PMC4812909_01
Front side view of patient upon presentation.
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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 1 and 2).
Intraoral periapical radiograph showing bone loss around the right central incisor and involving the mesial alveolar wall of the right lateral incisor.
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fig2
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 1 and 2).
Plaque and calculus can be observed on the root surface at the time of extraction, performed with minimal trauma.
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The extraction was performed with minimal trauma and the extraction socket was filled with absorbable hemostatic gelatin sponge (Spongostan  Dental, Ethicon, Edinburgh, UK) (Figures 3 and 4).
Occlusal view of the fresh alveolar socket after extraction and application of Spongostan .
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fig4
The extraction was performed with minimal trauma and the extraction socket was filled with absorbable hemostatic gelatin sponge (Spongostan  Dental, Ethicon, Edinburgh, UK) (Figures 3 and 4).
The crown of the extracted tooth was splinted to the adjacent elements and used as provisional pontic.
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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 5 and 6).
Postoperative X-ray after tooth extraction.
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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 5 and 6).
Frontal (a) and occlusal (b) views after six weeks of healing.
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After six weeks of healing soft tissues were well conditioned by the provisional pontic (Figures 7(a) and 7(b)) but a large bone defect was radiographically noticed (Figure 8).
The radiograph taken before implant insertion shows a complete loss of the buccal and palatal bone.
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fig8
After six weeks of healing soft tissues were well conditioned by the provisional pontic (Figures 7(a) and 7(b)) but a large bone defect was radiographically noticed (Figure 8).
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.
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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 (Figure 9), from where a free connective tissue graft was harvested (Figure 10).
Aspect of the harvested connective tissue graft.
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fig10
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 (Figure 9), from where a free connective tissue graft was harvested (Figure 10).
Surgical placement of the Bicon implant. The implant lies 1 mm below the margin of the buccal bone dehiscence.
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fig11
After that a 5.0 x 8.0 mm, plateau design, locking-taper implant (Bicon LLC, Boston, MA) was placed under the buccal margin of the bone dehiscence (Figure 11).
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.
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To maintain a proper bone and mucosal tunnel, a stealth abutment was modified on its top and then connected to the implant (Figures 12(a) and 12(b)), and in the meantime the connective graft was fixed to the buccal flap.
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).
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fig13
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 13(a) and 13(b)).
Bio-Oss  was applied to cover the defect around the implant.
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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 (Figure 14).
Frontal (a) and occlusal (b) view at the end of the surgical intervention.
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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 15(a) and 15(b)).