restoration of failing single teeth in compromised anterior sites

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Tidu Mankoo, BDS

Windsor Centre for Advanced Dentistry

Windsor, United Kingdom

CASE REPORT

THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY

VOLUME 2 • NUMBER 4 • WINTER 2007

352

Restoration of Failing Single Teeth

in Compromised Anterior Sites

with Immediate or Delayed Implant

Placement Combined with

Socket Preservation—A Report

of Two Cases

Correspondence to: Dr Tidu Mankoo

Windsor Centre for Advanced Dentistry, Dorset House, 1 Dorset Rd, Windsor, Berks, SL4 3BA, United Kingdom;

fax: 44 (0)1753 830477; e-mail: [email protected].

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353

have been utilized, socket preservation and

socket seal in combination with immediate

or delayed implant placement can be a

valuable protocol. The use of this technique

is illustrated in two challenging cases of pa-

tients with high lip lines.

(Eur J Esthet Dent 2007;2:352–368.)

Abstract

Restoring failing anterior teeth with a den-

tal implant restoration when there is signif-

icant damage to the bone, soft tissues, or

both presents a difficult clinical challenge.

The goal is to produce a result in which the

soft tissue contours, papillae, and in partic-

ular the labial soft tissues remain stable

over time. While a number of techniques

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354

be said that reliable predictability has been

achieved in cases with a thin tissue biotype.

Certainly, these techniques are contraindi-

cated, and delayed implant placement is

usually the treatment of choice when there

is significant compromise to the labial bone

and tissues through trauma, infection, or

previous surgery.

In the past, some clinicians have advo-

cated socket preservation using tech-

niques such as socket seal.10

The main

idea is to preserve the labial gingival archi-

tecture (when it is more or less correct)

and therefore avoid a more aggressive

surgery involving bone and tissue grafting

or augmentation. When a labial flap is

raised it may need to be advanced to

close over any increased bulk produced

by grafting, and this may alter the labial

gingival harmony, particularly if the mu-

coperiosteal junction must be advanced

into the esthetic zone. Whether this truly

makes a difference to the end result is de-

batable; however, the socket preservation

technique does have the advantage that

implant placement can usually be carried

out using a flapless (or minimal flap) tech-

nique either at the time of tooth removal or

later as the case dictates. This makes the

surgical experience significantly less trau-

matic for the patient. Simultaneous implant

placement with the socket seal and

preservation procedure may be used

when there is an intact labial plate and

good primary fixation of the implant is

achievable, but delaying the placement of

the implant until the grafted socket is suit-

ably healed only has the disadvantage of

increasing the length of the overall treat-

ment time. It has also been reported that

the socket seal graft may not always be

successful.11

However, in the author’s ex-

perience this is rare if microsurgical tech-

The goal of single-tooth implant therapy is

to produce restorations that mimic the pa-

tient’s natural teeth and maintain harmo-

nious soft tissue contours. In cases with a

failing post crown with a root fracture or

previous apical surgery, this goal can be

difficult to attain predictably. Furthermore,

a high lip line and thin gingival biotype

can present significant hurdles to a lasting

esthetic outcome, particularly regarding

labial soft tissue stability over time. In a

previous article, the author outlined con-

temporary concepts in implant treatment

in the esthetic zone, and described how

the implant, abutment, and prosthetic

contours all have a biologic impact on the

peri-implant tissues.1The goal today is to

manage implant treatments with a better

understanding of the factors that provide

a durable esthetic result, especially in re-

spect to the soft tissue esthetics.

In recent years, the popularity of imme-

diate and flapless implant placement tech-

niques has increased, since these proce-

dures offer a minimally invasive and often

virtually atraumatic surgery. This has obvi-

ous benefits for the patient in terms of the

surgical experience and perhaps treatment

acceptance, although it may not be so ad-

vantageous from a long-term clinical out-

come viewpoint, especially regarding the

stability of the labial bone and gingival tis-

sues. Both recession and labial volume

loss are often associated with the tech-

nique,2–6

prompting many clinicians to ad-

vocate a number of additional surgical

steps such as grafting of biomaterials and

tissue grafting in an attempt to increase the

predictability of the soft tissue outcomes.5–9

These additional steps require a higher de-

gree of surgical skill and are by no means

easy when working in a small site such as

an extraction socket. In addition, it cannot

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355

esthetic zone is the recession of the labial

gingiva.14–16

However, the biotype, quality,

and thickness of the labial tissue along with

the transmucosal contours of the abutment

and prosthetic components have a key role

to play in terms of the esthetic outcome and

maintenance of soft tissue esthetics in the

long-term, especially in regard to preven-

tion of the labial recession commonly re-

ported in the first year following placement

of the final crown.5–9

It should also be stressed that an “early-

delayed” approach as described in a pre-

vious paper1

is just as effective in these

cases, but does invariably involve a far

more aggressive surgery with bone graft-

ing/augmentation, guided bone regenera-

tion, and often additional soft tissue graft-

ing. The options for these cases are

outlined in Table 1.

The scope and application of the above

concepts are illustrated by two case re-

ports with 1- to 4-year follow-ups. In both

cases, there were complicating factors that

presented considerable challenges, and

the end results are an encouraging confir-

mation of the validity of these methods in

selected cases.

niques are employed,12

as outlined in the

cases below, using ultra-fine sutures (6-0

or 7-0 monofilament polypropylene) and

ensuring accurate and meticulous trim-

ming of the graft to fit the socket precisely.

Therefore, the main goal of socket seal

and preservation is to reduce the invasive

nature of the surgery and maintain as much

of the labial gingival architecture as possible.

Inevitably, there will be some degree of labi-

al volume loss even with these preservation

techniques,13

but this is usually relatively

small and can easily be compensated for by

a simple roll of the tissue on the crest of the

ridge to the labial aspect of the transmucos-

al components, either when placing the im-

plant in a one-stage approach or at the sec-

ond stage when simultaneous implant

placement (ie, immediate implant place-

ment) with the socket seal and preservation

technique is performed. This still allows for a

roll flap or indeed any further connective tis-

sue grafting in a tunnel-technique at sec-

ond-stage surgery to increase the labial bulk

of tissue and compensate for any slight labi-

al volume loss.

One of the commonly accepted failings

of single-tooth implant restorations in the

Table 1 Indications for immediate or delayed single-tooth implant placement

Immediate Delayed

No/minimal grafting Bone grafting required

Small bone defects only Large bone defects

Thick biotype (additional CT graft/orthodontic extrusion?) Thin biotype (CT graft/orthodontic extrusion?)

Adequate soft tissue thickness Inadequate soft tissue thickness

Single-stage placement One- or two-stage placement

Immediate provisionalization Provisional prosthesis

Socket seal not required Socket preservation/socket seal

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356

be replaced. The intention was also to car-

ry out root-coverage procedures for the

right incisor and both canines and then to

allow the extraction site to heal for 6 weeks

in order to carry out delayed implant place-

ment. The immediate concern was to re-

move the failing tooth.

The crown on the right central incisor

was removed, the tooth preparation was

refined, and impressions were taken for an

immediate cantilever fixed dental prosthe-

sis. Care was taken to maintain the existing

labial preparation margin of the crown on

the right central incisor, because the inten-

tion was to augment the tissue and cover

the exposed root surfaces. Interestingly, on

extraction it was found that the labial bone

in the socket was intact, although there was

a small fenestration associated with the fis-

tula, which was easily debrided. The labial

bone height was slightly deficient, but was

judged to be more or less where the labial

bone would normally remodel should it

have been intact, ie, about 1.5 mm from the

head of an ideally placed implant where

the fixture head would be 2 to 3 mm from

Case 1

The 46-year-old female patient was referred

in February 2002 for implant restoration of

her maxillary left central incisor. Both cen-

tral incisors were restored with porcelain-

fused-to-metal crowns and the left incisor

was root treated and had a post and core.

She had a history of three attempted

apicectomies, which had failed to bring the

tooth under control. She had a recurring fis-

tula above the mucogingival junction and

periodic tenderness, but the main compli-

cating factors were her thin labial gingiva

with medium scalloping, gingival recession

on both central incisors and canines, high

lip line, and triangular tooth form of the max-

illary left lateral incisor with an already defi-

cient mesial papilla. The recession was par-

ticularly pronounced on the failing left

incisor and left canine (Figs 1 and 2).

It was decided that the failing tooth

should be extracted and that a provisional

cantilever fixed dental prosthesis would be

fabricated, retained by the right central in-

cisor since the crowns would both need to

Figs 1 and 2 Initial situation. Note the recession and thin tissues.

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357

the desired gingival margin. Therefore, it

was felt that an implant could be placed at

this stage 1.5 to 2 mm palatal to the labial

plate of bone, in accordance with com-

monly accepted protocol. This was done

by preparing the initial pilot hole of the im-

plant osteotomy in the palatal wall of the

socket about 3 mm from the apex. Thus,

the abutment connection would be supra-

osseous, reducing the potential influence

of the abutment on vertical bone remodel-

ing.17

A 5 x 13 mm Replace Select hydrox-

yapatite-coated implant (Nobel Biocare)

was placed and the cover screw was at-

tached. In immediate cases, the author al-

ways packs the labial void with anorganic

bone mineral (Bio-Oss, Geistlich), because

this improves the maintenance of the labi-

al volume.5,6,13,18–22

Esthetically, the main challenge was

now the labial gingival level, which would

be likely to recede further if a one-stage

surgery was attempted. The options at this

stage were then to raise a flap and ad-

vance the flap coronally or carry out a

socket seal graft. The clear problem with

the former approach is that the flap would

have to be significantly advanced for clo-

sure and the mucoperisteal junction would

be brought into the esthetic zone—a prob-

lem in patients with a high lip line. The ad-

vantage of the socket seal approach is that

the volume of tissue and particularly kera-

tinized tissue would be increased.

The internal socket epithelium was de-

epitheliased. A template (using foil from the

suture pack) was trimmed to fit the socket

opening and used to guide the incision for

a full-thickness flap taken from the palate

(Figs 3 and 4). The implant cover screw

was placed and the graft was meticulous-

ly sutured into place using 6-0 monofila-

ment polypropylene sutures, with care tak-

en not to place sutures in the papillae. Fig

5 shows the precise fit of the graft to the

socket. The provisional restoration was ce-

mented with temporary cement after the

pontic was adjusted to fit passively against

the ridge (Fig 6). The graft was taken from

an area of the palate free from rugae to pre-

vent future problems with the texture of the

tissue in the recipient site.

Fig 3 Socket-seal donor site in the palate. Fig 4 The implant at placement. The labial socket

was packed with anorganic bone mineral. The graft

was stabilized by a single suture on the palatal aspect,

the cover screw was placed, and the flap was sutured.

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Fig 5 The tissue graft was meticulously sutured. Fig 6 Provisional fixed dental prosthesis in place.

Fig 7 Soft tissue healing at 2 months. Fig 8 A sub-epithelial connective tissue graft was

taken from the palate using a single horizontal incision

for access.

Fig 9 A split-thickness flap was raised at the implant

site. The head of the implant is just shining through the

tissue.

Fig 10 A carbide bur was used to create the subgin-

gival undercontour on the labial aspects of the roots pri-

or to grafting. The composite filling was removed to the

level of the cementoenamel junction.

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359

Antibiotic therapy (penicillin V 250 mg four

times a day for 5 days) was prescribed,

and the sutures were removed at 1 week.

Healing was allowed for 2 months, at

which point the gain in keratinized tissue

was clearly visible, along with good main-

tenance of the bucco-palatal ridge width

and labial contour (Fig 7). At this point, sur-

gery was performed to further augment

the tissue in the edentulous site and per-

form the necessary root coverage. A small

split-thickness flap was raised and further

augmentation of the area was carried out

with connective tissue taken from the

palate. The graft was harvested using a

single incision and sutured to the perios-

teum with 5-0 vicryl sutures. The flap was

then released slightly apically and closed

with 6-0 monofilament polypropylene su-

tures (Figs 8 and 9). Root coverage of the

anterior teeth was then carried out using a

coronally replaced flap, along with addi-

tional connective tissue grafts for the max-

illary left canine and a simple coronally re-

placed flap for the right central incisor and

canine. A carbide bur was used to remove

any composite fillings from the root sur-

face, and the labial root surfaces were

modified to create a flat or slightly concave

subgingival profile to allow for better post-

treatment stability of the tissues (Fig 10).

The flaps were meticulously sutured, and

the sutures were removed at 7 to 10 days

(Figs 11 and 12). The patient was advised

to avoid brushing the area for the first week

and to clean the area twice daily with a cot-

ton bud soaked in chlorhexidine mouth-

wash.

After a further 2 months, good healing

was evident, the buccolingual ridge form

was well maintained, and the root coverage

was successful (Figs 13 and 14). The im-

plant was uncovered with a simple U-

shaped incision on the crest of the ridge

(with the bottom of the U pointing toward

the palate). This was de-epitheliased and

rolled back on itself under the labial gingi-

va. The de-epitheliasation helps overcome

any issues with tissue color if the grafted

palatal tissue is slightly different from the

labial tissue. However, in the author’s expe-

rience this is not generally a problem. A

healing abutment was customized chair-

side so that that the labial aspect would be

Fig 11 The flaps were sutured after root coverage

was carried out with coronally replaced flaps along with

connective tissue grafts.

Fig 12 Healing at 7 days.

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360

undercontoured; this increases the space

available for soft tissue and hence main-

tains the labial soft tissue thickness (Fig 15).

After a further 6 weeks, the crown prepara-

tion on the right central incisor was refined

and the final impressions of the tooth and

transfer impression of the implant were tak-

en. Note that the implant transfer impres-

sion coping was also customized chairside

to have a flat, undercontoured labial profile

(Fig 16). This is an important step to help the

technician develop the transmucosal under-

contour necessary to maintain the labial

Fig 13 Excellent ridge maintenance was observed

after an additional 2 months.

Fig 14 Radiograph of the implant 4 months after

placement.

Fig 15 Healing abutment customized to preserve

labial tissue thickness.

Fig 16 The corresponding transfer impression cop-

ing was customized to maintain the labial transmucos-

al undercontour.

Fig 17 Custom porcelain-fused-to-metal abutment

with porcelain shoulder in place.

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361

tissue thickness. A custom porcelain-fused-

to-metal abutment using a machined

castable abutment was then fabricated, and

shoulder porcelain was used to position the

crown margin slightly subgingivally on the

labial aspect to facilitate cement removal

(Fig 17). Biologically speaking, this solution

is not as good as a titanium, alumina, or zir-

conia abutment, and certainly the author’s

material of choice today would be a custom

zirconia abutment designed with the same

shape, as this provides greater biocompat-

ibility23–25

; however, at the time of treatment

these abutments were not available. The fi-

nal alumina-based all-ceramic crowns were

fitted with glass-ionomer cement (Fuji 1, GC)

after placing retraction cord around the

abutment to facilitate excess cement re-

moval and prevent any cement from travel-

ling apically. The cord was removed once

the cement was set and the occlusion was

checked. The success of the treatment and

excellent soft tissue stability are shown in

Figs 18 to 22 at 2-year and 4-year follow-ups.

Figs 18 to 20 At the 2-year follow-up, excellent soft tissue maintenance and stable bone levels were observed.

Figs 21 and 22 At the 4-year follow-up, continued excellent results were ob-

served.

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Case 2

A 29-year-old woman was referred for

restoration of her failing maxillary left cen-

tral incisor (Figs 23 to 25). The patient had

a complicated history of trauma, subse-

quent endodontic treatment to three max-

illary incisors carried out at a young age,

and later surgical endodontic treatment.

There was recurrent infection on the left

central incisor and this had been sympto-

matic and treated by her dentist with antibi-

otic therapy. It was felt that further endodon-

tic treatment was contraindicated and that

extraction of the tooth was the only option.

There was also concern as to the progno-

sis of the right central and lateral incisors,

although these were asymptomatic. After

discussion of all these considerations, it

was decided that the left central incisor

should be treated at this stage, leaving the

other incisors untreated until they became

symptomatic. The patient had a very high

lip line and there was some darkening of

the tissues due to the nonvital roots along

with some scar tissue from the previous

surgery, although this was not too notice-

able since it was just under her lip when

she smiled.

The final treatment approach should be

decided upon once the tooth has been

carefully extracted. This enables careful

evaluation of the socket and the surround-

ing tissues. In this case, it was decide that

a conservative approach should be used,

because the lip line left no room for any es-

thetic compromise. After careful extraction,

the socket was evaluated, and although

the labial plate was intact, there was a con-

siderable lesion apically and it was felt that

an immediate implant would be inappro-

priate given the demanding esthetic situa-

tion. At this stage, a delayed approach

Figs 23 to 25 Initial situation. Note the high lip line

with large gingival display. The gingiva is slightly dark-

ened by nonvital roots. Some scarring is visible from

previous endodontic surgery, and a large apical radi-

olucency is present around the left central incisor.

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363

could have been used, but it was felt that a

socket preservation technique would have

the advantage of preserving the labial con-

tours while enabling the later surgery to be

less aggressive and traumatic. To deal with

the apical lesion, a flap was raised using a

beveled horizontal incision just coronal to

the lesion (Fig 26). Vertical beveled releas-

ing incisions were made to enable good

access to the site. The socket and lesion

were thoroughly degranulated, debrided,

and rinsed copiously with 1% chlorhexi-

dine gluconate. Anorganic bone mineral

Fig 26 The tooth was ex-

tracted and the socket was

debrided. A beveled incision

was used to raise the flap for

access to the apical lesion. A

wide band of labial-attached

gingiva was left over the

intact labial bone plate.

Fig 27 After thorough de-

bridement, anorganic bone

mineral was packed into the

socket and apical defect.

Fig 28 A double layer of resorbable collagen mem-

brane was placed

Figs 29 and 30 The flap was meticulously sutured along with the socket seal graft taken from the palate.

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364

cover and seal the grafted socket (Figs 29

and 30). A removable prosthesis was ad-

justed and fitted, ensuring that there was no

pressure on the site and that the denture

tooth fitted passively to the grafted ridge

(Fig 31). Sutures were removed at 7 to 12

days (Fig 32) and a systemic antibiotic was

prescribed for 5 days postoperatively.

Healing was uneventful (Figs 33 and

34) at 7 months, and excellent mainte-

nance of the ridge and gingival architec-

(Bio-Oss, Geistlich) was packed into the

socket and apical lesion (Fig 27). The graft

was then covered with two layers of re-

sorbable collagen membrane (Bio-Gide,

Geistlich). In the author’s experience, this

double layer of Bio-Gide seems to provide

better stability of the particulate material.

The flap was then meticulously sutured

(Fig 28). A template was again used to har-

vest a full-thickness socket-seal graft from

the palate, which was precisely sutured to

Fig 31 The provisional prosthesis was adjusted to fit

passively over the grafted ridge.

Fig 32 Healing of the socket graft 12 days postoper-

atively.

Fig 33 Radiograph of the grafted socket. Fig 34 Excellent maintenance of the ridge contours

at 7 months, just prior to exposure. Note the tissue

blanching caused by local anesthetic.

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365

ture was observed. The decision was made

to perform flapless surgery using a tissue

punch to access the bone, and the implant

osteotomy and placement was carried out

through this access (Figs 35 to 37). The im-

plant selected allowed for maximum main-

tenance of soft tissue thickness in the

transmucosal zone by means of under-

contoured concave transmucosal compo-

nents (Ankylos, Dentsply Friadent).26

A con-

cave healing abutment was positioned and

the denture was adapted to fit passively

over the abutment (Figs 38 and 39). Fig-

ures 40 and 41 show the healing at 1 week.

At 3 months, transfer impressions were tak-

en in order to fabricate the final crown (Fig

42). The abutment and crown were tried in

at the bisque-bake stage and amendments

were made as necessary. A provisional

crown could have been fitted at this stage,

but it was deemed unnecessary in this case.

A Balance Zirconia abutment (Ankylos)

Fig 35 A tissue punch was used to create the ac-

cess hole for the implant osteotomy.

Fig 36 Removal of the tissue plug.

Fig 37 The implant was placed with a flapless tech-

nique.

Fig 38 Healing abutment in place.

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Fig 39 The denture was adjusted and fitted passive-

ly over the healing abutment.

Fig 40 Healing at 1 week

Fig 41 Radiograph at 3

months. Curvature of the

arch gives a misleading im-

pression, with the implant

superimposed over the ad-

jacent root. Clinical obser-

vation showed clearly

that the implant was well

positioned between the

teeth.

Fig 42 Transfer impression coping in position.

Fig 43 The abutment was correctly positioned using

a Pattern Resin jig.

Fig 44 Zirconia abutment in place.

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367

was used and an alumina crown was fab-

ricated on the abutment. Because there is

no indexing in this implant design, it was

necessary to use a laboratory-fabricated

Pattern Resin jig (GC) to locate the abut-

ment in the correct position in the implant

(Fig 43). The abutment was torqued to the

manufacturer’s recommendations (Fig 44)

and the crown was finalized using the pro-

tocols described in the first case (Fig 45).

The 1-year follow-up demonstrated excel-

lent stability of the labial gingiva (Figs 46

and 47).

Conclusions

The cases illustrated demonstrate the use

of the socket-preservation/socket-seal

technique in combination with immediate

and delayed implant placement for the

restoration of single maxillary central inci-

sors in complex situations. These tech-

niques offer a useful alternative to the con-

ventional delayed implant placement

approach and have the advantages of

maintaining good ridge architecture and

minimizing the surgical experience for the

patient. As always, careful case selection is

essential along with meticulous soft tissue

management.

Fig 45 Facial view of the posttreatment smile with fi-

nal crown in position. Note the improved gingival col-

or over the implant relative to the darkened gingiva over

nonvital roots.

Figs 46 and 47 At the 1-year follow-up, excellent

stability of the labial tissue margin was observed.

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19. Berglundh T, Lindhe J. Healing

around implants placed in

bone defects treated with Bio-

Oss. An experimental study in

the dog. Clin Oral Implants

Res 1997;8:117–124.

20. Norton MR, Odell EW, Thomp-

son ID, Cook RJ. Efficacy of

bovine bone mineral for alveo-

lar augmentation: A human

histologic study. Clin Oral

Implants Res 2003;14:775–783.

21. Cornelini R, Cangini F, Martus-

celli G, Wennstrom J. Depro-

teinized bovine bone and

biodegradable barrier mem-

branes to support healing fol-

lowing immediate placement

of transmucosal implants:

A short-term controlled clinical

trial. Int J Periodontics Restora-

tive Dent 2004;24:555–563.

22.Esposito M, Grusovin MG,

Coulthard P, Worthington HV.

The efficacy of various bone

augmentation procedures for

dental implants: A Cochrane

systematic review of random-

ized controlled clinical trials.

Int J Oral Maxillofac Implants

2006;21:696–710.

23.Abrahamsson I, Berglundh T,

Glantz PO, Lindhe J. The

mucosal attachment at differ-

ent abutments. An experimen-

tal study in dogs. J Clin Peri-

odontol 1998;25:721–727.

24.Rimondini L, Cerroni L, Carras-

si A, Torricelli P. Bacterial colo-

nization of zirconia ceramic

surfaces: An in vitro and in

vivo study. Int J Oral Maxillofac

Implants 2002;17:793–798.

25.Degidi M, Artese L, Scarano A,

Perrotti V, Gehrke P, Piattelli AJ.

Inflammatory infiltrate,

microvessel density, nitric oxide

synthase expression, vascular

endothelial growth factor

expression, and proliferative

activity in peri-implant soft tis-

sues around titanium and zir-

conium oxide healing caps.

Periodontol 2006;77:73–80.

26.Chou CT, Morris HF, Ochi S,

Walker L, DesRosiers D.

AICRG, Part II: Crestal bone

loss associated with the Anky-

los implant: Loading to 36

months. J Oral Implantol 2004;

30:134–143.

10. Landsberg CJ. Socket seal

surgery combined with imme-

diate implant placement:

A novel approach for single-

tooth replacement. Int J

Periodontics Restorative Dent

1997;17:140–149.

11. Tal H. Autogenous masticatory

mucosal grafts in extraction

socket seal procedures: A

comparison between sockets

grafted with demineralized

freeze-dried bone and depro-

teinized bovine bone mineral.

Clin Oral Implants Res 1999;

10:289–296.

12. Burkhardt R, Lang NP. Cover-

age of localized gingival

recessions: Comparison of

micro- and macrosurgical

techniques. J Clin Periodontol

2005;32:287–293.

13. Nevins M, Camelo M, De Paoli

S, et al. A study of the fate of the

buccal wall of extraction sockets

of teeth with prominent roots.

Int J Periodontics Restorative

Dent 2006;26:19–29.

14. Bengazi F, Wennström JL,

Lekholm U. Recession of the

soft tissue margin at oral

implants. A 2-year longitudinal

prospective study. Clin Oral

Implants Res 1996;7:303–310.

15. Grunder U. Stability of the

mucosal topography around

single-tooth implants and adja-

cent teeth: 1-year results. Int J

Periodontics Restorative Dent

2000;20:11–17.

16. Small PN, Tarnow DP. Gingival

recession around implants: A

1-year longitudinal prospective

study. Int J Oral Maxillofac

Implants 2000;15:527–532.

17. Hermann JS, Buser D, Schenk

RK, Schoolfield JD, Cochran

DL. Biologic width around one-

and two-piece titanium

implants. Clin Oral Implants

Res 2001;12:559–571.

18. Jensen SS, Aaboe M, Pinholt

EM, Hjorting-Hansen E,

Melsen F, Ruyter IE. Tissue

reaction and material charac-

teristics of four bone substi-

tutes. Int J Oral Maxillofac

Implants 1996;11:55–66.

References

1. Mankoo T. Single tooth implant

restorations in the esthetic

zone—Contemporary concepts

for optimization and mainte-

nance of soft tissue esthetics in

the replacement of failing teeth

in compromised sites. Eur J

Esthet Dent 2007;2:274–295.

2. Botticelli D, Berglundh T, Lindhe

J. Hard-tissue alterations follow-

ing immediate implant place-

ment in extraction sites. J Clin

Periodontol 2004;31:820–828.

3. Araujo MG, Sukekava F,

Wennstrom JL, Lindhe J. Ridge

alterations following implant

placement in fresh extraction

sockets: An experimental study

in the dog. J Clin Periodontol

2005;32:645–652.

4. Araujo MG, Sukekava F,

Wennström JL, Lindhe J.

Tissue modeling following

implant placement in fresh

extraction sockets. Clin Oral

Implants Res 2006;17:615–624.

5. Mankoo T. Contemporary

implant concepts in aesthetic

dentistry—Part 2: Immediate sin-

gle-tooth implants. Pract Proced

Aesthet Dent 2004;16:61–68.

6. Mankoo T. Contemporary

implant concepts in aesthetic

dentistry—Part 3: Adjacent

immediate implants in the aes-

thetic zone. Pract Proced Aes-

thet Dent 2004;16:327–334.

7. Kan JYK, Rungcharassaeng K,

Klyotaka U, Kois JC. Dimen-

sions of peri-implant mucosa:

An evaluation of maxillary ante-

rior single implants in humans.

J Periodontol 2003;74:557–562.

8. Kan JY, Rungcharassaeng K,

Lozada JL. Bilaminar subep-

ithelial connective tissue grafts

for immediate implant place-

ment and provisionalization in

the esthetic zone. J Calif Dent

Assoc 2005;33:865–871.

9. Bianchi AE, Sanfilippo F. Sin-

gle-tooth replacement by

immediate implant and con-

nective tissue graft: A 1-9-year

clinical evaluation. Clin Oral

Implants Res 2004;15:269–277.

restoration of failing single teeth in compromised anterior sites

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