Soft tissue management has become a crucial part of implant therapy in the esthetic zone, as implant placement nowadays requires not only functional success, but also pleasing esthetic outcomes. New surgical techniques and materials provide clinicians with helpful tools that contribute to functional and esthetic success. More importantly, sophisticated clinical concepts are required to achieve the best possible result despite initially differing circumstances. During therapy, there are different points in time when it is possible to improve soft tissue conditions: at tooth extraction, together with implant placement or at uncovering. In the case of tissue deficits, augmentations using autologous soft tissue can be performed in different ways, such as socket seal surgery, the modified roll flap procedure or incision-free tunneling techniques. Often not just one of them, but also a combination also have to be used subsequently at the different treatment steps. Once the desired soft tissue shape is created, it needs to be transferred from the provisional to the final restoration in the prosthetic part of the treatment. This article gives an overview of a strategic approach from tooth extraction to implant impression.
When it comes to implant placement in the esthetic zone, clinicians are nowadays required to implement a lot of innovative aspects in their treatment concept and meet the standard of knowledge from tooth extraction to insertion of the final prosthetic solution. Thanks to new surgical techniques and improved materials much better results can be achieved nowadays to the benefit of the patient. This includes tissue-conserving extraction methods, scientifically documented methods for the preservation and augmentation of hard and soft tissues, the application of modern incision and suturing techniques as well as careful pre-implantation diagnostics (Bäumer et al. 2013).
In contrast to earlier times when a high survival rate was the focus, special attention is now paid to the esthetic outcome. This relates not only to the appearance of the prosthetic solution, but also to that of the peri-implant tissues. Because “red-and-white esthetics” strongly influence the way in which people perceive themselves and are perceived by others, the appearance of the teeth and peri-implant tissues must be equally weighted during treatment planning to successfully restore balanced dentofacial harmony (Chiche et al. 1994, Kokich et al. 1984, Magne & Belser 2002). One important part of the treatment, therefore, consists of addressing the soft tissues adequately: taking the parameters of the pink esthetic score (Furhauser et al. 2005) into account, the aim is to (1) achieve sufficient soft tissue volume, (2) an adequate vertical gingival level around the implant with complete interdental papillae and (3) a natural surface texture without scarring from surgical interventions. The peri-implant tissues are restored not only for esthetic reasons, but also to achieve the right functional properties: sufficient tissue is needed for long-term stability (Zuhr et al. 2014) and to improve peri-implant hygiene conditions.
The surgical techniques that are applied in order to achieve these goals should be as atraumatic as possible and avoid the creation of scars, which has led to the development of minimally invasive techniques. During the course of implant therapy, there are three different points in time when it is possible to improve the peri-implant soft tissue: at the time of tooth extraction, at implant placement or afterwards at implant uncoverage. The point chosen for soft tissue improvement depends on the extent of the soft tissue defect at the implant site, which should be evaluated at each treatment step.