Journal of Dental Implant Research 2024; 43(2): 9-18
Minimally invasive immediate implantation in teeth with gingival recession: 3 case reports
In-Soon Park1 , Young-Kyun Kim2 , Dong-Gi Jeong3 , Jae-Chang Kim4 , Min-Jeong Kim5 , Seung-Jin Park6
1Department of Oral and Maxillofacial Surgery, Dunsan E-comfortable Dental Clinic, Daejeon, 2Department of Oral and Maxillofacial Surgery, Section of Dentistry, Seoul National University Bundang Hospital, Seongnam, 3Department of Orthodontics, Bubu Dental Clinic, Geoje, 4Department of Oral Medicine, Bubu Dental Clinic, Gumi, 5Department of Prosthodontics, Kim Min Jeong Dental Clinic, Daegu, 6Department of Dentistry, Seoul National University, Seoul, Korea
Correspondence to: In-Soon Park,
Department of Oral and Maxillofacial Surgery, Dunsan E-comfortable Dental Clinic, 396 Daedeok-daero, Seo-gu, Daejeon 35203, Korea. Tel: +82-42-489-2870, Fax: +82-42-489-2871, E-mail:
Received: January 7, 2024; Revised: February 15, 2024; Accepted: April 5, 2024; Published online: June 30, 2024.
© The Korean Academy of Implant Dentistry. All rights reserved.

This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
For teeth with a gingival recession in aesthetic areas, many clinicians recommend delayed placement after soft tissue maturation rather than immediate implantation after extraction. We report three cases wherein an implant was placed at the same time as the extraction of the tooth with a gingival defect, and bone grafting was performed through a flapless procedure. The gingival defects was also successfully restored. We are pleased to report the positive outcomes of the minimally invasive surgery using a free gingival graft, platelet-rich fibrin (PRF), and CollaTape to repair gingival defects in three cases involving both soft and hard tissue in the buccal region.
Keywords: Gingival recession, Immediate implantation, Minimally invasive surgery

Many clinicians have been practicing immediate implantation with a single-stage approach to minimize peri-implant tissue changes when extracting teeth in aesthetic areas, regardless of whether a temporary tooth is fabricated. Nicolas Elian et al. classified the sockets of single-rooted teeth into three types based on the presence or absence of buccal hard and soft tissue1). Type I sockets were classified as those with no buccal soft tissue and hard tissue defects, Type II as those with no buccal soft tissue defects but with hard tissue defects, and Type III as those with both buccal soft tissue and hard tissue defects. In Type I sockets, a flapless approach that preserves the shape of the surrounding soft tissue and does not impair the blood supply to the surrounding tissues can yield predictable results. Due to the potential risk of midfacial recession with immediate placement in Type II sockets, the current approach involves making a decision between immediate and delayed placement based on the operator's judgment. In Type III sockets, there is a gingival defect, which involves the loss of soft and hard tissue on the buccal side. Therefore, a delayed approach is recommended due to soft tissue and hard tissue problems, as well as the need for additional surgery to achieve aesthetic results. In Type III sockets, achieving aesthetic results by placing implants at the same time as extraction through minimally invasive approaches is a great option for both the patient and the operator. Flapless surgery was performed to avoid altering the surrounding gingival tissue and to achieve regeneration of the destructed gingiva with minimal additional surgical intervention. We tried to do with three different approaches, utilizing an implant with a unique design and structure called MagicCore to regenerate the missing gingiva while simultaneously placing the implant after extraction. The MagiCore implant can be divided into three parts (Fig. 1). The implant is a one-body implant that consists of the Magic Fin thread, featuring a slender core with Resor-bable Blast Media (RBM) surface treatment, and a thin, long thread positioned inside the alveolar bone; Magic Cuff, which has 2 mm, 3 mm, 4 mm, and 5 mm, which can be selected based on the varying thickness of soft tissues (gingival thickness+alveolar bone height of deficient width=thickness of soft tissue). Additionally, it includes a Magic post with a double connection structure that can securely hold the prosthesis inside and outside. Thin, long fin threads achieve initial fixation by making morphological contact with the residual bone rather than relying on compression for fixation. However, good initial fixation can still be achieved with thin residual bone. The Magic cuff has a soft tissue affinity because of its machined surface, and it is thin compared to the diameter of the implant. This can be expected to create a platform-switching effect, reducing the interface with soft tissue where the implant penetrates into the oral cavity. Additionally, it has the morphological advantage of obtaining thicker soft tissue around the implant. We would like to report on three cases in which destructed gingiva was restored using different methods, including the extraction of a tooth with destructed gingiva and simultaneous implant placement. We utilized the MagiCore implant (InnoBioSurg Co., Ltd., Daejeon, Korea), which provides the advantages of an implant without connections under the soft tissue, a slender soft tissue attachment site, various lengths (2 mm, 3 mm, 4 mm, 5 mm), and a soft tissue-friendly machined surface.

Figure 1. The MagiCore implant consists of three parts the Magic Post, the Magic Cuff, and the Magic Fin Thread.

1. Case 1

A 52-year-old male patient visited us with a complaint of discomfort in the maxillary anterior teeth and the right molar area. He has no specific medical problems. The maxillary right canine had root caries (Fig. 2A∼C) and was planned for extraction and implantation. Addi-tionally, a free gingival graft was planned to repair the gingival defect. After local anesthesia, atraumatic extraction was performed without elevating the flap. A guide pin was placed to determine the position and orientation of the implant, which was evaluated by taking panoramic and CBCT imaging, and then the implant socket was prepared. After protecting the implant site, allogenic bone (Freeze Dried Bone Allograft, MAGIC BONE, L&C Bio Co., Korea), cortical & cancellous bone particles (0.3 mm∼0.8 mm in size) were grafted and the implant was installed using a motor (Fig. 2D∼F). An implant of 4.0 diameter, 13 mm length, Magic Cuff 4 was used. After implantation, the abutment for the temporary tooth was connected, and free gingival tissue equal to the amount of the gingival defect was harvested from the ipsilateral palatal side and immobilized using 5-0 nylon (Fig. 3B). A temporary tooth was then fabricated on the chair-side (Fig. 2F). He showed good healing over time, and the nylon was removed on postoperative day 16 (Fig. 3C, D). Based on the clinical and radiographic findings, the final prosthesis was placed 2 months after the surgery (Fig. 4B). The CT views at 7 months (Fig. 4A) and 40 months (Fig. 4C) postoperatively show thinning of the buccal alveolar bone but a stable appearance of the cervical alveolar bone. Clinical photographs at 2 months (Fig. 4B) and 40 months (Fig. 4D) postoperatively show a stable cervical line and a natural soft tissue appearance.

Figure 2. Pre-operative and post-operative clinical and radiographic photographs. (A) Preoperative panorama. (B) Preoperative CT view. (C) Preoperative clinical photograph. (D) Postoperative panorama. (E) Postoperative CT view. (F) Postoperative clinical photograph. Red line: Line connecting the cervical of adjacent teeth.

Figure 3. The healing process of grafted free gingiva. (A) Buccal view after implantation with post margin above gingival margin. (B) The exposed post margin is covered by the grafted gingiva. (C) A view of the grafted gingiva at 8 day post-op. (D) View of the gingiva after suture removal at 16 day post-op.

Figure 4. Preoperative and postoperative clinical photographs and radiographs. (A) Preoperative panorama. (B) Preoperative CT view. (C) Preoperative clinical photograph. (D) Postoperative panorama. (E) Postoperative CT view. (F) Postoperative clinical photograph. Red line: Line connecting the cervical of adjacent teeth.

2. Case 2

A 65-year-old male patient presents with masticatory discomfort due to mobility of the right lateral incisor of the mandible. He had a stent placed in his coronary artery and is taking aspirin. He showed tooth mobility due to significant alveolar bone loss (Fig. 5A, B) and planned for an immediate implant after extraction. After tooth extraction, the implant was placed following the standard procedure: guide pins, radiographic readings, body preparation, bone grafting (FDBA), and implantation (Fig. 5D, E, 6A, B). An implant of 3.0 diameter, 13 mm length, Magic Cuff 3 was used. The platelet-rich fibrin (PRF) was placed in the areas of gingival recession to protect the grafted bone and restore the destructed gingival tissue. It was immobilized using 5-0 nylon (Fig. 5F, 6C). The crown of the extracted tooth was resin-fixed to the adjacent teeth and replaced with a temporary tooth to prevent aesthetic problems. Due to the patient's situation, he was unable to visit us. Nine months after the implant surgery, he came to us because the resin-bonded temporary tooth had become dislodged. We then created a temporary tooth (Fig. 6D) and took a final impression to make the final prosthesis. Radiographic and clinical images at 9 months (Fig. 7A, B) and 31 months (Fig. 7C, D) postoperatively show the stability of the grafted bone, volume enhancement of the cervical soft tissue, and stable peri-implant sealing.

Figure 5. Observation of changes after final prosthesis. (A) CT view at 7 months post-op. (B) Intraoral photograph of the final prosthesis setting at 2 months post-op. (C) CT view at 40 months post-op. (D) Intraoral photograph at 40 months post-op. Red line: Line connecting the cervical of adjacent teeth.

Figure 6. Surgical procedure and healing results. (A) Buccal view with placement of platelet rich fibrin (PRF) after implant placement. (B) Occlusal view with placement of platelet rich fibrin (PRF) after implant placement. (C) Sutured to secure Platelet Rich Fibrin (PRF). (D) Temporary tooth fabrication at 9-month post-op visit.

Figure 7. Observation of changes after final prosthesis. (A) CT view after final prosthesis setting at 9 months post-op. (B) Intraoral photograph after final prosthesis setting at 9 months post-op. (C) CT view at 31 months post-op. (D) Intraoral photograph at 31 months post-op. Red line: Line connecting the cervical of adjacent teeth.

3. Case 3

A 64-year-old male patient presents with a chief complaint of general care. He has no specific medical problems. Preoperative radiographs (Fig. 8A, B) and clinical photographs (Fig. 8C) of the maxillary left first premolar show complete loss of buccal alveolar bone and a severe buccal gingival defect. On the postoperative radiograph (Fig. 8D, E), the implant has achieved fixation at the maxillary sinus floor, and the grafted allograft is visible on the buccal side. Due to insufficient residual bone, an instrument called the Magic Expander was used to lift the maxillary sinus without bone grafting and achieve implant fixation in the maxillary sinus floor. An implant of 4.0 diameter, 11 mm length, Magic Cuff 4, was used. The post-operative clinical photographs show the implant placed on the palatal side as far as possible, the Collatape (Integra Lifesciences Co., USA) placed on the buccal side to protect the grafted allograft (FDBA) and to aid in the growth of the destructed gingiva through stabilization of the blood clot, and a loose net-like suture placed to stabilize the Collatape (Fig. 8F). The healing process of the destructed gingival area matures from granulation tissue to soft tissue over time, with downward growth of the gingiva and volume growth of the buccal gingiva observed (Fig. 9). In the CT view and clinical photographs at 5.5 months (Fig. 10A, B) and 19 months (Fig. 10C, D) postoperatively, the CT view shows an increase in bone mass and maturation on the buccal side where allogeneic bone was grafted, and the clinical photographs show a downward migration of the marginal gingiva and an increase in gingival volume.

Figure 8. Pre-operative and post-operative clinical and radiographic photographs. (A) Preoperative panorama. (B) Preoperative CT view. (C) Preoperative clinical photograph. (D) Postoperative panorama. (E) Postoperative CT view. (F) Postoperative clinical photograph.

Figure 9. The healing process of areas of gingival recession. (A) Clinical photograph at 8 days post-op. (B) Clinical photograph at 50 days post-op. (C) Clinical photograph at 70 days post-op. (D) Clinical photograph at 3 months post-op.

Figure 10. Observation of changes after final prosthesis. (A) CT view at 5.5 months post-op. (B) Intraoral photograph of the final prosthesis setting at 5.5 months post-op. (C) CT view at 19 months post-op. (D) Intraoral photograph at 19 months post-op.

A tooth with moderate to severe alveolar bone destruction caused by periodontitis in the posterior region was restored through implantation immediately after extraction. The procedure involved using a flapless technique and an allograft without the use of a membrane2). In cases of soft tissue deficiency caused by a gingival defect in a visible area, or an aesthetic area, the implant was placed simultaneously with tooth extraction to restore the destructed gingiva through flapless, minimally invasive approach. In Case 1, a crescent-shaped free gingival graft was used on the ipsilateral palatal side. In Case 2, platelet-rich fibrin (PRF) was utilized, and in Case 3, Collatape was employed to restore the destructed gingiva. Despite three different methods for gingival regeneration, successful gingival regeneration was achieved.

There are many studies on the advantages and disadvantages of dental implants based on the timing of tooth extraction3). In the comparison of delayed versus immediate implantation after tooth extraction in the esthetic area, there are reports indicating the stability of the delayed approach, which helps to prevent the occurrence of gingival defects that can happen with immediate implant placement after tooth extraction4). Tooth extraction leads to horizontal and vertical resorption of alveolar bone. In the aesthetic zone, significant effort is needed to reconstruct the lost alveolar bone and restore the natural soft tissue appearance. Despite the disadvantages of alveolar bone changes and gingival defects that can occur with immediate implantation, a number of immediate implants are performed in aesthetic areas, with or without a temporary tooth. In Type III sockets with soft tissue deficiency caused by gingival recession, immediate implantation after extraction is highly operator-dependent. In 2017, Tarnow et al. published a case study in which a tooth with labial malposition and internal resorption was extracted and immediately replaced with an implant. A provisional prosthesis was then successfully fabricated, yielding positive outcomes. The diagnostic keys to success in Type III clinical situations are as follows: 1) pre-existing labial tooth malposition, 2) flapless tooth removal with the palatal tissues at the proper height, 3) palatal implant position, 4) dual-zone bone grafting, 5) provisional restoration placement in non-occlusal function, and 6) proper tissue healing for 4 to 6 months5). To reduce the possibility of gingival recession, which is a concern when implants are placed immediately after tooth extraction, we were trying to prevent gingival recession by increasing gingival thickness through connective tissue grafting, i.e., modification of the gingival biotype6). To prevent gingival recession caused by changes in the alveolar bone after tooth extraction during immediate implantation with a bone-level implant, a crescent-shaped free gingival graft was performed after connecting the healing abutment. This approach yielded positive outcomes as reported7).

In the aforementioned studies, a free gingival graft or connective tissue graft was performed to achieve gingival stability for immediate implantation following tooth extraction. On the other hand, in Case 1, a flapless, atraumatic extraction was performed along with minimally invasive immediate implantation, allogeneic bone grafting, and free gingival grafting to restore the aesthetic defect resulting from gingival recession. He had an uneventful healing after the surgery and has remained stable for up to 40 months post-operation. Once the grafted free gingival tissue has gained vitality, it is possible to achieve tissue stability by improving the gingival phenotype as well as restoring the destructed gingiva in a very short period. However, it requires additional surgery to harvest the gingiva from the donor site.

Platelet-rich fibrin (PRF) is a complex fibrin matrix that contains various growth factors promoting the healing of both soft and hard tissues. Platelet-rich fibrin (PRF) has been utilized for alveolar ridge preservation, sinus augmentation, guided bone regeneration, gingival recession treatment, and other procedures. In Case 2, to restore the destructed gingiva, platelet-rich fibrin (PRF) obtained through blood sampling was placed in the destructed gingival area. This approach avoided the need for creating an additional surgical site, as was done in Case 1, and the PRF was secured in place with 5-0 nylon. In the clinical photographs taken 31 months after the operation, a stable buccal gingival appearance and an increase in buccal gingival thickness can be observed. When PRF is used, it acts as a membrane that can physically protect the allogeneic bone grafted in destructed areas of soft tissue without additional surgery and contains various growth factors to promote healing. However, PRFs are unlikely to gain vitality, and I believe their role is to help with the stabilization of blood clots and protect wounds.

In Case 3, there are severe defects in the buccal bone and gingiva, as well as poor residual bone thickness to fix the implant. We selected the MagiCore implant due to its capability to achieve stable fixation in thin bone, its capacity to overcome the difference in alveolar bone height between the palatal and buccal sides with minimal invasiveness, the absence of sufficient horizontal bone quantity, and its compatibility with soft tissue without impeding the growth of the destructed gingiva. We evaluated the height of the gingival tissue on the palatal side and the adjacent interdental papilla. The implant was positioned near the palatal side to accommodate potential downward growth of the gingival tissue from the buccal side. To protect the grafted allograft on the buccal side, promote blood clot formation (the first step in soft and hard tissue healing), and assist in stabilizing the blood clot. Collatape, a collagen material, was placed and loosely sutured to prevent leakage. To protect the blood clot from external forces, we used an Omnivac made of a 1mm thick soft sheet. Collatape contributes to the formation of blood clots, which is the first step in healing, and Omnivac is used to stabilize the clots and protect the granulation tissue, resulting in the physiological healing of the patient. In the case of PRF and Collatape, unlike the case of free gingival graft, the results of the treatment were obtained through physiological healing, so long-term observation was required, and the desired results of the treatment were obtained by the regeneration of the gingiva and an increase in gingival volume through spontaneous healing of the patient over time. However, it has the advantage of being minimally invasive and allowing the patient's physiological healing to take over. The authors propose that the concepts of treatment should encompass the patient's physiological spontaneous healing, which can potentially expand the scope of minimally invasive treatment.

Immediately after the surgery, impressions were taken for the fabrication of the Omnivac, which was worn for about 3 weeks from postoperative day 1. This was followed by the placement of fixed temporary teeth made of acrylic resin. Clinical photographs taken at 5.5 months and 19 months post-operation show a downward gingival growth even after the final prosthesis was placed. The regeneration of the destructed gingiva results from the downward expansion of the connective tissue sealing area formed by the Magic Cuff as it heals after implant placement and the downward expansion of the connective tissue sealing area due to the volume growth of the connective tissue. The downward growth of the gingiva observed after the final prosthesis placement, called Gingival Ongrowth, is the outcome of the marginal gingiva's downward growth to establish the biologic width with the function of the implant.

Most MagiCore implants are placed through flapless surgery. In March 2020, a free gingival graft was used to restore the gingival defect at the time of implantation immediately after tooth extraction through flapless surgery, referring to the journal5). While performing various immediate implantations via flapless surgery in the posterior dentition, PRF was used for insufficient soft tissue coverage. Through observing the soft tissue healing of the surgical site with PRF, I realized the possibility of using it for soft tissue defects and used it in a case with an aesthetic defect on February 21. However, we have experienced cases where minor gingival defects in aesthetic areas have been restored by simply placing the implant in the proper position. Through this experience, we realized that the regeneration of destructed gingival tissue depends on the formation of a space for gingival regeneration and the formation and stability of blood clots that can differentiate into various tissues in the formed space. So, in December 2021, I used Collatape for the formation and stabilization of the clot, and Omnivac for the protection of the clot.

We know that the healing of destructed gingiva after tooth extraction occurs within a physiological healing range. This range is limited by the height of the palatal/lingual soft tissue and the height of the interdental papilla of adjacent teeth. Therefore, I believe that predicting the patient's physiological potential for healing, not interfering with the healing process, and ensuring that the conditions necessary for healing are present, rather than attempting to artificially manipulate the repair of defective tissue like a flap advancement, is the way to go for minimally invasive surgery.


Restoring a tooth with soft and hard tissue defects in aesthetic areas using minimally invasive methods is challenging. For the regeneration of the destructured gingiva, free gingival grafts, PRF, and Collatape were used with good results. The grafted free gingival graft was able to regenerate the destructed gingiva quickly when it received blood supply from the surrounding tissues. PRF seems to engraft where it receives a blood supply, and some are shed as they protect the blood clot. Good results were obtained with the use of Collatape for the formation and stabilization of the blood clot and Omnivac for the protection of immature tissues. To achieve good regeneration of the destructed gingiva during flapless implantation, it is important to carefully evaluate the implant site (interdental bone height of adjacent teeth, gingival height of palatal/lingual side, bucco-lingual width of alveolar bone) and place the implant in the correct position (as close as possible to the palatal/lingual side, adequate vertical position), as well as to select the implant.

  1. Nicolas Elian, Cho Sang-Choon, et al. A simple socket classification and repair technique. Practical Procedures & Aesthetic Dentistry 2007;19:99-104.
  2. Park In-Soon, Kim Young-Kyun, et al. Immediate implantation via a minimally invasive approach in aggressive periodontitis of the posterior maxilla using the MagiCore implant-3 case reports. Journal of Dental Implant Research 2023;42:35-45.
  3. Stephen T. Chen, Daniel Buser. Clinical and esthetic outcomes of implants placed in postextraction sites. The International Journal of Oral & Maxillofacial Implants 2009;24(supplement):186-217.
  4. Tommaso Grandi, Paolo Guazzi, et al. Imediate provisionalisation of single postextractive implants versus implants placed in healed sites in the anterior maxilla: 1-year results from a multicentre controlled cohort study. Eur. J. Oral Implantology 2013;6:285-95.
  5. Dennis P. Tarnow, Stephen J. Chu. Clinical management of type 3 recession defects with immediate implant and provisional restoration therapy -A case report. Compendium:468-73.
  6. Kitichai Rung, Joseph Y.K. Kan, et al. Immediate implant placement and provisionalization with and without a connective tissue graft: An analysis of facial gingival tissue thickness. The International J. of Periodontics & Restorative Dentistry 2012;32:656-63.
  7. Thomas Han, Chul-Woong. Bone and crescent shaped free gingival grafting for anterior immediate implant placement - Technique and case report. The Journal of Implant & Advanced Clinical Dentistry 2009;1:23-33.

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