Teeth may be lost due to many different reasons . Dental
caries and periodontal disease count of major causes of
loose teeth , other causes could contribute in losing teeth
in anterior maxilla is trauma, which has a greater anatomical
projection and susceptible to this type of injury . Minor
trauma cause loss of alveolus and gingiva. Major trauma can
cause extensive vertical and horizontal bone loss . Restoration
of missing anterior maxillary teeth is challenging due to
compromised esthetics associated with missing teeth itself in
addition gradual alveolar bone resorption which will further
compromise esthetics .
Aesthetics and functional demands in the restoring of this
particular area have always been a major factor of choosing
the treatment option available. In addition; the psychological
advantage over the use of partial removable provisional
An advent of osseointegration terms (direct structural and
functional connection between ordered living bone and the surface of a load- carrying implant) . Allow rehabilitation
of missing anterior teeth using osseointegrated dental implant
because of its high predictability.
Endosseous implant success required full coverage of implant
surface with bone. Augmentation of local defect of alveolar
ridge with bone grafts enable to achieve these prerequisite in
insufficient bone volume.
Different surgical procedure available to create enough bone
volume such as autogenous bone graft, include only graft, interpositional
bone graft, guided bone regeneration and combination
of these procedure [8-10].
Estimating the degree of bone defect is not easy since the mucosal
contour can mask the actual dimension of the alveolar
ridge, ridge mapping, CBCT and Denta Scan can be used.
A female patient born in 1973 came to prosthodontics department
– Implant center, (Wuhan University dental hospital)
complaining of the upper anterior teeth 11, 21, 22 were missing
for 3 years (Figure 1).
The following teeth 11, 21, 22 were extracted 3 years ago after
car accidents which fracture the crown and leave the roots. Now she asked for the urgent restoration to improve the function
Conducting a thorough medical history, we found the patient
had a good physical condition and denied any systematic diseases
or any allergic diseases that were relevant to dental treatment.
And she had no mucosal lesions, no bleeding disorder,
no tobacco smoking, and alcohol and drug abuse.
Questioning the patients reported that teeth 11, 21, and 22
were extracted in another hospital 3 years ago. And since then
no any further treatment try to solve the problem due to economical
Clinical examination was conducted, and through deep examination
of both extra and intra oral examination of reported
Extra-oral: No gross facial asymmetry or swelling was detected.
No clicking of TMJ or limitation and deviation of opening.
Intra-oral: Hard tissue examination revels that Teeth 11, 21,
22 were missing. Evaluation of edentulous space shows that
the quantity and quality of edentulous area (alveolar bone) was
not good. There were obvious bone defect and labial ridge in
form of concavity. (Labial dehiscence) The inter-alveolar spaces
were enough for restoration.
Soft tissue examinations show. The thickness of the soft tissue
of the edentulous ridge was assessed at different point of the
edentulous space and it’s about 2 mm measured by a graduated
periodontal probe. The color and texture of mucosa was
No obvious mucosal lesions, fibrous connective tissue displacement
and other abnormities were detected.
Periodontal status: Oral hygiene was good. No marginal gingival
inflammation was detected. No periodontal pockets were
detected. No other tooth mobility was found.
Occlusion: The overbite and over-jet were normal. The occlusion
Radiographic evaluation showed an excellent condition of
the remaining teeth, and there was adequate bone height of 15 mm. the remaining bone was of moderate quality. Alveolar
bone had bone defect in missing teeth number 22 (Figure 2).
Labial bone dehiscence required bone augmentation in order
to achieve long term success .
The treatment options were discuss with patients and where
summarized as following , implant supported crown of each
missing tooth , or two implant supported bridge, FPD and
RPD were presented to the patient, and the time, expenditure,
advantages, and disadvantages of each plan were introduced.
The patient wanted the best way for restoration, and she didn’t
care about the time consume. So she chose the implant denture
Details of Treatment
Step 1. Preoperative radiograph examination
Before start implant surgery and as a part of treatment plan
process, the patient must have initial radiographic screening.
Which is in this case was peri-apical X-ray accomplished by
intraoral long cone paralleling technique.
Step 2. Oral hygiene instruction and scaling
The patient understanding of the financial, time, and maintenance
requirements was crucial, and these obligations must be
made clear to the patient initially and during subsequent appointments.
Before the surgery, all the supragingival and subgingival
calculus must be removed and blood screening test
Step 3. Onlay guided bone regeneration
The patient was informed about the common complications
of the implant surgery that could happen, and then he signed
a consent form. Because of the lack of enough bone, Onlay
guided bone regeneration technique was used after implant placement. Particulated bone and bone graft from the Bone-
TrapTM collected during preparation of the implant site along
with Bio-Oss granules for covering the implant .
Step 4. Sugical procedure
After local anesthesia injection, surgical stent was positioned
and supported by adjacent teeth (Figure 3).
A small, sharp-tipped guiding drill was used to create a precise,
minimally invasive initial penetration through the mucosa
and into bone to locate the exact position of planed implant
Then full muco-periostal flap were reflected exposing the underplaying
bone (Figure 5). Position the surgical stent and
prepare the implant site with correct angulations and depth
for implant fixture (Figure 6). A 2mm diameter twist drill was
used to drill to the desired depth. The site was 13mm in length.
The direction indicator was used to check orientation.
The drill of 3.5mm in diameter was used to open out the cortical
bone to the ￠3.5mm.Then the site was enlarged with the
￠4.3mm twist drill. Parallel pin was check in prepared site to
evaluate parallelism of prepared implant site for optimal result
Then screw the site. The Nobel® Replace Select tapered implant(
￠4.3X13mm) and tapered implant(￠4.3X13mm) were
inserted in the site of 11 and 22 respectively initially with an
adapter attached to a special contra-angle at slow revolutions,
and then by hands using tap wrench and ratchet wrench. The
implant was placed with its head just below the crest of the
bone, the implant internal triangle tip direct to labial. The insert
torque was 45 Ncm (Figure 8&Figure 9).
The implant was placed with its head at crest bone level, and
then put the healing screw on the abutment connection area.
Bio-Oss and collagen membrane filled in spacing. The wound
was sutured (Figure 10,Figure 11,
& Figure 12). The patient was informed to
maintain the oral hygiene. 7-10 days later, she must come back for the removal of the sutures and took a new radiographic for
history information (Figure 13).
Step 5. Stage II surgery procedure
After 6 months later, stage II surgery was taken. Providing
transmucosal healing abutment for two weeks. The fabrication of nonfunctional acrylic resin provisional bridge in form of
screw retained (Figure 14, Figure 15,
Figure 16, Figure 17 & Figure 18).
Step 6. Impression for the master cast
After 4 weeks , the soft tissue healed perfectly. Removed the
provisional bridge, and took impressions directly with polyether
material for the working cast (Figure 19).
Step 7. Try-in and cementation
The occlusal contacts should be checked with occlusal indicator
papers before and after cementation. Finally, the metal ceramic
bridge was cemented with glass ionomer cement (GIC)
Then a radiograph was taken to verify seating of the restoration
and acted as a record of alveolar bone status for comparison
Step 8. Periodic recall
The patient was informed some knowledge about maintain the
oral hygiene and using of the implant restoration. Recall the
patient periodically. The patient was evaluated clinically and
radiographically at 1 week, 1 months, 3 months, 6 months,
and one year. The examinations should include mobility of
implant, soundness and integrity of provisional crowns, periodontal
status, and marginal bone resorption and so on.
Discussion and Conclusion
Endosseous dental implants are a predictable modality of tooth
replacement that can improve the dental health and quality of
life for many people.
Different study conducted by many researches has reported
that, the success and survival rate of dental implant placed in
anterior maxilla are almost same to other segment of jaw .
However, there is often inadequate bone to receive and support
implants. This can be the result of trauma, periodontal
disease, endodontic infection, post-extraction ridge defects,
disuse atrophy, etc. .
Successful implant placement in planed site required enough
bone volume of sufficient density to enable an implant of the
appropriate size to be placed in a desirable position and orientation.
Placement of bone grafts in conjunction with endosseous dental
implant shortens the treatment time without influencing
the success rate or increase the complication .
The interaction between the graft and the surrounding host
bone is very important and is the subject of much research
The degree of bone grafting required for implant placement
varies from localized deficiencies to cases where there is a need
to change the entire arch form and/or jaw relationship.
Augmentation to create enough bone volume is done using
either (GBR) Guided bone regeneration [15,16], autogenous
bone grafts, including onlay grafts [17,18] and interpositional
bone grafts , and combinations of these procedures.
These grafting materials can be used in different clinical
situation which can be summarized and following [20-23]:
• Regeneration of periodontal bone and furcation defects.
• Osseous defect regeneration.
• Regeneration of extraction sockets.
• Regeneration of gaps around block grafts.
• Horizontal alveolar crest augmentation.
• Sinus augmentation.
Using guide bone regeneration in construction of bone defects
in predictable methods for regeneration of adequate bone volume
for proper placement of dental implant. These can be simultaneously
with implant placemat or staged approach .
Using of particular dental implant of specific body design and
surface characteristic will influence the treatment success .
Tapered dental implant which mimicking the shape of natural
root will have high initial stability . The surface of dental
implant using here is TiUnite surface, which enhanced osseointegration and anchorage in surrounding bone. In the long
term, it maintains marginal bone and soft tissue levels, maximizing
functional endurance and esthetics [27-29].
Here a grafting with particulated hydroxyapatite bone graft to
cover implant threaded exposed and to establish good labial
bone contour to improve esthetic.
Another pre-requesting of this case to achieve optimal result is
soft tissue management. Successful dental implant restoration
in issue framing esthetic zone required a healthy and correctly
contoured soft tissue framing, which is defined as the gingival
contour that surrounds the prosthesis [30,31]. Preservation of
interdental papilla and gingival margin which is symmetrical
with gingival architecture of adjacent gingival [32,33]. Achieving
aesthetics interdental papilla which is completely fill the
space between teeth or implants required interproximal bone
crest of 5 mm. of estimated contact point in planned restoration
Three dimensional position of implant required to achieve
optimal emergence profile . Mesiodistally positioning of
implant required 1.5 mm space between implant and adjacent
teeth or between implant / implant [32,36].
Labio-Palatel positioning is also important, too far labillay result
in overcontouring of the crown and can cause recession
due to decrease thickness of buccal bone . While palatal
positiong produce ridge lap which limiting the type of design
and increasing the difficulty for maintenance [37-39]. The
third position is apicoronal positiong , which if the implant
is too far apically positiong they will be bone resorption and
gingival recision. On other hand if there is coronal placement
the esthetics may be comprmise due to visibility of implant
shoulder . The implant should be placed 1.5 mm to 3.0
mm below the CEJ for optimal implant esthetics .
Tissue training help to develop a proper emergence profile and
natural tooth appearance, help in re-establish normal gingival
tissue contours and interdental papillae . Fabricating provisional
restoration before inserting the final prosthesis which
will improve esthetics.