implants - international magazine of oral implantology International Edition

research I _Treatment plan Taking into consideration that the goal of surgi- cal periodontal treatments is a screening index of 2–3 mm and that they almost always result in re- cessions, the outcome of these procedures is aes- thetically poor. Especially in highly scalloped bio- types,patientsarerarelysatisfied.Longerprosthet- icstocoverthefreerootsurfacedonotimprovethis outcome. On the other hand, these procedures are not always successful, resulting additionally in thermal sensitivities and persisting tooth mobility. Because of the high costs of surgical periodontol- ogy and the previous arguments, patients increas- ingly ask for alternative procedures. In the case dis- cussed in this article, periodontal treatment would further neither aesthetic nor functional improve- ment, but only maintain the teeth for some months or years. The risk would be additional loss of bone and soft tissue, compromising future plans and prosthetic possibilities. The treatment plan for this case included conservative periodontal treatment and recall to treat inflammations, tooth extraction and immediate implantation with guided bone and tissue regeneration. _Surgery Beforeextractingtheincisors,thecrowns13and 23wereremovedandtheteethwerepreparedtore- ceive temporary bridgework. With a wax-up on the situation model and pontics, an optimal form was created to support and manipulate soft tissue dur- ing the healing phase. At the same time the tempo- rary bridge functions as wound coverage if primary closure is not possible (Figs. 3–6).1-4 In the next step, the teeth 12 to 22 were ex- tracted. The flap outline spared the middle papilla and mesial ones on 12 and 22. Due to interproximal bone defects, raising of the papilla in this region would have led to severe recessions. The vertical bone defects, especially between 11 and 12, were obviousafterraisingafull-thicknessflap.Releasing incisionswereplaceddistallyatthecaninesandonly in the attached gingiva to prohibit scar formation through vertical cuts in the mucosa. The low vestibulemadeasplitthicknessorperiostealpocket flap less logical. Mobilizing soft tissue from the lips byotherflapdesignswouldprovokefunctionallim- itations, suture tension and a secondary gum plas- tic to reposition the coronal transpositioned soft tissue. The wound margins were freshened to re- move prolonged epithelia and the bone defects freed from soft tissue ingrowth (Figs. 7–10). The horizontal bone loss was moderate. Implants were placed slightly subcrestally. Although the gap be- tween implants and the buccal plate was approxi- mately 1–1.5 mm and the buccal plate thickness 1–1.5 mm due to the resorption, we decided for 3.8 mm implants, leaving a 1.5 mm gap to the buc- cal plate.5-10 Theinterimplantspaceandthebuccalplatewere augmented with a combination of allograft and xenograft. Xenograft was also placed on the buccal plate so as to manipulate buccal plate resorption. A pericardiummembranewasusedasbarrier(Fig.11). Fig. 4_Wax-up of the provisional bridge. Fig. 5_Provisional bridgework with pontics. Fig. 6_Provisional bridgework frontally. Fig. 7_Extraction sockets. I 07implants1_2014 Fig. 4 Fig. 5 Fig. 6 Fig. 7