Guided Implant Placement in the Anterior Maxilla After GBR Retreatment

Dr. Alessandro Fasano (Italy)

Case Summary 🔎

This case involved an esthetically demanding maxillary anterior region. Tooth #11 had a history of endodontic failure and a root fracture, accompanied by significant bone loss. Initial extraction and guided bone regeneration (GBR) were performed, but the first GBR did not achieve sufficient bone regeneration.

A second GBR procedure was performed using a completely occlusive titanium membrane, resulting in successful bone regeneration. Considering the proximity to adjacent natural teeth, a Neo NaviGuide was fabricated to ensure precise osteotomy and ideal implant positioning. The CMI IS-II implant was placed in a prosthetically driven position, with special attention given to the orientation of the screw access channel to optimize esthetics.

A digital impression was taken for the final restoration, and a zirconia crown was fabricated and delivered. Given the esthetic importance of the anterior maxilla, careful management of both hard and soft tissues was essential. Techniques such as the roll flap were used to enhance soft tissue volume and achieve a natural emergence profile.

This case demonstrates that even after an unsuccessful GBR attempt, successful ridge reconstruction is achievable with appropriate re-intervention. Additionally, digital guides can support accurate implant placement, contributing to optimal esthetic and functional outcomes.

Case Presentation

1️⃣Pre-op

• Tooth #11 had previously undergone endodontic treatment but presented with signs of endodontic failure, including root fracture, inflammation, and pain. Extraction was planned, followed by implant placement and esthetic prosthetic rehabilitation.

2️⃣ Surgical Phase - Guided Implant Placement

Tooth Extraction and Initial GBR

• A localized deep periodontal pocket was noted, suggestive of a possible root fracture.

• #11 was extracted atraumatically. A vertical root fracture was clearly visible during extraction, along with inflammation of the surrounding tissue.

• The post-extraction site exhibited labial bone fracture due to a vertical root fracture. Immediate guided bone regeneration was performed.

• Given the esthetic demands of the maxillary anterior region, a connective tissue graft was performed.

• Periapical radiograph taken immediately after guided bone regeneration shows successful graft placement.

Secondary GBR with Titanium Membrane

• 6 months post-op, an incision was performed to assess the graft site.

• The grafted site exhibited insufficient bone regeneration due to total resorption of the graft material.

• Autogenous bone was harvested from the mandibular posterior region and mixed with synthetic bone for grafting at the surgical site.

• A completely occlusive titanium membrane was placed over the alveolar ridge.

• Primary closure was achieved without flap tension.

Guided Implant Placement

• At 6 months, the titanium membrane was removed, and the site showed well-formed bone with successful regeneration.

• The Neo NaviGuide was properly seated and used to perform the guided surgery.

• The implant was placed in an ideal position. For maxillary anterior cases, positioning the screw access toward the palatal side is essential to ensure favorable esthetic outcomes.

• Bone grafting was performed and covered with a resorbable collagen membrane, and the site was sutured to secure the graft.

Soft Tissue Management

• At 3 months postoperatively, the surgical site shows well-healed soft tissue with healthy gingival contours.

• Second-stage surgery was performed, followed by a roll flap technique to augment soft tissue volume around the implant.

4️⃣ Prosthetic Phase

• Two weeks postoperatively, sutures were removed and a digital impression was taken using a scan body.

• A provisional restoration was fabricated and delivered.

• The final restoration was delivered with esthetic integration and a stable gingival contour.