case_images: PMC4812909_01
case_images: Front side view of patient upon presentation.
case_images: CRID2016-1236310.001.jpg
case_images: PMC4812909_01_CRID2016-1236310.001.jpg
case_images: fig1
case_images: A 43-year-old woman was referred to us presenting a hopeless upper left central incisor, affected by a large endoperiodontal lesion involving the buccal wall of the alveolar crest and the mesial aspect of the neighboring lateral incisor (Figures 1 and 2).
case_images: Intraoral periapical radiograph showing bone loss around the right central incisor and involving the mesial alveolar wall of the right lateral incisor.
case_images: CRID2016-1236310.002.jpg
case_images: PMC4812909_01_CRID2016-1236310.002.jpg
case_images: fig2
case_images: A 43-year-old woman was referred to us presenting a hopeless upper left central incisor, affected by a large endoperiodontal lesion involving the buccal wall of the alveolar crest and the mesial aspect of the neighboring lateral incisor (Figures 1 and 2).
case_images: Plaque and calculus can be observed on the root surface at the time of extraction, performed with minimal trauma.
case_images: CRID2016-1236310.003.jpg
case_images: PMC4812909_01_CRID2016-1236310.003.jpg
case_images: fig3
case_images: The extraction was performed with minimal trauma and the extraction socket was filled with absorbable hemostatic gelatin sponge (Spongostan  Dental, Ethicon, Edinburgh, UK) (Figures 3 and 4).
case_images: Occlusal view of the fresh alveolar socket after extraction and application of Spongostan .
case_images: CRID2016-1236310.004.jpg
case_images: PMC4812909_01_CRID2016-1236310.004.jpg
case_images: fig4
case_images: The extraction was performed with minimal trauma and the extraction socket was filled with absorbable hemostatic gelatin sponge (Spongostan  Dental, Ethicon, Edinburgh, UK) (Figures 3 and 4).
case_images: The crown of the extracted tooth was splinted to the adjacent elements and used as provisional pontic.
case_images: CRID2016-1236310.005.jpg
case_images: PMC4812909_01_CRID2016-1236310.005.jpg
case_images: fig5
case_images: The root of the extracted tooth was cut out and the remaining crown was used as provisional pontic element until the implant would have been placed (Figures 5 and 6).
case_images: Postoperative X-ray after tooth extraction.
case_images: CRID2016-1236310.006.jpg
case_images: PMC4812909_01_CRID2016-1236310.006.jpg
case_images: fig6
case_images: The root of the extracted tooth was cut out and the remaining crown was used as provisional pontic element until the implant would have been placed (Figures 5 and 6).
case_images: Frontal (a) and occlusal (b) views after six weeks of healing.
case_images: CRID2016-1236310.007.jpg
case_images: PMC4812909_01_CRID2016-1236310.007.jpg
case_images: fig7
case_images: After six weeks of healing soft tissues were well conditioned by the provisional pontic (Figures 7(a) and 7(b)) but a large bone defect was radiographically noticed (Figure 8).
case_images: The radiograph taken before implant insertion shows a complete loss of the buccal and palatal bone.
case_images: CRID2016-1236310.008.jpg
case_images: PMC4812909_01_CRID2016-1236310.008.jpg
case_images: fig8
case_images: After six weeks of healing soft tissues were well conditioned by the provisional pontic (Figures 7(a) and 7(b)) but a large bone defect was radiographically noticed (Figure 8).
case_images: Occlusal view of the surgical incision at implant insertion time. A full thickness flap at the single gap continued with a partial thickness flap to harvest a connective tissue graft.
case_images: CRID2016-1236310.009.jpg
case_images: PMC4812909_01_CRID2016-1236310.009.jpg
case_images: fig9
case_images: A full thickness flap was raised at the edentulous ridge and was continued on the palatal side with a partial thickness flap till the last molar (Figure 9), from where a free connective tissue graft was harvested (Figure 10).
case_images: Aspect of the harvested connective tissue graft.
case_images: CRID2016-1236310.010.jpg
case_images: PMC4812909_01_CRID2016-1236310.010.jpg
case_images: fig10
case_images: A full thickness flap was raised at the edentulous ridge and was continued on the palatal side with a partial thickness flap till the last molar (Figure 9), from where a free connective tissue graft was harvested (Figure 10).
case_images: Surgical placement of the Bicon implant. The implant lies 1 mm below the margin of the buccal bone dehiscence.
case_images: CRID2016-1236310.011.jpg
case_images: PMC4812909_01_CRID2016-1236310.011.jpg
case_images: fig11
case_images: After that a 5.0 x 8.0 mm, plateau design, locking-taper implant (Bicon LLC, Boston, MA) was placed under the buccal margin of the bone dehiscence (Figure 11).
case_images: A stealth abutment was tested (a) and then modified on its top (b) to primarily close the wound maintaining a proper bone and mucosal tunnel.
case_images: CRID2016-1236310.012.jpg
case_images: PMC4812909_01_CRID2016-1236310.012.jpg
case_images: fig12
case_images: To maintain a proper bone and mucosal tunnel, a stealth abutment was modified on its top and then connected to the implant (Figures 12(a) and 12(b)), and in the meantime the connective graft was fixed to the buccal flap.
case_images: After fixation of the connective tissue graft to the buccal flap (a), Emdogain  was applied on the lateral incisor root surface to regenerate the lost periodontal attachment (b).
case_images: CRID2016-1236310.013.jpg
case_images: PMC4812909_01_CRID2016-1236310.013.jpg
case_images: fig13
case_images: Following implant placement, the connective tissue graft was fixed to the buccal flap, and the compromised root surface of the lateral incisor was treated with a regenerative approach, using enamel matrix derivatives (Emdogain , Straumann, Basel, Switzerland) (Figures 13(a) and 13(b)).
case_images: Bio-Oss  was applied to cover the defect around the implant.
case_images: CRID2016-1236310.014.jpg
case_images: PMC4812909_01_CRID2016-1236310.014.jpg
case_images: fig14
case_images: A bovine xenograft material (Bio-Oss Collagen , Geistlich Pharma, AG, Wolhusen, Switzerland) was grafted around facial and buccal aspects till the top of the implants abutment (Figure 14).
case_images: Frontal (a) and occlusal (b) view at the end of the surgical intervention.
case_images: CRID2016-1236310.015.jpg
case_images: PMC4812909_01_CRID2016-1236310.015.jpg
case_images: fig15
case_images: The connective tissue graft was used as a membrane, over which the buccal flap was advanced and sutured to obtain a primary wound closure without tension (Figures 15(a) and 15(b)).