By primary closure with rotative palatal flap, immediate implant placement without good primary stability in a socket with labial cortical plate defects can achieve stable results

The benefits of immediate implant placement (IIP) and immediate implant placement and provisionalization (IIPP) have been well discussed and become a trend for implant placement.^1,2 Many efforts were made not just for higher patient satisfaction and better esthetic results, but also for decreased surgical treatment times and periods.³ When performing IIP in sockets with labial cortical plate defects, such as type IIB and U-shaped labial defects, simultaneously guided bone regeneration is usually indicated.⁴ Many clinicians are more comfortable achieving primary closure in these challenging situations, especially without good primary stability. In these conditions, a rotative palatal flap can help when the implant is already inserted.

Here, we presented a case with a patient who suffered from purulent root fracture of tooth 12 several days after biting a bone. He visited our outpatient department on February 4, 2013, because his prosthesis had been completely dislodged and presented with an abscess (Fig. 1A). After evaluation with the periapical radiograph (Fig. 1B), tooth extraction and following treatments were immediately arranged. After the affected tooth was extracted with minimal trauma, a type IIB U-shaped labial defect, 7 mm in width and 8 mm in depth, was noted (Fig. 1C and D). The socket was well debrided and irrigated with saline. The dissection between labial cortical plate and facial gingiva was carefully done without detaching interdental papilla. The implantation site preparation was done following implant company drilling protocol. A dental implant was then inserted into the implant site with an insertion torque just greater than 20 NTcm. A collagen membrane was placed between the labial bone and gingiva and the labial gap was then filled with freeze dried bone allograft (FDBA) (Fig. 1E). Primary closure was then achieved with a rotative palatal flap (Fig. 1F) and periapical radiography was taken to check (Fig. 1G). After eight months, on October 14, 2013, the second stage surgery of the implant was done and the patient refused any additional contouring esthetic surgery, though a labial depression in the gingiva was still noted (arrow, Fig. 1H). Comparing the pre-operative and 5-year follow-up gingiva level, this treatment showed stable implant and gingival condition (Fig. 1l). A cone beam computed tomography taken on October 6, 2020 showed that although there was a depression in labial architecture, there was still bone covering the implant surface after 7 years (Fig. 1J).

Figure 1.

Clinical and radiographic photographs of the patient. (A) Fistula formation (marked with yellow arrows) was noted at the tooth #12 with root fracture lines (marked with a red arrow). (B) A periapical radiograph showed the endodontically-treated tooth 12 with more than 5 mm of intact apical bone. (C) The afflicted tooth was extracted with minimal trauma and a buccal bone defect was noted in the pocket, measuring 7 mm in width using a probe. (D) The socket defect measured 8 mm in depth with the periodontal probe. (E) The immediate implant placement was performed and a membrane was inserted on the labial side of the labial cortical defect (shown as a yellow dotted line). The labial cortical defect and the labial gap were then filled with FDBA bone powder. (F) The site was then primarily closed with a rotative palatal flap. (G) The periapical radiograph of tooth 12 after immediate implant placement. (H) The clinical photograph showed the healing condition 8 months after immediate implant placement. The labial depression can be noted. (I) The clinical photographs showed that the gingival level of tooth 12 was very stable during the follow-up. (J) The 7-year follow-up CBCT showed that the grafted bone was stable around the implant.

With enough primary stability, IIPP can be done even in U-shaped defects with guided bone regeneration procedure due to the improvement of knowledge.^3,4 On the other hand, when good primary stability cannot be achieved, primary closure of the wound can be a better choice than the modern transmucosal option such as customized healing abutment or a provisional crown. With a rotative palatal flap, primary closure can be done without changing of the mucogingival level or leaving a labial scar. Additionally, the thickness of the palatal gingiva also aids in thickening the biotype. Without the rotative palatal flap as an option in many difficult cases, IIP may not be feasible and socket preservation protocol may be conducted instead.⁵

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.