PMC5817416_01
Case report.. Notes: (A) Initial presentation. Tooth 21 was fractured subgingivally, and tissue was inflamed and cyanotic. (B) Periapical radiography showing the remaining short root and level of interproximal bone. (C) Presentation at osseointegration check. Peri-implant tissue is healthy, but located at an apical level when compared to the adjacent tooth. (D) Periapical radiography of the implant replacing tooth 21. (E) Occlusal view of the healing abutment. (F) Tunnel preparation extending apically using curved elevator. (G) Connective-tissue graft harvested from the contralateral side of the palate. Wide, thick tissue is needed. (H, I) The CTG is inserted into the dome first buccally then palatally and stabilized by 6-0 sutures. At least two-thirds of the graft has to be covered to allow the survival of the uncovered part. (J) Healing of the area at 2 weeks. (K) Amount of vertical tissue augmentation achieved at the uncovering of the implant at 6 weeks. (L) Final cement-retained crown. Adequate esthetic results were achieved with harmonious gingival margin between the implant and the adjacent teeth. (M) Occlusal view showing amount of augmented tissue on the buccal aspect.. Abbreviation: CTG, connective-tissue graft.
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The tooth was fractured at the gingival margin and deemed unrestorable (Figure 3A and B). At this stage, it was clear that the future crown margin would be apical to that of the contralateral tooth, thus creating a gingival margin disharmony (Figure 3C-E). The recipient bed was prepared by a partial-thickness incision and blunt dissection utilizing a curved, thin periosteal elevator (Figure 3F), which extended along the facial aspect of the implant and laterally under the adjacent mesial and distal interdental papillae. CT was harvested from the palate (Figure 3G), inserted under the buccal flap first, and then laid over the implant head, extending into the palatal and interdental areas of the prepared surgical bed. 5-0 chromic gut sutures were used to stabilize the graft (Figure 3H and I). Healing was uneventful (Figure 3J). After 6 weeks, the implant was exposed and a new healing abutment placed (Figure 3K). The tissue surrounding the implant was thick and healthy (Figure 3L and M).
24-Month follow-up.. Notes: (A) Stable esthetic results were achieved with the gingival margins on both central incisors at equal levels. (B) Buccal soft-tissue augmentation is maintained. (C) Patient smile. (D) Periapical radiography of the implant replacing tooth 21 with stable bone level.
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The patient was observed up to 24 months following crown insertion, with stable results and maintenance of the marginal gingival tissue (Figure 4).