Evaluation of periosteal membranes and coronally positioned flaps in the treatment of Class II furcation defects: a comparative clinical study in humans

Biomaterials for Alveolar Ridge Preservation as a Preoperative Procedure for Implant Treatment: History and Current Evidence

In implant treatment, the reduction and structural changes in the alveolar ridge that occur after tooth extraction limit the length, width, and placement position of the implant body, impair esthetics, and, in some cases, make implant placement difficult. To solve these problems, an alveolar ridge preservation (ARP) technique, which is performed simultaneously with tooth extraction, generally aims to promote bone regeneration and prevent alveolar ridge reduction by filling the extraction socket with bone graft material and then covering it with a barrier membrane to protect against the invasion of epithelial tissue. The extraction socket provides a favorable environment for bone regeneration throughout the healing period because the blood supply is abundant, and it effectively retains the bone graft material by using the remaining bone wall of the socket. In recent years, advances in bioengineering technology have led to the development of graft materials with various biological properties, but there is currently no clear consensus regarding the selection of surgical techniques and materials depending on the condition of the alveolar ridge. This review will provide a comprehensive survey of the evidence accumulated to date on ARP, present many cases according to the clinical situation, and discuss various treatment options.

Ascertaining the regenerative potential of the "gold standard" grafts: Achieving 100% root coverage in Miller's Class III recession with periosteal pedicle graft and autogenous bone

Recession of the gingiva is defined as the stripping of a portion of the dental root surface as a result of gingival margin shifting apically. Various techniques have been advocated for root coverage. The practice of utilizing periosteal pedicle graft for covering gingival recession defects is a contemporary development. Utilizing bone grafts for hard tissue regeneration has also been implemented. This case report assesses the effectiveness of the surgical approach utilizing autogenous bone and periosteum for recession coverage. A participant with Miller's Class III gingival recession in #23 and #24 was treated using this technique. The loss of periodontal attachment was recorded to be 8 mm and 5 mm on the mid-buccal surface of the upper left canine and first premolar, respectively. Clinical parameters were recorded at 1, 3, 6, 9, and 12 months postoperatively. Complete root coverage was achieved when evaluated from baseline till 12 months, with clinical attachment level and keratinized tissue gain. The results of esthetics in terms of color match and tissue contours were satisfactory to the patient as well as to the clinicians.

Periodontal regeneration - furcation defects: a systematic review from the AAP Regeneration Workshop

BACKGROUND

The aim of this review is to present the available evidence regarding the effectiveness of different regenerative approaches for the treatment of furcation defects in specific clinical scenarios compared with conventional surgical therapy to provide clinical guidelines for the therapeutic management of furcation defects and to identify priorities for future research that may advance the understanding of periodontal regenerative medicine.

METHODS

A comprehensive search based on predetermined eligibility criteria was conducted to identify human original studies and systematic reviews on the topic of periodontal regeneration of furcation defects. Two reviewers independently screened the title and abstract of the entries yielded from the initial search. Subsequently, both reviewers read the full-text version of potentially eligible studies, made a final article selection, and extracted the data of the selected studies considering specific clinical scenarios. The clinical scenarios contemplated in this review included the following: 1) facial and interproximal Class I defects in maxillary molars; 2) facial and lingual Class I defects in mandibular molars; 3) facial and interproximal Class II furcation defects in maxillary molars; 4) facial and lingual Class II furcation defects in mandibular molars; 5) Class III furcation defects in maxillary molars; 6) Class III furcation defects in mandibular molars; and 7) Class I, II, or III furcation defects in maxillary premolars. Endpoints of interest included different clinical, radiographic, microbiologic, histologic, and patient-reported outcomes.

RESULTS

The initial search yielded a total of 1,500 entries. The final selection consisted of 150 articles, of which six were systematic reviews, 109 were clinical trials, 27 were case series, and eight were case reports. A summary of the main findings of previously published systematic reviews and the available evidence relative to the indication of regenerative approaches for the treatment of furcation defects compared with conventional surgical therapy are presented. Given the marked methodologic heterogeneity and the wide variety of materials and techniques applied in the selected clinical trials, the conduction of a meta-analysis was not viable.

CONCLUSIONS

On the basis of the reviewed evidence, the following conclusions can be drawn. 1) Periodontal regeneration has been demonstrated histologically and clinically for the treatment of maxillary facial or interproximal and mandibular facial or lingual Class II furcation defects. 2) Although periodontal regeneration has been demonstrated histologically for the treatment of mandibular Class III defects, the evidence is limited to one case report. 3) Evidence supporting regenerative therapy in maxillary Class III furcation defects in maxillary molars is limited to clinical case reports. 4) In Class I furcation defects, regenerative therapy may be beneficial in certain clinical scenarios, although most Class I furcation defects may be successfully treated with non-regenerative therapy. 5) Future research efforts should be primarily directed toward the conduction of clinical trials to test novel regenerative approaches that place emphasis primarily on patient-reported outcomes and also on histologic demonstration of periodontal regeneration. Investigators should also focus on understanding the influence that local, systemic, and technical factors may have on the outcomes of regenerative therapy in furcation defects.

Periosteal Pedicle Flap Harvested during Vestibular Extension for Root Coverage

Root exposure along with inadequate vestibular depth is a common clinical finding. Treatment option includes many techniques to treat such defects for obtaining predictable root coverage. Normally, the vestibular depth is increased first followed by a second surgery for root coverage. The present case report describes a single-stage technique for vestibular extension and root coverage in a single tooth by using the Periosteal Pedicle Flap (PPF). This technique involves no donor site morbidity and allows for reflection of sufficient amount of periosteal flap tissue with its own blood supply at the surgical site, thus increasing the chances of success of root coverage with simultaneous increase in vestibular depth.

Effect of periosteum attached to autogenous iliac block bone graft on bone resorption in rabbits

The purpose of this study was to evaluate the effect of the periosteum attached to an iliac block bone graft on resorption of the grafted bone. Twenty-one rabbits were used. Iliac bone was harvested with (experimental group) or without a periosteum (control group) and grafted on the rabbit calvarium and fixed with miniscrews. The animals were killed, and specimens were harvested at 1, 4, and 8 weeks after the surgery. Histologic examination and histomorphometry were done. Grafted bones were severely resorbed, and the overall shapes were changed in the control group. On the contrary, the overall shape of the grafted bone was maintained, although the grafted bone was resorbed in the experimental group. Moreover, there were no osteoclasts adjacent to the periosteum of the graft. These results suggest that the periosteum attached to grafted bone can help establish early revascularization and prevent the resorption of grafted bone.

Periosteal pedicle graft: A novel root coverage approach

Gingival recession along with reduced width of attached gingiva and inadequate vestibular depth is a very common finding. Many techniques have been adopted in order to treat such defects and obtain predictable root coverage. Several graft procedures are used to obtain the coverage, but they have not been able to deliver predictable and satisfactory results (except connective tissue graft). Some of them also resulted in the secondary surgical site that was very uncomfortable for the patients. There was an intense need for a technique that provides not only good and predictable root coverage, but also reduces the need for secondary surgical site. Hence, this paper describes a single stage technique for increasing the width of attached gingiva and root coverage by using the periosteal pedicle graft.

Efficacy of Connective Tissue with and without Periosteum in Regeneration of Intrabony Defects

Background and aims. Connective tissue grafts with and without periosteum is used in regenerative treatments of bone and has demonstrated successful outcomes in previous investigations. The aim of present study was to evaluate the effectiveness of connective tissue graft with and without periosteum in regeneration of intrabony defects.

Materials and methods. In this single-blind randomized split-mouth clinical trial, 15 pairs of intrabony defects in 15 patients with moderate to advanced periodontitis were treated by periosteal connective tissue graft + ABBM (test group) or non-periosteal connective tissue graft + ABBM (control group). Probing pocket depth, clinical attachment level, free gingival margin position, bone crestal position, crest defect depth and defect depth to stent were measured at baseline and after six months by surgical re-entry. Data was analyzed by Student’s t-test and paired t-tests (α=0.05).

Results. Changes in clinical parameters after 6 months in the test and control groups were as follows: mean of PPD reduction: 3.1±0.6 (P<0.0001); 2.5±1.0 mm (P<0.0001), CAL gain: 2.3±0.9 (P<0.0001); 2.2±1.0 mm (P<0.0001), bone fill: 2.2±0.7 mm (P<0.0001); 2.2±0.7 mm (P<0.0001), respectively. No significant differences in the position of free gingival margin were observed during 6 months compared to baseline in both groups.

Conclusion. Combinations of periosteal connective tissue graft + ABBM and non-periosteal connective tissue graft + ABBM were similarly effective in treating intrabony defects without any favor for any group. Connective tissue and perio-steum can be equally effective in regeneration of intrabony defects.

Connective tissue graft as a biological barrier for guided tissue regeneration in intrabony defects: a histological study in dogs

BACKGROUND

The use of the autogenous periosteal graft as biological barrier has been proposed for periodontal regeneration. The aim of this study was to evaluate the histometric findings of the subepithelial connective tissue graft as barrier in intrabony defects compared to a bioabsorbable membrane.

METHODS

Three-walled intrabony defects were created surgically in the mesial aspect of the right and left maxillary canines in five healthy mongrel dogs. The defects were chronified, and two types of barriers were randomly carried out for guided tissue regeneration in a split-mouth design: the test group with a subepithelial connective tissue graft and the control group with a bioabsorbable membrane. The specimens were processed for histometric analyses of the epithelium (E), connective tissue (CT), newly formed cementum (NC), new bone (NB), and total newly formed tissues (NFT).

RESULTS

The test side showed smaller mean of NC (3.6 ± 1.2), NB (2.1 ± 0.7), and NFT (7.7 ± 0.8) than the control group (NC 7.3 ± 0.5; NB 5.3 ± 1.3; NFT 10.1 ± 2.2; P < 0.05). No statistically significant differences were verified for E (test 3.1 ± 2.0; control 2.8 ± 2.1; P > 0.05) and CT (test 2.5 ± 1.1; control 2.0 ± 0.5; P > 0.05) between groups.

CONCLUSION

The bioabsorbable membrane was more effective in maintaining the space for periodontal regeneration than periosteal connective graft when used as barrier.

CLINICAL RELEVANCE

The bioabsorbable membrane showed more favorable regenerative results in intrabony defects in dogs than the subepithelial connective tissue graft as biological barrier.

Periosteum as a barrier membrane in the treatment of intrabony defect: A new technique

OBJECTIVE

The purpose of the study was to evaluate the clinical effectiveness of periosteum as a barrier membrane for the treatment of intrabony defects.

MATERIALS AND METHODS

The study was conducted in patients having bilateral intrabony defects. A total of 20 intrabony defects in 10 patients were treated, out of which 10 defects received periosteal barrier and the other 10 defects received conventional open flap debridement procedure. The efficacy of the treatment was assessed using clinical parameters and dentascan.

RESULTS

Statistically significant gain in clinical attachment level (CAL) was found in the test group (2.00 ± 0.26 mm) as compared to the control group (0.60 ± 0.22 mm). In both the treatment modalities (test and control groups), a significant decrease in probing pocket depth of 3.90 ± 0.35 mm and 2.90 ± 0.31 mm was observed, respectively. The difference between the two groups was not statistically significant. Bone defect fill was 1.40 ± 0.16 mm for the test group and 0.90 ± 0.18 mm for the control group, but the difference observed was not statistically significant.

CONCLUSION

The results of this study show that periosteal barrier membrane can be a better alternative of barrier membranes for the treatment of intrabony defects.

Clinical and radiographic evaluation of Bio-Gen with biocollagen compared with Bio-Gen with connective tissue in the treatment of class II furcation defects: a randomized clinical trial

OBJECTIVE

Treatment of furcation defects are thought to be challenging. The purpose of this study was to evaluate the clinical and radiographic parameters of Bio-Gen with Biocollagen compared with Bio-Gen with connective tissue in the treatment of Class II furcation defects.

MATERIAL AND METHODS

In this clinical trial, 24 patients with Class II furcation defect on a buccal or lingual mandibular molar were recruited. After oral hygiene instruction, scaling and root planing and achievement of acceptable plaque control, the patients were randomly chosen to receive either connective tissue and Bio-Gen (case group) or Biocollagen and Bio-Gen (control group). The following parameters were recorded before the first and re-entry surgery (six months later): vertical clinical attachment level (VCAL), gingival index (GI), plaque index (PI), horizontal probing depth (HPD), vertical probing depth (VPD), gingival recession (GR), furcation vertical component (FVC), furcation to alveolar crest (FAC), fornix to base of defect (FBD), and furcation horizontal component (FHC) were calculated at the time of first surgery and during re-entry. A digital periapical radiograph was taken in parallel before first surgery and re-entry. The radiographs were then analyzed by digital subtraction. The differences with p value <0.05 were considered significant.

RESULTS

Only the mean changes of FAC, FHC, mean of FHC, FBD in re-entry revealed statistically significant differences between the two groups. HPD, VPD, FBD, FAC, and FHC showed statistically significant differences after 6 months in the case group. However, in the control group, statistically significant differences were found in GR and HPD. We did not observe any significant difference in radiographic changes among the two groups.

CONCLUSION

The results of this trial indicate that better clinical outcomes can be obtained with connective tissue grafts in combination with bone material compared with a resorbable barrier with bone material. The differences in radiographic changes between the two groups, however, were not statistically significant.

Periosteum: biology and applications in craniofacial bone regeneration

The bone-regenerative potentials of the periosteum have been explored as early as the 17th century. Over the past few years, however, much has been discovered in terms of the molecular and cellular mechanisms that control the periosteal contribution to bone regeneration. Lineage tracing analyses and knock-in transgenic mice have helped define the relative contributions of the periosteum and endosteum to bone regeneration. Additional studies have shed light on the critical roles that BMP, FGF, Hedgehog, Notch, PDGF, Wnt, and inflammation signaling have or may have in periosteal-mediated bone regeneration, fostering the path to novel approaches in bone-regenerative therapy. Thus, by examining the role that each pathway has in periosteal-mediated bone regeneration, in this review we analyze the status of the current research on the regenerative potential of the periosteum. The provided analysis aims to inform both clinician-scientists who may have interest in the current studies about the biology of the periosteum as well as dental surgeons who may find this review useful to perform periosteal-harnessing bone-regenerative procedures.

Vestibular deepening by periosteal fenestration and its use as a periosteal pedicle flap for root coverage

Gingival recession along with reduced width of attached gingiva and inadequate vestibular depth is a very common finding. Multiple techniques have been developed to obtain predictable root coverage and to increase the width of attached gingiva. Usually, the width of gingiva is first increased and then the second surgery is caried out for root coverage. The newer methods of root coverage are needed, not only to reconstruct the lost periodontal tissues but also to increase predictability, reduce the number of surgical sites, reduce the number of surgeries and improve patient comfort. Hence, this paper describes a single stage technique for increasing the width of attached gingiva and root coverage by using the periosteal pedicle flap.

Comparison of periosteal pedicle graft and subepithelial connective tissue graft for the treatment of gingival recession defects

BACKGROUND

The use of periosteum as a pedicle graft in the treatment of gingival recession defects is a recent advancement. The subepithelial connective tissue graft (SCTG) is considered the gold standard for the treatment of gingival recession defects. The present randomized controlled trial was done to compare periosteal pedicle graft (PPG) with SCTG for the treatment of gingival recession defects.

METHODS

10 males and 10 females between the ages of 16 and 40 years (mean age 25.2 years) with Miller's Class I and II recessions ≥3 mm participated in this one-year clinical study. They were assigned randomly to test group (PPG) and control group (SCTG). Results were evaluated based on parameters measuring patient satisfaction and clinical outcomes associated with two treatment procedures. Significance was set at p < 0.05.

RESULTS

At the end of the study, the defect coverage was 3.1 ± 0.13 mm or 92.6% in the test group compared to the control group in which the defect coverage was 2.70 ± 0.11 mm or 88.5%. The difference between the two groups was statistically significant (p < 0.0001). The average residual defect was comparable between the two groups, i.e. 0.3 ± 0.67 and 0.5 ± 0.84 in the PPG and SCTG group respectively. The test group was rated higher in terms of overall patient satisfaction (p < 0.02) and comfort during and after the procedure (p < 0.001).

CONCLUSIONS

PPG and SCTG have comparable clinical effectiveness, but PPG is superior to SCTG in terms of patient-centred outcomes, reflecting improved patient comfort and overall patient satisfaction.

Role of space provision in regeneration of localized two-wall intrabony defects using periosteal pedicle graft as an autogenous guided tissue membrane

BACKGROUND

Marginal pedicle periosteum (MPP) has been used as a rigid membrane in guided tissue regeneration (GTR) for osseous defects. The present study aims to study the effect of space provision by an alloplastic graft material in bone defect area (BDA) reduction of 2-wall defects.

METHODS

Twenty interproximal intrabony 2-wall defects in healthy non-smoking patients with chronic periodontitis were randomly divided in control (group 1, periosteum alone) and experimental (group 2, periosteum with alloplastic graft material) groups. Measurements of probing depth (PD), clinical attachment level (CAL), and radiographic BDA were done at the baseline and 6-month postoperative evaluations.

RESULTS

The 6-month postoperative assessment showed clinical and radiographic improvements with PD reduction, CAL gain, and changes in BDA in both groups, which was statistically significant compared with baseline (P <0.05). However, BDA reduction was statistically greater in group 2 (48.88% ± 18.61%) compared with group 1 (14.08% ± 12.97%) at the 6-month follow-up (P = 0.009).

CONCLUSION

Within the limitations of this study, it can be concluded that space provision by an alloplastic graft material increases the regenerative potential of MPP as a GTR membrane and results in increased defect fill.

Periosteum: a highly underrated tool in dentistry

The ultimate goal of any dental treatment is the regeneration of lost tissues and alveolar bone. Under the appropriate culture conditions, periosteal cells secrete extracellular matrix and form a membranous structure. The periosteum can be easily harvested from the patient's own oral cavity, where the resulting donor site wound is invisible. Owing to the above reasons, the periosteum offers a rich cell source for bone tissue engineering; hence, the regenerative potential of periosteum is immense. Although the use of periosteum as a regenerative tool has been extensive in general medical field, the regenerative potential of periosteum is highly underestimated in dentistry; therefore, the present paper reviews the current literature related to the regenerative potential of periosteum and gives an insight to the future use of periosteum in dentistry.

Treatment of multiple gingival recession defects using periosteal pedicle graft: a case series

BACKGROUND

The periosteum is a highly vascular connective tissue with immense regenerative potential. These qualities make it a suitable autogenous graft. A technique is described for using an autogenous periosteal pedicle graft (PPG) for the treatment of multiple gingival recession defects.

METHODS

Twenty teeth in six subjects with Miller Class I and II recessions ≥ 2 mm were treated using PPGs. In addition to the depth of the gingival recession defect, the probing depth and widths of keratinized and attached gingiva were recorded. The mean +/- SD was calculated for each of the clinical parameters. The paired t test was used to test the significance of the change.

RESULTS

At the end of 1 year, 90.95% of root coverage was attained with a significant increase in the widths of keratinized and attached gingiva (P = 0.0001); no change was observed in probing depths (P = 0.36).

CONCLUSION

The PPG technique can be successfully used for the treatment of multiple gingival recession defects.

Periosteal pedicle graft for the treatment of gingival recession defects: a novel technique

BACKGROUND

The periosteum is a highly cellular connective tissue with rich vascularity and regenerative potential. These qualities make it a suitable autogenous graft. A technique utilizing autogenous periosteal pedicle graft (PPG) for the treatment of gingival recession defects is described.

METHODS

Four patients with Miller Class I and II recessions > or = 3 mm were treated utilizing PPG.

RESULTS

At the end of one year, all defects were completely covered.

CONCLUSIONS

The PPG technique can be used for the treatment of gingival recession defects successfully.

Periodontal Regenerative Potential of Autogenous Periodontal Ligament Grafts in Class II Furcation Defects

BACKGROUND

The aim of the present study was to evaluate the regenerative potential of autogenous periodontal ligament (PDL) grafts in the treatment of Class II furcation defects.

METHODS

Twenty mandibular Class II furcation defects from 10 systemically healthy patients with chronic periodontitis were selected. In experimental defects, flaps were coronally positioned following placing autogenous PDL grafts that were obtained from third molars; in controls, coronally advanced flap procedure without graft was applied. Clinical measurements including plaque index, gingival index, probing depth (PD), vertical and horizontal clinical attachment level (CAL), and gingival recession (GR) were obtained at baseline and after 3 and 6 months postoperatively. Vertical and horizontal defect fill was evaluated with open clinical measurements at initial surgery and reentry after 6 months. Gingival biopsies from the experimental and control defects were obtained at reentry and evaluated histopathologically in order to examine the soft tissue response towards PDL grafts.

RESULTS

Sites treated with PDL grafts demonstrated significant improvement in vertical and horizontal defect fill, PD, and CAL at 3 and 6 months compared to presurgical values. The difference determined for the PD values of both groups at a statistically significant degree in favor of grafted sites was maintained at all observation periods. No foreign body reaction was observed in PDL grafts.

CONCLUSIONS

These short-term results point to the potential of PDL grafts in promoting healing of furcation lesions. This preliminary study suggests that the use of PDL grafts may have beneficial effects in the treatment of furcation defects.

Soft Tissue Closure Over Immediate Implants: Classification and Review of Surgical Techniques

Despite the different opinions regarding the success of implants and guided bone regeneration membranes, with and without establishing primary wound closure at the time of surgical placement, primary closure logically seems to be the ideal surgical protocol. It prevents bacterial invasion to the wound and prevents wound disruption. In immediate implantation, lack of keratinized tissue available to achieve this surgical goal is a problem. Various surgical techniques are described to overcome this surgical difficulty, each having its advantages and drawbacks. Sound clinical judgment must be exercised when selecting a method, because it will influence the treatment result both esthetically and functionally by altering adjacent soft tissue and bony topography.

A systematic review of guided tissue regeneration for periodontal furcation defects. What is the effect of guided tissue regeneration compared with surgical debridement in the treatment of furcation defects?

OBJECTIVES

To systematically review the evidence of effectiveness of guided tissue regeneration (GTR) for furcation defects.

BACKGROUND

The evidence for the effectiveness of GTR in furcation defects has not yet been systematically appraised.

METHODS

We searched for randomized controlled trials with at least 6 months' follow-up comparing GTR with surgical debridement (open flap debridement, OFD). Data sources included electronic databases, hand-searched journals and contact with experts. Screening, data abstraction and quality assessment were conducted independently by multiple reviewers. The primary outcome measure was reduction in open horizontal furcation depth, secondary outcomes were frequency of furcation closure, gain in horizontal and vertical probing attachment and reduction of vertical probing depth.

RESULTS

For the primary outcome, reduction in horizontal furcation depth assessed during re-entry, the weighted mean difference between GTR and control was 1.51 mm (95% CI [0.39-2.62], chi-square for heterogeneity 67.6 (df = 3), P < 0.001) in mandibular class II furcations, 1.05 mm (95% CI [0.46-1.64, chi-square for heterogeneity 34.9 (df = 3), P < 0.001) in maxillary class II furcations, and 0.87 mm (95% CI [-0.08-1.82], chi-square for heterogeneity 0.1 (df = 4), P = 0.991) in studies that had combined mandibular and maxillary class II furcations. For the secondary outcomes, GTR treatment led to significantly better results than open flap debridement. No meta-analysis could be performed for frequency of furcation closure because of sparse data.

CONCLUSIONS

Overall, GTR was consistently more effective than OFD in reducing open horizontal furcation depths, horizontal and vertical attachment levels and pocket depths for mandibular or maxillary class II furcation defects. However, these improvements were modest, variable and there was only a limited number of studies available to appraise the effects, thus limiting general conclusions about the clinical benefit of GTR. Future studies should aim to identify factors associated with achieving consistent and more pronounced benefits over open flap debridement.

Rotated split palatal flap for soft tissue primary coverage over extraction sites with immediate implant placement. Description of the surgical procedure and clinical results

Immediate implant placement after tooth extraction is becoming a common procedure in implant-supported oral rehabilitation. However, lack of primary full flap closure can jeopardize final results. A surgical approach that would enable predictable primary soft tissue closure over implants placed into fresh extraction sockets is described and evaluated. This technique is based on a rotated deep split thickness palatal flap (RSPF) containing periosteum and connective tissue, covering the implant and/or a barrier membrane. In 29 patients, 33 consecutive implants were placed immediately post extraction of 1 or 2 anterior or premolar maxillary teeth. Patients were divided in 2 groups: Group A (15 patients; n = 18 sites) where no barrier membrane was used and Group B (14 patients, n = 15 sites) where an occlusive resorbable collagen membrane was used. Distance between the alveolar crestal bone and the coronal aspect of the implant was measured at time of implant placement (Group A: mean 1.9 mm, SD 1.16; Group B: mean 4.6 mm, SD 1.18) and at second stage surgery (Group A: mean 0.3 mm, SD 0.46; Group B: mean 0. 7 mm, SD 0. 7). The difference between both records (crestal bone formation) was calculated (Group A: 1.7 mm, SD 1.03; Group B: 3.9 mm, SD 1.12) and found to be statistically significant (P <0.0001). Crestal bone formation, relative to the initial bone crest-implant distance at time of implant placement was approximately 85% in both groups. In 4 sites (2 in each group), where the cover screws were exposed before second stage surgery, complete crestal bone regeneration did not occur. Use of a barrier membrane may be obviated in appropriate cases while placing implants into fresh extraction sites. This procedure offers a predictable treatment approach in achieving complete soft tissue coverage, while allowing for healing of bony defects in immediate implantation procedures.