Editorial Manager(tm) for Journal of Oral Implantology

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Manuscript Number: AAID-JOI-D-10-00110

Title: Immediate Single Tooth Replacement with Subepithelial Connective Tissue Graft Using Platform
Switching Implants: A Case Series

Short Title:

Article Type: Clinical

Keywords: Immediate loading; immediate implant placement; immediate provisionalization; IIPP;

single tooth replacement; immediate tooth replacement; gingival recession; esthetics; biotype; gingival
biotype; papilla

Corresponding Author: Dr. Phillip Roe, DDS, MS

Corresponding Author's Institution: Loma Linda University School of Dentistry

First Author: Seunghwan Chung, DDS, MS

Order of Authors: Seunghwan Chung, DDS, MS; Kitichai Rungcharassaeng, DDS, MS; Joseph Y. K. Kan,
DDS, MS; Phillip Roe, DDS, MS; Jaime L. Lozada, DMD

Abstract: This case series evaluated the facial gingival stability following single immediate tooth
replacement in conjunction with subepithelial connective tissue graft (SCTG). Implant success rate and
peri-implant tissue response were also reported. Ten patients (6 males, 4 females), with a mean age of
52.1 (range = 22.7 to 67.1) years, underwent immediate implant placement and provisionalization
with SCTG and were evaluated clinically and radiographically at pre-surgery (T0), immediately after
immediate tooth replacement and SCTG (T1), 3-months (T2), 6-months (T3), and 12-months (T4) after
surgery. Data were analyzed using the Friedman and Wilcoxon signed-ranks tests at the significance
level of α = 0.05. At 1-year, 9 of 10 implants remained osseointegrated with the overall mean marginal
bone change of -0.31 mm and a mean facial gingival level change of -0.05 mm. The modified Plaque
Index scores showed that patients were able to maintain a good level of hygiene through out the study.
The Papilla Index Score indicated that at T4, more than 50% of the papilla fill was observed in 89% of
all sites. When proper 3D implant position is achieved and bone graft is placed into the implant-socket
gap, favorable success rate and peri-implant tissue response of platform switching implants can be
achieved following immediate tooth replacement in conjunction with subepithelial connective tissue
graft.
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Click here to download Article File: JOI 073010 ROE-1.doc

Immediate Single Tooth Replacement with Subepithelial Connective Tissue

Graft Using Platform Switching Implants: A Case Series

Seunghwan Chung, DDS, MS, Kitichai Rungcharassaeng, DDS, MS, Joseph Y. K. Kan, DDS,
MS, Phillip Roe, DDS, MS, Jaime L. Lozada, DMD

Seunghwan Chung DDS, MS* Advanced Education in Implant Dentistry, Loma Linda
University School of Dentistry, Loma Linda, California

Kitichai Rungcharassaeng DDS, MS, Associate Professor, Department of Orthodontics and

Dentofacial Orthopedics, Loma Linda University School of Dentistry, Loma Linda, California

Joseph Y. K. Kan, DDS, MS, Professor, Department of Restorative Dentistry, Loma Linda
University School of Dentistry, Loma Linda, California

Phillip Roe, DDS, MS, Assistant Professor, Department of Restorative Dentistry, Loma Linda
University School of Dentistry, Loma Linda, California

Jaime L. Lozada DDS, Director and Professor, Advanced Education in Implant Dentistry, Loma
Linda University School of Dentistry, Loma Linda, California

*This research was in partial fulfillment of a MS degree for the primary author

Correspondence address:

Phillip Roe, DDS, MS

Center for Prosthodontics and Implant Dentistry
Loma Linda University School of Dentistry
Loma Linda, CA 92350

Fax: (909) 558-0324

E-mail: proe03d@llu.edu

1
ABSTRACT

This case series evaluated the facial gingival stability following single immediate tooth

replacement in conjunction with subepithelial connective tissue graft (SCTG). Implant success

rate and peri-implant tissue response were also reported. Ten patients (6 males, 4 females), with

a mean age of 52.1 (range = 22.7 to 67.1) years, underwent immediate implant placement and

provisionalization with SCTG and were evaluated clinically and radiographically at pre-surgery

(T0), immediately after immediate tooth replacement and SCTG (T1), 3-months (T2), 6-months

(T3), and 12-months (T4) after surgery. Data were analyzed using the Friedman and Wilcoxon

signed-ranks tests at the significance level of  = 0.05. At 1-year, 9 of 10 implants remained

osseointegrated with the overall mean marginal bone change of -0.31 mm and a mean facial

gingival level change of -0.05 mm. The modified Plaque Index scores showed that patients were

able to maintain a good level of hygiene through out the study. The Papilla Index Score

indicated that at T4, more than 50% of the papilla fill was observed in 89% of all sites. When

proper 3D implant position is achieved and bone graft is placed into the implant-socket gap,

favorable success rate and peri-implant tissue response of platform switching implants can be

achieved following immediate tooth replacement in conjunction with subepithelial connective

tissue graft.

Key words: Immediate loading, immediate implant placement, immediate provisionalization,

IIPP, single tooth replacement, immediate tooth replacement, gingival recession, esthetics,

biotype, gingival biotype, papilla

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INTRODUCTION

The success of single immediate tooth replacement in the esthetic zone begins with

proper three dimensional implant placement along with a properly contoured provisional

restoration.1-5 The concept of immediate implant placement and provisionalization (IIPP) was

introduced by Worhle, and has since been proven to be a predictable treatment modality in ideal

esthetic situations with success rates comparable to that of delayed implant placement with

delayed prosthetic loading procedures.6-9

While IIPP has been shown to be a successful procedure, slight facial gingival recession

has been reported following the first year of function.10-14 Facial gingival biotype conversion

through subepithelial connective tissue graft (SCTG) procedure at the time of implant placement

has been advocated and proven to be successful in preserving soft tissue levels by rendering the

gingival tissue more resistant to recession. 1,10,15,16

Peri-implant marginal bone level change (MBLC) is one of the parameters used in

evaluating implant success rate.17 Recently, it has been suggested that the peri-implant marginal

bone level (MBL) may be influenced by the way the implant and the abutment connect, and that

the size discrepancy between the implant and the abutment used, also known as “platform

switching”, may be beneficial in maintaining the peri-implant MBL.18

The purpose of this study was to evaluate the success rate and peri-implant tissue

response of platform switching implants following immediate tooth replacement in conjunction

with subepithelial connective tissue graft.

3
MATERIALS AND METHODS

Patient selection

This study was approved by the Institutional Review Board (IRB) of Loma Linda

University and was conducted in the Center for Implant Dentistry, Loma Linda University

School of Dentistry, California. To be included in this study, the patient must: 1) be at least 18

years of age or older with good hygiene, 2) have a single failing maxillary (#4 – 13) or

mandibular (#20 – 29) tooth with the presence of adjacent and opposing natural dentition and

without active infection, 3) have sufficient bone volume to accommodate placement of a single

implant with a minimum dimension of 3.25 mm x 15 mm. The patients 1) with a history of

smoking,19 head and neck radiation treatment,20-22 bruxism,23 and parafunction, 2) with a lack of

stable posterior occlusion, or 3) in whom primary implant stability could not be achieved were

excluded.

Clinical Procedures

All patients received standardized diagnosis and treatment planning (Figures 1 and 2).

An acrylic resin provisional shell was fabricated prior to the implant surgery using an

autopolymerizing acrylic resin (Jet, Lang dental, Wheeling, IL). Following the administration of

local anesthetic, the failing tooth was removed atraumatically and an implant (Osseotite Prevail®,

Biomet 3i, Warsaw, IN) was placed immediately into the extraction socket with the implant-

prosthetic platform 3 mm apical to the pre-determined gingival margin (Figure 3).7 Primary

implant stability was achieved with a minimum insertion torque of 30 Ncm (manufacturer

recommended value, Biomet 3i). Xenograft (Bio-Oss, Osteohealth Co., Shirley, NY) was

utilized to fill the implant-socket gap. A customized temporary titanium cylinder (Temporary

Cylinder, Biomet 3i, Inc.) was then placed and hand-tightened onto the implant. Flowable

4
composite resin (PermaFlo, Ultradent Products Inc., USA) was expressed into the site and

photopolymerized to recreate the emergence profile of the extracted tooth. The prefabricated

provisional shell was relined with acrylic resin (Jet, Lang dental, Wheeling, IL) and adapted to

the custom temporary abutment. The provisional restoration was adjusted in order to clear all

contacts in centric and eccentric movements, polished and cemented with non-eugenol temporary

cement (TempBond, Kerr Corp., Orange, CA). A periapical radiograph was taken to ascertain

the fit of the provisional restoration and complete cement removal (Figure 4).

A SCTG was harvested from the palate utilizing a single incision technique. 24 A full

thickness envelope was created between the labial bony plate and the gingiva of the extraction

site.1 The SCTG was inserted into the prepared envelope space and secured using a resorbable

suture material (6-0 chromic gut blue, Ethicon Johnson & Johnson, Somerville, NJ) [Figures 5].

Light pressure was applied over the SCTG with moist gauze for 10 minutes to minimize blood

clot and dead space formation between the graft and the underlying bone. 1

Antibiotics and analgesics were prescribed for postoperative use. Patients were

instructed to rinse with 0.12% chlorhexidine gluconate solution (Peridex, Zila Pharmaceuticals

Inc., Phoenix, AZ), refrain from functioning at the surgical site, and to remain on liquid diet for

two weeks following the surgery. Over the next three months, a soft diet was recommended.

At six months, the final implant impression was made with poly (vinyl siloxane)

impression material (Aquasil Monophase, Dentsply, York, PA). The final restoration was

fabricated as a one-piece screw retained or two-piece cement-retained metal ceramic restoration.

The screw-retained restoration was cast in a high noble metal (W3 Ceramic Alloy, Ivoclar

Vivadent Inc., Amherst, NY) onto the cast gold abutment (UCLA Abutment, Biomet 3i)

followed by ceramic application (Vita Omega 900, Vident Inc., Brea, CA). The prosthetic screw

5
for the final one-piece metal ceramic restoration was torqued to 20 Ncm (manufacturer’s

recommendation, Biomet 3i, Inc.). The cement-retained restoration consisted of a definitive

custom abutment cast in Type IV gold (Monogram IV, Leach & Dillion, San Diego, CA) onto

the cast gold abutment (UCLA Abutment, Biomet 3i) and a definitive metal-ceramic restoration

(W-3, Vita Omega 900). The custom abutment was torqued to 20 Ncm (manufacturer’s

recommendation) and the definitive metal-ceramic restoration was cemented using resin-

modified glass ionomer cement (Rely-X, 3M ESPE, St. Paul, MN) [Figures 6, 7, and 8].

Data Collection

All examinations and corresponding data collection was performed by 1 examiner (S.C.).

The data, when indicated, was collected and compared between each follow-up time interval:

pre-surgery (T0), immediately after immediate tooth replacement and SCTG (T1), 3-months

(T2), 6-months (T3), and 12-months (T4) after surgery. The implant success/failure and

marginal bone level change were evaluated at T1, T2, T3, T4; facial gingival level change at T0,

T2, T3, T4; Periotest Values at T1, T3; modified Plaque Index at T2, T3, T4; and Papilla Index

at T1, T2, T3, T4.

Implant Failure: The implants were evaluated according to the criteria proposed by Smith and

Zarb where applicable.17 The implants were considered a failure with the presence of mobility,

peri-implant radiolucency, persistent pain, discomfort, and/or infection.

Marginal Bone Level Change (MBLC): The marginal bone levels (MBL) on the mesial and distal

aspects of each implant were measured with the use of sequential periapical radiographs and long

cone paralleling technique with a commercial Rinn XCP holder (XCP post bite blocks 54-0862,

Dentsply, Elgin, IL).25 An occlusal jig constructed with poly (vinyl siloxane) interocclusal

6
record material (Exabite II, GC America) was used to standardize the position and angulation of

the film to the x-ray beam. The platform of the implant was used as the reference line (RL)

[Figure 9]. The distance between the RL and the implant-bone contact was measured. A value

of zero was given when the marginal bone level was at or coronal to the RL. A negative value

was given when marginal bone level was apical to the RL. The overall MBL of each implant

was the average value of mesial and distal measurements. The overall MBL were compared

between each follow-up time interval (T1, T2, T3, T4) and the MBLC calculated. The

intraexaminer reliability of the measurements was determined by using double assessments of

MBL measured 3 months apart by one examiner and expressed as the intraclass correlation

coefficient (ICC).

Facial Gingival Level Change (FGLC): A master cast was made at different time intervals (T0,

T2, T3, T4) to evaluate the facial gingival level (FGL). A customized stent fabricated from the

pre-operative master cast was used to standardize probing points and the direction of probe

insertion. Baseplate wax (Type II Dentsply, York, PA) was placed around the failing tooth and

the modified cast was duplicated. A vacuum-formed, 0.060-inch-thick-polyethylene

terephthalate, glycol modified clear template (Ultradent Products, Inc., South Jordan, UT) was

adapted and trimmed to remove all undercuts. This allowed for sufficient clearance to

accommodate changes in the contours of the restoration from the provisional to the definitive

implant restoration. A perpendicular slot was created at the most apical part of the midfacial

gingival level, and the apical border of the customized stent was used as a reference line. The

FGL was evaluated at each time interval using a periodontal probe (15 UNC Color-Coded Probe,

Hu-Friedy, Chicago, IL) and the FGLC calculated. All measurements were made to the nearest

7
0.5 mm. The intraexaminer reliability of the measurements was determined by using a double

assessment of FGL measured 3 months apart by one examiner and expressed as the ICC.

Implant Mobility: The Periotest (Siemens AG, Bensheim, Germany) instrument was utilized to

evaluate implant stability at T1 and at T3.26-29 A 6-mm healing abutment (Biomet 3i, Inc.) was

hand tightened onto the implant and utilized as the tapping surface for the Periotest (Siemens)

instrument. Measurements were made 2 to 4 times, until two duplicate Periotest values (PTV)

were registered and recorded.

Modified Plaque Index (mPI): The presence of plaque was assessed at the mesiolabial, labial,

distolabial, mesiolingual, lingual, and distolingual surfaces of the implant provisional and

definitive restoration according to the mPI30. Only the highest index score of each implant was

used for statistical analysis.

Papilla Index Score (PIS): The interproximal soft tissue was evaluated using the PIS. 31 Mesial

and distal PIS were individually analyzed.

Surgical Complications: Surgical complications were documented as connective tissue graft

necrosis, infection around the implant, and/or any deviation from the manufacturers placement

protocol, which resulted in additional modifications to the surgical site in order to establish

adequate primary stability.

Prosthetic Complications: Prosthetic complications were documented as any repairs or

modifications of the provisional restoration or definitive prosthesis. These included, but were

not limited to; debonding of the provisional restoration, fracture of the provisional restoration,

occlusal adjustments, and/or abutment screw loosening.

8
Data Analysis

Friedman test was used to evaluate MBL, FGL, mPI, mBI, and PIS; and Wilcoxon

signed-ranks test for PTV. The level of significance was set at  = 0.05.

RESULTS

A total of 6 male and 4 female patients, between the ages of 22.7 and 67.1 (mean = 52.1)

years old, participated in this study. Of the 10 implants, 3 were located in the maxillary central

incisor, 3 in the maxillary lateral incisor, 2 in the maxillary canine, 1 in the maxillary second

premolar, and 1 in the mandibular second premolar position. The implants used were 3.25 x 15

mm (4), 4.0 x 15 mm (4), 5.0 x 13 mm (1) and 5.0 x 15 mm (1).

Implant Failure

One patient experienced an early implant failure (#9) at the 3-month follow-up

appointment (T2), due to mobility. Since the implant failure occurred at T2, it was excluded

from the data analysis. The remaining 9 implants were stable and maintained osseointegration at

the 1-year follow-up (T4) resulting in an overall cumulative implant success rate of 90% (9/10).

Marginal Bone Level Change (MBLC)

The ICC for marginal bone level (MBL) measurements was 0.955, indicating that the

measurement method was reliable and reproducible. Statistical values for the MBL are presented

in Table 1. The mean MBLC from T1 to T4 was -0.31 mm. No statistically significant

differences (p = .10) for MBL were noted between all time intervals.

Facial Gingival Level Change (FGLC)

The ICC for FGL measurements was 0.998, indicating that the measurement method was

reliable and reproducible. Statistical values for the FGL are presented in Table 2. The mean

9
FGLC from T1 to T4 was -0.05 mm. No statistically significant differences (p = .75) for FGL

were noted between all time intervals.

Implant Mobility

The mean PTV at T3 (-2.0 ± 0.9) was statistically significantly lower than that at T1 (-0.1

± 2.2) [p = 0.008].

Modified Plaque Index (mPI)

The mPI scores of 0, and 1 were consistently recorded throughout the study (Table 3).

There was no statistically significant difference in the mPI (p = .56) scores among the 3 time

intervals (T2, T3, T4).

Papilla Index Score (PIS)

The PIS ranged from 0 to 3 at all time intervals in this study (Table 4). No statistically

significant difference was noted on both mesial and distal papilla levels with respect to time (p =

.91 and .85 respectively) [Table 4]. At T4, more than 50% of the papilla fill was observed in

89% of all sites.

Surgical Complications

Despite the tearing of the facial gingival margin in one patient while preparing the

recipient site for the SCTG, the result was inconsequential. Partial necrosis of the SCTG was

observed in two patients. At T4, while one patient did not experience significant facial gingival

tissue change, 1.0 mm of facial gingival recession was noted on the other patient.

Prosthetic Complications

During the provisional phase, three episodes of provisional restoration debonding, four

fractured provisional restorations, and one abutment screw loosening were observed and resolved

uneventfully.

10
DISCUSSION

The cumulative implant success rate following single immediate tooth replacement and

SCTG in this study was 90% (9/10) after a follow-up period of 1-year. Although comparable

implant success rates have been reported with single immediate tooth replacement without SCTG

with similar implant system (91% to 100%), 32-45 it is slightly less than similar procedures

performed without SCTG with other implant systems (98% to 100%). 6,7,11-13,41,46-52 This is a

consequence of the small sample size, since each implant corresponds to 10% in the present case

series.

Studies involving single implants have reported peri-implant marginal bone level changes

from -0.2 mm to -1.0 mm for immediate tooth replacement procedures, 7,11,13,41,47,51 and -0.4 mm

to -1.6 mm for delayed loaded procedures after the first year of function. 9,53,54 It has been

suggested that the “platform switching” feature could be beneficial in maintaining peri-implant

MBL both mechanically (by reducing the force transmitted to the implant-bone interface) and

biologically (by creating a better seal at implant-abutment interface and relocating the

inflammatory zone [inward] away from the bone). 18 In regards to implants studies with platform

switching feature, marginal bone level changes have ranged from 0 mm to -0.78 mm with a

follow-up period of 6 to 57 months. 32-45 In this study, the mean peri-implant marginal bone level

change of -0.31 mm at T4 was within the range of the aforementioned studies and other studies

similar in nature.

Minimal mean facial gingival tissue recession (-0.5 to -0.8 mm) has been observed in

short-term studies (1 to 2 years follow-up) with immediate tooth replacement procedures.7,11,13

In this study, the viability of SCTG was examined in conjunction with immediate tooth

replacement. Despite partial necrosis encountered in 2 patients, the overall mean FGLC was

11
minimal at T4 (-0.05 mm; Table 2). In fact, the mean FGLC of the remaining 7 implants without

necrotic SCTG was +0.07 mm. This is similar to the data reported by Kan et al and Cornelini et

al respectively, where a mean facial gingival tissue gain of 0.2 mm was observed 1 year

following immediate implant placement with SCTG. 55,56 This implies that SCTG in conjunction

with immediate tooth replacement in the esthetic zone may be beneficial in minimizing facial

gingival tissue recession when proper 3D implant position is achieved and bone graft is placed

into the implant socket gap.55 Nevertheless, a high necrosis rate (2/10 = 20%) observed in this

study also implied that bilaminar SCTG in conjunction with immediate tooth replacement

procedures is a technique sensitive procedure with inherent risks that must not be overlooked.

The validity of the Periotest instrument has been the subject of debate, in any event, the

PTV of an implant seems to provide an acceptable level of objectivity for diagnosing initial

implant stability.26,57 It has been suggested that a PTV of -5 to +5 is required for proper

osseointegration.26 Based on this, the mean PTV at T1 of -0.1 (range = -2 to +5) reported in this

study suggested that primary stability of some implants were not optimal. The high PTV may be

related to the density/quality of the maxillary bone as well as the immediate implant placement

in an extraction site where implant stability relies mainly on the engagement of the apical and the

palatal aspects of the anterior extraction socket. 5 In addition, a statistically significant lower

mean PTV was noted at T3 (-2; range = -3 to -1) suggesting that osseointegration is a dynamic

process, and that the implant stability in this study improved over time.

While it is generally agreed that plaque accumulation can potentially induce a negative

mucosal response,7 the relationship between compromised oral hygiene and implant failure has

been contentious.58-63 The mPI scores observed throughout the duration of this study were either

0 or 1, implying that the patients were able to maintain a good level of oral hygiene (Table 3).

12
To minimize the peri-implant gingival tissue disturbance following immediate tooth replacement

and SCTG, the patients were advised to refrain from brushing the surgical site for one month.

Meanwhile, the oral hygiene was adequately maintained through light swabbing of the surgical

area with a cotton-tipped applicator soaked in 0.12% chlorhexidine gluconate (Peridex).

The PIS in the present study ranged from 0 to 3, at T1, T2, T3, and T4. There were no

statistically significant differences in the PIS among different time intervals (Table 4; p > .05)

when immediate tooth replacement with SCTG was performed, even when necrosis of the SCTG

in 2 patients was observed. This validates the idea that implant papilla level is dictated by the

proximal bone level of the adjacent teeth, 64,65 and the best way to maintain the papilla is to

provide support immediately after tooth removal. 4,5,7,66

Although useful information was found in this study, due to the small sample size, its

limitations should be acknowledged. Future studies involving a larger sample size with a control

group and long-term follow-up will undoubtedly provide more useful information on the

viability of this particular procedure.

CONCLUSIONS

When proper 3D implant position is achieved and bone graft is placed into the implant-

socket gap, favorable success rate and peri-implant tissue response of platform switching

implants can be achieved following immediate tooth replacement in conjunction with

subepithelial connective tissue graft.

ACKNOWLEGEMENTS

13
The authors thank Biomet 3i, Warsaw, IN, for providing the implants and related prosthetic

components related to this research.

14
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22
Tables

Table 1. Comparison of marginal bone level (MBL) at different time intervals using Friedman
Test at  < 0.05

MBL (mm)
Time Interval Mean ± SD Median Minimum Maximum
Pre-op 0±0 0 0 0
3-months -0.19 ± 0.37 0 -1.05 0
6-months -0.19 ± 0.36 0 -1 0
12-months -0.31 ± 0.34 -0.2 -1 0
p = .10; N = 9

Table 2. Comparison of facial gingival level (FGL) at different time intervals using Friedman
Test at  < 0.05

FGL (mm)
Time Interval Mean ± SD Median Minimum Maximum
Pre-op -3.67 ± 0.94 3.5 -5 -2.5
3-months -3.89 ± 1.08 4 -5.5 -2.5
6-months -3.78 ± 1.00 3.5 -5 -2.5
12-months -3.72 ± 1.03 3 -5 -2.5
p = .75; N = 9

23
Table 3. Comparison of distribution of modified Plaque Index (mPI) scores at different time
intervals using the Friedman Test at  = 0.05

Modified Plaque Index (mPI)

Time Interval 0 1 2 3 N
3-months 4 5 0 0 9
6-months 3 6 0 0 9
12-months 6 3 0 0 9
p = 0.56

Table 4. Comparison of distribution of Papilla Index Score (PIS) at different time intervals using
the Friedman Test at  = 0.05

Papilla Index Score (PIS)

Time Mesial (N = 9) Distal (N = 9)
Interval
0 1 2 3 4 0 1 2 3 4
0-months 0 1 1 7 0 1 0 3 5 0
3-months 0 1 2 6 0 1 2 1 5 0
6-months 0 0 2 7 0 1 1 1 6 0
12-months 0 0 1 8 0 1 1 1 6 0
p-value .91 .85

24
Figure Legends

Figure 1: Preoperative labial view of the failing maxillary left central incisor.

Figure 2: Preoperative periapical radiograph of the failing maxillary left central incisor due

to root resorption.

Figure 3: Implant placement.

Figure 4: Periapical radiograph immediately after implant surgery.

Figure 5: Labial view of the provisional restoration and connective tissue graft at implant

surgery.

Figure 6: Labial view of the definitive implant abutment and tooth preparations.

Figure 7: Labial view of the definitive restoration after 1 year of function.

Figure 8: Periapical radiograph 1 year after the implant surgery.

Figure 9: Reference line (RL) used to determine changes in marginal bone level (MBL).

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