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I case _ report

_Introduction

Esthetic requirements forimplant supported restorationsinclude the presence of naturalsoft tissue contours, and to theextend possible, the full pres-ence of the interdental papillae.Regardless of the techniqueused for tooth extraction, somedegree of soft and hard tissueloss is inevitable. The use ofguided tissue regenerationmembranes over sockets hasbeen shown to be one method topreserve bone after extraction,but most techniques involve theuse of large flaps and even ver-

tical incisions to achieve primary closure. Because ofthe unique features of Cytoplast® dense PTFE mem-branes and the ability of the membranes to remainexposed in the oral cavity without risk of infection,the soft tissue architecture, keratinized tissue widthand position of the mucogingival junction adjacentto the socket can be preserved. Using the minimallyinvasive tunneling technique described in this arti-cle facilitates minimally invasive socket reconstruc-tion avoiding vertical incisions and incision of theinterdental papillae. The technique described can beused for immediate implant placement, as in thiscase, or for socket preservation using particulategraft material if a staged approach is desired.

implants3_2009

Extraction, immediate implantplacement and guided bone regeneration using a flapless approachauthor_Barry K. Bartee, DDS, MD, USA

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case _ report I

implants3_2009

_Case Presentation

This is a 60-year-old female who presented witha crown-root fracture of a non-vital maxillary rightcentral incisor. The crown was temporarily stabi-lized with composite resin bonded to the adjacentteeth (Fig. 1). Extraction of the tooth and immedi-ate implant placement was planned. To minimizesoft and hard tissue recession, a flapless, minimallyinvasive extraction technique was employed (Fig.2). The tooth root was extracted using only an in-trasulcular incision. A #15 blade was used to severthe periodontal ligament and create space for rootluxation and elevation (Fig. 3). Next, a subperiostealpocket was created on the buccal and palatal aspectof the socket using a micro periosteal elevator (Fig.4). Following luxation and initial elevation of theroot with the micro elevator, the tooth was removedwith forceps (Fig. 5). The interdental papillae werecarefully undermined and elevated. This can bedone with a small periosteal elevator or curette (Fig.6). All remaining soft tissue was removed from theinterior and margins of the socket with a sharpcurette (Fig. 7). The implant osteotomy was done inthe standard fashion, with the implant being placedagainst the palatal wall of the socket (Fig. 8). The gapbetween the facial aspect of the implant and thebuccal wall was filled with a combination of auto-genous bone chips harvested from the implant os-teotomy combined with allograft bone (Fig. 9). Atextured, high-density PTFE barrier membrane isplaced. The membrane is trimmed, then placed intothe superiosteal pocket on the palatal aspect (Fig.10). The membrane is then tucked under the facialflap (Fig. 11). Next, the membrane is tucked under

the interdental papillae, taking care to keep the edgeof the material a minimum of 1.0 mm away from ad-jacent tooth roots (Fig. 12). A single 3-0 PTFE sutureis placed to further stabilize the membrane. Themembrane is intentionally left exposed, as primaryclosure is not required in this technique (Fig. 13).

Figure 14 shows the surgical site at three weeks.The exposed membrane is easily removed by grasp-ing with a tissue forcep. Topical anesthesia may beused, but local anesthesia is not necessary.

The site at six weeks after implant placement(three weeks after membrane removal), reveals ker-atinized mucosa forming across the former extrac-tion site (Fig. 15).

Figure 16 shows the clinical view followingplacement of the implant abutment and acrylic pro-visional restoration.

_Summary

The flapless technique described provides a min-imally invasive approach to extraction with socketgrafting or immediate implant placement. Becausethe interdental papilla remains intact, there is lessdisruption of blood supply. As a result, there is agreater potential for maintenance of soft tissue vol-ume. In addition, the use of a dense PTFE membraneimproves the predictability of immediate implantplacement, excluding the requirement for primaryclosure and resultant disruption of soft tissue archi-tecture._

Cytoplast® is a registered trademark of Os-teogenics Biomedical, Inc.

© 2008 Osteogenics Biomedical, Inc. BBFY0607

Barry K. Bartee, DDS, PA3234 64th StreetLubbock,Texas 79413USAPhone: +1-806-792-0030 Fax: +1-806-792-8730 E-mail: dr2bkb@aol.com

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