cosmetic dentistry_ beauty & science International Edition

technique _ periodontally compromised situation I _Treatment plan Taking into consideration that the goal of sur- gical periodontal treatments is a screening index of 2–3 mm and that they almost always result in recessions, the outcome of these procedures is aesthetically poor. Especially in highly scalloped biotypes, patients are rarely satisfied. Longer pros- theticstocoverthefreerootsurfacedonotimprove this 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 23 were removed and the teeth were prepared to receive temporary bridgework. With a wax-up on the situation model and pontics, an optimal form was created to support and manipulate soft tissue during the healing phase. At the same time the temporary 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 by other flap designs would provoke functional limitations, suture tension and a secondary gum plastic to reposition the coronal transpositioned soft tissue. The wound margins were freshened to remove 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 buccal 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 39cosmeticdentistry 1_2014 Fig. 4 Fig. 5 Fig. 6 Fig. 7 CDE0114_38-41_Papagiannoulis 11.06.14 14:09 Seite 2