Immediate implant placement, reconstruction

of compromised sockets, and repair of gingival

recession with a triple graft from the maxillary
tuberosity: A variation of the immediate
dentoalveolar restoration technique
José Carlos Martins da Rosa,a
Ariádene Cristina Pértile de Oliveira Rosa,b
Marcos Alexandre Fadanelli,c and
Bruno Salles Sotto-Maior, PhDd
São Leopoldo Mandic Dental Research Center, Campinas,
São Paulo, Brazil
Immediate implant placement into compromised sockets is challenging for clinicians. The 3-dimensional implant
position, status of the buccal bone wall, and regeneration of the soft tissue contours all affect adequate esthetic
and functional results. This clinical report presents a treatment protocol (a variation of the immediate dentoalveolar
restoration concept) consisting of immediate implantation and the reconstruction of the buccal bone wall and gingival
recession in a single procedure with a triple graft (cancellous and cortical bone and soft tissue graft). (J Prosthet Dent
2014;112:717-722)

The immediate placement of implants frequently associated with severe alve- proposed. This technique uses a bone
after tooth extraction is a common clinical olar bone resorption and soft tissue and soft tissue reconstructive pro-
practice, with a success rate similar to that loss5 (Figs. 1, 2). When the bone cedure involving immediate implant
of implant placement in healed sites.1 damage is extensive, as indicated by placement in sockets with severe
However, immediate implant placement changes in the level of the gingival buccal bone wall damage and gingival
in the esthetic zone is a challenging and margin, the esthetic risk increases, and recession in a single clinical session.
complex procedure.2 To achieve optimal immediate loading is commonly con-
esthetic and stability outcomes with the traindicated.7,8 To improve the es- PROCEDURE
immediate placement of implants in fresh thetics and clinical efficacy, as well as
sockets, a meticulous protocol for the to shorten the treatment period, a 1. After anesthesia, make an intra-
surgical and prosthodontic procedures variation of the immediate dentoal- sulcular incision around the tooth to be
is necessary.1,3 Surgical considerations veolar restoration (IDR) technique is extracted.
include the 3-dimensional (3D) posi-
tioning of the implants, primary stability,
the presence of the buccal bone wall, and
the soft tissue thickness.4 Prosthetic con-
siderations necessary for soft tissue
maturation include the correct design of
the emergence profile, the harmony of the
periimplant soft tissues relative to the
adjacent dentition, the restoration color,
and the contouring and polishing steps.5,6
Reasons for tooth extraction and
immediate implant placement include
endodontic treatment failure, ad-
vanced periodontal disease, trauma, 1 Abscess in right central incisor and poor soft tissue
and root fracture, all of which are quality.

a
Doctoral student, Department of Implantology.
b
Doctoral student, Department of Implantology.
c
Postgraduate student, Department of Operative Dentistry.
d
Full Professor, São Leopoldo Mandic Dental Research Center.

Rosa et al
718 Volume 112 Issue 4

2 Cone-beam computed tomographic image showed total

absence of buccal bone wall.

4 Emergence profile with concave

contour established on interim crown.

6. Evaluate the occlusion and

excursive movements after the interim
crown is screwed to the implant.
7. After finishing the prosthetic
procedures, make a horizontal incision
in the gingival papillae at the CEJ.
Divergent incisions must follow the
gingival recession pattern (Fig. 5). The
purpose of the divergent incisions is to
reposition the gingival tissue coronally,
thereby minimizing trauma to the tissues
3 Implant installed with palatine anchoring (Replace Select; and promoting scar-free, first-intention
Nobel Biocare).
healing. Make an intrassulcular incision
joining the incisions, and divide the
2. Extract the tooth with a mini- the contralateral tooth. Anchor the flap above the divergent incisions. A
mally invasive procedure by using a implant to the palatal wall, to provide microblade (69 WS; Swann-Morton)
periotome, a microlever, and atrau- correct space for buccal hard and soft may be used for all incisions.
matic forceps to preserve the integrity tissue reconstruction (Fig. 3). 8. Remove the gingival tissue pedi-
of the remaining bone wall. 5. Test the interim titanium abut- cles between the double incisions in the
3. Carefully curette the socket to ment, occlusal adjustment, and opaci- region of the papillae with a microblade
remove the granulation tissue and the fication of the metallic component with or microscissors (Fig. 6).
remaining periodontal connective tis- a composite opaque resin (Amelogen 9. Infiltrate the donor area with
sue. The socket walls should be probed Plus OW; Ultradent Products Inc). An anesthetic at the base of the vestibule
in the apicocoronal and mesiodistal interim crown is made by using a pre- and in the palatine portion of the
directions to assess the degree of bone viously prepared esthetic veneer with maxillary tuberosity.
damage and confirm the anatomic light-polymerizing composite resin. The 10. Make a mucoperiosteal incision
shape of the defect. ideal emergence profile with a concave at the maxillary tuberosity by following
4. Insert the implant into the ideal contour is established on the interim the distal contour of the last molar, 2
3D position, regardless of whether the crown (Fig. 4), allowing free space for or 3 mm from its distal side. This inci-
gingival margin is not level. The implant better accommodation of the soft tis- sion is followed by 2 mucoperiosteal
platform should be placed 3 mm apical sue and promoting a thicker and more relaxing incisions in the posterior di-
to the cementoenamel junction (CEJ) of stable gingival margin. rection, thus reproducing the shape of
The Journal of Prosthetic Dentistry Rosa et al
October 2014 719

5 Four incisions in gingival papillae area. Two horizontal 6 Removal of epithelial part of pedicles between 2 incisions.
incisions in gingival papillae (in area corresponding to
cementoenamel junction of adjacent tooth), followed
by 2 divergent incisions corresponding to gingival
recession pattern.

the defect in the receptor region. After

those 3 first mucoperiosteal incisions,
divide the flap starting at the buccal
line angle, then, directing the blade
to the most posterior portion of
the relaxing incisions, maintaining
connective tissue 1 to 2 mm in thick-
ness to cover the bone tissue (Fig. 7).
11. Cut the bone with a straight
chisel (Schwert IDR Kit; A. Schweick-
hardt GmbH & Co KG) along the
relaxing incisions to define the bone
fracture line. Position the chisel initially
perpendicular to the bone structure on
the incision line surrounding the distal
7 Flap division at donor site. Division starts at buccal angle part of the last molar. After it has been
and continues to posterior area, keeping uniform thickness of inserted 2 or 3 mm with a surgical
connective tissue over bone. hammer, change the chisel’s angulation
to be parallel to the outer surface of the

8 A, B, Triple graft is removed with straight chisel. Three layers of graft (connective tissue, cortical, and cancellous bone)
are present.
Rosa et al
720 Volume 112 Issue 4
is harvested from the same donor site
with a chisel to fill the gaps between the
triple graft and the exposed spirals of
the implant. The graft is embedded in
saline solution and transferred to the
receptor site as soon as possible.
12. Manipulate the triple graft to
reproduce the shape of the socket
defect and then test to achieve better
adaptation.
13. Compact the bone marrow har-
vested from the maxillary tuberosity in
the buccal surface of the implant to
cover the exposed implant threads
9 Absence of buccal bone wall.
(Fig. 9). The stability of this graft can be
connective tissue. Deepen the chisel tissue to remove the triple graft (cortical determined by the use of bone compac-
gradually as far as the distal limit of the and cancellous bone and soft tissue tors (Schwert IDR Kit; A. Schweickhardt
relaxing incisions to obtain a uniform graft), taking care to maintain an epi- GmbH & Co KG). This step is done
bone/gingiva graft (Fig. 8). After the thelial pedicle to ensure better nutri- before inserting the triple graft.
bone is fractured, an incision is made tion for the flap that will cover the 14. Insert the triple graft carefully,
in the distal portion of the connective donor site. Additional cancellous bone leaving the bone portion in contact with

10 A, B, Triple graft remodeled according to shape and size of defect and tested in receptor site; graft positioned with
connective portion turned to gingival mucosa and cancellous portion turned to previously compacted particulate bone.

11 Stabilization of graft by suturing connective tissue 12 Occlusal view at 4-month follow-up.

part on gingival flap of receptor area. Simple stitches
on mesial and distal papillae region.
The Journal of Prosthetic Dentistry Rosa et al
October 2014 721

13 A, B, Customized zirconia abutment prepared with adequate emergence profile and evaluating
relationship between soft tissue and abutment.

the previously packed bone marrow and of the graft must always be beyond the and seal the palatine orifice with pro-
the connective tissue portion in contact limits of the bone defect. visional filling material (Fermit; Ivoclar
with the internal portion of the gingival 15. Stabilize the graft by suturing the Vivadent).
flap (Fig. 10). The connective portion of connective tissue portion of the graft on 17. Finally, suture the gingival flap in
the graft should be stabilized up to the the gingival flap. The definitive flap the donor region with simple stitches.
level of the gingival margin that was coaptation is obtained by suturing the 18. Monitor every 2 days for the first
moved coronally. The bone portion of papillae with simple stitches (Fig. 11). 2 weeks and every 15 days for the next 4
the graft must be coincident with the 16. Apply a torque of 20 Ncm on the months. After a period of 4 months,
implant platform. The connective portion attachment screw of the interim crown once the bone and gingival architecture

14 A, B, Clinical image and soft tissue enhancement cone-beam computed tomographic scan made 2 years after
immediate dentoalveolar restoration procedure.
Rosa et al
722 Volume 112 Issue 4
has been reestablished (Fig. 12), a zir- rongeur to reproduce the same shape as 4. Wittneben JG, Buser D, Belser UC, Brägger U.
Peri-implant soft tissue conditioning with
conia abutment (Fig. 13) and ceramic the periimplant bone defect is funda-
provisional restorations in the esthetic zone:
crown is provided. The stability of the mental, given that the stabilization of the dynamic compression technique. Int J
buccal bone wall is monitored by peri- the triple graft is achieved by juxta- Periodontics Restorative Dent 2013;33:
odic cone-beam computed tomographic posing the bone defect borders. 447-55.
5. Da Rosa JC, Rosa AC, da Rosa DM,
sagittal sections (Fig. 14). The limitations of this technique Zardo CM. Immediate dentoalveolar restora-
include difficulty of access to the donor tion of compromised sockets: a novel tech-
site, especially in patients with a small nique. Eur J Esthet Dent 2013;8:432-43.
DISCUSSION 6. Petropoulou A, Pappa E, Pelekanos S. Esthetic
mouth opening. Another limitation is considerations when replacing missing maxil-
the low availability of tuberosity bone lary incisors with implants: a clinical report.
A buccal bone wall with sufficient
and soft tissue to restore large defects J Prosthet Dent 2013;109:140-4.
dimensions is a prerequisite to achieving 7. Bäumer D, Zuhr O, Rebele S, Schneider D,
or more than 1 tooth. Limitations
stability and esthetic soft tissue con- Schupbach P, Hürzeler M. The socket-shield
related to the receptor site include technique: first histological, clinical, and
tours in the esthetic zone.9 A lack of
insufficient amounts of residual to volumetrical observations after separation of
buccal bone wall to support the facial the buccal tooth segmentea pilot study. Clin
make the primary stability of the
mucosa may lead to recession and an Implant Dent Relat Res 2013;30:1-12.
implant feasible and gingival recession 8. Buser D, Martin W, Belser UC. Optimizing
incomplete papilla. Thus, implant
extending above the mucogingival line. esthetics for implant restorations in the ante-
treatment goals must be expanded to rior maxilla: anatomic and surgical consider-
include the reconstruction of these lost ations. Int J Oral Maxillofac Implants 2004;19:
anatomic structures. The technique REFERENCES 43-61.
9. Belser U, Buser D, Higginbottom F. Consensus
aims to restore the buccal bone wall
1. Del Fabbro M, Ceresoli V, Taschieri S, Ceci C, statements and recommended clinical pro-
and soft tissue contours by using the cedures regarding esthetics in implant
Testori T. Immediate loading of postextraction
same procedure as for implant place- implants in the esthetic area: systematic review dentistry. Int J Oral Maxillofac Implants
ment, thereby reestablishing esthetics of the literature [published online April 22, 2004;19:73-4.

and function. This technique is a varia- 2013]. Clin Implant Dent Relat Res.
http://dx.doi.org/10.1111/cid.12074. Corresponding author:
tion of the IDR technique, which is 2. Noelken R, Neffe BA, Kunkel M, Wagner W. Dr José Carlos Martins da Rosa
indicated for immediate implant place- Maintenance of marginal bone support and Avenida São Leopoldo 680
ment in compromised sockets and for soft tissue esthetics at immediately provision- Caxias do Sul, RS 95097-350
alized OsseoSpeed implants placed into BRAZIL
the repair of soft tissue recessions. The extraction sites: 2-year results. Clin Oral E-mail: josecarlos@rosaodontologia.com.br
stabilization of a thick graft tissue in Implants Res 2013;14:214-20.
a localized buccal wall defect is the 3. Cabello G, Rioboo M, Fábrega JG. Immediate Copyright ª 2014 by the Editorial Council for
placement and restoration of implants in the The Journal of Prosthetic Dentistry.
most challenging part of the treatment
aesthetic zone with a trimodal approach: soft
in damaged sockets. Therefore, the tissue alterations and its relation to gingival bio-
manipulation of the triple graft with a type. Clin Oral Implants Res 2012;9:1094-100.

The Journal of Prosthetic Dentistry Rosa et al