Page 45 - CEREC Q3 | 2014

QUARTER 3 | 2014 | CERECDOCTORS.COM | 43
the dehiscence defect was treated via
the buccal contour augmentation and
layered bone grafting technique. The
two different bone grafting materials
(MinerOss, BioHorizons and Bio-Oss,
Geistlich) were reconstituted and
mixed with PRF and a localized decor-
tication was then performed via intra-
marrow perforations. The first layer
of bone grafting consisted of applying
the corticocancellous MinerOss bone
graft onto the exposed implant threads
(Fig. 23). The second layer of bone
grafting consisted of applying the anor-
ganic bovine Bio-Oss bone graft onto
the previously applied MinerOss bone
graft (Fig. 24). This layered bone graft
was then covered with a double layer of
a cell-occlusive resorbable membrane
(CopiOs Pericardium membrane,
Zimmer), followedby a final layer of PRF
membranes (Figs. 25-26). A periosteal-
releasing incision was then performed
to allow tension-free submerged
primary flap closure with 5.0 Polypro-
pelene sutures (Fig. 27). The immediate
postoperative periapical radiograph
confirmed the accuracy of the implant
position according to the preoperative
plan (Fig. 28).
The third surgical procedure was
performed after an additional healing
period of two months (Fig. 29). This
surgical procedure was performed
under local anesthesia and consisted of a
punch-type uncovering of the implant in
site #8, soft tissue esthetic crown length-
ening and a midline frenectomy (Fig. 30).
The patient was then referred back to his
restorative dentist for the provisional and
final restorative treatment.
A provisional acrylic screw-retained
crownwas fabricated initially to develop
the ideal peri-implant soft tissue
contours over a four to six week time
period (Fig. 31), and thefinal restorations
— consisting of a composite bonding on
tooth #9 and a pressed e.max custom
abutment with a cemented e.max crown
on the implant in site #8 — were then
completed (Figs. 32-34).
The final view of the patient’s smile
(Fig. 35), and the comparison of the
patient’s preoperative and postoperative
full facial views (Figs. 36-37), revealed
an esthetically pleasing outcome with
improved proportions of the maxillary
anterior teeth due to the facially gener-
ated treatment plan.
The post-operative Periapical radio-
graph and CBCT scan revealed ideal
implant placement in accordance
with the pre-operative guided surgery
implant treatment plan, coupled with an
excellent and stable result of the buccal
contour augmentation establishing a
thick facial bone wall (Figs. 38-39).
DISCUSSION
The ultimate treatment objective in
esthetic implant therapy should be a
long-term successful esthetic and func-
tional outcome with a high degree of
predictability and a low risk of complica-
tions. To select the appropriate treatment
approach for post-extraction sites in the
esthetic zone, clinicians have to consider
several clinical parameters as each clinical
approach has its indications depending on
the specific clinical situation.
Although immediate implant place-
ment can result in excellent esthetic
outcomes, a number of systematic liter-
ature reviews have shown that imme-
diate implant placement is also associ-
ated with a significant risk for esthetic
complications — mainly the recession
of the facial gingival margin, especially
in cases with a thin periodontal biotype,
or in cases with a partially or completely
missing buccal bone plate (such as the
case outlined in this article).
33 34
31
32
30 29
Fig. 29: Facial view after an
additional eight weeks of healing
Fig. 30: Uncovering of implant,
soft-tissue crown lengthening,
and frenectomy
Fig. 31: Facial view of screw-retained
provisional restoration
Fig. 32: Facial view of final restoration
Fig. 33: Close-up view of final
restoration
Fig. 34: Occlusal view of final
restoration
The ultimate treatment
objective in esthetic
implant therapy
should be a long-term
successful esthetic and
functional outcome
with a high degree of
predictability and a low
risk of complications.