Management of the Post-Extraction Socket with Buccal Dehiscence in the Aesthetic Zone Associated with Immediate Implant Placement Using L-PRF and CTG: A Case Report

1. Introduction

Immediate implant placement following tooth extraction represents a widely adopted clinical strategy aimed at reducing overall treatment time and preserving tissue volumes [1].

However, this approach presents significant challenges, particularly in anterior regions with high aesthetic demands, where even minimal alterations to the alveolar bone contour and soft tissue architecture can compromise the functional and aesthetic outcome of the final restoration [2,3].After tooth extraction, alveolar bone resorption occurs rapidly and significantly, resulting in a loss of ridge volume that can jeopardize both implant stability and the aesthetic profile [2,4].

Indeed, the presence of a buccal osseous dehiscence is a frequently encountered clinical condition, and immediate implant placement introduces additional challenges with respect to achieving predictable bone regeneration and ensuring long-term stability [5] .

From an implant–periodontal perspective, in this case the management of peri-implant soft tissues represents a critical scenario. Recent studies have shown that the quality and quantity of peri-implant keratinized mucosa are strongly correlated with the risk of mucositis and peri-implantitis, directly influencing the biological stability of the implant and the final aesthetic outcome [6,7] . In particular, the absence of at least 2 mm of peri-implant keratinized tissue has been associated with higher levels of inflammation, increased marginal bone loss, and greater plaque accumulation [8].

To address the challenges associated with post-extraction ridge resorption, guided bone regeneration (GBR) techniques have become widely used in clinical practice. These techniques typically employ resorbable or non-resorbable membranes in combination with xenogeneic or synthetic biomaterials, aiming to promote new bone formation by excluding soft tissue ingrowth [3,9]. However, GBR is not without limitations: the procedures can be technically demanding, costly, and associated with risks such as membrane exposure and postoperative complications. Additionally, the use of non-autologous biomaterials may delay the healing process [10] .

In this context, the use of autologous biological materials has gained increasing interest. Particular emphasis has been placed on platelet concentrates, such as leukocyte- and platelet-rich fibrin (L-PRF).

L-PRF is a second-generation platelet concentrate characterized by a three-dimensional fibrin matrix that entraps platelets and leukocytes, capable of releasing a variety of growth factors and cytokines — including TGF-β, PDGF, VEGF, EGF, IGF-1, IL-1β, IL-4, IL-6, and TNF-α. These biological mediators promote neoangiogenesis, stimulate fibroblast proliferation, and enhance epithelial cell migration, thereby facilitating tissue healing. Such properties result in accelerated wound closure, more effective hemostasis, and faster, aesthetically favorable scar remodeling [11].

It is now well established that the use of L-PRF enhances both hard and soft tissue healing and regeneration through the gradual release of growth factors. However, L-PRF membranes present an inherent limitation: their rapid resorption reduces their capacity to stabilize the clot and protect the regenerative site over the medium term.

To overcome this limitation and to ensure the preservation of the peri-implant soft tissues, the addition of a connective tissue graft (CTG) harvested from the palate can serve as a biological membrane, stabilizing the soft tissue contour, increasing vestibular thickness, and improving the quality of peri-implant mucosa [6,7]

In parallel, a recently introduced approach—the Periosteal Inhibition (PI) technique—has shifted the focus from promoting bone regeneration to preventing bone resorption [12]. This technique is based on the biological concept that post-extraction bone loss is largely mediated by osteoclast precursor cells originating from the periosteum. By placing a high-density polytetrafluoroethylene (d-PTFE) membrane between the periosteum and the buccal bone plate, the migration of these precursor cells is physically inhibited, thereby preventing their differentiation into mature osteoclasts and reducing osteolytic activity on the external bone surface. As a result, alveolar ridge dimensions may be preserved without the need for heterologous bone grafting materials, representing a paradigm shift in post-extraction management [12].

Building on this concept, the aim of the present case report was to evaluate the clinical and radiographic effectiveness of bone regeneration using autologous materials—specifically L-PRF membranes combined with a connective tissue graft—in association with immediate implant placement in a post-extraction site presenting buccal dehiscence in the aesthetic zone. Postoperative healing, implant survival, and the stability of regenerated bone volumes were assessed through clinical follow-up and cone-beam computed tomography (CBCT) at 12 months. Additionally, the study investigated the increase in keratinized tissue width (KT) and gingival thickness (GT) observed after the intervention at the 12-month follow-up.

2. Materials and Methods

2.1. Study Setting and Ethical Considerations

The study was conducted at the Unit of Periodontology and Oral Hygiene, University “G. D’Annunzio” of Chieti-Pescara (Italy). All procedures were performed in accordance with the ethical principles of the Declaration of Helsinki and written informed consent was obtained from the patient for the scientific and educational use of clinical data.

2.2. Clinical Presentation, Case Management, and Outcomes

A 50-year-old male patient, non-smoker, in good general health (American Society of Anesthesiologists classification I), with excellent oral hygiene, a stable periodontal condition, and no history of systemic or local conditions impairing bone or soft tissue healing, presented with Grade II mobility of tooth 1.2 associated with a periapical cystic lesion and vertical root fracture. Extraction of tooth 1.2 followed by immediate implant placement and simultaneous bone regeneration was planned. Clinical follow-up examinations were performed at baseline (T0) and 12 months postoperatively (T1). During the healing phase, the patient underwent regular maintenance visits for oral hygiene and periodontal assessment.

The primary outcome was horizontal bone thickness (HBT) obtained through alveolar ridge preservation (ARP) using L-PRF and CTG. Secondary outcomes included the gain in GT and KT, as well as patient-reported outcome measures (PROMs) assessing postoperative comfort: number of analgesics taken during the first postoperative week (AU), self-reported pain (D), Overall Treatment Satisfaction (OTS), and Patient-Related Esthetic Score (PRES).

2.2.1. Radiographic Measurements

2.2.1.1. Image Alignment and Standardization Protocol

For longitudinal assessment, CBCT volumes were standardized through a voxel-based reorientation protocol to ensure reproducibility between baseline (T0) and follow-up (T1). All datasets were reoriented using a three-dimensional coordinate system grounded on the anatomy of the hard palate, selected as a stable intra-subject reference across time.

Specifically, multiplanar reconstructions (MPR) were adjusted as follows: the median sagittal plane was aligned with the palatal midline bisector, defined by the line connecting the anterior nasal spine (ANS) and posterior nasal spine (PNS); the axial plane was oriented parallel to the palatal plane; and the coronal plane was automatically derived as orthogonal to both sagittal and axial planes. This approach ensured consistent spatial orientation and maximized voxel correspondence across different time points. In the sagittal view, the palatal midline (ANS–PNS axis) provides a reliable anatomical guide for correcting head pitch and defining the plane of symmetry. Finally, in the coronal view, once sagittal and axial orientations are standardized, the coronal plane, set perpendicular to both, benefits from the bilateral symmetry of the palatal vault, allowing correction of roll deviations and ensuring comparability of left–right measurements.

This validation step ensured the spatial superimposability of the analyzed sections and confirmed the reliability of the comparative measurements.

All analyses were performed using dedicated imaging software NNT- NewTom®. (Figure 2).

2.2.1.2. Morphometric Analysis and Linear Measurements

After reorientation of the axes as described above, the distance between the ANS and a predefined reference axis, positioned at 10.3 mm, was measured to standardize section positioning and enhance the reproducibility of measurements across time points. To standardize the measurements, the reference baseline (RBL) was positioned perpendicular to a line tangent to the nasal floor (NF). The vertical measurement, corresponding to the vertical extent of the dehiscence, was defined as the distance between the most coronal point of the buccal bone and the line tangent to the nasal floor, measured along the RBL (NF-AC). (Figure 3).

HBT was measured in the bucco-palatal direction at predefined apico-coronal levels along a RBL. Measurements were performed at 12, 15, 18, and 21 mm on the reference scale, progressing from the apical to the coronal aspect of the ridge (Figure 4).

The same measurement protocol was applied to the T0 and T1 datasets, allowing quantitative comparison of dimensional changes over time and assessment of peri-implant bone remodeling. The measurement strategy was defined in accordance with previously published CBCT-based morphometric approaches for immediate implant evaluation by Jin et al. [13] .

2.2.2. Clinical Measurements

• GT: Measured using the bone sounding technique with a #15 K-file inserted until bone contact. The distance between the file tip and a silicone stop (fixed with cyanoacrylate) was measured using a digital caliper (Newaner®, accuracy 0.1 mm). The measurement point was determined using a custom-fabricated resin stent supported on the adjacent teeth, incorporating a guide hole positioned 3 mm apical to the gingival margin of the tooth of interest prior to extraction. The same stent was consistently employed at T1 to ensure reproducibility of the measurements.
• KT: Measurements were obtained using a UNC-15 periodontal probe, from the most apical portion of the gingival margin to the mucogingival junction, on the tooth at T0 and on the implant at T1.
• PROMs: The patient reported the number of analgesics taken during the first postoperative week and pain levels, assessed using a Visual Analog Scale (VAS). At the 12-month follow-up, esthetic satisfaction was evaluated using the PRES [14]assessed with a VAS based on standardized preoperative (T0) and postoperative (T1) photographs. The OTS was assessed whether the patient would undergo the procedure again, considering esthetic outcomes and perceived pain (yes/no).

2.3. Pre-Surgical Phase

Before surgery, the patient received oral hygiene instructions, supragingival scaling, and professional polishing. The use of an electric toothbrush with pressure control and ultra-soft bristles was recommended. At the two-week re-evaluation, baseline (T0), clinical measurements were recorded.

2.4. Surgical Technique

After achieving adequate local anesthesia with 4% articaine and 1:100,000 epinephrine, an envelope intrasulcular flap was performed extending to adjacent teeth, without vertical releasing incisions, to preserve the interdental papillae and optimize vascularization (Figure 5a).

A full-thickness flap was raised to expose the buccal bone defect without surpassing the mucogingival junction (Figure 5b-c).

Atraumatic extraction of tooth 1.2 was performed to preserve the residual alveolar walls and minimize trauma. Thorough curettage of the periapical lesion was performed to eliminate the granulation tissue. A transmucosal implant (Waymix Geass®, 3.8 × 13 mm) was placed following the manufacturer’s protocol, achieving primary stability with an insertion torque >35 N/cm. A delayed loading protocol was adopted (Figure 5d-f).

2.4.1. L-PRF Membrane Preparation

L-PRF membranes were prepared according to Choukroun’s protocol [15]. Thirty milliliters of venous blood were drawn into three 10 mL tubes without anticoagulant and centrifuged at 3000 rpm for 10 minutes (IntraSpin™, Intra-Lock System Europa SpA, Salerno, Italy). The resulting fibrin clots were compressed in an L-PRF Box (Xpression™ Kit) for 120 seconds under ~100 g pressure. Two membranes were superimposed to achieve a ~2 mm thickness and inserted into the defect, while a third was positioned over the buccal bone defect (Figure 6a).

2.4.2. Connective Tissue Graft Harvesting

Two horizontal and two vertical incisions were made on the palatal mucosa distal to the upper premolars. A partial-thickness flap was elevated, leaving the periosteum intact. The harvested graft was de-epithelialized extra-orally to achieve ~1 mm thickness and shaped to fit the recipient site, where it was placed to stabilize the flap and augment vestibular soft tissue thickness. The flap was repositioned for complete coverage and secured with 5-0 PGA resorbable sutures (Hu-Friedy, Milan, Italy) (Figure 6b-e).

2.5. Postoperative Management

The patient received antibiotic therapy (amoxicillin/clavulanic acid 1 g every 12 hours for 6 days) and ketoprofen 80 mg as needed. Chlorhexidine mouth rinses 0.20% (Dentosan 0.20, Johnson & Johnson, Pomezia, Italy) and topical gel with chlorhexidine 1% (Corsodyl gel, GlaxoSmithKline Consumer Healthcare S.p.A.-Baranzate, Italy) were prescribed twice daily for 15 days. The patient was instructed to avoid brushing or trauma at the surgical site for at least 4 weeks. Follow-up visits were scheduled at 1 and 2 weeks for suture removal, monthly for the first 6 months, and finally at 12 months (T1) for the final evaluation.

Throughout the 12-month follow-up period, no complications were observed in either hard or soft tissues. The peri-implant tissues remained clinically healthy, with no evidence of inflammation, mucositis, or peri-implant bone loss.After 6 months, the implant was loaded (Figure 7a-c).

3. Results

3.1. Radiographic Analysis

Radiographic evaluation revealed measurable dimensional changes between T0 and T1, indicating a favorable hard tissue response at the treated site.

HBT demonstrated a consistent increase across all evaluated apico-coronal levels. Specifically, HBT increased from 2.4 mm to 5.2 mm at 21 mm (+1.4 mm), from 4.2 mm to 7.4 mm at 18 mm (+3.2 mm), from 5.5 mm to 8.6 mm at 15 mm (+3.1 mm), and from 8.8 mm to 10.2 mm at 12 mm (+1.4 mm). The most pronounced horizontal gains were observed in the mid-apical regions, whereas less change was detected at the coronal level (Figure 4a-b).

The NF–AC increased from 10.3 mm at T0 to 13.0 mm at T1, corresponding to a gain of +2.7 mm. Furthermore, the buccal dehiscence present at baseline appeared to be markedly reduced at the 12-month evaluation, suggesting substantial defect resolution (Figure 4a-b).

Overall, the radiographic findings indicate a non-uniform pattern of bone remodeling, characterized by greater dimensional gains in the mid-apical region of the ridge. This pattern is consistent with a favorable regenerative response, with improved ridge dimensions and partial restoration of the buccal bone profile (Table 1).

3.2. Clinical Outcomes and PROMs

Regarding soft tissue parameters, the KT increased from 3.0 mm to 5.0 mm, with a gain of +2.0 mm, while the GT increased from 1.4 mm to 3.2 mm, with a gain of +1.8 mm (Table 1).

The patient assumed only two doses of ketoprofen 80 mg during the two days following the surgical procedure. Thereafter, no further analgesics were required.

Pain was reported only on the first postoperative day (VAS = 7), decreased substantially on the second day (VAS = 3), was almost absent by the third day (VAS = 1), and completely resolved by the fourth day.

With regard to PRES, the subject assigned the maximum score (VAS = 10), stating that — based on the minimal discomfort experienced — he would undergo the same surgical procedure again (OTS: yes).

4. Discussion

This clinical report demonstrates the 12-month effectiveness of a fully autologous regenerative protocol combining L-PRF and CTG for the management of a post-extraction socket with buccal dehiscence and simultaneous immediate implant placement in the esthetic zone. The proposed approach was designed to enhance biologic healing while avoiding the use of heterologous biomaterials and reducing surgical complexity.

A standardized CBCT-based protocol enabled reproducible assessment of both horizontal and vertical dimensional changes. The use of stable anatomical landmarks, fixed reference planes, and multi-level measurements allowed consistent site matching over time and is in line with previously validated methodologies [13], supporting the reliability of the present findings.

The radiographic analysis revealed measurable dimensional changes between baseline and the 12-month follow-up, indicating a favorable hard tissue response. HBT increased at all evaluated apico-coronal levels, with gains of +2,6 mm at 21 mm, +3,2 mm at 18 mm, +3,1 mm at 15 mm, and +1,4 mm at 12 mm. Greater dimensional increases were observed in the mid-apical part of the ridge.

NF-AC measurements showed an increase of +2,7 mm, together with a marked reduction of the buccal dehiscence defect.

This pattern is consistent with the physiologic dynamics of post-extraction remodeling, which predominantly affect the coronal portion of the alveolar ridge due to bundle bone resorption and facial plate remodeling [16]. From a clinical standpoint, the relative stability observed coronally may therefore reflect modulation of physiologic resorption rather than true bone gain, particularly in sites presenting with buccal dehiscence. [2,17].

The biologic rationale underlying the present protocol is based on the complementary roles of L-PRF and CTG.

L-PRF provides a fibrin matrix that supports cell migration and angiogenesis through the sustained release of growth factors, thereby promoting early wound stability [11,18]. In parallel, CTG contributes to mechanical stabilization of the healing site and enhances soft tissue thickness, which is critical in preventing collapse of the facial profile. This combined effect is particularly relevant in compromised sites, where both vascular supply and tissue support are key determinants of regenerative outcomes[6,19].

The observed increase in KT and GT further supports the clinical relevance of this approach. Adequate peri-implant soft tissue dimensions have been associated with improved plaque control, reduced mucosal inflammation, and more stable marginal bone levels [6,7]. In particular, a keratinized tissue width ≥2 mm has been proposed as beneficial for long-term peri-implant tissue stability, especially in esthetically demanding areas [6,7,20,21,22]. Furthermore, in agreement with previous studies, the use of CTG in conjunction with immediate implant placement appears to positively influence peri-implant soft tissue conditions, including gingival biotype and keratinized tissue width, both of which are key determinants of long-term esthetic outcomes [23,24,25] The increase in soft tissue thickness may also play a protective role against crestal bone resorption, as previously suggested in the literature [23,24,25,26,27]. (Figure 8a-b).

In this perspective, the present approach transcends the conventional objective of ARP alone. By combining L-PRF with a CTG, the technique not only promotes clot stabilization and supports early wound healing, but also actively modulates the peri-implant soft tissue environment. The CTG, acting as a biologic scaffold, enhances tissue thickness and keratinization, thereby reinforcing the soft tissue seal and mitigating the risk of peri-implant complications.

Notably, in this case report the CBCT evaluation suggested that the buccal aspect of the implant was not completely covered by bone; as evident from Figure 4b, although the NF–AC distance increased after treatment, the crestal bone level did not reach the most coronal portion of the implant.

Indeed, the primary aim of our technique was to evaluate whether a connective tissue graft could function similarly to a dPTFE membrane [12] in providing periosteal inhibition. Therefore, it may be hypothesized that, if autogenous or xenogeneic bone graft material had been placed beneath the PRF membrane and the connective tissue graft, we might have achieved not only inhibition of buccal bone resorption, but also a further increase in HBT values, including at the level of the implant platform.

However, the implant was not clinically probeable (Figure 9a-c). This finding supports the hypothesis that the thickness and quality of the connective tissue graft may provide an effective biologic seal, limiting bacterial infiltration and contributing to implant stability despite incomplete radiographic bone coverage [20,23]. Although immediate implant placement may contribute to partial preservation of socket architecture, it does not prevent physiologic resorption of the facial bone plate, particularly in the presence of pre-existing defects [17]. Therefore, adjunctive strategies aimed at stabilizing the wound environment and enhancing the peri-implant soft tissue architecture appear necessary to preserve ridge contour in such clinical scenarios [28].

From a mechanistic standpoint, this concept shows parallels with the PI approach [12], which seeks to limit external bone resorption by preventing osteoclastic activity originating from the periosteum. When placed in contact with the facial bone, CTG may counteract resorptive processes indirectly by enhancing angiogenesis, clot stability, and soft tissue sealing. These biologically driven strategies may therefore converge toward a common objective, namely the preservation of the facial bone contour following extraction and implant placement and may position this approach as a potential alternative technique for ARP. Moreover, from a clinical standpoint, this approach may be particularly indicated in sites presenting with mild-to-moderate buccal dehiscence defects, where soft tissue support and vascularization are critical determinants of healing. Conversely, in large or non-contained defects, conventional GBR may remain the preferred treatment due to its superior ability to maintain space and support bone regeneration [29,30]. Compared with GBR, which remains the reference treatment for buccal defects, the present autologous approach avoids the use of grafting materials and barrier membranes, potentially reducing technique sensitivity, healing time, and biomaterial-related complications [29,31]. These findings are partially in line with previous clinical studies reporting that CTG does not necessarily promote new bone formation but may exert a preservative effect on existing alveolar bone by maintaining biologic sealing effect, hydration and supporting the stability of the blood clot during early healing phases [32].

The present report is limited by its single-case design and lack of a control group, which precludes definitive conclusions. In addition, CBCT-based linear measurements, although clinically informative, do not allow discrimination between true bone regeneration and compensatory remodelling. Furthermore, the relatively short 12 follow-up period does not allow conclusions regarding the long-term stability of peri-implant tissues. Future controlled clinical studies with larger sample sizes and extended follow-up are required to validate these findings.

5. Conclusions

Within the limitations of a single case report with a 12-month follow-up, the combined use of L-PRF and CTG in conjunction with immediate implant placement resulted in favorable clinical and radiographic outcomes in the management of a post-extraction socket with buccal dehiscence in the esthetic zone. These findings substantiate the hypothesis that a biologically driven, fully autologous approach may constitute a viable alternative in selected clinical settings, potentially reducing the complexity and biomaterial-related risks associated with conventional GBR [29,31], while capitalizing on the regenerative and angiogenic potential of L-PRF [11,33] and the phenotype-stabilizing and augmentative properties of CTG [6,19,34].

However, well-designed controlled clinical trials with larger cohorts and extended follow-up periods are required to confirm its predictability, establish comparative effectiveness, and clearly define the indications and limitations of this protocol.