Clinical Case Report, No. 000

Implant and Esthetics Reconstruction in #22 with Severe U-shape Buccal Bone Dehiscence and Mesial Papillae Recession

Case Overview

Clinical evaluation found #22 had root fracture, crowding,and sinus tract for 3 weeks. Mesial papillae had been missing due to recession. (Fig. 1) Radiographically, #22 was confirmed root fractured and the buccal bone plate had severe U-shape defect. (Fig. 2) #22 was diagnosed hopeless and extraction was suggested.

Figure 1.

Initial Examination

Figure 2.

Extraction-Flapless

The patient was given the treatment plan of implantation accompanied with bone grafting and gingiva augmentation. The patient chose to follow the treatment plan with informed consent.

Surgical Diagnosis

Tooth #22 was extracted with minimal invasion by periotome. (Fig. 3) Ridge preservation was done by flapless approach and modified ice cream cone technique on a U-shape defect. (Fig. 4) A provisional bridge was fabricated at the chairside. (Fig. 5) Following 3 months of healing, surgical site was found healing well and ready for implantation.

Full thickness flap procedure was performed and the flap was designed to preserve papillae. (Fig. 6)

A Prima Tapered Implant SD 3.5mm x 15mm was utilized (Keystone Dental, Inc., Burlington, MA). Insertion of the implant was followed by the recommended drilling sequence and bone grafting was applied simultaneously. (Fig. 7.)( 8.). Primary closure was performed.

After 3 months, the surgical site was found healing well. gingiva augmentation was required at the buccal side. (Fig. 9) Healing abutment with a 4.0mm contour was delivered and followed by the roll technique.(Fig. 10)

Figure 3.

Ridge Preservation –Membrane Placement

Figure 4.

Ridge Preservation –Membrane Placement Bone Grafting (FDBA)

Figure 5.

Ridge Preservation –Provisionalization

Figure 6.

Post Operative 3 month

Figure 7.

Ridge Preservation –Membrane Placement

Figure 8.

Surgical Implantation-GBR

Figure 9.

Post Operative 3 month

Figure 10.

Post Operative 3 month Surgical Exposure-Rolled Tech I+II

Restorative Diagnosis

A Prima Esthetic Ti Abutment was selected. The abutment was placed with cement single crown.

Results

Approximately 5 years following restoration, clinical evaluation found implant site #22 presented healthy and reached esthetic outcome.
(Fig. 11)The buccal tissue had been reconstructed and well-maintained
(Fig. 12). Radiographic evaluation found the Prima implant and bone level was stable. (Fig. 13.)( 14.).

Discussion

Healthy buccal bone and papillae are the keys for esthetics in anterior zone. In this case, the buccal plate was almost lost with deep U-shape dehiscence and the mesial papillae were completely missing. The strategy is to reconstruct esthetics with implantation and hard and soft tissue management.
Several important techniques were introduced in this treatment. For example, ridge preservation with modified ice cream cone technique was used to re-establish the missing buccal plate. Roll technique was an easy-to-apply way to thicken the gingiva without harvesting another donor site. These techniques seemed to have promising results in 5-year follow-up. Compared to the poor appearance in pre-operation, esthetics was successfully reached and maintained. (Fig. 15)

Figure 11.

Post Operative 5 year

Figure 12.

Post Operative 5 year

Figure 13.

Pre Op, Post 3Y

Figure 14.

Post 4Y, Post 5Y

Figure 15.

Comparison between Pre and Post 5 Year