PMC6421801_01
Anterosuperior sector: the clinical crown fracture of tooth #21 is clinically not observed (a); panoramic x-ray (b) and computerized axial tomography (c).
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In the intraoral clinical evaluation (Figure 1(a)), mobility grade 3 of the clinical crown of tooth #21 was diagnosed. A panoramic X-ray was taken to assess the root morphology of tooth #21 (Figure 1(b)). The CT revealed that tooth #21 was fractured at the cervical level of the clinical crown (Figure 1(c)) and that dental extraction was indicated without the possibility of placing a postextraction implant, since there was insufficient thickness of the external vestibular table and the available remnants would lead to a fenestration or lack of primary stability.
Extracted autologous clinical crown (a); filling of the alveolus with InterOss  (b); formation of the ovoid pontic in the cervical part of the clinical crown (c); adherence with conventional composite and orthodontic wire in the palatal sides of teeth #11 and #22 (d); the provisional restoration is left out of occlusion in intercuspid position (e).
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The tooth extraction procedure for tooth #21 consisted of first separating the fractured clinical crown (Figure 2(a)) to subsequently and atraumatically extracting the root remnant with #65 forceps. The alveolus was curetted to eliminate any remaining granulation tissue and periodontal ligament, and to induce bleeding, an InterOss  alveolus was placed in the 0.5 g bone xenograft (Anorganic Cancellous Bone Graft Granules) (Figure 2(b)) to subsequently seal the alveolus surface with a collagen membrane of 8 mm x 12 mm (Colla Tape, Zimmer) sutured with Vicryl 4-0. Once the clinical crown was separated from the root of tooth #21, it was washed with physiological serum and disinfected with 2% chlorhexidine, and a pulpotomy of the crown was performed to eliminate the pulp tissue and to seal the pulp chamber with a conventional composite and the ovoid pontic (Figure 2(c)). The crown was fused with a metal ligature and conventional composite on the palatal surfaces of teeth #11 and #22 (Figure 2(d)). The provisional restoration was omitted from the occlusion in the opening-closing and mandibular eccentric movements (Figure 2(e)).
The patient is scheduled for a weekly appointment for the removal of the sutures (a); good aesthetic after 1 month with papilla preservation (b); the provisional restoration is removed (c-d).
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The patient was scheduled for an appointment 1 week after the tooth extraction to remove the sutures (Figure 3(a)) and to evaluate possible inflammation after extraction. At 1 month after surgery, the soft tissue was evaluated and was not collapsed, did not present gingival inflammation, and demonstrated a maintained confirmation of the volume and dimension of the papillae (Figure 3(b)). Next, we evaluated the conformation of the ovoid pontic, and we decided to add a small amount of the conventional composite on the pontic to provide a natural emergence profile (Figures 3(c) and 3(d)).
Final result after 3 months with the autologous clinical crown as a provisional restoration (a); emerging dimensions of the alveolar contours (b).
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At 3 months after the extraction, the level of the soft tissue was observed (Figures 4(a) and 4(b)).
Images obtained from an intraoral scanner to plan the placement of the implant.
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An intraoral scanner (3Shape) was applied for dental implant placement and surgical guidance (Figures 5(a) and 5(b)).