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V e rtic a l R id g e A u g m e n ta tio n a n d
S o ft T is s u e R e c o n s tru c tio n o f th e
A n t e r io r A t r o p h ic M a x illa e :
A C a se S e rie s

Istvan A. Urban, DMD, MD, PhD1 An unavoidable series of events

A lberto Monje, DDS2 takes place after tooth extraction,
Horn-Lay Wang, DDS, MSD, PhD3 often leading to vertical and hori­
zontal ridge deficiencies.1-5 Schropp
et al3 reported that 50% of the hori­
zontal and 0.7-mm vertical volumet­
Severe vertical ridge deficiency in the anterior maxilla represents one o f the ric changes occurred within the first
most challenging clinical scenarios in the bone regeneration arena. As such, a 3 months after extraction. In a sys­
combination o f vertical bone augmentation using various biomaterials and soft tematic review, Van der Weijden et
tissue manipulation is needed to obtain successful outcomes. The present case
al6 showed that after all the resorp-
series describes a novel approach to overcome vertical deficiencies in the anterior
atrophied maxillae by using a mixture o f autologous and anorganic bovine bone. tive events are over, a mean buc-
Soft tissue manipulation including, but not limited to, free soft tissue graft was used colingual/palatal loss of 3.87 mm
to overcome the drawbacks o f vertical bone augmentation (eg, loss o f vestibular and vertical reduction of 1.7 mm
depth and keratinized mucosa). By combining soft and hard tissue grafts, optimum might result in difficulty in obtain­
esthetic and long-term implant prosthesis stability can be achieved and sustained. ing implant stability in the adequate
(Int J Periodontics Restorative Dent 2015;35:613-623. doi: 10.11607/prd.2481)
positions. In addition, periodontal
disease as well as trauma can lead to
ridge deficiencies. Therefore, it has
been suggested that these clinical
difficulties might be overcome by
placing shorter implants,7 perform­
ing bone augmentation,8'9 placing
tilted implants, or using restorations
with artificial gingiva as well as other
approaches.10
Vertical ridge augmentation
(VRA) is one way to overcome these
challenges, but it remains one of the
most difficult clinical procedures
'Assistant Professor, Graduate Implant Dentistry, Loma Linda University, Loma Linda,
California, USA; Director, Urban Regeneration Institute, Budapest, Hungary. currently performed.11 When deal­
2Graduate Student and Research Fellow, Graduate Periodontics, Department of Periodontics ing with vertical ridge deficiency,
and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, Michigan, USA. the regenerative treatment option
3Professor and Director of Graduate Periodontics, Department of Periodontics and Oral
will be based on severity. Although
Medicine, School of Dentistry, University of Michigan, Ann Arbor, Michigan, USA.
for slight vertical atrophy (< 3 mm),
Correspondence to: Dr Istvan A. Urban, Director, Urban Regeneration Institute, more conservative approaches
Sodras utca 9, Budapest, 1026 Hungary.
might be proposed (ie, orthodontic
Fax: +36-1-2004447. Email: [email protected]
extrusion), for medium (4 to 6 mm)
©2015 by Quintessence Publishing Co Inc. or large (> 7 mm) defects, guided

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bone regeneration (GBR) or onlay local confounding factors (ie, loca­ results in less tissue shrinkage,31
bone graft m ight be preferred.12 tion, morphology, or biomaterials) which provides enhanced stability,
Certainly, autogenous bone blocks are yet to be determined. To pre­ even though the esthetic outcome is
have demonstrated successful dictably achieve successful bone usually less favorable than that of the
VRA13: a recent systematic review re­ augmentation, a PASS principle nonepithelized graft.32
ported that a mean gain of 4.75 mm (Primary wound closure, Angiogen­ The purpose of this case series
vertical height can be achieved,14 esis, clot Stability, and Space main­ is to describe a novel approach that
whereas others have pointed out tenance) should be used.26 As such, combines hard and soft tissue grafts
that only 0.6-mm vertical bone when performing VRA, space cre­ to successfully correct severe anteri­
gain can be achieved from intraoral ation and maintenance are essential. or atrophic maxillae and to develop
blocks.13 However, this technique Nonresorbable titanium-reinforced a positive gingival architecture be­
is not exempt from complications, barrier membranes fulfill the afore­ tween implants placed in vertically
with exposure of the bone block mentioned criteria and have been augmented ridges.
being the most common regardless suggested for large VRA.27-28
of the placement of barrier mem­ Another im portant factor is flap
branes.13 Nevertheless, this expo­ closure during bone augmentation. M e th o d and m aterials
sure rate increased to 33% when The key to achieving wound closure
titanium mesh was used.15 Further­ is not only the clinician's ability to Cases in c lu d e d
more, Ozaki and Buchman16 exam­ obtain tension-free release flap but
ined the resorptive pattern of block also good soft tissue quality and Six patients (mean age: 37 years;
grafts for bone augmentation and quantity. In an attem pt to achieve range: 23-55 years; five women and
found that regardless of the embry- wound closure and hence graft sta­ one man) in need of bone augmen­
ologic origin o f the bone graft, an bility, the buccal mucosa is often tation to achieve implant placement
unavoidable resorption (15%—60%) broadly released, and this often at the ideal three-dimensional posi­
might occur.13'17-19 Recently, the use results in a severe apical transloca­ tion were treated with composite
of allogeneic bone blocks showed tion of the mucogingival line, loss of bone grafts (1:1 ratio of autogenous
some promising results; neverthe­ vestibule, and keratinized mucosa bone and bovine hydroxyapatite) for
less, there is still a lack of long-term (KM). When the vestibule becomes VRA (Fig 1).
evidence supporting its utilization.20 shallow, it often leads to an esthet­
Therefore, clinicians are examining ic challenge as well as a phonetics
other possibilities (eg, materials and problem. Moreover, research has S u p ra im p la n t b o n e h e ig h t
techniques). GBR using anorganic shown that areas with minimal KM
bovine bone in combination with often have a higher peri-implant Implant bone level was deter­
autologous bone was shown to be plaque accumulation, inflammation, mined by parallelized periapical
effective in augmenting atrophied and attachment loss.29'30 radiographs using the lmageJ64
maxillary ridges vertically.21-23 The A recent systematic review dem­ program. One examiner (A.M.) per­
rationale behind this mixture is that onstrated that the combination of formed the measurements to cal­
the autologous bone supplies the apically positioned flap and free gin­ culate the amount of bone height
graft with the osteoinductive capac­ gival graft (FGG) is the most success­ achieved beyond the implant fixture
ity and the anorganic bovine bone ful approach to increase the width of level at the different time points. The
acts as a scaffold for space creation KM and deepen the vestible.31 How­ measurement recorded the distance
and maintenance.24 Even though ever, when comparing the use of ep- from implant neck to the coronal-
a wide range o f complication rates ithelialized gingival grafts with free most portion of the interproximal
have been reported in the literature connective tissue grafts, their ability bone level. Cohen's kappa intra- and
for this approach (0%-45%),25 the to promote KM is similar32 but FGG interexaminer coefficients were used

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Fig 1a Labial views o f the anterior teeth demonstrating advanced Fig 1b Labial view demonstrating a vertical defect after extraction
tissue loss. o f the four incisors.

(with I.U. as the second examiner) closure after the bone grafting (referred to as composite bone graft)
to test their reliability in 25% of the procedure despite the increased and then applied to the defect. The
cases analyzed to ensure accuracy. dimension of the ridge. A remote composite bone graft was im m obi­
flap procedure was performed in­ lized and covered with a titanium-
cluding crestal and vertical releasing reinforced membrane, which was
S urgica l phases incisions. A full-thickness, midcrest- stabilized with titanium bone tacks
al incision was made into the KM. (Master Pin Control, Meisinger) and/
First phase: V e rtical b on e a u g ­ The tw o divergent vertical incisions or titanium screws (Pro-Fix Tenting
m e n ta tio n were placed at least one tooth away Screw, Osteogenics Biomedical)
All patients were treated with VRA from the surgical site. In edentulous (Fig 2). Defects were measured dur­
using a titanium-reinforced polytet- areas, the vertical incisions were ing the grafting procedures with a
rafluoroethylene (PTFE) membrane placed at least 5 mm away from the calibrated periodontal probe. Ver­
(either an expanded [e]-PTFE re­ augmentation site. After primary tical bone defects were measured
generative membrane [Gore-Tex, incisions, periosteal elevators were from the most apical portion of the
W.L. Gore] or dense PTFE mem­ used to reflect a full-thickness flap bony defect to a line connecting the
brane [Cytoplast Ti-250, Osteogen- beyond the mucogingival junction interproximal bone height between
ics Biomedical]) and a combination (MGJ) and at least 5 mm beyond neighboring teeth.
of autogenous bone and anorgan­ the bone defect. The recipient bone Once the membrane was com­
ic bovine bone-derived mineral bed was prepared with multiple in- pletely secured, the flap was m obi­
(ABBM) (Bio-Oss, Geistlich Pharma). frabony marrow penetration using a lized to perm it tension-free primary
The medications, flap design, and small round bur. closure. A periosteal releasing inci­
sutures, and bone harvesting proce­ The autografts were harvest­ sion connecting the tw o vertical
dure used in this cases series have ed and particulated in a bone mill incisions was made to achieve elas­
been described previously.22'23'33'34 (R. Quetin Bone-Mill, Roswitha Que- ticity of the flap. The releasing inci­
Briefly, the flap design was cho­ tin Dental Products). A 1:1 mixture of sion was further reinforced until a
sen to ensure primary tension-free autograft and ABBM was prepared completely tension-free closure was

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Fig 2 Labial (left) and occlusal (right) views

o f the particulated composite bone graft.

possible. The flap was sutured in a 30%:70% autograft/ABBM mix­ was about 10 mm. Care was taken
two layers: first, horizontal mattress ture to increase the vertical height not to expose the head of the im­
sutures (Gore-Tex CV-5 and Cyto- and to mimic the interproximal bone plants or the overlying bone. A sub-
plast 3.0) were placed 4 mm from height. The goal was to increase epithelized connective tissue graft
the incision line; then, single inter­ bone thickness by 3 mm to prevent was harvested with a single incision
rupted sutures with the same e-PT- crest resorption and develop in­ technique. The length of the graft
FE suture were placed to close the terimplant bone support for the soft occupied the entire partial-thick­
edges of the flap, leaving at least a tissue architecture. The graft was ness flap and was about 10 mm in
4-mm-thick connective tissue layer further covered using a collagen width. The connective tissue graft
between the membrane and the membrane (Bio-Gide resorbable bi­ was secured with simple loop su­
oral epithelium. This intimate con­ layer membrane, Geistlich Pharma) tures and cross-mattress sutures
nective tissue-to-connective tissue and then immobilized using internal using a resorbable monofilament
contact provides a barrier prevent­ mattress sutures (6-0 polydioxanone suture (6-0 PDS-II) (Fig 4). The flap
ing exposure of the membrane. Ver­ [PDS] II, Ethicon) (Fig 3). The flaps was then closed over the connective
tical incisions were closed with single were readapted and a primary ten­ tissue grafts with simple interrupted
interrupted sutures. The single inter­ sion-free closure was achieved. The sutures using a PTFE monofilament
rupted sutures were removed be­ secondary bone graft and implants suture (Osteogenics Biomedical).
tween 10 and 14 days after surgery, were left to heal for an additional 6 Sutures were removed 2 weeks lat­
and mattress sutures were removed months. er. In the postoperative period, non­
2 to 3 weeks later. The membrane steroidal analgesics were used and
was then removed after 9 months of Third phase: Soft tissue thickening no antibiotics were given.
healing using a full-thickness flap. Two months after implant and sec­
ondary bone graft placement, a Fourth phase: Modified apically
Second phase: Implant placement beveled floating incision was made positioned flap (MAPF) and
and secondary bone graft in the KM about 0.5 mm palatal free soft tissue grafting
Implants were placed in the correct from the MGJ, which was located Both augmentation procedures re­
prosthetic position using a surgical more palatal than the implants. The sulted in a severe loss of vestibular
guide. The depth of implant place­ incision was of partial thickness and depth and shift of MGJ (Fig 5). The
ment corresponded to the regener­ about 1 mm in depth. The incision goal of the MAPF was to displace
ated ridge height and no implants involved the entire crest to 1.5 mm the mucosal tissue and at the same
were sunk into the newly formed away from the neighboring teeth. time preserve the previously trans­
bone. The implants and newly At this point, two divergent inci­ planted connective tissue fibers
formed bone were then covered sions were performed at the same over the augmented ridge. This sur­
with a composite bone graft using depth. The length of these incisions gical intervention was performed

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Fig 3a (left) Labial view of the regenerated ridge after 9 months of Fig 3b (right) Occlusal view o f implants placed in the regenerated
healing. ridge.

Fig 3c (left) Labial view of the supraimplant composite bone graft. Fig 3d (right) Labial view of the collagen membrane covering the
bone graft.

6 weeks after the soft tissue thick­ thelium was removed and care was palatal mucosa. This graft was only
ening procedure. taken to leave the previously trans­ 2 to 3 mm in width and 1 to 1.5 mm
The surgical intervention start­ planted soft tissue fibers intact. in thickness (strip graft), and was su­
ed with drawing a horizontal incision However, after bypassing the ridge tured immediately after its retrieval
on KM parallel to the MGJ. The flap and the first 4 mm apically, a deeper to the apical end of the recipient
was then elevated with a split-thick­ preparation was started to get close bed with resorbable monofilament
ness dissection to reposition the to the periosteum. In this region of sutures. The remainder of the peri­
MGJ apically to its original position the recipient site, the periosteal bed osteal bed not covered with the
before the bone regenerative sur­ was smoothed using sharp dissec­ strip graft was covered with a free
gery and was sutured in this apical tion to avoid any loose fibers or ir­ connective tissue graft and sutured
position. Two different split thick­ regularities. An autogenous FGG in place using the same resorbable
nesses were prepared and divided of appropriate length to cover the suture and techniques (Fig 6). The
by regions. On top of the implants full apical extension of the recipient palatal wound was closed using
and the coronal 4 mm, only the epi­ gingival bed was harvested from the 16-mm Cytoplast 3-0 mattress

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Fig 4 Labial view o f the subepithelial connective tissue graft placed to increase the thickness.

Fig 5 Labial (left) and occlusal (right) views o f the mucogingival distortion.

Fig 6a Labial view o f the combination o f autogenous free connec­ Fig 6b Labial view o f the healed soft tissue graft after 2.5 months
tive tissue and strip gingival graft. o f healing. Note the good development o f vestibule, keratinized
tissue, and tissue thickness.

sutures. Patients were instructed propriate systemic anti-inflamma­ comply with the prescribed regi­
to rinse twice a day with 0.2% tory medication (50 mg diclofenac, men and return 7 and 14 days after
chlorhexidine solution (eg, Corsodyl, Cataflam, Novartis) was prescribed surgery. Patients were given a fixed
GlaxoSmithKline) for 1 minute. Ap­ and patients were instructed to resin-bonded prosthesis.

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Fig 7a (left) Labial view

of the four single implant
crowns in place.

Fig 7b (right) Periapical

radiograph at uncovering
of the implants. Note
that customized healing
abutments were used.

Fig 7c (left) Periapical

radiograph demonstrating
the stability of the
supraimplant vertical bone
level after 5 years of loading.

Fig 7d (right) Lateral clinical

view o f the same case. Note:
Following this technique
it was possible to achieve
enough keratinized mucosa
to maintain the peri-implant
tissues under healthy
conditions and to accomplish
a harmonious gingival
display.

Final phase: Restorative treatment not interfere with the bone graft in patients achieved adequate verti­
After 2 months of healing, the between the implants. Four years cal bone height with the aforemen­
implants were uncovered using after restoration, positive soft tis­ tioned combination grafts to allow
a minimally invasive approach. sue architecture of the implants for properthree-dimensional implant
Localized incisions were made was maintained after vertical aug­ placement. Mean VRA was 5.83 mm
above the cover screws. The bone mentation in the anterior maxilla (max: 9 mm; min: 3mm). The VRA
graft above the cover screw was using the supraimplant grafting amount was associated with defect
scraped off through the soft tissue technique (Fig 7). atrophy. In other words, the more
tunnel using a microsurgical instru­ severe the defect, the more vertical
ment. Reduced configuration heal­ bone gain was achieved.
ing abutments were placed and Results
the provisional implant-supported
restoration was placed within 2 V e rtic a l r id g e g a in b e fo re S u p r a im p la n t b o n e h e ig h t
weeks after the procedure. Af­ im p la n t p la c e m e n t
ter 6 months of temporization, Inter- and intraexaminer Cohen's
all-ceramic crowns were placed. Healing of the bone graft was un­ kappa were 0.91 (95% confidence
Abutments were constructed to eventful in all six patients, and all interval [Cl] = 0.90 to 0.92) and 0.86

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has the potential to be colonized by

Table 1 Supraimplant vertical bone gain at different time
osteocytes CD44 positive to pro­
points after implant placement
mote neovascularization within the
No. of interimplant bone Supraimplant bone height particles.36 This biomaterial in com­
Time point height measurements (mm)* bination with autologous bone has
Baseline 12 2.21 ± 1.21 also been studied for VRA using the
12 mo 9 1.20 ± 1.46 same approach.21’22’33
24 mo 9 1.69 ± 0 .7 6 In addition, Urban et al22 dem­
36 mo 7 1.40 ± 0.99
onstrated that under histomorpho-
metric analysis after 8 months of
48 mo 7 1.82 ±0.81
graft healing, regenerated bone
60 mo 3 1.72 ±1.41
and newly formed bone results were
72 mo 4 1.37 ± 1 .0 8 36% and 19%, respectively, whereas
84 mo 3 1.39 ± 1.21 grafted particles were only 16%.
*Mean ± standard deviation. They also showed the interconnec­
tivity of the ABBM particles through
a dense network of newly formed
bone and the appearance of blood
(95% Cl = 0.84 to 0.88), respectively, Discussion vessels. Therefore, based on clinical,
indicating a high degree of reliabil­ radiographic, and histologic evalu­
ity in the measurements. This was The case series reported herein ation, it seems that this bone graft­
extracted from 18 Nobel Biocare demonstrates that a combination ing mixture is a safe and predictable
implants (2 Nobel Replace RP CC, of VRA with GBR and soft tissue re­ way to achieve vertical bone gain.
1 Nobel Active RP, 11 Branemark constructive surgery can be used to In addition, the use of titani­
MKIII RP, 3 Branemark MKill NP, and successfully reconstruct the vertical­ um-reinforced PTFE membrane
1 Replace Select NP). From these, ly deficient anterior maxilla with an enables space creation as well as
an overall number of 12 interimplant esthetically pleasing and functional graft stability to avoid disruption of
bone levels (from 6 patients) were result (Fig 8). With the advancement the osseous remodeling process.37
available to be measured at base­ in biomaterials, GBR in the anterior PTFE is a synthetic fluoropolymer
line (implants' healing abutment maxillae is becoming a frequently of tetrafluorethylene that has been
placement), whereas only 3 interim­ performed procedure for most ver­ proven to be effective in exclud­
plant bone levels (from 2 patients) tical and horizontal ridge augmenta­ ing fibroblastlike cells from grow­
could be measured at 84 months' tion procedures. In conjunction with ing into the grafted defect.22’38
follow-up. Table 1 displays the the following modifications, GBR However, the main complication
mean (± standard deviation) supra- has slowly become a predictable of this technique is membrane ex­
implant bone height values. It was clinical procedure in augmenting posure, documented with a wide
noted that the mean supraimplant not only horizontal but also vertical incidence,22’23'25 which may signifi­
bone height obtained at baseline bone. The mixture of autogenous cantly jeopardize the final regener­
decreased significantly compared bone and ABBM not only trig­ ative outcome.18 In a meta-analysis,
with 12-month postloading values gers the release of osteoblasts and Machtei39 reported that sites with
(2.21 ± 1.21 mm vs 1.20 ± 1.46 mm). growth factors (autogenous graft), membrane exposure had six times
Nonetheless, from this point up to but also acts as a space-making or less bone gain than sites without
84 months later, bone level changes maintainer (ABBM) because of its exposure. In this regard, soft tissue
were not significant (1.20 ± 1.46 mm slow resorption rate.35 A recently re­ characteristics then become very
at baseline vs 1.39 ± 1.21 mm). ported study has shown that ABBM important to achieving complete

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 621

Vertical bone augm entation Soft tissue augm entation

'v 'vv ;

A n te rio r a trophy Restorative phase

CT FGG

Fig 8 Timeline showing the stages o f VRA with GBR and soft tissue reconstructive surgery used to successfully reconstruct the vertically
deficient anterior maxilla with an esthetically pleasing and functional result. CTG = connective tissue graft; FGG = free gingival graft.

Fig 9 Representative radiographs (from

case 2) o f the maintenance o f supraimplant
bone preservation demonstrating good
supraimplant stability after 84 months o f
loading.

and stable wound closure. Most level that results in thin tissue over FGG has been shown to be the
clinicians will attempt to release/un- the regenerated crest. The aim of most reliable way to increase the
dermine the flap so the tissue can the tissue-thickening surgery with amount of KM and vestibular deep­
be passively moved coronally to al­ a connective tissue graft was to ening.42 This was further confirmed
low for primary wound closure. Do­ achieve the mucosal thickness nec­ by a recent systematic review, which
ing so allows the vestibular depth essary to establish a stable biologic reported that FGG remains the best
to become shallow, which then cre­ width over the implants without any documented and most successful
ates several challenges for patients. loss of crestal bone.40 The goal was approach to increase KM width.31
These include but are not limited to to achieve at least 4 mm of tissue FGG results in less tissue shrink­
esthetic, phonetic, and future main­ thickness over the implants. How­ age31 and enhanced stability, but it
tenance. The experience of the ever, this covered autogenous graft provides a less favorable esthetic
authors is that this distorted muco­ will not result in keratinized tissue outcome than the nonepithelized
sal tissue is usually stretched to a gain as demonstrated previously.41 graft.32 Hence, the authors used a

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622

combination of an apically placed tance. The patients selected must A c k n o w le d g m e n ts

FGG strip and a more crestally be highly motivated and follow strict
positioned free connective tissue compliance with an oral hygiene This study was partially supported by the
graft. The combination approach regimen that is a key for success­ University of Michigan Periodontal Graduate

was placed over a recipient bed, ful outcomes. Although many other Student Research Fund. We thank Stepha­
nie O'Neill (School of Dentistry, University
which was prepared according to alternatives are described in the
of Michigan) for developing the timeline in­
the MAPF. This way, a thick KM was literature, such as block grafting or cluded in Fig 8.
achieved, which was well attached GBR without soft tissue grafting, in Both Drs Urban and Wang have re­
to the recipient bed. This combina­ the present authors' experience this ceived honoraria from Osteogenics Biomedi­
tion graft achieved a stable and es- multiple-stage approach involves cal. Dr Urban has also received an honorarium

thetically pleasing result. not only oral function recovery, but from Geistlich Pharma and Osteogenics Bio­
materials. Dr Monje has no financial interests,
Interestingly, the mean su- also excellent esthetic results that
either directly or indirectly, in the products or
praimplant vertical bone height imply high patient satisfaction. To information listed in this article.
achieved in the present study was perform these procedures, signifi­
1.5 mm. This bone height was main­ cant clinical expertise is required
tained for up to 7 years despite to avoid surgical complications and R e fe ren c e s
being located above the implant- obtain successful results. Flence,
abutment interface (Fig 9). To the clinicians who perform these pro­ 1. Carlsson GE. Changes in the jaws and
authors' knowledge, this is the first cedures should have adequate facial profile after extractions and pros­
thetic treatment. Trans R Sch Dent
article to report this finding with training and understanding of bone Stockh Umea 1967;12:1-29.
the composite graft. More recently, graft as well as soft tissue behavior. 2. Carlsson GE, Ragnarson N, Astrand P.
Changes in height of the alveolar pro­
a combination graft technique us­ The results described herein should cess in edentulous segments. A longi­
ing a collagen matrix in combina­ be confirmed in multicenter studies tudinal clinical and radiographic study
of full upper denture cases with residual
tion with a strip gingival autograft of larger patient populations before lower anteriors. Odontol Tidskr 1967;
was documented as a successful this becomes routine clinical treat­ 75:193-208.
3. Schropp L, Wenzel A, Kostopoulos L,
alternative to the entirely autog­ ment.
Karring T. Bone healing and soft tissue
enous soft tissue grafting. This contour changes following single-tooth
might prove to be a less invasive extraction: A clinical and radiographic
12-month prospective study. Int J Peri­
approach that could lead to simi­ Conclusion odontics Restorative Dent 2003;23:
lar KT augmentation and increased 313-323.
4. Pietrokovski J, Massler M. Residual
patient comfort.43 By combining soft and vertical hard ridge remodeling after tooth extraction
The combination of bone aug­ tissue augmentation, an optimally in monkeys. J Prosthet Dent 1971 ;26:
119-129.
mentation and soft tissue grafting esthetic and functionally stable
5. Pietrokovski J, Massler M. Ridge re­
resulted in a positive gingival and implant-supported fixed prosthe­ modeling after tooth extraction in rats.
interimplant bone contour. If the sis can be achieved in the severe J Dent Res 1967;46:222-231.
6. Van der Weijden F, Dell'Acqua F, Slot
aforementioned technique can be anterior atrophic maxillae. In addi­ DE. Alveolar bone dimensional changes
proven to be predictable, clinicians tion, using the mixture of anorganic of post-extraction sockets in humans:
A systematic review. J Clin Periodontol
will have one more tool for solving bovine bone and autologous bone, 2009;36:1048-1058.
the lack of interimplant papillae. supraimplant bone gain can be suc­ 7. Garaicoa-Pazmino C, Suarez-Lopez
Del Amo F, Monje A, et al. Influence of
One of the major drawbacks cessfully achieved to support future
crown/implant ratio on marginal bone
of the proposed novel approach is interimplant papillae formation. loss: A systematic review. J Periodontol
the number of surgeries needed to 2014;85:1214-1221.
Nonetheless, future randomized
achieve adequate hard and soft tis­ controlled clinical trials are needed
sue support. Therefore, careful case to verify the treatment approach
selection is of paramount impor­ described herein.

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8. Tonetti MS, Hammerle CH, European 21. Urban I, Caplanis N, Lozada JL. Simul­ 32. Orsini M, Orsini G, Benlloch D, et al.
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Volume 35, Number 5, 2015

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