The Modified IVAN Technique: Hard and Soft Tissue Augmentation at Extraction for Delayed Implant Placement

Figure 1. Clinical presentation of the failing endodontically treated right central incisor with fistula present. Figure 2. Initial radiograph of failing maxillary central incisor with prior endodontic treatment demonstrating vertical root fracture and apical pathology. Figure 3. Following extraction of the affected tooth, a scalpel is utilized to create a tunnel for pediculated connective tissue graft insertion on the facial to permit augmentation of the lost facial wall of the socket. Figure 4. Illustration demonstrating palatal incisions to mobilize the connective tissue graft (CTG) maintaining blood supply at the anterior aspect (left) and rotation of the CTG over the extraction site (right).

Figure 5. A partial thickness flap is elevated on the palatal side of the extraction socket and the connective tissue layer is elevated, maintaining its connection at its base with its original location. Figure 6. A piece of Geistlich Bio-Gide resorbable collagen membrane is inserted into the facial tunnel previously created and a layer of xenograft osseous graft material Bego OSS is placed into the socket to augment the hard tissue forming a new facial socket wall. Figure 7. The remaining socket is filled with autogenous bone, then the connective tissue is flipped over the osseous graft occupying the socket to augment the soft tissue and allow closure of the site. Figure 8. The extraction site and palatal donor site are closed with Glycolon 6-0 sutures, leaving the socket covered by connective tissue.

Figure 9. A previously fabricated Essix-type retainer was placed as the provisional prosthesis during graft healing. Figure 10. Modified interpositional vascularized augmentation neogenesis site following 3 weeks of healing demonstrating soft tissue closure of the hard tissue graft and maintenance of the facial ridge contour. Figure 11. A fixed CAD/CAM milled polymethyl methacrylate resin bonded bridge (Telio CAD) was placed as a provisional at 3 weeks post-grafting with an ovoid pontic to help shape the soft tissue and maintain papilla. Figure 12. Four months post-augmentation surgery, demonstrating the fixed provisional bridge and soft tissue healing with maintenance of the papilla. Figure 13. Augmented site following 16 weeks (4 months) healing demonstrating keratinized tissue over the socket with an ovate depression created by the fixed provisional to aid in adjacent papilla maintenance. Figure 14. Cone beam computerized tomography cross-section of the site, demonstrating osseous fill of the extraction socket at 4 months and ready for implant placement.

Figure 15. Surgical stent with implant placement into the site with a flapless approach, positioning the center of the implant lingual to the planned tooth's incisal edge. Figure 16. A connective tissue graft is placed into a tunnel at time of implant placement to bulk out the facial contour related to slight atrophy. Figure 17. Radiograph following implant insertion of a 4.1 × 13 mm implant placed into the site with healing abutment attached. Figure 18. Immediate provisional crown placed on the implant at time of implant placement. Figure 19. Lateral view of the provisional crown placed on the implant demonstrating facial ridge contours that blend with the adjacent sites providing a natural appearance. Figure 20. Cone beam computerized tomography of the restored provisional immediate restored implant at 4 months postimplant placement, demonstrating maintenance of the facial aspect of the ridge following the modified interpositional vascularized augmentation neogenesis procedure.

Figure 21. Final implant restoration, demonstrating esthetic harmony with the adjacent teeth and a facial ridge contour that mimics a natural appearance. Figure 22. Periapical radiograph of the restored implant, demonstrating maintenance of crestal bone level 12 months following completion of the restoration. Figure 23. Clinical appearance at 12 months following completion of the restoration, demonstrating esthetic harmony with healthy soft tissue.