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this is a quite complicated case, as for the degree of bone destruction, the esthetic demand, and the surgical-prosthetic procedures involved in the process. View full processe here…

 
Initial phase: extractions and healing
Old metal-ceramic crown work over devitalized incisors. Periodontal abscess, retracted alveolar front wall, frontal gingival recession, central incisor presenting endo-periodontal injury around root apex.
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Extractions are done and an immediate removable prosthesis is placed during the healing period. Acrylic relines are successively done to keep contact between the resin and the gum, in order to prevent further resorption.
One thing should be taken into consideration: a different approach could be done by filling the sockets with bone graft and covering them with a membrane.  With the existing endo-perio pathology it may be a safer play to let it heal by itself. Second, there is short soft tissue over the central incisor as to cover the resorbable membrane.
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Surgical phase: implant placement, bone augmentation
The two implants are placed along the convenient axis, already expecting exposure of a few threads. The Bio-Guide membrane is cut to fit in the edentulous gap, holes are poked to screw the implants’ healing screws throw it, acting as fixation.
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Enough membrane margin  is left to fit under the palatal flap and several holes are poked on the apical end of the membrane.  First, to drill through the pin retention. Second, to nail the pins through.
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Once the pin holes are drilled with no tension on the membrane (it should be baggy enough as to allow for sufficient graft volume), a little blood is extracted, mixed with Algipore, and placed over the implant’s threads and the bone concavity.
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The resorbable pins are nailed carefully fitting them through the membrane holes and into the previously drilled socket retentions.
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Periosteal cuts are done under the full thickness flap. This permits further elongation of the flap in order to close the wound over the increased volume base.
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Implant osseointegration phase: 6 months
The acrylic removable prosthesis is immediately relined to fit over the suture and checked up periodically for later relines in order to keep contact with the gum.
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Prosthetic phase: Procera veneers and metal-ceramic crowns over angled pillars
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During the try-on, the left central incisor doesn’t fit precisely. Maybe due the tooth migration, maybe due to impression accuracy. So the cuspid’s veneer is cemented and second impressions are taken for the final result, incorporating pink ceramic to disguise the implants’ high emergence.
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