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CASE SERIES

Buccal Pedicle Flap Combined With Porcine Collagen Matrix: A Follow-Up

of 2 Years on 40 Consecutive Cases
Giorgio Tabanella∗

Introduction: A thick peri-implant mucosa is of importance to prevent recession, color alterations, bone remodeling
and promote “creeping attachment.” A volume stable porcine cross-linked collagen matrix has been recently introduced for
soft tissue regeneration and volume maintenance. The aim of this study was to investigate peri-implant soft tissue healing
and stability on 40 consecutive patients treated with buccal pedicle flap combined with the use of the collagen matrix.
Case Series: The buccal pedicle flap combined with a volume stable collagen matrix was executed at second stage
surgery. The average initial mucosa thickness was 1.32 mm whereas the average band of keratinized mucosa was 1.65 mm
and the height 1.3 mm. Four months after surgical procedure and before delivering the final restoration, the peri-implant
soft tissue measurements were significantly increased: the average band of keratinized mucosa was 5.10 mm, the mucosa
thickness was 3.27 mm, and the mucosa height was 3.32 mm. After 2 years of follow-up, the superimposition of 3D models
described an overall volumetric stability of the augmented mucosa with no signs of soft tissue collapse.
Conclusion: The proposed modified buccal pedicle flap was demonstrated to perform well in terms of decreased
morbidity, maintenance of blood supply, stabilization of the pedicle, superior haemostasis, and speed of treatment. No
significant variations of the keratinized tissue were registered when the buccal pedicle flap was executed in conjunction
with the collagen matrix that however provided color match with the surrounding tissue as well as an increased mucosa
thickness. Clin Adv Periodontics 2022;12:80–87.
Key Words: buccal mucosa; collagen matrix; guided tissue regeneration; mucosa; surgical flap; tissue transplantation.

BACKGROUND
The quality of peri-implant mucosa as well as its thickness
seems to play a key role1 in both ailing and failing dental
implants.2 In fact, a good quality and quantity of the
mucosa has been associated with esthetics, long-term
implant success rate, lower plaque, and bleeding indices
as well as peri-implant bone stability.3,4 Several plastic
surgical techniques5,6,3 have been developed to improve
its esthetics, hygienic, and functional outcomes. However,
some surgical approaches such as connective tissue and
epithelial connective tissue grafts are time consuming,
associated with morbidity and higher risk of postoperative FIGURE 1 The clinical picture is showing a reduced width of keratinized
mucosa as well as a buccal collapse of the residual ridge
∗ Oral Reconstruction and Education Center Rome (Italy), Rome, Italy
bleeding. Recently a volume stable porcine cross-linked
Received February 14, 2021; accepted March 27, 2021 collagen matrix† has been introduced to perform a

doi: 10.1002/cap.10161 † Geistlich Fibro-Gide Geistlich Pharma AG, Wolhusen, Switzerland.

80 Clinical Advances in Periodontics, Vol. 12, No. 2, June 2022 © 2021 American Academy of Periodontology.
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C A S E S E R I E S

FIGURE 2 The buccal pedicle flap is executed in combination with the collagen matrix. (A) A partial thickness flap is
elevated, and the matrix is gently inserted into the artificial envelope created by the flap design. (B) In cases of exposed
connective tissue, a spongious collagen is used to avoid exposure of the matrix. (C) After 5 days of healing, the exposed
spongious collagen is healed uneventfully

FIGURE 3 Two months after plastic surgery, the tissue appears to be stable and thicker compared to the pre-operative
picture (A-B). A first cast (C) is produced to start the sculpting of the mucosa

minimally invasive surgical approach for soft tissue
regeneration7,8 and volume maintenance.3 The aim of this
study was to investigate peri-implant soft tissue healing
and stability on 40 consecutive patients treated with
buccal pedicle flap6 combined with the use of the collagen
matrix.3
CLINICAL PRESENTATION
The study was designed as a single-center, prospective clin-
ical trial on the variations of implant mucosa thickness,
and it was conducted in accordance with the Declaration
of Helsinki on human studies, following approval from
the Ethical Committee Lazio 1 San Camillo-Forlanini
Hospital (Rome, Italy, Ref. no. #1079/CE Lazio 1). Forty
consecutive patients to undergo implant placement were
selected, and written informed consent was obtained.
At second stage surgery, the buccal pedicle flap com-
bined with the volume stable collagen matrix3 was per-
formed on each implant site. Four months after plastic
surgery, final cemented or screw retained restorations
were positioned. Before connecting the final crown to the

Tabanella Clinical Advances in Periodontics, Vol. 12, No. 2, June 2022 81


C A S E S E R I E S
FIGURE 4 Close-up showing how the buccal mucosa is generally shifted
coronally compared to the lingual
FIGURE 5 After 4 months from the buccal pedicle flap (A), the tissue is
significantly augmented (B)
FIGURE 6 The close-up of the mucosa is showing biomimetics as well
as an increased thickness and height
implant platform, the buccal and lingual thicknesses of the
peri-implant mucosa were measured with a caliper‡ on the
mesial, medial, and distal aspects considering the conical
connection as an absolute point of reference.
The width of keratinized mucosa was registered with
a periodontal probe§ buccally and lingually as well as
‡ Caliper Castroviejo long 0-40 mm straight, Hu-Friedy, Chicago, IL.
§ North Carolina 15 UNC color coded probe, Hu-Friedy, Chicago, IL.
82 Clinical Advances in Periodontics, Vol. 12, No. 2, June 2022
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FIGURE 7 The final restorations are then fixated. The harmony between
pink and white esthetics is evident at the interface between mucosa and
artificial prosthesis
mesial, distal, and medial from the mucogingival junction
to the free coronal margin of the mucosa. The mucosa
height was calculated at the same aspects from the implant
platform to the upper mucosal margin of the supra-
implant tissue. After the delivery of the final restoration
as well as at 24 months after loading impressions were
taken with polyether material . Each cast was scanned
by using an intraoral scanner,¶ and an indirect digitaliza-
tion of models was applied to evaluate dynamic minimal
morphological changes9 over a period of 2 years.
CASE MANAGEMENT
Each surgical site was treated following the protocol
as previously described.3 It was considered eligible for
modified buccal pedicle flap each site showing a buccal
deficiency and a reduced width of keratinized mucosa
(Figure 1). A partial thickness flap was generally raised
except for the sites that showed a thickness of less than
1.5 millimeter (Figure 2) which received full thickness flap.
The tissue was allowed to heal for 2 months (Figure 3)
before delivering a provisional restoration. The cast was
sculpted by creating areas of compression on the aug-
mented tissue (Figure 4) through the use of a provisional.
After 2 months (Figure 5), a final impression was taken in
order to produce the definitive implant-supported restora-
tion. The augmented tissue (Figure 6) received, then, a
CAD CAM full ceramic restoration (Figure 7).
CLINICAL OUTCOME
Forty patients (29 females, 11 males) with a mean age
of 54 years (range 30–72) were recruited to receive
implant-supported restoration. Six patients reported to
be smokers. Out of forty implants 16 were placed in the
mandible and 24 in the maxilla. At second stage surgery,
all patients received the buccal pedicle flap combined with
 Impregum Penta Super Quick Medium Body.
¶ Trios 3 Cart wired, 3Shape, Copenhagen, Denmark.
Modified Buccal Pedicle Flap

FIGURE 8 Examples of overlapped models. Each 3D evaluation (A-D) showed good results at 2 years with volume stability and minor
collapse of the mucosae (less than 0.3 mm)
FIGURE 9 Post-operative peri-apical radiograph of case a of Figure 8 showing radiological findings at the time of delivery of the
final restoration (A) and after 2 years of loading (B)
the porcine collagen matrix.3 All sites healed unevent-
fully except for three patients who reported respectively
pain, swelling, and delayed healing. Only these patients
requested medication to control pain after the surgical
procedure. The average initial mucosa thickness was 1.32
mm prior to the plastic surgery whereas the average band
of keratinized mucosa was 1.65mm and the height 1.3 mm
(Table 1). Four months after surgical procedure and before
delivering the final restoration, the peri-implant soft tissue
measurements were significantly increased (Table 2): the
average band of keratinized mucosa was 5.10 mm (rang-
ing from 3 to 6 mm), the mucosa thickness was 3.27 mm
(ranging from 3 to 4mm), and the mucosa height was
Tabanella
21630097, 2022, 2, Downloaded from https://aap.onlinelibrary.wiley.com/doi/10.1002/cap.10161 by Wuhan University, Wiley Online Library on [02/12/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
C A S E S E R I E S
3.32 mm (ranging from 2 to 5 mm). Significant volume
augmentations were reported beyond the mucogingival
junction. The superimposition of 3D models (Figure 8)
described an overall volumetric stability of the augmented
mucosa after a follow-up period of 2 years. These results
were in accordance with a stable peri-implant bone level
(Figures 9-12). Among the all surgical sites, 29 presented
stable or increased volume, seven showed a soft tissue
shrinkage of less than 0.5 mm and four a loss of more
than 3 mm. Three of the four patients who showed soft
tissue volume loss were those also who experienced com-
plications after the plastic surgery. Furthermore all three
reported complications occurred when the flap was less
Clinical Advances in Periodontics, Vol. 12, No. 2, June 2022 83
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C A S E S E R I E S

TABLE 1 Pre-surgical data showing an average thickness and TABLE 2 Post-surgical data. After the modified buccal pedicle
height of 1.3 mm flap, the band of keratinized mucosa as well as the mucosa
height and thickness significantly increased
Kerati- Initial Initial
nized mucosa mucosa Kerati-
mucosa thickness height nized Mucosa Mucosa
Patients (mm) (mm) (mm) Position mucosa thickness height
Patients (mm) (mm) (mm) Position
1 1 1 1 MANDIBLE
1 3 3 3 MANDIBLE
2 2 2 1 MAXILLA
2 5 4 3 MAXILLA
3 0 1 1 MANDIBLE
3 4 3 3 MANDIBLE
4 1 1 3 MAXILLA
4 5 3 4 MAXILLA
5 1 1 2 MAXILLA
5 5 3 4 MAXILLA
6 2 1 2 MAXILLA
6 5 3 4 MAXILLA
7 1 2 3 MANDIBLE
7 5 4 5 MANDIBLE
8 1 1 2 MANDIBLE
8 5 3 4 MANDIBLE
9 1 1 1 MANDIBLE
9 4 3 3 MANDIBLE
10 1 1 1 MANDIBLE
10 4 3 3 MANDIBLE
11 2 1 1 MAXILLA
11 5 3 3 MAXILLA
12 3 2 2 MAXILLA
12 5 4 4 MAXILLA
13 2 2 1 MAXILLA
13 5 4 3 MAXILLA
14 1 3 1 MANDIBLE
14 4 4 3 MANDIBLE
15 1 2 1 MANDIBLE
15 4 4 3 MANDIBLE
16 2 1 1 MAXILLA
16 5 3 3 MAXILLA
17 2 1 1 MAXILLA
17 5 3 3 MAXILLA
18 3 1 1 MAXILLA
18 6 3 3 MAXILLA
19 3 2 1 MAXILLA
19 6 4 3 MAXILLA
20 3 2 1 MAXILLA
20 6 4 3 MAXILLA
21 3 1 2 MAXILLA
21 6 3 4 MAXILLA
22 0 1 1 MANDIBLE
22 4 3 3 MANDIBLE
23 2 1 1 MAXILLA
23 6 3 3 MAXILLA
24 2 1 1 MAXILLA
24 6 3 3 MAXILLA
25 1 1 2 MANDIBLE
25 5 3 4 MANDIBLE
26 1 1 1 MANDIBLE
26 5 3 3 MANDIBLE
27 2 1 1 MAXILLA
27 6 3 3 MAXILLA
28 2 1 2 MAXILLA
28 6 3 4 MAXILLA
29 2 1 1 MAXILLA
29 5 3 3 MAXILLA
30 2 1 2 MAXILLA 30 6 3 4 MAXILLA
31 2 1 1 MAXILLA 31 6 3 3 MAXILLA
32 1 1 2 MANDIBLE 32 5 3 4 MANDIBLE
33 2 2 1 MAXILLA 33 6 4 3 MAXILLA
34 2 3 1 MAXILLA 34 6 4 3 MAXILLA
35 1 1 2 MANDIBLE 35 4 3 4 MANDIBLE
36 2 1 1 MAXILLA 36 6 3 3 MAXILLA
37 1 1 0 MANDIBLE 37 4 3 2 MANDIBLE
38 2 2 1 MAXILLA 38 6 4 3 MAXILLA
39 2 1 0 MAXILLA 39 6 3 4 MAXILLA
40 1 1 1 MANDIBLE 40 4 3 3 MANDIBLE
Average 1.65 1.32 1.3 Average 5.1 3.27 3.32

84 Clinical Advances in Periodontics, Vol. 12, No. 2, June 2022 Modified Buccal Pedicle Flap
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C A S E S E R I E S

FIGURE 10 Post-operative peri-apical radiograph of case b of Figure 8 showing radiological findings at the
time of delivery of the final restoration (A) and after 2 years of loading (B)

FIGURE 11 Post-operative peri-apical radiograph of case c of Figure 8 showing radiological findings at the
time of delivery of the final restoration (A) and after 2 years of loading (B)

FIGURE 12 Post-operative peri-apical radiograph of case d of Figure 8 showing radiological findings at the
time of delivery of the final restoration (A) and after 2 years of loading (B)

than 1.5 mm in thickness, and a partial thickness flap DISCUSSION

was still executed. No significant variations of the kera-
tinized tissue were registered when the buccal pedicle flap
was performed in conjunction with the collagen matrix6 ;
however, the collagen matrix provided a biomimetic color
match with the surrounding tissue.
A thick peri-implant mucosa is of importance to prevent
recession,10 color alterations,11 bone remodeling12 and
promote "creeping attachment."13 Among surgical tech-
niques,8,14,15 the proposed modified buccal pedicle flap
was demonstrated to perform well in terms of decreased

Tabanella Clinical Advances in Periodontics, Vol. 12, No. 2, June 2022 85

 21630097, 2022, 2, Downloaded from https://aap.onlinelibrary.wiley.com/doi/10.1002/cap.10161 by Wuhan University, Wiley Online Library on [02/12/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
C A S E S E R I E S

morbidity, maintenance of blood supply, stabilization of
the pedicle, superior haemostasis,3 and speed of treatment.
However, a possible drawback may be related to the orig-
inal thickness of the flap since a thin mucosa phenotype
may be more prompt to perforation when in contact with
a cross-linked collagen matrix. In fact, three of the four
complications occurred when the initial flap thickness was
thinner than 1.5 mm, but still a partial thickness flap was
executed. It would be advisable and more predictable to
shift to a full thickness flap in cases of thin phenotypes.
This approach would prevent flap perforation, delayed
healing, inflammation, and symptoms. Furthermore, the
results clearly demonstrated that in general the collagen
matrix did not significantly increase the free mucosal
thickness at the level of implant platform but a major aug-
mentation was reported mainly apical to the keratinized
mucosa. This can be explained by the fact that the matrix
has to be completely covered by the buccal pedicle flap
which is tightly sutured around the healing abutment.
However, the combination of both buccal pedicle flap
and collagen matrix did allow to increase the keratinized
tissue and thickness as well as reduce the buccal concavity
thus improving plaque control by reducing food trap.
Finally the significant long-term stability of the augmented
volume may also have an advantage in compensating the
bone remodeling that generally occurs more frequently
beyond the mucogingival junction in areas that have been
previously augmented.16
CONCLUSION
The proposed modified buccal pedicle flap was demon-
strated to perform well in terms of decreased morbidity,
maintenance of blood supply, stabilization of the pedicle,
superior haemostasis, and speed of treatment. No signif-
icant variations of the keratinized tissue were registered
when the buccal pedicle flap was executed in conjunction
with the collagen matrix that however provided color
match with the surrounding tissue as well as an increased
mucosa thickness.

SUMMARY

Why are these cases new  The case series describes a follow-up of 2 years after buccal pedicle flap
information? combined with a collagen matrix.
 This technique allows to significantly maintain the volumetric stability of
the peri-implant soft tissue.

What are the keys to  Proper evaluation of the original mucosa phenotype.
successful management of  Perform a full thickness flap in thin phenotypes.
these cases?

What are the primary  Smoking can significantly influence the healing process.
limitations to success in these  Soft tissue phenotype can influence the success of the surgical technique.
cases?  A minimum of 8 weeks is needed for tissue stabilization.


4. Thoma DS, Naenni N, Figuero E, et al. Effects of soft tissue augmenta-
ACKNOWLEDGMENTS tion procedures on peri-implant health or disease: a systematic review
and meta-analysis. Clin Oral Implants Res. 2018;2(15):32-49.
The author reported that this case series was supported by 5. Yukna RA, Sullivan WM. Evaluation of resultant tissue type follow-
a grant from Geistlich Fibro-Gide, Geistlich Pharma AG, ing the intraoral transplantation of various lyophilized soft tissues. J
Wolhusen, Switzerland. Periodont Res. 1978;13:177–184.

6. Tabanella G. The buccal pedicle flap technique for periimplant soft
tissue boosting. Int J Esthet Dent. 2019;14(1):18.
Correspondence 7. Thoma DS, Nänni N, Benic GI, Weber FE, Hämmerle CH, Jung RE.
Giorgio Tabanella, Oral Reconstruction and Education Center Rome Effect of platelet-derived growth factor-BB on tissue integration of
(Italy), Rome (Italy) Via Rovereto 6 00198, Italy. cross-linked and non-cross-linked collagen matrices in a rat ectopic
Email: gtabanella@gmail.com model. Clin Oral Implants Res. 2015;26:263–270.

8. Thoma DS, Zeltner M, Hilbe M, Hämmerle CHF, Hüsler J, Jung
RE. Randomized controlled clinical study evaluating effectiveness and
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