Dr Balaji presents a challenging case which required hard and soft tissue augmentation in order to replace a failing upper left bridge with an immediately placed implant-retained solution.
Patient presentation
A 60-year-old lady presented to the practice for treatment of a failing upper left bridge. The bridge was situated at the UL3–5 and was supported by UL3 and UL5 abutments, and the UL4 was a pontic.
Assessment and treatment planning
Clinical assessment revealed that the patient had bone and soft tissue loss in the UL4 region, attributed to tooth loss. The UL3 and UL5, the teeth that supported the bridge, were failing and required extraction. An x-ray was taken to aid in diagnosis and the planning of future implant placement – revealing the extent of bone loss and the need for augmentation in the region.
All appropriate treatment options were discussed with the patient, including the option of no treatment which was not recommended in this case. It was decided that the best option was immediate implant placement along with immediate loading of a bridge. In order to achieve a successful outcome, hard and soft tissue augmentation would be required. This would improve bone volume and gingival thickness at the UL4 site, and better support dental implants for a long-lasting result.
The patient provided informed consent to undergo this treatment, understanding that this would provide a fixed and long-term solution for her tooth loss, whilst also providing a functional and aesthetic outcome.
Treatment provision
A mucogingival flap was raised and the UL3 and UL5 were extracted. During the extraction of the UL3, the buccal bone fractured due to the lack of bone at the UL4 site. Once the teeth were removed, two dental implants were immediately placed using a fully guided approach in the UL3 and UL5 extraction sites. Bone augmentation was performed, using a mixture of autogenous bone and allograft. Bone was harvested from the operating side lateral sinus, and the graft material was placed on the implant surfaces and into the jump gaps. A layering technique was employed to ensure maximum stability, and this was secured with a native collagen membrane and periosteal suturing.
Following this, a connective tissue graft (CTG) was harvested from the palate and debilitated. The CTG was sutured to the buccal flap, to improve soft tissue thickness in the area. The flap was advanced to enable tension-free closure, and the temporary bridge was fitted. The use of a temporary bridge during healing helps to encourage soft tissue contour for a more aesthetic outcome.
After four months, the temporary bridge was removed, revealing a good thickness of soft tissue and bone. Following this, the final bridge was placed.
Reflection
Although this was a difficult case due to the immediate placement and temporisation, the outcome was very favourable for the patient. My advice for clinicians who are undertaking similar cases is to plan properly with guided surgery.
Dr Balaji provides industry-leading training courses on both hard and soft tissue management around dental implants with the ASHA Club.
For more information about how you could elevate your skills with the support of experts, please visit www.ashaclub.co.uk or call 07974 304269
Author bio: Dr Selvaraj Balaji: BDS, MFDS RCPS(Gla), MFD SRCS(Ed), LDS RCS(Eng)
Since he obtained the BDS Degree, Dr Balaji has worked in Maxillo-facial units in the UK for several years and gained substantial experience in surgical dentistry. He is the principal dentist of The Gallery Dental Group which is made up of Meadow Walk Dental Practice and The Gallery Dental & Implant Centre. Dr Balaji is also the founder of the Academy of Soft and Hard Tissue Augmentation (ASHA) and runs courses, lectures and study clubs in the UK and around Europe for aspiring implantologists.
