J Oral Maxillofac Surg

62:90-105, 2004, Suppl 2

Strategies for Management of Single-

Tooth Extraction Sites in Aesthetic
Implant Therapy
Anthony G. Sclar, DMD*

Achieving predictable aesthetic outcomes following the planned removal of a natural tooth suffering
from structural, endodontic, or periodontal compromise depends on a multitude of factors that, once
identified, guide the implant team in selecting the surgical and prosthetic treatment options best suited
for the individual clinical scenario. This article presents pertinent information regarding systematic
patient evaluation and special treatment planning considerations for patients facing the loss of a single
tooth in an area of high aesthetic importance. The rationale for and details of performing the Bio-Col site
preservation technique at the time of tooth removal; guidelines for immediate versus delayed implant
placement; selection and sequencing of site-development procedures according to the types of alveolar
ridge defects encountered following tooth removal despite the use of site preservation; and a description
of prosthetic techniques necessary for the successful management of single-tooth extraction sites in areas
of aesthetic concern also are reviewed.
2004 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 62:90-105, 2004, Suppl 2

Because of the increased awareness within both the
dental and lay communities of the conservative na-
ture, favorable long-term prognosis, cost effective-
ness, and, more recently, the aesthetic predictability
provided by the single-tooth implant restoration com-
pared with traditional restorative options, this treat-
ment modality is rapidly becoming one of the most
common clinical scenarios faced by the implant team.
As such, the implant surgeon must not only be famil-
iar with those clinical factors that favor a successful
functional outcome, but also must be able to identify
the factors that may jeopardize or limit aesthetic suc-
cess when an implant replacement is contemplated
following tooth removal. In addition, the implant
team must be able to select the appropriate surgical
and prosthetic treatment options to manage the com-
mon aesthetic clinical case scenarios with a high de-
gree of predictability. The purpose of this article is to
provide information pertinent to the diagnosis and
treatment planning as well as surgical and prosthetic
management of patients faced with removal of a sin-
gle tooth in an area of high aesthetic importance.
*Private Practice, South Florida OMS: Center for Excellence in
Dental Implant Surgery, Miami, FL; Adjunct Clinical Professor of
Surgery, University of Miami, Jackson Memorial Hospital, Miami, FL.
Address correspondence and reprint requests to Dr Sclar: South
Florida OMS, 7600 Red Road, Suite 101, Miami, FL 33143.
2004 American Association of Oral and Maxillofacial Surgeons
0278-2391/04/6209-0220$30.00/0
doi:10.1016/j.joms.2004.06.041
Systematic Patient Evaluation
Evaluation of the aesthetic implant patient begins
with the completion of a detailed health question-
naire and patient interview aimed at identifying the
general health status of the patient. In addition to
identifying common risk factors, such as uncontrolled
diabetes mellitus and smoking, it is critical to docu-
ment the details of the dental history that led to the
removal of the tooth in question. Specifically, a pre-
vious history of trauma (subluxation, avulsion with
reimplantation), and endodontic therapy (retreat-
ments, apical surgery) associated with acute or
chronic infections and their treatment should be doc-
umented. The chronology of such events should also
be recorded. In most instances, a past history of
trauma, surgical endodontic therapy or retreatments,
or infections results in a compromise in the circula-
tion to the supporting periodontal tissues and thus a
reduction in the regenerative potential of the site. As
a result, osseointegration may be jeopardized, re-
duced volume yields from hard and soft tissue site-
development procedures should be expected, and
increased complications from such procedures are
likely. Following the detailed medical and dental his-
tory, diagnostic radiographs, photographs, and study
casts should be obtained for treatment planning pur-
poses. These records also serve to establish the base-
line condition before initiating therapy and are useful
for subsequent comparison with the final treatment
outcome.

90
ANTHONY G. SCLAR
The pretreatment clinical evaluation of the aes-
thetic implant patient should include a complete
functional and aesthetic evaluation of both the tooth
indicated for removal as well as the neighboring den-
tition. Focusing attention exclusively on the area in-
dicated for tooth removal and implant replacement
often will result in aesthetic compromises that can be
avoided. While a comprehensive discussion of dento-
facial and dentoperiodontal evaluation of the aes-
thetic implant patient is beyond the scope of this
article, evaluation of the aesthetic implant patient
should include assessment of facial and dental sym-
metry; a careful study of upper and lower lip positions
at rest, in relaxed smile, and in fully animated posi-
tions to determine tooth and gingival exposure; eval-
uation of incisal and occlusal plane orientation and
morphologies; evaluation of tooth proportions, mor-
phology, and relationships including axial inclinations
and connector zones; evaluation of gingival plane
orientation and morphology; evaluation of the peri-
odontal status of the tooth in question as well as the
neighboring dentition; determination of periodontal
biotype; identification and classification of existing
soft-tissue recession defects; and evaluation of occlu-
sion for presence or absence of functional guidance
and adequate interdental and interocclusal space.1
While it is important for the surgeon to be able to
quantify the existing dentoperiodontal aesthetics, it is
critical that existing or potential dental and periodon-
tal deficiencies and anatomic limitations be identified
before implant therapy. Therefore, commonly en-
countered special treatment planning considerations
are emphasized herein.
Special Treatment Planning
Considerations
TOOTH MALPOSITION
When teeth are malposed in the patient contem-
plating aesthetic implant replacement of an ailing
tooth, orthodontic therapy may be indicated to create
ideal spacing for harmonious aesthetic restoration (ie,
1.5 to 2.0 mm distance between the implant body and
the adjacent dentition). This will also ensure mainte-
nance of proximal bone height and width to support
the overlying interdental papillae. In addition, fine
tuning of tooth positions and axial inclinations can be
performed to harmonize dental proportions, idealize
incisal and occlusal plane orientation and morphol-
ogy, and establish functional guidance on the natural
dentition. In certain instances orthodontic extrusion
can be used to optimize bone and soft tissue volume
on adjacent dentition as described below. Finally,
when orthodontic therapy is included as part of the
presurgical preparation, sufficient time must be al-
91
lowed for postorthodontic retention because mobility
or movement of the adjacent dentition can negatively
affect osseointegration or proper integration of hard
and soft tissue grafts.
PERIODONTAL BIOTYPE
Evaluation of the periodontal biotype2 is another
special treatment planning consideration of clinical
significance in aesthetic implant therapy. Knowledge
of the typical response of each periodontal biotype
allows the surgeon and restorative dentist to adjust
their approaches and the sequence of treatment to
ensure optimal aesthetic results. The thin, scalloped
periodontium is characterized by pronounced posi-
tive soft tissue architecture; friable soft tissues; mini-
mal amounts of attached tissues; and thin underlying
alveolar bone with dehiscence and fenestration de-
fects commonly found over the natural tooth roots.
Surgical and prosthetic implant procedures typically
result in some degree of soft tissue recession and
underlying resorptive osseous remodeling. Further-
more, a triangular tooth form with subtle cervical
convexities and small connector zones located in the
incisal third has been associated with the thin, scal-
loped periodontium. This tooth morphology presents
the additional aesthetic challenge of preserving the
existing soft tissue architecture with properly con-
toured interim provisional restorations that prevent
blunting of the papillae and provide subtle support of
the marginal tissues to minimize or prevent recession.
Despite careful surgical and prosthetic manipulation,
prophylactic soft tissue grafting is indicated in pa-
tients with a thin, scalloped periodontium to offset
the predictable loss of soft tissue volume that eventu-
ally will occur secondary to implant surgical and pros-
thetic procedures and subsequent oral hygiene main-
tenance (Fig 1).
In contrast, the thick, flat periodontium is charac-
terized by relatively flat soft tissue and bony architec-
ture; a dense, fibrotic soft tissue curtain with large
amounts of attached tissues; and a thick osseous form
that is resistant to resorption. A square tooth form
with large connector zones and bulbous cervical con-
vexities has been associated with the thick, flat peri-
odontium. Although this periodontal biotype is typi-
cally resistant to recession, the fibrotic nature of the
tissues creates a predisposition for poor incision line
cosmesis following flap elevation. Accordingly, the
implant surgeon should avoid flap elevation by using
peninsula flap and tissue punch approaches for im-
plant placement and exposure. When elevation of a
flap is necessary, the incisions should be camouflaged
by having them pass through existing anatomic mark-
ings, such as the mucogingival junction and interden-
tal grooves, and by beveling those portions of the
incision that pass through the attached tissues. Metic-
92 MANAGEMENT OF SINGLE-TOOTH EXTRACTION SITES

FIGURE 1.
ANTHONY G. SCLAR
ulous repair is then performed to avoid problematic
notching of the marginal tissues and unsightly step
defects along the incision line. Nevertheless, the pa-
tient with a thick, flat periodontium should be edu-
cated about the predisposition for soft tissue scarring
and the likely need for secondary gingivoplasty pro-
cedures or cosmetic soft tissue refinements following
flap elevation and implant site-development proce-
dures.
VERTICAL MAXILLARY DEFICIENCY
Vertical maxillary deficiency presents an anatomic
limitation to successful aesthetic outcomes in implant
therapy because of a reduced reconstructive soft tis-
sue envelope. Typically, these patients present with a
short upper lip length (defined as less than 20 mm for
males and less than 18 mm for females). Intraoral
palpation shows deficient vestibular depth in the an-
terior maxillary region with a shortened distance (less
than 10.0 mm) measured from the most coronal as-
pect of the interdental papilla between the central
incisors and the palpable anterior nasal spine. In ad-
dition, the nasal floor and piriform apertures are
closely approximated to the roots of the lateral incisor
and canine teeth as determined on pretreatment ra-
93
FIGURE 1 (contd). A and B, Preoperative views of failing right lateral
incisor with thin, scalloped periodontium. Note the highly scalloped soft
tissue architecture and thin, friable soft tissue drape. C, Postoperative
radiograph. Following minimally traumatic tooth removal, a submerged
implant was placed with the Bio-Col technique. To preserve the soft tissue
architecture at the site, the clinical crown of the tooth was modified into an
ovate pontic and resin bonded to the adjacent teeth. D and E, Immedi-
ately following delivery of the final restoration, the soft tissues were ery-
thematous and subsequently recession of the marginal tissues and blunting
of the mesial papilla became evident, a response that is typical of the thin,
scalloped periodontium. F, To stop the progressive soft tissue recession
and to restore gingival health and aesthetics, a subepithelial connective
tissue graft was performed via a closed-pouch recipient site. G, One year
later, soft tissue contours have been restored and gingival health is evi-
dent. H and I, Follow-up views show regeneration of the previously
blunted mesial papilla and restoration of natural gingival aesthetics.
Anthony G. Sclar. Management of Single-Tooth Extraction sites.
J Oral Maxillofac Surg 2004.
diographs or direct visualization at the time of sur-
gery. On occasion, patients with vertical maxillary
deficiency also have a concave alveolar ridge and
perinasal anatomy, making surgical management of
soft tissues and site-development procedures even
more difficult to perform because of further reduction
of the reconstructive soft tissue envelope.
In patients with these anatomic characteristics, the
author has identified a predisposition for apical mi-
gration of soft tissues following implant placement,
exposure, or site-development procedures. The prox-
imity of the anterior nasal spine and the nasal floor
significantly limits the surgeons ability to obtain pas-
sive flap adaptation during hard and soft tissue aug-
mentation because of diminished ability to gain coro-
nal flap advancement over these grafts. Consequently,
flap elevation for implant placement usually extends
beyond the mucogingival junction, hence the ten-
dency for apical soft tissue migration. When planning
aesthetic implant therapy for patients with these an-
atomic limitations, the implant surgeon should recog-
nize the increased need for hard or soft tissue aug-
mentation to overcome the anatomic limitations and
to offset predictable soft tissue retraction and associ-
ated loss of hard tissue.
94
Surgical management includes an exaggerated
wide-base curvilinear flap design with beveled inci-
sions, careful elevation of the periosteum from the
piriform aperture area, and periosteal releasing inci-
sions made at the confluence of the alveolar ridge and
nasal floor periosteum to obtain tension-free adapta-
tion of flaps on wound closure. Elevation of perios-
teum in these areas improves the overall elasticity of
the flap and detaches the levator labii superioris and
zygomaticus minor muscles, thereby reducing upper
lip activity in the immediate postoperative period. In
addition, exposure of the anterior nasal spine and, on
occasion, reduction osteoplasty are performed as part
of recipient site preparation for hard tissue site devel-
opment. Subsequently, vestibuloplasty is often re-
quired to re-establish adequate vestibular depth.
COMPROMISED BONE HEIGHT OR WIDTH ON
ADJACENT DENTITION
Compromise in the bone volume around adjacent
natural dentition presents another anatomic limitation
that can jeopardize aesthetic outcomes when implant
replacement of a failing tooth is contemplated3 or
when site-development procedures become neces-
sary following tooth removal.1 Specifically, loss of
height or width of the interdental bone between an
implant and the adjacent teeth make prosthetic com-
pensations necessary because of the blunted or miss-
ing interdental papillae that accompany interdental
bone loss. Similarly, when aesthetic ridge defects be-
come apparent following tooth removal, reduced in-
terdental bone height or width along with dehiscence
or fenestration defects over adjacent tooth roots di-
minish the outcomes obtainable from hard or soft
tissue site-development procedures because a portion
of the recipient site is avascular cementum. In many
instances, the loss of periodontal support around the
tooth in question or the adjacent dentition may be
hidden by soft tissue edema resulting from chronic
inflammation secondary to tooth mobility, violations
of biologic width, leakage from existing restorations,
or noninfectious tooth resorption.
As a result, the pretreatment examination should
always include a thorough clinical and radiographic
evaluation of the tooth in question as well as the
neighboring dentition. Radiographic evaluation should
focus on defining the interdental bone height and
width. When significant rotation or root proximity
exists, it is often necessary to obtain several radio-
graphs at different angulations. Clinical examination
may necessitate bone soundings under local anesthe-
sia to identify osseous defects at the buccal or lingual
alveolar crests. The radiographs and clinical measure-
ments serve as a baseline for future comparisons even
when there has been no loss of supporting periodon-
tal tissues.
MANAGEMENT OF SINGLE-TOOTH EXTRACTION SITES
Whenever there is a compromise in the interdental
bone height or width, either on the teeth adjacent to
a tooth planned for removal and implant replacement
or adjacent to an edentulous site with a ridge defect
that will require site development before implant
placement, orthodontic extrusion should be consid-
ered as an option for eliminating or diminishing the
severity of this anatomic limitation. Orthodontic ex-
trusion can often result in sufficient gain of vertical
bone height and width to support the overlying pa-
pillae, thereby enabling the fabrication of an aesthetic
restoration with harmonious connector zones. When
the gain in hard and soft tissues is insufficient follow-
ing orthodontic extrusion of the adjacent dentition,
cosmetic periodontal surgery such as aesthetic crown
lengthening can be considered to camouflage the
defects and improve the harmony between the im-
plant restoration and the neighboring dentition. Of
course, the patient must be willing to accept an aes-
thetic compromise to maintain these teeth, or alter-
natively, may consider their removal and subsequent
inclusion in the site-development efforts and eventual
implant restoration with single units or an implant-
supported fixed partial denture.
Rationale for and Use of the Bio-Col
Alveolar Ridge Preservation Technique
SITE PRESERVATION
Preservation or recreation of natural alveolar ridge
anatomy is a prerequisite for success in aesthetic im-
plant therapy. Natural hard and soft tissue contours
allow both ideal implant placement and the emergence
of a restoration that is harmonious with the adjacent
dentition and free of prosthetic compensations. As such,
site preservation is an extremely important concept for
the surgeon, the restorative dentist, and the patient to
embrace when implant therapy is contemplated in an
area of aesthetic concern. The use of site-preservation
techniques often reduces or in some instances elimi-
nates the need for subsequent site-development proce-
dures. Of greater significance, failure to use a site-pres-
ervation technique following tooth removal inevitably
increases the number and complexity of the site-devel-
opment procedures ultimately required to achieve ac-
ceptable aesthetic results. In aesthetic implant therapy,
the primary objective of site preservation is either to
preserve the osseous anatomy and scalloped soft tissue
architecture in conjunction with immediate implant
placement or to maintain the volume of reconstructive
soft-tissue envelope and positive soft tissue architecture
when subsequent site-development procedures will be
unavoidable.4 Just as in plastic and reconstructive sur-
gery, the reconstructive soft-tissue envelope is a prime
determinant of our ability to surgically reconstruct hard
and soft tissue alveolar defects in implant therapy.
ANTHONY G. SCLAR 95

FIGURE 2. A, Preoperative view of failing left central incisor. B, Preoperative radiograph showing extensive resorption. C, Following tooth removal,
an Aesthetic-plus implant (Straumann, Waltham, MA) was placed using the Bio-Col technique. Care was taken to place the implant in a fashion that
avoided loading of the buccal socket wall and adjacent interdental bone and the voids were grafted with Bio-Oss cancellous bone mineral. D and
E, Final restoration shows improved aesthetics compared with the preoperative condition.
Anthony G. Sclar. Management of Single-Tooth Extraction sites. J Oral Maxillofac Surg 2004.

BIO-COL ALVEOLAR RIDGE PRESERVATION
TECHNIQUE
Site preservation usually begins at the time of tooth
removal. In aesthetic areas, the author uses the Bio-
Col alveolar ridge preservation technique to preserve
hard and soft tissue alveolar ridge anatomy in prepa-
ration for immediate or delayed implant placement.4-6
This technique can be used to reduce or avoid osse-
ous ridge resorption by minimizing trauma during
tooth removal. The prepared extraction sockets or
the voids surrounding the immediately placed implant
are then grafted with Bio-Oss (Osteohealth, Shirley,
NY), a natural, porous bone-grafting material. Subse-
quently, the grafted socket is isolated with an absorb-
96
able collagen material (Collaplug; Zimmer Dental,
Carlsbad, CA) that has been coated with an impervi-
ous tissue cement (Isodent; Ellmann International,
Hewlett, NY); this allows for guided bone regenera-
tion without the need for flap elevation and primary
closure, thus preserving the surrounding soft-tissue vol-
ume. Finally, the scalloped soft tissue architecture is
preserved with the use of interim provisional restora-
tions, anatomic healing abutments, or custom tooth-
form healing abutments designed to support the mar-
ginal tissues and interdental papillae. This is of critical
aesthetic importance for implant patients who present
MANAGEMENT OF SINGLE-TOOTH EXTRACTION SITES
FIGURE 3. A, Preoperative view of failing right central incisor with
distorted soft tissues secondary to chronic irritation from ill-fitting resto-
ration and tooth mobility. B, Preoperative radiograph shows ill-fitting
restoration and evidence of resorption. C, Three months following
tooth removal and application of the Bio-Col technique, a small-volume
soft-tissue aesthetic ridge defect is evident. D, After placement of an
Aesthetic-plus implant, a custom tooth-form healing abutment (Peek,
Straumann) was customized to provide support for the adjacent
interdental papilla and to provide a scaffold for simultaneous soft tissue
augmentation.
Anthony G. Sclar. Management of Single-Tooth Extraction sites.
J Oral Maxillofac Surg 2004.
with thin scalloped periodontal biotypes who are pre-
disposed to loss of alveolar ridge volume secondary to
remodeling, resorption of bone following tooth re-
moval, and soft tissue recession following subsequent
surgical or restorative interventions.6
GUIDELINES FOR DELAYED VERSUS IMMEDIATE
IMPLANT PLACEMENT FOLLOWING TOOTH
REMOVAL AT SINGLE-TOOTH AESTHETIC SITES
In aesthetic areas, delayed implant placement is
indicated 1) when there is an osseous wall defect that
involves or jeopardizes the buccal alveolar crest, and
ANTHONY G. SCLAR
2) when tooth mobility or chronic irritation second-
ary to an ill-fitting restoration or when restorative
encroachment on the biologic width requirements for
the site has caused edema and distortion of the soft
tissues in the area critical for restorative emergence.6
In addition, when a site is compromised by a history
of trauma, infections, or multiple endodontic or sur-
gical interventions, or when inadequate bleeding is
observed following tooth removal, proceeding with im-
mediate implant placement carries significant aesthetic
risk. In these clinical scenarios, the Bio-Col technique
can be performed and the site subsequently re-evaluated
for possible hard or soft tissue site development before
or synchronous with implant placement.
When an osseous defect is encountered in the fragile
buccal alveolar housing following tooth removal, the
defect is classified as either favorable or unfavorable
based on the width of the defect.6 As a general rule, for
single-tooth sites, defects are considered either favorable
or unfavorable when the width of the defect is either
less than or greater than one third the mesiodistal di-
mension between the adjacent teeth. This directly cor-
relates with the remaining volume of host bone present
at the defect margins, which ultimately can contribute
to bone regeneration across the defect via the bridging
phenomenon. In either case, the Bio-Col technique is
modified by placing a resorbable barrier membrane into
97
FIGURE 3 contd). E, Subepithelial connective tissue secured at the
site. F, Three months after implant placement and synchronous soft
tissue graft. G, Final restoration 1 year after delivery shows harmonious
dental proportions and natural gingival aesthetics.
Anthony G. Sclar. Management of Single-Tooth Extraction sites.
J Oral Maxillofac Surg 2004.
a subperiosteal pocket extending approximately 2.0
mm beyond the periphery of the defect. This allows for
repair of favorable defects and maintenance of the re-
constructive soft-tissue envelope, thereby facilitating fu-
ture reconstruction at sites with unfavorable defects.
Finally, when patients present with a thin, scalloped
periodontium, the author recommends prophylactic
soft tissue grafting before commencement of the pros-
thetic phase of therapy, even when soft tissue volume
and architecture initially appear to be ideal as a result of
using the Bio-Col technique following tooth removal
and immediate or delayed implant placement. This pre-
emptive strategy fortifies the soft tissues to withstand
restorative procedures and future oral hygiene efforts
thereby avoiding soft tissue recession (Fig 1).
Immediate implant placement following tooth re-
moval is indicated when there is an intact socket and the
hard and soft tissues are healthy and free of pathosis.
Vigorous bleeding following tooth removal indicates ex-
cellent regenerative potential. In these instances, the
goal is to obtain apical stabilization of the implant and to
maintain a circumferential void between the implant
and the socket walls (Fig 2). Loading of the fragile buccal
plate or encroachment on the adjacent interdental bone
can jeopardize aesthetic outcomes secondary to osseous
resorption, resulting in recession of overlying soft tis-
sues and blunting of the adjacent interdental or interim-
98
plant papillae. Any voids are then filled by condensing
the porous bone mineral and then stabilized by forma-
tion of a blood clot in the area. Small pieces of absorb-
able collagen dressing are then condensed over the
Bio-Oss within the confines of the soft tissue socket and
a provisional restoration is modified to avoid loading of
the implant and to provide support for the soft tissues as
needed.
Selection and Sequencing of Site
Development Procedures According to
Type of Ridge Defect
When site preservation following tooth removal is
not successful in maintaining natural ridge anatomy at
MANAGEMENT OF SINGLE-TOOTH EXTRACTION SITES
FIGURE 4. A, Preoperative view of failing maxillary canine and
compromised lateral incisor following previous orthodontic eruption of
canine that resulted in periodontal defects around both teeth. B,
Following hard and soft tissue site development via orthodontic extru-
sion and subsequent block bone grafting, a large-volume soft tissue
aesthetic ridge defect persisted at the canine implant site. C and D, A
VIP-CT flap was used to expand the reconstructive soft tissue envelope
by intentionally submerging a 1-piece single-stage implant. E, After
allowing 3 months for osseointegration, a tissue punch was used to
expose and deliver a provisional restoration. An additional 3-month
period was necessary to ensure stabilization of the peri-implant soft
tissues before delivery of the final restoration, which shows harmonious
dental and gingival aesthetics.
Anthony G. Sclar. Management of Single-Tooth Extraction sites.
J Oral Maxillofac Surg 2004.
aesthetic implant sites following tooth removal (eg,
because of unfavorable osseous defect morphology
or soft tissue pathosis), the surgeon is faced with
the need to restore missing hard and soft tissues in
an inconspicuous fashion. Evaluating alveolar ridge
defects and determining whether to reconstruct
them in a staged fashion before or at the same time
as implant placement are the most important clini-
cal decisions facing the implant surgeon. When
site-development procedures are indicated in com-
bination with implant placement, the implant sur-
geon must be able to select and sequence them
appropriately according to the specific type of al-
veolar ridge defect encountered and the aesthetic
ANTHONY G. SCLAR 99

FIGURE 5. A and B, Preoperative view of missing lateral incisor with large-volume hard tissue defect. C, Block and particulate bone grafts were
performed to reconstruct osseous defect prior to implant placement. D, Four months following bone grafting, the ridge width has been restored;
nevertheless, soft-tissue augmentation is indicated synchronous with implant placement. E, After placement of a Narrow Neck implant (Straumann)
with an Aesthetic-plus healing abutment, a subepithelial connective tissue graft is secured around the abutment and to the periosteum at the site. F,
Final restoration is inconspicuous in appearance and smile aesthetics have been greatly improved via aesthetic crown extension and cosmetic
restorations of the neighboring dentition.
Anthony G. Sclar. Management of Single-Tooth Extraction sites. J Oral Maxillofac Surg 2004.

importance of the site. This not only improves the
long-term functional results achieved with implant
therapy but also allows the surgeon to predict re-
alistic aesthetic outcomes. Because of the increased
complexity and biologic requirements of recon-
structing alveolar ridge defects at aesthetic implant
sites, the author distinguishes the classification and
reconstruction of these defects from those found in
nonaesthetic areas and from alveolar ridge defects
associated with conventional fixed restorations,
where camouflage procedures are sufficient for
pontic site development.
100 MANAGEMENT OF SINGLE-TOOTH EXTRACTION SITES

FIGURE 6. A and B, Preoperative views of compromised edentulous site with large-volume combination hard and soft tissue aesthetic ridge defect.
The regenerative potential of the site was compromised as a result of the multiple interventions leading to loss of the incisor. C, Staged reconstruction
began with an autogenous corticocancellous bone graft procedure sequenced 6 months before submerged implant placement. Additional
particulate bone grafting was required at the time of implant placement to obtain optimal hard tissue contours. D, An additional 6 months of healing
time was allowed before performing the necessary soft tissue augmentation with a subepithelial connective tissue graft, which was allowed to mature
for 3 additional months. Note that restoration of adequate ridge contours for aesthetic implant emergence required 3 surgeries and a 15-month
treatment time. E and F, A conservative U-shaped palatal peninsula flap was used to deliver a custom abutment and provisional restoration that
provides the prosthetic-guided soft tissue healing necessary for optimal gingival aesthetics.
Anthony G. Sclar. Management of Single-Tooth Extraction sites. J Oral Maxillofac Surg 2004.

The author has developed a classification system in aesthetic areas are classified according to their
for aesthetic implant ridge defects based on the vol- volume (large or small) and nature (hard tissue, soft
ume and nature of the defect.1 Alveolar ridge defects tissue, or combination hard and soft tissue); this re-
ANTHONY G. SCLAR
FIGURE 6 (contd). G and H, The final restoration, delivered 19 months after commencement of treatment, shows harmonious proportions and
pleasing gingival aesthetics.
Anthony G. Sclar. Management of Single-Tooth Extraction sites. J Oral Maxillofac Surg 2004.
sults in 6 different types of aesthetic ridge defects.
Correlation of treatment options with specific defect
types simplifies the selection of indicated site-devel-
opment procedures.
Small-volume soft tissue defects are generally cor-
rected with subepithelial connective tissue grafts per-
formed at the time of implant placement (Fig 3). In
these situations, use of a 1-stage approach with pre-
fabricated or customizable healing abutments offers
the advantage of immediately supporting the grafted
soft tissues in much the same way a denuded root
surface acts as a scaffold during root-coverage proce-
dures. This results in maximum volume yield from the
soft tissue graft, especially in the vertical dimension.
Under these circumstances, aesthetic predictability is
improved by allowing adequate time for the develop-
ment of a stable peri-implant sulcus before initiating
implant restorative procedures. Alternatively, a
2-stage approach can be used with similar results
providing a tooth-form healing abutment or custom
abutment and provisional restoration is delivered at
the second stage surgery and approximately 3 addi-
tional months are allowed for the soft tissue integra-
tion process with stabilization of sulcus depth before
commencement of the definitive prosthetic proce-
dures.
In contrast, large-volume soft tissue aesthetic
ridge defects are usually corrected with several
subepithelial connective tissue grafts before im-
plant placement. A single-stage implant can be
placed following maturation of the first soft-tissue
graft if the residual defect is small in volume. Alter-
natively, a vascularized interpositional periosteal-
connective tissue (VIP-CT) flap7 can be used before
implant placement, in conjunction with submerged
implant placement, or to deliberately expand the
reconstructive soft tissue envelope by submerging a
101
2-piece implant with a low-profile healing abutment
or a 1-piece single-stage implant (Fig 4).
Small-volume hard tissue defects (fenestrations)
that do not jeopardize the buccal alveolar crest are
usually corrected with guided bone-regeneration
procedures performed simultaneously with the
placement of a submerged or nonsubmerged im-
plant. In these clinical scenarios, especially in pa-
tients who have a predisposition for soft tissue
recession (ie, a thin, scalloped periodontium), re-
evaluation of the site approximately 4 months fol-
lowing the guided bone-regeneration procedure is
recommended because of the possibility that soft
tissue grafting may be needed to improve soft tissue
volume and/or aesthetics.
Large-volume hard tissue aesthetic ridge defects
prevent ideal implant positioning and therefore are
always reconstructed in stages using autogenous
corticocancellous block and particulate cancellous
bone grafts. In these clinical scenarios, prophylac-
tic soft tissue grafting is indicated to offset the
predictable loss of soft tissue volume that follows
the large-volume bone graft reconstruction. Again,
a soft tissue graft can be performed simultaneously
with placement of a submerged or nonsubmerged
implant as previously described (Fig 5). Alterna-
tively, a VIP-CT flap can be performed simulta-
neously with the large-volume bone graft recon-
struction followed by implant placement 4 months
later.7
Whereas small-volume combination hard and soft
tissue aesthetic ridge defects are often camouflaged
with soft tissue grafts or alloplast grafts performed
simultaneously with implant placement, large-vol-
ume combination defects require staged recon-
struction (Fig 6). Nevertheless, the author prefers
the option of performing simultaneous hard and
102 MANAGEMENT OF SINGLE-TOOTH EXTRACTION SITES

FIGURE 7. A and B, Preoperative views of left central incisor implant site with large-volume combination hard and soft tissue aesthetic ridge defect.
C, Four months after synchronous hard and soft tissue reconstruction of the ridge defect with autogenous block and particulate bone grafts and VIP-CT
flap, ridge contours have been restored. D, The site is re-entered and a single-stage implant is placed. The advanced stage of bone graft integration
observed is attributed to the simultaneous use of the VIP-CT flap with the bone-grafting procedure. E, A custom tooth-form healing abutment was used
to immediately provide prosthetic-guided soft tissue healing. F, Three months later, scalloped soft tissue architecture is evident and a stable soft tissue
environment is present.
Anthony G. Sclar. Management of Single-Tooth Extraction sites. J Oral Maxillofac Surg 2004.

soft tissue site development with autogenous block
bone grafts and VIP-CT flap(s) and proceeding with
single-stage implant placement after 4 months of
healing (Fig 7). The use of customizable tooth-form
healing abutments offers tremendous advantages in
terms of maintaining adjacent papillary height and
natural scalloped soft tissue architecture. As the
soft tissues mature, this approach offers the sur-
geon the additional advantage of visualizing the soft
tissue aesthetics and performing soft tissue refine-
ANTHONY G. SCLAR
FIGURE 7 (contd). G and H, Final restoration is harmonious in appearance and natural gingival aesthetics have been restored. Use of
simultaneous hard and soft tissue reconstruction greatly reduced the total treatment time (8 months) required for reconstruction of this large-volume
combination aesthetic ridge defect compared with a traditional staged approach.
Anthony G. Sclar. Management of Single-Tooth Extraction sites. J Oral Maxillofac Surg 2004.
ments if necessary without significant delay in treat-
ment or inconvenience to the patient. Neverthe-
less, similar results may be obtained when the
principles of prosthetic-guided soft tissue healing
are applied at implant exposure, provided that ad-
equate time is allowed for stabilization of the peri-
implant soft tissues as detailed above.
Prosthetic Techniques Necessary for
Successful Management of Single-Tooth
Extraction Sites
PROSTHETIC-GUIDED SOFT TISSUE HEALING
The use of prosthetic-guided soft tissue healing
to enhance aesthetic outcomes in implant therapy
involves the early introduction of prosthetic com-
ponents (interim provisional restorations, tooth-
form healing abutments, and implant-supported
provisional restorations) that correspond to the
cross-sectional anatomy of the lost tooth or the
planned aesthetic replacement at the gingival level.
These components support and guide soft tissue
healing following various surgical interventions and
have tremendous influence on the final soft tissue
architecture obtained at the implant site. These
prosthetic elements can be used to preserve exist-
ing soft tissue anatomy following tooth removal and
as a scaffold for guided healing of peri-implant soft
tissues.
Custom Abutments and Provisional Restorations
Delivery of custom abutments and provisional res-
torations immediately upon exposure of submerged
implants is 1 method that can be used to initiate early
guided soft tissue healing for enhanced aesthetic soft-
tissue contours. At the time of implant placement, the
surgeon must perform a surgical index (fixture-level
103
impression) that is subsequently used to fabricate a
working model upon which the abutment and provi-
sional restoration are fabricated in the dental labora-
tory. The surgical index procedure involves attaching
a specialized fixture-level impression coping to the
implant and registering its 3-dimensional position rel-
ative to the adjacent dentition using a fast-set polyvi-
nylsiloxane impression material. The material is in-
jected around the index coping and over the incisal
and occlusal surfaces of a sufficient number of adja-
cent teeth to provide an accurate index. Subse-
quently, an implant analog is attached to the impres-
sion-coping complex and the combination is seated
on an altered master cast, where the analog is secured
with quick-set plaster or acrylic resin. The result is a
working model that contains a replica of the implant
as recorded at the time of surgery. Three months
following implant placement, another impression
captures the matured soft tissue contours, allowing
the addition of soft tissue contours to the index
model. The soft tissue model aids the laboratory tech-
nician in the placement of restorative margins at an
appropriate depth on the custom abutment. In most
instances, the laboratory either casts or mills a custom
abutment that incorporates a proximal rise to ensure
that the restorative margins are located in the super-
ficial aspect of the peri-implant sulcus circumferen-
tially. In addition, the provisional restoration is fabri-
cated with ideal contours to support and guide the
healing of the peri-implant soft tissues immediately
upon exposure of the submerged implant. In most
instances, the surgeon then delivers the abutment and
cements the provisional restoration at the second-
stage surgery via a conservative approach. Significant
occlusal adjustments or modifications to contours are
rarely necessary. Nevertheless, the author recom-
104
mends coordinating the exposure appointment with
the restorative dentist, who should reserve time for
the rare instance that significant modifications are
needed. Another important consideration to discuss is
the recommended timing and technique used by the
restorative dentist for final impressions. In most situ-
ations, 3 months are allowed for the tissues to stabi-
lize around the custom abutment and provisional res-
toration. In addition, this allows time for the
restorative dentist to modify contours as needed to
satisfy the patients phonetic and aesthetic demands
before delivery of a final restoration.
In summary, the use of custom abutments and pro-
visional restorations at aesthetic implant sites requires
that the surgeon perform a surgical index procedure
at the time of implant placement and subsequently
deliver the prosthetic components at implant expo-
sure. Although these techniques are very useful for
enhancing aesthetic outcomes through guided soft-
tissue healing, they require significant coordination
with the restorative dentist and laboratory technician.
There is also additional expense and time involved for
the surgeon. Nevertheless, the enhanced aesthetic
result and the significant convenience realized by the
patient warrant this approach in aesthetic implant
therapy.
Custom Tooth-Form Healing Abutments
Another prosthetic technique used by the surgeon
to initiate early guided soft tissue healing involves the
use of custom tooth-form healing abutments. These
anatomically shaped healing abutments closely ap-
proximate the cross-sectional anatomy of the lost
tooth or the planned replacement at the gingival
level. Because every anterior maxillary tooth is
unique, prefabricated components are unlikely to
yield an ideal result in terms of tissue support and
guided soft tissue healing. Although prefabricated an-
atomically shaped healing abutments have proven
useful for enhancing aesthetic soft tissue contours in
many cases, the use of custom tooth-form healing
abutments will yield superior soft tissue results in
certain instances. Custom tooth-form healing abut-
ments can be fabricated in the laboratory from a
surgical index, as described above, and subsequently
delivered at the time of implant exposure; alterna-
tively, they can be fabricated on a working cast in
preparation for nonsubmerged implant placement.
This process involves laboratory modification of a
prefabricated prosthetic component to approximate
the cross-sectional anatomy of the proposed final res-
toration.
To begin, a diagnostic wax-up of the final restora-
tion is made and a surgical guide is fabricated. The
laboratory technician alters the study cast, assumes
ideal implant placement by the surgeon, and secures
MANAGEMENT OF SINGLE-TOOTH EXTRACTION SITES
an implant analog in the altered cast according to the
surgical guide. A modifiable stock prosthetic compo-
nent is then secured to the analog, and a tooth-form
healing abutment is customized for that site. The
technician can use the contralateral tooth, when
present, as a guide for accurate reproduction of con-
tours. The surgeon then delivers the custom healing
abutment immediately upon placement of the non-
submerged implant. Minor chair-side modifications
are sometimes necessary.
Alternatively, the surgeon can modify a stock pros-
thetic component to create a custom tooth-form heal-
ing abutment for immediate use at the time of sub-
merged implant exposure or nonsubmerged implant
placement. A prefabricated component can be modi-
fied either by adding acrylic resin or by reducing,
shaping, and polishing an oversized cylindrical stock
component. The goal is to closely approximate the
cross-sectional form of the lost tooth or planned final
restoration, which can be very time-consuming. A
practical approach used by the author is to modify a
stock component to match the mesiodistal width of
the proposed replacement tooth and undercontour
the facial aspect of the custom healing abutment. The
abutment thus provides support and guidance for the
adjacent papillae while allowing excess soft tissues to
collapse over the facial aspect, thereby preventing
recession. The surgeon must have appropriate equip-
ment to shape and polish the custom tooth-form heal-
ing abutment before its delivery. The process is facil-
itated when the surgeon attaches the modifiable
abutment to an implant analog during the chair-side
fabrication process. In the authors experience, this
chair-side approach is relatively easy and yields excel-
lent results but requires additional chair time com-
pared with previously described laboratory tech-
niques.
In summary, the use of custom tooth-form healing
abutments is a practical approach for early initiation
of prosthetic-guided soft tissue healing. This approach
requires less time and expense than the use of custom
abutments and provisional restorations, as described
above. The restorative dentist can easily remove and
replace the custom tooth-form abutment during im-
pression procedures, thus facilitating subsequent
prosthetic management of the patient.
To successfully manage those patients facing the
loss of a single tooth in an area of high aesthetic
importance, the implant team should use a compre-
hensive strategy that begins with a systematic func-
tional and aesthetic evaluation aimed at identifying
the factors that could enhance or detract from the
final aesthetic outcome. This allows them to select
and sequence the unique combination of orthodontic,
surgical-periodontal, and implant prosthetic tech-
niques necessary to ensure a harmonious implant res-
ANTHONY G. SCLAR
toration. This article outlines pertinent information
for the management of patients facing the loss of a
single tooth in an area of high aesthetic importance;
however, further study is recommended for the
reader who seeks to consistently meet the formidable
challenges commonly encountered in aesthetic im-
plant therapy.
References
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Implant Therapy. Chicago, IL, Quintessence, 2003, pp 13-41
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with varying form of the upper central incisors. J Clin Periodon-
tol 18:78, 1991
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between the contact point to the crest of bone on the presence
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4. Berglundh T, Lindhe J: Healing around implants placed in bone
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Esthetic Considerations in Implant Therapy. Chicago, IL,
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