Quintessenz Journals

CLINICAL RESEARCH

Immediate placement and provisionalization of maxillary anterior single implant with guided bone regeneration, connective tissue graft, and coronally positioned flap procedures Tomonori Waki, DDS PhD Associate Clinical Professor, Osaka University Graduate School of Dentistry, Osaka, Japan Private Practice limited to Prosthodontics, Implant Dentistry, and Esthetic Dentistry, Tokyo, Japan

Joseph Y K Kan, DDS, MS Professor, Center for Prosthodontics and Implant Dentistry, Loma Linda University School of Dentistry, Loma Linda, CA Private Practice, Los Angeles, CA

Correspondence to: Tomonori Waki, DDS, PhD Azabu Tokyo Dental Clinic, Minami Azabu Centre 7F, 4-12-25 Minamiazabu, Minato-ku, Tokyo 106-0047, Japan; Tel: +81 3 5422 7518; Fax: +81 3 5422 7508; E-mail: [email protected]

174 THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6.&t/6.#&3t46..&3

WAKI/KAN

Abstract

lial connective tissue grafts have been advocated, and the resulting tissues ap-

Immediate implant placement and pro-

pear to be more resistant to recession.

visionalization in the esthetic zone have

The dimensions of peri-implant muco-

been documented with success. The

sa in a thick biotype were significantly

benefit of immediate implant placement

greater than in a thin biotype. Connec-

and provisionalization is the preservation

tive tissue graft with coronally positioned

of papillary mucosa. However, in cases

flap procedures on natural teeth has al-

with osseous defects presenting on the

so been documented with success. This

facial bony plate, immediate implant

article describes a technique combin-

placement procedures have resulted in

ing immediate implant placement, pro-

facial gingival recession. Subepithelial

visionalization, guided bone regenera-

connective tissue grafts for immediate

tion (GBR), connective tissue graft, and

implant placement and provisionaliza-

a coronally positioned flap in order to

tion procedures have been reported with

achieve more stable peri-implant tissue

a good esthetic outcome. Biotype con-

in facial osseous defect situations.

version around implants with subepithe-

(Int J Esthet Dent 2016;11:174–185)


CLINICAL RESEARCH

Introduction Recently, immediate tooth replacement with an implant in the esthetic zone has been documented with success in case cohort

studies1-3 and

a

randomized

controlled study.4 However, in the presence of an osseous defect on the facial bony plate, facial gingival recession has been reported after immediate implant replacement procedures.5 On the Fig 1

Preoperative smile view. Note the black tri-

angle between the maxillary central incisors.

other hand, biotype conversion around implants with subepithelial connective tissue grafts has been advocated, and the resulting tissues appear to be more resistant to recession.6-8 In addition, subepithelial

connective

tissue

graft

with coronally positioned flap procedures on natural teeth has been reported with success in a randomized clinical trial study.9 This article describes a technique combining immediate implant placement, provisionalization, guided bone regeneration (GBR), bilaminar subepithelial connective tissue graft, and a Fig 2

Preoperative facial view of the maxillary

central incisors. Clinical evaluation revealed a swelling approximately 3 mm apical to the facial free gin-

coronally positioned flap. This technique was devised to achieve more stable peri-implant tissue in facial osseous de-

gival margin.

fect situations.

Fig 3

Preoperative

periapical radiograph of tooth 8 (11).


WAKI/KAN

Case presentation A 57-year-old female presented with an infection in tooth 8 (11) and a black triangle between the maxillary central incisors (Fig 1). Clinical evaluation revealed a swelling approximately 3 mm apical to the facial free gingival margin (Fig 2).

Radiographic

evaluation

re-

vealed periapical radiolucency on tooth 8 (11) (Fig 3). A cone beam computed tomography (CBCT) scan (Classic iCAT, Imaging Sciences International)

Fig 4

Preoperative cone beam computed tomog-

raphy (CBCT) scan image of tooth 8 (11). Buccal plate was not recognized.

was performed (Fig 4). The buccal plate was not recognized in the image. Bone sounding revealed low crest (8 mm) at the facial aspect (Fig 5) and normal crest (3 mm) at the mesial and distal interproximal aspects of tooth 8 (11). An endodontic consultation for tooth 9 (21) was obtained (Fig 6). It was determined that it was likely the apical rarefaction was an apical scar. The rationale for this included the fact that the tooth was functioning without any symptoms. Furthermore, the CBCT scan showed complete reestablishment of the bone cortex despite the previous access for apical

Fig 5

Preoperative bone sounding of tooth 8 (11),

which revealed low crest (8 mm) at the facial aspect.

surgery. The endodontic recommendation was no treatment and observation for tooth 9 (21). The patient was presented with restorative options that included a removable partial denture, a fixed dental prosthesis, or a fixed implant restoration. Since the adjacent lateral incisor had not previously been restored, the patient consented to an implant-supported restoration to avoid adjacent lateral incisor preparation. Fig 6

Preoperative

periapical radiograph of tooth 9 (21).


CLINICAL RESEARCH

was changed on teeth 6 (13), 7 (12), 10 (22), and 11 (23) by direct bonding with composite resin (4 Seasons, Ivoclar Vivadent) (Fig 7). After placement of the provisional restorations with direct bonding to change the tooth shape and the incisal edge position, an impression (Exafast NDS) was made for making a surgical template. The surgical template was fabricated using autopolymerizing acrylic resin (Pattern Resin, GC; Jet Fig 7

Facial view of provisional restorations on

Acrylic).

teeth 8 (11) and 9 (21). Direct bonding on teeth 6 (13), 7 (12), 10 (22), and 11 (23).

Immediate implant placement A sulcular incision with transseptal fiberotomy was executed with a No. 15C surgical blade (Kai Medical) to separate tooth 8 (11) from the periodontal tisA treatment plan utilizing immediate

sue. A controlled expansion (Periotome,

implant placement with provisionaliza-

Nobel Biocare) of the bony socket was

tion, GBR, connective tissue graft, and

performed, except at the buccal bony

coronally positioned flap procedures

defect area, to avoid soft and hard tissue

was selected for tooth 8 (11).

damage. Tooth 8 (11) was atraumatically extracted without flap reflection. After extraction, vertical releasing incisions

Clinical procedure

were made at the mesial and distal line angle of the failing maxillary central inci-

Presurgical procedures

sor 8 (11) to avoid touching the papillae of the other teeth. As the patient’s

Before implant surgery, an impression

six maxillary anterior teeth had gingival

(Exafast NDS, GC) was made for diag-

recession, these teeth had a risk fac-

nostic waxing. Diagnostic waxing was

tor of losing the papillae when opening

performed and provisional shells fab-

the flap. The mucoperiosteal flap was

ricated for teeth 8 (11) and 9 (21) us-

carefully elevated using a Periosteal El-

ing autopolymerizing acrylic resin (Jet

evator No. 7 (H & H Company) expos-

Acrylic, Lang Dental). The existing pros-

ing the U-shaped osseous defect.5 An

theses were removed and provisional

osteotomy was performed with the aid

restorations delivered with provisional

of the fabricated surgical template. Be-

cement (TempBond, Kerr).

fore implant placement, numerous small

Incisal edge position was changed

cortical perforations were made around

with diamond burs (Shofu Dental), and

the osseous defect area for GBR. The

the cervical area of the tooth shape

implant (NobelReplace Tapered Groovy,


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Fig 8

The implant was placed 3 mm apical to the

predetermined facial gingival margin. Note the U-

Fig 9

View of the provisional restoration of im-

plant 8 (11).

shaped osseous defect.

Nobel Biocare) was placed (Fig 8) 3 mm

val emergence of the extracted tooth.10

apical to the predetermined facial gingi-

The customized metal temporary abut-

val margin,6,10 with an implant–tooth dis-

ment length and subgingival contour

mm.11

This was ac-

were adjusted extraorally with the finish

complished using the surgical template.

line at 0.5 mm below the predetermined

The implant angulation was positioned

free gingival margin. The customized

slightly palatal to the predetermined de-

metal temporary abutment was hand

finitive prosthesis incisal edge. Primary

tightened onto the implant and a peri-

implant stability was attained.

apical radiograph was made to ascer-

tance of more than 2

tain its fit. The provisional shells 8 (11)

Fabrication of a customized

and 9 (21) were then relined, adjusted

temporary abutment and

extraorally (Fig 9), and delivered with

provisional restoration on implant

provisional cement (IRM cement, Dentsply). Adjustments were made to clear

The mucoperiosteal flap was closed

all contacts in centric occlusion and dur-

temporarily (P-2 5-0 Vicryl, Ethicon,

ing eccentric movements.

Johnson & Johnson). Adhesive metal primer (Alloy Primer, Kuraray) was ap-

Guided bone regeneration

plied on the metal temporary abutment

on implant

(Temporary Abutment Engaging, Nobel Biocare) and was placed on the implant.

The temporary sutures were removed

Flowable composite resin (PermaFlo, Ul-

and the mucoperiosteal flap reflected.

tradent) was applied to the temporary

The periosteum was then released with a

abutment to duplicate the cervical gingi-

new No. 15 blade (Kai), therefore ensur-


CLINICAL RESEARCH

ing a tension-free coronally positioned

face epithelium around the incision area

flap procedure. Autogenous bone, which

was removed for a coronally positioned

was collected during the osteotomy, al-

flap. The flap was positioned 2 mm cor-

lograft (Puros Allograft, Zimmer Dental),

onal to the predetermined margin and

and xenograft (Bio-Oss, Osteohealth),

sutured to cover the graft using resorb-

was used to cover the osseous defect

able sutures (P-2 5-0 Vicryl). A cross-

and thread exposure, and to fill the gaps

sling suture was placed at the coronal

between the implant body and the tooth

aspect of the flap to secure it over the

extraction socket after immediate im-

graft. The connective tissue was then

plant placement (Fig 10).12,13 Resorb-

sutured onto the flap using gut sutures

able collagen membrane (Bio-Guide,

(P-3 5-0 Chromic Gut) (Fig 13). Light fin-

Osteohealth) was trimmed and placed

ger pressure was then applied over the

to cover and stabilize the graft material

grafted site with moist gauze for 5 min to

(Fig 11). Titanium tacks (truTACK, ACE

minimize blood clot formation between

Surgical Supply) were used to secure

the graft and its underlying and overly-

the membrane in place.

ing tissues.6 After surgery, a periapical radiograph was made (Fig 14) and a

Bilaminar subepithelial

CBCT scan (Classic i-CAT) performed

connective tissue graft and

to confirm the implant position and an-

coronally positioned flap procedures on implant

gulation (Fig 15).

Postoperative instruction

The subepithelial connective tissue graft with the dimensions of 14 mm in length,

Antibiotics (amoxicillin 500 mg, 3 times a

1.5 mm in thickness,6 and a width con-

day), analgesic medications (ibuprofen

sistent with the mesiodistal width of the

800 mg, every 4 to 6 hours as needed

crown,6

was harvested from the

for pain), and 0.12% chlorhexidine glu-

palate using the single-incision tech-

conate (Peridex, Procter & Gamble) as

nique.14,15,16

8 (11)

The harvested connective

a mouth rinse were prescribed. The pa-

tissue graft was maintained in a moist

tient was instructed not to brush the sur-

environment to prevent desiccation prior

gical site and remain on a liquid diet for

to its placement.6 Primary closure of the

2 weeks.1,6 After suture removal, a soft

donor site was attained using resorbable

diet was recommended for the remain-

sutures (P-3 5-0 Vicryl). The connective

ing duration (6 months) of the implant

tissue graft was then placed 2 mm coro-

and GBR healing phase. The patient

nally to the predetermined margin of the

was also advised to avoid any mechani-

osseous defect area (Fig 12). The sur-

cal trauma to the surgical site.1,6


WAKI/KAN

Fig 10

View of the bone graft material placement

Fig 11

View of the membrane placement on the

on implant.

bone graft material.

Fig 12

Fig 13

View of the connective tissue graft place-

View of the coronally positioned flap pro-

ment. Note the connective tissue graft was placed

cedure the day after surgery. Note the flap was pos-

in the bone graft and coronally positioned flap area

itioned 2 mm coronal to the predetermined margin

on implant.

to compensate for the 1.5 mm of recession.

Fig 14

Periapical

radiograph of tooth

Fig 15

8 (11) after surgery.

surgery.

CBCT scan image of tooth 8 (11) after


CLINICAL RESEARCH

Fig 16

Facial view 6 months after surgery. The

facial gingival recession had not been recognized.

Fig 17

View of the custom impression pin. Com-

pare the custom impression pin shape with the provisional restoration shape (Fig 9).

Fig 18

View of the final impression of implant 8

(11) and tooth 9 (21).

Fig 19

View of definitive custom abutment on im-

plant 8 (11). Note the papilla height between the maxillary central incisors.

Fig 21

Periapical ra-

diograph of the definitive prostheses. It was likely that the apical rarFig 20

View of the papilla between the maxillary

central incisors.


efaction on tooth 9 (21) was an apical scar.

WAKI/KAN

Fig 22

Postoperative smile view. Note that the black

Fig 23

Facial view of the definitive maxillary cen-

triangle has disappeared and the papilla has been es-

tral incisors prostheses. Note the high scalloped

tablished between the maxillary central incisors.

gingival line.

Final impression and definitive

established by the customized impres-

restorations

sion coping. The definitive abutment was torqued to 35 N (manufacturer’s rec-

There were no postoperative complica-

ommendation, Nobel Biocare) (Fig 19).

tions 6 months after surgery, and the fa-

The definitive metal ceramic prostheses

cial gingival recession had not been rec-

(Creation CC, Jensen Dental) subgin-

ognized (Fig 16). Post and core build up

gival contours were confirmed (Fig 20),

and tooth preparation were performed on

and a periapical radiograph was made

tooth 9 (21). Before the final impression,

to verify the fit of the prostheses (Fig 21).

the subgingival emergence profile of

The definitive prostheses were cement-

the provisional restoration was captured

ed 7 months after the surgery (Clearfil

using high-viscosity vinyl polysiloxane

SA Cement, Kuraray) (Figs 22 and 23).

(Aquasil, Dentsply/Caulk) for making the customized impression coping.17,18 The customized impression coping (Impres-

Discussion

sion Coping Implant Level Open Tray, Nobel Biocare) was then fabricated us-

Papilla preservation and ensuring stable

ing an autopolymerizing acrylic resin

peri-implant tissue is very important in

(Pattern Resin) (Fig 17). The final im-

the esthetic zone. The benefit of immedi-

plant and tooth impression were made

ate tooth replacement has been docu-

with the customized impression coping

mented for papilla preservation.1-4,19 On

using high-viscosity vinyl polysiloxane

the other hand, 0.41 to 0.55 mm of facial

(Aquasil) (Fig 18).

gingival recession has been reported

A definitive custom abutment was

1 year after surgery.1,3,4 As a solution

fabricated using gold abutment engag-

to this problem, connective tissue graft

ing (Nobel Biocare) and cast in medi-

for immediate implant placement and

um-gold dental alloy (V-Delta SF, Metalor

provisionalization procedures has been

Dental USA), with gingival emergence

documented.6


CLINICAL RESEARCH

In the event of an osseous defect pre-

implant platform, 6 mm of osseo bony

senting on the facial bony plate, greater

defect, and 3 mm under the bony de-

than 1.5 mm of facial gingival recession

fect.

was noted in 8.3% of V-shaped, 42.8% of

It has been reported that U-shaped

U-shaped, and 100% of Ultra U-shaped

defects have a 42.8% chance of hav-

defects.5 In this case, the shape of the

ing 1.5 mm of facial gingival recession.5

defect was U-shaped. Therefore, ac-

After a coronally positioned flap with a

cording to the literature, 42.8% of similar

connective tissue procedure, the mean

cases have had 1.5 mm of facial gingi-

root coverage has been documented

val recession.

to be 75% of the amount of coverage

Connective tissue grafts with coronal-

gained at the time of surgery.9 Under

ly positioned flap procedures on natural

such circumstances in this case, the

teeth have been reported with success

flap was positioned 2 mm coronal to

in a randomized clinical trial study.9 This

the predetermined margin to compen-

procedure showed a statistically signifi-

sate for the 1.5 mm of recession (75%

cant increase in keratinized tissue and

of 2 mm). In addition, after a coronally

gingival thickness compared to the cor-

positioned flap procedure, there is a re-

onally positioned flap alone.9

sultant increase in tissue thickness in

A positive association exists between

the area of the predetermined marginal

a greater flap thickness and mean, and

gingiva. This additional tissue thickness

the complete root coverage on natural

improves clinical results.20

teeth.20 In addition, the dimensions of peri-implant mucosa with a thick biotype were significantly greater than with a thin

Conclusions

biotype.21 Under such circumstances, to mini-

Based on this short-term clinical fol-

mize gingival recession after implant

low-up, simultaneous GBR, bilaminar

surgery, two options exist that can be

subepithelial connective tissue graft,

used to try to increase the quality and

coronally positioned flap procedures

quantity of the gingival tissue via con-

with immediate implant placement, and

graft,6

and then to com-

provisionalization seem to have been

pensate for the 1.5 mm of facial gingi-

successful. This procedure still needs

val recession afterwards via a coronally

additional studies. The favorable initial

positioned flap procedure.

results reported with this treatment mo-

nective tissue

The connective tissue graft should be covered on the bone–grafted area and

dality might suggest it to be a viable treatment option.

coronally positioned flap area, since thicker tissue improves clinical results.20 Therefore, the graft size was 14 mm in length, being 2 mm for the coronally

Acknowledgement The authors would like to acknowledge Naoki Aiba,

positioned flap, 3 mm for the distance

CDT (Monterey, CA) for his ceramic work in the pa-

from the predetermined margin to the

tient treatment presented in this article.


WAKI/KAN

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