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Immediate placement and provisionalization of maxillary anterior single
implant with guided tissue graft, and coronally positioned flap procedures
Article in The International Journal of Esthetic Dentistry · June 2016
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CLINICAL RESEARCH
Immediate placement and provision-
alization of maxillary anterior single
implant with guided bone regenera-
tion, connective tissue graft, and
coronally positioned flap procedures
Tomonori Waki, DDS PhD
Associate Clinical Professor, Osaka University Graduate School of Dentistry, Osaka, Japan
Private Practice limited to Prosthodontics, Implant Dentistry, and Esthetic Dentistry,
Tokyo, Japan
Joseph Y K Kan, DDS, MS
Professor, Center for Prosthodontics and Implant Dentistry, Loma Linda University
School of Dentistry, Loma Linda, CA
Private Practice, Los Angeles, CA
Correspondence to: Tomonori Waki, DDS, PhD
Azabu Tokyo Dental Clinic, Minami Azabu Centre 7F, 4-12-25 Minamiazabu, Minato-ku, Tokyo 106-0047, Japan;
Tel: +81 3 5422 7518; Fax: +81 3 5422 7508; E-mail: info@azabutokyodc.jp

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Abstract
Immediate implant placement and pro-
visionalization in the esthetic zone have
been documented with success. The
benefit of immediate implant placement
and provisionalization is the preservation
of papillary mucosa. However, in cases
with osseous defects presenting on the
facial bony plate, immediate implant
placement procedures have resulted in
facial gingival recession. Subepithelial
connective tissue grafts for immediate
implant placement and provisionaliza-
tion procedures have been reported with
a good esthetic outcome. Biotype con-
version around implants with subepithe-
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lial connective tissue grafts have been
advocated, and the resulting tissues ap-
pear to be more resistant to recession.
The dimensions of peri-implant muco-
sa in a thick biotype were significantly
greater than in a thin biotype. Connec-
tive tissue graft with coronally positioned
flap procedures on natural teeth has al-
so been documented with success. This
article describes a technique combin-
ing immediate implant placement, pro-
visionalization, guided bone regenera-
tion (GBR), connective tissue graft, and
a coronally positioned flap in order to
achieve more stable peri-implant tissue
in facial osseous defect situations.
(Int J Esthet Dent 2016;11:174–185)

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CLINICAL RESEARCH
Introduction
Recently, immediate tooth replacement
with an implant in the esthetic zone has
been documented with success in case
cohort studies1-3 and a randomized
controlled study.4 However, in the pres-
ence of an osseous defect on the facial
bony plate, facial gingival recession
has been reported after immediate im-
plant replacement procedures.5 On the
other hand, biotype conversion around
implants with subepithelial connective
tissue grafts has been advocated, and
the resulting tissues appear to be more
resistant to recession.6-8 In addition,
subepithelial connective tissue graft
with coronally positioned flap proced-
ures on natural teeth has been reported
with success in a randomized clinical
trial study.9
This article describes a technique
combining immediate implant place-
ment, provisionalization, guided bone
regeneration (GBR), bilaminar sube-
pithelial connective tissue graft, and a
coronally positioned flap. This technique
was devised to achieve more stable
peri-implant tissue in facial osseous de-
fect situations.
Fig 1 Preoperative smile view. Note the black tri-
angle between the maxillary central incisors.
Fig 2 Preoperative facial view of the maxillary
central incisors. Clinical evaluation revealed a swell-
ing approximately 3 mm apical to the facial free gin-
gival margin.
Fig 3 Preoperative
periapical radiograph
of tooth 8 (11).

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Case presentation
A 57-year-old female presented with
an infection in tooth 8 (11) and a black
triangle between the maxillary central
incisors (Fig 1). Clinical evaluation re-
vealed a swelling approximately 3 mm
apical to the facial free gingival margin
(Fig 2). Radiographic evaluation re-
vealed periapical radiolucency on tooth
8 (11) (Fig 3). A cone beam computed
tomography (CBCT) scan (Classic i-
CAT, Imaging Sciences International)
was performed (Fig 4). The buccal plate
was not recognized in the image. Bone
sounding revealed low crest (8 mm)
at the facial aspect (Fig 5) and normal
crest (3 mm) at the mesial and distal in-
terproximal aspects of tooth 8 (11). An
endodontic consultation for tooth 9 (21)
was obtained (Fig 6). It was determined
that it was likely the apical rarefaction
was an apical scar. The rationale for
this included the fact that the tooth was
functioning without any symptoms. Fur-
thermore, the CBCT scan showed com-
plete reestablishment of the bone cortex
despite the previous access for apical
surgery. The endodontic recommenda-
tion was no treatment and observation
for tooth 9 (21).
The patient was presented with re-
storative options that included a re-
movable partial denture, a fixed dental
prosthesis, or a fixed implant restoration.
Since the adjacent lateral incisor had not
previously been restored, the patient
consented to an implant-supported res-
toration to avoid adjacent lateral incisor
preparation.
Fig 4 Preoperative cone beam computed tomog-
raphy (CBCT) scan image of tooth 8 (11). Buccal
plate was not recognized.
Fig 5 Preoperative bone sounding of tooth 8 (11),
which revealed low crest (8 mm) at the facial aspect.
Fig 6 Preoperative
periapical radiograph
of tooth 9 (21).

6. CLINICAL RESEARCH
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A treatment plan utilizing immediate
implant placement with provisionaliza-
tion, GBR, connective tissue graft, and
coronally positioned flap procedures
was selected for tooth 8 (11).
Clinical procedure
Presurgical procedures
Before implant surgery, an impression
(Exafast NDS, GC) was made for diag-
nostic waxing. Diagnostic waxing was
performed and provisional shells fab-
ricated for teeth 8 (11) and 9 (21) us-
ing autopolymerizing acrylic resin (Jet
Acrylic, Lang Dental). The existing pros-
theses were removed and provisional
restorations delivered with provisional
cement (TempBond, Kerr).
Incisal edge position was changed
with diamond burs (Shofu Dental), and
the cervical area of the tooth shape
was changed on teeth 6 (13), 7 (12),
10 (22), and 11 (23) by direct bonding
with composite resin (4 Seasons, Ivo-
clar Vivadent) (Fig 7). After placement
of the provisional restorations with direct
bonding to change the tooth shape and
the incisal edge position, an impression
(Exafast NDS) was made for making a
surgical template. The surgical template
was fabricated using autopolymerizing
acrylic resin (Pattern Resin, GC; Jet
Acrylic).
Immediate implant placement
A sulcular incision with transseptal fiber-
otomy was executed with a No. 15C
surgical blade (Kai Medical) to sepa-
rate tooth 8 (11) from the periodontal tis-
sue. A controlled expansion (Periotome,
Nobel Biocare) of the bony socket was
performed, except at the buccal bony
defect area, to avoid soft and hard tissue
damage. Tooth 8 (11) was atraumatically
extracted without flap reflection. After
extraction, vertical releasing incisions
were made at the mesial and distal line
angle of the failing maxillary central inci-
sor 8 (11) to avoid touching the papil-
lae of the other teeth. As the patient’s
six maxillary anterior teeth had gingival
recession, these teeth had a risk fac-
tor of losing the papillae when opening
the flap. The mucoperiosteal flap was
carefully elevated using a Periosteal El-
evator No. 7 (H H Company) expos-
ing the U-shaped osseous defect.5 An
osteotomy was performed with the aid
of the fabricated surgical template. Be-
fore implant placement, numerous small
cortical perforations were made around
the osseous defect area for GBR. The
implant (NobelReplace Tapered Groovy,
Fig 7 Facial view of provisional restorations on
teeth 8 (11) and 9 (21). Direct bonding on teeth 6
(13), 7 (12), 10 (22), and 11 (23).

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Nobel Biocare) was placed (Fig 8) 3 mm
apical to the predetermined facial gingi-
val margin,6,10 with an implant–tooth dis-
tance of more than 2 mm.11 This was ac-
complished using the surgical template.
The implant angulation was positioned
slightly palatal to the predetermined de-
finitive prosthesis incisal edge. Primary
implant stability was attained.
Fabrication of a customized
temporary abutment and
provisional restoration on implant
The mucoperiosteal flap was closed
temporarily (P-2 5-0 Vicryl, Ethicon,
Johnson Johnson). Adhesive metal
primer (Alloy Primer, Kuraray) was ap-
plied on the metal temporary abutment
(Temporary Abutment Engaging, Nobel
Biocare) and was placed on the implant.
Flowable composite resin (PermaFlo, Ul-
tradent) was applied to the temporary
abutment to duplicate the cervical gingi-
val emergence of the extracted tooth.10
The customized metal temporary abut-
ment length and subgingival contour
were adjusted extraorally with the finish
line at 0.5 mm below the predetermined
free gingival margin. The customized
metal temporary abutment was hand
tightened onto the implant and a peri-
apical radiograph was made to ascer-
tain its fit. The provisional shells 8 (11)
and 9 (21) were then relined, adjusted
extraorally (Fig 9), and delivered with
provisional cement (IRM cement, Dent-
sply). Adjustments were made to clear
all contacts in centric occlusion and dur-
ing eccentric movements.
Guided bone regeneration
on implant
The temporary sutures were removed
and the mucoperiosteal flap reflected.
The periosteum was then released with a
new No. 15 blade (Kai), therefore ensur-
Fig 8 The implant was placed 3 mm apical to the
predetermined facial gingival margin. Note the U-
shaped osseous defect.
Fig 9 View of the provisional restoration of im-
plant 8 (11).

8. CLINICAL RESEARCH
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ing a tension-free coronally positioned
flap procedure. Autogenous bone, which
was collected during the osteotomy, al-
lograft (Puros Allograft, Zimmer Dental),
and xenograft (Bio-Oss, Osteohealth),
was used to cover the osseous defect
and thread exposure, and to fill the gaps
between the implant body and the tooth
extraction socket after immediate im-
plant placement (Fig 10).12,13 Resorb-
able collagen membrane (Bio-Guide,
Osteohealth) was trimmed and placed
to cover and stabilize the graft material
(Fig 11). Titanium tacks (truTACK, ACE
Surgical Supply) were used to secure
the membrane in place.
Bilaminar subepithelial
connective tissue graft and
coronally positioned flap
procedures on implant
The subepithelial connective tissue graft
with the dimensions of 14 mm in length,
1.5 mm in thickness,6 and a width con-
sistent with the mesiodistal width of the
8 (11) crown,6 was harvested from the
palate using the single-incision tech-
nique.14,15,16 The harvested connective
tissue graft was maintained in a moist
environment to prevent desiccation prior
to its placement.6 Primary closure of the
donor site was attained using resorbable
sutures (P-3 5-0 Vicryl). The connective
tissue graft was then placed 2 mm coro-
nally to the predetermined margin of the
osseous defect area (Fig 12). The sur-
face epithelium around the incision area
was removed for a coronally positioned
flap. The flap was positioned 2 mm cor-
onal to the predetermined margin and
sutured to cover the graft using resorb-
able sutures (P-2 5-0 Vicryl). A cross-
sling suture was placed at the coronal
aspect of the flap to secure it over the
graft. The connective tissue was then
sutured onto the flap using gut sutures
(P-3 5-0 Chromic Gut) (Fig 13). Light fin-
ger pressure was then applied over the
grafted site with moist gauze for 5 min to
minimize blood clot formation between
the graft and its underlying and overly-
ing tissues.6 After surgery, a periapical
radiograph was made (Fig 14) and a
CBCT scan (Classic i-CAT) performed
to confirm the implant position and an-
gulation (Fig 15).
Postoperative instruction
Antibiotics (amoxicillin 500 mg, 3 times a
day), analgesic medications (ibuprofen
800 mg, every 4 to 6 hours as needed
for pain), and 0.12% chlorhexidine glu-
conate (Peridex, Procter Gamble) as
a mouth rinse were prescribed. The pa-
tient was instructed not to brush the sur-
gical site and remain on a liquid diet for
2 weeks.1,6 After suture removal, a soft
diet was recommended for the remain-
ing duration (6 months) of the implant
and GBR healing phase. The patient
was also advised to avoid any mechani-
cal trauma to the surgical site.1,6

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Fig 10 View of the bone graft material placement
on implant.
Fig 11 View of the membrane placement on the
bone graft material.
Fig 12 View of the connective tissue graft place-
ment. Note the connective tissue graft was placed
in the bone graft and coronally positioned flap area
on implant.
Fig 13 View of the coronally positioned flap pro-
cedure the day after surgery. Note the flap was pos-
itioned 2 mm coronal to the predetermined margin
to compensate for the 1.5 mm of recession.
Fig 14 Periapical
radiograph of tooth
8 (11) after surgery.
Fig 15 CBCT scan image of tooth 8 (11) after
surgery.

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Fig 16 Facial view 6 months after surgery. The
facial gingival recession had not been recognized.
Fig 17 View of the custom impression pin. Com-
pare the custom impression pin shape with the pro-
visional restoration shape (Fig 9).
Fig 18 View of the final impression of implant 8
(11) and tooth 9 (21).
Fig 19 View of definitive custom abutment on im-
plant 8 (11). Note the papilla height between the
maxillary central incisors.
Fig 20 View of the papilla between the maxillary
central incisors.
Fig 21 Periapical ra-
diograph of the defini-
tive prostheses. It was
likely that the apical rar-
efaction on tooth 9 (21)
was an apical scar.

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Final impression and definitive
restorations
There were no postoperative complica-
tions 6 months after surgery, and the fa-
cial gingival recession had not been rec-
ognized (Fig 16). Post and core build up
and tooth preparation were performed on
tooth 9 (21). Before the final impression,
the subgingival emergence profile of
the provisional restoration was captured
using high-viscosity vinyl polysiloxane
(Aquasil, Dentsply/Caulk) for making the
customized impression coping.17,18 The
customized impression coping (Impres-
sion Coping Implant Level Open Tray,
Nobel Biocare) was then fabricated us-
ing an autopolymerizing acrylic resin
(Pattern Resin) (Fig 17). The final im-
plant and tooth impression were made
with the customized impression coping
using high-viscosity vinyl polysiloxane
(Aquasil) (Fig 18).
A definitive custom abutment was
fabricated using gold abutment engag-
ing (Nobel Biocare) and cast in medi-
um-gold dental alloy (V-Delta SF, Metalor
Dental USA), with gingival emergence
Fig 22 Postoperative smile view. Note that the black
triangle has disappeared and the papilla has been es-
tablished between the maxillary central incisors.
Fig 23 Facial view of the definitive maxillary cen-
tral incisors prostheses. Note the high scalloped
gingival line.
established by the customized impres-
sion coping. The definitive abutment
was torqued to 35 N (manufacturer’s rec-
ommendation, Nobel Biocare) (Fig 19).
The definitive metal ceramic prostheses
(Creation CC, Jensen Dental) subgin-
gival contours were confirmed (Fig 20),
and a periapical radiograph was made
to verify the fit of the prostheses (Fig 21).
The definitive prostheses were cement-
ed 7 months after the surgery (Clearfil
SA Cement, Kuraray) (Figs 22 and 23).
Discussion
Papilla preservation and ensuring stable
peri-implant tissue is very important in
the esthetic zone. The benefit of immedi-
ate tooth replacement has been docu-
mented for papilla preservation.1-4,19 On
the other hand, 0.41 to 0.55 mm of facial
gingival recession has been reported
1 year after surgery.1,3,4 As a solution
to this problem, connective tissue graft
for immediate implant placement and
provisionalization procedures has been
documented.6

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In the event of an osseous defect pre-
senting on the facial bony plate, greater
than 1.5 mm of facial gingival recession
was noted in 8.3% of V-shaped, 42.8% of
U-shaped, and 100% of Ultra U-shaped
defects.5 In this case, the shape of the
defect was U-shaped. Therefore, ac-
cording to the literature, 42.8% of similar
cases have had 1.5 mm of facial gingi-
val recession.
Connective tissue grafts with coronal-
ly positioned flap procedures on natural
teeth have been reported with success
in a randomized clinical trial study.9 This
procedure showed a statistically signifi-
cant increase in keratinized tissue and
gingival thickness compared to the cor-
onally positioned flap alone.9
A positive association exists between
a greater flap thickness and mean, and
the complete root coverage on natural
teeth.20 In addition, the dimensions of
peri-implant mucosa with a thick biotype
were significantly greater than with a thin
biotype.21
Under such circumstances, to mini-
mize gingival recession after implant
surgery, two options exist that can be
used to try to increase the quality and
quantity of the gingival tissue via con-
nective tissue graft,6 and then to com-
pensate for the 1.5 mm of facial gingi-
val recession afterwards via a coronally
positioned flap procedure.
The connective tissue graft should be
covered on the bone–grafted area and
coronally positioned flap area, since
thicker tissue improves clinical results.20
Therefore, the graft size was 14 mm in
length, being 2 mm for the coronally
positioned flap, 3 mm for the distance
from the predetermined margin to the
implant platform, 6 mm of osseo bony
defect, and 3 mm under the bony de-
fect.
It has been reported that U-shaped
defects have a 42.8% chance of hav-
ing 1.5 mm of facial gingival recession.5
After a coronally positioned flap with a
connective tissue procedure, the mean
root coverage has been documented
to be 75% of the amount of coverage
gained at the time of surgery.9 Under
such circumstances in this case, the
flap was positioned 2 mm coronal to
the predetermined margin to compen-
sate for the 1.5 mm of recession (75%
of 2 mm). In addition, after a coronally
positioned flap procedure, there is a re-
sultant increase in tissue thickness in
the area of the predetermined marginal
gingiva. This additional tissue thickness
improves clinical results.20
Conclusions
Based on this short-term clinical fol-
low-up, simultaneous GBR, bilaminar
subepithelial connective tissue graft,
coronally positioned flap procedures
with immediate implant placement, and
provisionalization seem to have been
successful. This procedure still needs
additional studies. The favorable initial
results reported with this treatment mo-
dality might suggest it to be a viable
treatment option.
Acknowledgement
The authors would like to acknowledge Naoki Aiba,
CDT (Monterey, CA) for his ceramic work in the pa-
tient treatment presented in this article.

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