Update in clinical procedures

The speaker clearly stated that he recommends treating fresh extraction compromised sockets with a single flapless procedure. The aim with this approach is to preserve and, at the same time, regenerate the natural biology of surrounding tissues. In the speaker’s experience, this approach is less invasive, and is shorter and less expensive than the conventional delayed approach. Above all, it can provide more predictable results.

The immediate dentoalveolar restoration (IDR) solution can be used in cases involving compromised alveolar sockets. It is a minimally invasive technique of grafting with bone, which eventually also uses soft tissue in it at the same time (not later), taken from the tuberosity at the time of implant placement. A portion of cortico-cancellous bone is removed from the tuberosity and placed as a membrane covering some particulate autogenous bone to restore the buccal bony wall and the lost volume (fig 1–2).

It has been well documented that the procedure can achieve long-term maintenance of the new buccal bone volume (Rosa et al., 2014; Rosa et al., 2016). The height of restored papillae have also been shown to remain stable, preventing subsequent marginal recessions.

As part of the procedure, it is recommended that the implant is placed palatally (after having been planned by a CBCT). The speaker said there should be 3mm between the implant shoulder and the gingiva on the buccal side. If there is 3mm of bone at the buccal aspect, a soft tissue graft to compensate won’t be needed.

When harvesting the bone graft from the tuberosity, the chisel should be angled perpendicular to the bone wall (or as much as is possible). As soon as the chisel goes deeper, the angulation should be adjusted progressively. The graft can then be reshaped according to the defect configuration and placed 1mm coronally to the implant position. The gap between the implant and the cortico-cancellous shield is filled with particulated bone also obtained from the tuberosity. An immediate temporary crown is finally screwed onto the implant without occlusion. A 2mm gap should be left to allow the soft tissue to grow inwards (fig 3–4).

If a patient presents with severe gingival recession, the speaker described a variation of the IDR protocol which should be used: the triple graft technique (da Rosa 2014). The ‘triple’ graft is a combination of connective tissue, cortical bone and particulate cancellous bone. It is harvested from the tuberosity using a scalpel and chisels. The graft is placed with the connective tissue layer facing the gingiva, and the cortical and cancellous bone facing the implant. A single suture in the middle is used to fix the graft in place, and two more sutures are used on each side in the papillae. A temporary crown is screwed with its margin levelled to the neighbouring teeth, without soft tissue recession, and leaving a gap for the tissue to grow in (fig 5–6). The speaker presented a case where this procedure was successfully used, with a 10-year follow-up. This technique can be applied even in cases where several bone walls have been lost, using autogenous block and particulate bone compacted through site preparation (da Rosa et al., 2019).

The final case presented by the speaker involved two central incisors which could not be maintained, with complete loss of the interdental papillae and partial loss of the lateral papillae. In this case an orthodontic approach was selected prior to surgery and extrusion was performed in order to gain bone and soft tissue vertically. After that, the incisors were extracted and the IDR technique was used.