Lateral Sliding Flap to Assist with Anterior Maxillary Dental … · The Journal of Implant &...

The Journal of Implant & Advanced Clinical Dentistry

Volume 7, No. 9 NoVember 2015

Treatment of maxillary periradicular cysts in combination with dental implants

Lateral Sliding Flap to Assist with Anterior Maxillary

Dental Implant Esthetics

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The Journal of Implant & Advanced Clinical Dentistry • 3

The Journal of Implant & Advanced Clinical DentistryVolume 7, No. 9 • NoVember 2015

Table of Contents

11 Laterally Sliding Flap Surgical Approach for Soft Tissue Closure in Post-Extraction Alveolar Ridges: Technique and Clinical Results Presented in a Case Series Hernán Bontá, Nelson Carranza, Facundo Caride, Mariana Rojas, Federico Galli

23 Multidisciplinary Approach for Treatment of Severly Resorbed Maxillary Anterior RIdge Complicated by Cysts in a Single Surgical Session Dr. Britto Falcón

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SURGICAL FLEXIBILITY. PROSTHETIC VERSATILITY.SYBRON DEPENDABILITY.

HEADQUARTERSUSA1717 West Collins AveOrange, California 92867 T 714.516.7800

EuropeJulius-Bamberger-Str. 8a28279 Bremen, GermanyT 49.421.43939.0

United Kingdom4 Flag Business ExchangeVicarage Farm RdPeterborough, UK PE1 5TXT 00.8000.841.2131

France16 Rue du Sergent Bobillot93100 Montreuil, FranceT 33.149.88.60.85

Australia# 10, 112-118 Talavera RdNorth Ryde, NSW 2113T 61.2.8870.3099

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Oralife is a single donor grafting product processed in accordance with AATB standards as well as state and federal regulations (FDA and the states of Florida, California, Maryland and New York). Oralife allografts are processed by LifeLink Tissue Bank and distributed by Exactech Inc.1. Data on file at Exactech. 2. McAllister BS, Hagnignat K. Bone augmentation techniques. J Periodontal. 2007 Mar; 78(3):377-96. 3. Blum B, Moseley J, Miller L, Richelsoph K, Haggard W. Measurement of bone morphogenetic proteins and

other growth factors in demineralized bone matrix. Orthopedics. 2004 Jan;27(1 Suppl):s161-5.

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31 Management of Complex Deeply Positioned, Severely Mal-Aligned Dental Implant: A Case Report Dr. Adnan Al-Fahd, Dr. Iman Radi

37 Management of the Wide Space in the Anterior Maxilla with a Dental Implant Restoration: A Case Report Dr. Amir Fayaz, Dr. Mohammad Jafarian, Dr. Yeganeh Memari, Dr. Seyedeh Mahsa Sheikh-Al-Eslamian



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Bontá et al

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Bontá et al

Background: Since the decade of the 1970s dif-ferent techniques have been developed to achieve primary closure. An alternate lingual/palatal slid-ing flap surgical technique to obtain primary soft tissue closure in post extraction socket sites was present with followed during six months.

Methods: Ten teeth including incisors, canines and premolars were atraumatically extracted, followed by a lingual or palatal slid-ing flap to obtain primary closure of the sock-ets. Before the extraction measurements of the mucogingival junction were done with a peri-odontal probe for displacement evaluation.

Results: The sites were followed-up to six months, and no complications such as flap necro-sis, excessive bleeding, pain, or displacement of the mucogingival junction (MGJ) were recorded.

Conclusions: The laterally sliding flap variant presented is a simple, versatile, and predictable, technique to obtain primary wound closure of maxillary and mandibular anterior teeth, while pre-serving the position of the mucogingival junction.

Laterally Sliding Flap Surgical Approach for Soft Tissue Closure in Post-Extraction Alveolar Ridges: Technique

and Clinical Results Presented in a Case Series

Hernán Bontá1 • Nelson Carranza2 • Facundo Caride1 Mariana Rojas3 • Federico Galli1

1.Associate Professor, Department of Periodontics, University of Buenos Aires, Buenos Aires, Argentina

2. Professor and Chairman, Department of Periodontics, University of Buenos Aires, Buenos Aires, Argentina

3. Clinical instructor. Specialist in Periodontics, Department of Periodontics, University of Buenos Aires, Buenos Aires, Argentina

Abstract

KEY WORDS: Orthodontics, periodontics, osteopenia, bone graft


12 • Vol. 7, No. 9 • November 2015

INTRODUCTIONAlveolar ridge bone defects may occur because of multiple factors: loss of periodontally com-promised teeth, root fracture, extensive root decay, periapical lesions or traumatic lesions.1,2

Also, traumatic tooth extraction injuries com-promising one of the socket walls involving the alveolar ridge bone may result in alveolar pro-cess ridge defects.3 The importance of post extraction ridge preservation grows significantly in implant therapy. The success of implants are not only measured by its survival rate but also by its functional stability and long-term esthetic outcome. The implant placement is based upon the final restauration, with a correct tridimen-sional placement enabling the optimum sup-port and hard and soft surrounding tissues stability.4,5 Several studies have documented the morphological and dimensional alveolar ridge changes following tooth extraction.6-18

In a clinical trial in human beings conducted

by means of a volumetric analysis, Schropp et al.13 in 2013 established that a loss of horizon-tal volume from 5 to 7 mm occurs within the first 12 months. The loss found corresponds to approximately 50% of the original alveolar ridge width.They further observed that the buc-cal bone plate was located 1.2 mm more api-cally than the lingual bone plate. It has been suggested that the largest resorption at the buccal aspect is due to a larger proportion of tooth derived bundle bone that loses its func-tion following extraction and hence undergoes bone atrophy.13 As a result of the buccal aspect resorption, collapsing of soft tissues appear.

Figure 1: Male patient, 42 years. Upper central incisor with external dentin resorption. Planned treatment involves atraumatic extraction with socket preservation and laterally sliding palatal flap for soft tissue closure.

Figure 2: Radiographic image. Note the dentin resorption and the poor restoration

Bontá et al


Particularly, in the anterior aspect of the mouth, this event can jeopardize esthetic results.15 Sev-eral treatment modalities have been suggested to minimize the volumetric changes following tooth extraction.19-26 Healing following immedi-ate implant placement has been observed in a series of trials demonstrating that the procedure is not only incapable of preserving the alveolar ridge dimensions, especially at the socket buc-cal aspect, but also could even result in mar-ginal osseointegration loss.19,20 Because of it, the placement of biomaterial grafting has been

suggested with the aim of preserving in some way the alveolar ridge dimensions. Many studies have shown that significant chance to avoid the alveolar ridge reduction is possible.21-24 Never-theless, data from experimental research have shown that biomaterial grafting is neither capa-ble of reducing the remodeling biological pro-cess that takes place at the buccal bone plate nor the complete ridge volume preservation.25, 26

The major number of studies reports the predictable achievement of bone regenera-tion through a suitable surgical protocol pay-

Figure 3: Luxation with periotomes. Figure 4: Extraction itself with forceps.

Figure 5: Extraction itself with forceps. Figure 6: Socket. Note the tissues integrity.

Bontá et al

14 • Vol. 7, No. 9 • November 2015

Bontá et al

ing special attention to the achievement of a tension-free and complete wound closure. The early implant and/or membrane exposi-tion has a negative effect on the regenera-tion process.27-29 Several techniques have been described with the aim of achieving the primary closure (sliding-rotated flap, free gin-gival graft, subepithelial connective tissue

graft).30-46 The alveolar socket seal by means of the free gingival graft with subepithelial con-nective tissue was used initially to minimize the soft tissue shrinkage following tooth extrac-tion, hold the coagulum, optimize esthetic out-comes and achieve primary wound closure avoiding biomaterial bacterial contamination and secondly, the regeneration failure.30-34

Figure 7: Schematic representation. Socket. Figure 8: Schematic representation. Flap design. The incision length corresponds with socket mesiodistal diameter.

Figure 9: Flap design. Incisions. Note the releasing vertical incision and the cut-back.

Figure 10: Schematic representation. Flap design. Incisions.


Bontá et al

The aim of the present study is to describe an alternative laterally sliding lingual or pala-tal graft surgical technique to be applied in upper or lower teeth to close sockets soft tissue following tooth extraction and offer the clinical outcomes following 6 months.

MATERIAL AND METHODSPatient Selection This study involves 10 sockets selected from 10 patients seeking dental care at the Depart-ment of Periodontics, Universidad de Buenos Aires. (FOUBA). The mean age of patients is 42.2 years (21-62 years). All participants were considered to be in good general health.

Figure 11: Split thickness flap. Note the tension-free flap rotation and the socket coverage.

Figure 12. Schematic representation. Flap rotation (a→ a’ – b→b´).

Figure 13: Socket preservation with Bone Ceramic (Straumman).

Figure 14: Internal horizontal matress suture to bring together tissues and closure with simple stitches. Note lack of tension and primary closure.

16 • Vol. 7, No. 9 • November 2015

Bontá et al

Smokers were excluded. The sample included upper incisors and premolars (4 central inci-sors, 3 lateral incisors, 1 cuspid, 2 first premo-lars. The reasons for performing tooth extraction were: caries (n = 4), periodontal disease (n = 3), longitudinal root fracture (n = 2) or trans-verse root fracture (n = 1). All the patients signed the informed consent accordingly to the approved FOUBA Ethics Committee rules.

Surgical Procedure All the patients received antibiotic prophylaxis (2 g amoxicillin) 1 hour prior to the clinical pro-cedures. Before the extraction measurements of the mucogingival junction were done with a periodontal probe (UNC probe, Hu-Friedy). The distance till the intersection was measured with another periodontal probe hold horizontally from the gingival cenit of neighboring teeth. The

Figure 15: Internal horizontal matress suture to bring together tissues and closure with simple stitches. Note lack of tension and primary closure.

Figure 16: Schematic representation. Closure. Note minimally exposed tissue. Moving flap generates tissue folds.

Figure 17: Provisional adaptation. Note lack of tissue contact.

Figure 18: Postsurgical examination at 7 days. Note the soft tissue closure.


Bontá et al

Figure 19: Postsurgical examination at 180 days. Note the scars lack.

Figure 20: Postsurgical examination at 180 days. Note the volume preservation.

extractions were done atraumatically by means of intrasulcular incision, luxation with perio-tomes and elevators to minimize tissue trauma and preserve the buccal bone plate (Figures 1-3). The extraction itself was done with for-ceps avoiding rough movements (Figures 4 and 5). The socket wall was debrided thoroughly.

The socket site was irrigated with saline physiological solution (Figures 6 and 7). It is important to point out that in the pres-ent technique, the sliding tissue move-ment can be done in upper teeth as well as in lower teeth taking into account the anatomic landmarks of each site.

Initially, the width of the tissue to slide was measured by a bone sound-ing to assess whether the flap is to be full thickness flap (less than 4 mm) or split thickness flap (equal or greater than 4 mm).42,43 The laterally sliding flap inci-sions length correspond with the socket mesio-distal diameter (Figure 8). A releasing vertical incision was made from the distal angle of the neighboring tooth, with a length similar to the

socket mesiodistal length. The releasing inci-sion ends in a cut-back of a minimal length of 3 mm to enable flap rotation to minimize tis-sue pulling (Figures 9 and 10). According to the previous statements, a full-thickness flap or a split flap was elevated. Once performed the disection, the rotation is checked out, rotation that could be modified extending the cut-back (Figures 11 and 12). Socket pres-ervation was achieved with Bone Ceramic® biphasic calcium phosphate (Straumann, Swit-zerland) (Figure 13). To bring together tis-sues an internal horizontal matress suture was made and simple stitches for the clo-sure (Nylon 5-0) (Figures 14-16). To avoid pulling on the tissues, the provisionals adap-tation was performed thoroughly (Figure 17).

Follow-upPatients were prescribed 0,12% chlorhexi-dine mouthrinses twice a day during 3 days and analgesic (ibuprofen 600 mg every 8 hours only for 24 hours).The sutures were retrieved after 7 days. Postsurgical checkup

18 • Vol. 7, No. 9 • November 2015

Bontá et al

examinations were performed after 7, 15, 30, 60, 90 and 180 days (Figures 18-20).

RESULTSFollowing 6 months, assesment of the muco-gingival junction (MGJ) was repeated applying the same mesurement method previously described. Postsurgical complications such as edema, excessive bleeding, pain, infec-tion, necrosis and dehiscence of tissues have been assessed. In the case series pre-sented no postsurgical complications were observed. Soft tissue closure was observed in every site. The pedicle graft has per-fectly integrated to the surrounding tissues.

DISCUSSIONSince the decade of the 1970s different tech-niques have been developed to achieve pri-mary closure. At the beginning, the concept of retaining de teeth roots was introduced with the aim of preserving de alveolar bone.35-37 At the end of the decade of the 1980, Bowers37

proposed the root submertion under the alveo-lar crest to promote granulation tissue growth for its further epithelization arriving this way to a primary closure. At a second stage of reen-try, the tooth extraction would be performed and then, the implant placement. Disadvan-tages of this procedure would be related to the possibility of complications due to peri-apical lesions in the submerged roots and with the coronal mucogingival junction (MGJ) repositioning because a coronally sliding flap is performed to achieve the primary closure.

Becker y Becker38 in 1990 developed a technique consisting in rotating a full thick-ness vestibular flap from the adjacent tooth to

achieve the primary closure when placing imme-diate implants along with bone regeneration. They propose performing a sliding flap to cover the exposed donor site. Limiting factors of this procedure are: 1) the availability of sufficient width of keratinized tissue, 2) possible altera-tions of the mucogingival junction and the for-nix depth and 3) potential donor site recession.

Tinti and Parma-Benfenati39 in 1995 introduced a new procedure consisting in a full thickness coronally positioned pala-tal sliding flap to provide a primary closure in implants performed along with bone regen-eration. It can be employed in single and mul-tiple teeth. The main drawback is the time and the sensitiveness and the requirement of having an adequate palatal thickness.

The use of a connective tissue over an immediate implant was described for the first time by Edel27 in 1995.

In 1996, Chen y Dahlin28 perform subepi-thelial connective tissue grafts to achieve pri-mary closure in immediate implants along e-PTFE membranes. According to the authors, the advantages of this approach are related to the need of only one verti-cal incision reducing surgical trauma and preserving dental papilla, of utmost impor-tance in esthetic sites. Since there is no displacement of the coronal flap, the mucogin-gival junction (MGJ) keeps its original position.

In 1997 Landsberg29 proposed the epithe-lial-connective tissue graft instead of using a membrane to seal the socket in immedi-ate implants with bone filling. According to the author, the advantages of this procedure imply avoiding the flap elevation, minimizing trauma to soft and hard tissues and improv-


Bontá et al

ing the alveolar ridge topography. The pro-cedure is a simple one and highly esthetic.

The previous procedures shortcomings27-29 arise from the requirement of a second surgical site and especially because the procedure suc-cess depends on the blood supply of the recipi-ent bed. Moreover, when there are multiple sites, the graft size can limit the sites coverage.

In 1997 Rosenquist40 proposed that gin-gival graft or vestibular pedicled flap should be used to seal sockets at the immediate implant placement. It is a limited technique since the thickness of the buccal tissue has to be enough in order not to be perforated.

Novaes and Novaes41 introduce a varia-tion to the technique developed by Becker and Becker38 to offset its limitations. The procedure consists in carrying out a split-thickness flap with vertical incisions at mesial or distal aspects (according to the side the tissue is displaced). The exposed periosteum at the site from which the flap has been rotated is covered with a free gingival graft taken from the flap distal portion, which is harvested to achieve an ade-quate tissue cooptation. This avoids the need for involving another tooth, as proposed by Becker and Becker.38 This technique shortcom-ings relates to the variations in the mucogingi-val junction (MGJ) position and its sensitivity.

In 1999 Nemcovsky and Artzi42 proposed a rotated pedicled split-thickness palatal flap to achieve the socket primary closure follow-ing extraction. The technique allows the high-est preservation of hard and soft tissues prior to implant placement and neither modifies the mucogingival junction (MGJ) position nor reduces the vestibulum depth. When mem-branes are used, the closure can be achieved at

the expense of the connective tissue harvested from the split-thickness flap and not because of the coronal displacement of the flap39 nor the adjacent tooth flap rotation.38 The pedicle flap preserves vascular supply unlike the tech-niques that utilize gingival grafts.27-29 The limi-tations appear in palates with scarce thickness (< 4mm).42,43 As a result, authors developed a variant of the proposed technique carrying out the full thickness flap, whose disadvan-tage lies in the greater patient discomfort ris-ing from the wound created in the palate.44,45

In 2002, Goldstein46 developed an advance-ment of the palatal tissue in a coronal direc-tion by means of the split pedicle palatal advanced flap. The author claims as advan-tages that the procedure is useful, fast, and simple to be performed, it does not change the MGJ and can be performed in multiple sites. A shortcoming related to this pro-cedure could be generated at the palatal area left exposed by the flap displacement.

Most of the aforementioned approaches present shortcomings: changes in the MGJ position, reduction of the buccal fornix deep-ness, patient discomfort and its sensitivity.

The rotated split palatal flap intro-duced by Nemcovsky y Artzi42-45 offers several advantages but it is a sensitive pro-cedure and the flap design involves the teeth mesial and distal to the extraction site.

By performing the lateral sliding flap proce-dure proposed in the present study only one tooth lateral to the site extraction to be done is involved, therefore reducing the patient discom-fort. The technique is simple and highly versatile.

20 • Vol. 7, No. 9 • November 2015

Bontá et al

CONCLUSIONSThe procedure described in the present study to achieve the soft tissue closure in sockets fol-lowing the extraction offers many advantages:● The technique is simple and minimize

trauma and tissue invasion. ● Due to its versatility it is feasible both

in upper and lower teeth always tak-ing into account the anatomical land-marks (major palatine arteria in the maxilla and lingual artery in the mandible).

● The MGJ position does not change nor is the buccal vestibule deepness reduced.

● The displacement of the graft exposed area left is minimum and does not require a second surgical site, reducing thus the patient discomfort and minimizing the potential postsurgical complications.

● The pedicle flap preserves the vascular supply. Within the boundaries of the present

study, it is possible to conclude that the pro-posed alternative surgical procedure is a pre-dictable, simple and highly eligible approach thus enabling the achievement of the soft tis-sues closing at sockets following extraction. ●

Correspondence:Marcelo T de Alvear 2142 Cátedra de Periodoncia. Piso 17 Sector APhone: (54 11) 4-838-0239Mobile: (54 11) 155-932-7898E-mail: [email protected]

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References1. Atwood DA. Some clinical factors related to the

rate of resorption of residual ridges. J Prost Dent 1962;12:441-50

2. Seibert JS. Treatment of moderated localized alveolar ridge defects. Preventive and reconstructive concepts in therapy. Dent Clin North Am 1993;37:265-80

3. O’Brien TP, Hinrichs JE, Schaffer EM.The prevention of localized ridge deformities using guided tissue regeneration.J Periodontol 1994;65:17-24

4. Hammerle 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 (suppl):26-28

5. Darby I, Chen ST, Buser D. Ridge preservation techniques for implant therapy. Int J Oral Maxillofac Impantsl 2009;24 (suppl):260-71

6. Johnson K. A study of the dimensional changes occurring in the maxilla after tooth extraction. Part I. Normal healing. Aust Dent J 1963; 8:428-33.

7. Boyne PJ. Osseous repair of the post extraction alveolus in man. Oral Surg Oral Med Oral Pathol 1966; 21:805-13.

8. Pietrokovski J, Massler M. Alveolar ridge resorption following tooth extraction. J Prost Dent 1967; 17:21-27.

9. Johnson, K. A study of the dimensional changes occurring in the maxilla following tooth extraction. Aust Dent J 1969; 14:241-44.

10. Huebsch Rf, Hansen LS. A histopathologic study of extraction wounds in dogs. Oral Surg Oral Med Oral Pathol 1969; 28:187-96.

11. Amler MH. The time sequence of tissue regeneration in human extraction wounds. Oral Surg Oral Med Oral Pathol 1969; 27:309-18.

12. Evian CI, Rosenberg ES, Cosslet JG, Corn H. The osteogenic activity of bone removed from healing extraction sockets in human. J Periodontol 1982; 53:81-85.

13. 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 Period and Rest Dent 2003; 23:313-23.

14. Cardaropoli G, Araujo M, Lindhe J. Dynamics of bone tissue formation in tooth extraction sites. An experimental study in healing of extraction socket 217 dogs. J Clin Periodontol 2003; 30:809-18.

15. Araujo MG, Lindhe J. Dimensional ridge alterations following tooth extraction. An experimental study in the dog. J Clin Periodontol 2005; 32: 212-18.

16. Fickl S, Zuhr O, Wachtel H, Bolz W, Huerzeler M. Tissue alterations after tooth extraction with and without surgical trauma: a volumetric study in the beagle dog. J Clin Periodontol 2008; 35(4):356-63.

17. Van der Weijden F, Dell’Acqua F, Slot DE.Alveolar bone dimensional changes of post-extraction sockets in humans: a systematic review.J Clin Periodontol 2009; 36(12):1048-58.

18. Araújo MG, Lindhe J. Ridge alterations following tooth extraction with and without flap elevation: an experimental study in the dog.. Clin Oral Impl Res 2009; 20(6):545-9.

19. Botticelli D, Berglundh T, Lindhe J. Hard tissue alterations following inmediate implant placement at extraction sites. J Clin Periodontol 2004; 31:820-828

20. Araujo MG, Sukekava F, Wennstrom 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

21. Cardaropoli G, Araujo M, Hayacibara R, Sukekava F, Lindhe J. Healing of extraction sockets and surgically produced augmented and non augmented defects in the alveolar ridge. J Clin Periodontol 2005;32:435-40

22. Carmagnola D, Adriaens P, Berglundh T. Healing of human extraction socket filled with Bio-Oss. Clin Oral Impl Res 2003;14:137-43

23. Lekovic V, Kenney E, Weinlaender, Han T, Klokkevold P, Nedic M, et al. A bone regenerative approach to alveolar ridge maintenance following tooth extraction. Report of 10 cases. J Periodontol 1997;68:563-70

24. Lekovic V, Carmargo P, KlokkevoldP, Weinlaender M, Kenney EB, Dimitrijevic B, et al. Preservation of alveolar bone in extraction sockets using bioabsorbable membranes. J Periodontol 1998;69:1044-49

25. Fickl S, Zuhr O, Wachtel H, Bolz W, Huerzeler MB. Hard tissue alterations after socket preservation: an experimental study in the beagle dogs. Clin Oral Impl Res 2008a; 19:1111-18

26. Fickl S, Zuhr O, Wachtel H, Stappert CF, Stein JM, Hurzeler MB. Dimensional changes of the alveolar ridge contour after different socket preservation techniques. J Clin Periodontol 2008b; 35:906-13

27. Jovanovic SA, Spiekerman H, Richter EJ. Bone regeneration around titanium dental implants in dehisced sites: A clinical study. Int J Oral Maxillof Implants 1992; 13: 29-45.

28. Lekholm U, Becker W, Dahlin C, Becker B, Donath K, Morrison E.The role of early versus late removal of GTAM membranes on bone formation at oral implants placed into immediate extraction sockets: An experimental study in dogs. Clin Oral Impl Research 1993; 4:121-29.

29. Simion M, Baldoni M, Rossi P, Zaffe D. A comparative study of the effectiveness of e-PTFE membranes with and without early exposure during the healing period. Int J Period and Rest Dent 1994; 14:167-80.

30. Edel A. The use of a connective tissue graft for closure over immediate implant covered with an occlusive membrane. Clin Oral Impl Res1995; 6: 60-5.

31. Chen ST, Dahlin, C. Connective tissue grafting for primary closure of extraction sockets treated with an osteopromotive membrane technique: Surgical technique and clinical results. Int J Period and Rest Dent1996; 16: 349-55.

32. Landsberg CJ. Socket seal surgery combined with immediate implant placement: A novel approach for single tooth replacement. Int J Period and Rest Dent1997; 17: 141-49.

33. Stimmelmayer M, Allen EP, Reichert TE, Ighaut G. Use of combination epithelized-subepithelial connective tissue graft for soft tissue augmentation of an extraction site following ridge preservation or implant placement: description of a technique. Int J Period and Rest Dent 2010;30:375-81

34. Thalmair T, Hinze M, Bolz W. The healing of free gingival autografts for socket-seal surgery: a case report. Europ J Esth Dent 2010;5:358-68

35. Goska FA, Vondrak RE: Roots submerged to preserve alveolor bone: a case report. Milit Med 1972; 137:446-47.

36. Gorver DG, Fenster RK. Vital root retention in humans: a final report. J Pros Dent 1980;43:368-73.

37. Bowers GM, Donahue J. A technique for submerged vital roots with associated intrabony defects. Int J Period and Rest Dent 1988;6:35-51

38. Becker W, Becker BE. Guided tissue regeneration for implants placed into extraction sockets and for implant dehiscences: Surgical techniques and case reports. Int J Period and Rest Dent1990:10: 376-91.

39. Tinti C, Parma-Benfenati S. Coronally positioned palatal sliding flap. Int J Period and Rest Dent1995; 15: 298-10.

40. RosenquistB. A comparison of various methods of soft tissue management following the immediate placement of implants into extraction sockets. Int J Oral Maxillofac Impl1997; 12: 43–51.

41. Novaes AB Jr, Novaes AB. Soft tissue management for primary closure in guided bone regeneration: surgical technique and case report.Int J Oral Maxillofac Impl. 1997; 12(1):84-7.

42. Nemcovsky CE, Artzi Z. Split palatal flap (I): A surgical approach for primary soft tissue healing in ridge augmentation procedures. Technique and clinical results. Int J Period and Rest Dent1999; 19: 175-81.

43. Nemcovsky CE, Artzi Z, Moses O. Rotated split palatal flap for soft tissue primary coverage over extraction sites with immediate implant placement: Description of the surgical procedure and clinical results. J Periodontol 1999; 70:926-34.

44. Nemcovsky CE, Artzi Z, Moses O. Rotated palatal flap in immediate implant procedures. Clinical evaluation of 26 consecutive cases.Clin Oral Impl Res 2000; 11: 83-90.

45. Nemcovsky CE, Moses O, Artzi Z, Gelernter I. Clinical coverage of dehiscence defects in immediate implant procedures: three surgical modalities to achieve primary soft tissue closure.Int J Oral Maxillofac Impl. 2000; 15(6):843-52.

46. Goldstein M, Boyan BD, Schwartz Z. The palatal advanced flap: a pedicle flap for primary coverage of immediately placed implants. Clin Oral Impl Res 2002; 13: 644-50.

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Falcón

Severe defects of the alveolar ridge can have many causes including the loss of teeth due to caries, periodontal problems,

trauma and in some cases the presence of cystic lesions, which can cause severe bone resorption,

which represent a challenge for the surgeons. This article aims to present a case report in which through a multidisciplinary approach is achieved rehabilitate a returning patient func-tion and aesthetics in a single surgical session.

Multidisciplinary Approach for Treatment of Severly Resorbed Maxillary Anterior RIdge Complicated

by Cysts in a Single Surgical Session

Dr. Britto Falcón1

1Magister in Odonto-Stomatology, Specialist in periodontics and Implantology, Coordinator APPO (Asociación Peruana de Periodoncia y Oseointegración)-Tacna, Private Practice. Tacna- Perú.

Abstract

KEY WORDS: Guide bone regeneration, mucogingival grafting, prosthodontics


24 • Vol. 7, No. 9 • November 2015

INTRODUCTIONThe therapeutic goal of periodontology it is the ability to restore patients achieving both aesthetics and function, with the lowest num-ber of surgical procedures. Severe defects of the alveolar ridge can occur for many rea-sons including tooth loss, periodontal disease, and cysts, among others. These are serious problems to consider when treatment plan-ing as these defects may hamper the contour and shape of the final prosthesis resutling in por final esthetics.1,2 Radicular cysts can cause

great destruction of bone tissue if not detected in time, accompanied by the loss of teeth.3,4

The available treatment modalities depend-ing on the type of defect of the alveolar ridge, are to achieve better conditions for making a fixed rehabilitation with the best conditions for our patients. These include soft tissue grafts, guided bone regeneration, pedicle flaps, etc.5,6

This article aims to present a case report in which through a multidisci-plinary approach, ranging from treat-ments of periodontal surgery, endodontics,

Figure 1: Pre-surgical extraoral view. Figure 2: Pre-surgical intraoral view.

Figure 3: Radiograph of tooth #22 (FDI numbering system).

Figure 4: Radiograph of teeth 12 and 13 (FDI numbering system) with suggetsion of radicular cysts.

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prosthetics and conditioning of the alveolar ridge, is achieved rehabilitate a returning patient func-tion and aesthetics in a single surgical session.

CASE REPORTA 63 year-old female patient reported to our office with a request for for esthetic rehabilitation of her missing upper front teeth. She was a con-trolled diabteic and relates that her teeth natu-ral “fell out on their own.” Extraorally, her upper lip was depressible. Intraoral clinical examina-tion revealed a deficient maxillary anterior eden-

tulous ridge complicated by the loss of teeth. Generalized gingivitis was observed and mobil-ity of grade 2 was noted in teeth 12 (FDI Num-bering System) and mobility grade 1 in tooth 13. Additionally, a low insertion of the labial frenu-lum was noted (Figures 1 and 2). Radiographic evaluation was performed and there was a large bone defect associate with tooth 22, which in a combined defect causes bone ridge resorption; with teeth 12 and 13 a circumscribed and well-defined radiolucent defect was observed at the level of the root apices, compatible with radicu-

Figure 5: Frenectomy and intra-root reinforcements. Figure 6: Exposure of the cysts and ridge defects.

Figure 7: Apiceptomy and curettage.

Figure 8: Guided bone regeneration and free mucogongival graft.

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26 • Vol. 7, No. 9 • November 2015

lar cysts (Figures 3 and 4). After taking initial records, trying to be as conservative as pos-sible, we decided to retain teeth 12, 13 and 23 to permit a fixed prosthetic bridge. Treat-ment was planned in multiple phases. First phase: Performing periodontal treatment and oral hygiene, scaling and root planing, and endodontic treatment. Second phase: Rein-forcements intra root, frenectomy upper lip, excision of radicular cysts, apiceptomies on teeth 12 and 13 with guided bone regeneration, free soft tissue grafts to the edge of the area of tooth 22, and a temporary prosthesis with ovate pontics all in one session. Third phase: Final installation of a fixed porcelain restoration.

Pharmacological medication 2 days before surgery was performed with metronidazole

500 mgr and naproxen sodium 550 mgr for 7 days. After routine preparation of the surgi-cal site with a Povidine Iodine solution (5% w/v) and clorhexidine gluconate 0,12%, the local anesthetic solution (2% adrenaline) was administered. The intraradicular reinforce-ments are cemented, Later, surgery begins with frenectomy lip frenulum and sutured with thread of ac. polyglycolic 6.0 (Figure 5).

One supracrestal incision of 13 and 23 was then made, and vertical diverging distal dis-charges being performed in the same piece and a full thickness flap was elevated to expose the ridge defects. In the area of tooth 22, there was a total loss of bone ridge and at the level teeth 12 and 13, exposure of the cysts and subsequent excision was performed (Figure 6).

Figure 9: Primary closure with suture.

Figures 10: Temporary fixed partial denture placement with ovoid pontics.

Figure 11: Post-surgical healing at one week. Figure 12: Post-surgical healing at 2 months.

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Figure 13: Final porcelain fixed partial denture.

Figure 14: Radiograph at 6 months post-surgery.

Figure 15: Final extraoral view.

Curettage around the cavity of the remaining bone is performed, culminating in the embodi-ment of apiceptomy and irrigation with sterile saline (Figure 7). Guided bone regeneration was carried out in the area of cysts with bovine hydroxyapatite (Bio-oss) and membrane reab-sorbed of collagen and in the area of tooth 22, a mucogingival graft was placed (Figure 8). We repositioned the flap and sutured with black silk 4.0 until closing with primary intention. The sur-gery ended with the installation of a temporary bridge with ovate pontics (Figures 9 and 10).

Postoperatively, the patient continued her medication to completion at 7 days and chlorhexidine gluconate mouth rinse (0.12%) twice daily 10 ml for 2 weeks. The sutures were removed after a week. The first post-surgical visit was performed at a week, observing cor-rect tissue healing and conditioning of eden-tulous ridge with ovoid pontics (Figure 11). A second post-surgical visit was performed at two months and a final restoration was placed at 3 months (Figure 12 and 13). At six months after surgery, another follow up visit was performed with radiographs observing bone regeneration in the área of the root cysts (Figures 14 and 15).

DISCUSSIONA radicular cyst, is usually associated with cari-ous and nonvital tooth. Is believed to form by proliferation of the epithelial cell rests of Mal-assez in inflammed periradicular tissues. Its size rarely exceeds 1 cm and is often seen in patients between 30 and 50 years old with higher incidence in the maxillary ante-rior región, is usually symptomless. However, as some of them grow, they can cause mobil-ity and displacement of teeth, causing great loss of bone tissue.4 Coinciding with clini-cal and radiographic findings of this report.

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28 • Vol. 7, No. 9 • November 2015

Ridge augmentation procedures prior to con-ventional fixed prosthodontics or implant therapy are indicated when an adequate width or height of the alveolar ridge is not present.7 The sufficient bone quantity will be essential prerequisite for esthetic rehabilitation. Several techniques have been described to enhance the bone volume, e.g. bone grafting, GBR8; and soft tissues that can be managed with flaps and free soft tissue grafts.1,2 So there are certain clinical situations in which soft tissue augmentation by mucogingival surgi-cal techniques can be justified and indicated.9 To achieve more stable results, soft tissue autografts, either in the form of free gingival grafts or free connective tissue grafts were recommended in these indications and provided more predictable results.6,9 So we use to achieve these autograft the vertical and horizontal ridge augmentation the area of tooth 12, where we found a total of bone loss.

Bovine xenografts are commonly used and well tolerated in intraoral procedures. Grafted particles once embedded in mineralized bone, and as long as no special stimuli occurs, act similarly to host bone, which often undergoes remodeling process at a very slow rate.7 In this case, we used Bio-oss for bone regen-eration of the cavities caused by cysts, which provided excellent results after 6 months.

To improve the integration of pontics estheti-cally, phonetically, and functionally, it is often necessary to modify the anatomy of the edentu-lous ridges with tissue management techniques. There are two possible clinical conditions: postex-traction sites and stabilized edentulous sites. The most favorable clinical situation for condi-tioning the edentulous site is at the moment of extraction, allowing the immediate insertion of a provisional pontic. And in an edentulous site

where healing has already occurred, corrective surgical techniques are indicated.5 The ovoid pontics are made with a convex internal sur-face that produces an optimal aesthetic result, atraumatic contact with the gum improving the function and phonetics. This must reproduce all aspects of the shape and contours of the clinical search obtained in the final prosthesis.2

This background provides us with the ele-ments to address this challenging case, place free gingival grafting des-epithialized and make bone regeneration in the area of cysts, we recover the lost bone tissue, stabilizing the remaining teeth so they can serve as pillars for the definitive fixed rehabilitation. These surgi-cal procedures are accomplished in a single surgery, such as in the case of alternative “all in one”,2 reducing over-exposure of the patient surgeries and thus achieving the objectives.

CONCLUSIONThe combination approach is useful in treat-ing severe defects involving multiple missing teeth, where individual approaches alone may not be sufficient to achieve desired results, this multidisciplinary approach for correction of large bone defects are achieved in one sur-gical session providing comfort, safety and effectiveness in achieving a good result in a case that is a challenge for rehabilitation. ●

Correspondence:

Name: Britto Falcón Guerrero

Address: Av. Tarapaca # 350- Tacna.

Phone: 052- 407409

Email: [email protected]

Falcón


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DisclosureThe author reports no conflicts of interest with anything mentioned in this article.

References1. Wang HL, Al-Shammari K. HVC ridge deficiency classification: a therapeutically

oriented classification. Int J Periodontics Restorative Dent. 2002; 22: 335-343.

2. Falcón GBE. Una alternativa «all in one» para el manejo de los defectos del reborde en la zona estética. Rev Mex Periodontol 2014; V (2): 75-79.

3. Gallego D, Torres D, García M, Romero MM, Infante P, Gutiérrez JL. Diagnóstico diferencial y enfoque terapéutico de los quistes radiculares en la práctica odontológica cotidiana. Medicina Oral 2002; 7: 54-62.

4. Joshi NS, Sujan SG, Rachappa MM. An unusual case report of bilateral mandibular radicular cysts . Contemporary Clinical Dentistry | Jan-Mar 2011 | Vol 2| Issue 1.

5. Calesini G, Micarelli C, Coppè S, Scipioni A. Edentulous site enhancement: a regenerative approach for the management of edentulous areas. Part 1. Pontic areas. Int J Periodontics Restorative Dent. 2008; 28: 517-524.

6. Camargo PM, Melnick PR, Kenney B. The use of free gingival grafts for aesthetic purposes. Periodontology. 2000; 27 (1): 72-96.

7. Deshpande S, Deshmukh J, Deshpande S, Khatri R, Deshpande S. Vertical and horizontal ridge augmentation in anterior maxilla using autograft, xenograft and titanium mesh with simultaneous placement of endosseous implants. J Indian Soc Periodontol 2014;18:661-5.

8. Gupta ND, Maheshwari S, Chaudhari PK, Rathi S. An interdisciplinary management of severely resorbed maxillary anterior ridge complicated by traumatic bite using a ridge splitting technique. J Indian Soc Periodontol 2015;19:96-8.

9. Urban IA, Lozada JL, Nagy K, Sanz M .Treatment of Severe Mucogingival Defects with a Combination of Strip Gingival Grafts and a Xenogeneic Collagen Matrix: A Prospective Case Series Study .Int J Periodontics Restorative Dent 2015;35:345–353. doi: 10.11607/prd.2287).

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Al-Fahd et al

Introduction: Misaligned implant presents a prosthetic challenge especially when accompa-nied with malposition. Sometimes such com-plex cases remain without restoration even if they are properly Osseo integrated. The fixed prosthesis which is the most acceptable option by the patient can be achieved by appropriate procedure as explained in this report to achieve a fixed prosthesis for such complex cases.

Case Report: In this case report a novel method to provide a fixed prosthetic restora-tion for a complex severe buccal inclined with severe deep positioned implant is explained.

Conclusion: The use of Transmuco-sal abutment with castable abutment is successful treatment option for complex mis-aligned and malposed single dental implant.

Management of Complex Deeply Positioned, Severely Mal-Aligned Dental Implant:

A Case Report

Dr. Adnan Al-Fahd1 • Dr. Iman Radi2

1. PhD Student, Prosthodontics Department, Faculty of Oral and Dental Medicine, Cairo University ,Egypt and Assistant Lecturer, Prosthodontics Department, Faculty of Dentistry, IBB University, IBB, Yemen

2. Associate Professor of Prosthodontics, Faculty of Oral and Dental Medicine, Cairo University

Abstract

KEY WORDS: Dental implant, Mal-position, Mal-alignment, Transmucosal abutment, plastic abutment.


32 • Vol. 7, No. 9 • November 2015

INTRODUCTION The implant restoration is a very predictable treat-ment in dental fixed restoration. However, implant placement has many requirements to be restored including proper implant position and angula-tion within the alveolar ridge. Surgically driven implant concepts which depend mainly on the presence of adequate bone for implant inser-tion is sometimes ignored nowadays. This often results in implants that are prosthetically chal-lenging or even impossible to restore and may lead to a failed implant. Prosthetic management for these cases with misaligned and/or mal-posed implants are usually challenging for both the prosthodontist and technician.1–3 Many tech-niques have been presented to overcome such complications including angulated abutments, castable abutments, or in severe cases, remov-able prostheses. However, the fixed restora-tion in these cases is mainly restricted to solve maligned cases within limits that do not exceed 30 degrees. Furthermore, removable prosthe-ses are not practical for single missing tooth in addition to be objectionable by many patients.4,5 Consequently, regarding a severe angulated

implant that is accompanied with severe deeply positioned implant, the prosthetic restoration is still a challenge up to date.1,6–8 In this case report, a simple predictable prosthetic procedure to restore a severe maligned accompanied with deeply positioned single implant is described.9

CASE REPORT A 52 year old female patient presented to the outpatient clinic of Prosthodontic Department, Faculty of Oral and Dental Medicine, Cairo Uni-versity with a deeply seated and buccally mal-aligned single implant at the maxillary right 2nd premolar area in need of a fixed prosthodontic restoration. Upon thorough clinical and pan-oramic radiographic examination, the implant was deeply seated without a cover screw (Figure 1). There was slight inflammation of the overly-ing soft tissue leading to patient discomfort with slight pain during eating. Also, the adjacent first right premolar was endodontically treated with a previous prosthetic preparation sans crown.

Figure 1: Preoperative panoramic radiograph revealing deep implant without covering screw.

Figure 2: Impression post attached to Transmucosal abutment for abutment level impression.

Al-Fahd et al


The treatment plan was made to overcome the two complex obstacles including deep seating and buccal mal-aligned implant that prevented prosthetic restoration with a standard abutment.

Initial treatment included chlorhexidine mouth wash and Augmentin antibiotic was prescribed for one week to resolve the presence soft tis-sue inflammation. After one week of this therapy, a crestal incision was made at upper right 2nd premolar area over the implant with slight exten-sion on the buccal side both anteriorly around the canine and posteriorly around the second pre-molar. Soft tissue reflection was made by using a periosteal elevator until the implant platform was reached. A transmucosal abutment (OCTA abut-ment, DENTIS implant system, KOREA) was con-nected to implant fixture and tightened properly by Transmucosal driver and torqued to 35 Ncm. A hygienic screw was placed over the Transmu-cosal abutment and left for two weeks. After two weeks, the hygiene covering screw was removed and an impression post was connected to Trans-

mucosal abutment (Figure 2) to take an abutment level final impression using an open tray impres-sion technique. Medium body polyvinylsiloxane (PVS) was mixed and loaded into a custom tray to impress the dental implant. After material set-ting, the tray was removed and checked for all required details. An abutment analogue was tightened to the impression post ensuring immo-bility of the impression post during this process. Next, soft tissue mimicking material was applied around gingival part of analogue and the whole impression was poured with improved stone. A castable abutment (plastic abutment, DENTIS implant system, KOREA) was used in this case over the transmucosal abutment to correct the severe buccal mal-alignment of implant. When the angulation was corrected, the castable abut-ment casting was performed. After casting final adjustment was performed by milling machine.

The angulation in this case was severe so it was impossible to use a castable abutment as screw retained because the screw hole would

Figure 3A: Final position of castable abutment intraorally (lateral view).

Figure 4: Periapical radiograph of the Transmucosal abutment with castable abutment.

Al-Fahd et al

34 • Vol. 7, No. 9 • November 2015

be at buccal side which is unaesthetic. Instead this case was planned to be considered as a cemented retained case. After correction, the finished castable abutment was connected to the substructure transmucosal abutment by tightening the abutment screw to 35 Ncm with a torque wrench (Figure 3). A periapical radio-graph was then utilized to confirm seating of the components (Figure 4). A porcelain fused to metal (PFM) crown was constructed over the castable abutment as a cement retained restoration. Additionally, an additional PFM was made to treat the adjacent endodonti-cally treated tooth (Figure 5A). Both PFM’s were adjusted interproximally and occlusally and cemented with glass ionomer cement (Figure 5B). Post-surgical evaluation at 12 months dem-onstrated proper clinical and radiographical out-comes with high patient satisfaction (Figure 6).

DISCUSSION The deeply seated implant is one of the most chal-lenging cases for the clinician, especially if com-

bined with improper angulations. In this particular case, the surgeon may have placed the implant with a severe buccal angulation to avoid maxil-lary sinus perforation.1,5 The antibiotic and mouth wash were described at the beginning promote soft tissue healing and resolve the present infec-tion.10 Other suggested solutions for this case included a removable prosthesis, leaving the implant without restoration, or implant removal. However, the fixed option for this case was more preferable to patient compared to the remov-able option.11 Because of the deep position and severe buccal angulation of implant in this case, there is no standard abutment that could be use-ful. Also a castable abutment alone would have difficulty fulfilling this requirement. Consequently, a novel technique was used in this case by divid-ing the prosthetic components into two parts: 1) first part to overcome the deep position by using a Transmucosal abutment that was terminated nearly at the gingival margin to allow soft tissue seal (cuff) to form around it; 2) the second part, to overcome the severe buccal angulation by

Figure 5A: Final separate PFM crowns on the cast model. Figure 5B: PFM crowns cemented inside the mouth.

Al-Fahd et al


castable abutment that was made to accom-modate the proper angulation firstly by plastic removal during a wax up procedure and secondly by metal milling after casting procedure. As the screw hole would be at the buccal side of the future crown, the screw retained prosthesis was inappropriate option due to esthetic issue. To resolve this problem the case was converted to cemented retained restoration. The adjacent tooth was restored with separate PFM crow not connected to implant to avoid the possible com-plication that may arise from natural tooth-implant connection as tooth intrusion.12 The post-opera-tive 12 month follow up revealed a good clinical and radiographic result regarding peri-implant soft and hard tissue with optimum patient satisfaction.

CONCLUSIONThis case report presents a simple novel tech-nique to restore a single implant with a severe deeply positioned with a severe buccaly angulated implant. This technique produces a satisfied result for both clinician and patient after one year. ●

Figure 6: Twelve month post-operative radiograph.

Correspondence:Dr. Adnan Abdullah Al-FahdEmail: [email protected]: 2 Ali Attia Hadayek Almaadi Cairo, Egypt.Tel. no: 00201142228430

DisclosureThe authors report no conflicts of interest with anything mentioned in this article.

AcknowledgementsI would like to thank Dr. Amr Hosni for his valuable support. Thanks are also due to Dr. Fahmi Al-Shugaifi for his cooperation.

References1. Greenstein, G., Cavallaro, J., Romanos, G. & Tarnow, D. Clinical recom-

mendations for avoiding and managing surgical complications associated with implant dentistry: a review. J. Periodontol.79, 1317–29 (2008).

2. Goodacre, C. J., Bernal, G., Rungcharassaeng, K. & Kan, J. Y. K. Clinical complications with implants and implant prostheses. J. Prosthet. Dent.90, 121–32 (2003).

3. Rosenfeld, A. L., Mandelaris, G. A. & Tardieu, P. B. Prosthetically directed implant placement using computer software to ensure precise placement and predictable prosthetic outcomes. Part 3: stereolithographic drilling guides that do not require bone exposure and the immediate delivery of teeth. Int. J. Periodontics Restorative Dent.26, 493–9 (2006).

4. Misch, K. & Wang, H.-L. Implant surgery complications: etiology and treatment. Implant Dent.17, 159–68 (2008).

5. Vaidya, S., Khalikar, A., P Dange, S. & Desai, R. Complications and their Man-agement in Implantology. Int. J. Prosthodont. Restor. Dent.2, 150–155 (2012).

6. Jemt, T., Lindén, B. & Lekholm, U. Failures and complications in 127 consecutively placed fixed partial prostheses supported by Brånemark implants: from prosthetic treatment to first annual checkup. Int. J. Oral Maxillofac. Implants7, 40–4 (1992).

7. Nedir, R., Bischof, M., Szmukler-Moncler, S., Belser, U. C. & Samson, J. Prosthetic complications with dental implants: from an up-to-8-year experi-ence in private practice. Int. J. Oral Maxillofac. Implants21, 919–28 (2005).

8. Kim, S. Clinical Complications of Dental Implants. www.intechopen.com (2010).

9. Vigolo, P., Givani, M. A., Majzoub, Z. & Cordioli, G. A 4-year Prospective Clinical Study. 19, (2004).

10. Esposito, M., Mg, G., Hv, W., Esposito, M., Grusovin, M. G. & Worthing-ton, H. V. Interventions for replacing missing teeth : antibiotics at dental implant placement to prevent complications ( Review ) Inter-ventions for replacing missing teeth : antibiotics at dental implant placement to prevent complications. Cochrane Database Syst. Rev. (2013). doi:10.1002/14651858.CD004152.pub4.Copyright

11. Kurtzman, G. M. Management of Malaligned Implants with Removable Prosthetics. Int. J. Oral Implantol. Clin. Res.1, 101–106 (2010).

12. Nickenig, H.-J., Schäfer, C. & Spiekermann, H. Survival and com-plication rates of combined tooth-implant-supported fixed par-tial dentures. Clin. Oral Implants Res.17, 506–11 (2006).

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Fayaz et al

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Fayaz et al

Complications could occur subsequent to the implant restoration (for wide space management) of the anterior

maxillary region. Therefore, to minimize these complications, meticulous examination, diag-nosis, temporalization and the patient aware-ness of the final results should be taken into consideration. Also, in order to achieve the best results reshaping of associated teeth may

become necessary through the course of treat-ment. Establishing soft tissue around implant restoration, appropriate emergence profile cre-ation prior to implant restoration and space division between anterior incisors are critical factors behind harmonic appearance. The pur-pose of this paper is to describe a case report in which the wide edentulous space closure was accomplished using implant restorations.

Management of the Wide Space in the Anterior Maxilla with a Dental Implant Restoration:

A Case Report

Dr. Amir Fayaz1 • Dr. Mohammad Jafarian2 • Dr. Yeganeh Memari1

Dr. Seyedeh Mahsa Sheikh-Al-Eslamian3

1. Assistant Professor, Department of Prosthodontics, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran

2. Associated Professor, Department of Oral Maxillofacial Surgery, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran

3. Assistant Professor, Dental Research Center, Research Institute of Dental Sciences, Dental School, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Abstract

KEY WORDS: Dental implant, maxilla, prosthetics, case report


38 • Vol. 7, No. 9 • November 2015

INTRODUCTIONIn recent years, the proper placement of dental implants in the anterior maxillary region turned into a challenge for clinicians due to the pres-ence of anatomical deficiency in the majority of cases as well as the patient’s urge for esthetic demands. various factors are crucial for the implant restoration success including anatomi-cal and surgical conditions,1 the soft tissue sur-rounding dental implant, biologic width2 and edentulous space management in vertical and horizontal dimensions.3 To provide a satis-factory outcome for an implant restoration an adequate space should be available in occluso-gingival, bucco-lingual and mesio-distal dimen-sions, therefore both inadequate and excessive tooth to tooth space(mesio-distally), may result in esthetic complications.4,5 Another impor-tant factor to obtain satisfactory esthetic results and ideal emeregence profile is to establish an acceptable soft tissue around the implant res-toration which was addressed previously in lit-erature.6,7 In restoration of the edentulous wide space in the anterior maxillary region, complica-

tions are not unexpected to occur, and a simple closure may not offer a natural and pleasant solu-tion to the patient; thus, an accurate assessment is required for a proper diagnosis in order to achieve a successful treatment.8 The purpose of this paper is to describe a case report in which the diastema and edentulous wide space closure was accomplished using implant restorations.

CASE REPORTA 40 year old male patient in excellent health, presented with the chief complaint of “esthetic enhancement”. On the clinical examination the presence of excessive space between lateral incisors indicated the increased probability of complications after treatment. Both permanent central incisors were clinically absent (Fig.1). Clinical and radiographic examinations showed that patient’s lateral incisors are vital. The patient had a class I and cuspid rise occlusal relation-ship. In order to analyze the edentulous space precisely, a wax trial denture was fabricated fol-lowing preliminary impression and preparation of mounted diagnostic casts. Three alternative plans

Figure 1A: Preoperative facial view of missing central incisors.

Figure 1B: Mounted diagnostic cast.

Fayaz et al


were determined for the replacement of central incisors and space closure as follows (Fig. 2):1. Employment of 4 narrower incisors compar-

ing to the normal size of the central incisors which result in complete space closure.

2. Replacement of 2 central incisors while leaving diastemas between incisors.

3. Utilization of two wide central incisors and recontouring lateral incisors without any diastema between incisors.Following clinical and esthetic appearance

evaluation, the third option with minor modifi-cation was recommended to the patient. The patient’s demand was implant restoration without any grafting procedures. CBCT were taken for presurgical bone assessment. In order to achieve the optimal esthetic outcome two bone level implants with dimensions of 4.1 mm in diameter and 10 mm in length (Straumann AG, Walden-burg, Switzerland) and with regular cross fit plat-form were inserted in central incisors location. Two weeks after surgery, continuous service was maintained by removable partial prosthesis. Fol-lowing a ten week healing period, in the second stage surgery osseointegration was confirmed, rehealing conical abutments were placed, and the patient was told to visit the prosthodontist after two weeks for placement of composite pro-visional restorations using polyetheretherketone (PEEK). Two screw retained provisional resto-rations that allow easy retrievability and prevent irritation of remaining cement were used (Fig.3).

In order to achieve an acceptable esthetic

Figure 2A: Four incisors with complete space closure.

Figure 2B: Two central incisors with space between central and lateral incisors.

Figure 2C: Two wide central incisors and recontouring lateral incisors.

Fayaz et al

40 • Vol. 7, No. 9 • November 2015

result and healthy soft tissue surrounding implant, the emergence profile should be restored by the progressive increase of the collar thickness along with the gradual correction of teeth width (Fig. 3). In general, the final impression for the implant res-torations can be taken after 4-5 weeks.9 However, in the present case the final impression was post-poned for 12 weeks to gain the patient satisfac-tion of optimal form and contour of the restoration.

The fabrication of definitive restoration was initiated after three months when the healing of soft tissue was accomplished thoroughly. Screw retained porcelain fused to metal crowns were customized by multi base abutments with plastic coping. Splinting of final restorations were carried

out as when the implants were splinted, stress has to reduce in supporting bone and implants.10

Compared to diastema existence between restorations, the complete closure resulted in a more harmonic appearance (Fig. 3). Ulti-mately, with this design both the patient and the prosthodontist were satisfied.

DISCUSSIONImplant supported restorations often consid-ered as an appropriate solution in most situa-tions of replacing missing anterior teeth. Patient’s desire is important and preparing a harmonic smile is a primary demand in most the cases.11 Implant therapy for replacing of the missing teeth in anterior maxillary region could be chal-lenging due to the limitations related to ana-tomical factors. From the surgical aspect of the implant restorations, the main esthetic objec-tive is to obtain a harmonious gingival margin.1

One of the most important factors for enhancement of the esthetic in anterior maxilla is the anatomic site analysis in regard to mesio-distal space dimension.8 To assess the size of the teeth correctly, it is mandatory to build up

Figure 3A: Healthy soft tissue surrounding implants. Figure 3B: Occlusal view of final restorations.

Figure 3C: Facial view of final restorations.

Fayaz et al


the stages and prepare wax trial prosthesis in advance. This is not only helpful to locate the best sites for placement of the implants but also to get a better imagination of the procedure’s final result. In this regard, the width to length ratio of normal maxillary anterior crown have been docu-mented.12 Excess dimension should be consid-ered through procedures. So it was mandatory to decide whether to eliminate or maintain the space prior to implant restoration. In this case after diagnostic procedures and preparing trial partial denture, it seemed that the alteration of normal ratio and the increase of the width of lat-eral incisors are necessary. Moreover, to compen-sate the extra interproximal distance of edentulous area it was critical to form wider central incisors.

CONCLUSION In order to achieve the highest success rate in implant restorations, particularly those placed in the esthetic zone, it is essential to consider outcomes by temporalization, precise diagno-sis and a proper treatment plan. In this case report temporalization assisted to gain both acceptable soft tissue form and harmonic tooth show; accordingly, the patient satisfaction was fulfilled in terms of esthetic enhancement. ●

Correspondence:Dr. Seyedeh Mahsa Sheikh-Al-Eslamian,5th floorDental Research CenterResearch Institute of Dental SciencesDental school, Shahid Beheshti University of Medical SciencesEvin, Tehran, Iran

DisclosureThe authors report no conflicts of interest with anything in this article.

References1. Buser D, Martin W, Belser UC. Optimizing esthetics for implant restorations in

the anterior maxilla: anatomic and surgical considerations. Int J Oral Maxillofac Implants. 2003;19:43-61.

2. Tarnow D, Cho S, Wallace S. The effect of inter-implant distance on the height of inter-implant bone crest. J periodontol. 2000;71(4):546-549.

3. Raghoebar GM, Batenburg RH, Vissink A, Reintsema H. Augmentation of localized defects of the anterior maxillary ridge with autogenous bone before insertion of implants. J oral maxillofac surg. 1996;54(10):1180-1185.

4. Misch C. Treatment options for a congenitally missing lateral incisor: a case report. Dent today. 2004;23(8):90, 92, 94.

5. Andersen E, Saxegaard E, Knutsen BM, Haanæs HR. A prospective clinical study evaluating the safety and effectiveness of narrow-diameter threaded implants in the anterior region of the maxilla. Int J Oral Maxillofac Implants. 2000;16(2):217-224.

6. Salinas T, Sadan A. Establishing soft tissue integration with natural tooth-shaped abutments. Pract Proced Aesthet Dent. 1997;10(1):35-42; quiz 44.

7. Davarpanah M, Martinez H, Celletti R, Tecucianu J. Three-stage approach to aesthetic implant restoration: emergence profile concept. Pract Proced Aesthet Dent. 2000;13(9):761-767; quiz 768, 721-762.

8. Belser UC, Buser D, Hess D, Schmid B, Bernard JP, Lang NP. Aesthetic im-plant restorations in partially edentulous patients–a critical appraisal. Periodon-tol 2000. 1998;17(1):132-150.

9. Abboud M, Koeck B, Stark H, Wahl G, Paillon R. Immediate loading of single-tooth implants in the posterior region. Int J Oral Maxillofac Implants. 2005;94(2):198-198.

10. Bal BT, Cağlar A, Aydin C, Yilmaz H, Bankoğlu M, Eser A. Finite element analy-sis of stress distribution with splinted and nonsplinted maxillary anterior fixed prostheses supported by zirconia or titanium implants. Int J Oral Maxillofac Implants. 2012;28(1):e27-38.

11. Buser D, Chen ST, Weber HP, Belser UC. Early implant placement following single-tooth extraction in the esthetic zone: biologic rationale and surgical procedures. Int J Periodontics Restorative Dent. 2008;28(5):441.

12. Sterrett JD, Oliver T, Robinson F, Fortson W, Knaak B, Russell CM. Width/length ratios of normal clinical crowns of the maxillary anterior dentition in man. J clin periodontol. 1999;26(3):153-157.

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