PMC5816876_01
Preoperative periapical X-ray.
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A 35-year-old female patient, nonsmoker, with noncontributory medical history, presented with a nonconservable mandibular right first molar due to extensive caries and periapical pathology (Figure 1).
Clinical view and periapical X-ray of the site immediately after the "atraumatic" flapless extraction. The septal bone is completely missing, and the buccal bone was defective. Note the shortage of buccal keratinized soft tissue.
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A periodontal probe was then utilized to explore the site which revealed that the septal bone and the buccal bone wall were completely missing (Figure 2).
Grafting of the site with the in situ hardening synthetic bone substitute. Attention was given not to overfill the socket.
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After application of the graft into the postextraction site, a bone plunger was used to condense the moldable graft particles, in order to occupy all the volume of the socket up to the level of the surrounding host bone (Figure 3).
Clinical view and periapical X-ray of the grafted site.
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The site was then covered with a hemostatic dressing material (Jason  Collagen Fleece, Botiss Biomaterials GmbH, Germany), and a cross-mattress tension-free 5/0 suture (Vicryl , Ethicon, Johnson & Johnson, Somerville, NJ, USA) was placed over to achieve soft tissue stability (Figure 4).
Periapical X-ray at 12 weeks showing that the site is occupied by newly formed hard tissue.
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A periapical X-ray at this point in time showed the consolidation of the grafting material, resulting in bone regeneration at the site (Figure 5).
Clinical reentry after 12 weeks of healing. The site is occupied by newly formed hard tissue.
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A site-specific full thickness flap was elevated revealing that the grafted area was filled with regenerated hard tissue (Figure 6).
Trephine bone biopsy taken at the center of the regenerated site.
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Prior to implant placement, a bone core biopsy was taken (Figure 7) with a depth of 7 mm from the center of the site using a trephine drill with a diameter of 2.3 mm (Komet Inc., Lemgo, Germany).
Implant placement at the optimal positioning.
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Following the harvesting of the bone sample, the preparation of the bony bed was completed at the same site and a tapered implant (Dio Co., Busan, Korea), of 4.5 mm in diameter and 10 mm in length, was then placed at the optimal position (Figure 8).
Histological sections of bone core biopsy harvested from the regenerated site using a trephine burr. (a) Overview image of the coronal-apical cut through the entire core biopsy showing new bone (NB) formation in the extraction socket. The new bone is marked, and its surface was calculated in accordance to the overall surface of the specimen, revealing a 50.28% percentage of new bone (H&E stain, original magnification x20). (b) EthOss particles (Gr) are embedded in well-perfused connective tissue (CT) and newly formed bone (NB) (H&E stain, original magnification x200). (c) High magnification showing new bone (NB) in contact with a graft particle (Gr). Osteocytes (OC) can be detected inside the new bone and osteoblasts (OB) forming osteoid (O) on its outer surface (H&E stain, original magnification x400).
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The graft particles were surrounded by or in contact with trabecular bone, while active osteoblasts forming osteoid and new woven bone could be identified, demonstrating persistent osteogenesis (Figure 9).
ISQ measurement at uncovering of the implant.
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After allowing 10 weeks for osseointegration, the implant was accessed using a tissue punch, and a higher ISQ (77) was measured (Figure 10).
Clinical view of the restoration immediately after fitting the restoration.
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Two weeks later, the implant was restored with the final stock titanium abutment (Dio Co., Busan, Korea) and a cement-retained lithium-disilicate glass-ceramic crown (PS e.max Press; Ivoclar Vivadent AG, Schaan, Liechtenstein), achieving pleasant clinical and radiological results (Figure 11).
Clinical view two years after loading the implant.
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Follow-up clinical examination two years after loading revealed stable peri-implant keratinized soft tissues with excellent preservation of the volume and architecture of the ridge (Figure 12).
Radiological examination two years after loading of the implant: periapical X-ray and axial and coronal planes of the CBCT showing the preservation of the dimensions of the regenerated bone.
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A periapical X-ray and CBCT showed further functional remodeling of the bone around the loaded implant with no radiological findings of residual biomaterial (Figure 13).