I case _ report

mediate implant placement, a combined soft andhard tissue augmentation and immediate non-func-tionalloading and the use of an implant system thatallows platform switching to preserve the buccalbone.

Extraction and Immediate ImplantPlacement Using a CombinedHard and Soft Tissue Augmentationand Provisionalization Techniqueauthor _ Suheil M. Boutros, USA

_Abstract

Provisionalization of Endosseous implants at thetime of placement has become more prominent in thefield of dental implantology over the past severalyears, especially in the esthetic zone. The advantagesof this modality of treatment include immediatetooth replacement, containment for bone grafting,soft tissue augmentation, formation and mainte-nance of esthetic softtissuecontours, minimizing thenumber of surgical procedures, the treatment timeand an improved sense of the patient's perception ofthe implant treatment process.Although the survivalrate for this technique is high and predictable, posttreatment gingival recession and bone resorption inthe aesthetic zone are potential limitations. Thiscase report presents a surgical technique for thepreservation and augmentation of anterior aesthet-ics that combines minimally invasive extraction, im-

Case Presentation

A49-yearold non-smoking female patient in goodhealth with no contra indications to treatment pre-sented with questionable maxillary right and left cen-tral incisors 15 years following traumatic injury thatresulted in root canal therapy post and crown. Severalapicoectomy surgeries were performed scaring fromsurgery was evident. Both incisors had mobil ity rangeof 2 to 3 (Fig. 1J.

Clinical and radiographic examinations revealedno signs of infection and there were root fractures onboth teeth, and they were given a hopeless prognosis.

20 I impla8~

Fig. 1_ Preoperativeappearanceof right and left maxillary central incisors. Fig. 2_ PreoperativeConeBeamCT-SCAN.Fig. 3_ 8.77 mm the width ofthe alveolarbonein the regionofthe maxillaryright incisor.Fig. 4_ 15.32 mm the heightof the alveolarbonein the regionof the maxillaryleft incisor.Fig. 5_ Flaplessextraction.Fig. 6_ Flapreflectionto determinethe interproximalboneheight.Fig. 7_ Twist drillswere usedas guides. Fig. 8_ Coronal-apicalposition of the fixtures. Fig. 9_Buccal-palatal position of the fixtures.Fig. 10_Temporary cylinders.Fig. 11_ Mineralizedfreezeddriedbone.Fig. 12_ Xenograftbovineboneasasecondlayer.Fig. 13_A connectivetissue graft sutured.Fig. 14_ Flapsuturedaroundthe healingabut-ments.

Pretreatment PlanningThe implant team conducted a complete medical and dental evaluation. Diagnos-

tic casts were obtained. Evaluation of the surgical site involved a diagnostic wax-upof the hard and soft tissue and the laboratory technician converted it to surgicalguide/restorative template. In addition to the periapical radiographs, a cone beam CT-SCAN was obtained to determine the amount of alveolar bone present apical to theroot tips of the maxillary incisors (Fig. 2, 3, 4). Treatment options were given and in-formed consent was signed.

AD

perfect aesthetics

internal hex

accelerated treatment

The Allfit@Xign@ implant system is designedfor enossal dental implantations.The Xign@ implant system is suitablefor single-step and dual-step implantprotocols.It is made of Grade 4 pure titanium.Xign@ implants are abraded withaluminium oxide and hot-etched andhave an osmotically active nanocoating.All accessory parts are colour-coded.

IHDEDENTAL 1>the implant.company

Dr.lhde Dental GmbHErfurter Str. 19 . D-85386 Eching/Munich. GermanyTelephone: (49) 89319761-0 . Fax (49) 89319761-33e-mail: info@ihde-dental.de . www.implant.com

I case _ report

Fig. 15_ Buccal palatal view offlap.

Fig. 16_ Provisional crowns out of

occlusion.

Fig. 17 _ Ten days post surgery.

Fig. 18_ The second temporary

crowns.

Fig. 19_ Thefinal restorations two

years post placement.

Fig. 20_ Final radiograph two years

post placement.

Fig. 21_ Thefinal restorations.

implants

Suheil M. Boutros,DDS,MSAssistant Prof, Departmentof PeriodonticsUniversity of MichiganPeriodontal Specialists ofGrand Blanc8185 Holly Road, Suite 19Grand Blanc, M148439,USAPhone: +1-810-695-6444E-mail:sboutros@umich.edu

22 I implap;~

Surgical PhaseFollowing the administration of intra-venous

sedation (Midazolam 8 mg, Fentanyl 100 microgram,and 8 mg ofDexamethasone) the local anesthetic wasadministered (lidocaine with epinephrine 1:100,000),atraumatic teeth extractions with periotomes wasperformed without flap reflection to preserve theinterproximal papillae and the buccal plate of bone(Fig. 5). A full thickness flap was reflected (Fig. 6)

The sockets were debrided using hand and rotaryinstruments. Using copious irrigation, preparation ofthe osteotomies began using a 2mm twist drill (Fig.7).

Preparation of the osteotomies continued with a3 mm drills and the implants were placed accordingto the manufacture's protocol (4/5/4x13 mm, CertainPrevail, BiometJi, Palm Beach, Florida). The implantswere 3 mm below the adjacent teeth CEJ(Fig. 8). Thebuccal-lingual position was more in a palatal position(Fig.9).

Provisiona IizationCertain Non-hexed PreFormance temporary

cylinders were used (Fig. 10). These abutments ful-filled the requirements for platform switching.

Bone and Soft Tissue GraftingA combination of mineralized freezed dried bone

allograft (MFDBA) and xenograft bovine bone wereused (Fig. 11).A subepithelial connective tissue graftwas harvested from the right palatal area of the firstand second bicuspid and was sutured using 4-0Vicrylsuture to aIlow the soft tissue augmentation (Fig. 13).The pedicle flap was coronally advanced and wassutured around the healing abutments while thetemporary crowns were finished by the restoringdentist (Fig. 14, 15).The provisiona I crowns were fab-

ricated in the office laboratory. The healing abut-ments were removed and the temporary crowns wereseated. The occlusion was checked to eliminate anyprematu re contacts (Fig. 16).

The patient was provided with appropriatepost operative instructions and returned in 10 daysfor a follow-up visit (Fig. 17).

Restorative PhaseTwelve weeks post extractions and implants

placement and provisionalization, the temporarycrowns were changed to different temporary crownsto improve the soft tissue healing (Fig. 18). Six weekslater, the patient was seen by her restorative dentistfor the final fixtures level impressions and the fabri-cation of the final restorations. Prefabricated Gingi-Hue abutments were used with the platform switch-ing concept.

Thefinal porcelain fused to metal crowns were ce-mented on the abutments using permanent cement.The patient seen for follow-up visits (Fig. 19).The buc-cal gingival height remained stable two years afterthe placement of the final restoration. Periapicalradiograph were taken after two years and confirmedthe stability of the bone level around the implants(Fig. 20).

ConclusionThis case report describes a tech nique to preserve

and augment anterior aesthetics by combiningatraumatic teeth extraction, hard and soft tissueaugmentation, immediate provsionalization andusing the platform switching concept to preservethe bucca I plate. The ging iva Itissue surrou nd ing theimplants has remained stable with no recession twoyears following final crowns placement (Fig. 21L