Xurxo Álvarez Lourido DDS.
Dental technician Emilio Lopez Prado
This case report describes the rehabilitation of the maxillary ridge, combining bone regeneration techniques and periodontal plastic surgery, together with novel techniques for the management of provisional prostheses, with the goal to return the patient a harmonious pink aesthetic outcome (Fürhauser et al. 2005).
A 56-year-old patient, with good general health conditions, showed up with edentulous posterior sectors and was concerned about teeth mobility in the anterior sector as well as a bad aesthetic appearance. On clinical examination, the patient presented with advanced periodontal disease at teeth 12, 22, 11 and 21 with grade 3 mobility, thus having a poor prognosis. In a first aesthetic analysis, type 3 gingival recessions (Miller 1985) with loss of papillae and imbalance of gingival margins were observed (Fig. 1). The patient expressed her wish for aesthetic, fixed teeth and a long-term stable situation. Thus, based on the present clinical situation, it was decided to perform a rehabilitation of the complete upper jaw with an implant-supported restoration.
At first, a basic periodontal phase was performed to eradicate all inflammatory conditions. As teeth 12, 22, 11 and 21 were no candidates for periodontal surgery, because of the severe periodontal hard and soft tissue loss, it was decided to extract them. For the chosen approach of the full arch reconstruction and for prosthetic reasons teeth 13 and 23 were also removed.
Next, an aesthetic analysis was performed, designing the ideal final restoration guided by the vertical dimension and position of the gingival margin of tooth 13. We decided to orient towards the position of the gingival margin of tooth 13 since it was the ideal one in terms bone height (Fig. 2).
In the CT scan a deficiency in the alveolar bone height, which hindered the placement of dental implants, was observed. Thus, bilateral sinus augmentation was planned. In the anterior area, after the treatment of a nasopalatine cyst, bone availability was checked and considered favorable for implant placement, presenting socket type I (Elian et al. 2007) (Fig. 3 and 4).
In the maxillary anterior sector, the most coronal position of the vestibular cortex was far from the ideal position of the gingival margin of the final restoration. For this reason, a vertical increase in the ridge was planned by using a connective tissue graft in a modified tunnel (Zuhr et al. 2007).
In the anterior area, a submerged root technique (Salama et al. 2007) for teeth 13 and 23 was planned. With this approach, a stable periodontium to keep the canine eminences, the vestibular cortex and the level of the interproximal bone crest can be achieved. It favors the future papillae maturation based on the concepts described by Tarnow (1992), i.e. predictability of the papilla based on the distance from the interproximal bone crest to the point of contact.
Implant distribution was considered another critical factor. It was decided based on functional and aesthetic factors to use contiguous implants at position 11 and 21. At this site, for the most critical papilla (Tarnow et al. 1992) to achieve an ideal location, there is no possibility of a symmetric comparison.
The implants placed in position 14 and 24 adjacent to submerged roots will ensure a good level of interproximal bone, preserved by the periodontium of the roots of teeth 13 and 23 (Salama et al. 2007).
A wide area of pontics in the anterior sector will be left in order to be able to handle the papillae in a predictable and symmetrical way (Tarnow et al. 1992). A flapless surgery was anticipated to maintain vascularization from the periosteum and thus, to minimize bone resorption (Blanco et al. 2008).
A provisional prosthesis was selected according the criteria of critical and subcritical contour (Oscar Gonzalez et al. 2010). The emergency profiles were transferred individually to the laboratory to achieve the final restoration.
SURGICAL PROCEDURE AND PROSTHESIS
- The Design of the ideal final situation was guided by vertical dimension and position of the gingival margin of tooth 13.
- Sinus floor augmentations were performed using cerabone® granules for filling. A collagen fleece (Diacoll®) was applied prior to grafting for protection of the Schneiderian membrane. The antrostromy was covered using Jason® membrane (Fig. 5 – 7).
- Vital submerged roots were left for teeth 13 and 23 in order to maintain the interproximal bone crest, vestibular cortex, and marginal position of soft tissue, and to keep the natural and symmetrical architecture of the canine eminences (Fig. 8). The roots were cut in a subcrestal position, leaving at least 3 mm that will be occupied by the soft tissue emergence profile, separating the vital root from the oral space, thus avoiding contamination. (The pain receptors are located in the pulp chamber, which was cut, thus minimizing post-operative discomfort.)
- The Distribution of the implants (positions 11, 21, 14 and 24) was chosen according to papilla criteria (Tarnow et al. 1992), which leads to a critical situation of contiguous implants at position 11 and 21 and the present single papilla. The implants distal to the esthetic zone will leave a wide area of pontics, which is more predictable to give symmetry (Fig. 9).
- Extraction sites 11 and 21 were treated according to the trimodal approach with osseous and mucosal modification described by Gustavo Cabello et al. 2015 (TAOM protocol) with the use of cerabone®. To resolve vestibular and interproximal, vertical soft tissue deficiencies, the protocol was performed in combination with a connective tissue graft and the modified coronally advanced tunnel technique (Zuhr et al. 2007). A flapless surgery was performed (Lee 2014) (Fig. 10 – 11).
- A 3D position guided by prosthetic rehabilitation (Grunder et al. 2005) was performed, which brings the emergence of the implants in direction to the palate. 2 mm of gap filling with cerabone® was performed (Araujo et al. 2011) (Lee et al. 2014), thus minimizing the horizontal and vertical resorption of the vestibular cortex (Fig. 12).
- The implants were submerged 4 mm with respect to the position of the ideal gingival margin, respecting the biological width of 4 mm in immediate implants (Vignoletti et al. 2009) to maintain space: placement of definitive 2 mm abutments (based on the one abutment one time concept) and 2 mm for the progression from the subcritical contour to the critical contour (Oscar Gonzalez et al. 2010) (Fig. 13).
- Connective tissue graft application was performed with microsurgical techniques using tunnel technique and coronal advancement in order to resolve Miller-type 3 recessions that existed in the initial situation and to support the new papillae (Fig. 14). A supraperiosteal application was performed in order to preserve vascularization.
- The connective tissue graft was harvested from the tuberosity. Connective tissue of this area is of higher density with less adipose and glandular tissue, which maintains the volume on the long term (Zuhr et al. 2014).
- An immediate provisional was used according to the concepts described by Oscar Gonzalez in 2010, which was expanded in 2020. According to it, with critical and subcritical contour, 4 mm space from the ideal position of the gingival margin to the implant platform was kept, to leave a concave subcritical contour with space for bone grafting with cerabone® and CTG application. It promotes a smooth progression to a critical contour (subgingival first millimeter) that directs the marginal soft tissue anatomy and the position of the zenith (Fig. 15).
- After four months, an impression with the individualized emergency profiles, i.e. an exact replica of the critical and subcritical contours of the provisional, was transferred to the laboratory technician.
The postoperative period was uneventful. The integration of the implants was confirmed to be in the prosthetic correct position. Thanks to the careful selection of the TAOM surgical technique, the periodontal plastic surgery technique and the conformation of the immediate provisional, an ideal pink aesthetic situation (Fürhauser et al. 2005) was achieved (Fig. 16 – 18). The patient expressed her high degree of satisfaction with the result obtained (Fig. 19 – 22).
The above described surgical steps and procedures favored a stable and satisfactory as well as an aesthetically demanding outcome with an ideal pink aesthetic score.
Araújo, M. G., Linder, E., & Lindhe, J. (2011). Bio‐Oss® Collagen in the buccal gap at immediate implants: a 6‐month study in the dog. Clinical Oral Implants Research, 22(1), 1-8.
Blanco, J., Nuñez, V., Aracil, L., Muñoz, F., & Ramos, I. (2008). Ridge alterations following immediate implant placement in the dog: flap versus flapless surgery. Journal of Clinical Periodontology, 35(7), 640-648.
Domínguez, G. C., Fernandez, D. A., Calzavara, D., & Fábrega, J. G. (2015). Immediate placement and restoration of implants in the esthetic zone: Trimodal approach therapeutic options. Int J Esthet Dent, 10(1), 100-21.
Elian, N., Cho, S., Froum, S., Smith, R. B., & Tarnow, D. P. (2007). A simplified socket classification and repair technique. Practical Procedures and Aesthetic Dentistry, 19(2), 99.
Fürhauser, R., Florescu, D., Benesch, T., Haas, R., Mailath, G., & Watzek, G. (2005). Evaluation of soft tissue around single‐tooth implant crowns: the pink esthetic score. Clinical oral implants research, 16(6), 639-644.
Grunder, U., Gracis, S., & Capelli, M. (2005). Influence of the 3-D bone-to-implant relationship on esthetics. Int J Periodontics Restorative Dent, 25(2), 113-9.
González-Martín, O., Lee, E., Weisgold, A., Veltri, M., & Su, H. (2020). Contour Management of Implant Restorations for Optimal Emergence Profiles: Guidelines for Immediate and Delayed Provisional Restorations. International Journal of Periodontics & Restorative Dentistry, 40(1).
Lee, E. A., Gonzalez-Martin, O., & Fiorellini, J. (2014). Lingualized flapless implant placement into fresh extraction sockets preserves buccal alveolar bone: a cone beam computed tomography study. Int J Periodontics Restorative Dent, 34(1), 61-68.
Miller Jr, P. D. (1985). A classification of marginal tissue recession. Int. J. Periodont. Rest. Dent., 5, 9.
Salama, M., Ishikawa, T., Salama, H., Funato, A., & Garber, D. (2007). Advantages of the root submergence technique for pontic site development in esthetic implant therapy. International Journal of Periodontics & Restorative Dentistry, 27(6).
Su, H., González-Martín, O., Weisgold, A., & Lee, E. (2010). Considerations of implant abutment and crown contour: critical contour and subcritical contour. International Journal of Periodontics & Restorative Dentistry, 30(4).
Tarnow, D. P., Magner, A. W., & Fletcher, P. (1992). The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. Journal of periodontology, 63(12), 995-996.
Vignoletti, F., De Sanctis, M., Berglundh, T., Abrahamsson, I., & Sanz, M. (2009). Early healing of implants placed into fresh extraction sockets: an experimental study in the beagle dog. III: soft tissue findings. Journal of clinical periodontology, 36(12), 1059-1066.
Zuhr, O., Fickl, S., Wachtel, H., Bolz, W., & Hurzeler, M. B. (2007). Covering of gingival recessions with a modified microsurgical tunnel technique: case report. International Journal of Periodontics and Restorative Dentistry, 27(5), 457.
Zuhr, O., Bäumer, D., & Hürzeler, M. (2014). The addition of soft tissue replacement grafts in plastic periodontal and implant surgery: critical elements in design and execution. Journal of clinical periodontology, 41, S123-S142.