Soft tissue-centered vertical ridge augmentation in a complex maxillary case

Clinical situation

A 34-year-old healthy patient presented with multiple failed grafting surgeries. Severe vertical bone loss in the anterior maxilla resulted in facial asymmetry and lack of lip support (A), with the defect extending across three missing teeth (B). The patient expressed significant dissatisfaction with her appearance.

A. Facial asymmetry due to inadequate bone support 
B. Vertical defect with loss of soft tissue volume and keratinized tissue

Treatment planning

A treatment plan involving vertical ridge augmentation followed by implant placement and an implant-supported bridge was developed. The treatment was initiated in 2020 and extended over a period of 17 months. Tooth positions #22 and #24 were identified as implant sites.

Surgical procedure

Following flap elevation, the vertical bone defect was fully exposed (C). A creos™ syntoprotect mesh membrane was first fixated on the buccal side, and a 1:1 mixture of autogenous and xenogenic bone particles was then placed into the defect before the membrane was adapted over the ridge and fixated labially using several titanium pins to maintain graft volume and contour (D).

C. Flap reflection showing severe bone loss 
D. Fixing the creos™ syntoprotect mesh to the recipient site and placing the bone particles

The mesh was fixated using titanium pins (E) and left in place for eight months to allow for uninterrupted healing. Healing was uneventful. Upon removal of the mesh (F), the site showed substantial vertical and horizontal bone regeneration, sufficient to support implant placement.

E. Flap reflection showing severe bone loss 
F. Regenerated ridge 8 months post-augmentation

Two Nobel Biocare N1™ implants were placed in the regenerated bone (G–H). A protective layer of particulate graft (20 percent autograft, 80 percent xenograft) was added in a “mini sausage”¹ configuration to prevent resorption and enhance ridge volume. This graft was secured with a collagen membrane and titanium pins (I). A surgical guide confirmed optimal prosthetic alignment (J).

G-H. Two Nobel Biocare N1 implants placed in the augmented ridge 
I. Mini sausage to protect the newly formed bone from resorption 
J. Surgical guide used to verify implant positions

Soft tissue management

A double-layer “Iceberg”² connective tissue graft was built by suturing small soft tissue grafts from the tuberosity to the ends of a wider connective tissue graft harvested from the palate, and placed to increase peri-implant soft tissue thickness for recreating the papilla later (K).  

In addition, a strip gingival graft harvested from the labial gingiva was combined with a collagen matrix³ to reconstruct the vestibule and reestablish keratinized tissue (L). Regenerated soft tissue contours were healthy, with natural architecture and natural color match (M-N).

K. Double layer iceberg connective tissue graft in position 
L. Strip gingival graft in combination with the collagen matrix 
M-N. Soft tissue before prosthetic delivery

Restorative procedure and outcome

Following soft tissue maturation, the final prosthesis was delivered (O). Radiographs showed stable interproximal bone levels and clear corticalization around the implants (P). Clinically, the facial profile showed significantly improved symmetry and lip support (Q).

O. Restored papillae and healthy peri-implant tissue after prothetic delivery 
P. Stable bone crest following loading 

Q. Smile line and facial profile restored

This case underscores the importance of a tissuepreserving approach in the anterior maxilla, where both functional and esthetic outcomes are paramount. By combining vertical ridge augmentation using creos syntoprotect mesh with a palate-less soft tissue strategy, employing labial strip grafts and collagen matrices, the hard and soft tissues were regenerated. The creos syntoprotect mesh, combining the vascularization benefits of a mesh with the soft-tissue friendliness of a membrane, alongside a fully integrated surgical and prosthetic protocol, enabled successful placement of Nobel Biocare N1™ implants. The result was a stable, esthetically pleasing restoration that not only met clinical expectations but also significantly enhanced the patient’s confidence and facial harmony.