Aesthetic Surgical Approach for Bone Dehiscence Treatment by Means of Single Implant and Interdental Tissue Regeneration: A Case Report with Five Years of Follow-Up
Identifieur interne : 002A14 ( Pmc/Corpus ); précédent : 002A13; suivant : 002A15Aesthetic Surgical Approach for Bone Dehiscence Treatment by Means of Single Implant and Interdental Tissue Regeneration: A Case Report with Five Years of Follow-Up
Auteurs : Giorgio Lombardo ; Jacopo Pighi ; Giovanni Corrocher ; Anna Mascellaro ; Jeffrey Lehrberg ; Mauro Marincola ; Pier Francesco NociniSource :
- Case Reports in Dentistry [ 2090-6447 ] ; 2016.
Abstract
The replacement of single anterior teeth by means of endosseous implants implies the achievement of success in restoring both aesthetic and function. However, the presence of wide endoperiodontal lesions can lead to horizontal hard and soft tissues defects after tooth extraction, making it impossible to correctly place an implant in the compromised alveolar socket. Vertical augmentation procedures have been proposed to solve these clinical situations, but the amount of new regenerated bone is still not predictable. Furthermore, bone augmentation can be complicated by the presence of adjacent teeth, especially if they bring with them periodontal defects. Therefore, it is used to restore periodontal health of adjacent teeth before making any augmentation procedures and to wait a certain healing period before placing an implant in vertically augmented sites, otherwise risking to obtain a nonsatisfactory aesthetic result. All of these procedures, however, lead to an expansion of treatment time which should affect patient compliance. For this reason, this case report suggests a surgical technique to perform vertical bone augmentation at a single gap left by a central upper incisor while placing an implant and simultaneously to regenerate the periodontal attachment of an adjacent lateral incisor, without compromising the aesthetic result.
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DOI: 10.1155/2016/1236310
PubMed: 27119031
PubMed Central: 4812909
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PMC:4812909Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Aesthetic Surgical Approach for Bone Dehiscence Treatment by Means of Single Implant and Interdental Tissue Regeneration: A Case Report with Five Years of Follow-Up</title><author><name sortKey="Lombardo, Giorgio" sort="Lombardo, Giorgio" uniqKey="Lombardo G" first="Giorgio" last="Lombardo">Giorgio Lombardo</name><affiliation><nlm:aff id="I1">Clinic of Dentistry and Maxillofacial Surgery, University of Verona, Piazzale Ludovico Antonio Scuro 10, 37100 Verona, Italy</nlm:aff></affiliation></author><author><name sortKey="Pighi, Jacopo" sort="Pighi, Jacopo" uniqKey="Pighi J" first="Jacopo" last="Pighi">Jacopo Pighi</name><affiliation><nlm:aff id="I1">Clinic of Dentistry and Maxillofacial Surgery, University of Verona, Piazzale Ludovico Antonio Scuro 10, 37100 Verona, Italy</nlm:aff></affiliation></author><author><name sortKey="Corrocher, Giovanni" sort="Corrocher, Giovanni" uniqKey="Corrocher G" first="Giovanni" last="Corrocher">Giovanni Corrocher</name><affiliation><nlm:aff id="I1">Clinic of Dentistry and Maxillofacial Surgery, University of Verona, Piazzale Ludovico Antonio Scuro 10, 37100 Verona, Italy</nlm:aff></affiliation></author><author><name sortKey="Mascellaro, Anna" sort="Mascellaro, Anna" uniqKey="Mascellaro A" first="Anna" last="Mascellaro">Anna Mascellaro</name><affiliation><nlm:aff id="I1">Clinic of Dentistry and Maxillofacial Surgery, University of Verona, Piazzale Ludovico Antonio Scuro 10, 37100 Verona, Italy</nlm:aff></affiliation></author><author><name sortKey="Lehrberg, Jeffrey" sort="Lehrberg, Jeffrey" uniqKey="Lehrberg J" first="Jeffrey" last="Lehrberg">Jeffrey Lehrberg</name><affiliation><nlm:aff id="I2">Department of Biomaterials, Implant Dentistry Centre, 501 Arborway, Jamaica Plain, Boston, MA 02130, USA</nlm:aff></affiliation></author><author><name sortKey="Marincola, Mauro" sort="Marincola, Mauro" uniqKey="Marincola M" first="Mauro" last="Marincola">Mauro Marincola</name><affiliation><nlm:aff id="I3">Universidad de Cartagena, Avenida del Consulado, Calle No. 30, No. 48-152, Cartagena, Bolívar, Colombia</nlm:aff></affiliation></author><author><name sortKey="Nocini, Pier Francesco" sort="Nocini, Pier Francesco" uniqKey="Nocini P" first="Pier Francesco" last="Nocini">Pier Francesco Nocini</name><affiliation><nlm:aff id="I1">Clinic of Dentistry and Maxillofacial Surgery, University of Verona, Piazzale Ludovico Antonio Scuro 10, 37100 Verona, Italy</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">27119031</idno><idno type="pmc">4812909</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4812909</idno><idno type="RBID">PMC:4812909</idno><idno type="doi">10.1155/2016/1236310</idno><date when="2016">2016</date><idno type="wicri:Area/Pmc/Corpus">002A14</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">002A14</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Aesthetic Surgical Approach for Bone Dehiscence Treatment by Means of Single Implant and Interdental Tissue Regeneration: A Case Report with Five Years of Follow-Up</title><author><name sortKey="Lombardo, Giorgio" sort="Lombardo, Giorgio" uniqKey="Lombardo G" first="Giorgio" last="Lombardo">Giorgio Lombardo</name><affiliation><nlm:aff id="I1">Clinic of Dentistry and Maxillofacial Surgery, University of Verona, Piazzale Ludovico Antonio Scuro 10, 37100 Verona, Italy</nlm:aff></affiliation></author><author><name sortKey="Pighi, Jacopo" sort="Pighi, Jacopo" uniqKey="Pighi J" first="Jacopo" last="Pighi">Jacopo Pighi</name><affiliation><nlm:aff id="I1">Clinic of Dentistry and Maxillofacial Surgery, University of Verona, Piazzale Ludovico Antonio Scuro 10, 37100 Verona, Italy</nlm:aff></affiliation></author><author><name sortKey="Corrocher, Giovanni" sort="Corrocher, Giovanni" uniqKey="Corrocher G" first="Giovanni" last="Corrocher">Giovanni Corrocher</name><affiliation><nlm:aff id="I1">Clinic of Dentistry and Maxillofacial Surgery, University of Verona, Piazzale Ludovico Antonio Scuro 10, 37100 Verona, Italy</nlm:aff></affiliation></author><author><name sortKey="Mascellaro, Anna" sort="Mascellaro, Anna" uniqKey="Mascellaro A" first="Anna" last="Mascellaro">Anna Mascellaro</name><affiliation><nlm:aff id="I1">Clinic of Dentistry and Maxillofacial Surgery, University of Verona, Piazzale Ludovico Antonio Scuro 10, 37100 Verona, Italy</nlm:aff></affiliation></author><author><name sortKey="Lehrberg, Jeffrey" sort="Lehrberg, Jeffrey" uniqKey="Lehrberg J" first="Jeffrey" last="Lehrberg">Jeffrey Lehrberg</name><affiliation><nlm:aff id="I2">Department of Biomaterials, Implant Dentistry Centre, 501 Arborway, Jamaica Plain, Boston, MA 02130, USA</nlm:aff></affiliation></author><author><name sortKey="Marincola, Mauro" sort="Marincola, Mauro" uniqKey="Marincola M" first="Mauro" last="Marincola">Mauro Marincola</name><affiliation><nlm:aff id="I3">Universidad de Cartagena, Avenida del Consulado, Calle No. 30, No. 48-152, Cartagena, Bolívar, Colombia</nlm:aff></affiliation></author><author><name sortKey="Nocini, Pier Francesco" sort="Nocini, Pier Francesco" uniqKey="Nocini P" first="Pier Francesco" last="Nocini">Pier Francesco Nocini</name><affiliation><nlm:aff id="I1">Clinic of Dentistry and Maxillofacial Surgery, University of Verona, Piazzale Ludovico Antonio Scuro 10, 37100 Verona, Italy</nlm:aff></affiliation></author></analytic><series><title level="j">Case Reports in Dentistry</title><idno type="ISSN">2090-6447</idno><idno type="eISSN">2090-6455</idno><imprint><date when="2016">2016</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>The replacement of single anterior teeth by means of endosseous implants implies the achievement of success in restoring both aesthetic and function. However, the presence of wide endoperiodontal lesions can lead to horizontal hard and soft tissues defects after tooth extraction, making it impossible to correctly place an implant in the compromised alveolar socket. Vertical augmentation procedures have been proposed to solve these clinical situations, but the amount of new regenerated bone is still not predictable. Furthermore, bone augmentation can be complicated by the presence of adjacent teeth, especially if they bring with them periodontal defects. Therefore, it is used to restore periodontal health of adjacent teeth before making any augmentation procedures and to wait a certain healing period before placing an implant in vertically augmented sites, otherwise risking to obtain a nonsatisfactory aesthetic result. All of these procedures, however, lead to an expansion of treatment time which should affect patient compliance. For this reason, this case report suggests a surgical technique to perform vertical bone augmentation at a single gap left by a central upper incisor while placing an implant and simultaneously to regenerate the periodontal attachment of an adjacent lateral incisor, without compromising the aesthetic result.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Esposito, M" uniqKey="Esposito M">M. Esposito</name></author><author><name sortKey="Grusovin, M G" uniqKey="Grusovin M">M. G. Grusovin</name></author><author><name sortKey="Willings, M" uniqKey="Willings M">M. Willings</name></author><author><name sortKey="Coulthard, P" uniqKey="Coulthard P">P. Coulthard</name></author><author><name sortKey="Worthington, H V" uniqKey="Worthington H">H. V. Worthington</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Higginbottom, F L" uniqKey="Higginbottom F">F. L. 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Case Rep Dent</journal-id><journal-id journal-id-type="iso-abbrev">Case Rep Dent</journal-id><journal-id journal-id-type="publisher-id">CRID</journal-id><journal-title-group><journal-title>Case Reports in Dentistry</journal-title></journal-title-group><issn pub-type="ppub">2090-6447</issn><issn pub-type="epub">2090-6455</issn><publisher><publisher-name>Hindawi Publishing Corporation</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">27119031</article-id><article-id pub-id-type="pmc">4812909</article-id><article-id pub-id-type="doi">10.1155/2016/1236310</article-id><article-categories><subj-group subj-group-type="heading"><subject>Case Report</subject></subj-group></article-categories><title-group><article-title>Aesthetic Surgical Approach for Bone Dehiscence Treatment by Means of Single Implant and Interdental Tissue Regeneration: A Case Report with Five Years of Follow-Up</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Lombardo</surname><given-names>Giorgio</given-names></name><xref ref-type="aff" rid="I1"><sup>1</sup></xref><xref ref-type="corresp" rid="cor1"><sup>*</sup></xref></contrib><contrib contrib-type="author"><name><surname>Pighi</surname><given-names>Jacopo</given-names></name><xref ref-type="aff" rid="I1"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>Corrocher</surname><given-names>Giovanni</given-names></name><xref ref-type="aff" rid="I1"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>Mascellaro</surname><given-names>Anna</given-names></name><xref ref-type="aff" rid="I1"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>Lehrberg</surname><given-names>Jeffrey</given-names></name><xref ref-type="aff" rid="I2"><sup>2</sup></xref></contrib><contrib contrib-type="author"><name><surname>Marincola</surname><given-names>Mauro</given-names></name><xref ref-type="aff" rid="I3"><sup>3</sup></xref></contrib><contrib contrib-type="author"><name><surname>Nocini</surname><given-names>Pier Francesco</given-names></name><xref ref-type="aff" rid="I1"><sup>1</sup></xref></contrib></contrib-group><aff id="I1"><sup>1</sup>Clinic of Dentistry and Maxillofacial Surgery, University of Verona, Piazzale Ludovico Antonio Scuro 10, 37100 Verona, Italy</aff><aff id="I2"><sup>2</sup>Department of Biomaterials, Implant Dentistry Centre, 501 Arborway, Jamaica Plain, Boston, MA 02130, USA</aff><aff id="I3"><sup>3</sup>Universidad de Cartagena, Avenida del Consulado, Calle No. 30, No. 48-152, Cartagena, Bolívar, Colombia</aff><author-notes><corresp id="cor1">*Giorgio Lombardo: <email>giorgio.lombardo@univr.it</email></corresp><fn fn-type="other"><p>Academic Editor: Adrian Kasaj</p></fn></author-notes><pub-date pub-type="ppub"><year>2016</year></pub-date><pub-date pub-type="epub"><day>16</day><month>3</month><year>2016</year></pub-date><volume>2016</volume><elocation-id>1236310</elocation-id><history><date date-type="received"><day>13</day><month>1</month><year>2016</year></date><date date-type="accepted"><day>15</day><month>2</month><year>2016</year></date></history><permissions><copyright-statement>Copyright © 2016 Giorgio Lombardo et al.</copyright-statement><copyright-year>2016</copyright-year><license xlink:href="https://creativecommons.org/licenses/by/4.0/"><license-p>This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p></license></permissions><abstract><p>The replacement of single anterior teeth by means of endosseous implants implies the achievement of success in restoring both aesthetic and function. However, the presence of wide endoperiodontal lesions can lead to horizontal hard and soft tissues defects after tooth extraction, making it impossible to correctly place an implant in the compromised alveolar socket. Vertical augmentation procedures have been proposed to solve these clinical situations, but the amount of new regenerated bone is still not predictable. Furthermore, bone augmentation can be complicated by the presence of adjacent teeth, especially if they bring with them periodontal defects. Therefore, it is used to restore periodontal health of adjacent teeth before making any augmentation procedures and to wait a certain healing period before placing an implant in vertically augmented sites, otherwise risking to obtain a nonsatisfactory aesthetic result. All of these procedures, however, lead to an expansion of treatment time which should affect patient compliance. For this reason, this case report suggests a surgical technique to perform vertical bone augmentation at a single gap left by a central upper incisor while placing an implant and simultaneously to regenerate the periodontal attachment of an adjacent lateral incisor, without compromising the aesthetic result.</p></abstract></article-meta></front><body><sec id="sec1"><title>1. Introduction</title><p>Implant therapy was first introduced for the rehabilitation of completely edentulous jaws and has become today a viable option for the rehabilitation of partial and single edentulism [<xref rid="B1" ref-type="bibr">1</xref>]. In the anterior maxilla, a successful implant procedure requires not only well-anchored implants, but also natural looking result. The only way to gain this result is to correctly place implants in all the three dimensions of bone (i.e., apicocoronal, faciolingual, and mesiodistal) [<xref rid="B2" ref-type="bibr">2</xref>]. Unfortunately, this cannot always be achieved with dental implants due to the presence of alveolar defects. Several clinical and histologic studies have shown the dynamic resorptive process that unfolds after tooth extraction [<xref rid="B3" ref-type="bibr">3</xref>]. When the alveolar site presents deficiencies, many techniques can be used for its development. Vertical ridge augmentation has shown to be effective with several techniques, such as onlay autografts or particulate autogenous and xenogeneic bone covered by nonresorbable membranes [<xref rid="B4" ref-type="bibr">4</xref>–<xref rid="B6" ref-type="bibr">6</xref>]. Paramount to the success of vertical ridge augmentation are five crucial factors: biocompatibility, cell occlusion, space-provision, tissue integration, and ease of use [<xref rid="B7" ref-type="bibr">7</xref>].</p><p>Most of the published studies report on the outcomes of augmentation procedures in completely edentulous areas. The surgical management of edentulous ridges involves a simpler management of soft tissues in order to obtain a primary wound closure and reduce the risk of bacterial contamination. Alternatively, the presence of teeth in close proximity to the atrophic alveolar ridge can affect the procedure, in particular when teeth present periodontal morbidity [<xref rid="B8" ref-type="bibr">8</xref>]. The presence of horizontal defects on implant adjacent teeth limits the possibility of interproximal soft tissue overgrowth between teeth and implants, leading to the need to regenerate the lost periodontal attachment. While ridge augmentation has proven to be effective and predictable, supra-alveolar periodontal regeneration has not yet been demonstrated. Therefore, in clinical practice, periodontal regeneration should precede alveolar augmentation and implant placement. Furthermore, although vertical bone regeneration should occur, it is impossible to predict the amount of resorption of the grafted material, thus leading to the risk of finding part of the implant surface exposed after a certain period of time, if bone augmentation and implant placement are performed simultaneously.</p><p>Few reports can be found concerning the feasibility of regenerating a lost periodontal attachment around a tooth, while at the same time performing a vertical ridge augmentation to allow for the delayed placement of an implant [<xref rid="B9" ref-type="bibr">9</xref>].</p><p>The case report presented here illustrates a technique to regenerate the lost periodontal attachment, improve bone volumes, and allow the simultaneous placement of an implant in the adjacent edentulous alveolar ridge in order to achieve a good aesthetic result in a short rehabilitation time.</p></sec><sec id="sec2"><title>2. Case Presentation</title><p>A 43-year-old woman was referred to us presenting a hopeless upper left central incisor, affected by a large endoperiodontal lesion involving the buccal wall of the alveolar crest and the mesial aspect of the neighboring lateral incisor (Figures <xref ref-type="fig" rid="fig1">1</xref> and <xref ref-type="fig" rid="fig2">2</xref>). The patient accepted the proposal of extracting the tooth and to replace it with an implant. The extraction was performed with minimal trauma and the extraction socket was filled with absorbable hemostatic gelatin sponge (Spongostan<italic>™</italic> Dental, Ethicon, Edinburgh, UK) (Figures <xref ref-type="fig" rid="fig3">3</xref> and <xref ref-type="fig" rid="fig4">4</xref>). The root of the extracted tooth was cut out and the remaining crown was used as provisional pontic element until the implant would have been placed (Figures <xref ref-type="fig" rid="fig5">5</xref> and <xref ref-type="fig" rid="fig6">6</xref>).</p><p>After six weeks of healing soft tissues were well conditioned by the provisional pontic (Figures <xref ref-type="fig" rid="fig7">7(a)</xref> and <xref ref-type="fig" rid="fig7">7(b)</xref>) but a large bone defect was radiographically noticed (<xref ref-type="fig" rid="fig8">Figure 8</xref>). A full thickness flap was raised at the edentulous ridge and was continued on the palatal side with a partial thickness flap till the last molar (<xref ref-type="fig" rid="fig9">Figure 9</xref>), from where a free connective tissue graft was harvested (<xref ref-type="fig" rid="fig10">Figure 10</xref>). The alveolar defect was degranulated and the root surfaces of the adjacent elements were decontaminated using ultrasonic tips and then polished with low abrasive burs (Intensiv Perio Set®, Intensiv SA, Montagnola, Switzerland). After that a 5.0 × 8.0 mm, plateau design, locking-taper implant (Bicon LLC, Boston, MA) was placed under the buccal margin of the bone dehiscence (<xref ref-type="fig" rid="fig11">Figure 11</xref>). To maintain a proper bone and mucosal tunnel, a stealth abutment was modified on its top and then connected to the implant (Figures <xref ref-type="fig" rid="fig12">12(a)</xref> and <xref ref-type="fig" rid="fig12">12(b)</xref>), and in the meantime the connective graft was fixed to the buccal flap.</p><p>Following implant placement, the connective tissue graft was fixed to the buccal flap, and the compromised root surface of the lateral incisor was treated with a regenerative approach, using enamel matrix derivatives (Emdogain®, Straumann, Basel, Switzerland) (Figures <xref ref-type="fig" rid="fig13">13(a)</xref> and <xref ref-type="fig" rid="fig13">13(b)</xref>). A bovine xenograft material (Bio-Oss Collagen®, Geistlich Pharma, AG, Wolhusen, Switzerland) was grafted around facial and buccal aspects till the top of the implants abutment (<xref ref-type="fig" rid="fig14">Figure 14</xref>). The connective tissue graft was used as a membrane, over which the buccal flap was advanced and sutured to obtain a primary wound closure without tension (Figures <xref ref-type="fig" rid="fig15">15(a)</xref> and <xref ref-type="fig" rid="fig15">15(b)</xref>). After taking a postoperative radiograph (<xref ref-type="fig" rid="fig16">Figure 16</xref>), the provisional pontic was placed again and the patient was suggested to take oral antibiotics (Augmentin®, GlaxoSmithKline, UK) and to rinse the mouth twice a day using 0.2% chlorhexidine mouthrinse. Postoperative controls, during which professional oral hygiene was always performed, were made at one and two weeks and then once a month for four months. After four months, the implant and the grafting material appeared well integrated (Figures <xref ref-type="fig" rid="fig17">17</xref> and <xref ref-type="fig" rid="fig18">18</xref>), so a small circular incision was made to allow for the removal of the customized abutment (Figures <xref ref-type="fig" rid="fig19">19(a)</xref> and <xref ref-type="fig" rid="fig19">19(b)</xref>), and a provisional integrated abutment crown was connected (Figures <xref ref-type="fig" rid="fig20">20</xref> and <xref ref-type="fig" rid="fig21">21</xref>). To respect the new regenerated hard interproximal tissues, we chose an abutment with a long post (<xref ref-type="fig" rid="fig22">Figure 22</xref>). Six months after the contralateral incisors were endodontically treated and then reduced to abutment along with the right lateral incisor (<xref ref-type="fig" rid="fig23">Figure 23</xref>). Lateral/anterior protrusion of the definitive restorations was achieved using canine guidance: in this way, mutually protected occlusion prevented contact between incisors during all mandibular eccentric movements, and incisors came into contact with their antagonists only during maximum intercuspation. To orient the seating of the final abutment, a jig was fabricated and utilized to aid in correct positioning. A direct impression was then taken using a polyether impression material (Impregum Penta, 3MESPE, St. Paul, MN). A stone cast using type IV extra-hard dental stone was then prepared, from which the definitive abutment could be individually modified. Finally, four zirconia crowns were fabricated. The implant crown was cemented on the abutment using extraoral cement (RelyX Unicem, 3M ESPE, St. Paul, MN) (<xref ref-type="fig" rid="fig24">Figure 24</xref>). The abutment and crown were then tapped through the long axis of the post into the implant well using a 250 g mallet (Figures <xref ref-type="fig" rid="fig25">25(a)</xref> and <xref ref-type="fig" rid="fig25">25(b)</xref>). The other crowns were cemented on the natural abutments using a zinc phosphate definitive cement (Harvard Cement®, Harvard Dental International, Hoppegarten, Germany) (Figures <xref ref-type="fig" rid="fig26">26</xref><xref ref-type="fig" rid="fig27"></xref>–<xref ref-type="fig" rid="fig28">28</xref>).</p></sec><sec id="sec3"><title>3. Results</title><p>The patient returned to our observation after five years of prosthetic loading. The clinical follow-up examination revealed a satisfying aesthetic result, with adequate contours of peri-implant soft tissues and an almost complete filling of interproximal spaces (<xref ref-type="fig" rid="fig29">Figure 29</xref>). The periapical radiograph obtained showed the implant completely integrated in native bone, while new bone was visible around the implant abutment until the margins of the ceramic crowns (<xref ref-type="fig" rid="fig30">Figure 30</xref>).</p><p>The peri-implant tissues surrounding the implant were found to be in healthy conditions, free from any sign of inflammation and not bleeding after probing. Furthermore, the right lateral incisor presented probing depths below 5 mm, without bleeding after probing.</p><p>The patient concluded that she was fully satisfied with both the aesthetic and functional results of the procedure.</p></sec><sec id="sec4"><title>4. Discussion</title><p>In the present case report, the regeneration of a horizontal periodontal defect was achieved while simultaneously placing an implant and performing a vertical ridge augmentation. Success of periodontal regeneration usually depends on the initial probing depth in relation to the amount of the intrabony/vertical component [<xref rid="B10" ref-type="bibr">10</xref>]. In general, effectiveness of enamel matrix derivatives in inducing periodontal regeneration of intrabony defects was proven to be almost equal if compared to guided tissue regeneration [<xref rid="B11" ref-type="bibr">11</xref>]. On the other hand, outcomes of regenerative therapy of periodontal supra-alveolar defects are known to be unpredictable, and there is little evidence to support such a procedure [<xref rid="B4" ref-type="bibr">4</xref>–<xref rid="B6" ref-type="bibr">6</xref>, <xref rid="B12" ref-type="bibr">12</xref>]. In a recent animal trial, enamel matrix derivatives were combined with a scaffold material to obtain successful supracrestal bone regeneration around implants [<xref rid="B13" ref-type="bibr">13</xref>]. Also, with respect to vertical ridge augmentation, it is not possible to predict the amount of vertical bone gain; therefore, for both the procedures, we sought the use of a barrier able to provide stable space for tissue regeneration against the pressure made by the uppermost soft tissues and to avoid the migration of epithelial cells. Under this point of view, however, both nonresorbable and resorbable barriers have resulted in the same performance [<xref rid="B14" ref-type="bibr">14</xref>]. Despite this, a disadvantage of using nonresorbable barriers is that they need a second intervention for their removal. Membranes, however—particularly nonresorbable membranes—are susceptible to exposure during the healing-phase, leading to only a partial regeneration. Assuming that the placement of an implant occurred followed by membrane exposure, then the aesthetic appearance of soft tissues might be negatively affected, thus compromising the overall success of implant therapy in the anterior maxilla.</p><p>Tooth loss in aesthetic areas has a profoundly negative impact on the patient's social life, and attempts to reduce rehabilitation times were of primary concern; for this reason, a simultaneous approach for periodontal regeneration, alveolar regeneration, and implant insertion was attempted.</p><p>Therefore, to reduce rehabilitation time, we forgo the use of membrane and we used a subepithelial free connective tissue graft to protect the underlying grafting material and to prop up peri-implant soft tissues. The use of free or pedicle soft tissue grafts to preserve gingival color and tissue characteristics is supported by the literature [<xref rid="B15" ref-type="bibr">15</xref>–<xref rid="B17" ref-type="bibr">17</xref>]. Moreover, connective tissue grafts have proven their capability of performing an effective barrier function [<xref rid="B18" ref-type="bibr">18</xref>–<xref rid="B20" ref-type="bibr">20</xref>].</p><p>Vertical ridge augmentation was also performed due to the presence of the customized abutment connected to the implant at the time of its insertion, which maintained the space for grafting material preventing any possible collapse due to compression. As a result of the subcrestal placement and vertical ridge augmentation, the abutment post had to cross a long transmucosal tunnel to connect to the implant. Implant subcrestal placement should lead to further bone resorption in presence of microgaps located at the implant-abutment connection. However, the literature has shown that some locking-taper implant-abutment connections, like the one used in this study, are resistant to bacterial leakage [<xref rid="B21" ref-type="bibr">21</xref>, <xref rid="B22" ref-type="bibr">22</xref>], and some studies have demonstrated minimal bone resorption around similar implants placed subcrestally [<xref rid="B23" ref-type="bibr">23</xref>, <xref rid="B24" ref-type="bibr">24</xref>].</p><p>While the sloping shoulder design of the implant used provides space for interproximal bone regeneration, only histological analysis could distinguish the presence of new bone or simply a filled defect. Nevertheless, the absence of inflammation, along with radiological findings, indicates that the material is well integrated and does not induce a deleterious immunological response. Furthermore, the implant was placed in native bone immediately under the buccal ridge of the alveolar defect, in order to prevent complications if graft resorption occurred. This means that the regenerated hard tissue served to give support to peri-implant soft tissues, to ensure their stability, and to improve the periodontal attachment of the lateral incisor. Finally, for the case shown here, a time period of five years has shown to be sufficient to permit the stability of peri-implant tissues using this aforementioned approach.</p><p>To the best of our knowledge, this is the first report concerning the simultaneous application of periodontal and alveolar regeneration at the implant surgery stage. Based on the positive aesthetic and functional results obtained with the subcrestal placement of a locking-taper connection implant in the anterior maxilla, we look forward to further investigate the efficacy of this treatment as a therapeutic approach.</p></sec></body><back><sec><title>Disclosure</title><p>Jeffrey Lehrberg, Ph.D. (JL), received research support from Bicon LLC (Boston, MA) and consults Bicon LLC on matters pertaining to scientific research. Jeffrey Lehrberg is not involved with any aspect of Bicon LLC sales, marketing, or equivalent business practices; furthermore, Jeffrey Lehrberg understands his obligation to share scientific results and materials with the scientific community, when appropriate and/or applicable. No manager, employee, or other agents associated with Bicon LLC have had any role in the current study's design, data collection methods, analysis, decision to publish, or preparation. At the time of the submission of the report, none of the other authors report any conflict of interests that might raise questions about sources of bias.</p></sec><sec sec-type="conflict"><title>Conflict of Interests</title><p>Jeffrey Lehrberg is funded in part by Bicon LLC. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the paper. 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1</label><caption><p>Front side view of patient upon presentation.</p></caption><graphic xlink:href="CRID2016-1236310.001"></graphic></fig><fig id="fig2" orientation="portrait" position="float"><label>Figure 2</label><caption><p>Intraoral periapical radiograph showing bone loss around the right central incisor and involving the mesial alveolar wall of the right lateral incisor.</p></caption><graphic xlink:href="CRID2016-1236310.002"></graphic></fig><fig id="fig3" orientation="portrait" position="float"><label>Figure 3</label><caption><p>Plaque and calculus can be observed on the root surface at the time of extraction, performed with minimal trauma.</p></caption><graphic xlink:href="CRID2016-1236310.003"></graphic></fig><fig id="fig4" orientation="portrait" position="float"><label>Figure 4</label><caption><p>Occlusal view of the fresh alveolar socket after extraction and application of Spongostan<italic>™</italic>.</p></caption><graphic xlink:href="CRID2016-1236310.004"></graphic></fig><fig id="fig5" orientation="portrait" position="float"><label>Figure 5</label><caption><p>The crown of the extracted tooth was splinted to the adjacent elements and used as provisional pontic.</p></caption><graphic xlink:href="CRID2016-1236310.005"></graphic></fig><fig id="fig6" orientation="portrait" position="float"><label>Figure 6</label><caption><p>Postoperative X-ray after tooth extraction.</p></caption><graphic xlink:href="CRID2016-1236310.006"></graphic></fig><fig id="fig7" orientation="portrait" position="float"><label>Figure 7</label><caption><p>Frontal (a) and occlusal (b) views after six weeks of healing.</p></caption><graphic xlink:href="CRID2016-1236310.007"></graphic></fig><fig id="fig8" orientation="portrait" position="float"><label>Figure 8</label><caption><p>The radiograph taken before implant insertion shows a complete loss of the buccal and palatal bone.</p></caption><graphic xlink:href="CRID2016-1236310.008"></graphic></fig><fig id="fig9" orientation="portrait" position="float"><label>Figure 9</label><caption><p>Occlusal view of the surgical incision at implant insertion time. A full thickness flap at the single gap continued with a partial thickness flap to harvest a connective tissue graft.</p></caption><graphic xlink:href="CRID2016-1236310.009"></graphic></fig><fig id="fig10" orientation="portrait" position="float"><label>Figure 10</label><caption><p>Aspect of the harvested connective tissue graft.</p></caption><graphic xlink:href="CRID2016-1236310.010"></graphic></fig><fig id="fig11" orientation="portrait" position="float"><label>Figure 11</label><caption><p>Surgical placement of the Bicon implant. The implant lies 1 mm below the margin of the buccal bone dehiscence.</p></caption><graphic xlink:href="CRID2016-1236310.011"></graphic></fig><fig id="fig12" orientation="portrait" position="float"><label>Figure 12</label><caption><p>A stealth abutment was tested (a) and then modified on its top (b) to primarily close the wound maintaining a proper bone and mucosal tunnel.</p></caption><graphic xlink:href="CRID2016-1236310.012"></graphic></fig><fig id="fig13" orientation="portrait" position="float"><label>Figure 13</label><caption><p>After fixation of the connective tissue graft to the buccal flap (a), Emdogain® was applied on the lateral incisor root surface to regenerate the lost periodontal attachment (b).</p></caption><graphic xlink:href="CRID2016-1236310.013"></graphic></fig><fig id="fig14" orientation="portrait" position="float"><label>Figure 14</label><caption><p>Bio-Oss® was applied to cover the defect around the implant.</p></caption><graphic xlink:href="CRID2016-1236310.014"></graphic></fig><fig id="fig15" orientation="portrait" position="float"><label>Figure 15</label><caption><p>Frontal (a) and occlusal (b) view at the end of the surgical intervention.</p></caption><graphic xlink:href="CRID2016-1236310.015"></graphic></fig><fig id="fig16" orientation="portrait" position="float"><label>Figure 16</label><caption><p>Postoperative X-ray shows fulfilling of the defect, with the implant lying in native bone below the grafted material.</p></caption><graphic xlink:href="CRID2016-1236310.016"></graphic></fig><fig id="fig17" orientation="portrait" position="float"><label>Figure 17</label><caption><p>Frontal view following provisional pontic removal, after four months of healing.</p></caption><graphic xlink:href="CRID2016-1236310.017"></graphic></fig><fig id="fig18" orientation="portrait" position="float"><label>Figure 18</label><caption><p>Radiograph at four months of healing showing good integration of the implant and the grafted material.</p></caption><graphic xlink:href="CRID2016-1236310.018"></graphic></fig><fig id="fig19" orientation="portrait" position="float"><label>Figure 19</label><caption><p>After performing a circular incision (a), the provisional stealth abutment was removed (b).</p></caption><graphic xlink:href="CRID2016-1236310.019"></graphic></fig><fig id="fig20" orientation="portrait" position="float"><label>Figure 20</label><caption><p>The provisional integrated abutment crown before fixation.</p></caption><graphic xlink:href="CRID2016-1236310.020"></graphic></fig><fig id="fig21" orientation="portrait" position="float"><label>Figure 21</label><caption><p>Frontal view after application of the provisional integrated abutment crown.</p></caption><graphic xlink:href="CRID2016-1236310.021"></graphic></fig><fig id="fig22" orientation="portrait" position="float"><label>Figure 22</label><caption><p>Radiograph showing the long abutment post, chosen to respect the bone and mucosal tunnel.</p></caption><graphic xlink:href="CRID2016-1236310.022"></graphic></fig><fig id="fig23" orientation="portrait" position="float"><label>Figure 23</label><caption><p>Frontal view before prostheses delivery. The implant abutment was tested before extraoral cementation of the crown.</p></caption><graphic xlink:href="CRID2016-1236310.023"></graphic></fig><fig id="fig24" orientation="portrait" position="float"><label>Figure 24</label><caption><p>Aspect of the implant crown after extraoral cementation.</p></caption><graphic xlink:href="CRID2016-1236310.024"></graphic></fig><fig id="fig25" orientation="portrait" position="float"><label>Figure 25</label><caption><p>The abutment and crown were inserted through the long axis of the implant well (a) and then manually pressed (b) before tapping with mallet.</p></caption><graphic xlink:href="CRID2016-1236310.025"></graphic></fig><fig id="fig26" orientation="portrait" position="float"><label>Figure 26</label><caption><p>Frontal view after prostheses delivery.</p></caption><graphic xlink:href="CRID2016-1236310.026"></graphic></fig><fig id="fig27" orientation="portrait" position="float"><label>Figure 27</label><caption><p>The patient's natural looking smile at the end of the therapy.</p></caption><graphic xlink:href="CRID2016-1236310.027"></graphic></fig><fig id="fig28" orientation="portrait" position="float"><label>Figure 28</label><caption><p>Control X-ray at the end of therapy.</p></caption><graphic xlink:href="CRID2016-1236310.028"></graphic></fig><fig id="fig29" orientation="portrait" position="float"><label>Figure 29</label><caption><p>Frontal view showing the aesthetic result at the five-year follow-up examination.</p></caption><graphic xlink:href="CRID2016-1236310.029"></graphic></fig><fig id="fig30" orientation="portrait" position="float"><label>Figure 30</label><caption><p>The radiograph performed after five years shows full integration of the implant and good stability of interproximal soft tissues, along with almost full filling of the lateral incisor's periodontal defect.</p></caption><graphic xlink:href="CRID2016-1236310.030"></graphic></fig></floats-group></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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