Abstract

Implant dentistry has been established as a predictable treatment modality with high clinical success rates. Esthetic considerations of implant restorations have been gaining increased interest over the years. The role of periodontal plastic surgical procedures in the creation and maintenance of peri-implant soft tissue heights to facilitate better esthetics has become more popular. The available plastic surgery procedures and their clinical applications are reviewed in this article. Emphasis is placed on factors to consider for proper case selection and ideal treatment planning.

Introduction

Implantology has evolved into an accepted, predictable treatment for restoring lost teeth. Consequently, as the practice of implant rehabilitation has developed and matured, both patients and the reconstructive team have reframed their treatment expectations. No longer is implant rehabilitation simply a vehicle to restore lost masticatory and phonetic function; achieving ideal treatment outcomes in the structural and esthetic “regeneration” of edentulous spaces has become an integral part of modern implant dentistry. Many of these esthetic requirements have arisen from significant advancements in esthetic restorative dentistry in recent years. Patients have come to expect esthetically pleasing restorative treatments and now consider a visible crown margin or a poor porcelain/composite color match an unsatisfying treatment outcome. In turn, implantology has had to meet these new challenges, which are, in many instances, difficult if not impossible to attain. Although implant success, as measured through fixture osseointegration and restoration of function, is high, the procedures available to create esthetic implant “success” are not always so predictable. Fortunately, esthetic plastic surgical techniques have existed for many years and are considered routine treatment for the correction of various soft tissue defects, from recession and mucogingival defects to improper gingival contours. Implantology can, in turn, benefit from adaptations and modifications to these time-tested periodontal plastic surgery techniques, but, in contrast to natural teeth, the timing of these procedures becomes more critical.

In this article, procedures and techniques used in the development of implant recipient sites will be presented and discussed. These techniques influence both hard and soft tissues, ideally resulting in healthy peri-implant tissues that are resistant to mechanical forces and masticatory trauma while providing a satisfying esthetic appearance. This becomes especially important in areas of esthetic concern and less so in posterior areas where appearance is of little consequence. Unfortunately, there is little if any scientific support in the literature as to the overall success and longevity of these techniques in well-controlled, long-term studies. Indeed, scant evidence, mainly case reports, exists in the literature to guide our decisions in managing implant soft tissue considerations. Most procedures presented here have been described by leading experts in the field and are generally accepted treatments for soft tissue augmentation and modification around dental implants. In organizing this discussion, the classification of tissue and ridge defects will first be reviewed, followed by the presentation of management techniques organized into these categories of implant soft tissue modification: pre-implant placement, stage 1 and 2 surgery, and postimplant placement.

Classification

In order to achieve optimal esthetic implant rehabilitation, the following prerequisites are considered essential1: adequate bone volume (horizontal, vertical, and, contour), optimal implant position (mesiodistal, apicocoronal, buccolingual, and angulation), stable and healthy peri-implant soft tissues, esthetic soft tissue contours, and ideal emergence profile. The restoration of these conditions necessitates effective communication between all members of the restorative team. The expectations and limitations of restoring lost supporting structures must be understood by both the dentist and patient before treatment begins. These limitations are best understood through proper classification of the existing structural defects.

Classification of tissue volume

The first classification of ridge deficiency was proposed by Seibert in 19832 and later modified by Allen in 1985.3 Seibert divided ridge deficiencies into three classes, with a class I defect describing the apicocoronal loss of ridge contour, class II, buccolingual, and class III, a combined loss of both apicocoronal and buccolingual dimensions. Allen further quantified the loss of ridge dimension into mild (<3 mm), moderate (3–6 mm) and severe (>6 mm). Although Seibert's classification was originally intended for edentulous soft tissue defects receiving a pontic, both are based on the amount of available ridge volume in horizontal and vertical aspects. Recently, a classification was proposed that attempts to recommend specific treatment options based on the classification and the severity of the presenting ridge defect, and both soft- and hard-tissue augmentation procedures are addressed.4 

Classification of bone volume

Two bone volume classifications were proposed simultaneously in the literature and are frequently used in describing edentulous ridge architecture in terms of remaining bone volume. Lekholm and Zarb described the shape of the residual edentulous ridge in terms of remaining bone volume, with a 5-point classification system from A (intact ridge form) to E (severely deficient ridge form). This classification lacks specific categorical ridge dimensions and has less detail within categories addressing vertical or horizontal ridge deficiency.5 Misch and Judy classified available bone into 4 divisions: abundant, barely sufficient, compromised, and deficient (A–D). Adequate bone requires no augmentation and is greater than 5 mm in width, 10 to 13 mm in height, and 7 mm in length. Barely sufficient bone is 2.5 to 5 mm in width, greater than 10 to 13 mm in height, and greater than 12 mm in length and can be modified with osteoplasty or augmentation of hard or soft tissues, depending on the nature of the defect (B-w). Compromised bone necessitates osteoplasty and some form of hard or soft tissue augmentation depending on the extent of the defect in height (less than 10 mm, C-h) or width (less than 2.5 mm, C-w). Deficient bone requires substantial hard tissue augmentation from extraoral sites and is generally not amenable to implant rehabilitation.6,7 Salama and Salama described a classification system relating the quality and quantity of bone surrounding a condemned tooth to implant placement and the need for ridge augmentation.8 A class I extraction site is described as having less than 5 mm of potential buccal bone loss, good regenerative potential, and a good esthetic prognosis. Class II extraction sites have the potential of a postimplant placement dehiscence greater than 5 mm and require regenerative procedures prior to implant placement if apical bone socket structure is insufficient for initial stability. Finally, a Class III extraction site finds that a majority of the root resides in a defective environment, necessitating ridge augmentation before implant placement. In a recent attempt to combine hard and soft tissue deficiencies, Wang and Al-Shammari recommend specific treatment options based on the classification and the severity of the presenting ridge defect.4 

Optimal implant position

A prerequisite to successful implant rehabilitation, both functionally and esthetically, is the proper location of the implant fixture and restoration in the edentulous space. This “restoration-driven implant placement” necessitates implant insertion in an optimal 3-dimensional position (mesiodistal, buccolingual, and apicocoronal) that relates to the final restorative phase of treatment rather than bone availability.9 To do this, we must have criteria to evaluate space and distances between natural teeth, implants, and anatomic structures as well as guidelines on how to manage soft tissue dimensions to achieve optimal functional, esthetic, and healthy implant restorations.

Mesiodistal Position

It has been suggested that a minimum of 1.25 to 1.5 mm of clearance be maintained between the implant fixture and adjacent teeth for proper osseointegration and decreased risk of damage to adjacent natural teeth.10,11 This is based primarily on the periodontal ligament width of adjacent teeth, although it fails to consider other important aspects such as the coronal and cervical width of the replaced tooth, the proximity of adjacent roots, the presence or absence of a diastema, and the necessity of maintaining the integrity of the interdental papillae.12 In natural teeth, a direct relationship has been demonstrated between the distance of the interproximal tooth contact point to the alveolar crest and the presence of an interproximal papilla.13 This has, in turn, led to recommendations of a 2-mm distance between the cervical implant face and the natural tooth and greater than a 3-mm cervical distance between two implants. Maintaining these space requirements has been shown to minimize the amount of crestal bone loss and increase the probability of proper papilla bone support and soft tissue fill.14 

Buccolingual Position

Correctly orienting the implant in a buccolingual position is important in obtaining a natural buccal and proximal restorative contour and in preventing restorative phase correction of implant fixtures that are oriented too far buccally or palatally. Two and 4 mm of space should be maintained between the external implant collar surface and the longitudinal implant axis to the buccal and cervical contours of the adjacent teeth, respectively.15,16 Spray and colleagues have proposed a critical facial bone thickness of 1.8 mm to maintain the implant soft tissue profile and increase the likelihood of an esthetic outcome. Implants placed in areas with less than this critical bone thickness are more prone to future bone loss and soft tissue recession (Figure 1).17 A facially oriented implant creates an excessively long crown and a misalignment of the collar with respect to the adjacent contralateral tooth.18 Additionally, subgingival emergence profile development cannot be achieved. In this instance, it is recommended to orient the implant 5° palatally and closer to the palatal cortical aspect to minimize buccal angulation, an improper implant-to-crown ratio, and resorption of the buccocortical plate, especially in cases where it is already thin.11,12 If an implant must be placed palatally, for each millimeter of palatal inclination, the implant should be placed an additional millimeter apically.19 

Figure 1.

Ridge (socket) preservation. (a) Root tip was left on tooth #8. (b) Periotome (Hu-Friedy, Chicago, Ill) was used to loosen (via periodontal ligament space) the remaining root in the socket. (c) The tooth was atraumatically extracted, preserving the labial bony plate. (d) Socket occlusal view showed signs of angiogenesis. (e) Demineralized freeze-dried human bone allograft (Puros, Centerpulse, Carlsbad, Calif) was placed on the bottom two thirds of the socket. (f) Colla-plug (Centerpulse, Carlsbad, Calif) was cut and placed on the top one third of the socket. (g) Socket was compressed with all the materials underneath. (h) Cross mattress suture with 4-0 Vicryl suture (Ethicon, Inc, Somerville, NJ). (i) Two weeks postoperative showed uneventful healing

Figure 1.

Ridge (socket) preservation. (a) Root tip was left on tooth #8. (b) Periotome (Hu-Friedy, Chicago, Ill) was used to loosen (via periodontal ligament space) the remaining root in the socket. (c) The tooth was atraumatically extracted, preserving the labial bony plate. (d) Socket occlusal view showed signs of angiogenesis. (e) Demineralized freeze-dried human bone allograft (Puros, Centerpulse, Carlsbad, Calif) was placed on the bottom two thirds of the socket. (f) Colla-plug (Centerpulse, Carlsbad, Calif) was cut and placed on the top one third of the socket. (g) Socket was compressed with all the materials underneath. (h) Cross mattress suture with 4-0 Vicryl suture (Ethicon, Inc, Somerville, NJ). (i) Two weeks postoperative showed uneventful healing

Apicocoronal Position

According to Saadoun and colleagues, the apicocoronal location of the implant shoulder is dependent on a number of factors: the cervical bone resorption morphology, the diameter of the implant, the size discrepancy between the root and the diameter of the implant, the thickness of the marginal gingiva, and the proximal tissues. They suggest that the implant collar be located 2 mm apical to the CEJ of the adjacent tooth if no gingival recession is present and 3 mm from the free gingival margin when it is. Implants positioned too far apically typically result in infrabony defects, peri-implant pocketing, second stage complications, difficulties in abutment connection, and excess cement during restoration seating.12 Implant sulcus depths should be limited to 3 or 4 mm, because deeper pockets are associated with increasing counts of anaerobic bacteria and long-term soft tissue complications.20–22 Excessive occlusal implant orientation can induce soft tissue recession, prevent a proper emergence profile, and result in compromised esthetics.12 

Emergence profile

Esthetic soft tissue contours are described by a harmoniously scalloped gingival line, the avoidance of abrupt vertical changes or differences in clinical crown length between adjacent teeth, a convex buccal mucosa of sufficient thickness, and distinct papillae.23,24 The existing status of the gingival tissues must be evaluated for quantity, quality, color, texture, and biotype (scalloped vs flat) before implant surgery is initiated in order to establish expectations regarding esthetic outcome.

The importance of developing a proper emergence profile is critical to achieving a final restoration whose appearance on exiting the soft tissues closely mimics that of adjacent natural teeth. A more ideal emergence profile can be obtained when using an implant of similar diameter to the tooth being replaced.25 Saadoun et al12 provide guidelines for implant fixture diameters when replacing specific natural tooth types.12 For example, for a central incisor, a mesiodistal dimension of 8.6 mm is needed at the crown level, 6.4 mm at the CEJ level, and 5.5 mm at 2 mm apical to the CEJ, in contrast to the available implant dimensions commonly used of 4.1 to 5 mm. Therefore, development of the proper emergence profile begins after stage 2 surgery, with the placement of a properly contoured provisional restoration that places expansion pressure on the surrounding peri-implant tissues. This “double-guidance concept” facilitates ideal gingival scalloping and papillae reformation while creating a natural emergence profile that will be supported by the final restoration.14,26–30 Before considering soft tissue augmentation procedures, the ridge deficiency of the implant site should be within 3 mm of its optimal contour, with a buccal bone wall of at least 1 to 2 mm in thickness (critical facial bone thickness), which may necessitate hard tissue augmentation.1,11,31 In sites with adjacent implants in the esthetic zone, the midcrest of the ridge should approximate the papillary tips of adjacent teeth.13,32 When augmenting soft tissues, it is important to overcontour by a minimum of 2 to 3 mm (corresponding to a tissue volume of 20%) because subsequent surgical and restorative procedures tend to cause at least 1 mm of tissue recession, especially if the tissue augmentation is performed before stage 1 implant surgery. An additional 0.75 mm and 0.90 mm of tissue recession has been documented at 6 months and 1 year, respectively, following abutment connection.14,33 Anterior implants significantly benefit from gingival augmentation procedures, which can resolve discrepant gingival and mucosal contours, enhance existing thin facial tissues, and mask metal fixture and crown components, ultimately creating an inconspicuous final treatment outcome.34,35 All esthetic tissue management should be completed before seating of the definitive restoration because postplacement esthetic management is severely limited.36 

Biologic Width

In understanding the soft tissue–implant relationship, it is necessary to discuss the concept of biologic width, which, in natural teeth, defines the distance between the most apical extension of the gingival sulcus and the crest of the alveolar bone. In the natural tooth, this space is occupied by about 1 mm each of connective tissue attachment and epithelium.9 Similarly, around implants, the junctional epithelial dimension is about 1.88 mm, and the connective tissue attachment is about 1.05 mm.37 This overall dimension appears stable over time, with slight variations in each component measure.38 It is important to note that there is no direct attachment between the implant surface and the connective tissue components as there is in natural teeth, so that a periodontal probe, even with the correct pressure, can probe close to the alveolar crest.39,40 This becomes important when considering implant soft tissue resistance to bacterial invasion, inflammation, recession, and trauma from oral hygiene measures; it will be discussed subsequently.

Keratinized vs Nonkeratinized Tissues

Discussion of the necessity of keratinized tissue around implants is central to procedures in implant plastic surgery. This topic has been debated in the literature and evidence has been presented stating that keratinized tissue around implant fixtures with rough surfaces is desirable, if not necessary41–51 and conversely, that smooth-surface implant fixture survival is unaffected by the absence of keratinized tissue.41,52–54 Indeed, it has been reported that the complete lack of masticatory mucosa around an implant fixture results in a mucosal seal that is not as resistant to movement and subsequent disruption of the implant-epithelial junction, plaque accumulation, and inflammatory changes.46,55,56 Ensuring that a keratinized tissue border exists at the implant-soft tissue interface helps develop tight tissue adaptation and a marginal seal at the implant surface and provides a connective tissue circumferential fiber system that resists mechanical stress and facilitates oral hygiene procedures.42,44,45,51,55–58 

Tissue preservation and modification

A large number of soft and hard tissue procedures have been described to facilitate edentulous ridge augmentation prior to implant placement. Many of these procedures have been used successfully in periodontal and oral surgery for several decades to cover recession and for alveolar ridge reconstruction, and they will be briefly outlined here.59–65 Other procedures—not well known in the periodontal literature—will be discussed in more detail. Soft tissue modification before implant placement is advantageous in that proper tissue contours and support exist before stage 1 surgery, increasing the predictability of a satisfying treatment outcome. These procedures are indispensable in critical esthetic regions, but they unfortunately necessitate additional surgical procedures and increased cost to the patient.

Ridge (Socket) Preservation (Figure 1)

Ridge-retention procedures, using bone grafts, membrane placement, or grafting, along with 6 months of healing prior to implant placement, have been demonstrated to be predictable, and they are preferred by many clinicians.66–68 Although these procedures increase overall treatment time, they are preferable to simple extraction when considering that 3 to 4 mm of resorption can occur during the first 6 months after extraction in the absence of intervention.69,70 The ideal solution to successful ridge preservation is the flapless, atraumatic removal of the hopeless tooth, leaving much of the bony architecture, including the often-thin buccal cortical plate, intact. Schulte developed the Periotome (Friadent North America, Lakewood, Colo) for the purpose of removing teeth without damage to the surrounding bone.71 These instruments have been designed for both anterior and posterior teeth. They are used by inserting the small, thin blade around the tooth socket and severing the periodontal ligament connection to the socket wall as far apically as possible to loosen the tooth, which is then easily removed with minimal surrounding bony trauma. After extraction, the socket is curetted and a decision is made as to what material to use in grafting. Many materials have been suggested in the literature, from an absorbable collagen matrix (Collaplug, Centerpulse Dental, Inc, Carlsbad, Calif), autogenous bone, demineralized freeze-dried bone allograft, combinations of growth factors, to a variety of synthetic grafting materials. Examples of frequently used materials include osteoconductive human hydroxyapatite (HA) (Puros, Centerpulse Dental, Inc, Carlsbad, Calif) and bovine xenograft (OsteoGraf N-300, Dentsply, Lakewood, Colo).72–78 Another option to consider is the use of a barrier membrane, which necessitates complete tissue coverage without subsequent membrane exposure and infection for crestal bone regeneration to occur.79–81 Several difficulties in using a barrier membrane during ridge preservation include reduction of keratinized gingiva, alterations of gingival contours, and migration of the mucogingival junction, which may occur during coronal displacement of the flap during tissue closure of the membrane. Even with these drawbacks, some studies have demonstrated success in the use of a variety of membranes for ridge preservation, including absorbable, nonabsorbable, and acellular dermal allografts.81–84 

Bio-Col technique

Sclar has developed a socket (ridge) preservation technique that is unique and has met with some success.85,86 The technique involves: 1) atraumatic tooth extraction followed by socket curettage and cortical socket perforation, 2) socket grafting with deproteinized bovine bone HA, 3) placement of an absorbable collagen dressing (CollaPlug, Sulzer Calcitek, Inc, Carsbad, Calif), and 4) socket sealing with an impervious tissue cement (Isodent, Ellman International, Hewlett, NY). An interim ovate, pontic-form, provisional restoration is delivered after the procedure to replicate the contours of the extracted tooth and to support the surrounding soft tissues.

Modified graft preservation

This technique involves 1) atraumatic tooth extraction without a periodontal flap followed by socket curettage, 2) socket grafting with demineralized freeze-dried bone allograft (DFDBA), and 3) placement of a free gingival palatal graft over the extraction socket. The dimensions of the socket are measured after tooth extraction using a periodontal probe and transferred to a harvest site in the palatal tissue at least 3 mm apical to the free gingival margin of the premolars or molars. An additional 1 mm is added to the diameter of the free gingival graft to increase keratinized tissue at the extraction site and expand the existing tissues to minimize shrinkage during the healing phase. The graft is harvested and the thickness adjusted to match the thickness of the existing tissues at the extraction site. The graft is immobilized with interrupted sutures and left to heal for 6 months before implant surgery. This technique results in preservation of existing papillary, crestal, and buccal bony support while maintaining ideal tissue contours during healing.87 

Forced Orthodontic Eruption

The use of orthodontics in erupting hopeless teeth before extraction has been used successfully to augment bone and soft tissue support at future implant sites.8,88,89 In order to advance the periodontal attachment apparatus and the alveolar bone coronally for the correction of bony defects and augmentation of hard and soft tissue contours, the extrusion must be done using a slow eruption technique.90–92 One drawback to this technique is the potential loss of proximal alveolar bone support, because orthodontic extrusion tends to level the crestal alveolar bone; it might even create reverse midcrestal architecture, depending on the degree of extrusion. This may reduce or eliminate the fill of interproximal papillae, which is not favorable in anterior esthetic regions. Therefore, when a tooth is buccally oriented, it is often advisable to remove the tooth and perform osseous augmentation (eg, monocortical onlay grafting). Other drawbacks in using this technique include longer treatment time and increased cost to the patient.

Osseous Augmentation Techniques (Figure 2)

Figure 2.

Bone augmentation to enhance soft tissue profile. (a) Tooth #9 has root fracture. (b) Occlusal view of the healing socket. (c) Initial incision. Two vertical, diverging, releasing incisions were done. (d) Full thickness periosteal reflection indicated inadequate bone width for proper implant placement. (e) Implant drill sequence (2 mm twist drill). (f) Implant (3.75 × 13 mm) placement (Nobel BioCare, Yorba Linda, Calif). (g) Decortication was performed using one-half round bur on the side of the implant to promote regional acceleratory phenomenon (RAP). (h) Demineralized freeze-dried bone allograft was placed. (i) Collagen membrane (BioMend Regular, Centerpulse, Carlsbad, Calif) was placed to cover the bone graft area and extended to the lingual. (j) Sutured with passive tension. A modified vertical mattress suture was placed on the center of defect to ensure proper wound coverage. (k) Two weeks postoperatively showed uneventful healing. (l) Four months healing after ovate pontic site development by temporary crown. (m) New bone formation was noted on the buccal side. (n) Healing abutment was placed. (o) Sutured around healing to allow soft tissue maturation. (p) Two weeks after healing. (q) Final radiography. (r) Final restoration

Figure 2.

Bone augmentation to enhance soft tissue profile. (a) Tooth #9 has root fracture. (b) Occlusal view of the healing socket. (c) Initial incision. Two vertical, diverging, releasing incisions were done. (d) Full thickness periosteal reflection indicated inadequate bone width for proper implant placement. (e) Implant drill sequence (2 mm twist drill). (f) Implant (3.75 × 13 mm) placement (Nobel BioCare, Yorba Linda, Calif). (g) Decortication was performed using one-half round bur on the side of the implant to promote regional acceleratory phenomenon (RAP). (h) Demineralized freeze-dried bone allograft was placed. (i) Collagen membrane (BioMend Regular, Centerpulse, Carlsbad, Calif) was placed to cover the bone graft area and extended to the lingual. (j) Sutured with passive tension. A modified vertical mattress suture was placed on the center of defect to ensure proper wound coverage. (k) Two weeks postoperatively showed uneventful healing. (l) Four months healing after ovate pontic site development by temporary crown. (m) New bone formation was noted on the buccal side. (n) Healing abutment was placed. (o) Sutured around healing to allow soft tissue maturation. (p) Two weeks after healing. (q) Final radiography. (r) Final restoration

To facilitate ideal implant placement, several osseous augmentation procedures have been developed and implemented with promising results. These procedures include guided bone augmentation, monocortical onlay grafting (symphysis, ramus, iliac crest, tibia), distraction osteogenesis, ridge splitting techniques, and combination procedures. Because of the nature and scope of this review, we have decided not to discuss these augmentation techniques in detail.

Gingival Augmentation Techniques

Creative methods of gaining excess autogenous gingival tissues have been described in the literature with some success.

Controlled tissue expansion

This technique was proposed by Bahat in 1989 as a unique way to expand soft tissues in ridge deficiencies.68,93 By exploiting the elastic properties of the gingival epithelium, the tissue is expanded using a technique modeled after breast implants to gain adequate soft tissue for primary coverage of subsequent osseous grafts. Full thickness mucoperiosteal flap reflection of the deficient ridge is performed with releasing incisions extending into the buccal vestibule. The inflatable silicon balloon expander is then positioned and sutured in place, the port of the expander exiting the soft tissue at the height of the vestibule. The expander is inflated through the exposed self-sealing port with sterile saline every 3 or 4 days for 2 to 3 weeks, depending on the size of the ridge defect and the anticipated amount of soft tissue coverage required for bone grafting. One particular drawback of this technique is the potential need for additional soft tissue procedures to gain keratinized tissue, because this technique preferentially expands the moveable alveolar mucosa over the thicker, more resistant masticatory mucosa.

Spontaneous in situ gingival augmentation

This technique is used to augment a future implant site through allowing the body to manufacture gingival tissue around a tooth scheduled for extraction; it has been reported to reduce the need for additional grafting procedures at implant placement.94,95 This technique involves reduction of the condemned tooth below the level of the free gingival margin followed by 2 to 3 weeks of soft tissue healing. The gingival tissues proliferate, covering the remaining tooth root with keratinized gingiva, after which a flap can be elevated, the remaining root extracted, and an implant immediately placed. Some distinct advantages of this technique include complete primary coverage of the implant at stage 1 surgery, reduced treatment time, and cost to the patient, when compared with other socket preservation techniques. Drawbacks include the possibility of damaging the crestal bone during extraction and the presence of fenestration or dehiscence defects, which would necessitate further grafting procedures.

Soft Tissue Grafting

Soft tissue grafting procedures have been used successfully for many years in periodontics and oral surgery in resolving recession defects around natural teeth and augmenting alveolar ridge contours.59–65 Many of these procedures can be translated directly to peri-implant tissue modification, although scientific evidence of longitudinal success and stability has yet to be established. The following procedures are designed for use in augmentation of edentulous ridge defects: the roll technique,96 pouch procedures,2,3,61,62,68,93,97–104 interpositional grafts,105–108 onlay grafts,2,109,110 and combination grafts. These techniques might differ in name and approach; however, when properly utilized in their indicated clinical situations, they can provide significant gains in soft tissue volume and contour that can contribute to the esthetic management of implant sites.

Papilla Regeneration Technique

This technique was developed to correct deficient interproximal papillae contours between multiple implants at stage 2 surgery and is primarily an esthetically driven procedure. The procedure involves elevating a full thickness mucoperiosteal flap at the palatal or lingual extent of the implant cover screws. Vertical releasing incisions are used to aid in flap elevation, and the incisions are made so as to exclude the papillary tissue of adjacent natural teeth. Semilunar, beveled incisions are then created in the buccal flap extending toward each abutment, beginning with the distal aspect of the most mesially located implant. The pedicles are secured between the abutments using tension-free suturing and are allowed to heal for 4 to 6 weeks before final restoration.

Tissue Punch (Flapless) Technique

This technique was developed for minimally invasive stage 1 implant placement and stage 2 implant exposure in the presence of abundant keratinized gingiva or previously augmented sites. It has the benefits of maintaining existing soft tissue and papilla contours, and it can be used to create pressure on the surrounding peri-implant tissues with a healing abutment or provisional crown in developing an ideal emergence profile, which is especially useful in anterior esthetic regions. Limitations include inadequate preoperative keratinized gingiva and the presence of gingival defects that require additional soft tissue grafting at stage 2 surgery.89 

Titanium Papillary Insert

The titanium papillary insert (TPI) is composed of a pyramidal-shaped, polished titanium core 2 to 3 mm in height, 1 mm in width, and 3 mm in length. It was designed as foundational support for the development of interimplant papillae; it yields immediate results, and it is thought to allow for a predictable and stable esthetic outcome. The TPI is placed between adjacent implants, and it requires more than 3 mm of interimplant distance to ensure sufficient blood supply. A 1-mm diameter twist drill is used to create a 5-mm deep osteotomy, then the insert is screwed in with cotton pliers until it is flush with the alveolar crest. Primary soft tissue closure is obtained and healing ensues.111 This unique procedure appears to produce favorable results in limited cases, and it may prove useful in recreating the elusive interimplant papilla; however, it is not readily available, and long-term results have not been substantiated.

Treatment sequencing

At the time of implant placement or abutment connection, the previously discussed soft tissue modification techniques are employed. Gaining keratinized tissue at stage 2 implant surgery is commonly performed in nonesthetic areas using an apically positioned flap and allowing crestal healing to progress via secondary intention.112,113 Planning soft tissue augmentation at implantation or uncovery has the benefit of eliminating separate surgical procedures and decreasing overall treatment time. Additionally, the underlying bony contours and adequacy of alveolar support can be evaluated for the need of modification or augmentation, which may be concomitantly performed. In addition to those procedures previously discussed, several other techniques merit review.

Immediate Implant Placement

Using techniques of immediate implant placement eliminates the need for preplacement hard and soft tissue augmentation or ridge preservation when there is sufficient alveolar support around the tooth to be replaced (Figure 3). Evidence exists demonstrating immediate implant placement success with the preservation of existing alveolar bone and supporting structures.85,114–117 Many clinicians prefer to use membranes to cover immediately placed implants, creating difficulties in primary flap adaptation at a site that may already lack adequate keratinized tissues. Most techniques advocate coronal advancement of the buccal flap through periosteal releasing incisions to achieve primary closure, which often decreases the zone of keratinized tissue and displaces the mucogingival junction in the area of the implant. These difficulties often require secondary grafting procedures at stage 2 surgery to correct. It may be obviated by the use of grafting procedures concurrently with stage 1 surgery.118 

Figure 3.

Immediate implant placement. (a) Tooth #10 has fractured apical to the CEJ. The crown was bonded to the adjacent teeth by the referring dentist. (b) Occlusal view of the remaining root in the socket. (c) The tooth was atraumatically extracted, preserving the labial bony plate. (d) Endosseous implant placed (occlusal view). (e) Endosseous implant placed (facial view). (f) Indexing of the implant was performed. (g) The crown was rebonded as a temporary restoration. (h) The replicated cast used for crown fabrication. (i) Final view after 6 months. Note the preservation of the interproximal papilla

Figure 3.

Immediate implant placement. (a) Tooth #10 has fractured apical to the CEJ. The crown was bonded to the adjacent teeth by the referring dentist. (b) Occlusal view of the remaining root in the socket. (c) The tooth was atraumatically extracted, preserving the labial bony plate. (d) Endosseous implant placed (occlusal view). (e) Endosseous implant placed (facial view). (f) Indexing of the implant was performed. (g) The crown was rebonded as a temporary restoration. (h) The replicated cast used for crown fabrication. (i) Final view after 6 months. Note the preservation of the interproximal papilla

Postplacement soft tissue modification

All esthetic tissue management should be completed before seating of the definitive restoration inasmuch postplacement esthetic management is severely limited.36 Traditional periodontal soft tissue grafting procedures do not fare well when one attempts to cover a nonvital implant surface, because the tissues do not respond as they do around vital teeth. Postplacement soft tissue modification in this context therefore consists primarily of hard tissue regenerative procedures or hard or soft tissue resective procedures in an attempt to restore the health of peri-implant tissues.

Vertical Defects

To correct vertical bone defects around existing implants, a full thickness mucoperiosteal flap is elevated and the defect is curetted to remove any soft tissue, while ensuring that the implant surface remains untouched. If the extent of bone loss is less than 2 mm, the defect can be grafted with autogenous bone or it can be removed through osteoplasty, converting the defect into a horizontal deficiency. Osteoplasty in this instance is more predictable. Vertical defects larger than 2 mm are generally grafted, unless it represents one half or more of the total implant height, in which case it is removed. Another option in treating mesial or distal vertical defects involves creating a wedge into the bone several millimeters away from the implant body. This creates bone compression against the implant surface and resolves the vertical defect, while the distant site heals uneventfully. Similarly, buccal or lingual defects can be corrected by using a blunt instrument and mallet to compress the buccal or lingual bone against the implant body. If the defect is greater than 2 mm in depth and extends over 25% of the implant circumference, it is suggested that a barrier membrane be placed over the grafted area.119 

Horizontal Defects

The most predictable method of treating horizontal implant defects is through reduction of the soft tissue thickness via apical repositioning. If threads or a rough surface are present above the bone, a white stone and rubber wheel are employed to smooth the area, thus limiting plaque accumulation. If the horizontal defect extends beyond one half of the implant body, it should be removed. Another option is to attempt regenerative procedures using autogenous bone and a barrier membrane to gain height around the implant fixture. This is indicated only in single- or multiple-implant fixed restorations or when additional bone-to-implant interface is required to withstand the forces exerted on the prosthesis.119 

Conclusions

Many procedures exist to augment soft tissue contours around dental implants, although no effort to date has been made to organize this body of literature into a coherent treatment approach. As such, the term “implant plastic surgery” is appropriate in describing this loosely connected collection of principles and techniques, which facilitate future development of this subspecialty of implantology. The table summarizes the various implant plastic surgery procedures recommended at different stages of implant placement.

Table Implant plastic surgery procedures at different stages of treatment

Table Implant plastic surgery procedures at different stages of treatment
Table Implant plastic surgery procedures at different stages of treatment

It is evident that little scientific literature exists in this area and that there is a strong need for further research in establishing the long-term success and stability of the many techniques discussed here, as they relate to implant soft tissue modification. To date, most of the evidence in this area is based on clinical opinion and isolated case reports rather than well-controlled, longitudinal investigations from which sound treatment recommendations can be formulated. From existent evidence concerning soft tissue modification around natural teeth and the evidence presented here, implant plastic surgery should emerge as a distinct subdiscipline of implantology that will continue to develop and expand as dental implants are accepted as a routine treatment for the restoration of function and esthetics.

Note

The authors have no financial interests, either directly or indirectly, in the products listed in this study.

Figure 2.

Continued

Figure 2.

Continued

Acknowledgments

This paper was partially supported by the University of Michigan Periodontal Graduate Student Research Fund.

References

References
1
Jovanovic
,
S. A.
Bone rehabilitation to achieve optimal aesthetics.
Pract Periodontics Aesthet Dent
1997
.
9
1
:
41
51
.
quiz 52
.
2
Seibert
,
J. S.
Reconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts.
Compend Contin Educ Dent
1983
.
4
pt 1
:
437
453
.
3
Allen
,
E. P.
,
C. S.
Gainza
,
G. G.
Farthing
, and
D. A.
Newbold
.
Improved technique for localized ridge augmentation: a report of 21 cases.
J Periodontol
1985
.
56
:
195
199
.
4
Wang
,
H-L.
and
K.
Al-Shammari
.
HVC ridge deficiency classification: a therapeutically oriented classification.
Int J Periodontics Restorative Dent. In press
.
5
Lekholm
,
U.
and
G.
Zarb
.
Patient selection.
In: Branemark PI, Zarb G, Albrektsson T, eds. Tissue Integrated Prostheses. Osseointegration in Clinical Dentistry. Chicago, Ill: Quintessence; 1985:199–209
.
6
Misch
,
C. E.
and
K. W.
Judy
.
Classification of partially edentulous arches for implant dentistry.
Int J Oral Implantol
1987
.
4
:
7
13
.
7
Misch
,
C. E.
Treatment planning and implant dentistry [abstract].
Misch Implant Institute Manual. Dearborn, Mich; 1985
.
8
Salama
,
H.
and
M.
Salama
.
The role of orthodontic extrusive remodeling in the enhancement of soft and hard tissue profiles prior to implant placement: a systematic approach to the management of extraction site defects.
Int J Periodontics Restorative Dent
1993
.
13
:
312
333
.
9
Garber
,
D. A.
and
U. C.
Belser
.
Restoration-driven implant placement with restoration-generated site development.
Compend Contin Educ Dent
1995
.
16
:
796, 798
802
.
804
.
10
Ohrnell
,
L. O.
,
J. M.
Hirsch
,
I.
Ericsson
, and
P. I.
Branemark
.
Single-tooth rehabilitation using osseointegration. A modified surgical and prosthodontic approach.
Quintessence Int
1988
.
19
:
871
876
.
11
Adell
,
R.
,
B.
Eriksson
,
U.
Lekholm
,
P. I.
Branemark
, and
T.
Jemt
.
Long-term follow-up study of osseointegrated implants in the treatment of totally edentulous jaws.
Int J Oral Maxillofac Implants
1990
.
5
:
347
359
.
12
Saadoun
,
A. P.
,
M.
LeGall
, and
B.
Touati
.
Selection and ideal tridimensional implant position for soft tissue aesthetics.
Pract Periodontics Aesthet Dent
1999
.
11
:
1063
1072
.
quiz 1074
.
13
Tarnow
,
D. P.
,
A. W.
Magner
, and
P.
Fletcher
.
The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla.
J Periodontol
1992
.
63
:
995
996
.
14
Tarnow
,
D. P.
,
S. C.
Cho
, and
S. S.
Wallace
.
The effect of inter-implant distance on the height of inter-implant bone crest.
J Periodontol
2000
.
71
:
546
549
.
15
Saadoun
,
A. P.
and
M.
LeGall
.
Implant positioning for periodontal, functional, and aesthetic results.
Pract Periodontics Aesthet Dent
1992
.
4
:
43
54
.
16
Saadoun
,
A. P.
,
D. Y.
Sullivan
,
M.
Krischek
, and
M.
Le Gall
.
Single tooth implant—management for success.
Pract Periodontics Aesthet Dent
1994
.
6
:
73
80
.
quiz 82
.
17
Spray
,
J. R.
,
C. G.
Black
,
H. F.
Morris
, and
S.
Ochi
.
The influence of bone thickness on facial marginal bone response: stage 1 placement through stage 2 uncovering.
Ann Periodontol
December 2000
.
5
:
119
128
.
18
Grunder
,
U.
,
H. P.
Spielman
, and
T.
Gaberthuel
.
Implant-supported single tooth replacement in the aesthetic region: a complex challenge.
Pract Periodontics Aesthet Dent
1996
.
8
:
835
842
.
quiz 844
.
19
Potashnick
,
S. R.
Soft tissue modeling for the esthetic single-tooth implant restoration.
J Esthet Dent
1998
.
10
:
121
131
.
20
Yukna
,
R. A.
Periodontal considerations for dental implants.
In: Block MS, Kent JN, eds. Endosseous Implants for Maxillofacial Reconstruction. Philadelphia, Pa: WB Saunders; 1995:587–590
.
21
Misch
,
C. E.
The maxillary anterior single tooth implant aesthetic-health compromise.
Int J Dent Symp
1995
.
3
1
:
4
9
.
22
Bichacho
,
N.
and
C. J.
Landsberg
.
Single implant restorations: prosthetically induced soft tissue topography.
Pract Periodontics Aesthet Dent
1997
.
9
:
745
752
.
quiz 754
.
23
Belser
,
U.
,
D.
Buser
,
D.
Hess
,
B.
Schmid
,
J. P.
Bernard
, and
N. P.
Lang
.
Esthetic implant restorations in partially edentulous patients: a critical appraisal.
In: Lang NP, ed. Periodontology 2000: Implant Dentistry. Vol 17. Chicago, Ill: Quintessence; 1998:132–150
.
24
Belser
,
U. C.
,
J. P.
Bernard
, and
D.
Buser
.
Implant-supported restorations in the anterior region: prosthetic considerations.
Pract Periodontics Aesthet Dent
1996
.
8
:
875
883
.
quiz 884
.
25
Wohrle
,
P. S.
The synergy of taper and diameter: enhancing the art and science of implant dentistry with the Replace™ implant system.
Int J Dent Symp
1997
.
4
:
48
52
.
26
Touati
,
B.
Improving aesthetics of implant-supported restorations.
Pract Periodontics Aesthet Dent
1995
.
7
:
81
92
.
quiz 93
.
27
Touati
,
B.
Custom-guided tissue healing for improved aesthetics in implant-supported restorations.
Int J Dent Symp
1995
.
3
1
:
36
39
.
28
Touati
,
B.
The double guidance concept.
Pract Periodontics Aesthet Dent
1997
.
9
:
1089
1094
.
29
Touati
,
B.
Double guidance approach for the improvement of the single-tooth implant replacement.
Dent Implantol Update
December 1997
.
8
:
89
93
.
30
Touati
,
B.
,
G.
Guez
, and
A.
Saadoun
.
Aesthetic soft tissue integration and optimized emergence profile: provisionalization and customized impression coping.
Pract Periodontics Aesthet Dent
1999
.
11
:
305
314
.
quiz 316
.
31
Buser
,
D.
and
T.
von Arx
.
Surgical procedures in partially edentulous patients with ITI implants.
Clin Oral Implants Res
2000
.
11
suppl 1
:
83
100
.
32
Salama
,
H.
,
M. A.
Salama
,
D.
Garber
, and
P.
Adar
.
The interproximal height of bone: a guidepost to predictable aesthetic strategies and soft tissue contours in anterior tooth replacement.
Pract Periodontics Aesthet Dent
1998
.
10
:
1131
1141
.
quiz 1142
.
33
Bengazi
,
F.
,
J. L.
Wennstrom
, and
U.
Lekholm
.
Recession of the soft tissue margin at oral implants: a 2-year longitudinal prospective study.
Clin Oral Implants Res
1996
.
7
:
303
310
.
34
Alpert
,
A.
A rationale for attached gingiva at the soft-tissue/implant interface: esthetic and functional dictates.
Compendium
1994
.
15
:
356, 358, 360
362
.
passim; quiz 368
.
35
ten Bruggenkate
,
C. M.
,
H. A.
Kraaijenhagen
,
W. A.
van der Kwast
,
G.
Krekeler
, and
H. S.
Oosterbeek
.
Autogenous maxillary bone grafts in conjunction with placement of I.T.I. endosseous implants. A preliminary report.
Int J Oral Maxillofac Surg
April 1992
.
21
:
81
84
.
36
Hurzeler
,
M. B.
and
D.
Weng
.
Periimplant tissue management: optimal timing for an aesthetic result.
Pract Periodontics Aesthet Dent
1996
.
8
:
857
869
.
quiz 869
.
37
Cochran
,
D. L.
,
J. S.
Hermann
,
R. K.
Schenk
,
F. L.
Higginbottom
, and
D.
Buser
.
Biologic width around titanium implants. A histometric analysis of the implanto-gingival junction around unloaded and loaded nonsubmerged implants in the canine mandible.
J Periodontol
1997
.
68
:
186
198
.
38
Hermann
,
J. S.
,
D.
Buser
,
R. K.
Schenk
, and
D. L.
Cochran
.
Crestal bone changes around titanium implants. A histometric evaluation of unloaded non-submerged and submerged implants in the canine mandible.
J Periodontol
2000
.
71
:
1412
1424
.
39
Ericsson
,
I.
,
T.
Berglundh
,
C.
Marinello
,
B.
Liljenberg
, and
J.
Lindhe
.
Long-standing plaque and gingivitis at implants and teeth in the dog.
Clin Oral Implants Res
September 1992
.
3
:
99
103
.
40
Ericsson
,
I.
and
J.
Lindhe
.
Probing depth at implants and teeth. An experimental study in the dog.
J Clin Periodontol
1993
.
20
:
623
627
.
41
Warrer
,
K.
,
D.
Buser
,
N. P.
Lang
, and
T.
Karring
.
Plaque-induced peri-implantitis in the presence or absence of keratinized mucosa. An experimental study in monkeys.
Clin Oral Implants Res
1995
.
6
:
131
138
.
42
Kirsch
,
A.
and
K. L.
Ackermann
.
The IMZ osteointegrated implant system.
Dent Clin North Am
1989
.
33
:
733
791
.
43
Buser
,
D.
,
H. P.
Weber
, and
U.
Bragger
.
The treatment of partially edentulous patients with ITI hollow-screw implants: presurgical evaluation and surgical procedures.
Int J Oral Maxillofac Implants
1990
.
5
:
165
175
.
44
Zarb
,
G. A.
and
A.
Schmitt
.
The longitudinal clinical effectiveness of osseointegrated dental implants: the Toronto study.
J Prosthet Dent
Aug 1990
.
64
pt 3
:
185
194
.
45
Block
,
M. S.
and
J. N.
Kent
.
Factors associated with soft- and hard-tissue compromise of endosseous implants.
J Oral Maxillofac Surg
1990
.
48
:
1153
1160
.
46
Schroeder
,
A.
,
E.
van der Zypen
,
H.
Stich
, and
F.
Sutter
.
The reactions of bone, connective tissue, and epithelium to endosteal implants with titanium-sprayed surfaces.
J Maxillofac Surg
1981
.
9
:
15
25
.
47
McKinney
Jr,
R. V.
,
D. E.
Steflick
,
D. L.
Koth
, and
B. B.
Singh
.
The scientific basis for dental implant therapy.
J Dent Educ
1988
.
52
:
696
705
.
48
Simons
,
A. M.
,
D. G.
Darany
, and
J. R.
Giordano
.
The use of free gingival grafts in the treatment of peri-implant soft tissue complications: clinical report.
Implant Dent
1993
.
2
1
:
27
30
.
49
van Steenberghe
,
D.
Periodontal aspects of osseointegrated oral implants modum Branemark.
Dent Clin North Am
April 1988
.
32
:
355
370
.
50
Worthington
,
P.
,
C. L.
Bolender
, and
T. D.
Taylor
.
The Swedish system of osseointegrated implants: problems and complications encountered during a 4-year trial period.
Int J Oral Maxillofac Implants
Spring 1987
.
2
:
77
84
.
51
Sevor
,
J. J.
The use of free gingival grafts to improve the implant soft tissue interface: rationale and technique.
Pract Periodontics Aesthet Dent
1992
.
4
9
:
59
64
.
52
Adell
,
R.
,
U.
Lekholm
,
B.
Rockler
, and
P. I.
Branemark
.
A 15-year study of osseointegrated implants in the treatment of the edentulous jaw.
Int J Oral Surg
1981
.
10
:
387
416
.
53
Albrektsson
,
T.
,
G.
Zarb
,
P.
Worthington
, and
A. R.
Eriksson
.
The long-term efficacy of currently used dental implants: a review and proposed criteria of success.
Int J Oral Maxillofac Implants
1986
.
1
:
11
25
.
54
Strub
,
J. R.
,
T. W.
Gaberthuel
, and
U.
Grunder
.
The role of attached gingiva in the health of peri-implant tissue in dogs. 1. Clinical findings.
Int J Periodontics Restorative Dent
1991
.
11
:
317
333
.
55
Rapley
,
J. W.
,
M. P.
Mills
, and
J.
Wylam
.
Soft tissue management during implant maintenance.
Int J Periodontics Restorative Dent
1992
.
12
:
373
381
.
56
Listgarten
,
M. A.
,
N. P.
Lang
,
H. E.
Schroeder
, and
A.
Schroeder
.
Periodontal tissues and their counterparts around endosseous implants [corrected and republished with original paging; article originally printed in Clin Oral Implants Res 1991 January–March;2:1–19].
Clin Oral Implants Res
July–September 1991
.
2
:
1
19
.
57
Buser
,
D.
,
H. P.
Weber
, and
N. P.
Lang
.
Tissue integration of non-submerged implants. 1-year results of a prospective study with 100 ITI hollow-cylinder and hollow-screw implants.
Clin Oral Implants Res
1990
.
1
1
:
33
40
.
58
Newman
,
M. G.
and
T. F.
Flemmig
.
Periodontal considerations of implants and implant associated microbiota.
J Dent Educ
1988
.
52
:
737
744
.
59
Raetzke
,
P. B.
Covering localized areas of root exposure employing the “envelope” technique.
J Periodontol
1985
.
56
:
397
402
.
60
Miller
Jr.,
P. D.
Root coverage with the free gingival graft. Factors associated with incomplete coverage.
J Periodontol
1987
.
58
:
674
681
.
61
Langer
,
B.
and
L. J.
Calagna
.
The subepithelial connective tissue graft. A new approach to the enhancement of anterior cosmetics.
Int J Periodontics Restorative Dent
1982
.
2
2
:
22
33
.
62
Langer
,
B.
and
L.
Calagna
.
The subepithelial connective tissue graft.
J Prosthet Dent
1980
.
44
:
363
367
.
63
Langer
,
B.
and
L.
Langer
.
Subepithelial connective tissue graft technique for root coverage.
J Periodontol
1985
.
56
:
715
720
.
64
Harris
,
R. J.
The connective tissue and partial thickness double pedicle graft: a predictable method of obtaining root coverage.
J Periodontol
1992
.
63
:
477
486
.
65
Jahnke
,
P. V.
,
J. B.
Sandifer
,
M. E.
Gher
,
J. L.
Gray
, and
A. C.
Richardson
.
Thick free gingival and connective tissue autografts for root coverage.
J Periodontol
1993
.
64
:
315
322
.
66
Nevins
,
M.
and
J. T.
Mellonig
.
Enhancement of the damaged edentulous ridge to receive dental implants: a combination of allograft and the GORE-TEX membrane.
Int J Periodontics Restorative Dent
1992
.
12
2
:
96
111
.
67
Buser
,
D.
,
K.
Dula
,
U.
Belser
,
H. P.
Hirt
, and
H.
Berthold
.
Localized ridge augmentation using guided bone regeneration. 1. Surgical procedure in the maxilla.
Int J Periodontics Restorative Dent
1993
.
13
1
:
29
45
.
68
Bahat
,
O.
and
L. M.
Koplin
.
Pantographic lip expansion and bone grafting for ridge augmentation.
Int J Periodontics Restorative Dent
1989
.
9
:
344
353
.
69
Atwood
,
D. A.
and
W. A.
Coy
.
Clinical, cephalometric, and densitometric study of reduction of residual ridges.
J Prosthet Dent
1971
.
26
:
280
295
.
70
Johnson
,
K.
A study of the dimensional changes occurring in the maxilla after tooth extraction. Part I: Normal healing.
Aust Dent J
1963
.
8
:
428
433
.
71
Quayle
,
A. A.
Atraumatic removal of teeth and root fragments in dental implantology.
Int J Oral Maxillofac Implants
1990
.
5
:
293
296
.
72
Brugnami
,
F.
,
P. R.
Then
,
H.
Moroi
,
S.
Kabani
, and
C. W.
Leone
.
GBR in human extraction sockets and ridge defects prior to implant placement: clinical results and histologic evidence of osteoblastic and osteoclastic activities in DFDBA.
Int J Periodontics Restorative Dent
1999
.
19
:
259
267
.
73
Ashman
,
A.
Postextraction ridge preservation using a synthetic alloplast.
Implant Dent
2000
.
9
2
:
168
176
.
74
Ashman
,
A.
and
J.
Lopinto
.
Placement of implants into ridges grafted with bioplant HTR synthetic bone: histological long-term case history reports.
J Oral Implantol
2000
.
26
:
276
290
.
75
Artzi
,
Z.
,
H.
Tal
, and
D.
Dayan
.
Porous bovine bone mineral in healing of human extraction sockets. 2. Histochemical observations at 9 months.
J Periodontol
2001
.
72
:
152
159
.
76
Froum
,
S.
and
W.
Orlowski
.
Ridge preservation utilizing an alloplast prior to implant placement–clinical and histological case reports.
Pract Periodontics Aesthet Dent
2000
.
12
:
393
402
.
quiz 404
.
77
Gross
,
J.
Ridge preservation using HTR synthetic bone following tooth extraction.
Gen Dent
1995
.
43
:
364
367
.
78
Thompson
,
D. M.
Extraction site—foundation for restorative excellence.
Compend Contin Educ Dent
1999
.
20
:
156
158
.
160, 162–153 passim
.
79
Warrer
,
L.
,
K.
Gotfredsen
,
E.
Hjorting-Hansen
, and
T.
Karring
.
Guided tissue regeneration ensures osseointegration of dental implants placed into extraction sockets. An experimental study in monkeys.
Clin Oral Implants Res
1991
.
2
4
:
166
171
.
80
Becker
,
W.
,
B. E.
Becker
,
M.
Handelsman
,
C.
Ochsenbein
, and
T.
Albrektsson
.
Guided tissue regeneration for implants placed into extraction sockets: a study in dogs.
J Periodontol
1991
.
62
:
703
709
.
81
Iasella
,
J. M.
,
H.
Greenwell
, and
R. L.
Miller
.
et al
.
Ridge preservation with freeze-dried bone allograft and a collagen membrane compared to extraction alone for implant site development: a clinical and histologic study in humans.
J Periodontol
2003
.
74
:
990
999
.
82
Fowler
,
E. B.
,
L. G.
Breault
, and
G.
Rebitski
.
Ridge preservation utilizing an acellular dermal allograft and demineralized freeze-dried bone allograft.
J Periodontol
2000
.
71
pt 1
:
1353
1359
.
83
Becker
,
W.
,
S. E.
Lynch
, and
U.
Lekholm
.
et al
.
A comparison of ePTFE membranes alone or in combination with platelet-derived growth factors and insulin-like growth factor-I or demineralized freeze-dried bone in promoting bone formation around immediate extraction socket implants.
J Periodontol
1992
.
63
:
929
940
.
84
Lekovic
,
V.
,
P. M.
Camargo
, and
P. R.
Klokkevold
.
et al
.
Preservation of alveolar bone in extraction sockets using bioabsorbable membranes.
J Periodontol
1998
.
69
:
1044
1049
.
85
Sclar
,
A.
Ridge preservation technique for optimal esthetics and function: the Bio-Col technique.
Compend Contin Educ Dent
1999
.
6
suppl
:
3
11
.
86
Sclar
,
A.
Cosmetic soft-tissue enhancement for dental implants.
Alpha Omegan
2000
.
93
3
:
38
46
.
87
Landsberg
,
C. J.
and
N.
Bichacho
.
A modified surgical/prosthetic approach for optimal single implant supported crown.
Pract Periodontics Aesthet Dent
March 1994
.
6
pt 1
:
11
17
.
quiz 19
.
88
Salama
,
H.
,
M.
Salama
, and
J.
Kelly
.
The orthodontic-periodontal connection in implant site development.
Pract Periodontics Aesthet Dent
1996
.
8
:
923
932
.
quiz 934
.
89
Spear
,
F. M.
,
D. M.
Mathews
, and
V. G.
Kokich
.
Interdisciplinary management of single-tooth implants.
Semin Orthod
March 1997
.
3
:
45
72
.
90
Ingber
,
J. S.
Forced eruption. 1. A method of treating isolated one and two wall infrabony osseous defects—rationale and case report.
J Periodontol
1974
.
45
:
199
206
.
91
Ingber
,
J. S.
Forced eruption.
J Periodontol
1976
.
47
pt 2
:
203
216
.
92
Brown
,
S. I.
The effect of orthodontic therapy on certain types of periodontal defects. 1. Clinical findings.
J Periodontol
1973
.
44
:
742
756
.
93
Bahat
,
O.
and
M.
Handelsman
.
Controlled tissue expansion in reconstructive periodontal surgery.
Int J Periodontics Restorative Dent
1991
.
11
1
:
32
47
.
94
Langer
,
B.
Spontaneous in situ gingival augmentation.
Int J Periodontics Restorative Dent
1994
.
14
:
524
535
.
95
Langer
,
B.
and
L.
Langer
.
Overlapped flap: a surgical modification for implant fixture installation.
Int J Periodontics Restorative Dent
1990
.
10
:
208
215
.
96
Abrams
,
L.
Augmentation of the deformed residual edentulous ridge for fixed prosthesis.
Compend Contin Educ Dent
1980
.
1
:
205
213
.
97
Smukler
,
H.
and
M. S.
Chaibi
.
Ridge augmentation in preparation for conventional and implant-supported restorations.
Compendium
1994
.
18
suppl
:
S706
710
.
quiz S714–707
.
98
Langer
,
L.
Enhancing cosmetics through regenerative periodontal procedures.
Compendium
1994
.
18
suppl
:
S699
705
.
quiz S714–697
.
99
Cohen
,
E. S.
Ridge augmentation utilizing the subepithelial connective tissue graft: case reports.
Pract Periodontics Aesthet Dent
March 1994
.
6
:
47
53
.
quiz 55
.
100
Miller
Jr.,
P. D.
Ridge augmentation under existing fixed prosthesis. Simplified technique.
J Periodontol
1986
.
57
:
742
745
.
101
Rosenberg
,
S.
,
J.
Greenberg
, and
N. A.
Cucharale
.
Use of ceramic material for augmentation of the partially edentulous ridge: a case report.
Compend Contin Educ Dent
April 1984
.
5
:
279
284
.
102
Kaldahl
,
W. B.
,
G. J.
Tussing
,
F. M.
Wentz
, and
J. A.
Walker
.
Achieving an esthetic appearance with a fixed prosthesis by submucosal grafts.
J Am Dent Assoc
1982
.
104
:
449
452
.
103
Garber
,
D. A.
and
E. S.
Rosenberg
.
The edentulous ridge in fixed prosthodontics.
Compend Contin Educ Dent
July–August 1981
.
2
:
212
223
.
104
Bahat
,
O.
,
C.
Deeb
,
T.
Golden
, and
O.
Komarnyckij
.
Preservation of ridges utilizing hydroxyapatite.
Int J Periodontics Restorative Dent
1987
.
7
6
:
34
41
.
105
Seibert
,
J. S.
Treatment of moderate localized alveolar ridge defects. Preventive and reconstructive concepts in therapy.
Dent Clin North Am
April 1993
.
37
:
265
280
.
106
Seibert
,
J. S.
Reconstruction of the partially edentulous ridge: gateway to improved prosthetics and superior aesthetics.
Pract Periodontics Aesthet Dent
June–July 1993
.
5
:
47
55
.
quiz 55
.
107
Seibert
,
J. S.
Surgical preparation for fixed and removable prostheses.
In: Genco RJ, Goldman HM, Cohen DW, eds. Contemporary Periodontics. St Louis, Mo: CV Mosby; 1990:637–652
.
108
Seibert
,
J. S.
Ridge augmentation to enhance esthetics in fixed prosthetic treatment.
Compendium
1991
.
12
:
548
.
550, 552 passim
.
109
Meltzer
,
J. A.
Edentulous area tissue graft correction of an esthetic defect. A case report.
J Periodontol
1979
.
50
:
320
322
.
110
Seibert
,
J. S.
Soft tissue grafts in periodontics.
In: Robinson PJ, Geurnsey LH, eds. Clinical Transplantation in Dental Specialties. St Louis, Mo: CV Mosby; 1980:107–145
.
111
el-Salam el-Askary
,
A.
Use of a titanium papillary insert for the construction of interimplant papillae.
Implant Dent
2000
.
9
:
358
362
.
112
Misch
,
C. E.
Single tooth implants.
In: Misch CE, ed. Contemporary Implant Dentistry. 2nd ed. St Louis, Mo: CV Mosby; 1999:397–428
.
113
Ono
,
Y.
,
M.
Nevins
, and
E. G.
Cappetta
.
The need for keratinized tissue for implants.
In: Nevins M, Mellonig JT, eds. Implant Therapy: Clinical Approaches and Evidence of Success. Vol 2. Chicago, Ill: Quintessence; 1998:227–237
.
114
Becker
,
W.
and
B. E.
Becker
.
Guided tissue regeneration for implants placed into extraction sockets and for implant dehiscences: surgical techniques and case report.
Int J Periodontics Restorative Dent
1990
.
10
:
376
391
.
115
Denissen
,
H. W.
,
W.
Kalk
,
H. A.
Veldhuis
, and
M. A.
van Waas
.
Anatomic consideration for preventive implantation.
Int J Oral Maxillofac Implants
1993
.
8
2
:
191
196
.
116
Lazzara
,
R. J.
Immediate implant placement into extraction sites: surgical and restorative advantages.
Int J Periodontics Restorative Dent
1989
.
9
:
332
343
.
117
Dahlin
,
C.
,
L.
Sennerby
,
U.
Lekholm
,
A.
Linde
, and
S.
Nyman
.
Generation of new bone around titanium implants using a membrane technique: an experimental study in rabbits.
Int J Oral Maxillofac Implants
Spring 1989
.
4
:
19
25
.
118
Langer
,
B.
The esthetic management of dental implants.
In: Nevins M, Mellonig JT, eds. Implant Therapy: Clinical Approaches and Evidence of Success. Vol 2. Chicago, Ill: Quintessence; 1998:219–226
.
119
Misch
,
C. E.
Stage II surgery: uncovery and treatment of healing complications.
In: Misch CE, ed. Contemporary Implant Dentistry. 2nd ed. St Louis, Mo: CV Mosby; 1999:385–395
.

Author notes

Christopher E. Kazor, DDS, MS, PhD, is in private practice in Lansing, MI

Khalaf Al-Shammari, DDS, MS, is a staff dentist in the Ministry of Health, Kuwait

David P. Sarment, DDS, MS, is an assistant professor in the Department of Periodontics/Prevention/Geriatrics, School of Dentistry, University of Michigan, Ann Arbor, MI

Carl E. Misch, DDS, MDS,is an adjunct professor in the Department of Periodontics/Prevention/Geriatrics, School of Dentistry, University of Michigan, Ann Arbor, MI, and is in private practice

Hom-Lay Wang, DDS, MSD, is a professor and director of Graduate Periodontics, Department of Periodontics/Prevention/Geriatrics, School of Dentistry, University of Michigan, Ann Arbor, MI. Address correspondence to Dr Wang at the University of Michigan School of Dentistry, 1011 North University Avenue, Ann Arbor, MI 48109-1078 (homlay@umich.edu)