Overview
Immediate implant placement is often the preferred treatment option when adequate bone is present, as it can reduce treatment time and help preserve existing hard and soft tissue architecture.
However, successful immediate implant therapy requires more than adequate bone volume. Proper evaluation of the surrounding soft tissue is equally important. In this case, immediate implant placement alone would likely have resulted in inadequate keratinized tissue around the future implant restorations, increasing the likelihood of a secondary soft tissue grafting procedure in the future.
To minimize the number of surgical interventions and optimize long-term peri-implant tissue health, immediate implant placement was combined with simultaneous connective tissue grafting during a single surgical procedure.
The result was stable peri-implant soft tissue and healthy keratinized tissue maintained over a 5-year follow-up period.
Treatment Planning
Diagnosis
Sites #30 and #31 presented with conditions favorable for immediate implant placement. However, the existing soft tissue condition suggested that insufficient keratinized tissue would remain around the implants if only immediate implant placement was performed.
Treatment Plan
- Immediate implant placement at sites #30 and #31
- Bone grafting around the implants
- Modified connective tissue grafting technique
- 3D-printed surgical guide for accurate implant positioning
The goal was to establish and maintain adequate keratinized tissue around the implants while avoiding the need for additional soft tissue grafting procedures later.
Clinical Steps
✓ Comprehensive pre-operative evaluation of both hard and soft tissue conditions
✓ Guided immediate implant placement using a 3D-printed surgical guide
✓ Modified connective tissue grafting to increase the width of attached keratinized tissue
A critical factor for success is maintaining a favorable ratio of covered to uncovered graft. Excessive exposure of the epithelial portion of the graft may compromise healing and graft integration.
Clinical Tip: Limit the exposed epithelial portion of the graft to approximately 1 mm or less whenever possible.
Clinical Outcome
At least 2 mm of attached keratinized tissue was created adjacent to the final implant crowns.
5-Year Follow-Up
At the 5-year follow-up evaluation, both implants remained stable with healthy peri-implant tissues and a consistent band of attached keratinized tissue surrounding implant crowns #30 and #31.
By combining immediate implant placement with simultaneous connective tissue grafting, the desired hard and soft tissue outcome was achieved with a single surgical intervention.
For clinicians who are not comfortable performing connective tissue grafting at the time of implant placement, a staged treatment approach may be a more predictable option. Allowing the site to fully epithelialize following extraction or ridge augmentation before implant placement can simplify soft tissue management.
Nevertheless, proper soft tissue management remains one of the most important factors influencing long-term implant success and peri-implant tissue stability.
Clinical Pearls
✓ Evaluate both hard tissue and soft tissue conditions before deciding on immediate implant placement.
(Case 2 had adequate attached keratinized tissue to begin with, so tissue loss associated with immediate implant placement was not a major concern.)
✓ Adequate keratinized tissue around implants contributes to long-term tissue stability and easier maintenance.
✓ Limit exposed epithelial graft tissue to no more than 1 mm to promote predictable integration.
✓ Proper soft tissue management can reduce the number of surgical procedures and shorten overall treatment time.
✓ Combining immediate implant placement with connective tissue grafting can improve long-term peri-implant tissue stability and patient outcomes.
Learn More
Detailed step-by-step protocols for immediate implant placement, connective tissue grafting, GBR, phlebotomy, sticky bone preparation, and PRF membrane fabrication are covered in ECDA Module A: Anterior Implant • Soft Tissue • GBR.
