3. Surgical procedure
Background Information
This 28-year-old patient was referred to manage the replacement of the upper left central incisor (21)
with an implant supported restoration. The tooth was causing symptoms of intermittent pain. When
she was 12 years of age, she fell and traumatised teeth 12, 11 and 21. The 21 was avulsed and reimplanted.
Subsequently 11 and 21 required endodontic treatment. The crown of 12 gradually darkened over time,
but endodontic treatment was not required.
She presented with a high lip line and medium tissue biotype. Her aesthetics expectations were high.
A closer examination of 21 indicated an area of erythema on the mesiobuccal aspect of the tooth in
association with a midline papilla and the presence of a cervical resorptive lesion on the mesial aspect.
An aesthetic risk assessment (ERA) using the ITI’s online Aesthetic Assessment tool confirmed that
the treatment to replace this tooth was complex. Of particular risk was the potential for blunting or
loss of the papilla due to the location of the region of external root resorption.
The following treatment plan was proposed:
> Extraction of tooth 21 and placement of an implant 8 weeks later in accordance with an early implant
placement protocol. This approach was selected due to the high aesthetic demand and the need to
maximise volume and thickness of the peri-implant soft tissues, as well as to protect the bone graft
which will be required as part of the treatment.
Fig. 1 This 28-year-old patient was referred to manage the replacement of the upper left central incisor (21) with an implant supported restoration.
> Furthermore, it was planned for the socket to be grafted with Geistlich Bio-Oss® Collagen and Geistlich
Mucograft® Seal at the time of extraction to minimise post extraction dimensional changes.1 Due to
the limited orofacial bone width, this ridge preservation procedure was recommended to ensure that
the subsequent implant could be placed in the correct orofacial positioning and with sufficient
supporting bone.
The 28-year-old Patient's Risk Profile
2. Aims of the therapy
Primary objective following the extraction:
> Flapless extraction without shift of the mucogingival line
>R
idge Preservation with Geistlich Bio-Oss® Collagen and Geistlich Mucograft® Seal to minimise
post extraction dimensional changes
> Minimise contour augmentation surgery at the time of implant placement
Secondary objectives during and after the implantation:
> Implantation in the correct 3-dimensional position and with sufficient supporting bone
> Local contour augmentation in the facial region with Geistlich Bio-Oss® granules and
Geistlich Bio-Gide®
> Aesthetic restoration with screw-retained implant crown
Fig. 2 Close up showing an area of erythema on the
mesiobuccal aspect of the tooth in association with
the midline papilla.
Aesthetic Risk Assessment
Low
Medical status
Healthy
Smoking habits
Non-smoker
Light smoker
(≤ 10 cigarettes per day)
Heavy smoker
(> 10 cigarettes per day)
Patient's aesthetic expectations
Low
Moderate
High
Smile line
Low
Medium
High
Gingival biotype
Thick biotype, low-scalloped
Medium scalloped, medium thick
Thin biotype, high scalloped
Tooth crown shape
Rectangular
Alveolar infection status
Infection-free
Chronic infection
Acute infection
Bone level of the adjacent teeth
≤ 5 mm to contact point
5.5 to 6.5 mm to contact point
≥ 7 mm to contact point
Restoration status of the adjacent
teeth
Natural
Gap breadth
Single tooth gap (> 7 mm)
Soft tissue anatomy
Intact soft tissue
Bone anatomy
Alveolar ridge with no
bony defect
Fig. 3b CBCT examination of 21 revealed that the
alveolar process was narrower orofacially. The facial
bone was thin. The palatal and apical bone volume
was also rather limited.
2
Fig. 3a Intraoral radiographic examination confirmed
the presence of a cervical resorptive lesion on the
mesial aspect.
Moderate
Fig. 7 After thorough debridement of the granulation tissue, Geistlich Bio-Oss® Collagen was then
prepared for grafting into the socket. The Geistlich
Bio-Oss® Collagen was soaked in sterile saline to hydrate the graft. Subsequently, the graft was placed
into the socket and gently tamped with a flat ended
instrument.
Fig. 8 A piece of Geistlich Mucograft® Seal placed
over the graft within the confines of the socket and
sutured into place with a combination of continuous
and interrupted sutures. At this time, it is important
that the Gesitlich Mucograft® Seal is absorbed with
blood from the site to establish a clot.
Fig. 9 8 weeks after extraction and grafting, the 21
site had healed uneventfully. A slight invagination
over the crest of the ridge was noted. However the
soft tissues had completely regenerated over the
socket and graft.
Fig. 10 A CBCT at this time point, showed the presence of the graft in the socket and maintenance of
the orofacial dimension of the ridge.
Fig. 11 Surgical re-entry was then performed for the
placement of a dental implant. Intraoperative view
revealed the situation at the time of surgery. The
Geistlich Bio-Oss® Collagen could be seen within
the original socket and was well incorporated into
the site.
Fig. 12 Following preparation of the osteotomy,
maintenance of thick bone walls on both the facial
and palatal aspect could be observed.
Fig. 13 A guide pin inserted into the osteotomy confirmed the ideal orofacial and mesiodistal position of
the preparation.
Fig. 14 Buccal view following insertion of the implant
confirmed the ideal apicocoronal position of the
implant shoulder. Thus, the principle of placing the
implant into the correct three-dimensional position
was observed.
Fig. 15 A 2 mm healing abutment was then attached
to the implant and additional grafting onto the buccal aspect of the ridge was completed. The graft
consisted of Geistlich Bio-Oss® reconstituted with
venous blood. This graft was required for additional
augmentation to reconstruct the facial contour of
the ridge, which is necessary to achieve an optimum
aesthetic result in the front region.
Fig. 16 Two layers of Geistlich Bio-Gide® were applied to protect and to stabilise the graft.
Fig. 17 The base of the flap was released to allow
slight coronal repositioning for primary closure.
High
Reduced immune system
Triangular
Res F