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J Oral Maxillofac Surg

62:90-105, 2004, Suppl 2

Strategies for Management of Single-


Tooth Extraction Sites in Aesthetic
Implant Therapy
Anthony G. Sclar, DMD*

Achieving predictable aesthetic outcomes following the planned removal of a natural tooth suffering
from structural, endodontic, or periodontal compromise depends on a multitude of factors that, once
identified, guide the implant team in selecting the surgical and prosthetic treatment options best suited
for the individual clinical scenario. This article presents pertinent information regarding systematic
patient evaluation and special treatment planning considerations for patients facing the loss of a single
tooth in an area of high aesthetic importance. The rationale for and details of performing the Bio-Col site
preservation technique at the time of tooth removal; guidelines for immediate versus delayed implant
placement; selection and sequencing of site-development procedures according to the types of alveolar
ridge defects encountered following tooth removal despite the use of site preservation; and a description
of prosthetic techniques necessary for the successful management of single-tooth extraction sites in areas
of aesthetic concern also are reviewed.
2004 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 62:90-105, 2004, Suppl 2

Because of the increased awareness within both the Systematic Patient Evaluation
dental and lay communities of the conservative na-
Evaluation of the aesthetic implant patient begins
ture, favorable long-term prognosis, cost effective-
ness, and, more recently, the aesthetic predictability with the completion of a detailed health question-
provided by the single-tooth implant restoration com- naire and patient interview aimed at identifying the
pared with traditional restorative options, this treat- general health status of the patient. In addition to
ment modality is rapidly becoming one of the most identifying common risk factors, such as uncontrolled
common clinical scenarios faced by the implant team. diabetes mellitus and smoking, it is critical to docu-
As such, the implant surgeon must not only be famil- ment the details of the dental history that led to the
iar with those clinical factors that favor a successful removal of the tooth in question. Specifically, a pre-
functional outcome, but also must be able to identify vious history of trauma (subluxation, avulsion with
the factors that may jeopardize or limit aesthetic suc- reimplantation), and endodontic therapy (retreat-
cess when an implant replacement is contemplated ments, apical surgery) associated with acute or
following tooth removal. In addition, the implant chronic infections and their treatment should be doc-
team must be able to select the appropriate surgical umented. The chronology of such events should also
and prosthetic treatment options to manage the com- be recorded. In most instances, a past history of
mon aesthetic clinical case scenarios with a high de- trauma, surgical endodontic therapy or retreatments,
gree of predictability. The purpose of this article is to or infections results in a compromise in the circula-
provide information pertinent to the diagnosis and tion to the supporting periodontal tissues and thus a
treatment planning as well as surgical and prosthetic reduction in the regenerative potential of the site. As
management of patients faced with removal of a sin- a result, osseointegration may be jeopardized, re-
gle tooth in an area of high aesthetic importance. duced volume yields from hard and soft tissue site-
development procedures should be expected, and
*Private Practice, South Florida OMS: Center for Excellence in
increased complications from such procedures are
Dental Implant Surgery, Miami, FL; Adjunct Clinical Professor of likely. Following the detailed medical and dental his-
Surgery, University of Miami, Jackson Memorial Hospital, Miami, FL. tory, diagnostic radiographs, photographs, and study
Address correspondence and reprint requests to Dr Sclar: South casts should be obtained for treatment planning pur-
Florida OMS, 7600 Red Road, Suite 101, Miami, FL 33143. poses. These records also serve to establish the base-
2004 American Association of Oral and Maxillofacial Surgeons line condition before initiating therapy and are useful
0278-2391/04/6209-0220$30.00/0 for subsequent comparison with the final treatment
doi:10.1016/j.joms.2004.06.041 outcome.

90
ANTHONY G. SCLAR 91

The pretreatment clinical evaluation of the aes- lowed for postorthodontic retention because mobility
thetic implant patient should include a complete or movement of the adjacent dentition can negatively
functional and aesthetic evaluation of both the tooth affect osseointegration or proper integration of hard
indicated for removal as well as the neighboring den- and soft tissue grafts.
tition. Focusing attention exclusively on the area in-
dicated for tooth removal and implant replacement PERIODONTAL BIOTYPE
often will result in aesthetic compromises that can be Evaluation of the periodontal biotype2 is another
avoided. While a comprehensive discussion of dento- special treatment planning consideration of clinical
facial and dentoperiodontal evaluation of the aes- significance in aesthetic implant therapy. Knowledge
thetic implant patient is beyond the scope of this of the typical response of each periodontal biotype
article, evaluation of the aesthetic implant patient allows the surgeon and restorative dentist to adjust
should include assessment of facial and dental sym- their approaches and the sequence of treatment to
metry; a careful study of upper and lower lip positions ensure optimal aesthetic results. The thin, scalloped
at rest, in relaxed smile, and in fully animated posi- periodontium is characterized by pronounced posi-
tions to determine tooth and gingival exposure; eval- tive soft tissue architecture; friable soft tissues; mini-
uation of incisal and occlusal plane orientation and mal amounts of attached tissues; and thin underlying
morphologies; evaluation of tooth proportions, mor- alveolar bone with dehiscence and fenestration de-
phology, and relationships including axial inclinations fects commonly found over the natural tooth roots.
and connector zones; evaluation of gingival plane Surgical and prosthetic implant procedures typically
orientation and morphology; evaluation of the peri- result in some degree of soft tissue recession and
odontal status of the tooth in question as well as the underlying resorptive osseous remodeling. Further-
neighboring dentition; determination of periodontal more, a triangular tooth form with subtle cervical
biotype; identification and classification of existing convexities and small connector zones located in the
soft-tissue recession defects; and evaluation of occlu- incisal third has been associated with the thin, scal-
sion for presence or absence of functional guidance loped periodontium. This tooth morphology presents
and adequate interdental and interocclusal space.1 the additional aesthetic challenge of preserving the
While it is important for the surgeon to be able to existing soft tissue architecture with properly con-
quantify the existing dentoperiodontal aesthetics, it is toured interim provisional restorations that prevent
critical that existing or potential dental and periodon- blunting of the papillae and provide subtle support of
tal deficiencies and anatomic limitations be identified the marginal tissues to minimize or prevent recession.
before implant therapy. Therefore, commonly en- Despite careful surgical and prosthetic manipulation,
countered special treatment planning considerations prophylactic soft tissue grafting is indicated in pa-
are emphasized herein. tients with a thin, scalloped periodontium to offset
the predictable loss of soft tissue volume that eventu-
ally will occur secondary to implant surgical and pros-
Special Treatment Planning thetic procedures and subsequent oral hygiene main-
Considerations tenance (Fig 1).
In contrast, the thick, flat periodontium is charac-
TOOTH MALPOSITION terized by relatively flat soft tissue and bony architec-
When teeth are malposed in the patient contem- ture; a dense, fibrotic soft tissue curtain with large
plating aesthetic implant replacement of an ailing amounts of attached tissues; and a thick osseous form
tooth, orthodontic therapy may be indicated to create that is resistant to resorption. A square tooth form
ideal spacing for harmonious aesthetic restoration (ie, with large connector zones and bulbous cervical con-
1.5 to 2.0 mm distance between the implant body and vexities has been associated with the thick, flat peri-
the adjacent dentition). This will also ensure mainte- odontium. Although this periodontal biotype is typi-
nance of proximal bone height and width to support cally resistant to recession, the fibrotic nature of the
the overlying interdental papillae. In addition, fine tissues creates a predisposition for poor incision line
tuning of tooth positions and axial inclinations can be cosmesis following flap elevation. Accordingly, the
performed to harmonize dental proportions, idealize implant surgeon should avoid flap elevation by using
incisal and occlusal plane orientation and morphol- peninsula flap and tissue punch approaches for im-
ogy, and establish functional guidance on the natural plant placement and exposure. When elevation of a
dentition. In certain instances orthodontic extrusion flap is necessary, the incisions should be camouflaged
can be used to optimize bone and soft tissue volume by having them pass through existing anatomic mark-
on adjacent dentition as described below. Finally, ings, such as the mucogingival junction and interden-
when orthodontic therapy is included as part of the tal grooves, and by beveling those portions of the
presurgical preparation, sufficient time must be al- incision that pass through the attached tissues. Metic-
92 MANAGEMENT OF SINGLE-TOOTH EXTRACTION SITES

FIGURE 1.
ANTHONY G. SCLAR 93

FIGURE 1 (contd). A and B, Preoperative views of failing right lateral


incisor with thin, scalloped periodontium. Note the highly scalloped soft
tissue architecture and thin, friable soft tissue drape. C, Postoperative
radiograph. Following minimally traumatic tooth removal, a submerged
implant was placed with the Bio-Col technique. To preserve the soft tissue
architecture at the site, the clinical crown of the tooth was modified into an
ovate pontic and resin bonded to the adjacent teeth. D and E, Immedi-
ately following delivery of the final restoration, the soft tissues were ery-
thematous and subsequently recession of the marginal tissues and blunting
of the mesial papilla became evident, a response that is typical of the thin,
scalloped periodontium. F, To stop the progressive soft tissue recession
and to restore gingival health and aesthetics, a subepithelial connective
tissue graft was performed via a closed-pouch recipient site. G, One year
later, soft tissue contours have been restored and gingival health is evi-
dent. H and I, Follow-up views show regeneration of the previously
blunted mesial papilla and restoration of natural gingival aesthetics.
Anthony G. Sclar. Management of Single-Tooth Extraction sites.
J Oral Maxillofac Surg 2004.

ulous repair is then performed to avoid problematic diographs or direct visualization at the time of sur-
notching of the marginal tissues and unsightly step gery. On occasion, patients with vertical maxillary
defects along the incision line. Nevertheless, the pa- deficiency also have a concave alveolar ridge and
tient with a thick, flat periodontium should be edu- perinasal anatomy, making surgical management of
cated about the predisposition for soft tissue scarring soft tissues and site-development procedures even
and the likely need for secondary gingivoplasty pro- more difficult to perform because of further reduction
cedures or cosmetic soft tissue refinements following of the reconstructive soft tissue envelope.
flap elevation and implant site-development proce- In patients with these anatomic characteristics, the
dures. author has identified a predisposition for apical mi-
gration of soft tissues following implant placement,
VERTICAL MAXILLARY DEFICIENCY exposure, or site-development procedures. The prox-
Vertical maxillary deficiency presents an anatomic imity of the anterior nasal spine and the nasal floor
limitation to successful aesthetic outcomes in implant significantly limits the surgeons ability to obtain pas-
therapy because of a reduced reconstructive soft tis- sive flap adaptation during hard and soft tissue aug-
sue envelope. Typically, these patients present with a mentation because of diminished ability to gain coro-
short upper lip length (defined as less than 20 mm for nal flap advancement over these grafts. Consequently,
males and less than 18 mm for females). Intraoral flap elevation for implant placement usually extends
palpation shows deficient vestibular depth in the an- beyond the mucogingival junction, hence the ten-
terior maxillary region with a shortened distance (less dency for apical soft tissue migration. When planning
than 10.0 mm) measured from the most coronal as- aesthetic implant therapy for patients with these an-
pect of the interdental papilla between the central atomic limitations, the implant surgeon should recog-
incisors and the palpable anterior nasal spine. In ad- nize the increased need for hard or soft tissue aug-
dition, the nasal floor and piriform apertures are mentation to overcome the anatomic limitations and
closely approximated to the roots of the lateral incisor to offset predictable soft tissue retraction and associ-
and canine teeth as determined on pretreatment ra- ated loss of hard tissue.
94 MANAGEMENT OF SINGLE-TOOTH EXTRACTION SITES

Surgical management includes an exaggerated Whenever there is a compromise in the interdental


wide-base curvilinear flap design with beveled inci- bone height or width, either on the teeth adjacent to
sions, careful elevation of the periosteum from the a tooth planned for removal and implant replacement
piriform aperture area, and periosteal releasing inci- or adjacent to an edentulous site with a ridge defect
sions made at the confluence of the alveolar ridge and that will require site development before implant
nasal floor periosteum to obtain tension-free adapta- placement, orthodontic extrusion should be consid-
tion of flaps on wound closure. Elevation of perios- ered as an option for eliminating or diminishing the
teum in these areas improves the overall elasticity of severity of this anatomic limitation. Orthodontic ex-
the flap and detaches the levator labii superioris and trusion can often result in sufficient gain of vertical
zygomaticus minor muscles, thereby reducing upper bone height and width to support the overlying pa-
lip activity in the immediate postoperative period. In pillae, thereby enabling the fabrication of an aesthetic
addition, exposure of the anterior nasal spine and, on restoration with harmonious connector zones. When
occasion, reduction osteoplasty are performed as part the gain in hard and soft tissues is insufficient follow-
of recipient site preparation for hard tissue site devel- ing orthodontic extrusion of the adjacent dentition,
opment. Subsequently, vestibuloplasty is often re- cosmetic periodontal surgery such as aesthetic crown
quired to re-establish adequate vestibular depth. lengthening can be considered to camouflage the
defects and improve the harmony between the im-
COMPROMISED BONE HEIGHT OR WIDTH ON plant restoration and the neighboring dentition. Of
ADJACENT DENTITION course, the patient must be willing to accept an aes-
Compromise in the bone volume around adjacent thetic compromise to maintain these teeth, or alter-
natural dentition presents another anatomic limitation natively, may consider their removal and subsequent
that can jeopardize aesthetic outcomes when implant inclusion in the site-development efforts and eventual
replacement of a failing tooth is contemplated3 or implant restoration with single units or an implant-
when site-development procedures become neces- supported fixed partial denture.
sary following tooth removal.1 Specifically, loss of
height or width of the interdental bone between an Rationale for and Use of the Bio-Col
implant and the adjacent teeth make prosthetic com- Alveolar Ridge Preservation Technique
pensations necessary because of the blunted or miss-
ing interdental papillae that accompany interdental SITE PRESERVATION
bone loss. Similarly, when aesthetic ridge defects be- Preservation or recreation of natural alveolar ridge
come apparent following tooth removal, reduced in- anatomy is a prerequisite for success in aesthetic im-
terdental bone height or width along with dehiscence plant therapy. Natural hard and soft tissue contours
or fenestration defects over adjacent tooth roots di- allow both ideal implant placement and the emergence
minish the outcomes obtainable from hard or soft of a restoration that is harmonious with the adjacent
tissue site-development procedures because a portion dentition and free of prosthetic compensations. As such,
of the recipient site is avascular cementum. In many site preservation is an extremely important concept for
instances, the loss of periodontal support around the the surgeon, the restorative dentist, and the patient to
tooth in question or the adjacent dentition may be embrace when implant therapy is contemplated in an
hidden by soft tissue edema resulting from chronic area of aesthetic concern. The use of site-preservation
inflammation secondary to tooth mobility, violations techniques often reduces or in some instances elimi-
of biologic width, leakage from existing restorations, nates the need for subsequent site-development proce-
or noninfectious tooth resorption. dures. Of greater significance, failure to use a site-pres-
As a result, the pretreatment examination should ervation technique following tooth removal inevitably
always include a thorough clinical and radiographic increases the number and complexity of the site-devel-
evaluation of the tooth in question as well as the opment procedures ultimately required to achieve ac-
neighboring dentition. Radiographic evaluation should ceptable aesthetic results. In aesthetic implant therapy,
focus on defining the interdental bone height and the primary objective of site preservation is either to
width. When significant rotation or root proximity preserve the osseous anatomy and scalloped soft tissue
exists, it is often necessary to obtain several radio- architecture in conjunction with immediate implant
graphs at different angulations. Clinical examination placement or to maintain the volume of reconstructive
may necessitate bone soundings under local anesthe- soft-tissue envelope and positive soft tissue architecture
sia to identify osseous defects at the buccal or lingual when subsequent site-development procedures will be
alveolar crests. The radiographs and clinical measure- unavoidable.4 Just as in plastic and reconstructive sur-
ments serve as a baseline for future comparisons even gery, the reconstructive soft-tissue envelope is a prime
when there has been no loss of supporting periodon- determinant of our ability to surgically reconstruct hard
tal tissues. and soft tissue alveolar defects in implant therapy.
ANTHONY G. SCLAR 95

FIGURE 2. A, Preoperative view of failing left central incisor. B, Preoperative radiograph showing extensive resorption. C, Following tooth removal,
an Aesthetic-plus implant (Straumann, Waltham, MA) was placed using the Bio-Col technique. Care was taken to place the implant in a fashion that
avoided loading of the buccal socket wall and adjacent interdental bone and the voids were grafted with Bio-Oss cancellous bone mineral. D and
E, Final restoration shows improved aesthetics compared with the preoperative condition.
Anthony G. Sclar. Management of Single-Tooth Extraction sites. J Oral Maxillofac Surg 2004.

BIO-COL ALVEOLAR RIDGE PRESERVATION This technique can be used to reduce or avoid osse-
TECHNIQUE ous ridge resorption by minimizing trauma during
Site preservation usually begins at the time of tooth tooth removal. The prepared extraction sockets or
removal. In aesthetic areas, the author uses the Bio- the voids surrounding the immediately placed implant
Col alveolar ridge preservation technique to preserve are then grafted with Bio-Oss (Osteohealth, Shirley,
hard and soft tissue alveolar ridge anatomy in prepa- NY), a natural, porous bone-grafting material. Subse-
ration for immediate or delayed implant placement.4-6 quently, the grafted socket is isolated with an absorb-
96 MANAGEMENT OF SINGLE-TOOTH EXTRACTION SITES

FIGURE 3. A, Preoperative view of failing right central incisor with


distorted soft tissues secondary to chronic irritation from ill-fitting resto-
ration and tooth mobility. B, Preoperative radiograph shows ill-fitting
restoration and evidence of resorption. C, Three months following
tooth removal and application of the Bio-Col technique, a small-volume
soft-tissue aesthetic ridge defect is evident. D, After placement of an
Aesthetic-plus implant, a custom tooth-form healing abutment (Peek,
Straumann) was customized to provide support for the adjacent
interdental papilla and to provide a scaffold for simultaneous soft tissue
augmentation.
Anthony G. Sclar. Management of Single-Tooth Extraction sites.
J Oral Maxillofac Surg 2004.

able collagen material (Collaplug; Zimmer Dental, with thin scalloped periodontal biotypes who are pre-
Carlsbad, CA) that has been coated with an impervi- disposed to loss of alveolar ridge volume secondary to
ous tissue cement (Isodent; Ellmann International, remodeling, resorption of bone following tooth re-
Hewlett, NY); this allows for guided bone regenera- moval, and soft tissue recession following subsequent
tion without the need for flap elevation and primary surgical or restorative interventions.6
closure, thus preserving the surrounding soft-tissue vol-
ume. Finally, the scalloped soft tissue architecture is GUIDELINES FOR DELAYED VERSUS IMMEDIATE
preserved with the use of interim provisional restora- IMPLANT PLACEMENT FOLLOWING TOOTH
tions, anatomic healing abutments, or custom tooth- REMOVAL AT SINGLE-TOOTH AESTHETIC SITES
form healing abutments designed to support the mar- In aesthetic areas, delayed implant placement is
ginal tissues and interdental papillae. This is of critical indicated 1) when there is an osseous wall defect that
aesthetic importance for implant patients who present involves or jeopardizes the buccal alveolar crest, and
ANTHONY G. SCLAR 97

FIGURE 3 contd). E, Subepithelial connective tissue secured at the


site. F, Three months after implant placement and synchronous soft
tissue graft. G, Final restoration 1 year after delivery shows harmonious
dental proportions and natural gingival aesthetics.
Anthony G. Sclar. Management of Single-Tooth Extraction sites.
J Oral Maxillofac Surg 2004.

2) when tooth mobility or chronic irritation second- a subperiosteal pocket extending approximately 2.0
ary to an ill-fitting restoration or when restorative mm beyond the periphery of the defect. This allows for
encroachment on the biologic width requirements for repair of favorable defects and maintenance of the re-
the site has caused edema and distortion of the soft constructive soft-tissue envelope, thereby facilitating fu-
tissues in the area critical for restorative emergence.6 ture reconstruction at sites with unfavorable defects.
In addition, when a site is compromised by a history Finally, when patients present with a thin, scalloped
of trauma, infections, or multiple endodontic or sur- periodontium, the author recommends prophylactic
gical interventions, or when inadequate bleeding is soft tissue grafting before commencement of the pros-
observed following tooth removal, proceeding with im- thetic phase of therapy, even when soft tissue volume
mediate implant placement carries significant aesthetic and architecture initially appear to be ideal as a result of
risk. In these clinical scenarios, the Bio-Col technique using the Bio-Col technique following tooth removal
can be performed and the site subsequently re-evaluated and immediate or delayed implant placement. This pre-
for possible hard or soft tissue site development before emptive strategy fortifies the soft tissues to withstand
or synchronous with implant placement. restorative procedures and future oral hygiene efforts
When an osseous defect is encountered in the fragile thereby avoiding soft tissue recession (Fig 1).
buccal alveolar housing following tooth removal, the Immediate implant placement following tooth re-
defect is classified as either favorable or unfavorable moval is indicated when there is an intact socket and the
based on the width of the defect.6 As a general rule, for hard and soft tissues are healthy and free of pathosis.
single-tooth sites, defects are considered either favorable Vigorous bleeding following tooth removal indicates ex-
or unfavorable when the width of the defect is either cellent regenerative potential. In these instances, the
less than or greater than one third the mesiodistal di- goal is to obtain apical stabilization of the implant and to
mension between the adjacent teeth. This directly cor- maintain a circumferential void between the implant
relates with the remaining volume of host bone present and the socket walls (Fig 2). Loading of the fragile buccal
at the defect margins, which ultimately can contribute plate or encroachment on the adjacent interdental bone
to bone regeneration across the defect via the bridging can jeopardize aesthetic outcomes secondary to osseous
phenomenon. In either case, the Bio-Col technique is resorption, resulting in recession of overlying soft tis-
modified by placing a resorbable barrier membrane into sues and blunting of the adjacent interdental or interim-
98 MANAGEMENT OF SINGLE-TOOTH EXTRACTION SITES

FIGURE 4. A, Preoperative view of failing maxillary canine and


compromised lateral incisor following previous orthodontic eruption of
canine that resulted in periodontal defects around both teeth. B,
Following hard and soft tissue site development via orthodontic extru-
sion and subsequent block bone grafting, a large-volume soft tissue
aesthetic ridge defect persisted at the canine implant site. C and D, A
VIP-CT flap was used to expand the reconstructive soft tissue envelope
by intentionally submerging a 1-piece single-stage implant. E, After
allowing 3 months for osseointegration, a tissue punch was used to
expose and deliver a provisional restoration. An additional 3-month
period was necessary to ensure stabilization of the peri-implant soft
tissues before delivery of the final restoration, which shows harmonious
dental and gingival aesthetics.
Anthony G. Sclar. Management of Single-Tooth Extraction sites.
J Oral Maxillofac Surg 2004.

plant papillae. Any voids are then filled by condensing aesthetic implant sites following tooth removal (eg,
the porous bone mineral and then stabilized by forma- because of unfavorable osseous defect morphology
tion of a blood clot in the area. Small pieces of absorb- or soft tissue pathosis), the surgeon is faced with
able collagen dressing are then condensed over the the need to restore missing hard and soft tissues in
Bio-Oss within the confines of the soft tissue socket and an inconspicuous fashion. Evaluating alveolar ridge
a provisional restoration is modified to avoid loading of defects and determining whether to reconstruct
the implant and to provide support for the soft tissues as them in a staged fashion before or at the same time
needed. as implant placement are the most important clini-
cal decisions facing the implant surgeon. When
Selection and Sequencing of Site site-development procedures are indicated in com-
Development Procedures According to bination with implant placement, the implant sur-
Type of Ridge Defect geon must be able to select and sequence them
When site preservation following tooth removal is appropriately according to the specific type of al-
not successful in maintaining natural ridge anatomy at veolar ridge defect encountered and the aesthetic
ANTHONY G. SCLAR 99

FIGURE 5. A and B, Preoperative view of missing lateral incisor with large-volume hard tissue defect. C, Block and particulate bone grafts were
performed to reconstruct osseous defect prior to implant placement. D, Four months following bone grafting, the ridge width has been restored;
nevertheless, soft-tissue augmentation is indicated synchronous with implant placement. E, After placement of a Narrow Neck implant (Straumann)
with an Aesthetic-plus healing abutment, a subepithelial connective tissue graft is secured around the abutment and to the periosteum at the site. F,
Final restoration is inconspicuous in appearance and smile aesthetics have been greatly improved via aesthetic crown extension and cosmetic
restorations of the neighboring dentition.
Anthony G. Sclar. Management of Single-Tooth Extraction sites. J Oral Maxillofac Surg 2004.

importance of the site. This not only improves the sites, the author distinguishes the classification and
long-term functional results achieved with implant reconstruction of these defects from those found in
therapy but also allows the surgeon to predict re- nonaesthetic areas and from alveolar ridge defects
alistic aesthetic outcomes. Because of the increased associated with conventional fixed restorations,
complexity and biologic requirements of recon- where camouflage procedures are sufficient for
structing alveolar ridge defects at aesthetic implant pontic site development.
100 MANAGEMENT OF SINGLE-TOOTH EXTRACTION SITES

FIGURE 6. A and B, Preoperative views of compromised edentulous site with large-volume combination hard and soft tissue aesthetic ridge defect.
The regenerative potential of the site was compromised as a result of the multiple interventions leading to loss of the incisor. C, Staged reconstruction
began with an autogenous corticocancellous bone graft procedure sequenced 6 months before submerged implant placement. Additional
particulate bone grafting was required at the time of implant placement to obtain optimal hard tissue contours. D, An additional 6 months of healing
time was allowed before performing the necessary soft tissue augmentation with a subepithelial connective tissue graft, which was allowed to mature
for 3 additional months. Note that restoration of adequate ridge contours for aesthetic implant emergence required 3 surgeries and a 15-month
treatment time. E and F, A conservative U-shaped palatal peninsula flap was used to deliver a custom abutment and provisional restoration that
provides the prosthetic-guided soft tissue healing necessary for optimal gingival aesthetics.
Anthony G. Sclar. Management of Single-Tooth Extraction sites. J Oral Maxillofac Surg 2004.

The author has developed a classification system in aesthetic areas are classified according to their
for aesthetic implant ridge defects based on the vol- volume (large or small) and nature (hard tissue, soft
ume and nature of the defect.1 Alveolar ridge defects tissue, or combination hard and soft tissue); this re-
ANTHONY G. SCLAR 101

FIGURE 6 (contd). G and H, The final restoration, delivered 19 months after commencement of treatment, shows harmonious proportions and
pleasing gingival aesthetics.
Anthony G. Sclar. Management of Single-Tooth Extraction sites. J Oral Maxillofac Surg 2004.

sults in 6 different types of aesthetic ridge defects. 2-piece implant with a low-profile healing abutment
Correlation of treatment options with specific defect or a 1-piece single-stage implant (Fig 4).
types simplifies the selection of indicated site-devel- Small-volume hard tissue defects (fenestrations)
opment procedures. that do not jeopardize the buccal alveolar crest are
Small-volume soft tissue defects are generally cor- usually corrected with guided bone-regeneration
rected with subepithelial connective tissue grafts per- procedures performed simultaneously with the
formed at the time of implant placement (Fig 3). In placement of a submerged or nonsubmerged im-
these situations, use of a 1-stage approach with pre- plant. In these clinical scenarios, especially in pa-
fabricated or customizable healing abutments offers tients who have a predisposition for soft tissue
the advantage of immediately supporting the grafted recession (ie, a thin, scalloped periodontium), re-
soft tissues in much the same way a denuded root evaluation of the site approximately 4 months fol-
surface acts as a scaffold during root-coverage proce- lowing the guided bone-regeneration procedure is
dures. This results in maximum volume yield from the recommended because of the possibility that soft
soft tissue graft, especially in the vertical dimension. tissue grafting may be needed to improve soft tissue
Under these circumstances, aesthetic predictability is volume and/or aesthetics.
improved by allowing adequate time for the develop- Large-volume hard tissue aesthetic ridge defects
ment of a stable peri-implant sulcus before initiating prevent ideal implant positioning and therefore are
implant restorative procedures. Alternatively, a always reconstructed in stages using autogenous
2-stage approach can be used with similar results corticocancellous block and particulate cancellous
providing a tooth-form healing abutment or custom bone grafts. In these clinical scenarios, prophylac-
abutment and provisional restoration is delivered at tic soft tissue grafting is indicated to offset the
the second stage surgery and approximately 3 addi- predictable loss of soft tissue volume that follows
tional months are allowed for the soft tissue integra- the large-volume bone graft reconstruction. Again,
tion process with stabilization of sulcus depth before a soft tissue graft can be performed simultaneously
commencement of the definitive prosthetic proce- with placement of a submerged or nonsubmerged
dures. implant as previously described (Fig 5). Alterna-
In contrast, large-volume soft tissue aesthetic tively, a VIP-CT flap can be performed simulta-
ridge defects are usually corrected with several neously with the large-volume bone graft recon-
subepithelial connective tissue grafts before im- struction followed by implant placement 4 months
plant placement. A single-stage implant can be later.7
placed following maturation of the first soft-tissue Whereas small-volume combination hard and soft
graft if the residual defect is small in volume. Alter- tissue aesthetic ridge defects are often camouflaged
natively, a vascularized interpositional periosteal- with soft tissue grafts or alloplast grafts performed
connective tissue (VIP-CT) flap7 can be used before simultaneously with implant placement, large-vol-
implant placement, in conjunction with submerged ume combination defects require staged recon-
implant placement, or to deliberately expand the struction (Fig 6). Nevertheless, the author prefers
reconstructive soft tissue envelope by submerging a the option of performing simultaneous hard and
102 MANAGEMENT OF SINGLE-TOOTH EXTRACTION SITES

FIGURE 7. A and B, Preoperative views of left central incisor implant site with large-volume combination hard and soft tissue aesthetic ridge defect.
C, Four months after synchronous hard and soft tissue reconstruction of the ridge defect with autogenous block and particulate bone grafts and VIP-CT
flap, ridge contours have been restored. D, The site is re-entered and a single-stage implant is placed. The advanced stage of bone graft integration
observed is attributed to the simultaneous use of the VIP-CT flap with the bone-grafting procedure. E, A custom tooth-form healing abutment was used
to immediately provide prosthetic-guided soft tissue healing. F, Three months later, scalloped soft tissue architecture is evident and a stable soft tissue
environment is present.
Anthony G. Sclar. Management of Single-Tooth Extraction sites. J Oral Maxillofac Surg 2004.

soft tissue site development with autogenous block terms of maintaining adjacent papillary height and
bone grafts and VIP-CT flap(s) and proceeding with natural scalloped soft tissue architecture. As the
single-stage implant placement after 4 months of soft tissues mature, this approach offers the sur-
healing (Fig 7). The use of customizable tooth-form geon the additional advantage of visualizing the soft
healing abutments offers tremendous advantages in tissue aesthetics and performing soft tissue refine-
ANTHONY G. SCLAR 103

FIGURE 7 (contd). G and H, Final restoration is harmonious in appearance and natural gingival aesthetics have been restored. Use of
simultaneous hard and soft tissue reconstruction greatly reduced the total treatment time (8 months) required for reconstruction of this large-volume
combination aesthetic ridge defect compared with a traditional staged approach.
Anthony G. Sclar. Management of Single-Tooth Extraction sites. J Oral Maxillofac Surg 2004.

ments if necessary without significant delay in treat- impression) that is subsequently used to fabricate a
ment or inconvenience to the patient. Neverthe- working model upon which the abutment and provi-
less, similar results may be obtained when the sional restoration are fabricated in the dental labora-
principles of prosthetic-guided soft tissue healing tory. The surgical index procedure involves attaching
are applied at implant exposure, provided that ad- a specialized fixture-level impression coping to the
equate time is allowed for stabilization of the peri- implant and registering its 3-dimensional position rel-
implant soft tissues as detailed above. ative to the adjacent dentition using a fast-set polyvi-
nylsiloxane impression material. The material is in-
Prosthetic Techniques Necessary for jected around the index coping and over the incisal
Successful Management of Single-Tooth and occlusal surfaces of a sufficient number of adja-
Extraction Sites cent teeth to provide an accurate index. Subse-
quently, an implant analog is attached to the impres-
PROSTHETIC-GUIDED SOFT TISSUE HEALING sion-coping complex and the combination is seated
The use of prosthetic-guided soft tissue healing on an altered master cast, where the analog is secured
to enhance aesthetic outcomes in implant therapy with quick-set plaster or acrylic resin. The result is a
involves the early introduction of prosthetic com- working model that contains a replica of the implant
ponents (interim provisional restorations, tooth- as recorded at the time of surgery. Three months
form healing abutments, and implant-supported following implant placement, another impression
provisional restorations) that correspond to the captures the matured soft tissue contours, allowing
cross-sectional anatomy of the lost tooth or the the addition of soft tissue contours to the index
planned aesthetic replacement at the gingival level. model. The soft tissue model aids the laboratory tech-
These components support and guide soft tissue nician in the placement of restorative margins at an
healing following various surgical interventions and appropriate depth on the custom abutment. In most
have tremendous influence on the final soft tissue instances, the laboratory either casts or mills a custom
architecture obtained at the implant site. These abutment that incorporates a proximal rise to ensure
prosthetic elements can be used to preserve exist- that the restorative margins are located in the super-
ing soft tissue anatomy following tooth removal and ficial aspect of the peri-implant sulcus circumferen-
as a scaffold for guided healing of peri-implant soft tially. In addition, the provisional restoration is fabri-
tissues. cated with ideal contours to support and guide the
Custom Abutments and Provisional Restorations healing of the peri-implant soft tissues immediately
Delivery of custom abutments and provisional res- upon exposure of the submerged implant. In most
torations immediately upon exposure of submerged instances, the surgeon then delivers the abutment and
implants is 1 method that can be used to initiate early cements the provisional restoration at the second-
guided soft tissue healing for enhanced aesthetic soft- stage surgery via a conservative approach. Significant
tissue contours. At the time of implant placement, the occlusal adjustments or modifications to contours are
surgeon must perform a surgical index (fixture-level rarely necessary. Nevertheless, the author recom-
104 MANAGEMENT OF SINGLE-TOOTH EXTRACTION SITES

mends coordinating the exposure appointment with an implant analog in the altered cast according to the
the restorative dentist, who should reserve time for surgical guide. A modifiable stock prosthetic compo-
the rare instance that significant modifications are nent is then secured to the analog, and a tooth-form
needed. Another important consideration to discuss is healing abutment is customized for that site. The
the recommended timing and technique used by the technician can use the contralateral tooth, when
restorative dentist for final impressions. In most situ- present, as a guide for accurate reproduction of con-
ations, 3 months are allowed for the tissues to stabi- tours. The surgeon then delivers the custom healing
lize around the custom abutment and provisional res- abutment immediately upon placement of the non-
toration. In addition, this allows time for the submerged implant. Minor chair-side modifications
restorative dentist to modify contours as needed to are sometimes necessary.
satisfy the patients phonetic and aesthetic demands Alternatively, the surgeon can modify a stock pros-
before delivery of a final restoration. thetic component to create a custom tooth-form heal-
In summary, the use of custom abutments and pro- ing abutment for immediate use at the time of sub-
visional restorations at aesthetic implant sites requires merged implant exposure or nonsubmerged implant
that the surgeon perform a surgical index procedure placement. A prefabricated component can be modi-
at the time of implant placement and subsequently fied either by adding acrylic resin or by reducing,
deliver the prosthetic components at implant expo- shaping, and polishing an oversized cylindrical stock
sure. Although these techniques are very useful for component. The goal is to closely approximate the
enhancing aesthetic outcomes through guided soft- cross-sectional form of the lost tooth or planned final
tissue healing, they require significant coordination restoration, which can be very time-consuming. A
with the restorative dentist and laboratory technician. practical approach used by the author is to modify a
There is also additional expense and time involved for stock component to match the mesiodistal width of
the surgeon. Nevertheless, the enhanced aesthetic the proposed replacement tooth and undercontour
result and the significant convenience realized by the the facial aspect of the custom healing abutment. The
patient warrant this approach in aesthetic implant abutment thus provides support and guidance for the
therapy. adjacent papillae while allowing excess soft tissues to
collapse over the facial aspect, thereby preventing
Custom Tooth-Form Healing Abutments recession. The surgeon must have appropriate equip-
Another prosthetic technique used by the surgeon ment to shape and polish the custom tooth-form heal-
to initiate early guided soft tissue healing involves the ing abutment before its delivery. The process is facil-
use of custom tooth-form healing abutments. These itated when the surgeon attaches the modifiable
anatomically shaped healing abutments closely ap- abutment to an implant analog during the chair-side
proximate the cross-sectional anatomy of the lost fabrication process. In the authors experience, this
tooth or the planned replacement at the gingival chair-side approach is relatively easy and yields excel-
level. Because every anterior maxillary tooth is lent results but requires additional chair time com-
unique, prefabricated components are unlikely to pared with previously described laboratory tech-
yield an ideal result in terms of tissue support and niques.
guided soft tissue healing. Although prefabricated an- In summary, the use of custom tooth-form healing
atomically shaped healing abutments have proven abutments is a practical approach for early initiation
useful for enhancing aesthetic soft tissue contours in of prosthetic-guided soft tissue healing. This approach
many cases, the use of custom tooth-form healing requires less time and expense than the use of custom
abutments will yield superior soft tissue results in abutments and provisional restorations, as described
certain instances. Custom tooth-form healing abut- above. The restorative dentist can easily remove and
ments can be fabricated in the laboratory from a replace the custom tooth-form abutment during im-
surgical index, as described above, and subsequently pression procedures, thus facilitating subsequent
delivered at the time of implant exposure; alterna- prosthetic management of the patient.
tively, they can be fabricated on a working cast in To successfully manage those patients facing the
preparation for nonsubmerged implant placement. loss of a single tooth in an area of high aesthetic
This process involves laboratory modification of a importance, the implant team should use a compre-
prefabricated prosthetic component to approximate hensive strategy that begins with a systematic func-
the cross-sectional anatomy of the proposed final res- tional and aesthetic evaluation aimed at identifying
toration. the factors that could enhance or detract from the
To begin, a diagnostic wax-up of the final restora- final aesthetic outcome. This allows them to select
tion is made and a surgical guide is fabricated. The and sequence the unique combination of orthodontic,
laboratory technician alters the study cast, assumes surgical-periodontal, and implant prosthetic tech-
ideal implant placement by the surgeon, and secures niques necessary to ensure a harmonious implant res-
ANTHONY G. SCLAR 105

toration. This article outlines pertinent information 3. Tarnow DP, Magner AW, Fletcher P: The effect of the distance
between the contact point to the crest of bone on the presence
for the management of patients facing the loss of a
or absence of the interproximal dental papilla. J Periodontol
single tooth in an area of high aesthetic importance; 63:995, 1992
however, further study is recommended for the 4. Berglundh T, Lindhe J: Healing around implants placed in bone
reader who seeks to consistently meet the formidable defects treated with Bio-Oss: An experimental study in the dog.
Clin Oral Implants Res 8:117, 1997
challenges commonly encountered in aesthetic im- 5. Sclar AG: Preserving alveolar ridge anatomy following tooth
plant therapy. removal in conjunction with immediate implant placement. The
Bio-Col technique. Atlas Oral Maxillofac Surg Clin North Am
7:39, 1999
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