Prosthetic-surgical-prosthetic approach for treating an esthetically compromised single dental implant.

Introduction:

Managing esthetic peri-implant complications can be challenging, with a prevalence of up to 64% among immediate implants. Historically, the primary focus was on bone quality for long-term success. Today, experts emphasize the importance of considering the peri-implant soft tissue component, not only from a biological perspective but also from an aesthetic standpoint.

Objective:

This report aims to present an appropriate treatment approach for compromised esthetics associated with dental implants involving the combined loss of peri-implant papillae and loss of periodontal attachment on adjacent teeth.

Case presentation:

A 37-year-old male patient presented with a failing mal-positioned implant in the esthetic zone, replacing missing tooth #9 in a patient with a high smile line. The defect was classified as Class III Subclass C according to Zucchelli et al. classification (figures 1A-C). 

The proposed approach began with temporary implant submergence, a key step before any surgical intervention, achieved by removing the crown and abutment and leaving the interproximal soft tissue to fill the space previously occupied by the crown.  A Maryland Bridge was delivered as an interim solution and adjusted every month for the first 6 months (figures 2A-B and schematic figure 5A).

After 6 months of prosthetic rehabilitation, a connective tissue graft (CTG) platform technique was applied, involving vertical and horizontal soft tissue augmentation (figures 3A-C and schematic figures 5B-D).

Two months later, the conditioning phase began and continued for another 4 months. Afterward, a definitive monolithic zirconia screw-retained crown was delivered with complete coverage, and both papillae entirely filled the interproximal spaces (figures 4A-H).

Discussion:

A critical factor in clinical decision-making process for utilizing CTG for peri-implant soft tissue defects involves the presence of interproximal soft tissue with adequate thickness, height, and width, to provide the vascular bed for a CTG and give the support required to coronally advance the flap (CAF). As seen in this clinical report, presence of thin, delicate interproximal papillae requires replacement of the crown with a narrower one to facilitate pre-surgical coronal growth of the interproximal tissue. Temporary implant submergence is also a viable treatment modality as it creates an environment more amenable to augment soft tissue horizontally and vertically with a CTG, without tension during primary closure, and to potentially restore lost papilla. Hence, the modifications for vertical and horizontal soft tissue augmentation with CAF were proposed using a CTG on the crest of healed edentulous spaces as a platform to support the graft. 

Summary:

In this case, the connective tissue platform technique proved to be a successful approach in maintaining esthetics and soft tissue stability. However, the pre-surgical prosthetic phase was crucial in achieving these results.