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ePaper created 2018-03-14, 10:36:46 | version 1.38.0
C.E. article_ labial soft-tissue recession I Fig. 3 Figs. 3-4_ Patient with gingival recession and discoloration due to exposure of the underlying dental implants (teeth No. 7, 8, 9) three years after implant placement. Note the lack of keratinized peri- implant mucosa. Fig. 5_Flap elevation illustrat- ing labial bone dehiscence and implant exposure. Fig. 4 Fig. 5 At the AO _Case report The patient was a healthy 22-year-old male non- smoker with a history of traumatic fracture of the maxillary right lateral incisor and two central incisors. The teeth were extracted with immediate placement of three external hex dental implants (Biomet 3i Dental, Palm Beach Gardens, Fla.). Three years after definitive restoration, the patient presented with a chief complaint of, “I can see the metal portion of my implants.” Examination at this time revealed long unesthetic maxillary crowns with visible abutment metal and a dark shadow along the gingival sulcus (Figs. 1-4). Clinical and radiographic evaluations were conducted to assess the patient’s soft-tissue health, position and emergence profile of the implant relative to the alveolar housing and adjacent teeth, gingival contour, amount of gingiva visibility when the patient smiled, and the shapes of the prosthetic and clinical crowns. There were no active signs of inflammation or infection around the peri-implant mucosa and all three implants appeared to be in good three- dimensional position. A two-stage surgical approach was planned. The first stage would involve augmen- tation of the missing labial bone using guided bone regeneration with tenting screws (“screw tent-pole” technique described by Le, et al), followed by a second stage surgery to remove the middle implant with ad- ditional bone augmentation to develop a pontic site. Following a healing period, provisional restorations would be used to sculpt the soft-tissue architecture prior to definitive restorations. On the day of surgery, the patient was asked to rinse with 0.12 percent chlorhexidine gluconate (15 mL) prior to IV sedation. A crestal incision and distal, curvilinear, vertical incision that followed the gingival margin of the distal proximal tooth were made. A full-thickness, subperiosteal flap15 was ele- vated to expose two to three times the treatment area (Figs. 5-6). Significant labial bone loss was noted in the anterior maxilla with moderate thread exposure on two adjacent implants. Decontamination of the im- plant surfaces was not performed because the patient did not exhibit signs of mucositis, periimplantitis- related infection or purulence around the peri-im- plant gingival sulci. The soft tissue was generously re- leased and advanced to ensure tension-free closure. Prior to graft placement, three roughened tita- nium tenting screws were placed 3-4 mm below the implant platforms to create a tenting effect over the graft site and help reduce tension over the graft (Fig. 6). Mineralized bone allograft was placed over the defect sites and over-contoured by approximately 20-30 percent to compensate for the anticipated Dr. Bach Le will be one of the Academy of Osseointegra- tion’s ‘Morning with the Masters’ presenters at AO’s upcoming annual meeting on Friday, March 2, at the Los Angeles Convention Center. His presentation is titled, ‘Strategies for Managing Severe Implant Failures in the Esthetic Zone.’ implants 1_2018 I 05