Hindawi

Case Reports in Dentistry

Volume 2018, Article ID 1672170, 11 pages
https://doi.org/10.1155/2018/1672170

Case Report
Application of Immediate Dentoalveolar Restoration in Alveolus
Compromised with Loss of Immediate Implant in Esthetic Area

Rafael de Lima Franceschi ,1,2,3 Luciano Drechsel,1,3,4 and Guenther Schuldt Filho5
1
Brasilian Association of Dental Surgeons, Curitiba, PR, Brazil
2
Dental Institute of the Americas, Balneário Camboriú, SC, Brazil
3
São Leopoldo Mandic University, Curitiba, PR, Brazil
4
Brazilian Dental Association (ABO), Ponta Grossa, PR, Brazil
5
Federal University of Santa Catarina, Florianópolis, SC, Brazil

Correspondence should be addressed to Rafael de Lima Franceschi; odontorafael@yahoo.com.br

Received 10 December 2017; Accepted 10 April 2018; Published 21 June 2018

Academic Editor: Konstantinos Michalakis

Copyright © 2018 Rafael de Lima Franceschi et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work
is properly cited.

In the reported clinical case, the immediate dentoalveolar restoration (IDR) technique was applied to reconstruct the buccal bone
wall, with autogenous graft of the maxillary tuberosity, which had been lost due to a root fracture, and to provide the necessary bone
substrate for the installation of an implant and its provisioning. One of the greatest risks inherent in the survival of immediate
implants is the maintenance of their stability during the healing period. In this case, due to a mechanical trauma in sports
activity in the first postoperative month, there was a total failure in the osseointegration process, confirmed by tomographic
examination of both the implant and the bone graft. The deleterious effects of this accident were compensated with a new
approach and reapplication of IDR technique using a smaller-diameter implant and with conical macrogeometry in conjunction
with the new bone reconstruction under the same compromised alveolus; associated, after the period of osseointegration, with
the maneuvers of volume increase of the gingival tissue by subepithelial connective tissue graft. The tomographic result
demonstrated the success of the surgical procedures, and the clinical/photographic analysis obtained showed the stability of the
gingival margin without compromising the esthetic result of the prosthetic restoration.

1. Introduction clinical predictability [2]. The possibility of installing an

immediate implant and its adequate provisioning are is a fac-
Esthetic dentistry has currently reached a level of excellence tor that contributes to the maintenance of esthetics and peri-
that no longer allows teeth subject to exodontia for reasons implant health, and when associated with the autogenous
such as trauma and bacterial infections, resulting in pros- graft, the osteogenic, osteoinductive, and osteoconductive
thetic works that do not adequately mimic homologous capacity of this material results in a more rapid vasculariza-
teeth and the surrounding gingival tissues. The challenge tion and incorporation, with no immune response, being
of removing a dental element and facing the events that the gold standard of regenerative procedures [3].
occur on the protective and sustaining tissues requires deep Immediate loading, even in infraocclusion, to which
knowledge in the areas of periodontics, surgery, and dental immediate implants are installed postexodontia in esthetic
prosthesis [1]. areas, increases the risks of postoperative failures and com-
Partial or total loss of the vestibular bone wall potentiates plications [4]. If the loss of a dental element is already bad,
the deleterious effects on the periodontal tissues that occur in an immediate implant is even worse because the bone bed
a postextraction alveolus and indicate the need for preserva- has already been milled, and failure in the osseointegration
tion and simultaneous alveolar reconstruction to the exodon- process results in a rapid formation of granulation tissue;
tia, allowing the stability of these tissues and enhancing their alteration of local irrigation; formation of areas of necrosis,
2 Case Reports in Dentistry

in short, a severe collapse of the peri-implant tissues with

increased bone remodeling; and alteration in the vestibular
gingival margin, compromising the esthetic result of the pro-
cedure [5, 6].
The immediate dentoalveolar restoration (IDR) tech-
nique aims at regenerating, via the autogenous bone of
the maxillary tuberosity, the postextracting alveolus that
has one or more compromised bone walls, allowing the
installation of an immediate implant and its provisioning.
In the situation of loss of one immediate implant with total
loss of the vestibular bone wall, IDR would be a viable tool
to repair the alveolus, creating a clinical situation that Figure 1: Presence of ceramic restorations in the upper anterior
allows the installation of a new implant and its prosthesis, teeth with swollen gingival area on the vestibular face of element 11.
immediately recovering the esthetics of the patient who
can subsequently receive regenerative procedures aimed at
maintaining or improving the level and contours of the the original technique advocated the preparation of the pro-
peri-implant soft tissues, which are critical for esthetics visional crown at this time, using a titanium UCLA directly
and long-term success [7]. in the internal connection of the implant, and due to the
objective of using an intermediate prosthetic abutment
2. Case Report between the implant and the provisional crown, this phase
was postponed until after bone reconstruction.
A male patient, thirty-five years of age, attended the clinic for Anesthesia was performed in the region of the right tuft
care after reporting intense pain during chewing in which he (2% mepivacaine, epinephrine 1 : 100,000) in the vestibular
reported hearing a fractured tooth 11 and its subsequent and ischemic anterior region at the crest and palatine area.
mobility. He received a ceramic crown (metal-free) rehabili- A supracristal incision was performed until the periosteum
tation on the upper teeth two years ago. The clinical exami- and subsequent total displacement of the flap until the relax-
nation revealed that the gingival biotype was thick, there ing incisions in the region corresponding to the position
was a small active fistula on the vestibular surface, and the where the third molar is generally located. With the aid
depth of probing in this area was 7 mm, with mobility of of a surgical hammer and a goose chisel number 08, the
the crown in the vestibular-palatine direction (Figure 1). cortical-medullary bone sheet was removed and taken to
After a CBCT scan, the diagnosis of vertical root fracture a glass plate where it was carved in the shape of the defect
and invasion of the biological space with a compromised ves- to be reconstructed (Figure 3(a)). The blade was then
tibular bone wall was confirmed (Figure 2(a)). The treatment fitted into the defect, and the gap between the implant
proposed to the patient was an immediate dentoalveolar res- and the blade was filled with the remainder of the bone
toration with grafting material from the right maxillary material collected from the tuberosity which was particu-
tuberosity, implant, and immediate provision. late with a delicate and properly condensed alveoli.
According to the protocol of the technique, the antibiotic The implant cover was removed and an intermediate pil-
therapy with amoxicillin 500 mg every 8 hrs was initiated five lar of 1.5 mm height was installed (Figure 3(b)). A stock tooth
days before surgery and afterwards for another 7 days in facet was captured under a titanium UCLA duly prepared
order to reduce and modulate the inflammatory process with flow resin (Opallis, FGM) and Z-350 A1B composite
aided by dexamethasone 4 mg 2 tablets 1 hour before surgery resin (3M Espe). Adequate adjustments were made in the
and 1 tablet every 8 hours for 3 days and paracetamol 750 mg emergency profile and in the disocclusion guides with incisal
every 8 hours for 3 days. height reduction. The reconstruction allowed the complete
After an infiltrative anesthesia in the vestibule and the closure of the spaces and there was no need for sutures in
palatine region of tooth 11 with 2% mepivacaine and epi- tooth region 11 (Figures 4(a) and 4(b)). Only the tuft was
nephrine 1 : 100,000 (DFL), an intrasulcular incision was adequately sutured with 4.0 silk thread (Ethicon).
made with a 15C (Swann-Morton) blade with the aid of a Postoperative guidelines were followed in relation to a
peritoneum, apical levers, and delicate forceps, minimally soft diet without using the tooth in question. The patient
invasive exodontia was performed (Figure 2(b)) without was monitored every 7 days, with total remission of the ves-
compromising the integrity of the papillae. Thorough curet- tibular fistula.
tage and irrigation were performed until all granulation tis- Twenty-two days after the initial surgical procedure, the
sue was removed. patient scheduled emergency care. He also reported that
A mapping of the vestibular wall defect was performed when doing a jiu-jitsu class, he received an elbow in the
using a millimeter probe inside the fresh alveolus and the mill- operated tooth with bleeding and pain after the trauma
ing sequence started at 5 mm from the cervical margin of the (Figures 5(a) and 5(b)).
palatal bone wall and a cylindrical Cone Morse (Intraoss, After the clinical examination, a change was observed in
Brazil) implant with a diameter of 4.0 mm × 13.0 mm to the three-dimensional position of the implant/crown with
3 mm infrabony, in a more palatinate position. Primary sta- vestibularization and gyroversion of the same. The crown
bility was achieved with a torque record of 35 Ncm. Altering was removed, and small fragments of bone abduction were
Case Reports in Dentistry 3

(a) (b)

Figure 2: Root fracture and its subsequent bacterial contamination caused the vestibular wall to become impaired. (a) Tomography
demonstrating the loss of vestibular bone wall in element 11. (b) The root fracture and invasion of the biological space generated
inflammation on the vestibular face.

(a) (b)

Figure 3: IDR surgical phase. (a) Cortical-medullary blade removed from the right maxillary tuberosity. (b) Cone Morse implant installation
and pillar height test.

(a) (b)

Figure 4: Immediate postoperative preserving the protective tissues with maintenance of vestibular volume and gingival margin. (a) Front
view of the IDR. (b) Occlusal view with incisal relief.
4 Case Reports in Dentistry

(a) (b)

Figure 5: Trauma during sports procedure in the immediate implant region. (a) Due to the trauma, there was vestibularization. (b) Implant-
crown turning compromising the entire osseointegration process.

(a) (b)

Figure 6: The provisional crown was removed and then reinstalled and attached to the neighboring teeth. (a) Presence of bone sequestration
arising from the reconstruction of the vestibular wall. (b) Repositioning of the crown and union to the neighboring teeth with resinous
cement.

found in the abutment region (Figure 6(a)). It was reinstalled as previously described with only the following modifica-
and through the crown fixing screw, the entire structure was tions: total curettage of the alveolus with removal of all the
manipulated towards the palatal in an attempt to reposition it bone fragments and granulation tissue gift was performed;
as close as possible to the original position. Temporary union the new implant had a smaller diameter, 3.5 × 13 mm
with U-200 resin cement (3M Espe) of the acrylic crown was (Intraoss, Brazil), and its macrogeometry was conical; its
performed on the neighboring teeth 12 and 21 (Figure 6(b)). insertion was searching the center of the alveolus, even if it
An implant tomography was ordered to assess the extent of was not possible to make a screwed prosthesis; and the max-
the problem. illary tuberosity that provided the material for grafting was
After ten days of trauma, the tomographic image analysis the left tuft.
recorded that the three-dimensional positioning of the After implanting the implant with 45 Ncm torque, recon-
implant was out of the proper position, compromising the struction of the buccal bone wall was performed with the
entire reconstruction of the vestibular wall. The loss of insertion of medullary bone compacted at the apex of the
implant stability is directly related to the absence of support- implant up to half its length, only after the cortical-
ing bone tissue in the vestibular area (Figures 7(a) and 7(b)). medullary lamina was positioned throughout the vestibular
Several treatment alternatives were then presented to the region leaving a 3 mm gap of the lamina to the implant that
patient to remove the implant and to perform alveolar pres- was filled by a new insertion of compacted medullary bone.
ervation through grafting of biomaterials and membranes A new 2.5 mm height abutment was installed with a torque
for guided bone regeneration. However, it was a consensus of 32 Ncm, and immediate provisioning was still possible
among the surgeons that any of the cases presented could with a screwed crown even though the prosthetic connection
lead to a change and instability of the vestibular gingival mar- of the abutment was in a more vestibularized position
gin, further compromising the esthetic outcome of the case. (Figures 8(a) and 8(b)).
Alternatively, the possibility of retreatment through a new The tubal suture was identical to the previous report, and
IDR was suggested. Although there were no reports of this, the postoperative care was reinforced and amplified even
the idea behind the treatment was to consider the implant with the use of an acrylic total plate in the upper arch to pro-
lost as if it were a root compromised with total loss of the ves- tect against any new trauma. The patient was monitored
tibular bone wall, aided at this time by the absence of the weekly until the ninety days of the surgical intervention
infectious process. and then every two weeks for a further two months. In this
With the endorsement of the patient, all the steps of the period, two CBCT scans were performed: the first ten days
protocol of the technique were initiated through previous after the new IDR (Figures 9(a) and 9(b)) and the second
antibiotic therapy, and the surgical sequence was the same after five months, confirming the osseointegration of the
Case Reports in Dentistry 5

fenest

01

implante

11

(a) (b)

Figure 7: Radiographic analysis ten days after the trauma. (a) The tomographic image registers the implant in an inadequate three-
dimensional position. (b) Loss of vestibular wall that had been rebuilt.

(a) (b)

Figure 8: Immediate postoperative of the second IDR applied to element 11 with peri-implant tissue normality. (a) Immediate frontal view
and (b) occlusal view demonstrating the maintenance of vestibular volume.

enxerto

oi 1
cn

fenest

11

(a) (b)

Figure 9: Tomography 10 days after surgery to visualize the 3D position of the implant and the presence of the cortical-medullar lamina. (a)
Tomographic section where it is possible to visualize the grafted bone tissue. (b) Image recording bone reconstruction.
6 Case Reports in Dentistry

fenest

11 implante

(a) (b)

Figure 10: Tomography after five months of the second IDR. (a) Tomography performed with oral retractor to reveal soft tissues. (b)
Recording of total graft incorporation and presence of a new vestibular bone wall.

implant and maintenance of the new vestibular bone wall

(Figures 10(a) and 10(b)).
In the sixth month after the new intervention, the screw
crown was removed to evaluate the peri-implant soft tissue
emergence and visualization profile. The pillar torque that
continued with 32 Ncm was also verified. At this time, an
esthetic evaluation of the gingival margin was made, and it
was found that in the operated region, there was a smaller
volume, and the gingival margin was more apical than the
other incisors (Figure 11).
Even though he was satisfied with the result, the patient
reported that he would like to improve his case as much as Figure 11: Result obtained after five months of healing. Despite
possible and that he would go through further interventions clinical success, there was a slight discrepancy in the gingival
if necessary. Then, the possibility of a subepithelial connec- margin of element 11.
tive tissue graft that would improve the height of the gingival
margin and give more volume to the peri-implant tissues was
presented to him, being of great value in the maintenance and in the center of the margin and fixed directly to the
and stability of these tissues in the long term. acrylic crown with flow resin (Opallis, FGM) for better tis-
After his endorsement, a new surgical procedure was sue stability. In the weeks following the removal of the
scheduled. Anesthesia of the vestibular and ischemic fun- points, the area of the emergency profile was checked
dus was performed in the vestibular region of tooth 11 and polished until complete visual healing of the peri-
and in the palatine region of teeth 14 to 16 with 3% arti- implant tissues.
caine and epinephrine 1 : 100,000 (DLF). An intrasulcular Concluding this phase after ninety days, the provisional
incision with 15 C lamina (Swann-Morton) was performed crown was removed, the final healing of the peri-implant tis-
around the implant, and the tissue division was done with sues was evaluated, the pillar torque was checked, and the
the aid of tunneling. After mapping the amount to be final crown was made (Figure 15).
grafted, the palate was accessed, and through an “L” inci- The prosthetic phase begins with an additional silicone
sion, the connective tissue was removed (Figure 12(a)) molding (Variotime, Heraeus/Kulzer) in an open tray with
and sutured in the vestibular region (Figure 12(b)) with customization of the transfer abutment with acrylic resin
5.0 absorbable suture thread Technew. After the position- (Pattern Resin LS, GC America Inc.) which copied the shape
ing of the graft with the flap moved to the incisor, the gin- of the peri-implant tissues, achieved during the phase of the
gival margin was repositioned (Figures 13(a) and 13(b)), provisional crown.
the crown was removed, the critical and subcritical area After scanning of the model, an STL file was generated,
of the emergency profile was resized (Figures 14(a) and and the analysis of the positioning of the implant/abutment
14(b)), and the suspensory suture was made in the papillae complex was analyzed by the CAD of the Zirkonzahn
Case Reports in Dentistry 7

(a) (b)

Figure 12: Connective tissue graft. (a) Subepithelial connective tissue removed from the palate. (b) Suture of the graft divided into the
vestibular flap using the provisional crown as a foundation for better position and support of the gingival margin.

(a) (b)

Figure 13: Grafted tissue in maturation process. (a) Occlusal view of the scar area after 30 days with increased volume. (b) Positioning of the
new vestibular gingival margin.

(a) (b)

Figure 14: Correct delineation of the emergency profile is crucial to the long-term success of the technique. (a) Concave emergency profile in
the cervicovestibular region. (b) The critical line corresponds to the position of the gingival margin, and below it is the subcritical area that
should accommodate and maintain healthy peri-implant soft tissues.

system. It was decided by a cemented crown so that the

technician had enough space to apply ceramic layers that
reproduced the contralateral tooth in relation to shape
and color.
A custom screwed pillar and a coping, both using zirconia
(Figures 16(a) and 16(b)), were milled (CAM, Zirkonzan).
After the necessary tests and adjustments of the infra-
structures, there was the application of stratified ceramics
(Figure 17). The zirconia abutment was radiographed to
confirm its adaptation and screwed with 32 Ncm torque,
Figure 15: Occlusal view where the volume and quality of the peri- the screw hole was closed with Teflon tape (PTFE), the
implant tissues obtained after the completion of the IDR with crown was cemented with U-200 resin cement (3M, Espe),
connective graft can be visualized. and extreme attention was given to the cementation line
8 Case Reports in Dentistry

(a) (b)

Figure 16: Prosthetic phase using custom zirconia abutment. (a) Screwed zirconia abutment and pure ceramic crown. (b) Occlusal view
of the abutment screwed with the screw in the incisal line of the other incisors proving the more vestibular positioning of the prosthetic
connection.

3. Discussion
The literature describes that the buccal bone plate has on
average less than 1 mm thickness and that the bone remodel-
ing that occurs after the exodontia will alter the vestibular
gingival margin independent of the installation of an imme-
diate implant [8, 9].
Among the various methods to prevent spontaneous
remodeling of tissues and to preserve the alveolar ridge, the
most used is through biomaterials of low rate of reabsorption
and protection with membranes, called guided bone regener-
Figure 17: Lateral view of the abutment test and the stratified ation (GBR) [10].
ceramic crown demonstrating adaptation to the peri-implant The major challenge for performing immediate implants
tissues, appropriate color, and shape. is when one or more bone walls are lost. Clinically, the most
common is the total or partial loss of the buccal bone wall,
and IDR is presented as an alternative for the use of GBR.
so that there was no infiltration into the peri-implant tissues The idea of the technique is similar, and in the case of IDR,
(Figure 18(a)). All occlusal adjustments were reviewed, and the cortical-medullary bone graft installed in the shape of
the disocclusion guides were checked (Figure 18(b)). A the defect to be reconstructed will be a barrier to stabilize
new tomography was performed with a buccal retractor in the particulate bone graft that will exist in the gap between
order to record the measurements of the hard and soft tis- the implant and the new bone wall. The use of the autoge-
sues in the vestibular region after twelve months of the nous bone material of the maxillary tuberosity provides
IDR reapplication to determine the zero (follow-up zero) factors different from traditional biomaterials [11]. As the
momentum, serving as a basis for follow-up and future vascular pattern is vital for the success of bone grafts, the
comparisons (Figures 19(a) and 19(b)). Measurements at medullary nature of the grafts harvested at this site indicates
two points on the vestibular wall (cervical 4.6 mm and api- that there is indeed a possibility of transferring bone mate-
cal 6.3 mm at the implant) recorded the formation of the rial with viable and high-capacity osteoprogenitor cells into
new vestibular wall with a considerable increase of the bone the receptor bed which provides faster and more effective
tissue, mainly in relation to the homologous tooth (21), healing with minimal alteration to the involved tissues. In
whose measurements at similar points recorded a typical addition to early and low-intensity stimulation that does
buccal bone board as described in the literature with values not compromise mechanical stability, increased blood flow
lower than 1 mm in the cervical and median and only in the and contact osteogenesis will accelerate the full incorpora-
apical region of the root with a measurement of 2.3 mm. In tion of the bone graft, ensuring the substrate necessary for
relation to the soft tissues, the subepithelial connective tis- the success of the implant and peri-implant tissues [12, 13].
sue graft practically doubled the values found in the contra- The risks inherent in immediate loading techniques such
lateral tooth (8.2 mm versus 4.6 mm cervical, 11.2 mm as a minimally traumatic and flapless surgery, a 3D implant
versus 6.9 mm apical), being of paramount importance for position, a gap filling, and its provisioning may not prevent
maintaining a stable gingival margin and avoiding possible postexodontic alveolar changes, and recessions may compro-
recessions that can affect the vestibular face of the immedi- mise the gingival margin and longevity of supporting and
ate implants. protective tissues [14].
The end result in relation to the reconstruction of sup- The alveolus-dental topography in the anterior maxilla
port and protection tissues projects clinical success in the region, due to the inclination of the teeth, results in a very
long term (Figure 20). thin vestibular bone board and a thicker and more robust
Case Reports in Dentistry 9

(a) (b)

Figure 18: Final result after cementation with resin cement. (a) Front view of the cemented crown. (b) Occlusal view showing the correct 3D
positioning of the prosthetic crown.

(a) (b)

Figure 19: CBCT scan of the follow-up of the IDR reapplication. (a) Tomography with measures of bone and gingival tissue in the vestibule of
implant 11 which was reconstructed by the surgical procedures. (b) Tomography where it is possible to compare the volumes of bone and
gingival tissue in the vestibular area of a healthy tooth 21.

palatine bone wall [15]. The bone perforation for implant

installation should always be in a palatal approach where
greater primary stability is obtained. The preparation of the
bone bed in this position allows the formation of a gap
between the implant and the buccal wall that should be filled
by grafting material. Its filling confers a substrate site for the
osteoblasts to secrete a new bone matrix [16]. The materials
most used for this purpose are autogenous bone and xeno-
genic hydroxyapatite. Both are important sources in recon-
structive procedures and can often even be associated
according to the need of the recipient site [17].
Proper positioning of the implant in the mesiodistal
direction allows the preservation of the papilla, in the
vestibular-palatine sense, determines the dimensions of the
prosthetic crown, and is a preponderant factor in the choice
Figure 20: Case completed. Photo of the case with different light of definitive restorations, whether cemented or screwed [18].
intensities, after one year of IDR reapplication, demonstrating the A vestibular wall approximately 2 mm thick is ideal for
normality of the peri-implant tissues and the maintenance of the long-term esthetic success, as it allows peri-implant soft tis-
final gingival margin compatible with esthetic rehabilitation. sue stability. In cases of impairment of the buccal bone plate,
10 Case Reports in Dentistry

the use of smaller-diameter implants concomitant with the References

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