Case One

A 52‐year‐old man presented with the complaint of severe mobility of his maxillary left lateral incisor. Gingival recession was observed at all his maxillary anterior teeth, with the greatest severity at the lateral incisor (Figure 5.2.1a). In the preoperative radiograph (Figure 5.2.1b), a supernumerary tooth was observed apical to the adjacent central incisor, while the supporting bone of the lateral incisor was resorbed almost to its the apex.

Disregarding the small supernumerary, implant placement was planned simultaneously with the extraction of the lateral incisor, which was easily removed with forceps under local anesthesia, and after preoperative intravenous administration of an antibiotic. Vials of the patient’s venous blood were taken from his forearm to prepare autologous fibrin glue, as first described by Sohn et al. [8] using a specific centrifuge and protocol. The prepared autologous fibrin glue was then mixed with allograft/xenograft material to make a “sticky bone” graft. Further samples of the patient’s blood collected in glass vacutainers were centrifuged for 12 minutes using the same centrifuge to make concentrated growth factor (CGF) membranes. CGF and the original platelet‐rich fibrin (PRF) membranes are basically identical, although prepared by slightly different methods. [9]

Surgery was initiated with a full‐thickness palatally favored crestal incision and connected to anterior and posterior vertical incisions made at 45‐degree angles and extending beyond the mucogingival junction. Periosteal release of the flap was performed with a new no. 15c blade to allow later tension‐free flap closure and suturing. All granulation tissue in the extraction defect was removed with a bone scraper tip connected to a piezoelectric bone surgery unit. An undersized osteotomy was developed using a final drill 0.5 mm narrower in diameter than the planned implant. A 3.75‐mm wide × 13 mm‐long implant (AlphaBio Inc., Seattle, WA) was placed immediately thereafter with its prosthetic platform located 2 mm subcrestal to the adjacent proximal bone heights. A 2‐mm high healing abutment was placed on the implant to function as a vertical tenting device. Approximately 5 mm of the implant’s buccal surface was left exposed (Figure 5.2.1c). Decortications were made into the adjacent alveolar bone. A mixture of 0.25 g cancellous bovine bone and 0.5 cc of bone allograft was combined at chairside with the autologous fibrin glue to create a “sticky bone” graft. This composite sticky biomaterial was then grafted over the exposed implant surface defect (Figure 5.2.1d) and healing abutment. A CGF membrane with its complement of platelet‐derived growth factors was used to cover the bone graft. Next, a vascularized interpositional periosteal connective tissue (VIPCT) flap [10] was prepared from the left palate and rotated to seal the socket soft tissue defect. The VICT flap was secured to the advanced buccal flap and the wound closed with tension‐free suturing (Figure 5.2.1e). Wound healing was uneventful.

The uncovering of the implants at 3 months was performed using a small stab incision to insert a temporary abutment and provisional crown. Sufficient alveolar bone augmentation and an increase in soft tissue were confirmed (Figure 5.2.1g,h,i).

After a further 3 months of healing to stabilize the soft tissues, the temporary prosthesis was replaced with a porcelain‐based definitive restoration. During the 10‐year follow‐up of the final prosthesis in function, the stability of soft tissues and bone augmentation was observed through radiographs and intraoral examination (Figure 5.2.1J,k,l).

Case Two

A patient presented with two hopeless maxillary central incisors (Figure 5.2.2a,b). Bone sounding suggested significant loss of buccal bone for both teeth and this was confirmed after raising a large flap (Figure 5.2.2c). Nevertheless, the clinician felt that there was sufficient apical bone remaining to stabilize IIPs. In fact, it was possible to place two implants in adequate three‐dimensional positions within the original boney housing (Figure 5.2.2d,e). The exposed implant surfaces were grafted with a mixture of mineralized allograft and collected autogenous bone particulate (Figure 5.2.2f), covered with a collagen membrane (Figure 5.2.2g) and allowed submerged healing for optimal integration.

The implants remained covered until the re‐entry surgery and were subsequently restored with two splinted crowns (Figures 5.2.5.2.2h,i).

Case Three

A patient presented with a hopeless maxillary left central incisor following endodontic failure that had led to development of a large periapical defect, total loss of the buccal plate of bone and extrusion of the tooth (Figure 5.2.3a) As a result, it was not possible to place an IIP as the site needed extensive hard and soft tissue regeneration. The tooth was extracted and left to heal before regenerative efforts could be undertaken (Figure 5.2.3b). A split‐thickness palatal flap was then raised at the site to allow preparation and rotation of a pedunculated, palatal connective tissue graft meant to thicken the crestal soft tissues overlying the former socket (Figure 5.2.3c,d). The rotated palatal connective tissue was successful in thickening the soft tissues overlying the hard tissue defect (Figure 5.2.3e).

After 8 weeks of soft tissue healing, a large mucoperiosteal flap was raised to expose the socket defect for hard tissue regeneration (Figure 5.2.3f). The original socket deficiency was grafted with a mixture of mineralized allograft and xenograft, which was then covered with a collagen membrane followed by a collagenous soft tissue allograft (Figure 5.2.3g). Finally, the site was overlain with PRF membranes to add platelet‐derived growth factors to the composition (Figure 5.2.3h), and the flap repositioned and sutured passively (Figure 5.2.3i).

After 3 months of healing, the site was ready for implant insertion (Figure 5.2.3j). A small flap was raised, revealing more than sufficient new bone to receive an implant (Figure 5.2.3k,l). An implant was inserted subcrestally, to the extent that when a healing cap was added, its top was more or less flush with the crest to allow for undisturbed integration despite the use of a removable temporary acrylic denture (Figure 5.2.3m). The implant was submerged using three interrupted sutures (Figure 5.2.3n). The final restoration is shown in Figure 5.2.3o.