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1 (43 - 51): A Comparison of Various Methods of Soft Tissue Management F

A Comparison of Various Methods of Soft Tissue

Management Following the Immediate Placement of
Implants Into Extraction Sockets
Bo Rosenquist, DDS, PhD

Various techniques of soft tissue management following the immediate placement of implants into
extraction sockets are evaluated; the merits of the Rehrman-plasty, the free mucosal graft, the
pedicled island flap, and membranes to seal the socket are discussed as are the esthetic effects of
various surgical techniques used at abutment connection. Two treatment strategies are suggested.
Presently, the treatment of choice seems to be to close the extraction socket after implant
placement by means of either a pedicled island flap or a thin cortical bone membrane. In addition,
a new excisional technique is described for use at abutment connection. If a flap has to be raised to
extract the tooth, the implant should be covered by means of either a Rehrman-plasty or a cortical
bone membrane. If a Rehrman-plasty is chosen, the apically repositioned flap should be used at
abutment connection.
(INT J ORAL MAXILLOFAC IMPLANTS 1997;12:43–51)
Key words: attached gingiva, buccal volume, esthetics, gingival margin, immediate placement, implant, papilla

T he Brånemark osseointegration system (Nobel Biocare, Göteborg, Sweden) was introduced to

provide the edentulous patient with a fixed prosthesis. It was thus regarded as a functional system
focused exclusively on long-term stability of the implants. To obtain predictable results, the surgical
protocol has been strictly observed. Variations of the surgical technique have been regarded as suspect
and, when discussed, judged exclusively on their impact on implant survival. Even various techniques for
soft tissue management have usually been discussed in these terms, since the main purpose is to obtain a
transmucosal perforation for the abutment that is beneficial for long-term implant stability. 1,2
However, as a result of trauma, increasingly more single incisors and canines are replaced by
implants. The patients involved are often younger individuals who expect a short treatment period and
have high esthetic demands. To reduce the treatment period, the implants are often placed at the time the
damaged tooth is extracted. This procedure has proved functionally successful but has complicated the
task of the surgeon because the procedure is often associated with an esthetically compromised result.3-5
Surgical techniques that offer improved soft tissue esthetics are thus required.
In discussions regarding immediate implant placement, esthetics, and soft tissue handling, four
factors are important: (1) the width and position of the attached gingiva; (2) the buccal volume (contour)
of the alveolar process; (3) the level and configuration of the gingival margin; and (4) the size and shape
of the papillae. These four factors are profoundly affected by how the extraction socket is closed.
Although deficiencies can be adjusted at the abutment connection or even later, correction is usually
more complicated with time. Thus, the relative merits of various techniques used to seal the extraction
socket are at least as important for the final result as the techniques used at the abutment connection. In
the present review, various soft tissue surgical techniques for enhancing the esthetic result of immediate
implant placement are discussed.

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Methods to Seal the Extraction Socket

When a root is replaced by a cylindrical implant in one operation, ideal conditions for
osseointegration are not present. Only a part of the implant is in contact with the surrounding bone. To
optimize the conditions for bone formation around the implant, it is imperative that the extraction socket
be tightly sealed to prevent soft tissue downgrowth. This can be accomplished by various techniques.
Rehrman-plasty (Fig 1). The Rehrman-plasty was originally developed as a method to close
oroantral fistulae. The technique is equally suited to close extraction sockets into which implants have
been placed. A vestibularly based flap is raised buccal to the extraction site, and the periosteum is incised
through the base of the flap. The flap can then be lengthened and sutured over the extraction socket.
The method has been proven to be an efficient means for obtaining a tight seal of the extraction
socket. However, from an esthetic standpoint, the method is less satisfactory. The attached gingiva is
displaced toward the top of the alveolar crest. In some cases, this may lead to minor functional
complications, but the most obvious disadvantages are esthetic: a reduction in buccal volume of the
alveolar process; a deficit in the buccal width of the attached gingiva; and an uneven mucogingival
borderline are regular findings. This can be seen clearly in Fig 1.
Free Mucosal Graft (Figs 2a and 2b). In most cases, it is not necessary to raise a flap to allow
extraction of the root and subsequent placement of an implant. In these cases, the socket can be closed by
means of a free graft from the buccal mucosa. The size and shape of the graft is designed to obtain a tight
fit against the surrounding mucosa to which it is secured by sutures such as 5–0 Supramid sutures (Braun
Melsungen AG, Melsungen, Germany). The aim of the procedure is to allow a blood clot to organize
around the implant. During this process, the clot is protected and stabilized by the mucosal graft, which is
devitalized and eventually decomposes. By then, the organized clot should be stable and should make
bone ingrowth around the implant possible.
The surgical procedure is fast and simple, and the esthetic result is usually excellent. The amount and
position of the attached gingiva and adjacent papillae are not affected. The texture of the graft contrasts
the texture of the surrounding papillary tissue. Thus, the graft tissue is easily identified and excised at
abutment connection, which facilitates the recreation of papillae by the lateral compression technique
described below. However, sometimes the graft decomposes before the clot has been fully organized. In
these situations, normal healing may still eventually occur, but frequently the cover screw may perforate
the mucosa, which can then either initiate infection and loss of the implant or can jeopardize the esthetic
result.
Pedicled Island Flap (Figs 3a to 3c). The implant is placed into the extraction socket without a
preceding flap. A horizontal flap is raised in the vestibule outside the attached gingiva. The base is
placed immediately lateral to bottom of the socket and the flap is made approximately 20 mm long and as
wide as the extraction socket. The surface is partially de-epithelialized, except for an area of the apex
corresponding to the surface of the extraction socket. A subperiosteal tunnel is made buccal to the
extraction socket reaching the area in the vestibule where the flap was earlier raised. The flap is pulled
through the tunnel until the (epithelialized) apex of the flap can be sutured to the gingiva surrounding the
socket. Finally, the vestibular wound is closed.
The esthetic result of this procedure can be as excellent as the result obtained by the free mucosal
graft. As with the free mucosal graft, use of the pedicled island flap facilitates the stage 2 procedure
because the texture of the apex contrasts to the surrounding tissue. The flap procedure is slightly more

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time consuming but is safe and predictable.6

Membranes (Figs 4a and 4b). The optimum solution would be to close the socket until the clot is
organized by means of a provisional inert lid. This approach is preferable and safer than the free mucosal
graft and easier to handle than the pedicled island flap. Barrier membranes are intended to be covered by
a flap to avoid infection. The author has tried two types of membranes to seal the socket after implant
placement: one is artificial (Gore-Tex, WL Gore, Flagstaff, AZ), and the other is made from 100- to
300-µm thick sheets of demineralized, freeze-dried, ethylene oxide sterilized cortical bone (Lambone,
Pacific Coast Tissue Bank, Los Angeles, CA). The Lambone membrane is soaked in sterile saline for
approximately 10 minutes before surgery; in other respects, the surgical procedure is the same. The
papillae on both sides of the socket are incised, and the mucoperiosteum surrounding the socket is
undermined. The membrane is cut to shape, placed over the socket, and secured under the surrounding
mucoperiosteum. The papillae are then sutured. Thus, only the periphery of the membrane is completely
covered by gingiva.
The artificial membranes may be rapidly infected, and the blood clot may be lost. The Lambone
membrane has shown promising results, however. This membrane seems to preserve the created space
and allow bone healing of the socket. It is usually not clinically infected, and in most cases it is slowly
covered by the surrounding gingiva. However, the results thus far should be regarded as preliminary
because conclusions have been drawn from minimal use.
Width and Position of the Attached Gingiva
Excision at Stage 2 Surgery. This method has been recommended, possibly because it is fast and
simple.7 Either a punch, a surgical blade, or a fine-grain diamond on a high-speed air rotor or an
electrotome can be used.2 Satisfactory adaptation of the mucosa against the abutment can usually be
obtained, but from an esthetic point of view, the method has considerable disadvantages. Adjacent
papillae are usually more or less destroyed by the punch. In situations with a thin alveolar crest or when
the implants are positioned slightly too far buccally, the punch will cut through the buccal gingiva. This
will result in gingival retraction. Thus, for esthetic reasons, this method is not recommended.
Cervical Folding of a Flap at Stage 2 Surgery (Fig 5). This method has been advocated by Hertel
and coworkers2 as a means to obtain tight adaptation of peri-implant mucosa against the abutment. The
cover screw is exposed and removed after a short mucosal incision. The abutment is connected, and very
short vestibular relief incisions are made mesial and distal to the abutment. The buccal attached gingiva
can then be adapted and sutured against the buccal and lateral sides of the abutment.
The main advantage of this incisional technique is that it saves tissue and it results in tight attachment
of epithelial and connective tissue to the titanium surface of the abutment. For single-tooth situations, the
method has certain disadvantages: no papillae are created because the soft tissue on top of the alveolar
crest is displaced from the surrounding teeth. Hence, the method should be restricted to conditions in
which more than one implant has been placed. However, even in these cases the esthetic result may be
questionable because a mucosal concavity usually develops between the abutments on top of the crest.
This can be seen in Fig 5.
Apically Repositioned Flap at Stage 2 Surgery (Figs 6a and 6b). The position of the cover screw is
identified, and a C-shaped incision is made palatal to the cover screw. The convexity of the C should
point buccally. From each end of the C, parallel relief incisions are made into the vestibule, and a flap is
raised. When the abutment has been connected, the flap is pushed in a vestibular direction until the C can

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be adapted to the buccal aspect of the abutment.

The advantage of this method is that the amount of attached gingiva buccal to the abutment is
increased. In addition, the gingival margin can be shaped by varying the configuration of the C, and the
buccal volume of the alveolar process can be increased by placing the C incision more palatal. However,
a minor technicality should be stressed; in contrast to the Rehrman-plasty with divergent relief incisions,
the apically repositioned flap should have parallel relief incisions or difficulties will arise in closing the
lateral (relief) wounds. This method is especially successful in situations where a Rehrman-plasty has
been performed at stage 1 surgery. The soft tissues that have been displaced toward the top of the crest
during stage 1 surgery can be repositioned in their original position at the abutment connection.
However, in some patients the relief incisions may result in permanent scars in the attached gingiva.
Buccal Volume (Contour) of the Alveolar Process
A root fracture or apical root resorption frequently initiates resorption of the buccal wall of the alveolus.
After extraction and healing of the socket, a buccal concavity of the alveolar ridge often remains. Even if
it does not interfere with the placement of an implant, the buccal concavity usually compromises the
esthetic result. The concavity may attract attention as a dark area under the lip, which is enhanced as it is
reflected in the tooth. The volume of the alveolar process may be corrected either at stage 1 or 2 implant
surgery. The choice depends partially on which method is used.
Bone Graft From the Tibia (Figs 7a to 7c). The tibia is a frequently used donor site for sinus floor
elevations. It offers a surprisingly large amount of good quality cancelleous bone that is equally suitable
for onlays to deficiencies in the buccal volume of the alveolar ridge. At the recipient site, a wide
marginal incision is made, the concavity is reached by tunnelation, and the concavity is filled with the
graft. Overfilling of the cavity is recommended because the degree of resorption of this type of graft is
unpredictable. Any surplus may be corrected at stage 2 surgery or later. Resorption may be reduced if the
cancelleous bone is covered by a thin layer of cortical bone, which is easily accessible from the lateral
wall of the maxillary sinus.
Because some patients may have considerable tibial pain postoperatively and the procedure is
relatively invasive, it is highly questionable if it could be recommended as a standard procedure, except
in cases when a sinus lift is performed simultaneously.
Bone Graft From the Chin (Figs 8a and 8b). The mandible is an excellent source of cortical bone.
To fill a facial concavity in the alveolar process, the graft is usually obtained as a straight or slightly
curved piece from between the mental foramina. However, cortex can also be grafted from the area
posterior to the foramina. In some patients, a combined facial and marginal defect can be found in the
alveolar crest. In these situations, an L-shaped transplant can be obtained by extending the osteotomies
halfway through the inferior border of the mandible, and the combined defects can be corrected with only
one piece of cortical bone. Although bone grafting is preferably performed before the implant is placed,
it may be done simultaneously or even delayed until the abutment connection.
Several things should be observed; it is imperative that the transplant be firmly secured to the
recipient site. This can be accomplished either by the implant (when an L-shaped graft is used), a special
transplant retainer attached to the implant, a lag screw, or the creation of a subperiosteal pocket that fits
tightly around the graft. All incisions should be placed well outside the area where the graft is placed to
prevent infection resulting from leakage through the incisions. The use of nonresorbable membranes in
combination with cortical bone grafts should be limited because of the increased risk for infection.

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Provided these basic rules are adhered to, the method is satisfactory. Surgery can be performed under
local anesthesia, the morbidity is low, and resorption of the transplant seems to be limited.
Free Connective Tissue Graft (Figs 9a to 9c). The maxillary tuberosity and the palatal side of the
maxillary alveolar ridge offers readily accessible and safe donor sites for fibrous tissue that can be used
to fill concavities of the alveolar process. The graft can be placed either simultaneously with the implant
or at the abutment connection. The short-term results are usually excellent. The long-term results may be
less satisfactory because the connective tissue tends to shrink.
Apically Repositioned Flap. The apically repositioned flap was presented earlier (see Figs 6a and
6b) as a method for increasing the width of the attached gingiva. However, this flap is equally useful for
increasing the volume of the buccal gingiva and thus compensating for concavities in the bone. By
varying the length of the relief incisions, the position of the increased volume can be controlled. Short
relief incisions place the volume close to the ridge crest; longer incisions place most of the increased
volume higher in the vestibule but also tend to spread the volume over a larger surface.
The apically repositioned flap may be the simplest way to obtain a satisfactory result in most cases.
When a Rehrman-plasty has been used to seal the extraction socket after implant placement, the method
should be used routinely. However, when the buccal concavity is very deep, other methods should be
considered.
Sandwich Flap. This is another modification of the Rehrman flap that in some situations may be
useful to compensate for a hard tissue concavity. A flap is raised and the periosteum is incised as has
been described earlier. Approximately 10 mm of the apex of the flap is de-epithelialized and folded 180
degrees inward. The (now double) flap is adapted against the abutment.
In most situations, the advantage of this method does not outweigh the disadvantage. Only a small
increase in the vestibular volume is obtained, and the method has the same main disadvantage as all
Rehrman-plasties: the width of the attached gingiva is reduced. Thus, the indications seem limited.
Configuration of the Gingival Margin
A correct level and contour of the gingival margin are highly essential to achieve an esthetic result.
Unfortunately, both are affected by the shortcomings of the various surgical methods used at abutment
connection.
Excision at Stage 2 Surgery. According to some surgical protocols, excision with a punch is the
method of choice at stage 2 surgery. 7 This is highly questionable. The disadvantage of the method is
obvious when the alveolar crest is thin. In these instances, use of a punch will result in gingival retraction
with exposure of the facial surface of the abutment and sometimes even the head of the implant. As part
of the papillary tissue is also excised, the shape of the papillae is destroyed. The method should thus be
limited to those few single implant cases where the esthetic result is of little importance.
Cervical Folding of a Flap at Stage 2 Surgery. This method has been discussed above (see Fig 5).
The main advantage of the method is that a tight soft tissue attachment to the titanium surface of the
abutment is obtained. The level of the gingival margin can be adjusted and there is only a limited risk of
retraction. However, to recreate papillae of correct size and shape using this method seems very difficult
and unpredictable.
Coronally Repositioned Flap at Stage 2 Surgery. This is essentially another modification of the
Rehrman-plasty with parallel relief incisions (Fig 10). The flap should be 2 to 3 mm wider than the

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abutment, and the apex of the flap is shaped as a C with the convexity pointing buccally. Because it is
possible to lengthen the flap, the level of the gingival margin is easy to adjust. The configuration of the
gingival margin can be adjusted by varying the depth of curvature of the C. In addition, papillae can be
created by this method. The main disadvantage is that the width of the attached gingiva is reduced, which
limits the value of the method.
Apically Repositioned Flap at Stage 2 Surgery. As with the coronally repositioned flap, a correct
level and contour of the gingival margin can be obtained with this method (see Figs 6a and 6b). The
width of the attached gingiva is increased. If the flap is narrow, adjacent papillae can be saved but never
created.
Methods to Save and Create Papillae
To make an artificial tooth look natural, correct shape and size of adjacent papillae are of the utmost
importance, especially in the anterior part of the maxilla. Unfortunately, many methods of soft tissue
management used at the time of immediate implant placement result in the destruction of adjacent
papillae.
Coronally Repositioned Flap (Fig 10). The design has been described above. If the curvature of the
C is made deeper than the circumference of the abutment, the result is a surplus of tissue when the flap is
positioned coronally and sutured tightly against the abutment. Because the surplus of tissue is positioned
between the abutment and the adjacent tooth, a papilla may be formed. This method results in a small
reduction in the width of the buccal attached gingiva but can result in almost perfectly shaped papillae.
The result may sometimes be unpredictable.
Multiple C Incisions and a Large Coronally Repositioned Flap (Fig 11). This is a modification of
the procedure advocated by Moy et al.8 A marginal incision covering two to three teeth on each side of
the abutment is made. A periosteal relief incision is made in the base of the flap to allow lengthening.
Multiple C incisions are made, one facial to each tooth and implant. These incisions are made shallower
with increased distance from the implant. Thus, the amount of coronal repositioning is most pronounced
at the abutment and lesser with increased distance from the implant. The maximum effect is thus
obtained at the abutment.
The esthetic result of this variation of the coronally repositioned flap seems to be better than the
result obtained with the standard coronally repositioned flap. The main advantage is that the reduction of
the attached gingiva is disguised because it is spread over several teeth. Papillae are created as
successfully and no step in the mucogingival border is created, since no relief incisions are usually
needed.
Buccally Repositioned Flap With Approximal Pedicles (Fig 12). This procedure was presented by
Palacci.9 An incision at the palatal aspect of the cover screws is made along the crest with buccal relief
incisions at each end. The flap is raised, and toward each abutment, semilunar incisions are made,
creating small pedicles. These are rotated 90 degrees to fill the approximal spaces, since the main flap is
repositioned slightly buccally.

Excellent results have been reported by Palacci,9 but a few points are critical; there is a very delicate
balance between how far palatal to the cover screws the initial incision is made, the width of the small
pedicles, and the shape of the created papillae. If the incision is made too far palatally, either the flap has
to be repositioned apically and the mucogingival border will be broken, or the pedicles need to be made

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wider. If they are made too wide, they can be easily strangled between the abutment and adjacent teeth
because of their delicate blood supply, and the papillae will be lost. If the incision is made too far
buccally, either the flap has to be repositioned coronally with a broken mucogingival border, or the
pedicle will be too thin to produce papillae and only the space created when the flap was repositioned
buccally will be filled. The procedure is thus clever, but careful planning is imperative or the result will
be disappointing.
Lateral Compression of the Gingiva (Figs 13a and 13b). A closer study of the soft tissue
surrounding a fresh extraction socket will usually reveal that the papillae tend to spread and hence get
wider and flatter after the extraction. The pattern of this spread varies among different teeth. The ideal
method to recreate papillae at the abutment connection should thus obviously be to use an incisional
technique that imitates the configuration of the soft tissue border of fresh sockets in that particular area.
The author uses this technique in appropriate situations, ie, when the socket has been sealed by a free
gingival graft, a pedicled island flap, or a thin laminar bone sheet, or in other patients when the amount
and position of the attached gingiva is satisfactory.
The center of the cover screw is carefully identified with a probe. The soft tissue on top of the cover
screw is excised in a fashion imitating a fresh extraction site in the area, ie, all of the papillary tissue is
retained. This means that the cover screw may still partly be hidden by papillary tissue, which must be
gently compressed before the cover screw can be removed. When the abutment is connected to the
implant, the surrounding papillary tissue is compressed and raised. The papillae return to their original
shape in a natural way by this compression.
Once the surgeon is familiar with the technique, the esthetic result can be excellent. Three
prerequisites for a satisfactory result should be stressed. It is imperative that the implant be placed in
exactly the correct position, the center of the cover screw must be carefully localized before the excision
is made, and it must be recognized that the papillae spread in different ways depending on which tooth is
extracted. The need to closely study the reaction of papillae and the look of fresh extraction sites in
different areas of the jaws may seem rather embarrassing to a surgeon who is expected to be familiar with
the matter but will prove rewarding when it comes to recreating natural-looking papillae.
A Suggestion of a Treatment Strategy
The raison d’etre of immediate implant placement, in addition to shortening the treatment period, is that
all original tissue, bone, and mucosa can be saved. Since the implant replaces the root immediately
following the extraction, a maximum amount of residual bone is preserved. However, a certain amount of
soft tissue is frequently sacrificed because the socket has to be closed. By using a combination of various
techniques of soft tissue surgery, the surgeon should be able to resolve this problem.
The treatment of choice seems to be to close the extraction socket containing the implant by means of
a pedicled island flap. An alternative technique that is simpler but less frequently used is to seal the
socket by a demineralized laminar bone sheet. At the abutment connection, the center of the cover screw
should be localized by means of a probe and the mucosa on top of the cover screw should be excised in a
shape that copies a fresh extraction site in that area. Using this protocol, the amount of attached gingiva
and the buccal volume (contour) of the alveolar process are preserved, the configuration of the gingival
margin is optimized, and papillae adjacent to the artificial tooth are recreated.
If a vestibular flap must be raised to allow extraction, the flap should be repositioned and the socket
should be closed by a demineralized laminar bone sheet. An alternative is to close the socket by a

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modified Rehrman-plasty and reestablish normal anatomy at abutment connection by an apically

repositioned flap, a little narrower than the abutment. Thereby, the mucosa adjacent to the abutment will
be compressed to form esthetically pleasing papillae. Various combinations of these methods are equally
suitable to improve the esthetic result after conventional implant placement.

Bo Rosenquist

Associate Professor, Department of Oral and

Maxillofacial Surgery, University Hospital, Lund,
Sweden.

FIGURES

Figure 1

Fig. 1 Rehrman-plasty.

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Figure 2a-b

Figs. 2a and 2b Free mucosal graft. (Left) Implant placed into the socket. (Right) Mucosal graft
in situ.

Figure 3a-c

Figs. 3a to 3c Pedicled island flap. (Left) Diagram. (Top right) During surgery. (Bottom right) At
suture removal.

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Figure 4a-b

Figs. 4a and 4b Thin laminar bone membrane. (Left) At surgery. (Right) One week after
surgery.

Figure 5

Fig. 5 Cervical folding of flap for a multiple implant situation.

Figure 6a-b

Figs. 6a and 6b Apically repositioned flap at stage 2 surgery. (Left) Outline of the flap. (Right)
One week after surgery.

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Figure 7a-c

Figs. 7a to 7c Transplantation of cancelleous bone from the tibia. (Top left) Buccal concavity.
(Bottom left) Cancelleous bone graft. (Right) Surplus of organized bone at abutment connection.

Figure 8a-b

Figs. 8a and 8b Transplantation of an L-shaped cortical bone graft from the chin. (Left) Donor
site at surgery. (Below) Recipient site with cortical bone graft in situ.

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Figure 9a-c

Figs. 9a to 9c Free connective tissue graft. (Left) Buccal concavity. (Center) Connective tissue
graft in situ. (Right) Results.

Figure 10

Fig. 10 Coronally repositioned flap at stage 2 surgery.

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Figure 11

Fig. 11 Multiple C incisions and wide coronally repositioned flap.

Figure 12

Fig. 12 Buccally repositioned flap with approximal pedicles.

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Figure 13a-b

Figs. 13a and 13b Lateral compression of the gingiva. (Left) Diagram. (Below) Resultant
artificial maxillary left canine.

A Comparison of Various Methods of Soft Tissue Management Following the I

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