Horizontal GBR with simultaneous implant placement in anterior maxillary teeth

Case courtesy of Dr. Ignacio Ginebreda.

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Extraoral view (left).

Intraoral views. Lower teeth are overlaying the upper gum, which may cause implant loading problems. Decision to go for an interim restoration, 1-year orthodontic treatment, and then implant placement on #2.1 and #2.2 (center).

#1.1: Complicated oblique crown fracture., #2.1: Avulsed tooth. #2.2: Horizontal fracture at CEJ level (right).

Tooth #1.1 with coronal oblique fracture and displacement. Complete absence of tooth #2.1 (left).

Clinical aspect 15 days after trauma (center).

Tooth #2.2 with horizontal fracture at CEJ level and below (right).

Phase 1: Tissue healing, Endo-Perio-Resto and fixed interim restoration [1.1-x-2.2].
Phase 2: Orthodontic aligner treatment to correct overbite and provide restorative space.
Phase 3: After 1 year – GBR, implant placement, custom healing abutment [#2.2] and immediate provisionalization [#2.1].
Phase 4: Soft tissue management with new implant provisionals to achieve final contours.
Phase 5: Definitive Restoration.

Phase 1&2 : Endo-Perio-Resto (1.1-x-2.2) and Ortho treatment prior to reconstructive implant surgery.

#1.1-#2.2: Palatal crown lengthening, intra-surgical isolation, root canal treatment, abutment build-up (#2.2) and teeth preps (top images).

#1.1-#2.2: Interim provisional and orthodontic aligners at 12 months of healing (bottom images).

Phase 3: GBR, implant placement, custom healing abutment (#2.2) and immediate provisionalization (#2.1).

Implant planning on DTX Studio™ Implant. Notice insufficient bone width on the buccal aspect of implant #2.1 requiring additional GBR.

Phase 3: GBR, implant placement, custom healing abutment (#2.2) and immediate provisionalization (#2.1).

OsseoShaper drills through the surgical guide (left).

Narrow platform N1™ implants placed in the desired 3D position. Notice insufficient bone width on the buccal aspect of implant #2.1 requiring additional GBR (right).

Phase 3: GBR, implant placement, custom healing abutment (#2.2) and immediate provisionalization (#2.1).

creos™ syntogain S granules (0.2-1.0mm) placed in the surgical site and creos™ xenoprotect collagen mambrane fixed with titanium tacks in the apical aspect.

Phase 3: GBR, implant placement, custom healing abutment (#2.2) and immediate provisionalization (#2.1)

Buccal volume reconstruction: creos™ syntogain S granules wrapped with creos™ xenoprotect collagen membrane fixed with titanium tacks.

Phase 3: GBR, implant placement, custom healing abutment (#2.2) and immediate provisionalization (#2.1).

Restorative steps of immediate provisionalization. #2.1: Immediate provisional splinted to #1.1 and distal cantilever. #2.2: Custom healing abutment.

Phase 3: GBR, implant placement, custom healing abutment (#2.2) and immediate provisionalization (#2.1).

6 months post-op clinical and radiographic images. Notice the volume gain in the buccal aspect of both implant sites.

Phase 4: Soft tissue management with new implant provisionals to achieve final contours.

Implants are integrated. Start of the soft tissue management phase.

Phase 4: Soft tissue management with new implant provisionals to achieve final contours.

Final BOPT (Biologically Oriented Preparation Technique) preparation on #1.1 and definitive emergence profile created at the implant sites.

Phase 5: Definitive restoration.

Elos Accurate® Scan Body in place for final implant-level digital impression and prototype of the restorations (top images).

Definitive full contour zirconia crown in tooth #1.1 and screw-retained implant-supported crowns in positions #2.1 and #2.2 (bottom images).

Phase 5: Definitive restoration.

Occlusal and 3/4 view with the recovered horizontal volume.

Phase 5: Definitive restoration.

9 months after surgery. Peri-apical X-Ray and CBCT cross-sectional cuts at time of delivery of the final restorations.

Notice the inter-proximal peak of bone preserved in between the adjacent implants and the horizontal volume gain at the buccal aspect of both implants.