Case report
Surgical and restorative management of a dental implant in the esthetic zone and volumetric evaluation following deepithelialized connective tissue graft: a case report
Introduction (basis and objectives): After tooth extraction, changes occur in the soft tissues associated with bone resorption in a vertical and horizontal direction. This collapse can be addressed through bone grafts and connective tissue grafts. The objective of this clinical case is to describe the treatment sequence carried out from extraction to delivery of the definitive crown, combining regenerative, guided surgery, mucogingival and prosthetic concepts. Furthermore, changes in vestibular mucosal thickness that occurred after the use of a connective tissue graft are described and analyzed using digital analysis software.
Methods: The surgical sequence consisted of performing alveolar preservation. After 4 months, a guided implant was planned and placed in position 1.2 with simultaneous connective tissue graft. After integration, the soft tissues were conditioned with a provisional crown and then the definitive screw-retained restoration was placed.
Results: The guided implant placement approach and application of a connective tissue graft showed aesthetic results and significant soft tissue volumetric gains.
Conclusions: Careful management of hard and soft tissues, as well as planning through guided surgery, increases precision regarding the ideal position of the implant, which will impact the long-term stability of hard and soft tissues.
Key words: Surgery; Computer-Assisted; Dental implants; Soft tissue; Connective tissue; Software tool.
In the field of implantology, digital technology has emerged as an advancement to enhance surgical procedures and achieve high-quality treatments with aesthetic outcomes. In this context, guided surgery, introduced in the 1990s, is regarded as a contemporary dental practice based on digital planning and the utilisation of advanced imaging technologies1. Implant placement is performed using 3D-printed surgical guides and a specific kit designed for each system2. Compared with the conventional technique, guided implant placement has been demonstrated to significantly optimise safety, minimise injury to adjacent anatomical structures, and reduce surgical time as well as intra- and postoperative morbidity3–5. However, guided surgery requires a financial investment, more meticulous advance planning, and a professional with broader experience for its appropriate management2,6.
There is no doubt that the aesthetic outcome of treatment with implants in the anterior maxillary region is of great importance. For this purpose, it is essential to have adequate peri-implant tissue support, encompassing both hard and soft tissues. Each professional must assume responsibility for improving the phenotype of peri-implant soft tissues, focusing on three main components: gingival thickness, width of keratinised mucosa, and supracrestal tissue height7,8. Current research recognises soft tissue augmentation procedures as essential interventions. They not only enhance stability at the bone level but also control inflammatory signs and prevent future aesthetic complications7,9–11.
Over the past decade, the quantitative evaluation of augmented tissues has primarily relied on clinical methods such as the periodontal probe and endodontic files. However, the analogue instruments employed lack three-dimensional accuracy for the precise assessment of volumetric changes12. Consequently, the utilisation of digital technologies such as computed tomography, ultrasound, and three-dimensional analysis of STL (Standard Tessellation Language) files derived from the digitisation of plaster models or intraoral scanning is advantageous13–15. These digital and computerised tools offer significant advantages in dental diagnosis, planning, and treatment. Thus, they provide non-invasive and comfortable measurements for patients, greater accuracy in 2D and 3D evaluations (achieving a precision of 0.01 mm), and enable long-term monitoring by analysing changes occurring in the tissues16,17.
The objective of this clinical case is to present a treatment sequence in a clinical scenario where anatomical and restorative conditions precluded the placement of an immediate implant in the aesthetic sector. Furthermore, to describe and evaluate, using a non-invasive technique and three-dimensional analysis software, the volumetric changes of the soft tissue following the placement of a connective tissue graft on the buccal and occlusal aspects of the implant.
Quispe López, Norberto
Associate Lecturer, Department of Surgery, Stomatology Area, University of Salamanca (USAL).
Dahdouh, Manar
5th-year Dentistry student, University of Salamanca.
Ledesma Sánchez, Lucía
5th-year Dentistry student, University of Salamanca.
Rodríguez Muñoz, Pablo
4th-year Dentistry student, University of Salamanca.