PMC5543658_01
Retained root 23 is extracted, and the socket is left to heal for 2 months before implant placement.
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F1
Two months after (Fig. 1) the implant was placed, a full-thickness envelope was raised with the adjacent papillae.
Full-thickness flap is raised using crestal incision with papillary involvement to place an implant in the 23 area.
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F2
An osteotomy was performed according to manufacturer recommendations, and an implant 16 mm in length and 3.7 mm in diameter was placed (Fig. 2).
Re-entry surgery is performed 3 months after implant placement and palatal rotational flap performed simultaneously with a temporary abutment and crown. A three-sided flap with a more palatally placed crestal incision and the papillae reserved is created. Two vertical incisions are made to the vestibule so that the flap could be freely rotated.
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F3
After de-epithelization with scalpel the flap was rotated inward with the keratinized mucosa facing the temporary crown and simple interrupted suturing with vicryl suture was performed to fix the rotated flap against the crown and the palatal tissue (Fig. 3).
After one month, the crown is modified by adding composite filling material to shape the emergence profile to mimic a natural tooth.
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F4
After one month, the crown removed and reshaped by increasing the diameter; it was still kept out of occlusion (Fig. 4).
Soft tissue adaptation occurred and an emergence profile was shaped when a provisional crown was used. Bleeding occurred after the provisional crown was removed, which is a sign that the lining mucosa was attaching to the crown structure.
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F5
After 3 months with complete soft tissue maturation, the temporary crown was removed to reveal an excellent emergence profile (Fig. 5), the temporary abutment was removed, and impression coping was placed to make an impression at the bone level.
The permanent crown is placed, and gingival bulk is achieved. Still, gingival indentation persists at the vertical gingival incision, and partially loss of mesial and distal papillae is obvious.
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F6
The permanent crown was placed, excess cement was removed, and occlusion was adjusted (Fig. 6).
Periapical radiograph at the time the crown was placed shows a good crestal bone level.
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F7
After one month, the patient was followed up and radiographed (Fig. 7), and the papillae were still partially filling the interdental space.
Six months after the permanent crown is placed, the papillae regenerate and fill the gap, and the indentation scar from the vertical incision starts to disappear.
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F8
The patient was seen again after 3 months, at which time the papillae were almost filling the interdental space and the scar was faded (Fig. 8).
PMC5543658_02
Socket grafting after 21 extraction. The bone graft is covered with a collagen membrane and secured with sutures.
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F9
A cancellous bone graft was placed, covered with a collagen membrane (double layer) and secured with mattress sutures (Fig. 9).
Buccal contour concavity after 3 months period of implant placement.
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F10
A horizontal depression was observed in the center of implant site (Fig. 10).
Healing one week after the palatal rotational flap is performed. Overcorrection is mandatory to compensate for soft tissue remodeling.
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F11
The wound healed uneventfully, and ample gingival tissue thickness and even overbulging was observed (Fig. 11).
Soft tissue healing one month after rotational flap. A, the normal contour of the implant buccal gingiva; B, thick and healthy gingival tissue around the implant after the healing abutment is removed.
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F12
The wound was left to heal for 4 weeks (Fig. 12), and then an impression was taken with impression coping.
A permanent crown with a customized abutment is fabricated, a marked gingival augmentation can be appreciated.
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F13
A customized abutment with porcelain fused to metal crown was fabricated (Fig. 13) and cemented on, and the occlusion was adjusted for centric and eccentric movement.
Periapical radiograph at the time the crown was placed shows a good crestal bone level.
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F14
Patient was followed up by radiograph that show stable crestal bone level (Fig. 14).