Immediate implant placement combined with hard and soft tissue grafting has been suggested because it may preclude dramatic postextraction bone loss and may decrease overall discomfort with reduction in the number of surgeries and in treatment time. In this case report, the acellular dermal matrix was used as a membrane for immediate implantation via a bone augmentation procedure in an esthetically challenging situation. The author suggests that this surgical technique provides the clinician with an option for an immediate implant therapy when primary closure is not intended. Additional randomized controlled trials conducted over long periods are necessary to establish whether this procedure offers long-term benefit to patients.

Introduction

Achieving an esthetic and functional implant-supported restoration in the maxillary anterior segment can be challenging.1 Traditional guidelines suggested delaying dental implant placement for 2–3 months after tooth extraction to allow for adequate alveolar ridge remodeling2; loss of the labial alveolar bone plate following tooth extraction in the maxillary anterior may lead to esthetic complications.3 Immediate placement of dental implants, combined with hard and soft tissue grafting, has been suggested, because it may preclude dramatic postextraction bone loss, while decreasing overall operative discomfort and reducing the number of surgeries and the length of treatment time.4,5 

Acellular dermal matrix (ADM) has been utilized in a wide range of dental applications such as increasing keratinized tissue,6 performing soft tissue augmentation,7 or providing root coverage8 and as a barrier membrane.9 However, few reports have described the use of ADM for immediate implant placement in bone grafting procedures.10 

In this case report, the ADM was used as a membrane in immediate implantation via a bone augmentation procedure in an esthetically challenging situation.

Case Report

A 22-year-old male patient presented to the dental clinic for evaluation of the maxillary anterior region. The patient's medical history was negative, and he was not taking any medications that were associated with a compromised healing response. Clinical and radiographic examination indicated a fractured upper right central incisor (Figure 1a). Emergency treatment was provided, and the patient was sent back to the clinic at his troop for further treatment.

Eight months later, the patient was referred to the Department of Periodontology for evaluation of the maxillary anterior region because of an unfavorable prognosis. The upper right central incisor was mobile with a probing depth of 10 mm (Figure 1b). The patient was given a detailed explanation concerning his present state, alternative treatment plans, and the procedure, and informed consent was obtained from the patient. Treatment consisting of immediate placement of a dental implant with bone graft was planned after consultation.

Before surgery was performed, the patient rinsed for 2 minutes with a 0.12% chlorhexidine digluconate solution (Hexamedine, Bukwang, Seoul, Korea). Following an injection of 2% lidocaine with 1∶100 000 epinephrine local anesthetic, the crown portion and the residual roots were atraumatically removed. The extraction socket was thoroughly debrided and degranulated to remove all tissue. The site was prepared to accept a 3.8 × 13 mm implant (AVANA, Osstem, Seoul, Korea), and the implant was placed (Figure 2a). The buccal dehiscence measured 9.5 mm apicocoronally and 7 mm mesiodistally. The buccal surface and marginal voids were grafted with bovine anorganic hydroxyapatite (Bio-Oss, Geistlich AG, Wolhusen, Switzerland) (Figure 2b) and were covered with an ADM graft (Alloderm, Life Cell Corp, The Woodlands, Tex) such that the membrane extended at least 3 mm onto healthy bone and covered the occlusal surface completely. The full-thickness flap was repositioned, and the wound was closed by means of single sutures (Ethicon, Johnson and Johnson Medical Inc, Arlington, Tex) (Figure 2c). The central portion of the ADM graft was left intentionally exposed (Figure 2d).

The patient was given amoxicillin 500 mg 3/d for 5 days, mefenamic acid 500 mg initially then mefenamic acid 250 mg 4/d for 5 days, and chlorhexidine digluconate 0.12% 3/d for 4 weeks. He was asked to refraining from chewing on or brushing the surgical area for the first 4 weeks postoperatively. The patient showed up 2 months after the operation because of his military operations and reported exfoliation of the allograft around 3 weeks after surgery was performed. Granulation tissue had healed between the implant and the surgical site, and it was in part intermingled with deproteinized bovine bone. The abutment was connected and the provisional prosthesis was fabricated at the chairside.

Soft tissue maturation was achieved 3 months after delivery of the provisional restoration (Figure 3a). The width of keratinized tissue on the labial side is 6 mm, and the width of ridge is well preserved (Figure 3b). A permanent cemented restoration was delivered 5 months after surgery. The prosthesis was functioning well up to the time of final evaluation with no probing depth and no alveolar bone resorption (Figure 4a and b).

Discussion

This report describes successful treatment with immediate implantation and bone augmentation using ADM. Combining therapies for hard and soft tissue grafting with implant placement resulted in decreased numbers of appointments and reduced treatment time.1 Immediate implant placement and provisionalization may serve as good treatment options for the loss of anterior teeth11; this approach is recommended when there is no need for a bone augmentation procedure.12 In this case, bone deficiencies with a vertical and a horizontal component were evident after tooth extraction was performed. The submerged dental implant approach was used because successful bone augmentation requires primary stability.3 

ADM was used as the barrier for bone augmentation to treat the implant dehiscence defect. The addition of ADM compared with bone graft alone enhanced the gain in thickness of bone.13 According to several authors, some surgical sites encountered 2–4 mm of membrane exposure after 2 weeks of healing time, but all sites were completely covered at 3 months. ADM was applied to extraction sockets exposed to the oral cavity, and it was reported that ADM-covered sites resulted in the presence of more vital bone than was seen at expanded polytetrafluoroethylene membrane–covered sites.14 

Even though the exposed portion of the ADM material may have exfoliated, esthetic results were achieved. This may have been possible because of the maturation time of soft tissue. The central portion of the ADM was left exposed following suture; this may have contributed to the increased width of keratinized tissue.10 

This case report describes an esthetic and functional implant-supported restoration in the maxillary anterior when the ADM was used as a membrane for immediate implantation via a bone augmentation procedure performed in an esthetically challenging situation. The author suggests that this surgical technique provides the clinician with an option for an immediate implant therapy when primary closure is not intended. Additional randomized controlled trials conducted over long periods are necessary to establish whether this procedure offers long-term benefit to patients.

Abbreviations

     
  • ADM

    acellular dermal matrix

References

References
1.
Fagan
MC
,
Owens
H
,
Smaha
J
,
Kao
RT
.
Simultaneous hard and soft tissue augmentation for implants in the esthetic zone: report of 37 consecutive cases
.
J Periodontol
.
2008
;
79
:
1782
1788
.
2.
Augthun
M
,
Yildirim
M
,
Spiekermann
H
,
Biesterfeld
S
.
Healing of bone defects in combination with immediate implants using the membrane technique
.
Int J Oral Maxillofac Implants
.
1995
;
10
:
421
428
.
3.
Yildirim
M
,
Hanisch
O
,
Spiekermann
H
.
Simultaneous hard and soft tissue augmentation for implant-supported single-tooth restorations
.
Pract Periodontics Aesthet Dent
.
1997
;
9
:
1023
1031; quiz 1032
.
4.
Schropp
L
,
Kostopoulos
L
,
Wenzel
A
.
Bone healing following immediate versus delayed placement of titanium implants into extraction sockets: a prospective clinical study
.
Int J Oral Maxillofac Implants
.
2003
;
18
:
189
199
.
5.
Quirynen
M
,
Van Assche
N
,
Botticelli
D
,
Berglundh
T
.
How does the timing of implant placement to extraction affect outcome
?
Int J Oral Maxillofac Implants
.
2007
;
22
(
suppl
):
203
223
.
6.
Park
JB
.
Increasing the width of keratinized mucosa around endosseous implant using acellular dermal matrix allograft
.
Implant Dent
.
2006
;
15
:
275
281
.
7.
Batista
EL
Jr,
Batista
FC
.
Managing soft tissue fenestrations in bone grafting surgery with an acellular dermal matrix: a case report
.
Int J Oral Maxillofac Implants
.
2001
;
16
:
875
879
.
8.
de Souza
SL
,
Novaes
AB
Jr,
Grisi
DC
,
Taba
M
Jr,
Grisi
MF
,
de Andrade
PF
.
Comparative clinical study of a subepithelial connective tissue graft and acellular dermal matrix graft for the treatment of gingival recessions: six- to 12-month changes
.
J Int Acad Periodontol
.
2008
;
10
:
87
94
.
9.
Griffin
TJ
,
Cheung
WS
,
Hirayama
H
.
Hard and soft tissue augmentation in implant therapy using acellular dermal matrix
.
Int J Periodontics Restorative Dent
.
2004
;
24
:
352
361
.
10.
Novaes
AB
Jr,
Papalexiou
V
,
Luczyszyn
SM
,
Muglia
VA
,
Souza
SL
,
Taba Junior
M
.
Immediate implant in extraction socket with acellular dermal matrix graft and bioactive glass: a case report
.
Implant Dent
.
2002
;
11
:
343
348
.
11.
Ataullah
K
,
Chee
LF
,
Peng
LL
,
Tho
CY
,
Wei
WC
,
Baig
MR
.
Implant placement in extraction sockets: a short review of the literature and presentation of a series of three cases
.
J Oral Implantol
.
2008
;
34
:
97
106
.
12.
De Rouck
T
,
Collys
K
,
Cosyn
J
.
Immediate single-tooth implants in the anterior maxilla: a 1-year case cohort study on hard and soft tissue response
.
J Clin Periodontol
.
2011
;
38
:
746
753
.
13.
Park
SH
,
Lee
KW
,
Oh
TJ
,
Misch
CE
,
Shotwell
J
,
Wang
HL
.
Effect of absorbable membranes on sandwich bone augmentation
.
Clin Oral Implants Res
.
2008
;
19
:
32
41
.
14.
Froum
S
,
Cho
SC
,
Elian
N
,
Rosenberg
E
,
Rohrer
M
,
Tarnow
D
.
Extraction sockets and implantation of hydroxyapatites with membrane barriers: a histologic study
.
Implant Dent
.
2004
;
13
:
153
164
.