Clinical case

Facing dehiscence defects

in the anterior area
Dr. Shakeel Shahdad, UK
Consultant and Honorary Clinical Senior Lecturer in Restorative Dentistry at
The Royal London Dental Hospital and, Queen Mary University of London
Private Practice, London, UK

Soft tissue defects are Recently a two-layer, porcine-derived
often encountered prior to collagen matrix (Geistlich Mucograft®)
has been investigated for the treatment
implantation, resulting in of dehiscence defects around teeth
insufficient attached ke- and for augmenting keratinized tissue
ratinized mucosa, which, around teeth and implants supporting
if not corrected, results in fixed prosthetic restorations.1-4 The ma-
trix is composed of type I and type III col-
less than ideal aesthetic lagen and is thicker than conventional
outcomes. collagen membranes. Intraoral soft tissue
around the periphery of the graft grows
through, rather than under, the matrix, as
it is replacing it.
A 62-year old healthy, non-smoker male
presented with a 7 mm “v” shaped gin-
gival recession defect extending to the
apex of the upper left central incisor (Fig.
A, B). There was no underlying medi-
cal history of any significance. The tooth

FIG. 1: CASE STUDY OF A MILLER CLASS III RECESSION DEFECT

A B C

D E F G
Photos: Shakeel Shahdad

|  A  Pre-operative photographs demonstrating Miller Class III recession defect in 21.  |  B  Radiograph showing previous apicoectomy surgery, and a leaking post-crown.
|  C  Extraction socket with missing labial bone plate, and inter-dental bone loss at 22.  |  D  Haemostatic plug placed in extraction socket to prevent collapse of Geistlich
Mucograft®.   |  E  Geistlich Mucograft® adapted under the flap and extended into palatal pouch.  |  F  Graft sutured using single interrupted sutures without any attempt
to achieve primary closure or submerge Geistlich Mucograft® underneath the flap.  |  G  Healing after 1 week.

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 H I J

K L M

O Q R S

Photos: Shakeel Shahdad

|  H  Healing after 6 weeks.  |  I  Surgical exposure of the site showing complete loss of buccal bone including loss of interdental bone in 22.  |  J  Ideal 3-dimensional
placement of dental implant.   |  K  Geistlich Bio-Oss® mixed in blood placed on top of autologous bone chips to augment the missing buccal bone.  |  L  Geistlich Bio-Gide®
in place.   |  M  Healing after 1 week post implantation.   |  N  Healing after 8 weeks immediately prior to abutment connection surgery.  |  O  Pink aesthetics optimized with
a provisional crown.  |  P  Definitive restoration after 2 years.   |  Q  Definitive restoration after 5 years in function. Peri-implant soft tissues are stable despite recession in
natural teeth.  |  R  Peri-apical radiograph after 4 years.   |  S  CBCT scan of the implant demonstrating regeneration and maintenance of labial bone at 4-year review.

26 GEISTLICH NEWS 2-2018

was failing endodontically with a previ-
ous root filling and apicoectomy surgery.
The upper left central incisor was atrau-
matically extracted, followed by remov-
al of granulation tissue from within the
socket. A small pouch was created and ex-
tended a few millimeters beyond the intact
bone margins. Complete loss of the buccal
plate was noted, and in order to prevent
collapse of the graft, a collagen haemostat-
ic plug was placed in the extraction sock-
et (Hemospon Collagen CubesTM, Tech-
New, Brazil). Geistlich Mucograft® was
cut to size so that the edges extended be-
yond the bone margins to ensure coverage
by the overlying flap. It was stabilized to
the overlying flap margins with 6-0 mono-
filament nylon interrupted single sutures
(Figs. C-F). A provisional resin-bonded
bridge was cemented, avoiding contact
with the soft tissues or graft.
there was apical bone to the floor of the
nose to offer adequate primary stability
(Fig. I).
A Straumann® SLActive (Straumann AG,
Switzerland), Tapered Effect, tissue-level
type implant was placed in an ideal 3-di-
mensional position, resulting in a 6 mm
dehiscence of the roughened surface of
the implant. Following corticotomy, au-
tologous bone shavings were collected
from the adjacent area and placed over
the implant, followed by blood soaked
deproteinized bovine bone substitute
(Geistlich Bio-Oss®), which was covered
by a bi-layered porcine-derived collagen
barrier membrane (Geistlich Bio-Gide®
– Figs. J-L). The sutures were removed
after one-week (Fig. M), and the im-
plant exposure surgery was carried out
after eight weeks using a 4 mm soft tis-
sue punch (Fig. N).
pink and white aesthetics were noted.
The mucogingival line was correct-
ed, and 5 mm of keratinized mucosal
width was restored (Figs. P, Q). Radio-
graphs demonstrated stable bone lev-
els, and a CBCT scan revealed a maxi-
mum labial bone thickness of 3.6 mm.
In total, 1.6 mm labial bone thickness was
noted at the junction of the SLA surface
and the smooth collar, and the bone ex-
tended vertically beyond this junction,
albeit not in contact with the implant
surface (Figs. R, S).
References
1 Lorenzo R, et al.: Clin Oral Implants Res 2012,
23(3): 316-24.
2 Sanz M, et al.: J Clin Periodontol 2009; 36(10): 868-
76.
3 McGuire MK, Scheyer ET: J Periodontol 2016; 87:
221-227.
4 Cardaropoli D, et al.: L Periodontol 2012; 83(3):
321-8.

“After five years Geistlich Mucograft®

guarantees a stable peri-implant
soft tissue and an optimal pink and
white aesthetic.”

An uneventful healing was noted at one- A laboratory-made implant pro-

week, with Geistlich Mucograft® show-
ing some surface sloughing similar to the
healing anticipated with a free gingival
graft (Fig. G). The sutures were removed,
and the patient was advised to continue
using 0.2% chlorhexidine thrice daily and
refraining from tooth brushing around
the surgical site. After six-weeks of heal-
ing (Fig. H), an early delayed (Type II)
implant placement protocol was used
in conjunction with simultaneous guid-
ed bone regeneration. Complete loss of
the buccal plate was noted. Nonetheless,
visional crown was used for ma-
nipulation of soft tissues to opti-
mize the pink aesthetics (Fig. O).
Endodontic treatment in upper right
central incisor was revised and non-vi-
tal, and in-out bleaching was carried out
with concomitant home bleaching in
the remaining maxillary dentition. After
optimizing pink aesthetics, a screw-re-
tained, one-piece, metal-ceramic crown
was provided.
After two- and five-years, stable
peri-implant soft tissues and optimal

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