PMC10171974_01
Modified tunnelling procedure extending from the #23-#27 with connective tissue graft for #24, #25, #26 (a). The mucogingival complex was stabilised 1 mm coronal to the CEJ with sling sutures (b).
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The CTG was adjusted to ensure even thickness of 0.8-1.0 mm and carefully pulled into the tunnel by way of positioning sutures and stabilised 1 mm coronal to the cemento-enamel junction (CEJ) of teeth #24, #25, and #26 by sling sutures (7/0 Ethilon; Figure 2).
(a and b) Tooth #25 was minimally traumatically extracted. (c and d) The extraction socket was filled with deproteinised bovine bone (Bio-Oss granules, Geistlich). (e and f) The socket sealed using ovate pontic of the Maryland bridge. The pontic has been adjusted to remove all contacts in static and dynamic occlusion. There was a small gap between the pontic and palatal soft tissues (arrowed in f), resulting in escaping of some Bio-Oss particles and, therefore, preventing socket seal in this place.
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Minimally traumatic extraction of the tooth #25 was performed (Figures 3(a) and 3(b)). The socket was filled with deproteinised bone substitute (Bio-Oss granules, 0.25-1 mm, Geistlich) up to the level of the free gingival margin (Figures 3(c) and 3(d)), and the Maryland bridge was steam cleaned and cemented (Panavia, Kuraray; Figures 3(e) and 3(f)).
Six months following ridge reconstruction procedure. The buccal dashed line delineates the buccal extention of the ridge.
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The 6 months review revealed an increase in soft tissue volume, the extent of buccal augmentation, and complete bony infill to the base of the alveolar defect (Figures 4 and 5).
(a and c) Preoperative CBCT and (b and d) 6 months CBCT views were used for linear and horizontal measurements. Six months cross-sectional CBCT showed buccal augmentation and complete infill (delineated in dashed line) to the crest of the buccal defect (b, arrowed). Vertical measurements were taken from the CEJ to the buccal, or lingual alveolar crest (arrowed). (a and b) The preoperative BRH was 5.69 mm, and the postoperative BRH was 4.34 mm. (a and b) The preoperative LRH was 3.32 mm and postoperatively this measured 4.34 mm. (c and d) The preoperative HRW was 9.34 mm and reduced slightly to 8.10 mm postoperatively.
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The 6 months review revealed an increase in soft tissue volume, the extent of buccal augmentation, and complete bony infill to the base of the alveolar defect (Figures 4 and 5).
(a) A 10 mm x 4 mm (3i) implant fixture placed. (b) Periapical radiograph showing implant fixture and cover screw in place. (c) Healing at 3 months postoperative showed a soft tissue opening, possibly due to excessive pressive from the pontic of the Maryland bridge, which has been removed. The soft tissue opening allowed the impression coping to be directly connected to the fixture without surgical intervention for implant level impression. (d) The position of the impression coping also illustrates the position of the fixture.
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The ridge augmentation enabled the placement of 10.0 mm x 4.0 mm (3i) implant, in a prosthetically driven position, which was demonstrated by the angulation of the impression coping (Figure 6) and the emergence profile of the screw-retained provisional restoration (Figure 7).
(a) Fabrication of the screw-retained provisional restoration. (b) Occlusal adjustment and installation of the provisional restoration in in situ. (c) Radiograph showed complete seating of the temporary abutment.
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fig7
The ridge augmentation enabled the placement of 10.0 mm x 4.0 mm (3i) implant, in a prosthetically driven position, which was demonstrated by the angulation of the impression coping (Figure 6) and the emergence profile of the screw-retained provisional restoration (Figure 7).
(a) Buccal view of tooth #25 at baseline. (b) Implant provisional restoration in place at 1 year.
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The 1-year review showed optimal soft tissue aesthetics and 100% root coverage of the teeth #24 and #25 and partial root coverage of the tooth #26 (Figure 8).
The recent 6-year review. (a) The buccal view showing a good amount of KTW associated with tooth #25 implant. (b) The periapical radiograph showing minimal crestal bone loss. (c and d) Occlusal views highlighting the keratinised tissue thickness around the implant.
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Despite a four-year hiatus where the patient lost contact and did not receive maintenance care, the recent 6-year review showed an adequate amount of KTW and thickness associated with tooth #25 implant (Figures 9(a), 9(c), and 9(d)). The periapical radiograph showed minimal crestal bone loss (Figure 9(b)).