Case Description and Results
A 36-year-old Saudi Arabian woman presented to a private clinic with a
chief complaint of tooth mobility and pain. The patient was medically
fit with dental history of a few composite restorations performed 2
years previously. No medication usage was reported. Intraoral clinical
examination revealed that the intraoral soft and hard tissues were
within the normal limits. Tooth #19 presented with a vertical fracture
extending deep below the gingival margin with noticeable mobility of the
broken proximal halves. A fistula opening with purulent discharge on
pressure palpation was detected on the buccal gingival tissue. A
vitality test using the cold-testing technique was performed on tooth
#20 and revealed a vital pulpal response. Radiographic examination
revealed that tooth #19 had a deep fracture line extending halfway
between the cementoenamel junction and mesial root apex. A large
peri-apical/periodontal infection was observed around the fracture area
and distal root surface of tooth #20 (Fig. 1). Probing of the mesial
aspect of the fractured tooth showed an 11-mm-deep pocket with excessive
bleeding on probing.
A treatment plan was formulated to include extraction of tooth #19 with
simultaneous guided bone regeneration followed by implant-supported
crown replacement, also addressing the infected post-extraction socket
and distal root surface of tooth #20. Local anesthesia was administered
by buccal and lingual infiltration of Septanest with adrenaline
1/100,000 (Septanest, Septodont, France) and a short needle. A sulcular
incision was made using blade 15c mounted on a #5A blade handle
(Hu-Friedy, Chicago, IL, USA) extending from the mesial aspect of tooth
#20 to the distal aspect of tooth #18 for surgical accessibility. A
pouched mucoperiosteal flap was reflected using a Buser Periosteal
Elevator (Hu-Friedy, Chicago, IL, USA), and tooth #19 was extracted
using atraumatic extraction forceps (Hu-Friedy, Chicago, IL, USA) (Fig.
2). The extraction socket was thoroughly debrided to remove all
granulation tissues. The distal root surface of tooth #20 was curetted
carefully using a Molt surgical curette (Hu-Friedy, Chicago, IL, USA).
Grade II mobility was noted in tooth #20 due to significant loss of
bone support from the distal root aspect. After extraction, the debrided
socket showed a two-walled defect with buccal-plate loss, denuded distal
root surface of tooth #20, and damaged inter-radicular bone.
Guided bone regeneration was planned for future implant placement. Three
pieces of resorbable pre-medicated collagen sponge containing lidocaine,
chlorhexidine, and metronidazole (Alvanes, Vladmiva, Belgorod, Russia)
were adapted to the distal root surface of tooth #20 to facilitate
hemostasis and antimicrobial control of the infected area for proper
tissue/bone regeneration of the defect side. A resorbable collagen
membrane (T-Barrier Membrane, B&B Dental Implant Co., Italy) was tacked
under a buccal flap to ensure stability upon socket management. An
equal-parts mixture of small-sized particulate allograft and xenograft
bone materials (ACE Surgical Supply, Brockton, MA) was used to fill the
rest of the socket. The collagen membrane was then wrapped around to
cover the socket and tacked under the minimally reflected lingual flap.
A wound dressing collagen tape (HeliTape; Miltex Integra, Princeton, NJ)
was used to cover the collagen membrane and tacked under the buccal- and
lingual-flap edges. The site was sutured with mesial and distal simple
interrupted knots, and a figure-of-eight technique was used to stabilize
the socket contents using 5-0 monofilament polypropylene sutures (SMI
sutures, St. Vith, Belgium). The socket seal technique was implemented
by application of cyanoacrylate coating (PeriAcryl 90 HV; GluStitch
Inc., BC, Canada) on the surgical field (Figs. 3a and 3b). Occlusal
adjustment of tooth #20 was performed to achieve light contact on
maximum intercuspation and excursion movements. Postoperative
instructions and a prescription of Augmentin 625 mg TID for 7 days,
ibuprofen 400 mg prn pain, and Parodontax daily mouthwash for 2 weeks
were provided. The patient was recalled 2 weeks later for suture removal
and at 1, 4, and 6 months postoperatively for site evaluation. Clinical
and radiographic evaluations of the site were performed at the 6-month
recall visit to plan for implant surgery (Figs. 4a and 4b).
Following administration of local anesthesia, a flapless and free-hand
approach was used to place a 4.2×9 implant along with the cover screw in
a slightly sub-crestal vertical position (Astra Tech Implant EV;
Dentsply Sirona, Mannheim, Germany) (Fig. 5). An implant insertion
torque of 45 N·cm was achieved. The punched-out tissues were adapted and
sutured to seal the punched holes (Fig. 6). Postoperative instructions
and medication were provided, and the patient was followed up per
standard protocol. Three months after implant placement, the implant was
uncovered following the tissue punch, and a healing abutment of 4-mm
height was attached accordingly. Surgical closure and postoperative
instructions were provided. An implant-level closed-tray impression
technique was performed along with shade-matching 3 weeks after the
implant-uncovering procedure. A screw-retained implant-supported
zirconia crown was designed, inserted, and torqued to 25 N·cm to the
internal implant connection (Fig. 7). The screw hole was closed with
Teflon tape and a flowable composite. Occlusal adjustment was
accomplished with light contact on centric and eccentric movements. The
patient was followed up every 3 months in the first year and every 6
months thereafter. The periodontal condition of tooth #20 improved, and
no mobility was noted on recall visits. Post-treatment clinical
photographs showed favorable soft-tissue health and level on the buccal
and lingual aspects of the implant crown (Figs. 8a and 8b). CBCT
radiographs were obtained 1 and 2 years post-treatment and revealed
optimum bone quantity and quality around the implant and on the distal
root surface of tooth #20 (Figs. 9 and 10).
The report was conducted in accordance with the Helsinki Declaration of
1975, as revised in 2013. The patient provided written informed consent
for the publication of this case report and accompanying figures.
Patient anonymity was ensured. The report was exempt from institutional
review board approval.