Optimizing Anterior Implant Esthetics With a Vascularized Interpositional Periosteal Connective Tissue Graft for Ridge Augmentation: A Case Report
Achieving excellence in anterior rehabilitations requires close cooperation between the periodontist and the prosthodontist. Many techniques can be used to restore the lost alveolar hard and soft tissues. The more severe the peri-implant defect, the higher the challenge and lower the predictability of the procedure. The present case consists of Seibert Class III with malaligned implants in the esthetic zone resolved with a cost-modified treatment plan to reestablish esthetics in the anterior maxilla using a rotated palatal flap. The vascularized interpositional periosteal connective tissue graft was effective in augmenting the soft tissue in the esthetic zone and remained stable over a 2-year period. Additional long-term clinical studies are necessary to support these results.
Figure 1. Frontal view of the high smile showing a screw-retained porcelain fused to metal implant bridge from #7 to #8 with pink porcelain. Note the unesthetic smile. Figure 2. (a) Frontal view of the ridge defect Seibert Class III with a template showing the ideal esthetic result. (b) Occlusal view of the maxillary ridge 2 at day of surgery. Patient was placed on cover screws 2 weeks preoperatively to allow creeping of the epithelium for better flap closure. Figure 3. Final periapical radiographic image showing moderate horizontal osseous defect between implants #8 (Nobel Biocare Replace select RP 4.3 × 11mm) and #7 (Nobel Biocare Replace select NP 3.5 × 13 mm. Note that the crown abutment is of a higher diameter than the implant platform diameter. This modification was required to reach an adequate emergence profile of the prosthetic crowns. Figure 4. Working models of the maxillary arch: (a) Note the wax-up made according to the #6, which required crown lengthening of the teeth #9 through #11 to obtain a harmonious smile line. (b) Note the dark shaded area of the cast, which is attributable to the lack of underlying tissues. Figure 5. Mock-up placed intraorally. Note the extensive ridge defect for implant #7 and #8.
Figure 6. Occlusal view of the screw-retained bridge for implants #7 and #8. Figure 7. Frontal view of the patient with second mock-up made 2 months after the crown-lengthening procedure. Note the harmonious esthetic smile line. Figure 8. The patient accepted the procedure, and provisional crowns were made for #7 and #8 for her to use before the surgery. Note extensively overcountered crowns for implants #7 and #8 due to the extensive ridge defect. Figure 9. Occlusal view of the maxillary arch. Note that papilla preserving incisions were made for distal aspect of #9 and mesial aspect of #6. Supracrestal incision is shown from #7 to #9. An “L” shape incision is present from the distal aspect of #13 to the mesial aspect of #9, approximately 3 mm from the sulcus of the teeth. Figure 10. Frontal view of the maxillary arch showing the vascularized interpositional periosteal connective tissue graft over implant #7 and #8 sites. Note the thickness of the flap and extension of the surgical site. Figure 11. (a) Occlusal view of the surgical site after the rotated palatal flap was positioned on the buccal aspect of implants #7 and #8. Note the increased width of the ridge. (b) Frontal view of the surgical site after cementation of the fixed provisional bridge from #6 through #9.
Figure 12. Frontal view: (a) Twenty-one days postoperative. Note excessive tissue on the cervical aspect of the provisional bridge over implants #7 and #8. (b) Seventy-five days postoperative. A new set of provisionals was used to initiate gingival conditioning. Note that the tissues are less edematous. Figure 13. Frontal view 4 months postoperative. A new cement-retained bridge was made for the patient. Note that the tissues are less edematous compared with the 75-day postoperative clinical exam. Figure 14. (a) Frontal view at impression taking for final crowns 5 months postoperative. Note the presence of interproximal papilla for implants #7 and #8. (b) Absence of interproximal papilla in the buccal aspect of implants #7 and #8 at baseline. Figure 15. (a) Impression taking for fabrication of final porcelain fused to zirconia crowns for implants #7 and #8; and teeth #6, #9, #10, and #11. (b) Occlusal view after customized abutments were secured to implants #7 and #8. Note the thickness of the tissues on the buccal and palatal aspects.
Figure 16. (a) Two-year follow-up shows harmonious esthetics obtained using the vascularized interpositional periosteal connective tissue graft to restore the Seibert Class III alveolar ridge defect. (b) Frontal view at baseline with defective ridge and unesthetic prosthesis. Figure 17. (a) Lateral view of final crowns for implants #7 and #8. (b) Frontal view. Note the harmonious smile line. Figure 18. Panoramic radiograph showing stability of the peri-implant tissues.
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