As seen on Oprah and EXTRA 
FROM THE DESK OF ALAN M. MELTZER DMD MScD
In this monograph, I will explore the fate of the mid-facial free gingival margin around single tooth implants. As stated at the conclusion of the last monograph, papillae either stay the same over time or improve, while the mid-facial worsens over time.
How much worse does the mid-facial become over time? It is a well-documented fact that over a 12 to 24 month period the mid-facial will recede approximately 1 millimeter. The degree of recession is generally more pronounced in a thin periodontium than in a thick one.
Why does this happen? A tooth has the ability to form a periodontal supracrestal fiber attachment while implants do not. This variation in the formation of biologic width from supracrestal around teeth to crestal-subcrestal around implants is responsible for the aesthetic compromise.
How can this problem be overcome? The solution requires over-correction of the mid-facial either prior to tooth extraction, at the time of tooth extraction, or at the time of implant placement. Available techniques may include orthodontic extrusion prior to extraction, soft tissue augmentation, hard tissue augmentation or some combination of the above. It is because of this mid-facial aesthetic issue that immediate placements are generally contraindicated in thin periodontal biotypes with high smile lines and high aesthetic demands. This special requirement is not an implant integration problem, but rather an aesthetic issue. Correcting this deficiency after the implant and restoration have been placed is extremely difficult and in some cases impossible.
Does grafting the socket at the time of tooth extraction solve this problem? No. While socket grafting is necessary in the aesthetic zone at the time of tooth extraction, it must be combined with other clinical approaches to maximize the aesthetic outcome. Remember that socket preservation is not the answer to this mid-facial problem; overcorrection is required.
