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implants - international magazine of oral implantology International Edition

I research Fig. 8_Flap raising and implantation. Fig. 9_Implantation of four implants. Fig. 10_Inserted implants, coronally. Fig. 11_Radiological control after surgery. Fig. 12_Flap closure. Fig. 13_Provisional bridge in situ. The anatomyofthe upperjawandthelowvestibule did not allow primary closure. To protect the mem- brane from proteolytical resorption and the aug- ment,weplacedtwolayersoftissuefleeceabovethe membrane. Through the collagen fleece and the protection of the provisional bridge, free granula- tionoftheextractionsocketcoverwasexpectedaf- ter two weeks (Fig. 12).11,12 The patient received a weekly recall with prophy- laxisandhygieneinstructions.Threeweekspostoper- atively, sutures were removed. The clinical situation showed no irritation and the wound healing and clo- sureideal(Fig.13). _Re-entry and prosthetics The re-entry was performed after three months with minimally invasive crestal cuts. A papilloplastic adjustedthewoundmarginsbetween11-12and21- 22 (Fig. 14). After three additional weeks, impression wasperformed.Thehealedsituationshowedoptimal soft tissue quality and adequate attached gingiva quantity. We measured 2–2.5 mm soft tissue height above the implant necks, enough for the necessary emergence profile. With the help of convex or con- cave formed prosthetics, soft tissue can be manipu- lated to the direction needed for esthetics (Figs. 15 & 16).13-16 The final crowns show great results. The papillas and pseudopapillas fill up the approximal space. The approximal contact had to be longer and wider than normally in order to compensate the former vertical boneloss,especiallyintheregion11-12.Nevertheless, therewerenoblacktriangles,thepatientwassatisfied and with the proper hygiene, the aesthetic outcome willbeoptimizedinthenextmonths.Therefore,there wasnoneedtoworkwithroseceramics(Figs.17–19). _Discussion In the periodontally compromised situation, it is important to decide on whether a curative periodon- tal treatment offers satisfactory long term results. As in this occasion, the extraction in a crucial moment helpsuspreservewhatwehave,useittothemaximum for the implant surgery and risk no further bone loss or recessions. Any other procedure would have led to a two-stages surgical approach and probably to re- movable prosthetics. Very favourable was the thick biotypeofthepatient,suchasthelowlipline.Thesoft tissue quantity was evident. Tension on the flap clo- sure was prohibited by the surgical protocol and the free granulation of the wound. The bone quantity in- sured a primary stable implant insertion. Immediate implantationprovidedstabilityfortheaugmentation and less material. The positioning of the implant al- lowedustocreateanoptimalemergenceprofile,mak- ing complicated soft tissue procedures unneces- sary.17-19 The clinical situation and the bony defects made clear during surgery that we would have to make an aestheticcompromiseinregion11-12.Thebonysup- port of the interproximal soft tissue is difficult to re- generate and the pseudopapilla formation not pre- dictable. Immediate implantation in these regions preservehardandsofttissue.Throughthepositioning oftheimplantsandthefreegranulationoftheextrac- tion wound, we enhance the soft tissue, a major ad- vantageforthere-entryandprosthetics.20-22 08 I implants1_2014 Fig. 11 Fig. 13Fig. 12 Fig. 8 Fig. 10Fig. 9