PMC6033297_01
Presence of ceramic restorations in the upper anterior teeth with swollen gingival area on the vestibular face of element 11.
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The clinical examination revealed that the gingival biotype was thick, there was a small active fistula on the vestibular surface, and the depth of probing in this area was 7 mm, with mobility of the crown in the vestibular-palatine direction (Figure 1).
PMC6033297_02
Root fracture and its subsequent bacterial contamination caused the vestibular wall to become impaired. (a) Tomography demonstrating the loss of vestibular bone wall in element 11. (b) The root fracture and invasion of the biological space generated inflammation on the vestibular face.
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After a CBCT scan, the diagnosis of vertical root fracture and invasion of the biological space with a compromised vestibular bone wall was confirmed (Figure 2(a)). After an infiltrative anesthesia in the vestibule and the palatine region of tooth 11 with 2% mepivacaine and epinephrine 1 : 100,000 (DFL), an intrasulcular incision was made with a 15C (Swann-Morton) blade with the aid of a peritoneum, apical levers, and delicate forceps, minimally invasive exodontia was performed (Figure 2(b)) without compromising the integrity of the papillae.
IDR surgical phase. (a) Cortical-medullary blade removed from the right maxillary tuberosity. (b) Cone Morse implant installation and pillar height test.
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With the aid of a surgical hammer and a goose chisel number 08, the cortical-medullary bone sheet was removed and taken to a glass plate where it was carved in the shape of the defect to be reconstructed (Figure 3(a)). The implant cover was removed and an intermediate pillar of 1.5 mm height was installed (Figure 3(b)).
Immediate postoperative preserving the protective tissues with maintenance of vestibular volume and gingival margin. (a) Front view of the IDR. (b) Occlusal view with incisal relief.
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The reconstruction allowed the complete closure of the spaces and there was no need for sutures in tooth region 11 (Figures 4(a) and 4(b)).
PMC6033297_03
PMC6033297_04
Trauma during sports procedure in the immediate implant region. (a) Due to the trauma, there was vestibularization. (b) Implant-crown turning compromising the entire osseointegration process.
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He also reported that when doing a jiu-jitsu class, he received an elbow in the operated tooth with bleeding and pain after the trauma (Figures 5(a) and 5(b)).
The provisional crown was removed and then reinstalled and attached to the neighboring teeth. (a) Presence of bone sequestration arising from the reconstruction of the vestibular wall. (b) Repositioning of the crown and union to the neighboring teeth with resinous cement.
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The crown was removed, and small fragments of bone abduction were found in the abutment region (Figure 6(a)). Temporary union with U-200 resin cement (3M Espe) of the acrylic crown was performed on the neighboring teeth 12 and 21 (Figure 6(b)).
Radiographic analysis ten days after the trauma. (a) The tomographic image registers the implant in an inadequate three-dimensional position. (b) Loss of vestibular wall that had been rebuilt.
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The loss of implant stability is directly related to the absence of supporting bone tissue in the vestibular area (Figures 7(a) and 7(b)).
PMC6033297_05
PMC6033297_06
Immediate postoperative of the second IDR applied to element 11 with peri-implant tissue normality. (a) Immediate frontal view and (b) occlusal view demonstrating the maintenance of vestibular volume.
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A new 2.5 mm height abutment was installed with a torque of 32 Ncm, and immediate provisioning was still possible with a screwed crown even though the prosthetic connection of the abutment was in a more vestibularized position (Figures 8(a) and 8(b)).
PMC6033297_07
Tomography 10 days after surgery to visualize the 3D position of the implant and the presence of the cortical-medullar lamina. (a) Tomographic section where it is possible to visualize the grafted bone tissue. (b) Image recording bone reconstruction.
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In this period, two CBCT scans were performed: the first ten days after the new IDR (Figures 9(a) and 9(b)) and the second after five months, confirming the osseointegration of the implant and maintenance of the new vestibular bone wall (Figures 10(a) and 10(b)).
Tomography after five months of the second IDR. (a) Tomography performed with oral retractor to reveal soft tissues. (b) Recording of total graft incorporation and presence of a new vestibular bone wall.
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In this period, two CBCT scans were performed: the first ten days after the new IDR (Figures 9(a) and 9(b)) and the second after five months, confirming the osseointegration of the implant and maintenance of the new vestibular bone wall (Figures 10(a) and 10(b)).
Result obtained after five months of healing. Despite clinical success, there was a slight discrepancy in the gingival margin of element 11.
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At this time, an esthetic evaluation of the gingival margin was made, and it was found that in the operated region, there was a smaller volume, and the gingival margin was more apical than the other incisors (Figure 11).
PMC6033297_08
Connective tissue graft. (a) Subepithelial connective tissue removed from the palate. (b) Suture of the graft divided into the vestibular flap using the provisional crown as a foundation for better position and support of the gingival margin.
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After mapping the amount to be grafted, the palate was accessed, and through an "L" incision, the connective tissue was removed (Figure 12(a)) and sutured in the vestibular region (Figure 12(b)) with 5.0 absorbable suture thread Technew.
Grafted tissue in maturation process. (a) Occlusal view of the scar area after 30 days with increased volume. (b) Positioning of the new vestibular gingival margin.
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After the positioning of the graft with the flap moved to the incisor, the gingival margin was repositioned (Figures 13(a) and 13(b)), the crown was removed, the critical and subcritical area of the emergency profile was resized (Figures 14(a) and 14(b)), and the suspensory suture was made in the papillae and in the center of the margin and fixed directly to the acrylic crown with flow resin (Opallis, FGM) for better tissue stability.
Correct delineation of the emergency profile is crucial to the long-term success of the technique. (a) Concave emergency profile in the cervicovestibular region. (b) The critical line corresponds to the position of the gingival margin, and below it is the subcritical area that should accommodate and maintain healthy peri-implant soft tissues.
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After the positioning of the graft with the flap moved to the incisor, the gingival margin was repositioned (Figures 13(a) and 13(b)), the crown was removed, the critical and subcritical area of the emergency profile was resized (Figures 14(a) and 14(b)), and the suspensory suture was made in the papillae and in the center of the margin and fixed directly to the acrylic crown with flow resin (Opallis, FGM) for better tissue stability.
Occlusal view where the volume and quality of the peri-implant tissues obtained after the completion of the IDR with connective graft can be visualized.
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