Tissue Preservation and Maintenance of

Optimum Esthetics: A Clinical Report

Stephen L. Wheeler, DDS1/Robert E. Vogel, DDS2/Renzo Casellini, MDT3

Today, most tooth replacement in the esthetic zone is done using implants placed in a delayed
surgical protocol. Unfortunately, this delay can result in loss of both hard and soft tissue during
the healing period, necessitating guided tissue regeneration techniques at the time of implant
placement. Recent developments with tapered implants have facilitated predictable immediate
implant placement, preserving the osseous structure surrounding the socket. Further develop-
ments with custom healing abutments can preserve the crestal soft tissues, including the papil-
lae. This article reviews techniques that provide for the preservation of both bone and soft tissue
while enhancing the esthetic results around implants. (I NT J O RAL M AXILLOFAC I MPLANTS
2000;15:265–271)

Key words: custom healing abutment, immediate placement, tapered implant,

tissue preservation

T he use of dental implants has revolutionized

oral rehabilitation over the past 3 decades.
Multiple studies have proven the efficacy and excel-
implants are placed in a delayed manner, allowing
for both hard and soft tissue healing prior to
implantation. Unfortunately, this allows for resorp-
lent long-term prognosis with dental implants.1–4 tion of the alveolar ridge in both the buccolingual
While initial research and clinical use were directed and apicocoronal dimensions. Studies have shown
primarily toward the edentulous patient, more that as much as 3 to 4 mm of resorption can occur
recent studies have focused on the esthetic use of during the first 6 months postextraction without the
implants in the partially edentulous patient.5 The intervention of tissue regeneration techniques.6,7
most challenging area of modern implant dentistry This resorption can significantly affect the position
remains the “esthetic zone” in the anterior maxilla. and prognosis of a dental implant as well as the hard
Replacing single or multiple anterior teeth in the and soft tissue esthetics in the area. In most cases,
otherwise dentate patient requires careful consider- delaying implant placement will necessitate guided
ation of the location and volume of residual bone, tissue regeneration techniques to successfully
soft tissue esthetics, and the conservation of both by replace a maxillary anterior tooth, both functionally
the implant and prosthetic crown. and cosmetically.
Since the integration of an implant to the sur- Guided tissue regeneration techniques have pro-
rounding bone is predicated on its initial mechani- vided the ability to regenerate lost bone in a pre-
cal anchorage, immediate placement of implants dictable manner, but they necessitate primary
into extraction sockets has been difficult because of wound closure to prevent membrane exposure.
the incongruency between the shape of a standard Crestal levels of bone regeneration have been shown
cylindric implant and the alveolus. Therefore, most to improve only when membrane exposure and sub-
sequent infections are avoided.8,9 Primary closure of
an extraction site over a membrane is possible, but it
requires a full-thickness flap that may permanently
1Private Practice Limited to Oral and Maxillofacial Surgery, Encini- disfigure the soft tissue architecture and still may
tas, California. not predictably provide protection for the mem-
2Private Practice, Rancho Santa Fe, California.
brane. This concern also favors a delayed placement
3Master Dental Technician, Los Angeles, California.
approach to allow for primary soft tissue healing
Reprint requests: Dr Stephen L. Wheeler, 310 Santa Fe Drive, facilitating closure over a membrane.
Suite 112, Encinitas, CA 92024. Fax: (760) 942-0331. E-mail: However, if ideal hard and soft tissues are pre-
Steve@WheelerDDS.com sent at the time of extraction, it seems feasible to

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WHEELER ET AL

preserve them, rather than delaying implant place- tooth at the gingival crest. This provides accurate
ment and allowing resorption to occur. Several case information relative to the dimensions necessary to
reports have shown that early implantation may support the tissue.
allow preservation of the alveoli and surrounding From the preoperative periapical radiograph, it
structures. 10,11 Regeneration procedures require is possible to approximate the location of the
additional surgery, with more morbidity and greater cemento-enamel junction relative to the gingival
cost to the patient. While excellent regenerative crest. This depth is usually 2 to 3 mm. Measure-
results can be obtained, when possible it is more ment of the width of the root provides an accurate
practical and expedient to preserve hard and soft tis- guide to the final diameter of the implant body. A
sues through modification of normal implant place- hole is made in the cast at the same inclination as
ment protocols. Thus, it is clinically appropriate to the long axis of the root of the tooth. An implant
first consider placing implants immediately after analog of the probable diameter of the implant to
extraction. Several studies have shown that in the be used is inserted into the cast, with a flat surface
absence of infection, implants can be placed into of the internal hexagon placed directly to the labial
fresh extraction sockets with good mechanical or buccal aspect (Fig 1). An ovate shape is created
anchorage and yield success rates virtually identical from the top of the implant analog to the outline of
to implants placed into the healed alveolar the gingival crest. A ProTec abutment is placed on
ridge.12–15 the analog, and light-cured composite resin is
The development of stepped-tapered root analog added to fill the area that would be created by
implants has encouraged immediate placement in extraction of the tooth (Fig 2). The composite is
the anterior maxilla. Available in multiple lengths glazed for tissue compatibility. The labial or buccal
and widths of up to 6.5 mm in diameter, these aspect of the healing abutment is marked, and the
designs make immediate implant placement far chimney of the ProTec abutment is left to facilitate
more predictable than with the use of standard handling.
cylinder implants with parallel sides. Wider implant
diameters will fill the extraction socket (elimination Patient Selection and
of any dead space), preventing soft tissue growth Presurgical Treatment Planning
into the socket and eliminating the need for guided Two of 9 patients who have been successfully
bone regeneration and membrane techniques. This treated are presented in this article. Age and gender
also eliminates the need to place the implant into did not enter into the consideration of candidates
bone apical to the extraction socket, allowing imme- for treatment. All candidates were non-smokers and
diate placement near the sinus floor or other vital were selected for immediate implant placement
structures. with ideal hard and soft tissues around the tooth to
The purpose of this clinical report was to present be removed. The sites were required to be free from
a technique for support of both the hard and soft infection. The labial or buccal plates must have
tissues surrounding an extraction socket based on an been intact, with no fracture or fenestration. Uti-
immediate 1-stage surgical protocol. lization of the Frialit-2 system (Friadent, Irvine,
CA) provided secure anchorage of the implant
within the walls of the socket without the need to
MATERIALS AND METHODS drill apically into virgin or non-existent bone. This
allowed the inclusion of patients with maxillary
A custom healing abutment (EsthetiCap) based on teeth where the root apices were at or near the sinus
the ProTec abutment (Friadent America, Irvine, floor. Patients were also screened for any possible
CA) has been designed to facilitate the support of contraindications for implant placement and
hard and soft tissues in this procedure. This abut- advised as to the risks, benefits, and alternatives to
ment is prefabricated from a stone cast of the the proposed treatment plan.
patient’s teeth to mimic the natural tooth emergence During the prosthodontic consultation, impres-
contours. The cap is fabricated so that it extends no sions were made to fabricate a surgical guide, a cus-
more than 1 mm through the soft tissue. tom healing provisional restoration, and an interim
The custom-made EsthetiCap is designed to sup- prosthesis. The guide was fabricated from a generic
port the hard and soft tissues of the socket in the 0.060 vacuum-formed temporary splint material. It
same fashion as the tooth that is being extracted. On was used to accurately position the implant and make
the second pour of the initial diagnostic cast impres- an immediate record of this position after placement
sion, the tooth to be removed is sectioned from the using a technique described by Hochwald.16
cast, leaving a clear view of a cross section of the

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Fig 1 Two 5.5-mm Frialit-2 analogs are placed in the master Fig 2 Composite resin buildup on ProTec abutments mimics
cast in ideal positions. natural tooth contours and fills soft tissue voids.

Surgery
An atraumatic extraction was accomplished using
routine surgical extraction techniques and/or a Peri-
otom (Friadent), ideally without laying a flap.
Schulte developed the Periotom for the purpose of
removing teeth without damage to the surrounding
bone.17 The Periotom was worked firmly into the
periodontal ligament space until the root became
mobile and was lifted out of the socket. Once the
extraction was complete, the integrity of the socket
was evaluated and the area was debrided. If the walls
of the socket were intact, a tapered implant was
placed without incising the soft tissues or elevating a Fig 3 A 3.8  15-mm drill is taken to the proper depth, as indi-
cated by the colored band on the drill, aligning with the labial soft
flap. This alone helped to significantly preserve the tissues without reflecting a flap.
tissues around the socket. It is known that stripping
the periosteum off of the bony plate will cause
resorption. In the maxillary incisor region, implant
site preparation is begun in the palatal aspect of the
socket to prevent labial perforation. The site was the position of a flat surface on the internal hex so
enlarged until preparation filled the extraction that it can be properly positioned relative to the
socket up to the labial plate. The stepped drills were labial plate (Fig 4). When an infrequent gap was
taken to a final depth that was indicated by a colored noted with a probe around any part of the implant
ring on the shaft (Fig 3). When this ring was at the that was wider than 1.0 mm, it was filled with
soft tissue crest, the implant would be at an ideal BioGran (Orthovita, Malvern, PA) to prevent soft
depth, 3 mm deeper. tissue invagination.
If fenestration was detected, a labial flap was Once the implant was placed, a transfer coping
raised to allow for guided tissue regeneration tech- was inserted, and GC Unifast (GC America, Lake
niques over the fenestration after implant place- Zurich, IL) was used to lute the coping to the surgi-
ment. If the bone surrounding the prepared implant cal guide (Fig 5). To date, this has been found to be
site remained intact, a Frialit-2 implant of appropri- the only material that will chemically bond to the
ate diameter was placed without reflecting the soft vacuum-formed surgical guide instead of mechani-
tissues. Care was taken to assure that the internal cally locking to it. This was removed, and an
hex alignment was accurate so that a preangled EsthetiCap was then placed onto the implant to fill
MH-6 abutment (Friadent) could be used for a final the soft tissue defect left from the extraction and to
restoration without the need for preparation of a support the surrounding hard and soft tissues, elimi-
custom abutment. There is a groove on the press-fit nating the need for any sutures. If required, an
implant design, or a dot on the ratchet extension interim prosthesis was placed, making certain to
used to place the threaded implant, that indicates relieve it over the EsthetiCap. The patients were

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WHEELER ET AL

Fig 4 A groove on the press-fit Frialit-2 indicates the alignment Fig 5 GC Unifast is used to lute the transfer coping placed on a
of the internal hexagon for proper positioning to allow the use of Frialit-2 implant to the surgical guide for transfer to the master
a preangled abutment. cast.

placed on oral antibiotics, an analgesic, and Peridex and a 4.5  10-mm stepped drill was used to reshape
rinses (Zila Pharmaceuticals Inc, Phoenix, AZ). The the extraction socket in preparation for placing a Fri-
implants were allowed to integrate for 4 to 6 alit-2 implant (Fig 6b). The socket was widened
months, depending on bone density. without damaging the buccal plate. Since the buccal
plate was at an ideal height, approximately 2 mm
Second-Stage Surgery below the soft tissue crest, the stepped drill was taken
Following integration of the implant, the patient to the depth indicated by the color band on the shaft.
returned to the restoring dentist rather than the The drilling was stopped when this band was aligned
surgeon. The custom healing abutment was with the soft tissue on the buccal aspect of the socket.
removed with a standard screwdriver without any A 4.5  10-mm stepped-threaded Frialit-2 implant
need for an anesthetic. If progressive loading of the was then placed and ratcheted into final position.
implant body was desired, a composite provisional To obtain an immediate record of the implant posi-
restoration fabricated on a ProTec abutment was tion, a transfer coping was attached to the implant
placed. If no progressive loading was deemed neces- with a long transfer coping screw. The screw, not the
sary, the definitive restoration was seated. transfer coping, was lubricated, and the surgical guide
was repositioned over it. GC Unifast was used to lute
the transfer coping to the surgical guide. Care was
RESULTS taken to ensure that none of the light-cure resin mate-
rial was engaged in any adjacent undercuts prior to
Patient 1 curing. The long transfer coping screw was loosened,
A 49-year-old healthy male patient presented with a and the guide was removed with its transfer coping.
fractured and nonrestorable maxillary right second This guide was sent to the laboratory for incorpora-
premolar. A panoramic radiograph indicated a 10- tion into the master cast. During the patient’s healing
mm root with the sinus floor at the apex. The site period, the definitive prosthesis was fabricated.
was free from infection, with normal hard and soft A prefabricated EsthetiCap was then placed into
tissue contours. Immediate implant placement using the implant, and the height of the chimney was
cylindric implants would have been difficult. adjusted to avoid any possibility of occlusal contact.
Anchorage could not have been achieved apical to It was secured by an abutment-retaining screw (Fig
the existing root socket. A delayed approach to 6c). This effectively provided closure of the soft tis-
implant placement may have allowed for pneumati- sues without the need for sutures and supported the
zation of the sinus, necessitating placement of a short surrounding soft tissue contours. Four days later,
implant or sinus graft procedures. If the bone the chimney was removed and sealed. The patient
remained intact following extraction without reflect- elected to have no provisional restoration placed.
ing a flap, a custom EsthetiCap healing abutment After 4 months of uneventful healing, the Estheti-
would be placed to preserve the hard and soft tissues. Cap was removed to reveal healthy soft tissues with
At surgery, the maxillary premolar was extracted the ideal architecture and an osseointegrated
using a Periotom without damaging the surrounding implant. The procedure was done in the restorative
bone (Fig 6a). The extraction socket was debrided dentist’s office without the need for anesthetic. The

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Fig 6a The maxillary right second premolar is removed using Fig 6b The implant site is prepared using a 4.5  10-mm
the Periotom. stepped drill.

Fig 6c The EsthetiCap is placed onto the implant after immedi- Fig 6d The final crown is placed on the implant abutment using
ate placement and registration. Note the absence of incisions or a palatal screw.
flaps.

Fig 6e (Above) The hard and soft tissues have been main-
tained after final reconstruction.

Fig 6f (Right) Postoperative radiograph of 4.5  10-mm Frialit-

2 implant with definitive restoration 18 months after surgery.

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Fig 7a Preoperative clinical view of missing central incisors Fig 7b Postoperative view of EsthetiCap in maxillary left canine
and fractured left canine. area following cementation of provisional prosthesis.

Fig 7c Soft tissues after removal of the EsthetiCap in the left Fig 7d View of the final definitive restorations, with all anterior
canine area 5 months postoperatively. and posterior treatment completed.

final abutment was placed, and a prosthetic crown on the remaining abutment teeth (right canine, right
was secured with a single horizontal palatal screw lateral incisor, and left lateral incisor). Care was taken
(Figs 6d and 6e). An 18-month postoperative radio- to relieve the underside of the provisional restoration
graph (Fig 6f) demonstrated virtually no hard or soft such that no contact could be made between the heal-
tissue changes. ing abutment and the cemented provisional prosthesis
(Fig 7b). After 5 months of healing, the hard and soft
Patient 2 tissues in the canine site were maintained perfectly
This 48-year-old healthy female lost her 6-unit (Fig 7c). The EsthetiCap was removed, and a ProTec
anterior fixed prosthesis when an endodontically provisional abutment was attached to the implant.
treated left canine suffered a vertical root fracture The custom-made provisional crown supported the
(Fig 7a). No infection was present. The central tissue in a manner that has made it almost impossible
incisors had been missing for 31 years. Treatment to detect that the tooth has been replaced by an
consisted of removing the canine atraumatically implant-supported restoration.
with no flap reflection. This was followed by imme- An esthetic result was also obtained in the central
diate implantation of a 5.5  13-mm Frialit-2 incisor sites using customized ProTec abutments
stepped-threaded implant. The central incisor sites and provisional crowns. To achieve the final result,
received two 3.8  15-mm Frialit-2 implants using additional soft tissue plastic surgery was required,
guided tissue regeneration techniques to restore the along with months of manipulation with the provi-
long-lost labial contours. Immediate registration of sional crowns (Fig 7d). This patient example has
all implants was made at the time of implantation demonstrated the ease with which the hard and soft
for the purpose of fabricating custom provisional tissue architecture can be maintained utilizing a cus-
healing restorations. tom-made healing abutment and the difficulty in
An EsthetiCap was placed on the implant in the reconstructing esthetic soft tissue structures once
canine site and a provisional restoration was cemented they have been lost.

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SUMMARY 6. Atwood DA, Coy DA. Clinical, cephalometric and densito-

metric study of reduction of residual ridges. J Prosthet Dent
1971;26:280–293.
A technique has been presented that is based on sci-
7. Johnson K. A study of the dimensional changes occurring in
entifically proven modifications to conventional the maxilla after tooth extraction. Part I: Normal healing.
implant protocols. By placing stepped-tapered Aust Dent J 1963;8:428–433.
implants immediately into extraction sockets where 8. Warrer K, Gotfredsen K, Hjørting-Hansen E, Karring T.
normal hard and soft tissue contours were found, Guided tissue regeneration ensures osseointegration of den-
tal implants placed into extraction sockets. An experimental
and then attaching custom healing abutments that
study in monkeys. Clin Oral Implants Res 1991;2(4):
replicate the emergence profiles of the teeth being 166–171.
replaced, it has been possible to preserve both the 9. Becker W, Becker B, Handelsman M, Ochsenbein C,
hard and soft tissues surrounding the extraction Albrektsson T. Guided tissue regeneration for implants
sites. Not only is this procedure more predictable placed into extraction sockets. A study in dogs. J Periodontol
1991;62(11):703–709.
than trying to regenerate these tissues in a delayed
10. Dennisen HW, Kalk W, Veldhuis HAH, Van Waas MAJ.
implant placement protocol, but it involves less Anatomic consideration for preventive implantation. Int J
surgery for the patient. The result is less potential Oral Maxillofac Implants 1993;8:191–196.
morbidity, lower cost to the patient, and signifi- 11. Sclar AG. Ridge preservation for optimum esthetics and
cantly reduced overall treatment time. This has function: The “Bio-Col” technique. Postgrad Dent 1999;
6(1):3–11.
been found to be an advantageous addition to avail-
12. Mensdorff-Pouilly N, Haas R, Mailath G, Watzek G. The
able treatment protocols for patients who present immediate implant: A retrospective study comparing the dif-
with ideal hard and soft tissues surrounding non- ferent types of immediate implantation. Int J Oral Maxillo-
restorable teeth to be replaced with dental implants. fac Implants 1994;9:571–578.
13. Watzek G, Haider R, Mensdorff-Pouilly N, Haas R. Imme-
diate and delayed implantation for complete restoration of
the jaw following extraction of all residual teeth: A retro-
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OUT WRITTEN PERMISSION FROM THE PUBLISHER.