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Bone and Crescent Shaped Free Gingival Grafting for Anterior Immediate Implant Placement: Technique and Case Report

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Bone and Crescent Shaped Free Gingival Grafting for Anterior Immediate Implant Placement: Technique and Case Report Han et al Bone and Crescent Shaped Free Gingival Grafting for Anterior Immediate Implant Placement: Technique and Case Report Thomas Han, DDS, MS1t$IVM8PPOH+FPOH %%4 .4 1I%2 Abstract mmediate implant placement in a single staged peri-implant tissue have shown to pro- approach, with or without provisionalization, mote long-term stable gingival margins. Ican be advantageous in preserving gingival This article presents a simple surgical tech- anatomy around dental implants. However, plac- nique utilizing crescent shaped free gingival tis- ing implants immediately in the changing alveolar sue and bone grafting to promote thicker labial bone of an extraction socket may result in pro- bone and biotype. The surgical procedure gressive recession of the gingival labial margin as well as the biologic and clinical rationale is over the implant restoration. This negative out- described. One-year post-restoration results come may be overcome are evaluated and show with enhanced labial a stable, favorably posi- thickness. Thicker labial tioned labial gingival mar- gingiva and bone of the gin at the implant site. KEY WORDS: Immediate dental implant, connective tissue graft, bone graft 1. Adjunct Professor, Dept. of Periodontics, UCLA School of Dentistry, Los Angeles, California, USA 2. Private practice, Kwang Ju, Korea The Journal of Implant & Advanced Clinical Dentistry t 23 Han et al INTRODUCTION While this technique shows enhanced labial bio- Alveolar ridge resorption following the loss of type over the implants, it requires a large piece anterior teeth often creates challenging esthetic of connective tissue (approximately 9mm long problems in implant dentistry. Horizontal and and 1.5mm thick) which may increase the surgi- vertical bone change surrounding the extraction cal morbidity of the donor site. Additionally, this socket may create papilla loss, labial tissue reces- technique does not adequately address situa- sion, and poor unstable gingival foundations for tions where there are initially unfavorable gingi- an esthetic final restoration. If a harmonious gin- val margins and/or underlying bony architectures. gival form exists around the tooth proposed for This article describes a relatively simple gin- extraction, immediate implant placement and pro- gival tissue augmentation technique used with visionalization may effectively preserve the vertical immediate implant placement in a single stage height of the interdental papilla.1 However, with approach, either with or without provisional- this approach, the propensity for labial gingival ization, to convert unfavorable initial labial gin- recession over time can alter the appearance of gival level and thin biotype to a more stable the final restoration.2,3 While proper implant place- biotype with a favorable gingival margin for bet- ment and correct fabrication of the restoration are ter long term final esthetics. One year follow- important for esthetics in implant dentistry,4,5 it up of the implant restoration showing stability appears that for long term stable esthetics around of the peri-implant gingival tissue is included. dental implants, favorable peri-implant soft and hard tissues are also necessary.6 Studies support MATERIALS AND METHODS that grafting the extraction socket decreases the Soft and Hard Tissue Assessment amount of horizontal resorption and can enhance The advantage of single stage immediate the bone thickness.6 A modified ridge preserva- implant placement is more predictable tion technique called “socket seal surgery” which preservation of the periimplant gingival tissue combines bone and soft tissue grafting to pre- with less patient discomfort and less treatment serve/enhance hard and soft tissue profiles has time. Nonetheless, if mere preservation of been used with immediate implant placement.7 the existing tissue is insufficient to provide an While this technique provides a thick biotype, adequate peri-implant gingival foundation for stable labial gingiva, negligible loss of inter- esthetic restoration, other surgical approaches dental papillary height, and preservation of bone better suited to augmenting the deficient tissue graft material by sealing the socket with a gingi- should be utilized. The criteria and techniques val graft, it requires a second-stage surgery and for proper immediate implant placement have immediate provisionalization is not possible. A dif- previously been established and reported ferent technique attempting to preserve/enhance with successful long-term outcomes.5,7,9 One hard and soft tissue profiles involves a bilaminar of the more difficult aspects of immediate subepithelial connective tissue graft used in con- implant placement is positioning the implant junction with provisionalized immediate implant with sufficient primary stability in an extraction placement and bone grafting in the esthetic zone.8 socket, often without elevating a flap. The 24 t Vol. 1, No. 5 t July/August 2009 Han et al Figure 1: Gingival fracture of the maxillary right lateral Figure 1a: Probing of extraction socket. incisor. alveolar architecture in relation to the angle ing the labial margins of the adjacent canine and of the implant, the presence or absence of the central incisor (figure 1). The labial biotype bone concavity apical to the extracted tooth, was considered to be slightly thin. Placing an the amount of existing bone apical and palatal implant immediately after the removal of the root to the extraction socket, as well as the quality in this situation would most likely result in a less of the bone and soft tissues of the ridge than ideal labial gingival margin without surgically should all be thoroughly evaluated clinically compensating for the post treatment recession and radiographically prior to surgery. Many at the time of implant placement. Interproximal clinicians perform successful immediate implant papilla height was within normal range and the placement without the aid of a computerized underlying bone levels were within 3mm from tomographic (CT) scan, but if any questions the margin based on probing (figures 1, 1a, 2). exist regarding the proposed delivery site, use of a CT scan is advised. Socket Preparation In this case, the patient was 54-year-old male Atraumatic extraction results in minimal damage to with a fractured right lateral incisor at the dentog- the surrounding alveolar bone. If the root needs ingival junction. There were no medical contraindi- to be elevated, the elevator should be placed at cations for dental implant treatment. The fractured mesio-palatal or disto-palatal line angles to mini- root was in a slightly labial position, with the labial mize damage to labial, mesial, and distal inter- gingival margin already at the tangent line join- proximal bone. Use of a periotome to initiate the The Journal of Implant & Advanced Clinical Dentistry t 25 Han et al toration. This may be different from the existing gingival margin. Once this is decided, the proper apical position for implant placement can then be determined with the implant platform 2-4mm api- cal to the anticipated gingival margin. An implant with sufficient length should be used to engage the bone 3-5mm beyond the apex of the extrac- tion socket to provide initial primary stability; this is the single most important factor for its success. The angulations of the implant should avoid adjacent roots and be no more than 15 degrees off, bucco-lingually, from the long axis of the ideal position. One common mistake is to angle the implant too labially to accommo- date the existing bone for primary stabilization. This will not only cause restorative difficulties, but increase labial recession problems as well. In addition, bucco-lingual positioning of the implant must be within the outline of the crown, with 1-2mm of space present between the inner Figure 2: Preoperative periapical radiograph. surface of the labial osseous wall and the labial surface of the implant (figure 3). This also helps separation of the tooth from the alveolar peri- engage the palatal wall for primary stabilization. odontal ligament (PDL) junction can decrease The mesio-distal position must ensure that there the chance of labial bone fracture during the is sufficient room for the interdental papilla. extraction. The fresh extraction socket should Placing the implant in this manner will ensure be thoroughly degranulated and all walls pal- both proper implant restoration emergence pro- pated with hand instruments to assess osseous file and hygiene. After placing the implant in a integrity. The gingival walls of the socket orifice proper position, a bone profiler is used to profile are de-epithelialized with the use of a 15C blade, the interproximal bone so that a slightly flared or gently with a high-speed diamond bur. The healing abutment or a provisional restoration exposed, bleeding lamina propria will enhance fits passively. A healing abutment of 2-4mm in the revascularization of the connective tissue graft length, an appropriate abutment for a cement or which will be placed after implant placement. screw-retained provisional is placed with appro- priate torque. If a healing abutment is used, a Implant Placement removable denture or a tooth attached to an Implant placement starts with determining the final adjacent tooth can be placed over the abutment desired labial gingival margin for the implant res- for the healing period. For a cement-on type of 26 t Vol. 1, No. 5 t July/August 2009 Han et al Figure 3: Extraction Socket with implant immediately Figure 4: Bone graft material packed in the gap between placed in palatal position. the implant and facial bone. abutment, the margin of the provisional should with graft material minimizes both vertical and stay supragingival at this stage for minimal dis- horizontal resorption of the labial bone.13 Many ruption of the grafted site. Chemical irritation clinicians prefer the use of xenograft because from the monomer should be avoided during the there seems to be less shrinkage over time, but fabrication and polymerization of the cement-on the choice of grafting material does not appear provisional. There should be at least 1.5-2mm of to influence the survival of the connective tissue space labial to the abutment or provisional resto- graft.
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