Mucosa present in implant ready for uncovering: Case for Alloderm?

Try making an elliptical incision to the lingual and move the keratinized tissue facially to obtain facial keratinized tissue

What’s the tooth # and upload radiographs please. Screw retained would be way to go. This allows you a few attempts to correct the facial concavity. Just don’t know which tooth this is from the pic.

This appears to be a mandibular site but this technique can be applied to either arch. This is similar to the technique utilized for vestibuloplasty with Dermal Allograft. Mid-Crestal incision to bone extending sulcular each direction until joins with adequate zone of attached keratinized gingiva. Then turn that incision vertically to the width of the existing adjacent zones of attached gingiva. Dissect out PARTIAL-thickness buccal and lingual flaps (leaving the periosteum underneath intact) to the extent of the previous vertical incisions. So now you have exposed periosteum over the implant and adjoining keratinized gingiva distal and mesial and mucosa buccally and lingually. Now reflect the periosteum over the implant just enough to assemble the abutment and crown, whether screw retained or cemented to verify fit and occlusion. Remove crown and set aside, leaving abutment. IDENTIFY THE BASMENT MEMBRANE vs THE CONNECTIVE TISSUE SIDE OF THE DERMAL ALLOGRAFT AT THIS POINT!!! The basement membrane side (white vs red after soaked in blood) will be laid exposed to the oral environment. Keep track of BM side while trimming the Dermal Allograft (best thickness 1.8mm) to dimensions of exposed periosteum , hole punch the Alloderm at position of abutment/crown emergence AND ADJACENT TEETH WHERE FLAPS EXTENDED. Cut with scissors between hole punches for adjacent teeth allowing for some bunching of Alloderm interproximal to implant for papilla development. Lay in the Alloderm BM side up over implant abutment and buccal and lingual to adjacent teeth involved in graft. Suture interproximal to all involved teeth. Continuous Sling or border interrupted suture Alloderm through periosteum beyond exposed periosteum. You can either just tack cement the crown or screw it in or wait several days to fully cement it.

The approach Dr. Dex mentioned is a great way to remedy this issue. Just make sure to tack the Alloderm down securely to the periosteum using multiple 5.0 chromic gut sutures insuring that angiogenesis takes place. Knowing that the basement membrane is facing up, the dimple side is facing down. An alternative approach is to lay a full thickness flap as you would when placing a healing abutment. Cut the appropriate piece of Alloderm to fit over the implant area between the adjacent teeth (resorbable membranes can be butted against the root surface vs non resorbable needing a 2mm gap from the root surfaces) and down into the buccal vestibule. Punch a hole appropriate for the width of the implant platform and drape the Alloderm over the crest and place the healing abutment. Secure the area with primary closure, or as best as can be done and allow healing for 8 weeks. At the time of taking the final impression, do a split thickness flap in the zone of attached gingiva and reposition the tissue apically (from lingual to buccal) into the vestibule and secure with chromic gut. The tissue will granulate in and now you have a new broad band zone of keratinized gingiva.

animal, vegetable or mineral? Take an x-ray! Maybe a loose cover screw?

Sorry that was my first time posting a case. Sorry for the lack of information. Contacted the dentist who placed implant. #19 had VRF and was extracted, grafted and then delayed implant placement. One photo shows the implant being placed and the mucosal defect can already be seen so it would have been best to handle this then. It was a Conelog 5.0 x 7 and it appears that there was room for a longer implant. Last image was at uncovering and I followed some of the advice posted here. The image is of alloderm RTM 1 x 2 with hole punched in it and seated around healing abutment after flap reflection and undermining tissue in order to place Alloderm. I still have not sutured Alloderm to the flap. I will post follow up photos in future. Any thoughts on improvement would be appreciated. I did like working with the material and can see using it in many implant when necessary. I have no interest in using if for recession defects. I will leave that to the periodontist.