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I M P L A N T T R E AT M E N T

Innovations
for Minimally
Invasive Esthetic
Implant Surgery
Marc L. Nevins, DMD, MMSc

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Innovations for Minimally
Invasive Esthetic Implant Surgery
Marc L. Nevins, DMD, MMSc
ABSTRACT
The use of growth factor technology
and advances in minimally invasive
surgical techniques have enabled
dentists to modify the manner in
which they approach and sequence
cases requiring extractions, implant
placement, and/or corrective bone
and soft-tissue preservation and/or
augmentation. Simultaneously, these
innovations have contributed to
greater predictability in the outcomes
that can be achieved for esthetic
dental implant cases. This article
provides an overview of how flapless
extraction, bone/soft-tissue grafting,
implant placement techniques,
ridge volume preservation and
augmentation procedures, and
growth factor/biologic materials can
be incorporated to provide an overall
minimally invasive approach to
esthetic implant treatments.
LEARNING OBJECTIVES
• Identify considerations for flapless
extraction and bone/soft-tissue
grafting techniques.
• Discuss the differences between
ridge volume preservation versus
augmentation.
• Explain the benefits of growth
factors/biologics for bone and soft-
tissue grafting.
• Describe different approaches for
sequencing necessary procedures to
ensure predictable esthetic outcomes
for dental implant treatments.
VOLUME 3 • NUMBER 56
PEER-REVIEWED
2 CDE CREDITS
T
he introduction of new materials, products, and their ac-
companying techniques has changed the manner in which
dental implant treatments are performed. Concurrently,
they are enabling dentists to increasingly embrace and practice
a minimally invasive treatment philosophy. For dental implant
treatments—particularly in the esthetic zone—a minimally in-
vasive approach is predicated on thorough diagnosis, thoughtful
and comprehensive treatment planning that begins by envision-
ing the ultimate outcome, and incorporating those materials and
procedures that enable predictability with the fewest surgeries,
interventions, appointments, and augmentations.1-3
Thoughtful and comprehensive treatment planning involves
consideration of all facets of the patient’s condition and what
ultimately will be the least amount of dentistry to satisfy their
functional, clinical, and esthetic needs and demands.2,3 This re-
quires an assessment of the patient’s underlying bone/tissue health;
an evaluation of current esthetic status and how it can be preserved
(eg, Are tissue margins symmetrical and at appropriate levels/
height? Do soft-tissue contours create a healthy, natural profile?);
and potential complicating challenges that may result from any
procedures performed (eg, extraction and removable appliance
could lead to hard- and soft-tissue collapse, loss of papilla, and
loss of ridge width and height).4-6 Because “minimally invasive”
is a relative term, the biggest determinants of what the most ap-
propriate minimally invasive approach would be for a given patient
are dependent upon treatment decisions and case management.2,5,6
Fortunately, today’s intervention techniques and materials for im-
plant treatments enable dentists to manage the hard and soft tissues at
the time of tooth extraction, preserve existing esthetics, and reduce the
amount of surgery required for completing the treatment plan. Enabling
an overall minimally invasive approach to esthetic implant treatments
are flapless extraction, bone/soft-tissue grafting, and implant placement
techniques, ridge volume preservation (as opposed to augmentation)
procedures, and growth factor/biologic materials.2,7,8
CDEWORLD.COM 3
 1 2
Fig 1. In a preclinical trial, a bovine-bone block and membrane were placed and, after 4 months, almost no new bone or soft tissue was
observed growing in or around the implants or graft material. Fig 2. In the same trial, a bovine-bone block soaked in PDGF was placed and,
after 4 months, new bone was observed to have grown over the top of the defect. (Figure 1 through Figure 3 republished with permission
of Quintessence Publishing Company Inc, from Simion M, Rocchietta I, Dellavia C. Three-Dimensional Ridge Augmentation with Xenograft
and Recombinant Human Platelet-Derived Growth Factor-BB in Humans: Report of Two Cases. Int J Perio Restor Dent. 2007;27(2):109-115;
permission conveyed through Copyright Clearance Center, Inc.)

CONSIDERATIONS FOR FLAPLESS TECHNIQUES However, transitioning from a tooth to an im-

Flapless techniques are indicated when a patient
presents with good tissue health and contour,
volume in the marginal gingiva supported by
healthy bone, and overall good tissue volume.1,7
Ideal when the gingival tissue exhibits an esthetic
nature, flapless techniques require care to avoid
altering tissue contour and quality (ie, creating
scar tissue). In some cases, a modified flapless
approach (eg, using submarginal incisions) may
be necessary in order to maintain the marginal
gingival profile.8
For example, even in a case with a complete
loss of the buccal plates, the least invasive option
may still be a flapless coronal approach combined
with a submarginal incision. The incision can be
made with a diode laser, including a frenectomy,
to enable access for cleaning the apical area with
piezosurgery.9 After extraction and debridement,
bone material can be packed into place; a small
membrane placed over the graft material on the
labial aspect; the labial incision closed with a 6-0
chromic gut suture; and a small layer of collagen
membrane placed just within the surface tissue
present at the coronal aspect.10 After healing, an
implant can be placed in a minimally invasive,
guided surgical/tunneling approach.8
plant without damaging the esthetics of the existing
tissue can present challenges. In most instances,
soft-tissue grafting may be required to thicken the
gingival tissue biotype.11 Sites that have had con-
nective tissue grafting demonstrate much more
stable marginal tissue levels, particularly at 12
months after restoration.12,13 Although surgery may
not be desired, it is oftentimes necessary consider-
ing the long-term marginal tissue level stability
that is achieved.11
RIDGE PRESERVATION VERSUS AUGMENTATION
The sites in which implants are to be placed may
present with radiographic evidence (eg, CBCT)
of bone loss or damage that necessitates consid-
eration of ridge and/or volume preservation ver-
sus augmentation.14,15 Because tooth roots help
maintain tissue height and contour, their removal
leads to collapse. Additionally, in the presence
of thin bone, extraction initiates bone shrink-
age within 6 weeks. Therefore, intervening with
grafting (eg, hard- or soft-tissue grafting) at the
time of extraction helps to preserve the volume
with which a patient presents.14,15
Alternatively, augmentation techniques are
associated with staged interventions (ie, delayed

4 CDEWORLD.COM NOVEMBER 2016


3 Administration for periodontal regeneration
Fig 3. Under high-power magnification next to the implant, resorption
and replacement of the graft material by new bone was observed in 4
months; the implication is that a flapless approach can be undertaken
for tissue engineering to completely regenerate the bone.
grafting). By extracting the tooth and allowing
the tissues to heal, different challenges can pres-
ent when subsequently performing additional
surgical procedures to augment the tissues.16 For
this reason, anticipating the end results of treat-
ment is necessary to plan how the best outcome
can ultimately be achieved.3-5
Areas where augmentation is required due to
trauma, changes in tooth position, and/or loss of
bone and/or tissue volume and contour in spe-
cific regions may require grafting.16-18 Typically,
flap procedures for ridge augmentation can be
performed to enable hard-tissue augmentation to
increase the width of the ridge, and connective
tissue grafts (as needed) can be placed to enhance
soft-tissue volume.2,7,8,16-18 After bone healing
and successful thickening of the tissue, the site
can be reentered for implant placement; excess
tissue volume can be shaped with a contoured
healing abutment and provisional restoration.19
This will allow good preservation of the papilla
and maintenance of stable marginal tissue levels.
GROWTH FACTORS, BIOLOGICS,
AND rH-PDGF-BB
The use of growth factors in dentistry essentially
transforms the healing process following hard-
and soft-tissue periodontal procedures, as well as
implant surgeries. Whereas typical bone healing
with graft materials is osteoconductive (ie, bone
VOLUME 3 • NUMBER 56
emerging only from the lateral edges of a defect),
growth factors promote more robust levels of
new bone formation through osteoinductive
mechanisms (ie, bone growth and enhanced bone
metabolism throughout the extraction socket or
defect at an equal pace).20-22
Platelet-derived growth factor (PDGF) is ap-
proved in the United States by the Food and Drug
based on its ability to re-grow bone and tissues
around teeth. PDGF works by directly affecting
the osteoblastic cells and, secondarily, by raising
vascular endothelial growth factor (VEGF).10,23,24
In bone healing, the two most important aspects
are wound stability and vascular supply.
PDGF upgrades the vascular supply within the
wound indirectly through VEGF, which stimu-
lates new capillary formation therein, and also
upgrades bone metabolism.10,11,23,24 In fact, there is
an increase in bone metabolism with a surrogate
marker of bone turnover and interstitial collagen
telopeptide only found in bone.10,18,20 As a result,
when treating a large defect with freeze-dried
bone and PDGF using a flapless approach, it is
possible to take a bone biopsy at 5 months and,
under high-power magnification, observe new
bone growing through the graft particle.18,20,21
The extent of regeneration that can be achieved
with PDGF has been demonstrated in the litera-
ture, particularly when researchers took bovine-
bone block soaked in PDGF and, 4 months later,
observed new bone grown over the top of the de-
fect (Figure 1 through Figure 3).22 Without PDGF,
there was almost no new bone or soft tissue grow-
ing in or around the bovine-bone product.
Among the commercially available growth
factors today is recombinant human plate-
let-derived growth factor (rh-PDGF)-BB.
Manufactured through recombinant biotech-
nology, it is a synthetically engineered, pure
human protein used in esthetic implant cases
CDEWORLD.COM 5

6
to ensure the greatest predictability, even in
challenging sites (Figure 4 through Figure
7).21,22Another commercially available growth
factor is bone morphogenetic protein-2 (BMP-
2), which essentially has been touted as “doing
the work for us.” 25 Only a few months after
placement—even in cases with a complete lack
6 CDEWORLD.COM
5
7
Fig 4. Preoperative radiograph of a pivotal case demonstrating the
efficacy of PDGF soaked in beta-TCP. Fig 5. At 1-year reentry at
the interproximal site, 4.5 mm of new bone growth was observed, as
well as over the labial surface of the tooth. Fig 6. A radiograph taken
at 10 years postoperatively demonstrates the predictable longevity
of using PDGF for grafting procedures, as healthy bone support is
observed. Fig 7. Although a subsequent free gingival graft was placed
to augment the soft tissue to support this site, the use of the graft with
PDGF soaked in beta-TCP provided long-term healthy bone support
at the site. (Figure 4 through Figure 7 reproduced from J Periodontol.
2013;84(4):456-464. Used with permission from the American Academy
of Periodontology.)
of buccal plate and loss of palatal bone—almost
complete reconstitution of the ridge form has
been observed upon reentry.25
IMPLICATIONS FOR PATIENT TREATMENT
The use of growth factor technology, combined
with advances in minimally invasive surgical
techniques, has changed practices significantly
over the past decade. As a result, dentists can
modify the manner in which they approach treat-
ments for their patients who require extractions,
NOVEMBER 2016
8

11

12

Fig 8. Case 1: A patient presented in January 2006 with a large

9 periapical lesion, a root fracture, and significant buccal bone loss.
Fig 9. Despite the extent of bone loss revealed radiographically,
multiple surgical grafting procedures were not indicated. Instead, a
flapless surgery would be performed and biologic innovations used
to facilitate ridge preservation. Fig 10. The tooth was extracted;
the socket debrided and degranulated; and ridge preservation was
performed with FDBA/rhPDGF and an absorbable membrane.
Fig 11. The success and efficacy of this approach was confirmed
radiographically at 8 years post-treatment, as demonstrated by the stable
gingival margins, thickened biotype with a connective tissue graft, and
stable bone levels observed at the first thread of the fixture. Fig 12. At 8
years post-treatment, the results of the minimally invasive approach
remain an ideal esthetic implant placement, without visible damage
or scar tissue from the flapless approach or connective tissue graft
10 to thicken the biotype.

VOLUME 3 • NUMBER 56 CDEWORLD.COM 7

 13

14

15
16

17 18

Fig 13. Case 2: Close-up retracted preoperative view of a patient who presented with a worn crown and post that had been removed and
re-cemented several times. Fig 14. Preoperative radiographic view of the worn post. Fig 15. A tunneling procedure with a small connective
tissue graft was performed to establish extra soft tissue with a thickened biotype. Fig 16. Close-up view of the patient’s gingival architecture
following tissue graft healing. Fig 17. Piezosurgery was used for a minimally invasive extraction that did not damage the soft tissues. Fig 18.
Three-dimensional implant treatment planning software was used to ensure implant placement accuracy.

8 CDEWORLD.COM NOVEMBER 2016

19
Fig 19. Surgical guide for implant placement.
implants, and corrective bone and soft-tissue
procedures—all with less invasiveness but
with greater predictability. The following cases
demonstrate the manner in which growth factor
technology, combined with minimally invasive
techniques, has resulted in predictable outcomes
in esthetic dental implant treatments.
Case Report 1
A patient presented with a large periapical le-
sion, root fracture, and significant loss of buc-
cal bone (Figure 8 and Figure 9). Treatment for
this case involved an autogenous bone graft,
then implant placement and connective tissue
grafting. Recombinant human platelet-derived
growth factor-BB was used for ridge preserva-
tion and minimally invasive esthetic implant site
development with a flapless approach.
The tooth was extracted, and magnification was
used while debriding and degranulating the extrac-
tion socket. The site was irrigated with a significant
amount of sterile water from 10-mL syringes, and
the water pressure helped with debridement. Spoon
and #4 Gracey curettes were used.
Once degranulated and debrided, the growth
factor matrix (eg, freeze-dried bone allograft that
was presoaked in rh-PDGF-BB for about 10 min-
utes) was condensed into the site. The site was then
covered with a collagen membrane and sutured.
VOLUME 3 • NUMBER 56
20
Fig 20. The implant was placed immediately following extraction
according to the treatment plan.
After healing, the site was evaluated and a
high frenum attachment was observed (Figure
10). A frenectomy was performed prior to im-
plant placement, along with a connective tissue
graft to thicken the soft tissues.
At 8 years post-treatment, implant bone levels
were maintained as evidenced radiographically
(Figure 11), with stable gingival margins and
bone levels at the first thread of the fixture.
There was minimal visible damage and scar
tissue from the surgical approach to implant
placement and tissue grafting to thicken the
biotype. Despite the potential challenges, the
use of growth factor technology and minimally
invasive surgical techniques allowed the esthetic
treatment goals for this case to be achieved for
the long term (Figure 12).
Case Report 2
A patient presented with a worn crown and post
that had been removed and re-cemented several
times (Figure 13 and Figure 14). Among the ap-
proaches that could have been considered was
an extensive procedure to include extraction,
implant placement, bone grafting, and soft-tissue
grafting simultaneously.
However, by giving consideration to the most
appropriate and minimally invasive sequence of
care, this led to performing predictable procedures
CDEWORLD.COM 9
 21 22

23 24

26

Fig 21. Bone graft material enhanced with growth factor was
placed. Fig 22. The site was protected by the extra height of soft
tissue, along with a membrane. Fig 23. An Essex appliance was
used for the first 2 weeks of healing. Fig 24. View of the uncovered
implant and now-prepared adjacent tooth for finalizing prosthetic
treatment. Fig 25. Post-treatment, healthy bone and ideal implant
placement were observed radiographically. Fig 26. The results of
this esthetic treatment is an inconspicuous implant-supported crown
25 restoration.

10 CDEWORLD.COM NOVEMBER 2016

beginning with a tunneling procedure with a small
connective tissue graft (Figure 15). Once the con-
nective tissue graft healed (Figure 16), extra soft
tissue with a thickened biotype was available.
This would enable minimally invasive extraction
using piezosurgery—without damaging the soft
tissues (Figure 17)—followed by immediate im-
plant placement according to 3D implant treatment
planning (Figure 18 through Figure 20).
After implant placement, bone graft material
enhanced with growth factor was also placed,
which would be protected by the extra tissue
height (Figure 21 and 22). An Essex appliance
was used for the first 2 weeks (Figure 23), and
once the soft tissues healed, the crown on the
adjacent tooth could be removed to allow for an
interim cantilever prosthesis.
Second-stage surgery involved uncovering the
implant and finalizing the prosthetic treatment
(Figure 24). The ultimate outcome represented
a thickened biotype, healthy bone (Figure 25),
and an inconspicuous implant-supported crown
restoration (Figure 26).
CONCLUSION
In a minimally invasive approach to esthetic
implant treatments, incorporating updated sur-
gical approaches and harnessing the potential of
growth factor technology can make treatments
predictable and less invasive for patients. By be-
ginning the treatment planning process with a
vision of the ultimate outcome and then working
backwards, dentists can best understand and plan
what will be needed surgically to achieve those
results. Flapless techniques, a focus on ridge vol-
ume preservation at the time of extraction versus
post-healing remodeling, and using recombinant
human platelet-derived growth factors allows
for the fewest surgical interventions for esthetic
implant site development and restoration.
REFERENCES
1. Wang F, Huang W, Zhang Z, et al. Minimally invasive
VOLUME 3 • NUMBER 56
flapless vs. flapped approach for single implant place-
ment: a 2-year randomized controlled clinical trial. Clin
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[Epub ahead of print].
2. Hayashi J, Shin K, Takei HH. Minimally invasive sur-
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3. Dawson PE, Cranham JC. Aesthetics and function:
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5. Shah KC, Lum MG. Treatment planning for the single-tooth
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6. Leblebicioglu B, Rawal S, Mariotti A. A review of the
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radiographic, microbiological, and immunological
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spective randomized controlled clinical trial. Clin Oral
Implants Res. 2013;24(9):969-976.
8. Nevins ML, Camelo M, Nevins M, et al. Minimally in-
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matrices: a case series. Int J Periodontics Restorative
Dent. 2009;29(4):371-383.
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12. Grunder U. Crestal ridge width changes when placing
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months: report of 24 consecutive cases. Int J Periodontics
Restorative Dent. 2011;31(1):9-17.
13. Schneider D, Grunder U, Ender A, et al. Volume gain and
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Clin Oral Implants Res. 2011;22(1):28-37.
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2015;59(2):389-407.
17. Aloy-Prósper A, Peñarrocha-Oltra D, Peñarrocha-
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19. Shor A, Schuler R, Goto Y. Indirect implant-supported
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22. Simion M, Rocchietta I, Dellavia C. Three-dimensional
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NOVEMBER 2016
CDE
Innovations for Minimally Invasive Esthetic
Quiz
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Implant Surgery
Marc L. Nevins, DMD, MMSc

1.  For dental implant treatments a minimally invasive 6. When transitioning from a tooth to an implant, in
approach is predicated partly on thoughtful, most instances what may be required to thicken the
comprehensive treatment planning that envisions: gingival tissue biotype?
A. the ultimate outcome. B. new bone growth. A. Extra debridement after extraction
C. high-tech CBCT imaging. D. use of PDGF. B. Soft-tissue grafting
C. Piezosurgery
2. Implant treatment planning requires an assessment/ D. Placement of a large membrane
evaluation of:
A. the patient’s underlying bone/tissue health. 7. What techniques are associated with staged
B. the current esthetic status and how it can be preserved. interventions?
C. potential complicating challenges that may result from A. Extraction
any procedures performed. B. Augmentation
D. All of the above C. Immediate placement
3. Today’s intervention techniques and materials for D. Immediate loading
implant treatments enable dentists to: 8. Growth factors promote more robust levels of new
A. manage the hard and soft tissues at the time of tooth bone formation through:
extraction. A. suppression of vascular supply.
B. preserve existing esthetics. B. blocking new capillary formation.
C. reduce the amount of surgery required for completing C. osteoconductive mechanisms.
the treatment plan. D. osteoinductive mechanisms.
D. All of the above
9. PDGF is approved in the United States by the FDA for
4. Flapless techniques are indicated when a patient periodontal regeneration based on its ability to:
presents with which of the following circumstances? A. strengthen enamel.
A. Has good tissue health and contour B. increase dental implant primary stability.
B. Volume in the marginal gingiva is not supported by C. re-grow bone and tissues around teeth.
healthy bone D. proliferate minimally invasive implant treatment.
C. Overall tissue volume is poor
D. All of the above 10. In Case 2, a tunneling procedure with a small
connective tissue graft was used, which helped
5. Even with a complete loss of buccal plates, the enable minimally invasive extraction using:
least invasive option may still be a flapless coronal A. a diode laser.
approach combined with: B. piezosurgery.
A. delayed grafting. B. a submarginal incision. C. an osteotome.
C. use of an erbium laser. D. None of the above D. traditional forceps.

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attain a score of 70% on each quiz to receive credit. Participants will receive an annual report documenting their
accumulated credits, and are urged to contact their own state registry boards for special CE requirements.

Dental Learning Systems, LLC, is an ADA CERP Recognized

Provider. ADA CERP is a service of the American Dental
Association to assist dental professionals in identifying quality
providers of continuing dental education. ADA CERP does
not approve or endorse individual courses or instructors, nor
does it imply acceptance of credit hours by boards of dentistry. Approval does not imply acceptance by
Concerns or complaints about a CE provider may be directed a state or provisional board of dentistry
or AGD endorsement. The current term
TO TAKE THE QUIZ, VISIT to the provider or to ADA CERP at ADA.org/CERP
of approval extends from 1/1/2013 to
CDEWORLD.COM/EBOOKS/CE/56 12/31/2016. Provider #: 209722.

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