PMC5496111_01
An oblique fracture occurred in tooth 21 due to occlusal trauma. Clinically the patient presented a deep periodontal pocket in tooth 21 (a) thin biotype and shorter clinical crowns in teeth 13 and 12 (b). The buccal bone wall loss and periapical lesion were observed in the CBCT (c).
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Caucasian 61-year-old female patient with a thin gingival biotype and a high lip line presented an extensive oblique fracture of tooth 21. Clinically there was a marked mobility of the fragment and an increased pocket depth on the buccal aspect (Figures 1(a) and 1(b)). There was proper quantity of palatal bone to place a narrow implant, regardless of the complete loss of the buccal bone wall and the periapical lesion (Figure 1(c)).
The evaluation of the maxillary anterior teeth demonstrated the alteration of teeth form, zenith position of teeth 13 and 12, and the need to preserve the marginal tissue on tooth 21 after ITR.
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The patient was unsatisfied with her smile due to tooth form alterations and gingival asymmetry (Figure 2).
After atraumatic tooth extraction the palatal bone was drilled (a) and a 3.5 x 13 mm was installed (b) 4 mm below the buccal gingival margin (c).
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Sequential drilling was performed in the palatal bone (Figure 3(a)) to install a 3.5 x 13 mm implant (Figure 3(b)) with a Morse taper connection (Flash; Conexao Sistema de Proteses, SP, Brazil). In order to create an adequate gingival profile, the implant platform was installed 4 mm below the gingival margin and 0,5 mm more distal than the midtooth position; the obtained insertion torque was 50 Ncm (Figure 3(c)).
A thick connective tissue graft was sutured internally in the socket buccal tissue (a). A non-cross-linked membrane was trimmed and placed in contact with the soft tissue graft and the most apical portion of the socket (b). The socket was reconstructed with inorganic bovine bone graft containing 10% porcine collagen (c).
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The graft was inserted in the pouch and sutured into the buccal aspect of the socket at the level of the gingival margin with a 5-0 Polyglactin 910 suture (Vicryl; Ethicon, Brazil) (Figure 4(a)). Thereafter a non-cross-linked collagen membrane (Bio-Gide; Geistlich Biomaterials, Switzerland) was trimmed according to the bone defect and placed internally to the soft tissue graft (Figure 4(b)). The space between the collagen membrane and the implant was filled with an anorganic bovine bone mineral associated with porcine collagen (Bio-Oss Collagen; Geistlich Biomaterials, Switzerland) (Figure 4(c)).
Occlusal view of the reconstructed socket prior to the installation of the provisional with a concave subgingival contour without occlusal contacts.
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A healing abutment was installed and a provisional restoration was bonded to the adjacent tooth until the screw-retained provisional was fabricated with a tooth shell and titanium UCLA abutment (Figures 5 and 6(a)-6(d)).
Lateral images demonstrating the sequence (a-d) of the reconstruction of the socket with the grafts and the immediate provisional.
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A healing abutment was installed and a provisional restoration was bonded to the adjacent tooth until the screw-retained provisional was fabricated with a tooth shell and titanium UCLA abutment (Figures 5 and 6(a)-6(d)).
Operated area after 15 days demonstrating the maintenance of the gingival contour.
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After 15 days the sutures were removed and the gingival tissue presented an adequate form (Figure 7).
Ninety days after the first intervention a flapless crown lengthening surgery was performed to reposition the zenith in teeth 12 and 13. Bone removal was performed with periodontal Micro-Chisel and curette (a) to establish a 3 mm distance between the gingival margin and bone crest (b and c).
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To correct the gingival discrepancy at day 90, flapless crown lengthening of teeth 12 and 13 was performed to level the margin of the opposing teeth 22 and 23 (Figures 8(a)-8(c)).
After the osseointegration period, an impression of the implant was taken to fabricate a customized zirconia abutment with a subgingival concave contour (a-c).
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After abutment connection (Figures 9(a)-9(c)), teeth 14, 13, 12, 11, 22, 23, and 24 were prepared (Figure 10(a)) and molded with polyvinyl siloxane and a provisional was fabricated with resin (Protemp; 3M ESPE, USA).
The adjacent teeth were prepared and an impression was made to produce all ceramic restorations (a). A CBCT demonstrated the creation of bone tissue around the implant and the increase of the gingival tissue one year after ITR (b). Results obtained one year after the zenith-driven rehabilitation (c).
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After abutment connection (Figures 9(a)-9(c)), teeth 14, 13, 12, 11, 22, 23, and 24 were prepared (Figure 10(a)) and molded with polyvinyl siloxane and a provisional was fabricated with resin (Protemp; 3M ESPE, USA). Another soft tissue CBCT (Figure 10(b)) and clinical pictures were performed one year after the surgery where a short-term stability could be seen of the results achieved by the described protocol (Figure 10(c)).
Stable results were obtained after four years of follow-up of the zenith-driven rehabilitation.
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Four years later, the results were maintained (Figure 11).