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Case Study
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Correction of Buccal Fenetration Defects

Aesthetic Buccal Flap Design

Learning Objectives:

This case study presents a method to correct apical dehiscences using an ABF. Upon completion of this case study, the reader should:

  • Be aware of a clinical protocol that applies an ABF to correct the buccal apical fenestration.
  • Recognize the criteria for performing an ABF procedure.

 

In contrast to the focus on successful osseointegration that characterized the early years of implant dentistry, contemporary practitioners are primarily concerned with achieving the most natural-looking smile possible through implant placement procedures that preserve the anatomy of the soft tissue. When a single tooth is compromised and the gingiva and surrounding osseous structures remain healthy, flapless surgery with immediate implant placement provides an excellent means by which to maintain the natural soft tissue contours. However, when the development of an apical fenestration compromises the soft tissue and surrounding osseous structures, the creation of a full mucoperiosteal flap is required, and the subsequent healing of the soft tissue can have negative impacts on the aesthetic outcome.  

When the soft tissue presents no sign of recession, and only limited interproximal resorption of the bone has occurred, an aesthetic buccal flap (ABF) may be utilized to correct buccal apical fenestration while maintaining the overall aesthetic appearance. This technique employs guided bone regeneration (GBR) to preserve the natural supraosseous soft tissue profile.   

The ABF technique presented here is appropriate for single-tooth applications or when no more than two adjoining teeth require augmentation, as the creation of larger flaps poses too large a risk of necrosis. Furthermore, this technique is appropriate only for correcting apical buccal defects and is only applicable when the supporting interproximal crest has not undergone significant osseous resorption.

The ABF design is particularly beneficial in aesthetically sensitive areas (eg, the maxillary anterior region). In order to maintain a natural-looking result, the soft-tissue housing must be preserved. This technique allows a clinician to ensure soft tissue aesthetics, even when localized bone deficiencies have developed prior to or during implant-placement surgery.

 

*Adjunct Assistant Professor of Oral and Maxillofacial Surgery, Boston University, Boston, Massachusetts; private practice, Heidelberg, Germany.

  

Related Reading:

  1. Belser UC. Esthetic aspects in implant dentistry. In: Lang NP, Karring T, Lindhe J, eds. Proceedings of the 3rd European Workshop on Periodontology. Carol Stream, IL: Quintessence Publishing; 1999:304-332.
  2. Atwood DA. Post-extraction changes in the adult mandible as illustrated by microradiographs of mid-sagittal sections and serial cephalometric roentgenographs. J Prosthet Dent 1963;13:810-816. 
  3. Atwood DA. Some clinical factors related to rate of resorption of residual ridges. J Prosthet Dent 2001;86(2):119-125.
  4. Salama H, Salama MA, Garber D, Adar P. The interproximal height of bone: A guidepost to predictable aesthetic strategies and soft tissue contours in anterior tooth replacement. Pract Periodont Aesthet Dent 1998;10(9):1131-1141.
  5. Wang HL, Shotwell JL, Itose T, Neiva RF. Multidisciplinary treatment approach for enhancement of implant esthetics. Impl Dent 2005;14(1):21-29.
  6. Bichacho N, Landsberg CJ. Single implant restorations: Prosthetically induced soft tissue topography. Pract Periodont Aesthet Dent 1997;9(7):745-752.
  7. Steigmann M, Daum O. Diagnosis in implant esthetics [in German]. Implantol J 2004;75(3):50-52.
  8. Steigmann M. Aspects of implant esthetics [in German]. Cosmet Dent 2004;2:30-32.
  9. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. J Periodontol 1992;63(12):995-996.
  10. Garber DA, Salama MA, Salama H. Immediate total tooth replacement. Compend Contin Educ Dent 2001;22(3):210-216.
  11. Hahn J. Single-stage, immediate loading, and flapless surgery. J Oral Implantol 2000;26(3):193-198.
  12. Campelo LD, Camara JR. Flapless implant surgery: A 10-year clinical retrospective analysis. Int J Oral Maxillofac Impl 2002;17(2):271-276.
  13. Rocci A, Martignoni M, Gottlow J. Immediate loading in the maxilla using flapless surgery, implants placed in predetermined positions, and prefabricated provisional restorations: A retrospective 3-year clinical study. Clin Impl Dent Relat Res 2003;5(suppl 1):29-36.
  14. Schwartz-Arad D, Chaushu G. The ways and wherefores of immediate placement of implants into fresh extraction sites: A literature review. J Periodontol 1997;68(10):915-923.
  15. Wöhrle PS. Single-tooth replacement in the aesthetic zone with immediate provisionalization: Fourteen consecutive case reports. Pract Periodont Aesthet Dent 1998;10(9):1107-1114.
  16. Wang HL, Misch C, Neiva RF. “Sandwich” bone augmentation technique: Rationale and report of pilot cases. Int J Periodont Rest Dent 2004;24(3):232-245. 
  17. Steigmann M. Pericardium membrane and xenograft particulate grafting materials for horizontal alveolar ridge defects. Impl Dent 2006;15(2):186-191.
 
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