Early Implant Esthetics and Technique Refinements

When a new surgical modality is rolled out, it is always followed by a period of refinement. We have been in that process for the last two years and today we are going to share with you our current methodology.

New Understandings

Vertical gingival incisions for membrane placement are not required to achieve gingival hypertrophy necessary for ideal gingival architecture and esthetics. The most ideal esthetics and gingival architecture are achieved when the gingiva and membrane are secured by a tissue adhesive.

The following cases display the results of our recent refinements. Gingival esthetics are critical, but correct gingival contours are also a health issue. The proper shape of the gingiva allows for proper oral hygiene. With this in mind, proper gingival contours are required not only in the esthetic region but also on all implant supported crowns.

In the following case, tooth #10 was extracted, grafted with Socket Graft Injectable, and covered with a d-PTFE membrane. The membrane was placed under a buccal envelope flap, and on the lingual, vertical incisions were used. The membrane was secured with Oral Bond tissue adhesive. Four weeks after extraction, the membrane was removed and the implant was placed with a healing abutment. The following photographs were taken a few months after restoration.
Extraction without grafting will not only result in the collapse of the gingiva, but also the alveolar ridge. Traditional grafting with delayed implant placement will result in collapse of the gingiva and an irreversible esthetic and oral hygiene defect. Immediate implant without restoration will also result in complete collapse of the gingiva and an esthetic defect. The only traditional way to achieve an acceptable esthetic result is by placing an immediate implant with a properly contoured temporarily restoration. This technique is tedious and time-consuming, and also has increased potential for failure to integrate. Early implant placement achieves predictable excellent esthetics and gingival contours while avoiding the complexities and complications associated with traditional implant methods. A main feature of early implant placement is the ease and predictability of the therapy. No tedious, time-consuming temporaries and minimal waiting period between extraction and restoration. To the patient and practitioner, there are two main advantages to early implant placement:

  1. The implant is placed with no incisions, flaps, or sutures
  2. The time from extraction to restoration is 3 months

The following images will document the process, and the refinements over previous cases will be noted.
The tooth was extracted, grafted with Socket Graft Injectable, and covered with a d-PTFE membrane with buccal envelope flap. The flaps and membrane were secured with Oral Bond.
Four weeks after extraction.
Membrane removal at 4 weeks. The arrows indicate the gingival hypertrophy produced by the d-PTFE membrane.
After implant placement, the implant depth is checked. The healing abutment is 3.5 mm long. Placing the collar of the implant 3.5 mm below the gingival margin places the healing abutment flush with the gingiva. This measurement works with the Astra implant system and is used throughout the dentition to properly position the implant in the bone while producing an excellent emergence profile. Other implant systems may require a modification of this measurement.
Implant placement at 4 weeks post extraction.
6 weeks after implant placement and 10 weeks after extraction, the gingival hypertrophy remains, but the buccal and lingual hypertrophy is beginning to reduce. However, the crestal gingiva has not receded as the healing abutment remains flush with the gingiva.
The gingiva has lost no vertical dimension at 10 weeks after extraction as the healing abutment remains flush with the gingival margin. The patient is referred for restoration at this time.
A few months after restoration, the buccal hypertrophy has disappeared, however, the gingival margin on the implant crown is coronal to the gingival margin on #7.

A minor gingivoplasty on the gingival margin of #10 would bring the clinical crown length in line with #7 if precise esthetic balance is required.
Fractured mandibular first molar.
To facilitate ease of implant placement, the interradicular septum is removed at the time of extraction.

4 weeks post extraction.

6 weeks post extraction.
6 weeks post extraction.
Day of implant placement, 6 weeks post extraction.
Integration post-op check, prior to restoration. No gingival recession has occurred with the healing abutment flush with the gingival margin.
Normal gingival architecture allowing for excellent oral hygiene and esthetics.
Implant in function supported by healthy dense bone.

Early implant placement in sites grafted with either Socket Graft Injectable (syringe) or Socket Graft (trays) and a d-PTFE membrane produces predictable excellent esthetics and implant integration. These results, combined with a shortened time to restoration and a quick, minimally invasive flapless implant placement, provide significant improvements over traditional implant placement for both doctor and patient.

In the early stages of development of the early implant placement technique, the cases were limited to intact sockets. However, further understanding of the regenerative process is now allowing us to apply the early implant technique to cases where the buccal wall is missing. We will keep you posted on our progress.


American Society for Bone and Mineral Research (ASBMR)

Tissue Engineering and Regenerative Medicine International Society (TERMIS)