Immediate placement of dental implant after 1.2 tooth extraction and gum augmentation with subepithelial connective tissue graft on pedicle. Case report.


Kobyakov Alexander Vladimirovich

Maxillo-facial surgeon

Work expirience: Regional hospital named after N. I. Pirogova,

Maxillofacial surgery ward

4 years of dental implantation experience.

 46 years old Patient K., came to dental clinic unsatisfied with aesthetic defect of broken artificial crown on lateral incisor ( Figure 1 . ). The patient wore this construction of more than 7 years. CBCT tomography showed the 1.2 tooth root fracture with transposition of some fragments. This was considered as contraindication to re-prosthetics and as indication for extraction. It was decided to do immediate implantation surgery after tooth extraction. The Bio3 active implant Progressive 3.8 / 13 was chosen to accord to the D2-D3 bone type in order to achieve sufficient primer stability and further osseointegration. Surgical protocol: Under local anesthesia of 4% articaine, the dentist made atraumatic tooth extraction in order to maintain the vestibular well and avoid vestibular muco-periosteal flap formation. That method was applied in order to prevent significant atrophy of vestibular alveolar socket without formation of vestibular  mucoperiosteal flap (see Fig. 2). After socket operative exploration, the dentist made its curettage and treated it with antiseptic. According to Bio3 surgical protocols, the dentist made implant bed formation with correct axis positioning as for near teeth crowns and alveolar socket (Figure 3;. Figure 4.). Progressive implant was inserted into the implant bed (Fig. 5) and placed 3mm above the enamel-cement tooth border 1.1. Implant axis direction toward the cutting edge of future crown. After implant installation, the 20N / cm2 enchancement was achieved, which is a sufficient for future of osseointegration (Fig. 6). Immediate loading was contraindicated in this case. Next step was the formation of soft tissue graft on pedicle on the keratinized gum area (Fig. 7).  The alveolar socket was covered with graft and its distal part was placed under the vestibular mucosa and fixed with U-shaped suture. The last action was aimed at gums biotype thickening around the future implant. The wound with graft were tightly sutured (Fig. 8). The post-surgical analgesic and antibiotic therapy was conducted in accordance with international protocols. In order to hide the defect of the aesthetic zone, the dentist advised to use temporary cap until second surgical stage and implant integration (Fig. 9).


Fig.  1. The aesthetic zone defect


Fig. 2  Alveolar socket after tooth extraction


Fig. 3. The implant bed formation: it is important to create a “perfect” future position of the implant with pilot drill


Fig. 4. The final drill. The implant will be placed in this position.


Fig. 5. Dental implant placing in the formed bone cavity


Fig. 6. Installation of the implant and its fixation with a torque wrench.


Fig. 7. Subepithelial connective tissue graft in the hard palate area


Fig. 8. Subepithelial connective tissue graft was sutured in the wound


Fig. 9. The temporary cap