CASE REPORT

IMMEDIATE IMPLANT PLACEMENT

Soft-Tissue Grafting Techniques Associated

With Immediate Implant Placement
Mark Bishara, DDS; Gregori M. Kurtzman, DDS; Waji Khan, DDS; Joseph Choukroun, MD; and Richard J. Miron, DDS, dr.
med dent, MSc, PhD

Abstract: Immediate implant placement often presents challenges in terms of predictably obtaining soft-tissue
coverage over the implant site. While delayed implant placement offers the ability for soft tissues to grow and invade
the extraction socket making their attachment around implants more predictable, immediate implant placement
poses a significant risk of bacterial invasion towards the implant surface as a result of insignificant soft-tissue
volume. Soft-tissue grafting techniques have often been proposed for use during immediate implant placement to
augment soft-tissue deficiencies, including the use of either palatal connective tissue grafts (CTGs) or collagen-
derived scaffolds. However, both of these approaches have significant drawbacks in that CTGs are harvested with
high patient morbidity and collagen scaffolds remain avascular and acelluar posing a risk of infection/implant
contamination. More recently, platelet-rich fibrin (PRF) has been proposed as an economical and biological means
to speed soft-tissue wound healing. In combination with immediate implant placement, PRF offers an easily
procurable low-cost regenerative modality that offers an efficient way to improve soft-tissue attachment around
implants. Furthermore, the supra-physiological concentration of defense-fighting leukocytes in PRF, combined
with a dense fibrin meshwork, is known to prevent early bacterial contamination of implant surfaces, and the
biological concentrations of autologous growth factors in PRF is known to increase tissue regeneration. This article
discusses soft-tissue grafting techniques associated with immediate implant placement, presents several cases
demonstrating the use of PRF in routine immediate implant placement, and further discusses the biological and
economic advantages of PRF for the management of soft-tissue grafting during immediate implant placement.

I
mplant placement often presents challenges in terms of pre-
dictable soft-tissue coverage. This is especially true in the
esthetic zone where a lack of supporting keratinized soft
tissue during implant placement often compromises the final
esthetic outcomes when mucosal recession occurs around
these implants. Timing of implant placement has mainly been char-
acterized into four categories: (1) immediate implant placement
(type 1) occurring when implants are placed at the same time as the
surgical extraction of teeth; (2) early implant placement (type 2)
occurring when soft-tissue healing has transpired and implants are
placed typically within 4 to 8 weeks following extraction; (3) early
implant placement (type 3) when partial bone healing has occurred
in the socket by typically 12 to 16 weeks after extraction; and lastly,
(4) late implant placement (type 4) when the extraction socket has
fully healed after 16 weeks.1 The principles that will be discussed
in this article may be applied with either a one-stage or two-stage
surgical approach, depending on the practitioner’s preferences and
the clinical situation that presents.
Type 1 immediate implant placement is deemed the most surgically
challenging and possesses additional risks in that soft-tissue coverage
over the extraction site as primary closure is not easily achievable
without flap elevation and repositioning. Unlike types 2 through 4,
where soft tissue has formed over the socket, the practitioner is left
with limited methods to protect the implant site during the initial
healing period. Traditionally, soft tissue is relieved (often requiring
vertical releasing incisions) at the time of implant placement by un-
dermining the periosteum, thus allowing tissue mobilization without
tension to achieve a passive primary closure over the wound site.2
This often results in distortion of the mucogingival junction and a lack
of adequate attached gingiva on the buccal/facial aspect of the site.
Furthermore, an apical repositioning of the flap at second-stage sur-
gery (implant exposure) and/or soft-tissue grafting is often required
to allow for sufficient keratinized tissue coverage around the implant
emergence. An associated increase in swelling with associated pain
while utilizing this approach due to manipulation of the periosteum
related to undermining to permit flap release has also been noted.
Other techniques for wound coverage allow the site to heal by sec-
ondary intention and use barrier membranes to protect the implant
site and any associated bone graft that may have been placed simul-
taneously during implant placement. Such techniques include the use

1 COMPENDIUM February 2018 Volume 39, Number 2

 Fig 1. High-density and implant during the initial healing period. Because this approach
PTFE membrane used does not require periosteal releasing incisions, postoperative pain and
to cover an extrac-
tion socket. Fig 2. swelling are minimized. The margins of the socket are undermined
Fibrin clot (yellow) and the membrane is tucked under the soft tissue on the buccal and
in the tube following lingual, then sutures are placed to retain the membrane (Figure 1).
centrifugation. Fig
3. PRF clots formed These membranes are typically removed without local anesthesia at
after centrifugation, 4 to 6 weeks by grasping the exposed portion and gently tugging it out
which may be used of the site, as tissue does not grow into the membrane. New gingival
to make either PRF
Fig 1. membranes or plugs. tissue grows under the membrane and completely covers the site. While
this method is often utilized, it is expected that soft-tissue healing is
slightly slower and the nonresorbable membranes are known to create
a foreign body reaction with host tissues.8
While nonresorbable barrier membranes were first utilized, an
entire line of resorbable membranes fabricated from collagen de-
rived from various allograft and xenograft sources have seen a steady
increase in use due to their added biocompatibility and the elimina-
tion of the need for a second procedure to remove the membrane.9
Therefore, collagen-derived membranes were introduced as an al-
ternative either by acting as a barrier or by being utilized as a socket
seal as a collagen plug to protect the wound site.10,11 This technique
reduces postoperative discomfort because there is no need for pri-
mary closure or a second harvest site. Naturally, the gold standard
for soft-tissue coverage of either a graft or implant site is autologous
tissue, including a free gingival graft or connective tissue graft.12 While
clinically the final esthetic outcomes remain optimal, use of these
grafts is also associated with a higher incidence of postoperative
discomfort due to graft harvesting at the donor site.10
Deriving biological membranes from blood drawn from the pa-
Fig 2. tient’s peripheral veins has recently been proposed as an alternative
approach to packaged membranes. Briefly, blood is collected and im-
mediately centrifuged for 8 to 14 minutes to reach supra-physiological
doses of growth factors and leukocytes producing what has been
termed platelet-rich fibrin (PRF) (Figure 2). PRF can similarly be
used in an open membrane technique to protect the implant site and
may be left exposed to the oral cavity without major risk of infec-
tion due to its incorporation of supra-physiological concentration
of leukocytes, defense-fighting cells that engulf incoming pathogens.
Furthermore, the dense fibrin meshwork also prevents bacteria from
Fig 3.
penetrating toward the implant surface. Once centrifuged the fibrin
clot portion in the tube (PRF) is removed (Figure 3) and pressed to
of d-polytetrafluoroethylene (d-PTFE) membranes, which require create an autologous membrane derived without the use of antico-
removal of the nonresorbable membrane at a later date. Expanded agulants (Figure 4). The advantages of this approach include reduced
polytetrafluoroethylene (e-PTFE) membranes have also been widely cost and complete biocompatibility with host tissues, thus avoiding
used for guided bone regeneration (GBR) procedures in implant den- the use of creating a foreign body reaction. Additionally, remodeling
tistry since the early 1980s, and their long-term use has been well- of the PRF membrane naturally occurs within 2 weeks and acts as a
documented.3,4 Several disadvantages of e-PTFE include wound de- “tissue glue” when placed, aiding in containing the graft placed into the
hiscence and early membrane exposure that may compromise the bone site and protecting it from saliva and its bacterial components (Figure
augmentation procedure and lead to localized infection.5 d-PTFE can 5). The PRF membrane may also be used in a “poncho” technique,
also be used in an open membrane technique (part of the membrane retaining the membrane with the healing cap or cover screw to pro-
is left exposed due to an inability to achieve primary closure) as intro- vide wound protection and stabilization of soft tissues while further
duced in 2005 by Funakoshi.6 The advantage of this technique over the speeding the regenerative outcomes of soft tissues as a result of the
Fig 7.
use of e-PTFE is d-PTFE has a very low membrane porosity and, thus, supra-physiological doses of growth factors found in PRF.
prevents bacterial penetration through the membrane to the underly- The following case reports illustrate the typical steps undertaken
ing graft or implant.7 The smooth nonporous surface of this membrane to obtain advanced PRF (A-PRF) membranes used to cover an im-
allows portions to be left exposed while protecting the underlying graft mediate implant placement.

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CASE REPORT | IMMEDIATE IMPLANT PLACEMENT

Case 1 to eliminate potential of dermal bacteria at the needle site to collect

A 44-year-old healthy man presented following a work-related in-
cident in which his endodontically treated maxillary right central
incisor, which had been restored with a post/core and crown, was
fractured. The tooth fracture occurred at the gingival margin (Figure
6). Replacing the crown would require osseous crown lengthening to
achieve a restorative ferrule, thereby compromising the bone level on
the adjacent teeth. Clinically, no evidence of root fracture was noted
(Figure 7) and probing depths were within normal levels (1 mm to 3
mm). Treatment options presented to the patient included: osseous
crown lengthening with placement of a new post/core and crown,
extraction with placement of a fixed bridge using the adjacent teeth
as abutments, or extraction and implant placement with a single-
crown restoration. The patient chose the implant treatment option.
A thorough medical history was collected and extraction consent
given. Two carpules of 1.8 ml 2% Xylocaine Dental with 1:100,000
epinephrine (Dentsply Sirona, dentsplysirona.com) was administered
as infiltration locally and an incisive nerve block was achieved. A
disposable tourniquet was placed on the patient’s right arm, 10 cen-
timeters above the elbow. A vein was visually and physically located
in the antecubital fossa. An alcohol wipe was used to prepare the site
blood, and the site was allowed to dry for 30 seconds. A 23-gauge
venipuncture needle was attached to a vacutainer holder and two
10-ml red vacutainer tubes were used to harvest two vials of blood.
This was then immediately centrifuged at 1,300 rpm for 8 minutes
as per the A-PRF protocol.4,5
With the use of a Woodson elevator (Hu-Friedy, hu-friedy.com), the
gingiva was delicately dissected from the fractured central incisor; this
was done in a circumferential manner to expand the bone around the
tooth. The tooth was atraumatically extracted using a #76S forcep (Hu-
Friedy) employing a rotation/counter-rotation technique to prevent
fracture of the thin buccal plate. The extraction socket was examined;
the buccal plate was noted to be intact and no fenestration or dehis-
cence was observed (Figure 8). The extraction socket was debrided
using a curette to remove any residual soft tissue and then irrigated
with saline solution. A precision drill (MIS Implants, mis-implants.
com) was then used to engage the dense palatal cortical bone for the
pilot osteotomy to act as a guide for the subsequent osteotomy drills.
This was followed with use of the 2.3-mm pilot drill (MIS Implants),
placing the implant angulation to accommodate a screw-retained posi-
tion for the planned crown. The drilling sequence, thus, was completed.

Fig 4. Fig 5. Fig 6.

Fig 7. Fig 8. Fig 9.

Fig 10. Fig 11. Fig 12.

Fig 4. PRF clots compressed to form PRF membranes. Fig 5. PRF plugs used to fill an extraction socket without need for primary closure. Fig 6.
Radiograph of fractured central incisor with past history of root canal therapy. Fig 7. Occlusal view of fractured central incisor with past history
of root canal therapy. Fig 8. Atraumatic removal of central incisor. Fig 9. Implant placement in a palatal position. Fig 10. PRF plug used to seal the
implant site. Fig 11. Periapical radiograph taken during implant placement. Fig 12. Periapical radiograph taken at implant uncovery after 3 months
of healing, demonstrating bone fill around the implant.

3 COMPENDIUM February 2018 Volume 39, Number 2

 A UNC 15 periodontal probe (Hu-Friedy) was then used to assess Fig 13. Final heal-
the osteotomy site to ensure no fenestrations in the buccal plate ing and soft-tissue
emergence profile.
had occurred following osteotomy preparation. A 5-mm x 13-mm Fig 14. Radiograph
C1 implant (MIS Implants) was placed into the preparation (Figure of the completed
9). Implant primary stability was evidenced by a 30 Ncm insertion restoration on the
implant demon-
torque. Lateral stability was questionable based on the gap/jump strating a natural
junction observed between the buccal plate and the implant. A cover emergence profile.
screw was placed into the implant. The fibrin clots were removed Fig 15. Completed
restoration on the
from the glass vials to produce A-PRF membranes, and one of these implant demon- Fig 13.
membranes was then placed to augment the gap on the buccal and strating a natural
cover the extraction site (Figure 10). A figure 8 suture was placed over emergence profile
with healthy gingiva
the site with 3-0 silk on a reverse cutting C6 needle (LOOK™ Sutures, and the absence of
Surgical Specialties Corp., angiotech.com). A periapical radiograph inflammation.
was taken to document the implant placement (Figure 11). Fig 16. Central inci-
sor with post-and-
The patient returned a week later for postoperative evaluation core restoration
and suture removal and reported very minimal to no pain following resulting in a vertical
the procedure. At 3 months post implant placement, the patient re- root fracture.

turned for stage two surgery and a periapical radiograph was taken
(Figure 12). Half a carpule of 2% Xylocaine Dental with 1:100,000
epinephrine was administered into the gingiva overlaying the implant.
An incision was made with a 15c scalpel blade mesial-distally to the
palatal side of the mid-crestal line. The tissue was positioned to the
facial to preserve adequate attached gingiva and horizontal mattress
sutures with 6-0 Prolene® (Ethicon, ethicon.com) were used to se-
cure the repositioned flap. A screw-retained provisional crown was
created to develop the emergence profile of the soft tissue around
the uncovered implant. Fig 14.
Approximately 6 weeks later, the patient presented for impressions
and the screw-retained provisional crown was removed (Figure 13).
An open-tray impression coping was placed and a periapical radio-
graph was taken to ensure the impression coping was properly seated.
An open-tray fixture level impression was taken using Maxill® Light
and Heavy Body PVS (Maxill Dental, maxill.com) in a stock tray
(Master Tray®, Waterpik Oral Health, waterpik.com) and was sent
to the lab for fabrication of a screw-retained crown.
The laboratory returned the restoration for insertion. The patient
Fig 15.
presented and the provisional restoration was removed. The final
screw-retained crown was inserted and the screw was tightened with
finger pressure on a hex wrench. A radiograph was taken to verify
complete mating of the parts. A torque wrench was used to tighten
the fixation screw to the manufacturer’s recommendation of 30 Ncm.
A ball of PTFE tape was placed into the screw channel and sealed
with Filtek™ Flow composite (3M ESPE, 3m.com). Occlusion was
checked and the patient dismissed (Figure 14). Follow-up with the
patient at a post-insertion appointment demonstrated healthy non-
inflamed gingival tissue surrounding the implant restoration with a
natural emergence profile (Figure 15).

Case 2
A 38-year-old healthy woman presented to the clinic with issues
pertaining to a previously endodontically treated and restored maxil-
lary left central incisor. Radiographically the tooth appeared normal
(Figure 16). Clinically, a vertical root fracture was noted as evidenced
by an isolated probing depth on the facial of the tooth. Treatment op-
Fig 16.
tions were presented to the patient, which included: extraction with

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CASE REPORT | IMMEDIATE IMPLANT PLACEMENT
placement of a fixed bridge using the adjacent teeth as abutments,
or extraction and implant placement with a single-crown restoration.
She decided to pursue the dental implant option.
After a thorough medical history was collected, consent for treat-
ment was provided. Two carpules of 1.8-ml 2% Xylocaine Dental
with 1:100,000 epinephrine was administered as infiltration and an
incisive nerve block. Blood was collected at the antecubital fossa
as previously described in Case 1. A Woodson elevator was used to
circumferentially dissect the gingiva around the central incisor. The
tooth was atraumatically extracted using a #76S forcep in a rotation/
counter-rotation manner (Figure 17). The extraction socket was then
debrided using a curette and irrigated with saline solution. A precision
drill was then used to engage the dense palatal cortical bone to guide
the pilot drill for the osteotomy. The 2.3-mm pilot drill was used to
align the angulation to allow a screw-retained crown implant position.
The drilling sequence was then completed.
A UNC 15 periodontal probe was used to assess the osteotomy site
to ensure no fenestrations in the buccal plate were present. An MIS
SEVEN 5-mm x 13-mm implant (MIS Implants) was placed into the
osteotomy with primary stability as evidenced by a 30-Ncm inser-
tion torque (Figure 18). Again, the lateral stability was questionable
as a result of the gap/jump junction that was observed between the
buccal plate and implant. A cover screw was placed into the implant.
Because this case had a larger gap/jump junction then the previ-
ous case discussed, 0.25 cc cortical/cancellous bone allograft with a
particle size ranging from 250 µm to 1000 µm (OraGRAFT®, LifeNet
Heath, lifenethealth.org) was mixed with an injectable PRF (i-PRF,
centrifuged at 700 rpm for 3 minutes) to create a putty-like graft,
which was placed into the buccal gap (Figure 19). The fibrin clots
were removed from the centrifuged vials to produce A-PRF mem-
branes as previously described in Case 1, and an A-PRF membrane
was then used to cover the extraction site (Figure 20). This was fixed
Fig 17. Fig 18.
Fig 14.
Fig 20. Fig 21.
Fig 17. Atraumatic removal of affected tooth. Fig 18. Implant placement in a palatal position relative to facial plate. Fig 19. Freeze-dried bone
allograft used to fill gap between implant and buccal wall. Fig 20. PRF membrane placed over immediate implant and tucked under buccal and
lingual gingival margins. Fig 21. A figure 8 suture was used to secure PRF membrane placed over the immediate placed implant. Fig 22. Final
healing after 3 months.
5 COMPENDIUM February 2018
in place using a figure 8 suture utilizing 3-0 silk on a reverse cutting
C6 needle (Figure 21).
The patient returned a week later for postoperative evaluation and
suture removal. Three months post implant placement the patient
returned for stage two surgery demonstrating healthy non-inflamed
soft tissue overlaying the implant (Figure 22). A periapical radiograph
was taken to assess implant healing (Figure 23). Half a carpule of
2% Xylocaine Dental with 1:100,000 epinephrine was administered
locally and the implant cover screw was exposed. An open-tray im-
pression coping was placed and a periapical radiograph was taken
to verify that the impression coping was fully seated. An open-tray
fixture level impression was taken and sent to the lab for fabrication
of a screw-retained crown. A healing abutment was placed and the
patient was dismissed after modification of the removable provisional
prosthesis. The crown was returned from the lab and inserted onto
the implant (Figure 24).
Discussion
The present case reports highlight the use of autologous blood con-
centrates (ie, PRF) for everyday dental use. While PRF has gained
much attention as a regenerative agent capable of further speeding
tissue regeneration across many fields of medicine, the authors fo-
cused the present article on its use in immediate implant dentistry.
Currently, the trend in implant placement has slowly shifted from a
delayed approach toward immediate/early placement as patients con-
tinue to seek more rapid treatment protocols and final restorations.
As a result, immediate implant placement has received considerable
attention in recent years.
One of the main limitations of immediate implant placements is
that, unlike with early implant placement, soft tissue has not fully
matured over the extraction socket. This makes immediate implant
placement somewhat more biologically demanding as it is now known
Fig 19.
Fig 22.
Volume 39, Number 2
that poor integration of soft tissues to implants drastically increases
the risk of peri-implantitis and decreases long-term implant sur-
vival.13-16 While hard-tissue integration into bone was the primary
focus of the majority of research in the 1990s and early 2000s, over
the past decade more research has been done on soft-tissue integra-
tion around dental implants as a primary requirement for their long-
term success. Simply put, to maintain long-term integration of dental
implants, both soft and hard tissues must adequately be preserved.
Especially critical to implant dentistry is soft-tissue attachment to Fig 23.
the coronal portion of the implant. Should this criterion fail to be
fulfilled during implant placement, the implant is at greater risk for
bacterial contamination whereby incoming pathogens are able to
attach to the roughened portion of the implant posing a major risk
Fig 23. Radiograph
of peri-implantitis, a disease that is difficult to resolve once progres- demonstrating the
sion begins. final implant healing.
For these reasons, soft-tissue management around immediate Fig 24. Final restora-
tion of the implant
implant placement is critically important. While historically, most demonstrating
cases with deficient soft-tissue volume were regenerated with either healthy gingival
Fig 24.
a connective tissue graft (CTG) or a collagen-based scaffold, major tissue.

drawbacks were also noted. CTG harvesting is associated with high

morbidity to the patient in the palate, and acellular collagen-based
scaffolds pose a risk of infection if left exposed to the oral cavity
because they are avascular. More recently, PRF has been utilized as
a completely natural way of improving soft-tissue wound closure and
delivering localized growth factors to the microenvironment.17 PRF
poses several advantages when compared to other modalities: (1) It
contains a host of leukocytes entrapped within its fibrin matrix. This
serves the important role of preventing bacterial contamination.18
(2) PRF has also been shown to deliver supra-physiological doses of
important growth factors for regeneration, including platelet-derived
growth factor (PDGF), TGF-beta, vascular endothelial growth factor
(VEGF), and insulin-like growth factor (IGF), which support cell
growth and new blood vessel revascularization.19-22 (3) PRF also
supports faster soft-tissue wound healing when compared to hard
tissues.17 (4) Recently, it was shown that PRF specifically is able to
support better soft-tissue attachment of gingival fibroblast to implant
surfaces.22 This favors the quick colonization of host-regenerative
cells toward the implant surface as opposed to bacterial pathogens.
(5) Lastly, it has also been reported that PRF supports less morbidity
to patients whereby they take less medications and report less pain
as a result of faster soft-tissue defect closure.23,24
The present report also utilized the recent modifications to PRF
centrifugation speeds highlighted by the low-speed centrifugation
concept. While the first protocols of PRF designed by Dr. Joseph
Choukroun used high g-force with a 2700 RPM for 12 minutes,25 more
recently it has been proposed that lower centrifugation speeds and
time are favored to produce higher platelet, leukocyte, and growth
factor concentrations.20,21,25,26 Therefore, recent modifications to cen-
trifugation speeds and times (1300 RPM, 200 g-force for 8 minutes)
have been proposed, leading to higher levels of growth factor release,
cellular collagen synthesis, and more synergistic cellular activity when
compared to the original leukocyte- and platelet-rich fibrin (L-PRF)
formulations.20 Furthermore, even shorter and slower centrifuga-
tion speeds (700 RPM, 60 g-force for 3 minutes) have further been
shown to result in i-PRF, a liquid version of PRF that further enhances
leukocyte numbers and growth factor release that may be used in
combination with bonew grafting materials as demonstrated.5,26-29
Conclusion
The use of A-PRF as a fully biocompatible patient-generated biologi-
cal membrane lowers the cost of rendering treatment while simulta-
neously favoring faster soft-tissue wound healing around immediate
implant placement. Additionally, PRF is well-tolerated by the patient,
leading to better healing with fewer postoperative complications
as a result of its incorporation of defense-fighting leukocytes when
compared to routine traditional membrane use. While treatment with
PRF is still considered in its infancy, especially around immediate
implant placement, many advantages, both biological and economic,
are thought to further increase its use in everyday dental practice.
DISCLOSURES
Dr. Joseph Choukroun is the developer of A-PRF/i-PRF and owns distribu-
tion rights to the equipment to process the PRF products.
ABOUT THE AUTHORS
Mark Bishara, DDS
Private Practice, Bowmanville, Ontario, Canada
Gregori M. Kurtzman, DDS
Private Practice, Silver Spring, Maryland; Master, Academy of General
Dentistry; Diplomate, International Congress of Oral Implantologists
Waji Khan, DDS
Private Practice, Kingston, Ontario, Canada
Joseph Choukroun, MD
Private Practice, Nice, France
Richard J. Miron, DDS, dr. med dent, MSc, PhD
Adjunct Faculty, Department of Periodontics, Nova Southeastern
University, Fort Lauderdale, Florida

6
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COMPENDIUM 2
CASE REPORT | IMMEDIATE IMPLANT PLACEMENT
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February 2018 Volume 39, Number7
COMPENDIUM 2