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Dental Tribune Middle East & Africa Edition No. 5, 2015

28 Dental Tribune Middle East & Africa Edition | September-October 2015implant tribune “One miracle at a time” – an implant case report By Crawford Bain, UAE I mplant dentistry has evolved dramatically in the 50 years since Branemark’s first pa- tient was treated. The com- bination of improved micro- roughened implant surfaces and tapered implants offers both enhanced initial primary stabil- ity and more rapid osseointegra- tion. This has led to successful treatment of many patients in an accelerated protocol, often offer- ing early or even immediate res- toration of the implants. Those who have become involved with implants in the last few years may take this early or immedi- ate loading for granted, and con- sider it to be the norm for most patients; however only by care- ful case selection can we ensure predictable success. Some patients however present with a complex mix of prob- lems that necessitate a slower, systematic approach to implant treatment if optimum results are to be achieved. Professor Dennis Tarnow of Columbia University, one of the world’s leading im- plant specialists, has a well used maxim… “Let’s do one miracle at a time”. The purpose of this article is to present one such case when only by a stage by stage systematic approach was a good result achieved for the patient. Case Report Patient RR was a healthy non- smoking 44 year old male who presented with a complaint of an unaesthetic upper right cen- tral incisor with extensive reces- sion showing a large amount of darkened labial root surface. The situation was worsened by a high smile line and a por- celain crown contrasting dra- matically with the root colour. He had had periodic swelling at the apical part of the recession over a long period. There was a history of trauma in his teens leading to root canal treatment and a crown, and subsequent apicectomy in his 20s. Clinical examination revealed an other- wise periodontally healthy, well looked-after mouth. (Fig. 1, 2, 3) Diagnosis was of endodontic failure and possible root fracture leading to loss of labial bone and soft tissue. With a complex situation such as this, it often beneficial to visu- alize the end result – in this case an implant supported crown, supported by adequate bone and soft tissue providing gum line symmetry – then to work out “how do I get there from here”? In this case the treatment plan was essentially divided into 3 stages: • Rebuilding the lost soft tissue – necessary to close over bone graft materials and give sym- metry • Rebuilding the lost bone – nec- essary to provide support for an implant • Replacing the tooth In detail these involved: Rebuilding the lost soft tissue 1. Fabrication of a tooth borne immediate partial denture 2. Extraction and the split root confirmed (Fig. 4) 3. De-epithelialise the socket and ensure bone bleeding 4. A connective tissue and epi- thelial graft from the tuberosity – using a distal wedge technique 5. Bilateral pedicles using adja- cent papilla to cover the connec- tive tissue surfaces of the tuber- osity graft (Fig. 5) 6. Fitting and adjusting as neces- sary the tooth borne immediate partial denture 7. Monitoring of soft tissue heal- ing. Tissue from the tuberos- ity and adjacent papillae gives a better match than palatal tissue. We are ready to re-enter when incision lines fully closed. (Fig. 6, 7) Rebuilding the lost bone 1. Re-entry was carried out at 4 months using a full thickness flap for access. 2. Underlying bone was curet- ted with a Rhodes chisel and a round bur was used on the labially-facing surface of bone to ensure bone bleeding (Fig. 8) 3. Endobon xenograft material (Biomet 3i) was placed after be- ing moistened with blood and saline (Fig. 9) 4. OsseoGuard xenograft mem- brane (Biomet 3i) was trimmed and fitted once it seated passive- ly under the flap (Fig. 10) 5. The flap was sutured with 4-0 silk to achieve primary closure over the site. (Fig. 11) 6. The partial denture was ad- justed and refitted after ensur- ing there was no positive pres- sure in the area of the grafted bone. 7. Monitoring of healing. Sutures were removed at 2 weeks and periapical x-rays taken at 2 and 4 months to check for good graft condensation and to ensure there were no voids in the graft material. The timing of implant placement will also depends on bone available beyond root apex position Replacing the tooth 1. The graft was left to mature for 6 months then a full thick- ness papillae preserving flap was used to access the site, re- vealing excellent regenerated bone 2.A15mmFullOsseotitestraight sided external hex implant (Bi- omet 3i) was placed with an insertion torque of 45Ncm. Be- cause the implant was largely > Page 30 Fig. 1 Fig. 6 Fig. 2 Fig. 7 Fig. 3 Fig. 8 Fig. 4 Fig. 9 Fig. 5 Fig. 10

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