PMC10072960_01
Baseline status.
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fig1
A 48-year-old man, who was a heavy smoker, presented to the clinic with a missing right central incisor (Figures 1(a) and 1(b)).
Cone-beam computed tomography scans obtained before the surgery.
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A radiographic examination confirmed the complete absence of a buccal cortical plate up to the former apex and a missing interproximal peak between the central and lateral incisors, as well as 1.5 mm of marginal bone resorption palatally (Figures 2(a), 2(b), and 2(c)).
Flap design.
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fig3
The crestal incision was shifted 3 mm palatally to facilitate suturing and wound closure, as well as to move away from the augmented area (Figure 3).
Vertical hockey-stick-shaped releasing incisions.
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fig4
Vertical releasing incisions were started from the gingival margin and were advanced as deep as the mucogingival border with one stroke in a hockey-stick shape (Figure 4).
Defect topography.
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fig5
In order to access and visualize the defect, a full-thickness flap was reflected (Figures 5(a) and 5(b)) using a microsurgical periosteal elevator, also called "Mini Me", which was developed by Istvan Urban, in areas with thinner tissues (PFIWDS1MKX; Hu-Friedy Mfg.
Root conditioning with ethylenediaminetetraacetic acid and enamel matrix derivative application.
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(a) Split-thickness incision to facilitate access for the chisel. (b) Split-thickness incision to facilitate access for the chisel.
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fig7
To gain access to the tuberosity, we performed extraction of the third molar within the same quadrant, which had been discussed with and approved by the patient prior to the surgery (Figures 7(a) and 7(b)).
A triple graft containing a layer of soft tissue and cortical and cancellous bone.
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fig8
Jose Carlos Martins da Rosa (Figure 8).
The block securely positioned into the defect.
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fig9
The triple graft was then wedged into the apical part of the defect and was delicately compressed within the coronal portion (Figure 9).
An AstraTech OsseoSpeed  TX implant with a standard healing abutment.
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fig10
A standard prefabricated healing abutment (Ref. 24576; AstraTech Implant System, Dentsply Sirona, Dentsply Implants Manufacturing GmbH, Hanau, Germany) was placed on the implant at the time of suturing to facilitate wound closure (Figures 10(a) and 10(b)).
Passive wound closure.
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fig11
For the second step, vertical releasing incisions were sutured from the gingival margin to the vestibulum, and additional sutures were added around the healing abutment to ensure formation of a soft-tissue seal (Figure 11).
Day 5:before and after suture removal. The laboratory provisional crown is fixed.
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fig12
Sutures were removed on the fifth day, and a laboratory provisional crown was placed (Figures 12(a), 12(b), 12(c), and 12(d)).
One-month follow-up.
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Subsequently, the patient was followed up weekly for the first month (Figure 13) and every 3 weeks thereafter (until 3 months).
Surgical crown lengthening to level the gingival margin.
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fig14
Gingivectomy of the symmetrical central incisor was performed on the same day (Figure 14).
Soft-tissue maturation 2.5 months postoperatively.
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fig15
Even with heavy smoking and poor oral hygiene, the vertical releasing incisions were not visible 2.5 months after the surgery when the final impressions were taken (Figure 15).