Journal of Indian Society of Periodontology

: 2021  |  Volume : 25  |  Issue : 6  |  Page : 553--559

Soft-tissues stabilization after immediate implant; platform switch with supraperiosteal augmentation

Farhan Durrani, Rakhshinda Nahid, Samidha Pandey, Himani Painuly, Akanksha Shukla 
 Division of Periodontics, Faculty of Dental Sciences, IMS, BHU, Varanasi, Uttar Pradesh, India

Correspondence Address:
Farhan Durrani
Division of Periodontics, Faculty of Dental Sciences, IMS, BHU, Varanasi - 221 005, Uttar Pradesh


The architecture around an oral implant pushes the clinicians for an equalization of biological and physiological requirements. An esthetic implant-supported restoration needs plethora of knowledge and expertise. Surgeon skills can be of use for correct tridimensional position of implant in the extraction socket, shaped abutment contours, and anatomical final crown. An immediate implant placement for a fresh socket requires existing oral parameters judgment and evidence-based treatment plan. They are hard- and soft-tissue relationship, gingival biotype, and the tooth position. In this article, we describe a case of immediate implant placement, provisional crown, bovine bone contraction, soft-tissue collapse, and its management.

How to cite this article:
Durrani F, Nahid R, Pandey S, Painuly H, Shukla A. Soft-tissues stabilization after immediate implant; platform switch with supraperiosteal augmentation.J Indian Soc Periodontol 2021;25:553-559

How to cite this URL:
Durrani F, Nahid R, Pandey S, Painuly H, Shukla A. Soft-tissues stabilization after immediate implant; platform switch with supraperiosteal augmentation. J Indian Soc Periodontol [serial online] 2021 [cited 2022 Aug 19 ];25:553-559
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The loss of tooth results in residual ridge resorption as a consequence of the loss of periodontal ligament attachment. Ideal restorative outcomes at times necessitate augmentation before during and sometimes after the procedure. The preference should be given to techniques that have minimal risk, complications and have predictable results.[1] In this report, we explain a case of immediate implant placement in the maxillary anterior region with buccal bovine bone augmentation/contraction.[2],[3],[4] Studies state that xenograft increases the thickness of crest but often reduces with time.[5] It is also said that the horizontal and vertical soft tissue around an implant restoration in the maxillary anterior area is the determining factor for an esthetic result.[6] On clinical examination, our patient presented with soft-tissue deficiency around implant-supported restoration during provisionalization. There is a significant correlation between soft-tissue thickness and crestal bone loss. Thin tissues can be a reason for hard tissues deficiencies around implant-supported restorations. We did soft-tissue augmentation with minimal invasive method and careful supraperiosteal dissection through frenum that reduces tension on the gingival margin during coronal advancement and further maintained the anatomical integrity of interdental papilla. The vestibule incision further optimizes the blood supply and esthetics as superior alveolar arteries run in superior – inferior orientation in this area. There will be no disruption of blood supply as in case of horizontal incisions with no visible scarring.

 Case Report

A 23-year-old healthy male patient presented with the complaint of mobile upper front tooth. The patient revealed that he had a road traffic accident with a traumatic fall. On examination, the tooth was mobile but had not displaced from its housing [Figure 1]. The radiographic examination revealed a sub-crestal fracture of the root [Figure 2]. The oral hygiene condition was good. The patient was explained about the poor prognosis of the said tooth and was duly explained about the advantages and demerits of different replacement options. The patient's consent was taken for postextraction immediate implant placement which seemed to be the best option in the current circumstances. The patient was at a low level of esthetic risk for an implant-supported restoration in the said area as there were the presence of inter proximal bone levels, preserved anatomy of the alveolar crest, and virgin status of adjacent teeth. The anticipated disadvantage seemed thin and high scalloped gingiva around failing tooth.{Figure 1}{Figure 2}

After adequate local anesthesia, flapless extraction was performed to preserve tooth-supporting bone [Figure 3]. The socket was cleaned with saline and debrided for granulation tissues. The bone level implant# 3.3/13 mm (T.A.G Implants, Israel) was placed palatal and 4 mm apically from the free gingival margin [Figure 4]. The jumping distance (The buccal aspect of implant and labial wall of socket) was more than 2 mm. Bovine Bone (Bio-Oss, Geistlich Pharma, Switzerland) were slowly packed in the space [Figure 5]. This may be an ideal barrier material to preserve the ridge volume.[7] Torque achieved was <35 N. The implant head was closed with a modified long healing screw [Figure 6]. The patient was kept on 500 mg amoxicillin (antibiotic) every 8 hourly along with ibugesic plus (anti-inflammatory) three times daily for 5 days. The instructions given were rinsing with 0.12% chlorhexidine solution twice daily for 14 days; avoid chewing and brushing at the surgical site for a week. After 4 months of tissue healing, an impression was taken for the provisional crown. A screw-retained temporary crown was made in the laboratory [Figure 7]. The profile surface of the crown was kept flat to concave so that the soft tissue could creep and grow coronally [Figure 8]. A nonloaded, screw-retained provisional is preferred because of its removability and soft-tissue remodeling. As the patient was outstation resident, he made himself available only once in the next 5 months. It was noted that after 6 months, there was a soft-tissue collapse on the facial/buccal aspect of the implant restoration [Figure 9]. The gingival biotype and keratinized gingival width around implant-supported provisional restoration was measured.[8] The distance from the free gingival margin to mucogingival Junction was measured with probe (PQW7; Williams, Hu Friedy, Chicago, USA) and for transgingival probing an endodontic file with stopper was used. The gingival thickness was <1 mm, it was classified as thin. The bovine bone seems to be contracted to some extent as grafts cannot maintain the ridge volume.[9] Our patient had thin gingival biotype and reduced keratinization around implant-supported restoration. The loss of facial volume may be associated with thin facial bone. Frizzera et al.[10] discussed the role of soft-tissue grafts for reduction of peri-implant alterations. This study was on immediate implant placement and provisionalization in compromised extraction sockets with the conclusion that connective tissue graft is needed for increase in soft-tissue thickness around the facial aspect of the implant.{Figure 3}{Figure 4}{Figure 5}{Figure 6}{Figure 7}{Figure 8}{Figure 9}

The amount of soft-tissue graft required is defined on certain criteria.[11] A submerged implant and a defect of 2 mm at cervical area can be corrected by putting the flap buccally from lingual by single incision. If more than 2 mm, connective tissue graft can be added in this procedure. In exposed implant, provisional or final crown, pouch along with connective tissue graft for defects <2 mm and >2 mm envelope flap is required. In esthetic areas, the visibility of scars after surgery are evident even after 1 year because of intrasulcular and trapezoidal incisions.[12] Zadeh[13] described a novel technique for the treatment of gingival recession by minimal invasive method using periosteal approach through frenum. The technique has minimum scar formations from surface incisions. Lee et al.[14] used the said technique for soft-tissue deficiency around implant supported restorations. Our patient had large soft-tissue deficient area on the facial/buccal surface of the provisional crown (>2 mm).

The patient gave consent for the surgery for soft-tissue augmentation. The buccal vestibule was anesthetized with infiltration of local anesthesia (2% lignocaine with adrenaline). Frenectomy was made using a 15c blade [Figure 10]. A supra-periosteal tunnel was created using tunneling Knife TKN1 and 2 (Hufriedy) and was extended toward gingival sulcus of the affected restoration without perforating the flap [Figure 11]. The periosteum was left intact over the facial plate to provide the blood supply to the grafted area. The flap was further tested whether it can be moved coronally at least 2 mm [Figure 12]. A connective tissue graft was harvested from the palate with a single-incision technique[15] [Figure 13]. The graft was pushed downward underneath the supra-periosteal flap. Further, the split-thickness flap was moved 2 mm coronal taking cementoenamel junction of adjacent teeth as a reference [Figure 14]. Composite balls on tooth were used to pull the gingiva with modified sling suture (5-0 Vicryl). Knots were tightened in the middle of buccal gingiva [Figure 15]. The patient received medications amoxicillin 500 mg (antibiotic) along with ibugesic plus (anti-inflammatory) two times daily for 3 days. Chlorhexidine 0.2% mouth-wash two times daily (30 s) was advised for 1 week. The patient was kept on a soft diet and advised not to brush on the surgical area for 3 weeks. After healing period of 3 months, coronal and buccal gain of soft tissue (approx 2 mm) was achieved [Figure 16] and [Figure 17]. The anatomical computer aided design and manufacturing designed, platform switch titanium abutment (3.7 mm implant/3.5 mm abutment) was tightened on the implant (>35 N), facial and occlusal volume of soft tissue showed increase in thickness [Figure 18] and [Figure 19]. Final zirconia with lithium disilicate layered crown with concave subgingival profile was fabricated in the laboratory [Figure 20]. It was cemented with resin cement (Monobond Plus, Ivoclar) [Figure 21]. We evaluated the Pink Esthetic Score before and after the surgery with follow-up of 1 year to the scale of 0–2 [Figure 22], [Figure 23], [Figure 24]. Final score was 12 [Table 1] and [Table 2].{Figure 10}{Figure 11}{Figure 12}{Figure 13}{Figure 14}{Figure 15}{Figure 16}{Figure 17}{Figure 18}{Figure 19}{Figure 20}{Figure 21}{Figure 22}{Figure 23}{Figure 24}{Table 1}{Table 2}


Immediate implant placement does not reduce bone resorption.[16] However, postextractive implant placement is favorable in terms of esthetics only through a combination of different factors. Careful planning involves morphology of alveolar process, periodontal phenotype, surgical planning, management of peri-implant gap, flapless approach, soft-tissue conditioning with immediate loading, and provisional restoration.[17] In our case, it was a flapless to preserve the periosteum and supraperiosteal plexus in a way maintaining the blood supply to the alveolar bone. In a recent prospective study by Cosyn et al.[18] who evaluated single immediate implants in the esthetic zone with low-risk esthetic factors. The conclusion was unstable soft tissues around implant restoration. The recession and shrinkage were seen more on central incisors; the reason seems increased mesial-distal width leading to shrinkage of bone grafts as compared to lateral incisor. According to 2012 consensus report of European Academy Osseointegration, the prevalence of peri-implantitis is at 10% with implants and 20% of patients after 5/10 years of implant placement.[19] Peri-implantitis is associated with marginal bone loss and soft-tissue condition as parameters in its classification. Groenendijk et al. in their retrospective study studied the fate of buccal crest after immediate implant placement and bovine bone substitutes. The result showed a compaction of buccal crest from 2.4 mm at a mean of 103 weeks to 1.8 mm.[20] In our case, postprovisional crown attachment after 6 months on implant, the facial wall thickness reduced and the soft-tissue contour diminished. If we assume according to the studies, the bovine graft shrinks and then stabilizes in thickness with time. However, soft-tissue volume decrease may be associated with thin gingival biotype. The provisionalization with a temporary crown should have improved the soft-tissue contours during the healing phase. In spite of this, the horizontal soft-tissue dimensions were compromised. Migliorati et al. suggested the use of connective tissue grafts to increase thickness of gingiva and maintain soft tissue around implant-supported restorations. This can be achieved with tunneling technique or through creation of a pouch with preservation of papilla's around implant restoration or after removing the provisional.[21] In our case, soft-tissue augmentation during implant placement could have prevented the tissue loss. The reason for not doing the procedure during that time was coronal position of gingival margin of the affected tooth with respect to adjacent central incisor. It was assumed minimal recession will adjust during maturation. Noelken et al.[22] did a retrospective analysis of connective tissue graft during provisionalization of immediate implant placement, there was substantial gain in thickness of the tissues but often the scar tissue becomes visible. In this report, the approach for soft-tissue augmentation was single incision via Frenum, the access had broader view for the entire region including area above the buccal part of implant. The advantage of the explained method was no visible scarring and good esthetic outcome in the critical area. Rigid fixations of gingival margin by coronally anchored suturing in the technique minimized further the micromotion of regenerative tissue and scar tissue formation. The major drawback associated with this procedure is its technique sensitivity and its inapplicability in the posterior part of the mouth. Further with a platform switch abutment on our implant, there was more gain in volume of soft tissue around the subgingival area. Saito et al. conducted a prospective study for effect of platform switch abutment on regular implant and its significance on peri-implant soft-tissue thickness.[23] The conclusion was platform switching preserved the ridge dimension and enhanced peri-implant soft-tissue stability.


The loss of soft-tissue volume around collapsed implant supported esthetic restoration was gained with minimal scar tissue. The frenum/vestibule access provided an enhanced view of the affected area with reduced disruption of blood supply. This method can become an alternative for soft-tissue augmentation during the second stage of implant therapy in esthetic area with no visible scar tissue.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.


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