PMC5050379_01
Clinical view of the lateral aspect of the edentulous site.
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A 42-year-old female attended the office to investigate a localized ridge atrophy in the area of the upper right canine (Figure 1).
Clinical view of the occlusal aspect of the edentulous ridge.
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Upon clinical examination, the patient was found to have a horizontal bone loss with a minimal vertical component and a coronal ridge width of 2 mm (Figure 2).
Cross-sectional CBCT scan showing the residual graft material and the cortical screw more coronally.
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Tomography (CBCT) scan, confirmed the clinical evaluation and showed remnants of a non-well-defined graft consisting of few granules of a radiopaque material and a transcortical screw (Figure 3). The patient feared to be treated with a conventional bridge and was seeking for an implant treatment and an aesthetic solution.
Apicoectomy surgery performed in the symphyseal area.
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Super Eba , Skokie, IL, USA) (Figure 4). Subsequently, an osteotomy was conducted with rotating instruments in the underlying mandibular symphysis area to harvest a corticocancellous bone block (Figure 5).
Harvesting procedure of a corticocancellous bone block in the mandibular symphysis.
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Super Eba , Skokie, IL, USA) (Figure 4). Subsequently, an osteotomy was conducted with rotating instruments in the underlying mandibular symphysis area to harvest a corticocancellous bone block (Figure 5).
Anatomical view of the occlusal aspect of the edentulous ridge. The horizontal bone resorption is clearly represented.
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The bone was then exposed (Figure 6) and the cortical plate was perforated with a round bur under copious irrigation with sterile physiological saline solution to promote rapid angiogenesis and migration of osteogenic potential cells from the endosteal compartment.
Bone block fixed to the vestibular cortex of the edentulous ridge by means of two transcortical screws.
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The block, previously shaped, was adapted to the recipient site and fixed to the residual ridge with two transcortical screws (Figure 7).
Particulated anorganic bovine bone placed on top of the bone block to reduce the physiological shrinkage of the graft due to bone remodelling.
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The edges of the block were then smoothened with an oval bur and the graft was covered with a thin layer of anorganic bovine bone granules (Bio-Oss , Geistlich Pharma AG, Wolhusen, Switzerland) (Figure 8) and a collagen membrane (Bio-Gide , Geistlich Pharma AG, Wolhusen, Switzerland) (Figure 9).
Resorbable collagen membrane laid over the graft to prevent soft tissue cells ingrowth.
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The edges of the block were then smoothened with an oval bur and the graft was covered with a thin layer of anorganic bovine bone granules (Bio-Oss , Geistlich Pharma AG, Wolhusen, Switzerland) (Figure 8) and a collagen membrane (Bio-Gide , Geistlich Pharma AG, Wolhusen, Switzerland) (Figure 9).
Clinical view of the bone block during the reentry procedure. The graft is completely integrated with the surrounding bone, with no volumetric resorption as demonstrated by the bone levels circumferentially around the transcortical screw.
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After elevation of a mucoperiosteal flap, no signs of graft resorption were observed as from the absence of exposed threads of the transcortical screws (Figure 10).
Dental implant inserted in a prosthetically guided position in augmented bone.
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A 4.3 mm diameter per 13 mm length single implant (Camlog Screw-Line, Camlog Biotechnologies, Basel, Switzerland) was therefore placed in a prosthetically guided position (Figure 11).
Connective tissue graft harvested from the palatal mucosa of the flap to increase soft tissue thickness.
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A connective tissue graft (CTG), harvested from the inner part of the palatal mucosa at the surgical site, was placed to increase the thickness of the soft tissues (Figure 12).
Soft tissues defect after 4 months of healing.
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After 4 months, being the quality of the soft tissues unsatisfactory (Figure 13), a free deepithelized gingival graft was used to enhance the amount of tissue (Figure 14).
A free deepithelized gingival graft was used to enhance the amount of peri-implant soft tissues.
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After 4 months, being the quality of the soft tissues unsatisfactory (Figure 13), a free deepithelized gingival graft was used to enhance the amount of tissue (Figure 14).
First provisional crown in situ. After a 2-month healing time, the soft tissue profile was still unaesthetic when compared to the contralateral side.
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A first provisional crown was connected to the implant two months later, but the coronal level of the soft tissues was still aesthetically unacceptable, when compared to the contralateral canine (Figure 15).