Case submitted by: Dr. Gerald Rudick and Arta Prenga.
(Case photos are beneath the description)
A 40-year old male patient, a heavy smoker, presented with a mobile and sensitive upper right central incisor ( #11).
The preoperative radiograph revealed that this tooth had been treated endodontically, had a post and core, a crown and evidence of a possible root resection. He was given a local anaesthetic, and the tooth was extracted; however, a large portion of the root remained in the bone.
A full thickness flap was opened, and the remainder of the root was removed, and a lot damage to the buccal bone was observed. The soft tissues were approximated, sutured, and a plastic denture tooth was bonded to the adjacent teeth to act as a temporary replacement. A period of five weeks was left in order for the site to detoxify and clear itself of the deleterious tissues.
Prior to re-entering the site, four vials of PRF were drawn and centrifused for 8 minutes at 2700 rpms. The tubes were opened, and the PRF was withdrawn and pressed to obtain membranes.The exudate of fibronectin and vitreonectin were used to wet the grafting materials which were Cerasorb M, Osteogen, Osetodemin with a sprinkling of Metronidazol powder.
The soft tissue was reflected and with a piezo scaler, denuded the labial plate in the area of where the implant was to be placed. Selected an Adin 4.2 x 16 mm Touareg S implant; which was secured at the apex, and slightly on the sides, as the entire labial surface was exposed. A titanium mesh was cut to size and secured with the cover screw of the implant. The implant surface was rinsed with the PRF liquids, the grafting material packed on top of it, covered by two PRF pressed membranes, and the titanium membrane folded on top of it.
On top of the titanium mesh two remaining PRF membranes were placed, the soft tissue reapproximated and then sutured with sutures. The site was covered with Coepak periodontal dressing, which also secured the denture tooth. After 5 days, the periodontal pak was removed,and the denture tooth was bonded to the adjacent teeth, and left for observation. At 10 weeks, a decision was taken to open the soft tissues and remove the titanium mesh, and rebond the denture tooth to the adjacent teeth.
Four months after removing the titanium mesh, the labial tissue was reflected to expose the implant and it was observed that bone was developing on the labial surface of the implant, and holes were drilled in the adjacent bone to stimulate bleeding in preparation for a second grafting with Gen-Os which is a porcine xenograft, which was then covered with Evolution membrane. The evolution membrane covered the site and was sutured to place.
It must be observed that the implant was intentionally placed above the crest of the ridge, in order for the titanium mesh to generate bone above the height of the ridge . After four months the soft tissues were sufficiently healed, so that a titanium abutment was fitted on to the implant, and the temporary crown was totally implant supported. Post-op photos demonstrate excellent bone regeneration as verified in the radiograph, with the final restoration being a porcelain to metal cement retained crown.