About the Authors - Dental XPimmediate loading, such that the bone graft procedure needs to be prior to implant insertion. This paper describes an immediate loading procedure in a

About the Authors

José Carlos Martins da Rosa, M.Sc. in Prosthetics, São Leopoldo Mandic Dental Research Center, Campinas, SP, Brazil;Specialist in Periodontics/Prosthetics, Paulista Association of Dental Surgeons, Bauru, SP, Brazil.

Darcymar Martins da Rosa, Specialist in Prosthetics, Pontifical Catholic University, Porto Alegre, RS, Brazil; Specialist inImplant Dentistry, Pontifical Catholic University, Campinas, SP, Brazil.

Carla Mônica Zardo, Specialist in Orthodontics and Facial Orthopedics, HRAC, University of São Paulo, Bauru-SP, Brazil;MSc student of Implant Dentistry, São Leopoldo Mandic Dental Research Center, Campinas, SP, Brazil.

Ariádene Cristina Pértile de Oliveira Rosa, Specialist in Implant Dentistry, São Leopoldo Mandic Dental Research Center,Campinas,SP, Brazil.

Dario Adolfi, DDS, is a world renown dentist and ceramist. Dario lectures on practical techniques and performs hands on demonstrations inSouth America,Europe, USA, Australia and Asia. He has a private clinic in San Paolo Brazil and is the author of the book NaturalEsthetics, published by Quintessence.

22 TEAMWORK Vol.3-No.2

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Abstract

Background:Immediate loading of implants in undamaged socketsfollowing tooth extraction is very well established in theliterature. In cases of tooth loss with socket structure loss,the esthetic risk increases, thus contraindicatingimmediate loading, such that the bone graft procedureneeds to be prior to implant insertion. This paperdescribes an immediate loading procedure in a damagedfresh socket in the region of an upper central incisor thatpresented unevenness of gingival contour.

Methods:The implant was inserted immediately after the removalof the tooth. The socket defect was repaired using a graftconsisting of a bone sliver from the maxillary tuberosity,and an immediate single-unit prosthesis was installedabove the implant. The criteria that enabled success in

this clinical case were: (1) adequate positioning of theimplant, taking the gingival level of the neighboringteeth as a reference; (2) adaptation of the bone sliver tothe vestibular defect of the socket, as far as the level ofthe implant platform; and (3) adjustment of theemergence profile of the provisional crown, to providespace for the soft tissue to be accommodated.

Results:This procedure promoted (1) osseointegration of theimplant; (2) restoration of the bone architecture andimprovement of the contour of the gingival margin, and(3) esthetic restoration in a single surgical stage, withoutthe need for a flap.

Conclusions:The authors believe that the characteristics of graftharvested from the maxillary tuberosity and the use ofearly low-intensity stimulation favor reconstruction of the

Immediate Dentoalveolar Restoration – Immediate loading of implant in damaged fresh extraction socket with gingivalarchitecture involvement, using bone sliver graft from maxillary tuberosity: a clinical case.José Carlos Martins da Rosa1, Darcymar Martins da Rosa2, Carla Mônica Zardo3, Ariádene Cristina Pértile de OliveiraRosa4, Dario Adolfi5

Key words: Osseointegration, Immediate loading, Bone graft, Maxillary tuberosity, Flapless surgery, Freshsocket

TEAMWORK Vol.3-No.2 23



Fig. 1: Clinical evaluation showing unevenness in the outline of the gingival margin and vestibular depth of probing of 7 mm at the upper right central incisor.

damaged fresh socket, thereby accelerating the healingprocess and osseointegration and enabling immediateloading. The positioning of the bone sliver as far as thelevel of the implant platform, thus promoting formationof a vestibular bone plate of adequate height andthickness, the platform switching and the emergenceprofile of the prosthesis were the essential factors enablingstabilization of the gingival margin.

Introduction

In the initial study on tooth implants by Brånemark et al,they observed that, for osseointegration to occur, a periodof healing with the implant totally submerged would beneeded. Thus, premature loading would be avoided andtwo surgical stages would be needed before inserting theprosthesis.1 This principle for promoting osseointegrationsubsequently underwent significant changes with theemergence of a scientific basis for inserting implants withimmediate loading.2-4

Several authors have now achieved success rates greaterthan 90% for implants with immediate loading followingtooth extraction. Maintenance of bone and gingivalarchitecture, immediate esthetic restoration, excellentpostoperative recovery, lack of need for flaps or suturesand shorter duration of the treatment are the factors thathave enshrined the immediate loading technique. 5-12

It has been shown that certain forces are important fortriggering a series of biological reactions that acceleratethe bone repair process, thus encouraging implantation ina single surgical stage.13-14

Local infections associated with periodontal diseases,endodontic lesions, fractures or root reabsorption arecapable of directly reducing the quantity and quality ofthe soft and hard tissues at potential or adjacent sites.

When such infections are present, they require priortreatment. The socket walls may be involved, with orwithout associated gingival recession, and surgicaltechniques may be required to restore their anatomy,thereby contraindicating implants with immediateloading.15-18

It has been suggested that bone-reconstructive methods(guide tissue regeneration and grafting materials) shouldbe applied in conjunction with immediate implantplacement in order to ensure bone formation in peri-implant bone defects.9 In case of damaged sockets,however, the possibility for its reconstruction by graftingand immediate restoration in a single operation wouldpreserve patients from several surgical procedures, such asbone and/or gingival grafting, uncovering surgery andperi-implant soft tissue conditioning. Furthermore, theesthetic risk related to the mentioned procedures could beskipped.19

The aim of this paper is to report on treatment fordentoalveolar damage in the region of an upper centralincisor, with unevenness of the contour of the gingivalmargin, by means of an implant, bone graft andimmediate loading following tooth extraction, therebyenabling immediate dentoalveolar restoration andgingival leveling in a single procedure.

Clinical case report

The patient was a 52-year-old man with high estheticexpectations whose main complaint was estheticimpairment in the region of the upper right centralincisor and painful symptoms.

Clinical examination showed the followingcharacteristics: triangular-shaped crown, tooth mobility,vestibular bone loss presenting a probing depth of 7 mm,

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Fig. 2: Periapical radiographic evaluation showing sufficient bone height for initial stability of the implant, and evaluation of bone availability from the maxillarytuberosity.


gingival recession of around 2 mm and thin gingivalbiotype, with the presence of a narrow band of keratinizedmucosa and absence of fistula. (Fig. 1)

Radiographic examination showed the followingcharacteristics: endodontic treatment problems, castmetal core, metal-free crown, bone height above the rootapex of around 5 mm, thickening of the hard layer andreabsorption of the mesial bone crest suggestive of anendoperiodontal lesion. The donor area on the maxillarytuberosity presented good bone availability. (Fig. 2)

The treatment proposed consisted of extraction of thecompromised tooth, curettage of the socket, immediateinsertion of an implant, construction of a provisionalcrown and correction of the socket defect by bone graftharvested from the maxillary tuberosity, with the aim ofachieving the immediate dentoalveolar restoration andleveling of the gingival contour in a single procedure.

Firstly, a modeling procedure was performed toconstruct an acrylic resin facet using the gingival marginof the homologous tooth as the reference.

The following medications were prescribed:

• Amoxicillin 500 mg, taken as one capsule every eighthours, for seven days starting one hour before theprocedure.

• Dexamethasone 4 mg, taken as one pill of 8 mg onehour before the procedure and then 4 mg per day fortwo more days.

• Paracetamol 750 mg, taken as one pill every six hourswhile in pain, beginning one hour before theprocedure.

Sequence of procedures:

• Infiltrative anesthesia of 2% mepivacaine, withnorepinephrine, at the base of the vestibule, in thepalate and near the papillae adjacent to thecompromised tooth;

• Incision in the sulcus, using a microblade (69 WS,Swann-Morton®, England), around the tooth that wasto be extracted;

• Non-traumatic extraction of the tooth using aperiotome, performing a pendular movement in themesiodistal direction, with the aim of maintaining theintegrity of the remaining bone walls; (Fig. 3)

• Careful curettage of the socket, to remove thegranulation tissue;

• Insertion of a NobelReplace™ Tapered TiUnite®(Nobel Biocare™, Göteborg, Sweden) implant, ofdimensions 16.0 X 5.0 mm, with 50 N of initialstability and diameter compatible with the socketopening. By means of a surgical guide, the drill bitswere directed towards preparing the bone bed, usingthe palatine wall to ensure adequate bone support and


Fig. 4: Installation of the implant, 1mm from the vestibular gingival

margin, and evaluation of thequantity of bone material needed

for grafting.


Fig. 3: Non-traumatic tooth extraction andclinical evaluation of the extent of bone

loss in the apical and mesiodistaldirections.



Fig. 5: Installation of temporary titanium abutment, with the cervical portion narrower than the diameter of the implant; facet test piece made ofphotopolymerizable resin; and construction of the provisional crown prior to the grafting procedure.

insert the implant in the ideal three-dimensionalposition. The implant bed preparation was startedusing the 2.0 cylindrical drill bit and continued using3.5, 4.3 and 5.0 conical-shaped drill bits. The implantwas inserted such that the ideal apical-coronalpositioning was sought, independent of the localgingival contour. The implant platform was at adistance of 1 mm from the local vestibular gingivalmargin, since the gingival contour of the homologoustooth was taken as the reference. After insertion of theimplant, the vestibular spirals were exposed in thesocket defect region; (Fig. 4)

• Apical-coronal (measured from the most apical bonelevel to the implant platform) and mesio-distal socketbone defect assessment to know the anatomical shapeof the defect;

• Insertion of a temporary titanium abutment, with thecervical portion narrower than the diameter of theimplant platform (platform switching), adjustment ofthe occlusion and opacification of the metalliccomponent by using photopolymerizable opaque resin(Amelogen® Plus OW, Ultradent Products, Inc,USA);

• Construction of a provisional crown using facets thatwere prepared earlier using photopolymerizable resin.The ideal emergence profile was established on theprovisional prosthesis, with free space to allow foraccommodation of the soft tissues and promote athicker and more stable margin of gingival tissue onthe implant, and also to promote improvement of thegingival contour; (Fig. 5)



Fig. 6: Removal of a bone sliver from the maxillary tuberosity.

Fig. 7: Manipulation of the bone sliver, with the aim of achieving the anatomical shape of the vestibular defect.

• Temporary of the provisional crown insertion foradjustment of the occlusion avoiding centric andeccentric loading and clinical confirmation of itsadaptation, considering that the implant platform wasat a distance of 1 mm from the gingival margin;

• Removal of the provisional restoration for finishingand polishing, and to perform the stage ofreconstruction of the socket bone defects;

• Infiltrative anesthesia in the donor area by means of2% mepivacaine, with norepinephrine, into the baseof the vestibule and into the palatine portion of themaxillary tuberosity;

• Crestal incision at the center of the edge of themaxillary tuberosity, as far as the distal face of the lastmolar. Deepening of the incision until scratching thebone tissue, along the whole length of the incision.

There was no need for a relaxing incision, because ofthe size of the access area available;

• Selection of an appropriate chisel, to harvest the graftmaterial according to the shape of the region to bereconstructed and the ease of access to the donorregion. The width of the chisel used should be 2 mmgreater than the width of the bone defect;

• Careful harvesting of the bone sliver; (Fig. 6)

• Harvesting of bone marrow from the donor region tofill possible spaces between the bone sliver and theexposed spirals of the implant;

• Manipulation of the bone graft to reproduce the shapeof the socket defect; (Fig. 7)

• Careful adaptation of the bone sliver, as far as the level


Fig. 9: Final stabilization of the bone sliver by means of filling with medullary bone tissue between the vestibular surface of the implant and theinternal portion of the bone sliver.

Fig. 8: Insertion of the bone sliver, with the cortex on the vestibular side, as far as the level of the implant platform.

of the implant platform, with the cortex turnedtowards the vestibule, to achieve primary stabilizationof the graft; (Fig. 8)

• Compaction of the bone marrow that was taken fromthe maxillary tuberosity, between the internal portionof the bone sliver and the vestibular surface of theimplant, to ensure the final stabilization of the graft;(Fig. 9)

• Insertion of the provisional crown on top of theimplant; (Fig. 10)

• Torque of 20 N on the attachment screw of theprovisional crown and sealing of the palatine orificewith temporary filling material (Fermit, Ivoclar NorthAmerica, Amherst, NY, USA);

• Suturing in the donor region, using simple stitches.




It is always appropriate to perform the insertion of theimplant followed by construction of the provisionalcrown and only to perform the bone grafting afterconcluding this stage. This avoids the risk of graftcontamination through handling of the materials forconstructing the provisional crown.

It is advisable to perform the suturing of the donorregion after performing the grafting and installing theprovisional crown. This has the aim of achieving fasterhandling and lower exposure of the graft, in order to keepthe cells alive.

The patient was required to avoid any loading on thetreated region and to make topical application of 0.12%chlorhexidine, three times a day for seven days. Clinicalmonitoring was undertaken every two days for the firsttwo weeks and every fifteen days for the next four months.

After seven days, the soft tissue had migrated in theincisal direction by approximately 1.5 mm, thus levelingthe gingival contour with that of the homologous tooth. (Fig. 11)

After sixty-five days a clinical evaluation was realized(Fig. 12) and after three months of osseointegration andmaturation of the tissues, molding to transfer thepersonalized emergence profile was performed.

The abutment made of Procera® zirconia, with itscervical portion narrower than the diameter of theimplant (platform switching), was inserted with torque of20N. A new provisional crown was constructed, in orderto reproduce the emergence profile, and radiographicconfirmation of the adaptation was obtained. (Fig. 13)

A coping made of Procera® alumina was constructedfor personalized porcelain application. After testing theporcelain and performing esthetic and functional

Fig. 10: Provisional crown installed: periapical radiographic image confirming the adaptation of the provisional component.

Fig. 11: Seven days after the operation, showing the leveling of the gingival margin



adjustments, the crown was fixed with adhesive cement(Multilink®, Ivoclar Vivadent, Liechtenstein). Theesthetic success was judged in terms of the re-establishment of bone and gingival architecture, theProcera® abutment, the metal-free porcelain and theanatomical shape of the tooth.

Discussion

Immediate loading following tooth extraction, in cases inwhich the support tissue is undamaged, is very wellestablished in the literature. Primary stability is the mostimportant factor in indicating that the implant can gointo immediate use. This is associated with the quantityand quality of the bone, the geometry of the implant andthe surgical technique.5-12

Studies have suggested that immediate loading withplatform switching promotes greater stability of the softand hard tissues surrounding the implant.12

In situations of immediate loading following toothextraction in an undamaged socket, the implant should

be inserted beside the palatine wall of the socket becauseof the greater bone anchorage, better three-dimensionalpositioning for spreading the occlusal forces and greaterbone availability and quality. This positioning is directlyrelated to the diameter of the implant and the size of thesocket opening. The amount of space will define whetherfilling with particulate bone is needed. Such filling wouldpreferably be autogenous, since this presents the bestresults with regard to bone healing.9,20-21

The biological changes that occur when an implant isput into use at an early stage are of great importance inbone repair.22 Early low-intensity stimulation increasesthe local blood flow and the contact osteogenesis, therebyaccelerating the process of bone graft repair.23

Implants of conical shape are the ones most indicatedfor receiving immediate loading. They adapt better to thesocket, have a greater contact surface with the bone,increase the initial stability and make it possible to spreadthe occlusal load better. Conical implants compact thetrabecular bone laterally, thereby increasing bone density. 6,24-28

Fig. 12: Sixty-five days after the operation, showing maintenance of the leveling of the gingival margin through reestablishment of the biologicalperiodontal distances.


The presence of local infection is an important factor inassessing the esthetic risk of the treatment, and it isdirectly related to the quantity of bone and the gingivalphenotype. The highest esthetic risk is associated withacute infection with suppuration and local edema. Thisrequires effective therapy to control it, and it may resultin an additional loss of esthetically important periodontaltissue due to possible contraction of this tissue. Tominimize the risk of esthetic complications, localinfection should be treated before insertion of theimplant, regardless of whether the infection is chronic oracute. 15-18

In the case of tooth loss together with damage to theintegrity of the socket, the esthetic risk increases. Thiscontraindicates implants with immediate loading and, insuch cases, the bone grafting procedure is needed in orderto restore the anatomy of the socket edge, before insertingthe implant. 29

The morphology of damaged sockets immediately aftertooth extraction generally presents greater involvementof the vestibular cortical bone, because of its smallerthickness and lower vascularization and because it is

subject to occlusal forces. Since the vestibular wall of thesocket is fragile, total loss of this cortical bone can oftenbe seen, without involvement of the other walls.

The maxillary tuberosity is an excellent choice of donorarea for small reconstructions. It has a limited quantity ofbone material available for grafting and presents low bonedensity and difficulty of surgical access. On the otherhand, it has the advantages of excellent postoperativerecovery and ease of harvesting the graft material andadapting it in the receptor region because of its bonemalleability.

One study has indicated that the maxillary andmandibular periosteum and the maxillary bone marrowmay effectively serve as reliable and easy-to-harvestintraoral sources of osteoprogenitor cells.30

It is known that the vascularization pattern is vital forbone grafting success. Because of the trabecular nature ofgrafts coming from the maxillary tuberosity, they have ahigh capacity for revascularization and release of growthfactors to the receptor site. Thus, they need to bemanipulated quickly, such that the graft is exposed for aslittle time as possible, in order to keep the cells alive. 31-32

Fig. 13: After five months, clinical and radiographic evaluations on the zircon abutment, with the cervical portion narrower than the diameters of theimplant and temporary prosthesis.



Cell survival in the graft is related to the efficiency ofthe surgical technique and the time taken to transfer thegraft to the receptor área.33

Stabilization and close contact between the bone graftand the receptor site facilitates the revascularizationprocess and favors early incorporation of the graft into thehost’s vascular bed.33-37

Immediately after implant insertion and dentoalveolarrestoration, coagulum and a fibrin network form and fillthe remaining spaces between the implant and the graftedbone. With the passage of time and with appropriatemechanical stimulation, the resistance of the grafted areawill tend to increase 23,36-37.

After a four-month period of osseointegration, it wasobserved that the vestibular bone wall had thickened dueto palatine anchoring of the implant and the grafting ofthe bone sliver. Consequent to the greater thickness ofthe vestibular bone crest, associated with an adequateemergence profile for the prosthetic crown, a greatervolume of soft tissue was obtained, thus providing betterand more stable gingival margin contour.

Conclusions

• Graft harvested from the maxillary tuberositypromoted reconstruction of fresh damaged sockets andprevented cell competition between the hard and softtissue, thus making immediate restoration implantpossible.

• The positioning of the bone sliver as far as the level ofthe implant platform, thus promoting formation of avestibular bone plate of adequate height and thickness,the platform switching and the emergence profile ofthe prosthesis were the essential factors enablingstabilization of the gingival margin.

• Primary stability of the implant and graft wasfundamental to the success of this procedure.

• We believe that the characteristics of graft harvestedfrom the maxillary tuberosity and the use of early low-intensity stimulation favor reconstruction of damagedfresh socket enabling immediate dentoalveolar




restoration. Although the technique requires long-term follow-up, the result obtained so far have beensatisfactory and promising.

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Markham, ON Canada L3R 9Z4Phone Orders: 905. 489.1970 Fax Orders: 905. 489.1971 or order online at www.spectrumdialogue.com



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About the Authors - Dental XPimmediate loading, such that the bone graft procedure needs to be prior to implant insertion. This paper describes an immediate loading procedure in a