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Abstract
Soft tissue deficiency in a tooth extraction site in the aesthetic area is a common and challenging clinical situation. This case report demonstrates the successful treatment of extensive gingival recession and buccal bone dehiscence associated with a hopeless tooth. Initially, a connective tissue graft was used to cover the root and thicken the soft tissue. After 2 months, the tooth was extracted, an implant was immediately placed, and a temporary restoration was installed. After 3 months, the soft tissue exhibited a natural and harmonious architecture. A custom zirconia abutment and crown were then fabricated and placed. At the 4-year follow-up, the peri-implant tissue displayed satisfactory aesthetics, with a well-structured buccal bone plate and healthy peri-implant indicators. This two-stage approach, addressing gingival recession first and proceeding with immediate implant placement after soft tissue healing, proved to be a safe and effective method with stable long-term results.
- Dentistry and oral medicine
- Mouth
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Background
Immediate implant placement (IIP) in fresh extraction sockets has become a common clinical approach, especially in the aesthetic zone. IIP demonstrates high survival rates, reduces the overall treatment duration,1 and offers the possibility of immediately replacing the tooth with a provisional implant-supported crown.2 However, optimal results using IIP depend on the combination of many factors, including a careful presurgical analysis of bone morphology and gingival phenotype, a less invasive surgical technique, and, eventually, hard and soft tissue augmentation.1 2 Moreover, the treatment protocol, pre-operative hard and soft tissue morphology may influence the clinical outcome.3
A decisive factor is the pre-operative integrity of the buccal bone crest. The buccal bone in the maxillary area is usually thin, and buccal bone dehiscences (BBDs) are common.4 When BBD is present, clinical studies suggest a higher risk of mucosal recession.5 The current scientific opinion is that the loss of the buccal bone plate may be considered a contraindication for IIP, and early implant placement, ridge reconstruction at the time of tooth extraction, or delayed/late implant placement should be performed instead.6 However, these approaches result in longer overall treatments and require more surgical interventions.
Additionally, an immediate provisionalisation can be performed simultaneously with IIP.7 Although immediate provisionalisation can also be done with other protocols related to the timing of implant placement, in the context of IIP, it aids in preserving the soft tissue architecture present on the day of tooth extraction. In other scenarios, the soft tissues are left unsupported and may collapse.7 In other protocols for implant placement after tooth extraction (e.g., early soft tissue healing, partial bone healing, full bone healing or after alveolar ridge preservation),6 additional clinical sessions are necessary for conditioning the soft tissues with a provisional prosthesis to achieve a similar appearance to the soft tissues of the homologous tooth.8
Beyond that, gingival recessions are common in areas with BBD. A gingival recession at the compromised tooth is also considered a factor that increases the risk of mucosal recession after IIP.2 Nevertheless, the IIP in cases of damaged sockets in the presence of gingival defects has been scarcely investigated. Major soft tissue deficiencies are considered a contraindication for IIP. Ideally, the gingival margin of the hopeless tooth should be coronal or at the level of the homologous tooth to perform an IIP.5 Moreover, a thin periodontal phenotype may have a negative impact on the results and increase the risk of gingival recession after IIP.9
In these cases, root coverage prior to extraction may be a suitable option.9 10 The root coverage associated with thickening the gingiva prior to extraction may enhance the existing condition and establish a more suitable support structure for the future implant, consequently contributing to improved results.6 11
The current trends in implant dentistry emphasise the importance of developing implant treatment protocols that are predictable, less invasive and expeditious. Hence, exploring alternative approaches in this field is crucial. This 4-year follow-up case report describes an approach to replace a hopeless tooth with BBD and gingival recession using an IIP approach. Root coverage and soft tissue thickening using a subepithelial connective tissue graft (SCTG) were performed before tooth extraction Afterwards, the IIP was performed, and the GAP was filled with bone grafts without raising a flap, followed by the placement of an immediate provisional restoration.
Case presentation
A woman in her mid-20s was referred for the replacement of tooth #22. A thorough intraoral examination and complete periodontal charting were performed. A clinical attachment loss and gingival recession (RT1) were observed in tooth #22 (table 1, figure 1). A Cone Beam Computed Tomography (CBCT) examination of tooth #22 revealed the presence of BBD, crown damage and an iatrogenic root perforation on the palatal side in the middle third of the root. This perforation was the reason for deciding to extract the tooth (figure 2A–C). Importantly, there were no clinical signs of infection, such as suppuration, swelling, erythema or increased sensitivity.
Periodontal parameters of tooth #22 and adjacent teeth (baseline)
Baseline preoperative frontal view of tooth #22 and its corresponding periapical radiograph.
(A) Mesio-distal section, (B) sagittal section and (C) axial section of the Cone Beam Computed Tomography (CBCT) showing the perforation. (D) Tooth #22 immediately after extraction.
Differential diagnosis
The CBCT examination revealed a perforation, prompting the decision to extract the tooth. During the surgical procedure, after administering anaesthesia and performing the syndesmotomy, the limits of the perforation were clearly identified, along with a root fracture originating from this perforation (figure 2A–D).
Treatment
Initially, professional biofilm control was performed, followed by adjustments made to the prosthesis to allow for appropriate biofilm control (the first step of periodontal therapy).12 In the subsequent appointment, subgingival instrumentation was carried out on tooth #22 (the second step of periodontal therapy).12 Table 2 presents the periodontal parameters 6 weeks after the periodontal therapy (first and second steps).
Periodontal parameters of tooth #22 and adjacent teeth after subgingival debridement and prosthesis adjustments, before the surgery for root coverage with a subepithelial connective tissue graft
After the periodontal re-evaluation, the surgery for root coverage was scheduled. Following local anaesthesia, part of the restoration was removed, and scaling and root planing was performed using hand instruments. Subsequently, an intrasulcular incision and a full-thickness flap were carried out, according to Aroca et al.13 Then, an SCTG, harvested from the palate, was sutured into the tunnel (figure 3A,B). Anti-inflammatory medication (ibuprofen 600 mg every 8 hours) was prescribed, and the patient was instructed to rinse with 0.12% chlorhexidine twice a day for 15 days and to avoid tooth brushing and mechanical trauma at the surgical site. The sutures were removed 15 days after the surgical procedure. After 2 months (figure 3C), the tooth was extracted using a periotome (figure 3D). An implant (3.75×11.5 mm, Titamax EX CM, Neodent, Curitiba, Brazil) was placed using a flapless approach, maintaining a gap of 2 mm between the implant and the buccal bone crest, which was subsequently filled with bone graft material (figure 3E). The implant shoulder’s apicocoronal position was 3 mm apical to the midbuccal margin of the planned restoration. Primary stability was achieved, and a provisional abutment (2.5×3.3 mm, Neodent) was positioned. The temporary restoration was adjusted to remove all centric and eccentric contacts for subsequent cementation. The patient followed the same postoperative instructions, and the sutures were removed after 15 days. After 3 months, the hard and soft tissues were clinically adequate (figure 3F–I). Then, a customised zirconia abutment was fabricated, and a monolithic zirconia crown was installed.
(A) Removal of part of the restoration, followed by root scaling and planing. (B) Root coverage associated with subepithelial connective tissue graft. (C) Clinical aspect 2 months after the root coverage procedure. (D) Extraction socket after a minimally traumatic extraction using a periotome. (E) Implant placement with the maintenance of a GAP of 2 mm at the facial aspect. (F) Clinical aspect after 3 months of immediate implant placement and immediate placement of a provisional restoration (frontal view); (G) occlusal view; (H) occlusal view of peri-implant soft tissue; (I) frontal view of peri-implant soft tissue.
Outcome and follow-up
At the 4-year follow-up (figure 4A–D), peri-implant tissue presented satisfactory aesthetics based on the Pink Aesthetic Score14 (table 3). A thick and well-structured buccal bone plate was verified after 4 years (figure 4E,F). Moreover, the implant presented signs of peri-implant health with no bleeding on probing.
Pink Aesthetic Score evaluation at the day of definitive prosthesis placement and 4 years after the surgery
4-year follow-up: (A) close lateral view; (B) occlusal view; (C) lateral view; (D) frontal view; (E) Cone Beam Computed Tomography (CBCT) 4 years after the implant placement; (F) aligned CBCTs (initial and 4-year follow-up). Note the bone loss and unfavourable root position at the initial CBCT and the favourable amount of bone around the implant after the treatment at a sagittal view (OnDemand 3D, Cybermed, Daejeon, Korea).
Discussion
This case report presents an alternative treatment for replacing a compromised tooth with gingival recession and BBD using an IIP. The proposed approach aimed to improve the soft tissue condition of the hopeless tooth prior to extraction. After successfully achieving thicker gingival tissue and an optimal gingival margin position, the IIP was performed without raising a flap. This approach simplified the treatment plan, allowing the surgeon to prioritise tissue preservation during extraction and ensure precise 3D implant positioning. While previous reports have indicated a potentially higher risk of gingival recession following IIP in patients with BBD,5 6 15 there is a lack of evidence investigating whether improving gingival thickness and position prior to IIP can positively impact long-term stability.
Studies have shown that IIP with simultaneous bone grafting to fill the gap between the implant surface and the alveolar bone can effectively reconstruct the facial bone wall, even in cases with bone dehiscence.11 Some techniques have been proposed for buccal bone plate reconstruction simultaneously with IIP.5 11 Demineralised bovine bone mineral (DBBM) is commonly used to fill the gap between the implant surface and the alveolar bone.7 These studies demonstrated that using DBBM with or without a collagen membrane can reconstruct the buccal bone plate and maintain the volume and shape of the extraction socket over time.3 6 However, there has been limited evaluation of these techniques in cases of soft tissue deficiency.
The present case report demonstrated that performing a root coverage procedure using an SCTG before extracting a hopeless tooth with gingival recession may be a viable option to enhance preoperative conditions and improve the predictability of subsequent IIP. Increasing evidence emphasises the importance of soft tissue thickening, particularly in the context of IIP. Systematic reviews have shown that a thicker peri-implant mucosa improves margin stability,9 reduces the risk of mid-buccal recessions and inter-implant papilla loss and minimises marginal bone loss.10
Additionally, studies have shown that thicker soft tissues respond favourably to wound healing. Thick soft tissues contain a higher volume of extracellular matrix and collagen, and increased vascularity within the connective tissue layer. This enhances the clearance of toxic products and promotes immune response and growth factor migration.16 Alongside achieving satisfactory clinical outcomes, this approach offered several benefits, including reduced overall treatment time and immediate provisionalisation that aided in maintaining the original gingival architecture after tooth removal.7 17
Moreover, in addition to the thick gingival phenotype and proper gingival margin positioning after root coverage, the adequate 3D positioning of the implant, the maintenance of a buccal gap of 2 mm,18 and the flapless procedure19 might have played a significant role in the formation of a suitable bone wall during the healing process.20
Despite the interesting outcomes observed with the present clinical approach, further studies are needed to confirm the reproducibility of this technique. According to current evidence, the concept cannot be applied regularly. The influence of soft tissue thickening before IIP on long-term stability, and on buccal bone remodelling and thickness needs to be evaluated.
It is reasonable to speculate that a structured soft tissue wall may promote bone healing by providing better protection for the clot. Based on the present findings, this approach could be cautiously considered when a hopeless tooth, besides presenting gingival recession, has other anatomical factors that could allow for IIP, such as sufficient bone available apically and palatally to the socket to provide primary stability, the socket position within the alveolar bone envelope,21 a horizontal gap of at least 2 mm (at the implant shoulder),18 and no infection at the site.21 However, conducting randomised controlled trials to compare this approach with established techniques is crucial for understanding its place in clinical therapeutic options.
Patient’s perspective
The process began with consultations, X-rays and discussions about the implant. The team did their best to reassure me, explaining each step and answering my endless questions. Still, I couldn’t shake off the nervousness as the surgery day approached. On the day of the surgery, I was a bundle of nerves. The staff was incredibly supportive, though. They ensured I was comfortable, talked me through what would happen, and even played calming music. The local anaesthesia helped with the discomfort, but the sounds and sensations were overwhelming.
Postsurgery, the discomfort and swelling were more than I expected. I struggled to eat and found it challenging to communicate clearly. The first few days were rough, battling pain and trying to follow the aftercare instructions. Ice packs, painkillers and a liquid diet became my companions. I had to be extra cautious with my eating habits, and it took a while to get used to the implant. There were moments of doubt and worry, wondering if everything would heal properly and if the implant would feel natural.
However, gradually, things improved. The follow-up visits were reassuring, knowing that everything was healing as it should. Slowly, I regained my confidence in smiling, talking and eating without worrying about the implant. It became a part of me, something that was there but did not cause any trouble. Looking back now, I am grateful for the care and support from the dental team. The process was challenging, but their professionalism and empathy made it bearable. Though it took time, the implant feels like a natural tooth, and I am glad I went through with it. It is a relief to have a complete smile again.
Learning points
This case report showed that when a compromised tooth presents a gingival recession and buccal bone dehiscence, performing root coverage and soft tissue thickening before the extraction can be an alternative for replacing that compromised tooth using an immediate implant placement (IIP) approach. Performing a root coverage procedure before tooth extraction can enhance preoperative conditions and improve the predictability of subsequent IIP.
Adequate 3D positioning of implants, maintenance of a buccal gap of 2 mm, and flapless procedures also contributed to the formation of a suitable bone wall during the healing process, positively impacting long-term stability and healing outcomes.
Immediate provisionalisation aided in maintaining original gingival architecture after tooth removal, potentially contributing to reduced overall treatment time and improved clinical outcomes.
Despite promising outcomes, further research is required to confirm the reproducibility of the technique, assess its impact on long-term stability and bone remodelling, and compare it with established techniques through randomised controlled trials.
Ethics statements
Patient consent for publication
Footnotes
Contributors OV-C, IR and JBC-N were responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms, and critical revision for important intellectual content. GAR and IR gave final approval of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.