Immediate Implant placement with Allograft Bone and Guided Tissue Regeneration
This 56 year old lady was referred to me by a colleague to manage what seems to be a vertical root fracture on the first upper right Premolar. The patient complaints were pain when chewing and occlusal contact. Clinical tests showed deep probing (12mm) on the facial aspect, mobility typical with a root fracture and pain to percussion. The history of the tooth revealed an endodontic treatment and crown done over 15 years ago.
The radiological exam revealed radioluscency on the mesial aspect and large cylinder shape post in the buccal canal. Most probable diagnosis: a vertical root fracture with a poor to hopeless prognosis. To be determined upon surgical entry. Medical history: within normal limits and determined at ASA1.
Surgical exploration confirms severe vertical buccal root fracture to apex (hopeless prognosis)
Note: heavy granulation tissue
Tooth removed, granulation tissue cleaned and periosteum properly elevated.
Socket cleaned to healthy bone.
Implant (and cover screw) is placed with good initial stability that is obtained by engaging the palatal bone.
a) Connective tissue pediculed graft is prepared for primary occlusal coverage
b) Graft attached to palatal flap for increased vascularisation
Allograft mineralized bone insertion directly over implant. I did not use a menbrane over the bone graft since the periosteum was intact.
If the periosteum was compromised, then I would have laid a resorbable membrane over the bone graft.
Connective tissue for complete primary closure.
You can substitute the connective tissue graft by using a non-resobable membrane that would be removed 4 weeks after the surgery
Complete bone regeneration after 4 months
Notice bone regeneration distal 13
4 month post-op at second stage re-entry, note successful buccal wall reconstruction. Also note reconstruction on distal and buccal wall on the canine.
Are these results Reproducible? In the 10 years or so that I have been applying this technique I have found that the results have been extremely favourable. In order to achieve predictable results, some variables must be well controlled. Bone graft stability, primary stable closure, and tension free suturing are essential for success. Complete removal of any infected soft or hard tissue is also imperative.