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.