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cosmetic dentistry_ beauty & science International Edition

I technique _ periodontally compromised situation 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. Theanatomyoftheupperjawandthelowvestibule did not allow primary closure. To protect the mem- brane from proteolytical resorption and the aug- ment, we placed two layers of tissue fleece above the membrane. Through the collagen fleece and the protection of the provisional bridge, free gran- ulation of the extraction socket cover was expected after 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 closureideal(Fig.13). _Re-entry and prosthetics The re-entry was performed after three months with minimally invasive crestal cuts. A papilloplastic adjusted the wound margins between 11-12 and 21-22(Fig.14).Afterthreeadditionalweeks,impres- sion was performed. The healed situation showed optimal soft tissue quality and adequate attached gingiva quantity. We measured 2–2.5 mm soft tissue height above the implant necks, enough for the necessaryemergenceprofile.Withthehelpofconvex or concave formed prosthetics, soft tissue can be manipulated 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 perio- dontaltreatmentofferssatisfactorylongtermresults. Asinthisoccasion,theextractioninacrucialmoment 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 removable 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 insured a primary stable implant insertion. Imme- diate implantation provided stability for the aug- mentation and less material. The positioning of the implant allowed us to create an optimal emergence profile, making complicated soft tissue procedures unnecessary.17-19 The clinical situation and the bony defects made clear during surgery that we would have to make an aesthetic compromise in region 11-12. The bony support of the interproximal soft tissue is difficult to regenerate and the pseudopapilla formation not predictable.Immediateimplantationintheseregions preservehardandsofttissue.Throughthepositioning of the implants and the free granulation of the ex- traction wound, we enhance the soft tissue, a major advantageforthere-entryandprosthetics.20-22 40 I cosmeticdentistry 1_2014 Fig. 11 Fig. 13Fig. 12 Fig. 8 Fig. 10Fig. 9 CDE0114_38-41_Papagiannoulis 11.06.14 14:09 Seite 3