logo 19 • CAMLOG Partner Magazine • December 2018 14 Fig. 16: The peri-implant soft tissue, which was thickened with the rolled flap technique during exposure, had healed stably by the time the impression was to be taken. Fig. 17: During impression taking (open tray technique), the attached soft tissue with a clearly developed incisal papilla was visible. Fig. 18: A removable gingival mask is essential for the design of the subgingival abutment portion. Covering the defect site A saliva-proof primary wound closure is essential for the success of bone reconstruction. The bacteria-tight wound closure prevents inflammatory-resorptive remodeling processes. In the present case, the extraction wounds were covered with free combined connective tissuemucosa grafts taken from the palate in regions 13 to 15, 23 to 25 and 16 to 18. The grafts were de-epithelialized by approximately half. The combined grafts were placed on the alveolar openings with the epithelial supporting section and under the vestibular mucosa with the connective tissue section. Then the grafts were sutured saliva-proof (Figs. 11 and 12). The bilaminar provision of connective tissue increases nutrition to the grafts and thus ensures complicationfree closed healing [7]. In addition to better integration, soft tissue thickening and stabilization occurs both vertically and horizontally in the esthetic zone. This preventive procedure is indispensable for achieving a natural emergence profile. In addition, it minimizes the shrinkage of the localized fixed gingiva [8]. The preoperatively fabricated temporary restoration was used in the form of an interim prosthesis with a palatal plate. The bases of the three replaced front teeth had been shortened to avoid unfavorable pressure during the swelling phase. The prosthesis also served as a dressing plate to protect the graft harvesting sites (Fig. 13). A stable soft tissue situation was observed following suture removal after two weeks and after healing without complications (Figs 14 and 15). The implants were exposed four months after insertion. The incision was placed slightly palatal around the implants. Next to exposure, this cutting technique allowed the formation of two rolled flaps for additional soft tissue thickening. The flaps were deephitalized, buccally wrapped in tunnels and fixed with sutures. An impression taken six weeks later revealed a stable, fixed peri-implant soft tissue with a clearly developed incisal papilla. The transfer posts for the open tray technique were used to take an impression of the two implants and the entire upper jaw (Figs. 16 and 17). In the laboratory, the dental technician fabricated the master cast with removable gingival mask and mounted it in the articulator in which the temporary restoration had previously been fabricated with facebow transfer. Using a matrix from the esthetic set-up, he drew the crown emergence profile on the removable gingival mask and contoured the subgingival area to the implants and the pontic according to the anatomical profile (“ovate pontic design”). The design of the subgingival portion of the abutments and pontics is essential for a natural crown emergence profile. Zirconium dioxide (ZrO 2 ) has proven itself for superstructures in the anterior region, not only because of the stability and flexural strength of the material, but also because of the significantly reduced microbial colonization of ZrO 2 . In a systematic review [9], Nakamura et al. (2010) conclude that zirconium dioxide abutments can be used for single-tooth restorations in the anterior region with a high degree of reliability. The transition to the mucous membrane is free of irritation, which ensures long-term stable clinical results. Due to the root-like color, CASE STUDY Fig. 10: Augmentation of the defect site and filling of the jumping distance was performed with the bovine bone substitute material MinerOss X. Fig. 11: The free combined connective tissue-mucosa grafts were placed on the alveolar openings with the epithelial supporting part. Fig. 12: The connective tissue part of the combination graft was placed under the vestibular mucosa and the grafts were then sutured saliva-proof.
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