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The ‘Book’ Approach to Reflecting a Surgical Flap

Jack A. Hahn, DDS

article by Jack A. Hahn, DDS

Extraction with immediate implant placement is an appealing treatment protocol for patients who present with a tooth in the anterior that cannot be restored through conventional means due to fracture, severe decay or, as I commonly encounter in my office, failed endodontic treatment. These patients are often in a good deal of pain and quite concerned about the prospect of displaying a missing tooth in social situations. Immediate tooth replacement is an excellent means of addressing both the immediate and long-term needs of such patients.1 By following the proper diagnostic and surgical principles, the untreatable tooth can be extracted and replaced in the same visit, providing no small amount of relief for the patient concerned with the compromised esthetics of a missing tooth.

Practitioners providing this treatment for patients will eventually encounter cases where a defect in the facial bone is present. However, this situation can be addressed using straightforward surgical techniques, setting the stage for a predictable, esthetic outcome. One such technique is what I call the “book” approach to anterior flap reflection, which provides an atraumatic means of accessing the facial bone defect for evaluation and correction. To perform this technique, the interdental papillae are split buccal-lingually by making short mesial-distal incisions, while a single vertical releasing incision is made apical to the tooth adjacent to the defect (Figs. 1a, 1b). The surgical flap is then reflected like turning a page of a book (Fig. 2).


Figures 1a, 1b: The book approach to reflecting a surgical flap is performed by splitting the interdental papillae buccal-lingually with mesial-distal incisions. A single releasing incision is then made apical to the tooth adjacent to the labial defect.


Figure 2: After making the surgical incision, the flap is reflected like turning a page of a book, exposing the defect.

There are several benefits to the book approach. Because only one releasing incision is made, there is minimal trauma to the soft tissue. The single incision also minimizes the potential for grafting material leakage and leads to less postsurgical inflammation and pain. Since I began employing this technique several years ago in cases where a facial fenestration or dehiscence is present, the final soft-tissue contours and interdental papillae have improved significantly.

The following case presentation featuring immediate tooth replacement in the esthetic zone demonstrates how to identify, graft and properly place an implant in the presence of a labial bone defect. The book incision method is used to expose the fenestration for assessment and treatment. This case also illustrates the advantages of using the Hahn™ Tapered Implant, which has deep, angled threads that firmly engage the palatal wall of the extraction site, keeping the implant a safe distance from the facial defect while establishing a high degree of primary stability.

Case Presentation

A patient presented for treatment with a maxillary left central incisor that exhibited internal and external resorption and was fractured through the cervical area of the tooth, which was evident in the diagnostic X-ray (Fig. 3). The coronal portion of the tooth was on the verge of falling out and was being held in place only by the gingival attachment. The patient was referred to my office by her sister, for whom I had placed an implant several years ago. She was concerned about losing the crown and the embarrassment this could cause in her sales profession, where she meets with the public on a daily basis. I explained the extraction with immediate implant placement procedure and showed her photos of similar cases. The patient elected to receive treatment immediately.

To begin the procedure, horizontal incisions were made to split the interdental papillae of the extraction site in half buccal-lingually, which would maintain proper soft-tissue esthetics and avoid the occurrence of black triangles. The initial surgical incisions separated the connective gingival tissue from the crown, allowing it to be removed with ease (Fig. 4). The root was then extracted, taking care to preserve the labial plate.

A finger was placed on the gingiva apical to the edentulous space and a periodontal curette was dragged across the internal facial wall of the extraction socket. This caused the finger to move, revealing the presence of a fenestration and necessitating the reflection of a surgical flap to expose and graft the facial bone. This method is a reliable means of identifying facial defects when evaluating an extraction site for implant placement.

When employing the book approach, the releasing incision should be extended to a level beyond the apex of the adjacent tooth. In this case, the releasing incision was made above the left lateral incisor, halfway between the cervical of the tooth and the apex of the distal interdental papilla. The flap was then reflected like turning a page of a book (Fig. 5).

With the facial defect exposed, the site was cleaned thoroughly and prepared to receive a 4.3 mm x 13 mm Hahn Tapered Implant. The osteotomy was initiated with a 2 mm twist drill against the palatal wall in order to situate the implant a safe distance from the labial plate (Fig. 6). This path of insertion was followed with the 3.5 mm x 13 mm and 4.3 mm x 13 mm tapered sizing drills. I then threaded the implant into place, directing it against the palatal wall. Due to its prominent thread design, the implant performed perfectly during insertion, avoided migrating toward the facial aspect and achieved excellent initial stability of 45 Ncm (Figs. 7a, 7b).

Note that the healing abutment or provisional prosthesis should be attached to the implant prior to the bone augmentation procedure to ensure grafting material doesn’t get inside the prosthetic connection.

Next, the facial defect and the opening between the implant and the labial wall of the socket were completely filled with cortico-cancellous mineralized allograft granules (Fig. 8). In addition to treating the defect and maximizing the labial-lingual width of the ridge, the grafting procedure would help maintain the interseptal bone and thus preserve the interdental papillae. Note that when a large fenestration or dehiscence is present, grafting material may also be placed prior to implantation to maximize engagement with the implant. The flap was sutured and complete closure was achieved (Fig. 9).

After three months of healing, the patient returned for evaluation. The implant had successfully integrated while the graft material appeared to have been replaced with new healthy bone. The gingiva exhibited excellent health, esthetic contours and preservation of the interdental papillae. An impression coping was attached to the implant, and Capture® vinyl polysiloxane material (Glidewell Direct; Irvine, Calif.) was used to take a final impression (Figs. 10a, 10b). Based on the final impression, the lab digitally produced an Inclusive® Zirconia Custom Abutment with titanium base and a BruxZir® Anterior crown, the combination of which provides lifelike esthetics in the smile zone.

At the final delivery appointment, the custom abutment was seated with ease, providing optimal support for the soft tissue (Fig. 11). The implant crown was cemented over the custom abutment and displayed color that blended extremely well with the neighboring dentition (Fig. 12). Ample fibrous connective tissue was noted around the implant restoration, which exhibited a lifelike emergence profile. Final radiography illustrated healthy bone levels surrounding the implant (Fig. 13). The most important aspect of this case is that the patient was quite happy with the final result (Fig. 14).


When reflecting a surgical flap to access and graft a facial bone defect, the book approach can help minimize soft-tissue trauma and simplify surgery, as minimal incisions and sutures are needed to complete the procedure. For practitioners providing patients with the valuable service of immediate tooth replacement in the anterior, this technique offers a straightforward means of maintaining the bone volume and soft-tissue contours essential to a natural-looking final restoration.


  1. Noelken R, Neffe BA, Kunkel M, Wagner W. Maintenance of marginal bone support and soft tissue esthetics at immediately provisionalized OsseoSpeed implants placed into extraction sites: 2-year results. Clin Oral Implants Res. 2014 Feb;25(2):214-20.
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