international magazine of oral implantology

case report _ edentulous sites I andadequateamountandqualityofperiimplanthard andsofttissueshavetobeconsideredtomaintainlong term stability around implants. Therefore, the aim of the present cases was to evaluate the effect of a new step-by-step surgical technique designed to simulta- neouslyreconstructresorbedalveolarridgeandthead- jacently located intrabony defect to achieve a pre- dictable clinical outcome and adequate peri-implant tissuestability. _Materials and methods Three patients exhibiting chronic periodontitis with localized advanced periodontal bone loss were referred to the Department of Periodontology, Sem- melweis University, Budapest, for comprehensive pe- riodontaltherapy.Allthreepatientsweremiddleaged Caucasian males (51, 50 and 49 years-old), systemi- cally healthy and had never been smokers. Each pa- tient presented at least one deep advanced periodon- tal bony defect in the upper front region. After initial therapyteethwereconsideredtobehopelessbecause of their disadvantageous pathomorphology. Before tooth extraction each patient had completed basic cause related periodontal therapy including full mouth scaling and root planning and oral hygiene training.Beforesurgeryallexhibitedhighstandardsof oral hygiene. Treatment plan consisted of tooth removal followed by extraction site development (Surgery1),andsofttissueaugmentation(Surgery2), andimplantplacementwithsimultaneousridgeaug- mentation(Surgery3)andabutmentconnectionwith non resorbable membrane removal (Surgery 4). The following parameters were measured at baseline, im- mediatelybefore augmentationprocedureand11–20 months after implant placement: plaque index (PI), gingivalindex(GI),bleedingonprobing(BOP),probing depths (PD) around the neighbouring teeth at 6 sites, gingivalrecession(GR),clinicalattachmentlevel(CAL) with a millimetre calibrated periodontal probe (PCP- UNC 15, Hu-Friedy, Chicago, IL, USA) and also intra- surgicaldirectmeasurements:thelevelofperiodontal bone of neighbouring teeth, the width and height of the alveolar ridge. Standardized radiographs were takenwiththelongconeparalleltechniquepreopera- tively, between surgeries and postoperatively; for qualitative assessment of bone height. _The combined surgical technique Surgery1 Tooth extraction with extraction site development Following tooth removal a full thickness flap was raised up to the mucogingival line and beyond a par- tial thickness flap was mobilised with a horizontal ex- tension thus allowing a tension free soft tissue man- agement and wound closure. This flap design let the operatortoevaluateandtreattheperiodontaldefects around the neighbouring teeth. A combined alveolar site preservation technique was used with a slow re- sorbable membrane (Resolut Adapt LT 2530, Gore- Tex®, Newark, DE, USA) fixed with titanium pins (Ti- pins; DENTSPLY Friadent, Mannheim, Germany) to coverthemissingpart ofthebuccalplateandtomain- taintheoriginalformoftheearlier arch.Followingan appropriate-sized connective tissue graft was re- movedfromthepalatalmucosabyusingtheHürzeler technique(Hürzeler&Weng,1999).Theharvestedtis- sue was trimmed and sutured (5.0 non-absorbable polyamide monofilament, Braun AG, Tuttlingen, Ger- many)totheinnersurfaceofthepartialthicknessmu- Fig. 4_Clinical situation immediatly after tooth extraction. Fig. 5 & 6_A long term biodegradable membrane is fixed on the buccal aspect with titanium pins. Then the defect was filled with bovine derived xenograft (BDX) (BioOss) and covered with collagen membrane. Fig. 7_Tension-free wound closure after alveolar socket preservation. Fig. 8_The reentry revealed that the intrabony defect of the neighbouring tooth has also been filled with new bone. Fig. 9_The horizontal dimension of the implant site is already satisfac- tory but its vertical dimension needs further augmentation. I 33implants1_2011 Fig. 4 Fig. 5 Fig. 6 Fig. 7 Fig. 8 Fig. 9