serious esthetic failure of a recently completed rehabilitation. The young patient is very dissatisfied with the outcome even though she has a low smile line. The implant was inserted into the extraction socket of the maxillary left central incisor, which was removed following a fracture. The patient reports that daily cleaning is difficult, and the tissues surrounding the implant where there is no keratinized tissue are chronically inflamed. The patient also suffers from dentinal hypersensitivity affecting the other maxillary anterior teeth. The lateral clinical view and radiographs reveal that implant angulation is very buccal and the implant platform position is very apical (in relation to the adjacent tooth peaks) and overly buccal. In brief, implant failure is due to improper 3D implant positioning exacerbated by a thin, scalloped periodontal biotype, triangular teeth, and a tendency to gingival recession. The original decision to place an immediate postextraction implant when the tissue is so sensitive and the buccal cortical bone is undoubtedly damaged by the fracture was also highly questionable. (e) The main elements emerging from an esthetic analysis include the presence of a deep soft tissue dehiscence at the implant site, creating obvious asymmetry between the gingival scallops of the central incisors, which also have inconsistent axes. The adjacent teeth are also affected by gingival recession with root exposure, which is responsible for the dentinal hypersensitivity reported by the patient. The shape and color of the implant-supported restoration are also inappropriate. Due to the very deviated implant position, the only reliable and predictable solution is to remove the implant and carry out procedures to reconstruct the alveolar ridge and surrounding soft tissues and then carry out prosthetically guided placement of a new implant in a more favorable position. The treatment plan will also include treatment of gingival recessions around adjacent teeth.

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Clinical Case Studies

clinical case 8 (cont)

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Fig 11-20  (cont) (f to j) The first stage of treatment is to remove the restoration, abutment, and implant. Elevation of a small flap confirms that the implant position is completely incorrect, with its axis approximately 45 degrees to the adjacent teeth. Becausse of the smooth implant surface, the fragile osseointegration can be broken simply by unscrewing the implant using root forceps. When this maneuver is possible, it is undoubtedly the least invasive approach as far as the surrounding bone tissue is concerned. After repositioning the tissues using a fine resorbable suture (PGA 6-0), the patient is fitted with a removable partial prosthesis as a provisional rehabilitation. (k and l) After a healing period of 3 months, the appearance of the treated area is much improved, and spontaneous healing has led to the formation of a normal keratinized tissue band. It is now possible to go ahead with GBR.

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eleven  Treatment of Esthetic Failures in Implant Dentistry

clinical case 8 (cont)

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Fig 11-20  (cont) (m) The aim of reconstruction is to re-create sufficient bone volume and at the same time treat gingival recessions around teeth close to the edentulous site. A mucogingival surgery–derived flap design10 suitable for bone regeneration surgery is used for this purpose. This requires small releasing incisions in distal areas. Flap detachment considers the different needs in different sectors: Detachment is full thickness in the edentulous area and partial thickness around the gingival recessions. (n to r) Autologous bone required for bone reconstruction is taken from the mandibular ramus area, which is exposed by making a paramarginal linear incision. The next step is to harvest a block of cortical bone and convert it to particulate bone using a special bone mill (R. Quétin, KLS Martin). Currently, it is preferred to harvest particulate autologous bone using a scraper because this technique is simpler and less invasive.

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Clinical Case Studies

clinical case 8 (cont)

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Fig 11-20  (cont) (s to v) After installation and detachment of a flap in accordance with the above principles, a PTFE membrane with titanium reinforcement (Gore-Tex, W. L. Gore) is fixed by means of titanium pins to the recipient site, which is prepared by making multiple drillings into the cortical bone using a small-diameter rose-head bur mounted on a straight handpiece. The defect is then filled with particulate autogenous bone. Note that in current standard practice, in general, when GBR procedures are used, the use of nonresorbable PTFE is reserved for cases with pronounced bony defects and a significant vertical component. For less severe defects and particularly horizontal defects, resorbable collagen membranes have replaced PTFE membranes or titanium mesh. The filler material most commonly used is a mixture of autogenous bone and deproteinized bovine-derived bone (Bio-Oss), which is equally effective and reduces the morbidity associated with the need to harvest more autologous bone. (w to bb) Once GBR is complete, the mucogingival component of the procedure can start. Roots showing signs of recession are manually planed using a well-sharpened 5/6 mini Gracey curette. The anatomical papillae are de-epithelialized using a round diamond bur mounted on a straight handpiece. Lastly, the roots are chemically conditioned with ethylenediaminetetraacetic acid (PrefGel, Straumann) and treated with amelogenin (Emdogain, Straumann). As discussed in chapter 6, this procedure has proved effective in improving the prognosis of root coverage surgery procedures. The flap is then released and passively coronally repositioned, where it is sutured into its final position with 5-0 PTFE monofilament sutures.

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eleven  Treatment of Esthetic Failures in Implant Dentistry

clinical case 8 (cont)

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Fig 11-20  (cont) (cc and dd) Clinical follow-up after 2 weeks; 9 months prior to implant surgery. (ee to ii) The graft maturation time after GBR with a PTFE membrane is normally 9 months unless the membrane is exposed. After this time interval, a small trapezoid flap is elevated so that the PTFE membrane can be exposed and removed. It is normal to find a layer of fibrous tissue approximately 1 mm thick under the membrane, and this is not removed. The implant site is prepared following the customary milling sequence up to implant placement (SLActive Bone Level implant 4.1 × 10 mm, Straumann). The site is closed by first intention by means of a 6-0 monofilament suture. (jj) Two months later, the site is reopened for a healing abutment. This procedure is also important for realigning the mucogingival junction, which was moved palatally during previous procedures. With this aim, a small flap is designed with two parallel releasing incisions joined by a palatally displaced horizontal incision. The vertical incisions extend slightly beyond the mucogingival junction to allow apical displacement of the keratinized tissue band, and they are paramarginal, ie, they do not involve the papillae of adjacent teeth, which must not be disturbed.

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Clinical Case Studies

clinical case 8 (cont)

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Fig 11-20  (cont) (kk and ll) The healing abutment is connected. After replacing the cover screw with a healing screw, the flap is fixed in its new position with fine monofilament sutures (6-0). (nn to pp) Excellent soft tissue healing after 3 weeks allows an impression to be taken for a provisional crown. (qq to ss) A provisional crown is made.

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eleven  Treatment of Esthetic Failures in Implant Dentistry

clinical case 8 (cont)

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Fig 11-20  (cont) (tt and uu) Before taking an impression to fit a definitive restoration, the peri-implant soft tissues are conditioned with the provisional crown. (vv and ww) Buccal and occlusal images demonstrate soft tissue conditioning achieved by means of a provisional restoration. (xx) Information on the exact soft tissue morphology obtained by means of the provisional restoration is transferred to the dental laboratory using the customized impression transfer technique (see chapter 9). (yy to aaa) A definitive zirconia abutment designed and produced using CAD/CAM (CARES System, Straumann).

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Clinical Case Studies

clinical case 8 (cont)

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Fig 11-20 (cont) (bbb) A definitive lithium disilicate ceramic crown (e.max, Ivoclar) essentially mimics the contours of the provisional restoration. (ccc and ddd) Appearance of soft tissues conditioned by provisional restoration after definitive abutment placement. Note the sufficiently thick soft tissues and tissue symmetry at the central incisors. (eee to ggg) Clinical and radiographic follow-up and patient’s smile after rehabilitation. (Reconstructive, mucogingival, and implant surgery and prosthetic rehabilitation by Dr P. Casentini; prosthetic devices by Mr C. Pedrinazzi and Mr R. Colli.)

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eleven  Treatment of Esthetic Failures in Implant Dentistry

clinical case 8 (cont)

iii

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mmm Fig 11-20  (cont) (hhh and iii) Occlusal and profile views also show that the situation has been successfully restored. (jjj and kkk) The fluorescence of the restoration is very similar to that of the adjacent natural teeth, in which a fracture line can be detected in the enamel. Restoration material fluorescence is considered an important factor when attempting to achieve a natural-looking restoration under different types of lighting. (lll and mmm) A comparison between the clinical situations before and after treatment reveals correction of the implant failure as well as a distinct improvement in the mucogingival architecture achieved by treating the gingival recessions affecting the adjacent teeth. The patient was fully satisfied with the outcome and reported that her dentinal hypersensitivity problem was resolved.

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Clinical Case Studies

clinical case 9 Removal of an implant improperly positioned in the esthetic zone using a universal implant removal kit followed by prosthetically guided replacement

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Fig 11-21  (a and b) The initial clinical situation reveals esthetic failure of implant treatment at the maxillary right lateral incisor site. The patient has undergone immediate postextraction implant placement in an area showing discoloration due to a previous apicoectomy. Implant placement was overly buccal, resulting in soft tissue recession compensated for esthetically by lengthening the metal-ceramic restoration. Given the unfavorable implant position, it is not considered recoverable, and its removal is planned in combination with soft tissue augmentation, placement of a new implant, and GBR. (c) An occlusal view with an open flap confirms the overly buccal implant position. (d) Raising the flap also reveals lack of buccal cortical bone, exposure of the implant threads, and the presence of silver amalgam residues left over from the previous apicoectomy. (e) Special universal kits (Fixture Removal Kit, Neobiotech) are currently available for atraumatic removal of osseointegrated implants. The basic principle is that an initial screw is selected based on implant size, placed in the implant, and tightened clockwise. The implant extractor is then screwed counterclockwise onto the first screw. A torque wrench capable of high torque (up to 200 Ncm) can then be used to unscrew the implant in a counterclockwise direction. (f) The initial screw is tightened clockwise.

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eleven  Treatment of Esthetic Failures in Implant Dentistry

clinical case 9 (cont)

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Fig 11-21  (cont) (g to j) The implant extractor is tightened in a counterclockwise direction, and the implant is then removed by unscrewing it atraumatically with a torque wrench. (k to m) A combined hard and soft tissue deficiency remains after implant removal. A delayed approach is adopted, and initially only the soft tissue defect is treated, using a connective tissue graft taken from the palate. (n to q) Twelve weeks later, once the soft tissues have healed, surgery can be carried out to position a new implant. Following elevation of a partial flap, full thickness in the coronal portion and half thickness in the apical portion, an occlusal view reveals that the bone ridge is thin buccopalatally. Therefore, the new implant position will not be guided by bone volume availability but by prosthetic planning and construction of a surgical template.

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Clinical Case Studies

clinical case 9 (cont)

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Fig 11-21 (cont) (r to v) A new implant (T3 Certain Tapered 3.25 × 13 mm, Zimmer Biomet) is inserted in a position that is prosthetically guided in both the vertical and horizontal planes. The deficiency is managed by horizontal bone regeneration using bovine-derived particulate matter (Bio-Oss small granules, 0.25–1 mm) mixed with heterologous fibrin glue (Tisseel) and protected by a double layer of resorbable porcine collagen membrane (Bio-Gide). The flap requires a crestal incision connected by two vertical releasing incisions designed to avoid the interdental papillae. The flap is then sutured using a combination of simple interrupted O-shaped sutures and horizontal mattress sutures (PTFE 5-0). (w) A postsurgical radiograph demonstrates accurate implant placement. (x) Six months later at stage-two surgery, a good outcome of the regenerative technique is evident, with formation of new bone tissue that completely covers the implant threads buccally. (y) The soft tissues are then carefully repositioned around the implant healing screw. (z to bb) Clinical images taken 1 year after positioning the titanium abutment and ceramic crown show an excellent esthetic outcome, partly attenuated only by the loss of periodontal attachment on the distal aspect of the adjacent right central incisor. The soft tissues are also well shaped from the occlusal aspect, and an intraoral radiograph shows that the marginal bone levels are stable. (Prosthetic rehabilitation by Dr R. Salerno.)

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eleven  Treatment of Esthetic Failures in Implant Dentistry

clinical case 10 Treatment of esthetic failure affecting maxillary central incisor implants by implant removal, ridge preservation, and placement of new implants

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Fig 11-22  (a to c) This is another case of esthetic failure affecting a young patient, exacerbated by broad exposure when smiling. Another factor in common with the previous case is a history of immediate postextraction implant placement, in this case due to endodontic problems. Although the periodontal biotype is much more favorable here, with less scalloped tissues and square-shaped teeth, overly buccal implant positioning and excessive implant diameter have led to serious esthetic failure. (d and e) Profile view and an occlusal view following removal of the implant restorations reveal that both implants are located too far buccally. (f) The very unfavorable implant positions are considered a negative prognostic element. Other factors that are considered when drawing up the treatment plan include the unknown original implant type as well as the large-diameter implant platform and abutments cemented inside the implants. The patient’s age and her strong desire for a good esthetic outcome are also considered. Assessing all these elements leads to a decision to remove the current implants and replace them with new implants following hard and soft tissue augmentation procedures. However, some innovative factors are introduced to simplify the treatment in this case: The implants will be removed using a flapless technique immediately followed by ridge preservation. This is done to minimize damage to the residual bone tissue and immediately repair the implant sockets. An attempt will also be made to increase soft tissue thickness by sealing the residual ridge cavities with two soft tissue punches. Implant placement will take place 4 months later with the aid of planning software and a computer-guided template. (g and h) After removing the restorations, the implants are unscrewed by holding the prosthetic platform using extraction forceps and applying a strong counterclockwise force.

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Clinical Case Studies

clinical case 10 (cont)

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Fig 11-22  (cont) (i to m) After implant removal, the implant sockets are treated using ridge preservation. The epithelial layer of the transmucosal tunnel is removed using a diamond bur, and deproteinized bovine-derived bone (Bio-Oss Collagen) is gently compacted into the sites. The sites are sealed by means of two small gingival tissue punches taken from the palate, which are attached to the surrounding walls with fine-diameter resorbable sutures (PGA 6-0). In this case, autogenous soft tissue grafting is considered a useful tool for bringing about a rapid improvement in soft tissue shape and thickness. (n) A removable provisional prosthesis is made using a thermoformed template. (o and p) Two weeks later, suture removal reveals rapid healing and good integration of the autogenous soft tissue grafts.

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eleven  Treatment of Esthetic Failures in Implant Dentistry

clinical case 10 (cont)

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Fig 11-22  (cont) (q to u) After 6 months of healing, a template is produced for computer-guided planning. This is fitted to the patient for the purposes of 3D radiographic examination, which is subsequently assessed with the aid of guided surgery software (CARES, Straumann). (v to x) Virtual planning is used to check three main parameters. The first is integration of the osteoconductive biomaterial graft for subsequent implant osseointegration. The second is choice of implant diameter and length. In this case, there is enough residual bone volume to accommodate two small-diameter implants measuring 12 mm in length (SLActive Bone Level Roxolid 3.3 × 12 mm, Straumann). Reduced-diameter implants allow sufficient space between the implants to achieve an inter-implant papilla. The third parameter is choice of implant axis; when possible, it is always best to choose an implant axis compatible with a screw-retained restoration in the esthetic zone. This simplifies the provisional restoration management stages and eliminates the need for cement when placing the definitive restoration.

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Clinical Case Studies

clinical case 10 (cont)

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Fig 11-2 (cont) (y) After virtual planning of implant placement, the diagnostic template is modified, and a computer-guided surgical template is prepared with the usual metal sleeves for insertion of specifically calibrated burs. (z) Although surgery is computer guided, it is not performed using a flapless technique since the aim is to increase bone volume by means of GBR concomitant with implant placement. Flap elevation reveals that the biomaterial positioned during initial ridge preservation is so well integrated that it is now indistinguishable from the surrounding bone tissue. (aa) Implant sites are prepared using special guided surgery burs that are inserted fully to the surgical template sleeves. (bb to dd) Two 3.3 × 12–mm implants are placed. Note the optimal mesiodistal spacing between the implants. (ee) The GBR technique allows an improvement in the ridge profile. ee

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eleven  Treatment of Esthetic Failures in Implant Dentistry

clinical case 10 (cont)

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ll Fig 11-22  (cont) (ff to hh) The ridge profile appears slightly contracted despite the ridge preservation procedure. The Bio-Oss granules are stabilized using a double-layer collagen membrane (Bio-Gide) (ii and jj) The flap is then passively advanced and sutured by first intention using a reduced-diameter resorbable suture (PGA 6-0). (kk to mm) Four months later, minimally invasive flap reopening is carried out following removal of the provisional resin-bonded partial denture. Healing screws are connected to the implants after making a slightly palatal ridge incision that avoided the mesial papillae of the two lateral incisors. A suture (PGA 6-0) is only required in the inter-implant area.

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Clinical Case Studies

clinical case 10 (cont)

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Fig 11-22  (cont) (nn and oo) Impressions are taken for provisional crowns when the sutures are removed. Screw-retained transfers are usually used together with a perforated impression tray filled with polyether (Impregum and Permadyne). (pp and qq) If the rehabilitation involves a limited anterior sector, instead of using facebow registration to provide the dental technician with information to orient models accurately, the procedure can be simplified by using a linear reference (eg, a brush for adhesive procedures) positioned parallel to the bipupillary line and secured in place with a small amount of occlusal registration material (Ramitec, 3M ESPE). (rr) Cast assembly in the laboratory is guided by the previously registered reference marks. Accurate assembly is essential in cases involving both central incisors for correct vertical orientation of the interincisal line. (ss and tt) The dental technician prepares a wax-up of the central incisors as well as the lateral incisors and canines to optimize their shapes. Direct composite restorations can be applied to these teeth. The shapes are checked after applying gold paint to the cast. (uu and vv) Provisional restorations on the cast prior to fitting. In accordance with the computer-guided treatment plan, the restorations are tightened, and the holes for access to the retaining screws are optimally positioned. (Laboratory stages by Mr A. Schoenenberger.)

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eleven  Treatment of Esthetic Failures in Implant Dentistry

clinical case 10 (cont)

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Fig 11-22  (cont) (ww and xx) Initially, the provisional restoration emergence profile should not compress the soft tissues excessively. A small overlap is often present at this stage, which will subsequently be filled with composite (see chapter 9). (yy and zz) Intraoral appearance after placing provisional restorations on the central incisors and direct composite restorations on the lateral incisors and canines. (aaa to ddd) Once the peri-implant soft tissues have been properly conditioned, impressions are taken for the definitive crowns, and the bite is again registered using a reference mark parallel to the bipupillary line.

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Clinical Case Studies

clinical case 10 (cont)

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iii Fig 11-22 (cont) (eee to hhh) Custom zirconia abutments made using CAD/CAM are directly coated with ceramic. Transillumination with white and ultraviolet light reveals restoration translucency and fluorescence. (Laboratory stages by Mr A. Schoenenberger.) (iii) Clinical follow-up after placing the definitive crowns.

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eleven  Treatment of Esthetic Failures in Implant Dentistry

clinical case 10 (cont)

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Fig 11-22  (cont) (jjj and kkk) The restorations are well integrated with the surrounding hard and soft tissues. Note the correspondence between the extraoral reference lines (bipupillary line and facial midline) and intraoral reference lines (incisal margin line and interincisal line). (lll and mmm) A clinical follow-up 4 years later shows good hard and soft tissue stability and favorable integration of the restorations in the patient’s smile after completion of the prosthetic rehabilitation. (nnn and ooo) Comparison between before and after treatment reveals a considerable improvement in the soft tissue levels and appearance of the smile.

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Clinical Case Studies

clinical case 11 Treatment of partial regenerative failure using an implant-supported prosthesis with pink porcelain

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Fig 11-23  (a and b) Prosthetically guided bone reconstruction surgery is planned to treat this extensive defect, which is the outcome of injury to the maxilla. A thermoformed template is placed to guide bone reconstruction. (c and d) The large defect is treated with a bone block graft taken from the iliac crest combined with two smaller block grafts taken from the mandibular ramus. The blocks are fixed by means of osteosynthesis screws. (e) During the first stages of healing, wound dehiscence occurs, exposing the central part of the graft. The dehiscence is treated by curettage of the dehiscent borders and milling of the exposed graft. Healing eventually occurs. (f to h) Nevertheless, dehiscence and graft exposure result in greater than normal resorption in the central part of the graft. It is possible to place two implants (Bone Level Roxolid 3.3 × 12 mm, Straumann) using a prosthetically guided procedure in the lateral sectors unaffected by the dehiscence.

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eleven  Treatment of Esthetic Failures in Implant Dentistry

clinical case 11 (cont)

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Fig 11-23  (cont) (i) The bone ridge shape is not ideal at the time of prosthetic restoration, despite the attempt to compensate for graft resorption with biomaterial placement and a soft tissue graft. This deficiency has a negative impact on the patient’s smile due to her high smile line. (j) All the tissues below the dotted line must be restored; thus crowns as well as a certain amount of soft tissue are involved. (k and l) Impressions are then taken using a screw-retained transfer and a perforated impression tray (Impregum and Permadyne). (m and n) Interocclusal registration is then performed using a linear reference positioned parallel to the bipupillary line, as described in the previous case (see Figs 11-22pp and 11-22qq). (o and p) The residual tissue deficiency is corrected by means of a prosthesis that partly reproduces the soft tissues by incorporating a pink component.

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Clinical Case Studies

clinical case 11 (cont)

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Fig 11-23  (cont) (q and r) In restorations of this type, it is essential to include a provisional rehabilitation stage in order to establish that the patient can follow proper oral hygiene procedures at home. Prosthetic restoration design is also important because concave areas must be avoided at all costs. (s to v) After a trial period using a provisional prosthesis, a definitive screw-retained zirconia-ceramic prosthesis is prepared. In the definitive prosthesis, the connection between the implants and prosthetic mesostructure is secured by original metal components that are bonded into the zirconia-ceramic mesostructure. The zirconia structure is tried in the mouth prior to ceramic coating. The zirconia structure has been precolored before sintering to promote a better esthetic outcome after ceramic coating.

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eleven  Treatment of Esthetic Failures in Implant Dentistry

clinical case 11 (cont)

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bb Fig 11-23  (cont) (w) Testing the definitive prosthesis at the “biscuit” stage allows small changes in shape and color to achieve optimum final esthetic integration. (x) An extraoral photograph with retractors is used to check the correspondence between extraoral (bipupillary line and facial midline) and intraoral (incisal margin line and interincisal line) reference lines. (y and z) Definitive prosthesis prior to placement. (Prosthetic devices by Mr A. Schoenenberger.) (aa and bb) Intraoral views after fitting the definitive prosthesis confirm good integration of the prosthetic device in the surrounding tissues, creating a good biomimetic effect.

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Clinical Case Studies

clinical case 11 (cont)

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Fig 11-23  (cont) (cc and dd) The patient’s smile is pleasing and no pink porcelain is apparent. (Prosthetic rehabilitation by Dr P. Casentini.) (ee to ii) A clinical follow-up after 5 years reveals good hard and soft tissue stability. One of the main advantages of pink porcelain over composite resin is its color stability over time.

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eleven  Treatment of Esthetic Failures in Implant Dentistry

clinical case 12 Treatment of complete implant and regenerative failure by means of a tooth-supported prosthesis with pink porcelain

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Fig 11-24  (a to f) The patient reported previous placement of an implant at the maxillary left central incisor site. The implant failed, resulting in bone deficiency, and the patient underwent bone augmentation surgery that also failed. The edentulous maxillary left central incisor site is currently being treated by means of a provisional removable partial denture. Clinical examination reveals the presence of severe attachment loss at the adjacent lateral incisor, which displays grade 3 mobility and probing to the depth of the apical region on the mesial aspect. Extensive scarring is also present at the edentulous site. The smile line is difficult to assess at the time of examination because the patient is in a state of great psychologic distress. However, photographs taken prior to treatment, provided by the patient, show a medium-high smile line. The patient also provided a panoramic radiograph taken immediately after the failed implant placement. The proposed treatment plan considers the patient’s requirements, which are to avoid new implant treatment. Regardless of the patient’s requirements, placement of a new implant would be very risky because it would involve 3D bone reconstruction involving a significant vertical component with poor quality soft tissues and extensive scar tissue from the previous surgery. For this reason, the least risky and most reliable long-term solution is to prepare a traditional partial denture supported by the right central incisor and left canine. The prognosis of the left lateral incisor is poor, and it is extracted. When preparing tooth-supported prosthetic restorations, the greatest care is taken to sacrifice as little tooth substance as possible and preserve the vitality of the abutments. Pink porcelain is used to compensate for the tissue deficiency.

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Clinical Case Studies

clinical case 12 (cont)

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Fig 11-24 (cont) (g to i) Final preparation of prosthetic abutments before taking a final impression. The soft tissues are slightly retracted and displaced by positioning a fine braided fiber in the gingival sulcus. (j and k) This material’s good translucency promotes natural passage of light and good esthetic integration. (l and m) The dental technician must avoid the presence of concave areas that cannot be cleaned when designing a partial denture with pink porcelain.

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eleven  Treatment of Esthetic Failures in Implant Dentistry

clinical case 12 (cont)

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Fig 11-24  (cont) (n and o) The appearance of the completed rehabilitation shows satisfactory integration with the surrounding tissues and good biomimetic integration with no sign of the pink porcelain. The patient is given proper training in the daily use of Super Floss (Oral-B) for oral hygiene at home because of the additional pink resin. (Prosthetic rehabilitation: Dr P. Casentini; prosthetic devices by Mr C. Pedrinazzi and Mr R. Colli.) (p to u) Clinical and radiographic follow-up after 7 years shows a stable outcome. The prosthetic restoration is well integrated with the surrounding tissues, and the patient’s smile is pleasing, confirming the pretreatment assumption of a high smile line.

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References

References 1. Grunder U, Gracis S, Capelli M. Influence of the 3-D bone-to-implant relationship on esthetics. Int J Periodontics Restorative Dent 2005;25:113–119. 2. Evans CD, Chen ST. Esthetic outcomes of immediate implant placements. Clin Oral Implants Res 2008;19:73–80. 3. Burkhardt R, Joss A, Lang NP. Soft tissue dehiscence coverage around endosseous implants: A prospective cohort study. Clin Oral Implants Res 2008;19:451–457. 4. Zucchelli G, Mazzotti C, Mounssif I, Marzadori M, Stefanini M. Esthetic treatment of peri-implant soft tissue defects: A case report of a modified surgical-prosthetic approach. Int J Periodontics Restorative Dent 2013;33:327–335. 5. Roccuzzo M, Gaudioso L, Bunino M, Dalmasso P. Surgical treatment of buccal soft tissue recessions around single implants: 1-year results from a prospective pilot study. Clin Oral Implants Res 2014;25:641– 646.

6. Zucchelli G, Mazzotti C, Mounssif I, Mele M, Stefanini M, Montebugnoli L. A novel surgical-prosthetic approach for soft tissue dehiscence coverage around single implant. Clin Oral Implants Res 2013;24:957–962. 7. Levine RA, Huynh-Ba G, Cochran DL. Soft tissue augmentation procedures for mucogingival defects in esthetic sites. Int J Oral Maxillofac Implants 2014;29:155–185. 8. Zucchelli G, Felice P, Mazzotti C, et al. Five-year outcome after coverage of soft tissue dehiscence around single implant: A cohort prospective study. Eur J Oral Implantol 2018;11:215–224. 9. Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985;5:8–13. 10. Zucchelli G, De Sanctis M. The coronally advanced flap for the treatment of multiple recession defects: A modified surgical approach for the upper anterior teeth. J Int Acad Periodontol 2007;9:96–103.

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Cardaropoli Casentini

About the Authors

Soft Tissues & Pink Esthetics

Paolo Casentini, dds, earned his degree in dentistry from the University of Milan and subsequently attended the oral surgery and implantology program at San Paolo University Centre in Milan. He currently maintains a private practice in Milan, with a particular interest in regenerative surgery and esthetic treatment. Dr Casentini is the author of numerous journal articles in the fields of implantology and regenerative surgery as well as the online education channel. He is also the co-author of nine books on oral surgery, implant surgery and prosthetics, and advanced implantology. He has lectured in more than 40 countries and is a fellow and president of the Italian Section of the International Team for Implantology (ITI), director of the ITI Milan 1 Study Group, and an active member of the IAO and the SIdP.

Paolo Casentini,

in Implant Therapy

Daniele Cardaropoli, dds, graduated with honors with a degree in dentistry and dental prosthetics and subsequently pursued postgraduate studies in periodontology at the University of Turin. He obtained postgraduate diplomas in periodontology and implantology from the Harvard School of Dental Medicine and in biomechanics from the University of Siena in Italy. In addition to his private practice in Turin, Dr Cardaropoli is the scientific director of the Institute for Professional Education in Dentistry (ProEd) and head of oral implantology at the Sedes Sapientiae Clinic. He is a member of the editorial board of The International Journal of Periodontics & Restorative Dentistry and a reviewer for several journals. Dr Cardaropoli lectures widely and is also the author of numerous publications. He is the recipient of both the Henry M. Goldman Prize for clinical research from the Italian Society of Periodontology and Implantology (SIdP) as well as the Italian Society of Orthodontics (SIDO) National Award in Clinical Orthodontics. Dr Cardaropoli is an active member of the SIdP, the European Federation of Periodontology (EFP), the Italian Academy of Osseointegration (IAO), and the Academy of Osseointegration (AO) and an international member of the American Academy of Periodontology (AAP).

Daniele Cardaropoli,

DDS

DDS

Soft Tissues & Pink Esthetics

in Implant Therapy

ISBN 978-0-86715-815-1

90000>

9 780867 158151

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