Rolf Ewers, MD, DMD, Ph.D.
Professor and Chairman Emeritus, University Hospital for Cranio Maxillofacial and Oral Surgery, Medical University of Vienna Director, CMF-Institute of Vienna for Cranio Maxillofacial and Oral Rehabilitation and Telemedicine
Dear colleagues, Dor. Tolstinov asked me to speak today about post extraction placing an immediate implant with primary wound closure after preparing a supraperiosteal split thickness flap. This section of a panoramic radiograph demonstrates a forty seven year old male patient who had the maxillary right second molar removed. Following removal of the tooth, a trapeze like vestibular mucoperiosteal split thickness flap was raised from the mesial of the third molar to the distal of the first molar. The periosteum is then incised vertically on the mesial side. To prevent perforating through the mucosa it is advisable to hold the blade at a forty five degree angle. Only the periosteum is incised, therefore the underlying tissue will not be harmed. Using a round scissors, which is curved, a tunnel is created between the periosteum and the mucosal layer. The next cut is made vertically at an angle of forty five degree along the distal aspect of the periosteum, allowing the tip of your scissors to penetrate the second vertical periosteal cut and completing the tunnel as seen in the following slide. Here you see how the tip of the scissors penetrate the posterior vertical cut and start to form the tunnel with the scissors. The final step is a high horizontal periosteal cut until the periosteal tissue is loose and the tissue can be separated completely from the underlying mucosa tissue with a blunt Freer instrument. The arrow indicates the loose periosteum. This loose periosteal flap may now be stretched over the extraction defect. It is important to ensure that the length of the flap will allow for tension free primary closure of the extraction defect. After careful curettage of the three root sockets, implant site drilling begins with a pilot drill in the palatal socket. The osteotomy is enlarged to the desired width with latch reamer or hand reamer. All drilling is done at fifty rpm or less without irrigation, allowing to collect autogenous bone chips for later coverage of the implants. Some augmentation material may, at the surgeon’s discretion, be placed into the bottom of the socket. A five to six millimeter extra short Bicon implant was inserted into the palatal root socket. The image shows the seated implant without a healing plug, which will be inserted at the next step. Note that the insertion depth always should be at least two to three millimeter sub crestal. Before closing, the previously collected autogenous bone chips are used to cover the implant and the remaining socket defects. The final step will be wound closure with the periosteal flap. First, we undermine the periosteum on the palatal side and secure the periosteum flap under the palatal periosteum with at least two double mattress sutures. As seen on this image here and here, Successful preparation of the envelope, allowing it to be both loose and flexible, will enable us to easily pull the mucosa layer to the palatal mucosa and perform a primary double layer closure. In this operation, it was possible to perform a real double layer closure as the stretched undamaged mucosa covers the defect over the palatal flap. The post operative section of the panoramic radiograph shows an excellent position of the implant. The post operative implant and wound healing were uneventful. Six months later we found a very nicely healed soft tissue between the molars without any scar tissue. Now we started to open the soft tissue and found a completely covered extraction site and implant with newly formed bone due to the collected autogenous bone placed at the initial surgery. With a round bur, bone was carefully removed. This image shows the implant after the excess bone had been removed. Note the three millimeter subcrestal position of the implant. After removing the healing plug, inserting the impression post, suturing the surrounding mucosa and inserting the impression sleeve, an implant level impression for an integrated abutment crown was taken. The clinical view after inserting the IAC crown is seen in this image. This is a dental film at initial loading of the integrated abutment crown and implant in the maxillary right second molar region. And this is a section of a panoramic radiograph at initial loading. This is the clinical result at six point five years recall and it shows good peri implant mucosa. The dental film shows very active mineralization around the implant and a good implant bone level. Note that due to the three millimeters sub crestal positioning of the extra short implant, there is some crestal bone growth. The section of the panoramic radiograph also shows these findings at the six point five year recall. Thank you for sharing this patient case with me and goodbye.