INTEGRATED

ESTHETICS
IN PERIODONTICS AND IMPLANTOLOGY
Fausto Frizzera | Jamil Awad Shibli | Elcio Marcantonio Jr

INTEGRATED
ESTHETICS
IN PERIODONTICS AND IMPLANTOLOGY
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Title of original issue:

Estética Integrada
em Periodontia e Implantodontia
Copyright © 2018 Editora Napoleão Ltda., 2018

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ISBN: 978-3-86867-638-9

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PREFACE

Here at the first pages of this book, I have the feeling that we are
about to start a beautiful journey about the current knowledge in
periodontics and implant dentistry. I am convinced that many of us
readers will know how to do justice to the authors’ effort, by welcoming
this book the way it deserves.
In its 11 chapters, we can see the authors’ concern with presenting,
substantiating, and explaining to readers in detail critical aspects of
the development of new concepts and techniques that are reflected in
clinical work.
This book, for its clarity, objectivity, logic, and current scientific
concepts applied to the clinic, engages the reader. It is a democratic
work that allows room for broad learning about the subjects covered. It
presents strong clinical concepts and is based on the belief of the
irreplaceable role of education for the development of the different
specialties. This book is exceptional. The work is presented in an
organized way, and in a general context, it is vast. The arrangement of
the chapters is logical and well-documented, with the opening
chapters serving as a solid foundation in the creation of knowledge.
With several decades of combined high-level education and clinical
practice, the authors have experienced several paradigm shifts
involving periodontics and implantology as clinic-oriented science.
Additionally, they have accumulated many lessons from the learning
process and translated them into applied knowledge. Therefore, not
only the correct indications of different treatment options but also their
limitations and controversies are presented in this book.
The absolute respect and interest in others, to patients, is evident
between the lines of the book. The book explores several previously
untouched clinical questions, showing the use of biologic knowledge
and current scientific concepts as the basis of a demanding and
questioning clinic. It is an open-hearted critique of the status quo of
our specialties. It questions, examines, and does not accept second
best. Thus, with tremendous intensity, it directs us toward the
development of reliable, consistent clinical work and predictable and
longitudinal results. It is passionate! It is a great pride to have been
invited to preface it.

Mario Groisman
DEDICATION

This work is dedicated to the parents of today,

yesterday, or tomorrow who do,
did, or will do anything to make the world a better place for their
children.

In memoriam of Elcio Marcantonio and Awad Abdalla Awad Shibli

ACKNOWLEDGEMENTS

To our dear brothers and brothers-in-law

To the Frizzera, Valiate, Shibli, and Marcantonio families

To our wives and daughters

To our friends, colleagues, and patients.

To the contributors of this book

To our partners and employees of SCOE and Marcantonio Continuing

Education

To the deans, presidents, coordinators, teachers, colleagues, staff,

and students of our partner institutions

To the Napoleão Publishing House – Quintessence Publishing Brazil

To God

Thank you all for your support in the creation of this work.
AUTHOR

FAUSTO
FRIZZERA

Graduated in Dentistry from UFES

Master’s and Specialist in Periodontics, Faculty of Dentistry from
Araraquara (FOAr-UNESP)
PhD in Implantology from FOAr-UNESP
Professor of Periodontics and Implantology at FAESA University
Center
Postgraduate Professor of Implantology at ABO-ES
Partner responsible for Periodontics, Implantology and
Minor Oral Surgery of SCOE
Has written over 60 articles and book chapters published in
Portuguese, English, Spanish, French, and Bulgarian
Member of the Osteology Foundation and ITI Member
 JAMIL
AWAD SHIBLI

Graduated in Dentistry from FOAr-UNESP

Professor at the Postgraduate Program in Dentistry, Implantology
and Periodontics, Guarulhos University (UNG)
PhD, Master’s, and Specialist in Periodontology from FOAr-
UNESP
Professor at the Oral Surgery and Periodontology Department at
FORP-USP
Periodontist and Implant Dentist at Private Practice, Guarulhos,
São Paulo, Brazil

ELCIO
MARCANTONIO JR

Graduated in Dentistry from FOAr-UNESP

 Specialist in Periodontology from EAP/APCD, Araraquara
Master’s and PhD in Restorative Dentistry from FOAr-UNESP
Professor of Periodontology and Implant Dentistry at FOAr-
UNESP
Professor of the Master’s Program at ILAPEO University
Coordinator of the Graduate Program in Implant Dentistry at
FOAr-UNESP and FAEPO
Partner of Marcantonio Continuing Education
COLLABORATORS

ADRIANO PIATTELLI
Department of Oral, Medical and Biotechnological Sciences,
University of Chieti-Pescara, Italy
PhD Honoris Causa, University of Valencia, Spain
PhD Honoris Causa, Catholic University of San Antonio of Murcia,
Spain

ANA CAROLINA MONACHINI MARCANTONIO

Master’s and Specialist in Periodontics at FOAr-UNESP
PhD Student in Implant Dentistry. Specialist in Implant Dentistry at
FAEPO

BIANCA VIMERCATI
PhD and Master’s in Dentistry – focusing on Operative Dentistry –
UER J
Professor of Dentistry at UVV
Operative Graduate Program Director at ABO-ES
Coauthor to the books Odontologia Restauradora de A a
Z and Anatomia Dental de A a Z

CAMILA CHIERICI MARCANTONIO

Graduated at the College of Dentistry of Araraquara/Unesp.
Master’s and PhD Student in Dentistry focusing on Periodontics at
FOAr-UNESP
Specialist in Periodontics at FOAr-UNESP
CAMILA LORENZETTI
Specialist in Operative Dentistry at FAEPO/Araraquara
Master’s and PhD in Operative Dentistry at UNESP/Araraquara
Professor at the Graduate Program in Operative Dentistry –
FAEPO/Araraquara

CRISTIANO HOOPER PASCOAL

Master’s and specialist in Periodontics at SLMandic
Professor of Periodontics/Implant Dentistry – FAESA
Professor at the Graduate Program in Implant Dentistry at ABO-ES

DANIEL S. THOMA
Senior Lecturer at the Clinic of Fixed and Removable Prosthodontics
and Dental Material Science Centre for Dental Medicine, University of
Zurich

DEISE LIMA CUNHA

Master’s and Specialist in Orthodontics and Facial Orthopedics at
Facial-UER J
Professor at the Graduate Program in Orthodontics at ABO-ES
Professor of Orthodontics at Multivix

EDUARDO FERNANDEZ
Master’s and PhD in Operative Dentistry at UNESP/Araraquara
Professor at University of Chile

GABRIELA CASSARO DE CASTRO

Master’s and PhD in Clinical Dentistry – Dental Prosthesis at
FOP/Unicamp
Professor at the College of Dentistry at Faesa. Professor at the
Prosthesis Residency Program at SLMandic – Vila Velha

GIUSEPPE ALEXANDRE ROMITO

Professor of Periodontics at FOUSP
Master’s, PhD and Lecturer at FOUSP
Implant Dentistry Graduate Couse Director at FFO-USP
Chief Editor of the Brazilian Oral Research Journal

GUILHERME J. P. LOPES DE OLIVEIRA

Graduated in Dentistry at UFA
Specialist, Master’s, and PhD in Periodontics at FOAr-UNESP
Assistant Professor of Periodontics and Implant Dentistry at UFU

HINDRA COLODETTI
Master’s in Operative Dentistry at UER J
Specialist in Operative Dentistry at EAP/ABO-ES
Professor at ESFA
Coauthor of the books Anatomia Dental de A a Z and Odontologia
Restauradora de A a Z

JUDITH MARIA PINHEIRO OTTONI

Master’s in Physiology at UFES
Specialist in Periodontics at PUC – RJ
Graduate Program in Oral Craniofacial Implant Clinic – University of
Texas Health Science
Center Houston – Dental Branch (1995/1996)
Author of the books Cirurgia Plástica e Peri-implantar and
Manipulação Tecidual: Possibilidades e Realidade

LUIS MARCELO CALDERERO

Master’s in Periodontics at FOUSP
Lecturer Professor in over 50 Graduate Courses in Brazil
International Marketing Manager – Innovation – Geistlich Pharma
(Switzerland)

LUIZ GUILHERME FREITAS DE PAULA

Specialist and Master’s in Periodontics, Specialist and PhD in Implant
Dentistry at FOAr-UNESP
Professor of Periodontics and Dental Clinics at UniEVANGÉLICA,
Anápolis-GO
Professor of the Implant Dentistry Course at FAEPO – Araraquara

MARCO MASIOLI
PhD in Clinical Dentistry at UFR J
Master’s in Dentistry – Operative Dentistry – UER J
Associate Professor of Prosthodontics – UFES
Author of the books Fotografia Odontológica, Odontologia
Restauradora de A a Z, and Anatomia Dental de A a Z

MATEUS RODRIGUES TONETTO

Master’s and PhD in Operative Dentistry at FOAr-UNESP
Professor of the Graduate, Master’s, and PhD courses at UNIC

MATHEUS COELHO BANDÉCA

Master’s and PhD in Operative Dentistry at UNESP/Araraquara
Master’s and PhD Program Director at CEUMA University

RODRIGO NAHAS
Master’s and PhD in Periodontics at FOUSP
Graduate Program Director in Periodontics at SENAC
Postdoctoral Fellow/Scholar Augusta University, GA, EUA

RONALD E. JUNG
Chair of the Implant Dentistry Division and Vice-chair of the Fixed and
Removable Prosthesis and Dental Biomaterials Clinic, Dental
Medicine Center, University of Zurich

RUBENS MORENO DE FREITAS

PhD in Implant Dentistry at FOAr-UNESP
Professor of the Master’s Course in Implant Dentistry at ILAPEO
University
International Course Director at ILAPEO University

SUSANA d’AVILA
PhD in Oral Rehabilitation at FOAr-UNESP
Master’s in Oral Rehabilitation at FOAr-UNESP
Specialist in Oral Rehabilitation at FOAr-UNESP

ULISSES DAYUBE
PhD Student in Implant Dentistry at UNG
Master’s in Implant Dentistry at SL Mandic
Graduate Program Director in Implant Dentistry at GAPO – FUNORTE
Professor of Oral Surgery at UNG

VÍTOR MARQUES SAPATA

PhD in Periodontics at the College of Dentistr, University of São Paulo
Master’s in Clinical Dentistry at UEM
Specialist in Periodontics at UEM
CONTENT

1 ESTHETIC AND FUNCTIONAL PLANNING:

clinical and digital resources
Fausto Frizzera, Bianca Vimercati, Hindra Colodetti, Marco
Masioli, Jamil A. Shibli, Elcio Marcantonio Jr

2 GINGIVAL CONTOUR IN THE ESTHETIC

ZONE:
treatment for short clinical crowns
Fausto Frizzera, Cristiano H. Pascoal, Rodrigo Nahas,
Giuseppe A. Romito, Rubens M. de Freitas, Elcio Marcantonio
Jr

3 ROOT COVERAGE IN ESTHETIC

REGIONS:
treatment of long clinical crown
Fausto Frizzera, Cristiano H. Pascoal, Jamil A. Shibli, Luis M.
Calderero, Rodrigo Nahas, Giuseppe A. Romito

4 TREATMENT PLANNING IN IMPLANT

DENTISTRY:
the search for predictable result
Fausto Frizzera, Luiz Guilherme Freitas de Paula, Ana Carolina
 M. Marcantonio, Camila C. Marcantonio, Jamil A. Shibli, Elcio
Marcantonio Jr

5 SOCKET PRESERVATION:
how to maintain tissue architecture
Fausto Frizzera, Vítor M. Sapata, Ronald E. Jung, Elcio
Marcantonio Jr, Jamil A. Shibli

6 IMPLANT PLACEMENT IN FRESH

SOCKETS:
how to get an ideal position
Fausto Frizzera, Bianca Vimercati, Marco Masioli, Jamil A.
Shibli, Camila C. Marcantonio, Elcio Marcantonio Jr

7 IMMEDIATE PROVISIONAL ON TEETH OR

IMPLANTS:
determining chronology and restoration contouring
Mateus R. Tonetto, Fausto Frizzera, Eduardo Fernandez,
Camila Lorenzetti, Matheus C. Bandéca

8 IMMEDIATE REHABILITATION OF INTACT

AND COMPROMISED SOCKETS:
a predictable protocol
Fausto Frizzera, Jamil A. Shibli, Ana Carolina M. Marcantonio,
Elcio Marcantonio Jr

9 TREATMENT OF ESTHETIC
 COMPLICATIONS AROUND IMPLANTS:
the decision between keeping or removing an implant
Guilherme J. P. Lopes de Oliveira, Fausto Frizzera, Adriano
Piattelli, Jamil A. Shibli, Elcio Marcantonio Jr

10 LONG-TERM FOLLOW-UP OF IMPLANTS:

what should be expected
Judith M. P. Ottoni, Susana d’Avila, Gabriela C. de Castro,
Fausto Frizzera, Ulisses Dayube, Jamil A. Shibli

11 AVOIDING ESTHETIC AND FUNCTIONAL

DEFECTS ON IMPLANTS:
how to condition the transition zone
Fausto Frizzera, Guilherme J. P. Lopes de Oliveira, Deise Lima
Cunha, Daniel S. Thoma, Jamil A. Shibli, Elcio Marcantonio Jr
 CHAPTER 1
ESTHETIC AND FUNCTIONAL
PLANNING
clinical and digital resources
Fausto Frizzera, Bianca Vimercati, Hindra Colodetti, Marco Masioli, Jamil A.
Shibli, and Elcio Marcantonio Jr
1. INTRODUCTION

The evolution of dentistry in recent decades has been rapid and

remarkable. Every moment a new technique is described, mastered,
and popularized. In the not-too-distant past, dental treatment
consisted of seeking pain relief; often extracting the tooth was
considered the most effective treatment. With the understanding of the
importance of maintaining dentition for the correct functioning of the
stomatognathic system and general health of the individual, dentistry
focused on stopping the progression of caries, periodontal diseases,
and occlusal disorders.
Contemporary dentistry seeks the preservation and restoration of
teeth, periodontal tissues, and peri-implant tissues, with an
appropriate relationship between the arches. The treatment
philosophy should focus on the restoration of dentofacial function and
esthetics to provide or restore the patient’s physical, mental, and
social well-being, improving their quality of life.
Often dissociated, esthetics and function are integral parts of the
same system. They must act synergistically to provide greater
predictability and longevity to dental treatments.
Restorative materials have evolved to reproduce the characteristics
of teeth accurately. However, periodontal and peri-implant tissues
need a much higher dedication from the dental professional for their
reconstruction; preservation is key to avoiding the need for future
more invasive and sometimes less predictable procedures.
Comprehensive understanding and reconstruction of the biological
and functional characteristics of periodontal and peri-implant tissues is
challenging and requires interaction between specialties to achieve
the expected results. Nevertheless, it is necessary to be sensitive to
achieve perfect harmonization of a smile.
In the field of esthetics, many subjective components are linked to
ethnicity, belief, culture, age, and individuality. However, there are
rules and parameters that, when observed, become a good starting
point for the dentist to develop a clinical and digital plan of the
rehabilitating treatments. Digital Smile Design (DSD) is a tool that
facilitates the diagnosis of changes, planning, and interpersonal
communication, guiding professionals to obtain more feasible results1.

OBJECTIVES
At the end of the chapter the reader should be able to:
Understand the facial, dental, and periodontal aspects that guide
esthetics in dentistry.
Identify the presence of esthetic changes and the need for
multidisciplinary treatments to obtain the expected result.
Understand the importance of planning and communication with the
patient and other professionals involved in treatment.

2. PLANNING BASED ON CLINICAL EVIDENCE

2.1. FACIAL ANALYSIS

When we refer to esthetics, we have to take into consideration that the

concept of beauty is broad and generates diversity. Thus, we cannot
generalize the criteria to be evaluated. However, there are essential
elements that determine facial harmonies, such as planes, lines, and
contours, as well as the eyes and smile. From these analyses,
planning should take into account esthetic and functional parameters
according to the patient’s needs.
The first analysis performed when observing the face is its outline
(Figs 01A–C). The facial contour consists of the curves of the face
and determines, for example, the support of the upper lip and its
relationship with the lower lip and occlusal plane. Next, the field of
vision usually shifts to two areas: the smile and the eyes. Other
details, such as the nose and hair, are observed later.
01. A–G Facial contour: frontal view (A); mid-profile (B); and profile
(C). Types of face: triangular (D); square (E); round (F); and oval (G).

The face can be classified into four different types: triangular,

square, round, and oval (Figs 01D–G). The proportions between the
various planes of the face (frontal and lateral) are important to define
facial proportionality and esthetics2. In addition, the face can also be
divided into three thirds: upper, middle, and lower. A series of face
planes were created to allow comparisons and provide guidance.
2.1.1. FACIAL PLANES
The facial planes consist of lines and contours and can be horizontal
or vertical. The horizontal lines pass through different facial points,
such as the pupils and the lip commissure (Fig 02). The parallelism
between these lines generates harmony.

02. Horizontal lines and facial planes: interpupillary line (a);

intercommissural line (b); and incisal plane (c).

The interpupillary line is a horizontal line drawn over the center of

the eyes in the pupil. It should be parallel to the line of the labial
commissures, the incisal plane, and the gingival line. This line makes
it possible to evaluate the direction of the incisal line and gingival
contour of the maxilla2,3. A slight discrepancy between the
interpupillary and the intercommissural line is not esthetically relevant.
However, if it is a significant discrepancy, it should be corrected.
The incisal plane must follow the contour of the lower lip3; its
relationship to the gingival contour of the upper teeth can diagnose
mild, moderate, or severe inclination of the maxilla. Planning
procedures to correct a gummy smile require evaluation between the
planes/facial lines, the relationship between the middle and lower third
of the face, and the length and mobility of the upper lip. This
evaluation aims to avoid misdiagnosis and, consequently, treatment
failure. It usually requires multidisciplinary interventions such as
orthodontics, oral and maxillofacial surgery, periodontics, and even
esthetic medicine/dentistry with botulinum toxin application or
hyaluronic acid fillers.
The most important vertical lines to evaluate facial esthetics are the
midline and the interincisal line (Fig 03). The first passes through the
nasion and philtrum, and the second passes between the central
incisors. There are reference points for drawing the facial midline
(such as the glabella, tip of the nose, upper lip philtrum, and chin),
which divides the face into two parts. This line helps in the evaluation,
location, and orientation of the interincisal line; changes in it may
compromise the balance of other facial structures, thus impairing
esthetics4–6. Coincidence of the facial midline and interincisal line
occurs in 70.4% of the population7. Esthetically, the midline serves to
assess the location and orientation of the interincisal line. The
parallelism between them is more critical than their distance.
03. Vertical lines of the face: midline (a) and interincisal line (b).

The occlusal plane is determined by the incisal edges of the anterior

teeth and the occlusal surfaces of the posterior teeth. The outline of
the lips serves as a guide to determine the length and position of the
teeth. Movement of the upper lip determines the smile line of the
patient. The range of motion and amount of dental and gingival
exposure will depend on several factors, such as the degree of muscle
contraction, periodontal tissue level, skeletal conditions, and tooth
shape and wear.

2.1.2. LIPS AND SMILE LINE

In general, with the upper lip at rest position, exposure of the central
incisors ranges from 1 mm to 3 mm. Women usually expose more
teeth than men; with aging the incisal edges of the maxillary central
incisors become less visible because the natural process of tooth
wear occurs, accompanied by decreased muscle tone and amplitude.
The lips define and structure the smile, besides delimiting the so-
called esthetic zone. The lips can be broad, medium, or narrow in
form7. They can also be classified according to gingival exposure into
high, intermediate, or low smile line (Figs 04A–C). The high smile line
reveals the full length of the maxillary anterior teeth, as well as a band
of gingival tissue. If this gingival exposure is greater than 3 mm, the
patient has a gummy smile. The intermediate smile line shows from
75% to 100% of the length of the maxillary anterior teeth and may
show the gingival papillae. A low smile line exposes less than 75% of
the maxillary anterior teeth, without exposure of gingival tissue. From
an esthetic point of view, the intermediate smile line is the most
pleasant7–12.

04. A–C Smile lines: low (A), exposure of less than 75% of the
maxillary anterior teeth, no exposure of the gingival tissues;
intermediate (B), exposure of 75–100% of the maxillary anterior teeth,
may expose the papilla; high (C), exposure of the entire length of the
maxillary anterior teeth, exposure of a band of gingival tissue.

A pleasant smile should expose the maxillary teeth and a small

band of gingiva and papillae (Fig 05). Over time, muscle tone
decreases and the gingival exposure tends to decrease, even leading
to no exposure of the maxillary incisor crown in older patients, and
that may become a complaint.

05. Exposure of maxillary central incisors, lateral incisors, canines,

premolars and gingival tissue resulting in a pleasant smile.

The relationship between the incisal edge of the maxillary teeth and
the lower lip usually occurs in three ways (Figs 06A–C). The first and
most pleasant occurs when the incisal edges of the maxillary teeth
follow the curvature of the lower lip when the patient smiles. The
second occurs when the incisal edges are straight, giving the patient a
straight smile. The third, when the incisal edges are reversed in
relation to the lower lip, gives the patient an inverted or ‘sad’ smile.
06. A–C Relationship between the incisal edge of the maxillary
anterior teeth and lower lip: the incisal edges follow the curvature of
the lower lip (A); the incisal edges are aligned with the lower lip (B);
the incisal edges are inverted in relation to the lower lip (C).

2.2. DENTAL ANALYSIS

2.2.1. SHAPE
The definition of a pleasant smile is that the maxillary central incisors
are deemed the focal teeth due to their location in the dental arch,
being the most dominant and visible. Thus, in esthetic rehabilitation,
they should be the reference to determine the characteristics of the
other teeth. The shapes of the maxillary central incisors are commonly
classified as triangular, squared, and oval13,14 (Figs 07A–C). The
triangular shape of the maxillary central incisor is the most frequent,
followed by the square and, less frequently, oval shape. For the
complete assimilation of dental morphology, it is essential to have a
detailed observation of all surfaces in different views. The incisal view
allows the observation of morphological changes that occur from the
facial to the proximal surfaces; lateral visualization allows the
observation of the cervical, mid, and incisal planes (Figs 07D, E).
07. A–E Incisor shapes: triangular (A), squared (B), and oval (C).
Incisal view (D) – allows the observation of morphological changes
that occur from the facial to the proximal surfaces. Proximal view (E) –
allows the observation of the cervical, mid, and incisal planes.

The flat area on the facial surface of the central incisor is primarily
responsible for the reflection of light and, consequently, for the
appearance of the teeth. It may vary in shape, size, and location (Figs
08A–D). The concept of proportionality suggests that the upper central
incisors have a height/width ratio of 10:8 or 80% (Figs 09A–C).
However, when this ratio is slightly changed (Figs 10A–D) in the order
of 10:7.5 (75%) or 10:8.5 (85%), an esthetically pleasing arrangement
remains13,14.
08. A–D Light reflection area on the anterior teeth (A). These
characteristics should be reproduced in esthetic restorations (B). The
flat area is principally responsible for light and tooth appearance; it is
the area between the facial line angles (red lines) (C). Between the
proximal surfaces and line angles is an area called the proximal
transition (D). Ceramic crown done during the Clinical Prosthesis
Course at FAESA with supervision of Prof George Alves (B–D).

09. A–C Concept of proportionality: the maxillary central incisor should

have a height to width ratio of 10:8 or 80%.
10. A–D Alteration in the dental proportion and asymmetry between
homologous teeth (A). Surgical procedure performed to intentionally
keep the discrepancy in the gingival contour (B). Appearance after
tissue healing (C) and immediately after restorative therapy (D).
Surgical procedure: Dr Fausto Frizzera; restorative procedure: Dr
Marco Masioli.

2.2.2. TEXTURE (MACRO- AND MICROMORPHOLOGY)

Surface texture is a significant factor in the appearance of teeth
because it creates different forms of light reflection (Figs 11A, B). Two
types of texture are considered: (1) horizontal, which consists of
horizontal perikymata that tend to disappear with wear of the facial
surface of the teeth; (2) vertical, consisting mainly of developmental
lobes and grooves on the facial surface. The incisal edge usually has
three lobes (mesial, central, and distal) and two interposed grooves
(mesial and distal) 14.
11. A, B Surface texture of teeth in a young (A) and an elderly (B)
patient. Textures tends to disappear with age and wear of the buccal
surface. Images provided by Dr Matheus Bandéca.

The texture of teeth changes over time because of enamel wear

due to physiological activity. Texture can be associated with age. In
young patients, teeth have more surface texture; in middle-aged
patients, surface characteristics are less pronounced and usually
more polished; and in elderly patients, surface characteristics are
slight. Also, a higher degree of polishing usually occurs due to
toothbrush abrasion, eating, and lip action14.
Although there is a correlation between age and surface shine, this
may vary from person to person, being influenced by physiological
factors, degree of tooth mineralization, eating habits, and oral hygiene.
It is important not to confuse texture with surface shine. Some teeth
may present little texture and high shine, just as other teeth may have
heavy texture and high shine13.

2.2.3. INTERDENTAL RELATIONSHIP

The interdental relationship is as essential as the individual
assessment of each tooth. Therefore, contact between the central
incisors, symmetry, position of the incisal edges, width, contact points,
and embrasures should be taken into consideration for the treatment
plan of esthetic rehabilitations.
After the individual evaluation, the relationship between the central
incisors and the other teeth, and with the face, should be verified.
Ideally, the contact between the maxillary central incisors should be
linear, straight, and transverse to the horizontal plane and coincident
with the midline of the face (Figs 12A–C).However, even in cases
where it is not possible to match the facial midline with the dental
midline, contact between the maxillary central incisors should always
be parallel to the facial midline.
12. A–E Types of contact between the maxillary central incisors:
aligned to the horizontal plane (A); not aligned to the horizontal plane
(B); absence of contact between the maxillary central incisors with
presence of a diastema (C). Symmetry (D) and asymmetry (E)
between homologous teeth.

Anterior homologous teeth should have symmetry in a frontal view

(Figs 12D, E). The closer to the midline, the more desirable this
symmetry. Thus, the maxillary central incisors should be as
symmetrical as possible. Symmetry in the other teeth is desirable;
however this need decreases as the teeth move away from the
midline13.

ROOT COVERAGE PROCEDURE IN A SINGLE AND DEEP RECESSION

USING STRAUMANN MUCODERM®

In a pleasant smile, the incisal edge of the maxillary lateral incisors

is, on average, 1 mm more apically than the edge of the central
incisors. The incisal edges of the canines are in the same plane or
slightly more apical than the incisal edges of the central incisors.
The interdental contact of the maxillary anterior teeth descends from
the canine toward the central incisors (Fig 13). The contact between
the canine and lateral incisor is more apical than the contact between
the lateral and central incisors. The contact between the central
incisors is more incisal than the contact between the lateral and
central incisors. These contact points are usually tight unless there is
a mesiodistal discrepancy of the crown, with the presence of
diastemata between the teeth15,16. The position of the interdental
contact is related to the position of the tooth in the arch and its
morphology17. In a buccal or lingual view, it is possible to observe the
gingival and incisal embrasures. The gingival embrasure, which
houses the interdental papilla, is delimited by the contact point,
adjacent teeth, and bone crest. The incisal/occlusal embrasure is
delimited by the contact point, incisal angles, and by an imaginary line
from the end of each incisal angle.
13. Contacts between anterior teeth (lateral view).

The analysis of the incisal embrasure is a crucial Factor for the

planning of esthetic rehabilitation of anterior teeth. The pattern of the
shape produced by the incisal embrasures and separations between
the maxillary anterior teeth with the darker background of the mouth
helps to define a pleasant smile. The spaces between the embrasures
follow a pattern that begins between the central incisors and
progresses distally. Incisal embrasures increase in size and volume as
they move away from the midline18 (Figs 14 and 15A–F).
14. The incisal embrasure between the central and lateral incisors
should be bigger than the incisal embrasure between the central
incisors. The same aspect as the incisal embrasure between the
canine and lateral incisor should be bigger than the incisal embrasure
between the lateral and central incisors.
15. A–F The shape of the embrasures and the interproximal contact
should be considered because they influence the smile esthetics (A,
B). Diagnostic wax-up of the patient with the appropriate shape of
incisal embrasures can be used to visualize a greater harmony
between the anterior teeth (C). The result obtained with the wax-up
allows performing a mock-up, where a putty matrix is made from the
waxed model. Then, bis-acrylic resin is dispensed into the matrix (D)
and then positioned into the patient’s mouth (E). After the resin cures,
the matrix and excess are removed. The dentist and patient can
evaluate the proposed changes in the of anterior teeth (F). Restorative
procedure: Dr Mateus Tonetto.

2.2.4. DENTAL AXIS

The inclinations (facial-lingual positioning) and angles (mesiodistal
positioning) of the anterior teeth correspond to the dental axis. The
anterior and posterior teeth present a positive angulation of the buccal
axis of the clinical crown, that is, the occlusal portion of the buccal axis
is positioned more mesially to the gingival portion. These angles
should increase from the maxillary central incisors toward the
maxillary canines. The opposite happens with the inclinations, which
decrease from the maxillary central incisors toward the canines15,16
(Figs 16A, B and 17A, B). The long axis or direction of the anterior
teeth in an esthetic smile follows a progression as it moves away from
the midline. When the maxillary anterior teeth are angled mesially, the
overall esthetic impact is a harmonious relationship with the lower lip
curvature19.
16. A, B Adequate (A) and inadequate (B) angulation; note the right
maxillary lateral incisor.
17. A, B Adequate (A) and inadequate (B) inclination of the maxillary
anterior teeth.

The inclination of the maxillary incisors can be assessed by

analyzing the buccal surface of the existing maxillary central incisors
relative to the patient’s maxillary posterior occlusal plane. The buccal
surface of the maxillary central incisors should be perpendicular to the
upper occlusal plane (Figs 18A–C). This ratio allows maximum direct
light reflection from the buccal surface of the maxillary central incisors,
which improves their esthetic appearance20. If the teeth are reclined or
inclined, esthetics may be impaired and require correction.
18. A–C Maxillary central incisor with the facial surface perpendicular
to the maxillary occlusal plane (A); note the central incisor dominance
(B) and adequate light reflection (C).

2.2.5. DOMINANCE AND REGRESSIVE APPEARANCE

PROPORTION
Dominance refers to the fact that the maxillary central incisors should
be the dominant teeth and most visible when smiling. The curvature of
the dental arch shows less of the teeth in the distal position. The less
a tooth is visible, the less its importance on the smile. The maxillary
central incisors, because of their position in the center of the arch,
should appear as the widest and whiter ones and, consequently, are
the predominant teeth in the frontal aspect (Fig 19A).
19. A,B When viewed frontally teeth should be gradually less visible
from the center toward the posterior region (A). The golden proportion
determines the width of the other teeth, with the central incisors as a
reference. An approximate reduction of 61.8% of the width of the
maxillary central incisor in relation to the maxillary lateral incisor
should exist. For example, if the central incisor is 1-cm wide, the
lateral incisor must be 0.618 cm; the canine should be 0.38-cm wide,
and so on (B).
 The width of the maxillary central incisor is dependent on its height.
The other teeth, on the other hand, depend on the width of the
maxillary central incisors.An esthetic proportion with regard to the
relation ship between teeth is when the extent of the visualization
decreases from the central incisor to the posterior teeth by 1:0.618.
This ratio is called the ‘golden’ or divine proportion and refers to the
apparent width of the teeth when viewed frontally. Thus, starting from
the central incisor, each tooth appears to have 61.8% of the width of
the tooth located to its mesial aspect (Fig 19B).
The golden proportion is not always found in the dental composition
of the general population and should not be applied to all patients. It
should be used to guide esthetic evaluations and rehabilitations (Figs
20A, B).
20. A,B The alteration in teeth proportion can occur unilaterally (A) or
bilaterally (B). Unilateral asymmetries generally require a more
complex treatment.

2.2.6. BUCCAL CORRIDOR SPACE

The buccal corridor is the space between the buccal surface of the
upper teeth and the cheek’s mucosa that form the corner of the mouth
and cheek. It is dependent on the width of the upper arch and the
facial muscles responsible for the width of the smile21.
In a wide smile, the area and number of maxillary posterior teeth
that show are visible be considered. In patients with a narrow arch and
wide smile, the teeth displayed after the canines may be in the
shadow or disappear entirely. This condition is called a deficient
buccal display22. Reduced buccal exposure can have negative esthetic
consequences in some patients.
On the other hand, buccalized teeth or overcontoured restorations
and dentures that invade the space of the buccal corridor become
excessively visible during the smile (Figs 21A, B). Excess visibility of
the posterior teeth is an essential factor to be observed since it can
have negative esthetic consequences; thus, it should be evaluated
during treatment5,21.
21. A, B Adequate (A) and inadequate (B) buccal corridor, where the
posterior teeth invade the buccal corridor space and are more visible.

Dental characteristics are usually assessed qualitatively to verify the

presence of symmetry, color, and harmony (Figs 22A–C). One
quantitative method used to measure dental esthetics is the White
Esthetic (WES)23. The contralateral tooth is the object of comparison
and the maximum score of this evaluation is 10, indicating esthetic
excellence (Figs 23A–C and Table 01). If values lower than 6 are
determined, dental esthetics are classified as clinically unsatisfactory.
Satisfactory scores are greater than or equal to 6.
22. A–C Maxillary central incisors with adequate (A) and altered (B)
color or high translucency (C).

23. A–C WES analysis should be performed by choosing a tooth and

comparing it with its homolog (A,B). Shape (1), volume/contour (2),
color (3), texture (4), and translucency (5) are compared and a score
is assigned to each of these factors (C).
Table 01 Variables evaluated by the WES and their respective scores
(0, 1, or 2). Minimum total value = 0, maximum total value = 10

2.3. THE RELATIONSHIP BETWEEN TEETH AND

GINGIVA

The interaction between teeth and gingival tissue is an integral part of

the esthetics of the smile. The red esthetics relate to periodontal
health, the alignment of the gingival margins, and the presence of the
papillae. The papillae should fill the entire gingival embrasure,
avoiding the occurrence of black spaces. In situations where
periodontal or peri-implant tissue discrepancies are present, it may be
necessary to intervene in the soft tissue architecture (Figs 24A–C).
The anatomy and structure of periodontal and peri-implant tissues
should be known to prevent injury or detect changes (Figs 25A, B):
Gingival margin
Clinical sulcus
Attached gingiva
Mucogingival junction (MJ)
Alveolar mucosa (AM)
Papillae
24. A–C In addition to dental characteristics, it is important to analyze
the appearance of soft tissue, which may present an excess (A), may
be missing (B), or may present changes in color/texture (C).
25. A,B Anatomical components of the gingiva in frontal (A) and
lateral view (B).

The gingiva has a pinkish-reddish color, opaque surface, and firm

consistency in a healthy periodontium24. The gingival margin has a
parabolic contour and its most apical point is called the gingival zenith.
This shape is determined by the dental axis and buccal cervical
contour. Pre-established esthetic principles are used to guide the
position that the gingival margin of the anterior teeth should have. It is
necessary to consider the importance of establishing harmony
between periodontal esthetic components25.

2.3.1. GINGIVAL ZENITH

In frontal view, the gingival zenith of the central incisor and maxillary
canine is shifted distally; the zenith of the lateral incisor is located
slightly distal or coincident with the long axis of the tooth. This is
important in rehabilitations involving the entire buccal surface of the
tooth. In esthetic treatment, orthodontics or periodontal surgeries can
be performed to re-establish the location and relationship between the
zeniths. However, the dental phenotype, that is, the shape of the
tooth, influences the contour of the gingival zenith. Triangular teeth
tend to have a more pronounced zenith compared to square-shaped
teeth13,14,25.
The positioning of the gingival contour should follow the contour of
the upper lip and may be on the same level or slightly hidden under it.
Gingival contour changes are critical when they affect the central
incisors. On the other hand, small variations in the gingival contour of
the other teeth are more acceptable, resulting in a natural smile.

2.3.2. RELATIONSHIP BETWEEN GINGIVAL TISSUES

AND MAXILLARY ANTERIOR TEETH
The relationship between the gingival margins of the maxillary anterior
teeth can follow two esthetically pleasing contours. The most common
is when the gingival margin of the lateral incisor is more coronal to the
tangent drawn between the margins of the central incisor and canine
on the same side. Another possible harmony in gingival contour is
when the gingival margins of the central incisors, lateral incisors, and
canines on the same side are aligned on the same tangent13,14,25 (Figs
26A, B).
26. A,B Gingival margin of the maxillary lateral incisors more coronal
in relation to the gingival margin of the canines and central incisors
(A). Gingival margin of the maxillary lateral incisors at the same level
of the gingival margin of the canines and central incisors (B).

An unattractive gingival contour occurs when there are asymmetries

or when the gingival margin of the lateral incisor is apical to the
tangent drawn between the margins of the central incisor and canine
on the same side (Figure 27). To correct the position of the gingival
margin due to its coronal or apical migration, orthodontic or
periodontal procedures may be indicated (Figs 28A, B).
27. Asymmetry of gingival margins due to loss of tooth 21 and
orthodontic movement of the remaining anterior teeth to mesial to
close the space. Due to the difference in root width between the
contralateral teeth (11/22 and 12/23), treatment of this alteration by
surgical and restorative procedures only is.
28. A,B Patient with multiple gingival recessions (A) treated with a
periodontal procedure of root coverage (B).

The gingival margin is typically positioned at 1–2 mm from the

cementoenamel junction (CEJ). Insertion of a periodontal probe
between the gingival margin and the tooth is used to measure the
probing depth of the gingival sulcus. Increased values (> 4 mm) of
probing depth (PD) associated with periodontal bleeding and possible
changes in color and volume due to inflammation denote the presence
of periodontal pathology24. Its treatment through basic periodontal
therapy should precede any dental intervention. The goal is to obtain a
clinical PD between 1 mm and 3 mm, with no periodontal bleeding and
inflammation (Figs 29A, B). However, under more severe conditions,
it may not be possible to obtain these results immediately at the end of
treatment, so surgical techniques, reinterventions, or complementary
procedures (Figs 30A–G) may be applied to ensure the desired
periodontal health26.
29. A,B Patient gummy smile (A) who was treated with crown
lengthening surgery (B).
30. A–G A patient referred for periodontal esthetic evaluation (A)
before the removal of the maxillary orthodontic appliance had a deep
pocket (B) and the presence of premature contacts (C–E). The basic
periodontal treatment involved orientation and motivating oral hygiene,
scaling and root planning, and occlusal adjustment to obtain
periodontal health before any other procedure (F,G).

Apical migration of the gingival margin with root surface exposure

may occur after periodontal treatment or because of physiological
changes and mechanical trauma27. This condition is known as a
gingival recession (GR) and is measured by the distance between the
CEJ and the gingival margin. Another change in the position of the
gingival margin is the coronal migration of the gingival margin, above
the CEJ, which characterizes the presence of gingival hyperplasia
(GH). The evaluation of the gingival level (GL) and PD aims to verify
the clinical attachment level (CAL) of longitudinal periodontal control of
the patient (Figs 31A, B). CAL is calculated by adding to (recession
site) or subtracting (GH site) from the PD value.

31. A,B The clinical attachment level is determined by the sum (in
teeth with recession) or subtraction (in teeth with hyperplasia) of the
GL with the PD. Recession (A) and gingival hyperplasia (B) represent
the GL and are measured by the distance between the gingival margin
and the CEJ. If neither change exists, the GL is zero.
The amount of gingival attachment is determined by the distance
between the bottom of the sulcus and the MJ. This amount varies,
depending on the patient, region, and presence of associated
pathologies. In the past, the presence of a minimum of 2 mm of
attached gingiva was considered necessary for periodontal health.
Techniques for increasing this range have been employed extensively
with predictable results. Currently, both in teeth and implants, the
scientific literature28,29 considers that as long as the patient can keep
proper hygiene, this minimum range is not necessary for periodontal
health (Figs 32A, B). Some studies suggest that in the case implants,
the presence of gingival attachment is necessary to avoid peri-implant
problems. However, there is still no consensus in the literature30. The
major concern when the patient presents with only AM around teeth or
implants is due to the structure of this tissue, which is less resistant to
inflammation, and the painful sensitivity a patient may have when
cleaning the region24. In addition to functional problems, alteration of
the position of the AM may cause esthetic changes due to the
difference in color and contrast with adjacent tissues (Fig 32C).
Despite these adverse factors regarding the AM, it is necessary to pay
particular attention to this anatomical component in reconstructive
surgical techniques, due to its manipulation in the coronal or apical
direction, since its elasticity and nutritional capacity will allow the
closure, stabilization, and nutrition of the flap.
32. A–C Depending on the region and patient, it may be challenging to
remove dental biofilm in areas without attached gingiva. The right
mandibular canine region where the patient reported gingival pain and
difficulty with brushing (A) and left mandibular canine where the same
patient reported no discomfort or difficulty with brushing (B). Soft
tissue color change due to coronal traction of the AM for first intention
closure of a flap performed for implantation and grafting with bone and
gingival tissue (C).

The papilla occupies the gingival embrasure, the space below the
interdental contact. Its anatomy is determined by the width of the
interproximal space, the anatomy of the CEJ, the emergence profile,
and the proximal contact31. Because of these characteristics, it has a
pyramidal shape in the anterior teeth and a saddle shape in the
posterior teeth. In the posterior teeth, the papilla presents as a valley-
shaped depression that joins the lingual and buccal papillae24.
In rehabilitative planning, it is necessary to establish a papilla as a
reference; the one of choice is usually the papilla between the
maxillary central incisors, which should be positioned coronal in
relation to the other papillae (Fig 33). The papilla may fill the
interproximal space completely, partially, or be absent.

33. The interdental papillae are higher in the region of the maxillary
central incisors, being progressively more apical the further they are
from the midline.

Tarnow et al32 demonstrated the importance of the relationship

between the contact point and the bone crest to determine the
presence of interdental papillae. The gingival papillae filled the
embrasure in its entirety in 100%, 56%, and 27% when the distance
from the tip of the papillae to the bone crest was 5 mm, 6 mm, and 7
mm or less, respectively (Figs 34A–O).
34. A–O The relationship between the contact point and the bone
crest may influence the amount of soft tissue present in the gingival
embrasure. Decreased (A, E, I), normal (B, F, J, M), or increased
distance (C , D, G, H, K, L, N, O).

The unique anatomy of the papilla and its terminal vascularization

make the reconstruction of this periodontal component extremely
difficult. It is the real Achilles heel of periodontal reconstructive
techniques. Treatment of papilla loss should be carefully planned. It
should consider the position of the bone crest, its relationship to the
contact point, and the periodontal and dental condition of adjacent
teeth32.
Restorative and orthodontic treatment are more predictable than
surgical treatment to improve the appearance of the interproximal
region. When the defect is generalized and occurs between the
central or both sides, restorative therapy will provide satisfactory
results by re-anatomizing the gingival embrasure and transforming a
contact point into a contact area, approximating it to the bone crest
(Figs 35A–D).

35. A–D Bilateral papillae defects between central and lateral

maxillary incisors (A, B). Planning for replacement of restorations
should involve modifying the dental anatomy from triangular to square
to allow a better esthetic and functional outcome (C, D).

When the defect occurs unilaterally, restorations alone may not be

able to restore the esthetics of the patient successfully. These cases
are more challenging to resolve when they happen between the
maxillary central incisors. Orthodontic therapy may be necessary to
approximate the bone crest to the contact point by slow tooth
extrusion. This technique allows the increase of periodontal and bone
tissue in height (Figs 36A–C). After the orthodontic movement,
restorative and/or surgical therapy may be required to finalize the
case.
36. A–C Unilateral papillary defect between central and lateral
maxillary incisors treated exclusively with restorative therapy did not
guarantee a satisfactory outcome (A, B). Orthodontic extrusion may
be performed to allow bone and gingival gain in height (C). Contour
over image demonstrates optimal gingival shape.

The treatment of papilla defects in regions around implants is even

more unpredictable when extensive bone defects or misplaced
implants are present. Due to the impossibility of extruding the implant
or surgical procedures to increase the soft and bone tissue in height,
other alternatives may be necessary. Adjacent tooth extrusion,
injection of filler materials such as hyaluronic acid, and performing
restorative procedures with or without artificial gingiva may be
required33 (Figs 37A–L).
37. A–L Patient with missing maxillary lateral incisors and previously
treated with implants (A–C). Esthetic disharmony as a result of
maxillary lateral incisors longer than the central incisors and loss of
papillae (D–F). Clinical crown lengthening was performed in the
maxillary central incisor and canine. A connective tissue graft was
placed in the lateral incisor region to increase the volume and coronal
repositioning of the peri-implant margin (G–I). After tissue healing, the
anatomy of the anterior region changed (J–L). Surgical procedure: Dr
Fausto Frizzera; restorative procedure: Dra Bianca Vimercati.

The patient’s perception of the tissue around a tooth or implant

ranges between satisfactory and unsatisfactory. Because of its
importance for planning, execution, and preservation of the case,
methods have been developed to assess the soft tissue esthetics
numerically. Fürhauser et al34 initially proposed the quantification of
gingival esthetic susing the Pink Esthetic Score (PES), which takes
into consideration the mesial and distal papillae, the soft tissue margin
and contour, and color, texture, and volume. The seven aspects
chosen should receive a score from 0 to 2 with a maximum score of
14.
PES alone has a more significant number of items to be evaluated;
the number of analyses diminishes the importance of esthetic
components such as the papillae and gingival margin but allows the
identification of specific situations, such as the discrepancy in the
alveolar ridge volume. Belser et al23 proposed a modification of the
PES by condensing color, volume, and texture into a single category.
They reduced to five the number of esthetic evaluations that should
also receive a score from 0 to 2 with a maximum score of 10 (Figs
38A–C and Table 02). The modified PES is more accurate regarding
the evaluation of the gingival margin position and comparison with
adjacent teeth, but it condenses the characteristics inherent to the
alveolar ridge; in this index, the tissue aspect is considered as
esthetically satisfactory when it has a value equal to or greater than 6.

38. A–C Modified PES analysis should be performed by choosing a

tooth and comparing it with its homologous counterpart (A, B). The
mesial (1) and distal (2) papilla, curvature of facial mucosa (3), level of
facial mucosa (4), and root convexity/soft tissue color and texture (5)
are compared and a score is assigned to each of these categories (C).

Table 02. Aspects assessed with the PES and their scores (0, 1, or 2).
Total minimum value = 0, total maximum value = 10

2.4. DIGITAL SMILE DESIGN

Given the knowledge of what is normal or harmonic in dentistry, we

can detect what is altered in the esthetics of the patient. These
changes can be subtle and go unnoticed during the diagnosis and
design of a multidisciplinary esthetic treatment plan. DSD1 was
developed to facilitate diagnosis, planning, and interpersonal
communication and involves professionals from different specialties
such as laboratory technicians. Patients who have alterations in their
gingival tissue architecture are usually candidates for this type of
approach.
DSD combines knowledge of facial, dental, and gingival anatomy
with technology to create smiles (Table 03). With this tool, facial
reference lines are implemented in photographs to individually design
how the patient’s teeth should look at the end of treatment (Figs 39A,
B and 40A–I). This reverse planning will guide the type of treatment,
allowing professionals from different dental specialties to decide which
paths to follow in treating the patient.

PERIODONTAL
FACIAL ANALYSIS DENTAL ANALYSIS ANALYSIS

Symmetry Color Health

Facial height Characteristics and Contour of the

texture gingival margin

Upper lip width Arrangement Height of the

gingival margin

Lip mobility Shape Soft tissue – color,

texture, and volume

Smile line Volume Interdental papillae

Table 03. Facial, dental, and periodontal aspects

39. A, B A photograph of the face is rotated, if necessary, to allow
proper positioning of the patient’s face (A). The interpupillary line is
used to check if the position is correct and the midline of the face is
then drawn (B).

40. A–I An approximate photo of the smile is taken at the same angle
as the photograph of the face (A). The patient’s midline is added to
the image (B) as well as the maxillary edge of the lower lip (C), which
represents the curvature the smile should follow. Two lines are
created in the lateral region of the nose. These lines will represent the
distal aspect of the maxillary canine in a frontal view. The space
created on the right and left side is then divided according to the
golden proportion, delimiting the mesiodistal width of the maxillary
central and lateral incisors and canine (D). Taking into account the
mesiodistal width of the maxillary central incisor, its height is defined
using the ratio of height 10 to width 8, or 80%. The tooth is then
designed, taking into account the determined size (E). The lower edge
of the upper lip and the curvature of the gingival margins (F) are
drawn and then the interdental papillae (G) are created. With the
contour of the gingival tissue determined, the other teeth are drawn
(H) with the aim of solving the present alteration (I).

To help the diagnosis and planning (Figs 41A–E) of complex

esthetic cases that require multidisciplinary intervention, Robbins and
Rouse35 established specific requirements for facial, lip, dental, and
periodontal components (Table 04).
a – Right side; b – Left side; c – Upper third; d – Mid-third; e –
Lower third; f –Upper lip width; g – Upper lip mobility; h –
Length of maxillary central incisor; i – Gingival exposure; j –
Smile line.

41. A–E Typical facial components (A, B). Alteration of facial

components can compromise esthetics (C–E).

ANATOMICAL
COMPONENT MUST PRESENT

Facial height Ratio 1:1, where the mid-third = the lower

third of the face

Upper lip width Measurement ranges from 20 mmto 24 mm

(distance from the base of the nose to the
upper lip)

Upper lip mobility The lip should move around 6–8 mm from
rest to smile

Gingival contour Straight or sinuous presenting symmetry of

both sides

Length of maxillary central Average 10–11 mm

incisor
 Cementoenamel junction Detectable through probing

Table 04. Facial, lip, dental, and periodontal requirements

3. CLINICAL APPLICATION

Correction of esthetic and functional alterations requiring

multidisciplinary treatment will depend on the type of alteration
present. All professionals involved in the treatment should evaluate
the initial case and then any complementary exams in isolation. From
the diagnosis of the change and the possibilities for its resolution,
there should be communication between professionals from different
specialties to define the treatment plan. Professionals should
communicate to the patient the benefits of the therapy to be
undertaken and outline the risks and care that will be used to minimize
them.
A flowchart outlining the chronology of the procedures should be
prepared and the patient should be warned that some changes may
occur during treatment. The important thing is to direct the flow of
treatment to its resolution whereby working professionals understand
and follow the planning. Adopting this philosophy requires better
planning, but can avoid retreatment, reduce the time spent on
treatment, and the physical and biological effort needed from the
patient. The main goal is to customize the treatment to maximize the
results.
Facial alterations, where the middle third is different in size from the
lower third, may require orthognathic surgery. Muscle changes
involving the upper lip, which is short or hyperactive, will require
cosmetic procedures that increase lip volume by filling or reducing
muscle movement with botulinum toxin. Orthodontic and periodontal
procedures can correct the gingival contour; the choice will depend on
the relationship between the cementoenamel junction and the gingival
margin. Restorative dentistry can also be indicated before or during
treatment to modify the patient’s smile, motivate the patient, and
promote health. This last area of dentistry is also the end point of
multidisciplinary treatments where the initially expected result should
be achieved.
To plan a rehabilitation, the patient’s upper lip or upper central
incisor gingival zenith can be used as a reference (Figs 42A–C).
Rehabilitation will follow one of these anatomical components, which
will indicate the need for surgical, cosmetic, periodontal, orthodontic,
and restorative procedures.

42. A–C Position that the gingival zeniths should take after treatment
(A); the need for horizontal correction through orthodontic treatment is
demonstrated (B–C).

3.1. ESTHETIC CORRECTION WITH ORTHODONTIC,

SURGICAL, AND RESTORATIVE PROCEDURES
43. A–P Young patient with missing maxillary lateral incisors, gummy
smile, short teeth, and diastemas. During orthodontic therapy,
periodontal evaluation was requested for esthetic resolution of the
case (A). Harmony in the height/width ratio would require extensive
crown lengthening with root surface exposure, arch retraction,
diastema closure, and dental midline correction (B–D). After
completion of orthodontic movement in the maxillary arch, the
appliance was removed and the surgical procedure planned.
Reduction of the diastemas allowed the clinical crown augmentation to
be performed in a less invasive manner, avoiding exposure of the root
surface (E–J). The surgical procedure performed consisted of clinical
crown lengthening with removal of bone tissue. In the anterior region,
surgery was performed without flap reflection (K–P).

44. A–O Due to excess tissue in the posterior region, a flap was
reflected bilaterally to reduce bone height and thickness (A–C). Result
after combined surgical and orthodontic therapy (D–G). Images of
initial smile (social – H), after diastema closure (I, M), appliance
removal (J), periodontal surgery (K, N), and restorative treatment (L,
O). Case report partially published by Tonetto et al.36 Surgical
procedure: Dr Fausto Frizzera; restorative procedure: Dr Mateus
Tonetto.

3.2. ESTHETIC CORRECTION WITH SURGICAL AND

RESTORATIVE PROCEDURES

45. A–J Patient with oblique root fracture on tooth 21, absence of
buccal bone, thin periodontal biotype and complaint about smile
esthetics (A–F). The etiology of the fracture was attributed to occlusal
trauma to tooth 21 that had metal post and a ceramic crown with no
evidence of wear, while the other anterior teeth presented incisal
wear. Digital analysis of the smile verified the change in dental
proportion, gingival margin position, and midline deviation (G–J).
46. A–F Planning was guided by the ideal position of the gingival
zenith. Clinical crown lengthening proved necessary on teeth 12 and
13, in addition to maintaining the position of the gingival margin on
tooth 21 after its replacement by implant.
47. A–K After careful extraction of tooth 21, the extension of the
buccal bone defect was confirmed. Due to the presence of lingual
bone, an implant was installed and had sufficient stability to make an
immediate provisional.
48. A–K To maintain the gingival margin, in the same session, tissue
regeneration with bone and gingival graft was performed. An
immediate screwed provisional without occlusal contacts was installed
(A–G). The procedure showed a satisfactory result; after 4 months,
the crown lengthening on teeth 13 and 12 was planned (H–K).
49. A–M Clinical flapless crown lengthening was performed on teeth
13 and 12 (A–C). After tissue healing, impressions were taken, to
make a custom prosthetic component and diagnostic wax-up (D–M).

50. A–J A zirconia abutment was manufactured using the computer-

aided design/computer-assisted manufacture system and installed
without generating soft tissue compression (A–D). After the putty
matrix was done with heavy body polyvinyl siloxane, based on the
diagnostic wax-up, the matrix was filled with bis-acrylic resin and
placed into position. The preparation was performed on the mock-up
in a minimally invasive manner. A final impression was taken and sent
to the laboratory to manufacture the ceramic restorations (E–J).
51. A–K Porcelain contact lenses, veneers, and crowns were
fabricated to reestablish function and esthetics. The case partially
published by Frizzera et al37. Surgical procedure: Dr Fausto Frizzera;
restorative treatment: Dr Mateus Tonetto and laboratory technician
André Ferraz.

REFERENCES

1. Coachman C, Calamita M, Schyder A. Digital Smile Design: uma

ferramenta para planejamento e comunicação em odontologia
estética. Flo - rianópolis: Editora Ponto 2012, v.1, n.2.
2. Carrilho EVP, Paula A. Reabilitações estéticas complexas
 baseadas na proporção áurea. Rev Port Estomatol Med Dent Cir
Maxilofac 2007;48:43–53.
3. Mondelli J. Estética e Cosmética em Clínica Integrada
Restauradora. São Paulo, Brazil: Santos, 2003.
4. Conceição EN. Análise estética. In: Conceição EN (ed).
Restaurações Estéticas – Compósitos, Cerâmicas e Implantes.
São Paulo, Brazil: Artmed, 2005:33–57.
5. Marques S. Harmonia entre o sorriso e a face. In: Marques S
(ed). Estética com Resinas Compostas em Dentes Anteriores:
Percepção, Arte e Natura-Lidade. São Paulo, Brazil: Santos,
2005:15–23.
6. Rifkin R. Facial analysis: a comprehensive approach to treatment
planning in aesthetic dentistry. Pract Periodontics Aesthet Dent
2000;12:865–871.
7. Allen EP. Surgical crown lengthening for function and esthetics.
Dent Clin North Am 1993;37:163–179.
8. Sterrett JD, Oliver T, Robinson F, Fortson W, Knaak B, Russell
CM. Width/length ratios of normal clinical crowns of the maxillary
anterior dentition in man. J Clin Periodontol 1999;26:153–157.
9. Chiche G, Pinault A. Critères artistiques et scientifiques en
dentisterie esthétiques. In: Chiche G, Pinault A (eds.). Esthétique
et Restauration des Dents Antérieures. Paris, France: CdP,
1995:1–32.
10. Schluger S, Yuodelis RC, Johnson RH. Periodontal Disease, ed
2. Philadelphia, PA: Lea & Febinger, 1990.
11. Maynard JG. Mucogingival considerations for the adolescent
patient. In: Nevins M, Mellonig JT (eds). Periodontal Therapy:
Clinical Approaches and Evidence of Success. Chicago, IL:
Quintessence Publishing Co, 1998:291–303.
12. Benoît R, Genon P. Indications for mucogingival therapy in
children and adolescents. Actual Odontostomatol (Paris)
1985;39:173–196.
13. Masioli MA et al. Odontologia Restauradora de A a Z.
Florianópolis, Brazil: Editora Ponto, 2012:396.
14. Masioli MA et al. Anatomia Dental de A a Z. Porto Alegre,
Portugal: Ponto, 2015.
15. Andrews LF. The six keys to normal occlusion. Am J Orthod
1972;62: 296–309.
16. Andrews LF. Straight-Wire: The Concept and Appliance. San
Diego, CA: L.A. Wells, 1989.
17. Magne P, Belser U. Restaurações Adesivas de Porcelana na
Dentição Anterior: Uma Abordagem Biomimética. São Paulo,
Brazil: Quintessence, 2003.
18. American Academy of Cosmetic Dentistry. Accreditation
examination criteria, number 21: Is there a progressive increase
in the size of the incisal embrasures? Madison, WI: American
Academy of Cosmetic Dentistry, 1999.
19. Lombardi RE. The principles of visual perception and their clinical
application to denture esthetics. J Prosthet Dent 1973;29:358–
382.
20. Rufenacht C. Fundamentals of Esthetics. Chicago, IL:
Quintessence, 1990.
21. Mendes WB, Bonfante G. Fundamentos de Estética em
Odontologia, ed 2. São Paulo, Brazil: Santos, 1996.
22. Morley J, Eubank J. Advanced smile design. Course presented
at: 141st Annual Session of the American Dental Association
2000:17.
23. Belser UC, Grütter L, Vailati F, Bornstein MM, Weber H-P, Buser
D. Outcome evaluation of early placed maxillary anterior single-
tooth implants using objective esthetic criteria: a cross-sectional,
retrospective study in 45 patients with a 2- to 4-year follow-up
using pink and white esthetic scores. J Periodontol 2009;80:140–
151.
24. Lindhe J, Lang N, Karring T. Tratado de periodontia clínica e
implantologia oral, ed 5. Rio de Janeiro, Brazil: Guanabara
Koogan, 2010.
25. Câmara CA. Estética em ortodontia: parte I. Diagrama de
Referências Estéticas Dentais (DRED). R Dental Press Estét
 2004;1:40–57.
26. Ryder MI, Armitage GC. Minimally invasive periodontal therapy
for general practitioners. Periodontology 2000;71:7–9.
27. American Academy of Periodontology. International Workshop for
a Classification of Periodontal Diseases and Conditions. Ann
Periodontol 1999;4:53–54.
28. Wennstrom JL, Serino G, Lindhe J, Eneroth L, Tollskog G.
Periodontal conditions of adult regular dental care attendants. A
12-year longitudinal study. J Clin Periodontol 1993;20:714–722.
29. Bengazi F, Wennström JL, Lekholm U. Recession of the soft
tissue margin at oral implants. A 2-year longitudinal prospective
study. Clin Oral Implants Res 1996;7:303–310.
30. Salvi GE, Lang NP. Diagnostic parameters for monitoring peri-
implant conditions. Int J Oral Maxillofac Implants 2004;19:116–
127.
31. Gonzales MR, Pitta Ritto F, da Silveira Lacerda RA, Sampaio HR,
Monnerat AF, Pinto BD. Falhas em restaurações com facetas
laminadas: uma revisão de literatura de 20 anos. Rev Bras
Odontol 2011;68:238–243.
32. Tarnow DP, Magner AW, Fletcher P. The effect of the distance
from the contact point to the crest of bone on the presence or
absence of the interproximal dental papilla. J Periodontol
1992;63:995–996.
33. Lee WP, Seo YS, Kim H J, Yu SJ, Kim BO. The association
between radiographic embrasure morphology and interdental
papilla reconstruction using injectable hyaluronic acid gel. J
Periodontal Implant Sci 2016;46:277–287.
34. Fürhauser R, Florescu D, Benesch T, Haas R, Mailath G, Watzek
G. Evaluation of soft tissue around single-tooth implant crowns:
the pink esthetic score. Clin Oral Implants Res 2005;16:639–644.
35. Robbins JW, Rouse JS. Global Diagnosis: A New Vision of Dental
Diagnosis and Treatment Planning. Hanover Park, IL:
Quintessence Publishing Company, 2016:244.
36. Tonetto MR, Frizzera F, Silva MB, Bhandi SH, Kuga MC, Pereira
 KF, Pinzan-Vercelino CR, Bandéca MC. Semidirect restorations
in multidisciplinary treatment: viable option for children and
teenagers. J Contemp Dent Pract 2015;16:280–283.
37. Frizzera F, Tonetto M, Cabral G, Shibli JA, Marcantonio E Jr.
Periodontics, implantology, and prosthodontics integrated: the
zenith-driven rehabilitation. Case Rep Dent 2017;2017:1–
8.Rovidernam, quamet as
 CHAPTER 2
GINGIVAL CONTOUR IN
THE ESTHETIC ZONE:
treatment of short clinical crowns
Fausto Frizzera, Cristiano H. Pascoal, Rodrigo Nahas, Giuseppe A. Romito,
Rubens Moreno de Freitas, Elcio Marcantonio Jr
1. INTRODUCTION

Conceiving new smiles demands knowledge of biology and the proper

use of periodontal or peri-implant plastic surgery to combine esthetics
and function. It is necessary to evaluate the contour of the soft tissue
to establish harmony between the whole set to perform rehabilitation
in the anterior region. Tissue recontouring can be used to correct long
or short clinical crowns1.
Achieving an adequate gingival architecture is necessary, especially
in patients with high and intermediate smile lines. However, it can also
be an aim of patients with a low smile line with high esthetic demand.
Thus, the treatment plan should be guided by the future position of the
gingival zeniths2.
When the treatment plan involves implants, surgical and prosthetic
planning should initially determine the final gingival contour3. Based on
this treatment plan, it is possible to determine the position of the
implant. It also allows verifying the need for orthodontic corrections to
modify the gingival zenith in the horizontal and vertical directions.
Alternatively, surgical procedures may be necessary to modify the
position of the gingival zenith vertically.
Both periodontal recession, with root surface exposure, and short
clinical crowns, due to excess periodontal tissue, can cause changes
in the appearance of the length of the teeth4. To correct the position of
the gingival margin, periodontal plastic procedures can be performed
to recontour the tissue and provide a suitable contour for
rehabilitation. This chapter addresses the treatment of patients with
short clinical crowns and gummy smile.

OBJECTIVES
At the end of the chapter, the reader should be able to:
Understand the clinical and biological concepts in the treatment of
short clinical crowns.
 Choose the appropriate treatment for patients with a gummy smile.
Perform appropriate surgical treatment of teeth with short clinical
crowns.

2. SCIENTIFIC BACKGROUND

2.1 GINGIVAL EXPOSURE

The harmonious relationship between face, lips, teeth, and

periodontium is a common desire among patients who have a high
degree of gingival exposure when smiling. The tooth should ideally
have a height/width ratio of around 75–85% (Figs 01A–D). A reduced
clinical crown results in an anti-esthetic condition known as short tooth
syndrome5. It can be caused by tooth wear on the incisal edges,
gingival hyperplasia, or altered passive eruption (Figs 02A–C).

01. A–D Anterior teeth with short clinical crowns and altered
height/width ratio (A, B) verified by periodontal (C) or Chu (D) probe.
02. A–C Changes that may cause short clinical crowns: incisal wear
(A), gingival hyperplasia (B), and altered passive eruption (C).

Together with a reduced clinical crown, the patient may also have a
high smile line, making short crowns more noticeable. In a
spontaneous smile, if exposure of gingival tissue is greater than or
equal to 3 mm, the smile is classified as a gummy smile6. Studies
assessing the perception of dentists and patients about the amount of
gingival exposure and contouring have shown that exposure of more
than 2 mm of gingival tissue when smiling or the presence of gingival
asymmetries will impair facial esthetics7,8.
A gummy smile may be caused by dental, gingival, lip, or jaw
changes6. Both a gummy smile and the presence of short teeth may
be associated and intensify the existing discrepancy. Diagnosis of the
etiology of a gummy smile is necessary to determine the best
treatment plan. Several factors may act alone or in combination to
cause excessive gingival exposure when smiling (Table 01).

TEETH AND CHANGE IN SKELETAL POSITIONING

Excessive vertical growth of the maxilla

Protrusion and/or extrusion of the maxillary anterior teeth and ridge

MUSCULAR CHANGES

Lip hyperactivity

Short and/or thin upper lip

PERIODONTAL CHANGES

Gingival hyperplasia
 Altered passive eruption

Table 01 Factors that may influence gingival exposure in the smile

2.2. TEETH AND CHANGES IN SKELETAL POSITIONING

Orthodontics can treat bone alterations or dental mispositioning.

Orthognathic surgery may be necessary for three-dimensional
repositioning of the maxilla and correction of the gingival smile. The
presence of vertical maxillary excess is determined by augmentation
of the middle third of the face. The diagnosis is made by clinical and
radiographic methods (Figs 03A–G). This change is one of the
frequent causes of a gummy smile, and its treatment needs to take
into consideration surgical and orthodontic planning and treatment9.
03. A–G Presence of maxillary vertical excess (A), which requires
osteotomy (B, C) and repositioning (D). Clinical aspect of a patient
with maxillary vertical excess (E) and short teeth. Projection of the
possible results of orthodontic-surgical treatment (F, G).

Alteration of teeth positioning by extrusion or protrusion can be

treated exclusively using orthodontic procedures, depending on
severity. In these situations, it is necessary to understand the dental
changes that may occur during tooth movement. Tooth intrusion
should be performed extremely slowly to avoid damage to the
periodontium and root surface. In these situations, approximately 30%
of the periodontal volume is expected to accumulate in the cervical
region of the tooth, increasing gingival thickness. Periodontal or
restorative procedures to correct the dental proportion may be
required10,11 (Figs 04A–F).
04. A–F Patient with anterior open bite and gingival smile (A); in the
posterior region, gingival exposure was even more pronounced due to
the extrusion of the posterior teeth. Orthodontic treatment in the
maxillary and mandibular arch was performed to correct malocclusion
and intrusion of the maxillary teeth with the aid of two mini-plates (B–
D). Subsequently, clinical crown augmentation was performed before
restorative completion (E–F). Surgical procedure: Dr Fausto Frizzera;
orthodontic procedure: Dr Deise Cunha.

Lingual tooth movement usually reduces the length of the clinical

crown and also increases the gingival volume and may promote
spontaneous resolution of gingival recessions10.The opposite may
occur if the tooth is inclined or moved buccally. Care must be taken.
Tooth extrusion aims to increase the amount of bone and gingival
height but should be associated with surgical or restorative
procedures to rehabilitate the case (Figs 05A–C and 06A–F).

05. A–C Vertical tissue increase in periodontal patient obtained after

orthodontic extrusion of the two maxillary central incisors. Periodontal
treatment: Dr Rodrigo Nahas.
06. A–F Integrated approach to esthetic deficiency resolution in the
peri-implant region of tooth 13; note the possibility of improving the
position of the mesial papilla of tooth 12. Clinical procedures: Dr
Ulisses Dayube.

2.3. CHANGES IN MUSCULATURE

The lip musculature is activated in the act of smiling and can express
an authentic or social smile12. In an authentic smile, there is an
involuntary contraction of the muscles lifting the upper lip and
orbicularis oculi muscle(where it is possible to verify the formation of
slight wrinkles laterally to the eye). Unlike a social smile, it is not
possible to control the amount of gingival exposure. It is the smile
used for diagnosis and planning in dentistry (Figs 07A, B). The upper
lip rises between 6 mm and 8 mm from the resting to the smiling
position. When muscle hyperactivity is present, this distance may
even double13.

07. A, B Social (A) and authentic smile (B); note the contraction of the
periorbicular musculature and increased gingival exposure when
smiling.

To treat lip hyperactivity, we do not recommend invasive procedures

on the lip or upper lip elevator muscles because there is no scientific
evidence on the stability of long-term outcomes14. Few scientific
studies are available on these techniques and only provide 6 months
of results. Due concerns with the recurrence of a gummy smile, these
techniques have been questioned15. Given the long-term outcome of
these techniques and their invasiveness, semiannual botulinum toxin
therapy (Figs 08A, B) has proven more effective, with the advantage
of being less invasive16.

08. A, B Botulinum toxin application points to treat a gummy smile.

Short or thin lips may increase the amount of gingival exposure

when smiling; treatment can be performed by injecting temporary
filling material17. The commonly used material is hyaluronic acid,
which has the potential to increase lip volume and improve its contour.
A randomized clinical trial on the use of hyaluronic acid showed
significant improvement in upper and lower lip esthetic evaluations;
reported adverse effects such as bruising, edema, and pain were mild
and reversible18. Although it is a minimally invasive procedure, it
should only be performed by trained and experienced professionals
since major complications like thromboembolism and bruising may
occur17.
Exposure of gingival tissue while smiling is typical of young patients;
over the years, there is accommodation of the musculature and a
tendency to reduced teeth and gingival exposure19. Many patients with
adequately proportioned teeth and a gummy smile show self-
correction of this change over the years, requiring no intervention
(Figs 09A–D). If there is any degree of asymmetry between the
gingival margins or a change in the high/width ratio, it can be resolved
by surgical and/or restorative procedures.

09. A–D The reduction in gingival and maxillary teeth exposure occurs
over the years. Adolescent (A), young adult (B), adult (C), and elderly
(D) patients.
2.4. PERIODONTAL CHANGES

The patient may have a thin, intermediate, or thick gingival biotype.

The biotype influences the thickness of the gingival and bone tissue
and the shape of the tooth (Figs 10A–L). In addition, periodontal
changes may partially cover the clinical crown so that it appears
shorter. This condition impairs esthetics due to changes in the
height/width ratio of the tooth and by altering the gingival contour and
papillae.
10. A–L Biotypes and their relationship to bone crest and gingival
tissue.

2.4.1. GINGIVAL HYPERPLASIA

Gingival hyperplasia is a change in the periodontium that can occur
from periodontal inflammation due to biofilm accumulation, drugs, or
genetic alterations. The edema that occurs in gingivitis may be
potentiated with biofilm accumulation and excess gingival tissue
reduces the length of the visible clinical crown20. Treatment of this
alteration involves adequate oral hygiene and basic periodontal
therapy. The tissue becomes healthy and returns to its prior
dimensions with the reduction of inflammation and maintenance of low
biofilm levels. If it remains altered, surgical removal of excess tissue
may be indicated20.
Gingival hyperplasia can also be caused by medications that act at
the systemic level and are potentiated when biofilm is present (Figs
11A, B). Anticonvulsive drugs, immunosuppressants, and calcium
channel blockers are among the drugs that can affect gingival tissue.
Any area of the arch may be affected, but it most frequently affects the
facial surface of the anterior teeth, beginning in the interdental
papillae21. Prevention of this alteration focuses on biofilm control
before beginning drug therapy and maintenance of low biofilm levels
during the medication use. Treatment of drug-induced gingival
hyperplasia involves control of biofilm and basic periodontal therapy.
After restoring gingival health, the need for a surgical intervention is
verified.

11. A, B Patients with drug-induced gingival hyperplasia.

12. A, B Patient diagnosed with hereditary gingival fibromatosis.

Hereditary gingival fibromatosis (Figs 12A, B) is a condition caused

by a rare genetic disorder (1:750,000), with family aggregation, which
is clinically characterized by slow, continuous, and progressive growth
of gingival tissue in the maxilla and mandible22. Clinically, the gingiva
has normal coloration and firm consistency; it is asymptomatic and
nonhemorrhagic23. Severe gingival growth causes esthetic and
functional impairment to the point of causing diastema, interfering with
speech, chewing, occlusion, dental positioning, and facial
appearance24. Treatment involves excision of all hyperplasia tissue to
restore the proper shape of the gingiva; further interventions may be
necessary due to slow and continuous gingival growth.

2.4.2. ALTERED PASSIVE ERUPTION

Tooth eruption can be described in distinct stages: active eruption and
passive eruption. Active eruption is the displacement of the tooth from
its developmental position in the bone, through the oral epithelium,
erupting into the oral cavity. Active eruption happens until the tooth
contacts the opposing tooth, thus starting to function. This movement
brings with it the periodontal tissues; at the end of this process, the
gingival margin and part of the junctional epithelium still significantly
cover the anatomical crown. Then, the passive eruption stage begins,
where there is apical migration of these tissues in relation to the
cementoenamel junction (CEJ)25. There is an impression of “eruption”
with increased exposure of the crown, giving this stage its name
(passive eruption) the passive eruption name. In certain situations,
most commonly in sites with thick tissue biotype, this migration is
incomplete (Figs 13A–F and 14A–E). Thus, the tooth, despite having
a satisfactory anatomical crown, shows a short clinical crown,
compromising the esthetics of the tooth5,26.
13. A–F Tooth eruption may occur inappropriately when a change in
the relationship between the CEJ and bone crest occurs.

14. A–E Normally, the approximate distance between gingival margin

and bone crest is 3 mm and the CEJ is positioned 2 mm coronal to the
bone tissue.
 The definition of altered passive eruption (APE) should take into
account the age of the patient and should not be diagnosed until the
passive eruption process has been completed. This process occurs
during adolescence and is usually completed around the age of 2727.
Coslet et al28 classified APE into two types (Figs 15A, B) according to
the amount of gingival tissue measured from the free gingival margin
to the mucogingival line:
Type I: Short clinical crowns associated with an excessive amount of
keratinized tissue (measurement of mucogingival junction to free
gingival margin). This type is usually present in patients with athick
biotype;
Type II: Short clinical crowns associated with keratinized tissue
dimensions of less than or equal to 2 mm.

15. A, B Altered passive eruption type I (A) and II (B) according to the
distance between the gingival margin and mucogingival junction.

In patients with type I APE, it is possible to excise the excessive

gingival tissue without removing keratinized tissuecompletely. On the
other hand, patients with type II APE, because of the small band of
keratinized tissue, this tissue cannot be removed. Techniques for
apical tissue repositioning are recommended29.
In addition, a change in biologic width may occur, and the alveolar
bone crest (ABC) may be located closer to the CEJ. Classical studies
show that, on average, the connective tissue attachment and
junctional epithelium have a vertical dimension of 1 mm each, while
the histologic gingival sulcus is approximately 0.7 mm30. In patients
with a healthy periodontium, both connective tissue attachment and
junctional epithelium have stable dimensions; the sulcus may present
different measurements and lead to morphologic changes in the
appearance of the clinical crown. There are two subcategories of APE
regarding the position of the bone crest in relation to the CEJ:
Subcategory A: The distance from the ABC to the CEJ is greater
than 2 mm, with adequate space for the insertion of the connective
tissue attachment fibers. Thus, osteoplasty during the surgical
procedure is not necessary (Figs 16A, B).
Subcategory B: The distance from the ABC to the CEJ is less than 2
mm and there is not enough space for the insertion of the connective
tissue fibers apical to the CEJ. Thus, osteotomy is required to re-
establish the biologic width (Figs 17A, B).

16. A, B Subcategory A, where gingival tissue covering part of the

anatomical crown of the tooth (A) and an adequate relationship
between CEJ and alveolar bone crest can be seen (B).
17. A, B Subcategory B where it is possible to notice the gingival
tissue covering part of the anatomical crown of the tooth (A) and the
relationship between the CEJ and the alveolar bone crest (ABC) (B).

Bone probing and periapical radiographs can be used to determine

the size of the clinical crown (Figs 18A, B and 19A, B)6,31. It is also
possible to estimate the position of the CEJ but with limited accuracy.
To verify the real relationship between the CEJ and buccal bone, it is
necessary to perform a coe beam computed tomography scan, which
also enables measuring the gingival thickness when using a lip
retractor32. By establishing the relationship between the ABC and CEJ,
it is possible to classify the APE and define the surgical treatment plan
(Figs 20A–C and Table 02).

18. A, B Altered passive eruption type IB. Clinical smile (A) and
intraoral aspect (B).

19. A, B Type IB APE. The relationship between the ABC and CEJ is
less than 2 mm, requiring osteotomy (A). After osteotomy it is possible
to verify the re-establishment of the biologic width (B).
20. A–C Methods for estimating clinical crown size: bone probing (A);
periapical radiography (B); cone beam computed tomography that
allows gingival thickness to be measured and relationship between the
CEJ and bone crest (C).

GINGIVAL
CLASSIFICATION PROCEDURE BONE PROCEDURE

APE Type IA Surgical excision of No need for osteotomy

excess gingival tissue

APE Type IB Surgical excision of Osteotomy is needed to

excess gingival tissue re-establish the biologic
width

APA Type IIA Apically positioned flap, No need for osteotomy

with no soft tissue
excision

APA Type IIB Apically positioned flap, Osteotomy is needed to

with no soft tissue re-establish the biologic
excision width

Table 02 APE types and subcategories followed by the procedure

required for the treatment of each condition
2.5. SURGICAL TECHNIQUES FOR PERIODONTAL
RECONTOURING

2.5.1. GINGIVECTOMY
Each surgical technique should be defined according to the type of
periodontal alteration present. Gingivectomy alone is indicated when:
Excessive gingival tissue is present without bone involvement.
The patient has suprabony (false) pockets.
It is necessary to treat irregular gingival contours.
The choice between making an internal or external bevel should take
into account the need for bone tissue removal and gingival thickness
reduction (Figs 21A–G). The external bevel should be performed
when there is considerable gingival hyperplasia to recreate the facial
gingival anatomy and also in the papillae region. This technique has
the disadvantage of creating a wide bloody area with second-intention
healing but allows for a significant reduction in gingival volume.

21. A–G An external bevel can be used to perform gingivectomy,

allowing the removal of greater thickness and tissue height (A–F).
Histological aspect after gingival tissue removal (G). Image courtesy
of Dr Adriano Piattelli.
 Conventional gingivectomy in several teeth with gingival
hyperplasia, involving the gingival margin and papillae, is invasive.
The hyperplasic regions are probed and the measurement is
transferred to the facial through bleeding points. These points should
be connected to create a drawing of the parabolic gingival contour. An
external bevel with the blade positioned from apical to coronalis made.
The incision is made by following the drawing with the blade touching
the dental surface. Next, the tissue is incised mesiodistally with an
Orban periodontal scalpel. The gingival band is then removed with
curettes and the dental surface is cleaned to remove the biofilm.
Refinement can be done with microscissors, conventional or ceramic
burs, and with the scalpel blade itself to allow proper contouring of the
gingival tissue. If an extensive bloody area is created, it may be
possible to use materials to protect the region and prevent
postoperative pain (Figs 22A–I). Modification of this technique aims to
reduce the amount of bloody tissue and use of surgical cement, which
may hinder the healing process and presents an antiseptic aspect
when used in the anterior region.

22. A–I Conventional gingivectomy technique performed on a patient

with gingival hyperplasia due to biofilm accumulation associated with
orthodontic treatment. After the diagnosis of alteration (A), bleeding
points (B) are made and joined (C). The tissue is then removed using
scalpels (D and E), and curettes (F), regularized (G), and protected
with surgical cement over large areas (H). Six months after healing (I)
it is possible to notice improvement of the tissue aspect compared to
the initial condition (A); areas with inflammation should be treated
using basic periodontal therapy. Surgical procedure: Dr Adriana
Cabrera Ortega.

The choice of an internal bevel incision (Figs 23A–F) allows greater

versatility of intraoperative techniques and eliminates the need for
surgical cement. This type of incision can be used in patients with only
gingival or combined alterations (gingival and bone). Initially, bleeding
points should be performed without involving the interdental papillae.
These points should be joined together to establish the desired
gingival contour. The blade is positioned from coronal to apical until
contact with boneis made. Then an intrasulcular incision is made, and
the band of gingiva is removed with a periodontal curette. The
subgingival region is then instrumented with curettes to remove
periodontal fibers33. At this point, it is necessary to determine if there is
sufficient space between the bone crest and the new gingival margin
established for the biologic width.

23. A–F The internal bevel allows access to bone tissue after
gingivectomy. The bloody area is also smaller and does not requiring
placement of surgical cement.
 Errors in establishing an adequate biologic width may cause
recurrence and need for reintervention (Figs 24A–F). It is necessary
to wait for the periodontal tissues to heal for at least 8 weeks before
doing any restorative treatment34. If root exposure occurs after
gingivectomy, provisional restorations are indicated up to 2 weeks
after surgery35. They prevent cervical dentin hypersensitivity, facilitate
healing of the operated region, provide support for periodontal tissue,
and maintain the surgically established contour (Figs 25A–G).
Gingival tissue removal can also be performed using a high-frequency
laser, which allows good tissue healing and encourages hemostasis
(Figs 26A–E).

24. A–F Short clinical crowns due to excess gingival tissue. Gingival
(A) and bone (B) aspect before measurement (C) and removal of
excess gingiva. Gingival (D) and bone (E) aspect after gingivectomy,
where there is a distance of 2 mm between the ABC and CEJ (F).
25. A–G Patient with change in gingival margin level between
maxillary central incisors (A–C) undergoing gingivectomy (D–E). Due
to hemostasis of the operated area, it was possible to perform the
immediate relining of the provisional prosthesis (F). Appearance after
1 year of follow-up (G). Surgical procedure: Dr Fausto Frizzera;
restorative procedure: Dr Marco Masioli.

26. A–E A high-intensity laser (A) can be used to perform

gingivectomy and allows good hemostasis (B, C) and tissue healing
(D, E). Surgical procedure: Dr Adriana Marcantonio.

VIDEO OF GINGIVAL THICKNESS

REDUCTION USING A CERAMIC BUR

2.5.2. CLINICAL CROWN LENGTHENING WITH

OSTEOTOMY
Clinical crown lengthening with bone tissue removal is indicated when
there is violation or alteration of the biologic width, dental preparations
with insufficient axial height, short teeth, or gingival asymmetries with
bone involvement20. Osteotomy may not be recommended in teeth
with very short or conical roots when it will expose the furcation or
impair periodontal support. The vertical distance between gingival and
bone tissues will depend on the restorative plan. A space of 2 mm
(thin biotype) or 2.5 mm (thick biotype) between the ABC and the
surgically established gingival margin is sufficient in clinical situations
where restorations are not planned. If a restorative procedure is
required, this distance should be 2.5 mm (thin biotype) or 3 mm (thick
biotype) to establish the cervical endings of the restorations within the
gingival sulcus. If there is a shorter distance, an osteotomy should be
performed (Figs 27A–F). Osteotomy can be performed with flap
elevation (conventional) or flapless by removing bone tissue through
the gingival sulcus without the need for a facial flap36.

27. A–F Short clinical crowns due to excess gingival and bone tissue.
Gingival (A) and bone (B) appearance before measurement (C) and
removal of excess gingiva. Gingival (D) and bone (E) appearance
after gingivectomy and osteotomy. A distance of 2 mm between the
ABC and CEJ (F) was obtained. In this situation, removal of gingival
tissue alone would cause future recurrence.

A flap is recommended for patients with thick biotypes (Figs 28A–L

to 30A–N); bone tissue removal in height and thickness is required.
On the other hand, flap elevation is also recommended where there is
a narrow band of attached gingiva and surgical excision would
eliminate this tissue (Figs 31A–I and 32A–I)37. Elevation of a full-
thickness flap involving the papillae allows access to the bone tissue
in the interdental region. This is especially the case when a restorative
procedure is required and the ABC-contact point relationship is critical
for successful rehabilitation. Changing this relationship can impair
esthetics (presence of “black spaces”). Patients with triangular teeth
will benefit from a flap that preserves the papillae. Osteotomy can be
performed initially with rotatory instruments. Orientation grooves are
connected with a large round bur (3018 HL) in the interproximal
regions; these grooves are then joined together to reduce bone
thickness. Bone removal in height is performed with an end-cutting bur
(end-cut or 2173) recreating a parabolic and symmetrical contour
between the teeth. Hand instruments such as microchisels and
curettes can be used to refine the osteotomy. After establishing a
suitable bone contour, the flap is sutured and stabilized by means of
suspensory sutures.

CLINICAL CROWN LENGTHENING WITH A FLAP

28. A–L Clinical aspect of a patient who presented with short teeth,
gummy smile, angle class II, division II malocclusion, and
interproximal caries on tooth 11. The patient refused orthodontic
treatment (A–F). Large tissue volume and excess bone tissue were
detected by radiographic and clinical examination (G, H); bone
probing showed that the ABC and CEJ were at the same level and a
distance of 3 mm between the gingival margin and the CEJwas
observed (I). The proper height/width ratio has been established to
obtain a better gingival contour (J–L).
29. A–Q After lining the gingival contour, an internal bevel (A) and
intrasulcular (B, C) incision were made; the gingival band was
removed using a curette (D, E). With removal of the gingival band, it is
possible to see the actual size of the clinical crowns (F–H). In
situations where the soft tissue is very thick but there is a need for
intervention in the bone tissue, gingival peeling may be performed
before flap elevation (I). When the facial bone crest is at the same
level as the CEJ, APE this requires reestablishment of an adequate
bone contour (J–N). Bone tissue removal should be initiated with a
large round bur (O) to create orientation grooves in the facial surface
(P). Grooves should be connected to reduce bone thickness; then an
end-cutting bur (Q) should be employed for bone reduction in height.
30. A–N Chisels and curettes can be used to refine and establish the
correct bone anatomy and the distance between CEJ and ABC (A, B).
The flap is then stabilized with suspensory sutures (C). Tissue aspect
14 days after surgery (D–F). The infiltrated restoration has been
replaced. Tissue aspect after healing (G–L). Smile before (M) and 1
year after the surgical procedure (N). Case published in the
International Journal of Brazilian Dentistry by Frizzera et al43. Surgical
procedure: Dr Fausto Frizzera; restorative procedure: Dr William
Kabbach.

CLINICAL CROWN LENGTHENING WITH APICALLY

POSITIONED FLAP
31. A–I Patient undergoing orthodontic treatment with short clinical
crowns due to type IIB APE. Note the proximity of the orthodontic
bracket to the gingival margin, which increased the difficulty in
maintaining hygiene. During surgical planning, it was detected that
conventional clinical crown lengthening would reduce the amount of
attached gingiva to less than 2 mm; the apically positioned flap
technique with osteotomy was recommended (A–C). The gingival
margins were initially leveled before a partial thickness flap was made.
Removal of bone tissue on the facial surface (D–F). Maintaining the
periosteum in position allowed suturing of the flap in the apical
position to maintain an adequate amount of attached gingiva (G–I).
32. A–I Comparison of initial, immediate postoperative, and final
outcome at the end of orthodontic-restorative treatment (A–F).
Postoperative situation at 14 (G, H) and 180 days (I). Surgical
procedure: Dr Rubens Moreno de Freitas.
 Patients with a thin biotype, a satisfactory amount of attached
gingiva, and in whom the distance between the bone crest and CEJ is
less than 2 mm who do not need a reduction in bone thickness can be
treated through flapless osteotomy or flapless surgery. Special care
should be taken to create a favorable bone contour that supports the
healing of periodontal tissues. If the correct contour is not established,
recurrence may occur (Figs 33A–J). The advantages of this technique
include reduced surgical time, reduced bleeding, and postoperative
edema, absence of sutures, and reduced healing time compared to
the conventional flap osteotomy33. In this technique, after removal of
the gingival band, an osteotomy is performed through the gingival
sulcus using microchisels and curettes. The microchisel is positioned
and supported in contact with the bone crest and a gentle rotational
movement is performed to microfracture the ABC. Next, an active-tip
periodontal curette is used to recontour the bone in a similar way to
the gingival margin. The bone contour is checked using a periodontal
probe. It should follow the gingival contour. The probe is also used to
check if an adequate vertical distance between the ABC and gingival
margin has been established36.
33. A–J The discrepancy between the central incisors treated
exclusively by gingivectomy due to the patient’s concern about bone
tissue removal (A–D). Note a satisfactory result in the initial year (E,
F), but the relapse after 2 years of follow-up (G). Given the option of a
less invasive technique for osteotomy, the patient accepted the
removal of gingival and bone tissue (H, I). The stability of the results
was verified after 3 years of follow-up (J). This case was partially
published in the International Journal of Brazilian Dentistry by Frizzera
et al1. Surgical procedure: Dr Fausto Frizzera.

Primary wound healing is crucial to achieve superior outcomes with

periodontal plastic surgery. The phenomena that occur in wound
healing are the same regardless of their location. The time required for
complete tissue healing will depend on the complexity of the surgical
procedure, as well as the host response that will contribute to tissue
repair.
After clinical crown lengthening (CCL), several factors may affect
the position of the gingival margin during the healing period: (1)
gingival biotype; (2) position of the gingival margin after the surgical
procedure; (3) individual variations in biologic width; (4) level of bone
wear; (5) bone remodeling after surgery; and (6) the experienceof the
surgeon. Healing time is a key factor for periodontal tissue maturation
and stability, especially if restorative procedures are recommended in
esthetic areas38.
A minimum time for gingival margin stability is critical to complete
restorative treatments to generate long-term stable functional and
esthetic results. As with gingivectomy, it is possible to perform
temporary restorations provided they have optimal adaptation and
polishing within 1 to 2 weeks after the surgical procedure, if
necessary. It is accepted that between 6 and 12 weeks of healing after
CCL are sufficient for taking impressions and refine the cervical
cavosurface margin in the posterior teeth39. Between 12 and 24 weeks
are accepted as sufficient healing time in the anterior teeth40. Esthetic
concern is a parameter that governs the decision to rehabilitate, while
biologic and surgical factors (Figs 34A–G and 35A–F) may play an
essential role in the healing process, regardless of tooth location in the
arch.
34. A–G Osteotomy with flap (A–F) and its measurement with a
periodontal probe (G).

35. A–F Removal of bone tissue without flap elevation with

piezoelectric ultrasound tip (CVDentus) (A), microchisel (B), and
periodontal curette (C). Patient had excess gingival and bone tissue
(D–F).

For these reasons, the understanding of healing after CCL surgery

is limited and rarely based on scientific data. It is noteworthy that the
vast majority of surgical studies on CCL have a 6-month follow-up and
few studies evaluated healing in more extended periods (12 months).
The healing time after esthetic crown lengthening surgery should
not differ in the anterior and posterior regions since the same biologic
principles guide the healing process regardless of tooth location.
When evaluating the anatomical (biologic width and gingival biotype)
and surgical factors (amount of bone reduction and position of the
gingival margin after surgery) affecting the healing process, they
varied between sites and dental positions. These factors should be
considered for stable clinical outcomes within 6 months after surgery.
When the biologic width is respected for the future gingival position,
the gingival margin was stable or had a less than 0.5 mm difference
from the original position at 6 months after crown lengthening surgery.
When the flaps were positioned at or apical to the bone crest, the
position of the gingival margin had considerable variability. In such
cases, a longer healing time (6 months) may be required for gingival
maturation, particularly in patients with thick gingival biotypes41,42. In
addition to the time factor, it is necessary to observe the
characteristics of the operated tissue, which should present as pink in
color, with a surface texture similar to adjacent areas, and well-defined
gingival sulcus without the presence of ulceration. It is expected that
with the evolution of surgical techniques, and reduction in tissue
trauma, a reduction in healing time is expected. Although the flapless
crown lengthening technique has biologic aspects that favor a
reduction in healing time33, further scientific studies that support these
clinical findings are needed to establish the optimal waiting time for
restorative procedures to be performed safely.
For the correct diagnosis and treatment of short teeth, it is
necessary to consider the relationship with the lips to determine if
treatment should be exclusively periodontal, restorative, orthodontic,
or combined (Figs 36A–M). If teeth are short due to incisal wear and
the patient does not have a gummy smile and exposes little or nothing
of the central incisors at lip at rest, a restorative approach is
recommended. If there is integrity of the incisal edges, where they
follow the contour of the lower lip, with adequate exposure of the
central incisors at lip at rest, but the patient has short teeth and a
gummy smile, periodontal surgery is recommended (Figs 37A–F).
Treatment of cases that present with a combination of these factors
requires periodontal and restorative procedures. These areas must
work together during planning, treatment, and follow-up to allow
longevity of esthetic and functional results43,44.
36. A–M Clinical sequence and images of flapless bone removal.
Surgical procedure performed by Prof Cristiano Pascoal in the
Periodontics II course at FAESA.
37. A–F Need for multidisciplinary treatment for esthetic and functional
resolution, which can be performed with the help of restorative
dentistry. Surgical procedure: Dr Fausto Frizzera; restorative
procedure: Dr Marco Masioli (A–C) and/or orthodontics; orthodontic
procedure: Dr Alexandre Zilioli (D–F).

2.6. INTERACTION BETWEEN PERIODONTICS AND

RESTORATIVE DENTISTRY

The significant advancement of restorative materials has enabled the

possibility of producing prostheses with the morphological and
functional characteristics of natural teeth. These restorations must be
accompanied by a satisfactory gingival contour to enhance the
esthetic results45. The relationship between periodontal tissues and
teeth/restorations seeks to achieve homeostasis and harmony, where
the presence of periodontal health is a prerequisite for restorative
therapy. A healthy periodontium ensures stable gingival margins that
facilitate restorative procedures and ensure proper biologic integration
of the restoration. Issues with contouring, adaptation, and
smoothness, or violation of the biologic width itself can lead to
constant damage to the periodontium, which will respond with pocket
formation in patients with a thick biotype or gingival recession in
patients with a thin biotype46.
 The patient’s biotype is essential and should be taken into account
in restorative therapy. A 5-year follow-up clinical study by Tao et al47
showed that ceramic crowns had a higher exposure of their margins in
patients with a thin biotype (Fig 38). These crowns had greater
gingival recession when compared to a control tooth and patients with
a thick biotype47, considering that these patients were instructed to
perform adequate oral biofilm control, avoiding periodontal trauma;
this result may be associated with the type of preparation and the
contour of the restoration. Restorations in patients with a thin biotype
should present a flat cervical contour to avoid compression of the
gingival margin and its consequent recession; the marginal finish in
these cases should be chamfered or shoulder-shaped to ensure
enough space for ceramic application with an adequate emergence
profile. Restorations in patients with thick biotypes should have a
convex contour in the cervical region to support the gingival tissues;
lack of restorative material can lead to tissue collapse and redness.
Preparation in patients with a thick biotype may be less invasive, like a
modified shoulder, or chamfered (Figs 39A, B)48.

38. Crowns installed in the maxillary incisors; note the gingival

recession in areas with a thin biotype (teeth 11 and 22).
39. A, B The type of preparation and the outline of the provisional
should be customized according to the patient’s biotype. Thin biotype,
flat provisional profile, and beveled or shoulder margin (A). Thick
biotype, convex provisional profile, with chamfered or modified-
shoulder margin (B).

The interproximal area must also be taken into consideration when

defining an integrated treatment plan. The minimum distance between
the teeth should be 1 mm to allow the interdental papilla to be
accommodated and the teeth to be cleaned20. Treatment of the
alveolar-restoration interface, where slight wear of the root surfaces is
performed, can be done if this space is reduced. Although more
complicated, another option is orthodontic tooth movement and the
creation of a suitable prosthetic space. Increasing interproximal space
accompanied by a diastema may also require a combined approach
between surgical and restorative specialties because it can cause
food impaction, poor hygiene, and impair esthetic appearance (Figs
40A–F to 44A–F)44. Once again, orthodontic movement can be
considered now to reduce the interproximal space; this is indicated
mainly in patients with larger diastemas. It is necessary to correct the
position and axis of the teeth.

40. A–F At the end of the orthodontic treatment, a diastema was left
between the canines and maxillary lateral incisors for composite resin
restorations.
41. A–O The increased volume in the interproximal region prevented
the achievement of an adequate emergence profile compatible with
periodontal health. Removal of part of the interproximal soft tissue was
necessary. In addition, a discrepancy in the gingival margin of teeth 22
and 23 compared to 12 and 13 (A–C) was noted. For the diagnostic
wax-up, excess interproximal tissue was removed with a bur (D–F).
The wax was added to allow adequate profiling of the restoration’s
emergence profile, closing the diastema and establishing the height of
the contact point (J–L). To evaluate the relationship between contact
point and bone crest, red acrylic resin was used for reference (M–O).
With the addition of acrylic resin, a surgical guide was manufactured
to communicate to the surgeon the future position of the contact point.
42. A–O Surgical technique. The surgical procedure was initiated by
probing (A, B) the region that presented unevenness (C) of gingival
tissue (APE type IA). Bleeding points were made to facilitate the
definition of the gingival contour (D–F). An internal bevel and then
intrasulcular (G, H) incision were performed. Using a periodontal
curette, the gingival bands were removed (I–K) to obtain better
symmetry between the right and left sides (L). Detachment of
interproximal tissue (M) was performed to allow access to the bone
crest and verify the distance (N) between the bone crest and the
future contact point; 0.5 mm of bone was removed with a Schluger file
(O).
43. A–J After bone repair (A), a distance of 5 mm was established
between the bone crest and future point of contact (B). To allow better
adaptation of the papillae in the interdental region, an internal gingival
tissue repair was performed with scissors (C, D). The interproximal
tissue received the same type of treatment on the contralateral side
and was sutured apically (E–G). Restorative procedure: after 3
months excellent tissue healing was noted (H–J).
44. A–F Color selection and rubber dam (A); putty matrix was tried-in
(made respecting the wax-up) (B) and restorative procedures (C) were
performed. Six months later, a good relationship between the gingival
tissue and the restorationwas noted, without the occurrence of black
spaces after the surgical procedure, besides a satisfactory esthetic
outcome (D–F). Partially published by Frizzera et al44. Reproduction of
the photos from the article was approved by the editorial board of the
Journal of Prosthetic Dentistry, incorporated on 20 April 2018. Surgical
procedure: Dr Fausto Frizzera; restorative procedure: Dr William
Kabbach.

3. CLINICAL APPLICATION
Faced with a clinical situation where there is an esthetic complaint
about the appearance of teeth and gingival tissues, a multidisciplinary
approach is needed to determine the best type of treatment plan for
the case (Table 03). It is necessary to verify if the present periodontal
alteration only involves the gingival tissues or if there is also the need
to intervene in the bone43. At the same time, dental condition and
positioning are evaluated to determine whether a restorative,
orthodontic, or combined approach is required. Multidisciplinary
planning is then performed and the treatment sequence is discussed
with the patient. For better visualization, understanding, and treatment
adherence, the patient can view the digital planning of their smile,
orthodontic setup, or restorative essay.
The treatment plan will be guided by the desired zenith position at
the end of treatment. The choice of type of surgery will depend on how
the APE presents itself (Table 04). It will be necessary to establish
teeth and gingival margins as references. Achieving the proper
contour of the gingival margins may require orthodontic or surgical
approaches (Figs 45A–L to 55A–L). In addition to treating short
clinical crowns, surgical techniques may be used to reduce the length
of long clinical crowns.

Table 03 How to determine the type of therapy that should be

employed to treat teeth with short clinical crowns
Table 04 How to determine the type of surgical procedure to treat a
patient with an altered passive eruption

3.1. SURGICAL RESTORATIVE TREATMENT

45. A–L Diagnosis and planning. The patient presented with a
combination of changes created by the presence of short teeth, incisal
wear, gingival discrepancies, and diastemas (A–F). The gingival
margin of teeth 21 and 22 was used as a reference to outline all
surgical and restorative planning of the patient (G–I). Initially, excess
gingival tissue was removed (J–L).
46. A–H In the region of teeth 11 and 12, there were only gingival
tissue alterations (APE type IA). In the posterior region and maxillary
canines, there was excess volume and proximity between the CEJ
and ABC (APE type IB); flap and osteotomy (A–D) were required.
Sutures and result immediately after surgery (E–H).
47. A–N Three months after the surgical procedure it was possible to
obtain a satisfactory tissue contour (A–E). Restorative procedure. To
allow better distribution of the spaces in the anterior region, a 24-hour
maxillary incisor tooth separation was done (F). After removal of the
rubber bands, the retraction cord was packed (G–I). The teeth
underwent acid etching, adhesive system, and restorative procedure
(J–L). Observe increased incisal edges as determined by initial
planning (M, N).
48. A–L The anterior and posterior teeth were restored according to
previous planning (A–D). At a later appointment, the finishing and
polishing of the composite resins (D–I) were performed. Final aspect
(J), compared with the initial (K) and 1 year after the surgical
procedure. (L). Clinical case partially published in the in the
International Journal of Brazilian Dentistry by Frizzera et al49 and
Tonetto et al50. Surgical procedure: Dr Fausto Frizzera; restorative
procedure: Dr Mateus Tonetto.

3.2 FLAPLESS ESTHETIC CROWN LENGTHENING

49. A–L Patient with gummy smile and need for orthodontic treatment.
Clinical crown lengthening was performed before therapy to provide
better esthetic results and facilitate bonding and cleaning of
orthodontic brackets (A–F). A height/width ratio of 10/8 was used to
plan the incision design and gingival tissue removal (G–L).
50. A–L After removal of the gingival band in the maxillary incisors
and the right maxillary first premolar, a probe determined the presence
of APE by a distance of 1 mm between the gingival margin and the
bone crest (A–C). A 3–4 Weldsted or a Ochsenbein micro-chisel can
be used in the region between the bone crest and root surface and a
buccal and lingual movement to remove bone tissue (D–F). With an
active-tipped curette, the osteotomy was refined and bone tissue
regularized to restore the biologic width and provide a satisfactory
gingival contour (G–L).
51. A–E Fourteen days (A), 45 days (B), and 180 days of
postoperative (C–E). Surgical procedure: Dr Fausto Frizzera;
restorative procedure: DrJulia Reis and Dr Deise Cunha.

3.3. DIGITAL PLANNING FOR ESTHETIC CROWN

LENGTHENING
52. A–F Diagnosis and planning. Anterior gummy smile caused by
APE type IB and short upper lip (A–C). Intraoral evaluation showed 1
mm probing depth on the buccal surfaces of the anterior teeth and the
presence of a thick biotype (D–F).

ESTHETIC CROWN LENGTHENING VIDEO

53. A–G The tomographic examination demonstrated the close
relationship between CEJ and ABC (A). The clinical crown size of
each tooth was determined with the examination, as was the distance
between the bone crest and gingival margin. An incremental wax-up
was performed without reducing the cast model. The size of the
waxed crowns was similar to that found in cone beam computed
tomography and digital planning. The wax thickness ranged from 2
mm to 3 mm to ensure the stability of the surgical guide (B–F). A putty
matrix was done using heavy body PVS (G).
54. A–G The teeth were isolated (A), the silicon impression was cut,
filled with acrylic resin, and placed in position (B) to make the mock-
up/surgical guide (C). Surgical procedure. After anesthesia, excess
bone volume in the region between the maxillary central incisors was
detected (D). The surgical guide was placed in position and used to
define the future gingival margin (E, F). The tissue was incised and
removed with precision (G).
55. A–L After removing all gingival bands (A), it was possible to verify
the new gingival contour and the absence of distance between the
new gingival margin and the bone crest. This aspect was after flap
elevation (B); the osteotomy restored the biologic width (C, D), and
the flap was sutured (E). Postoperative result after suture removal (F).
Aspect after volume reduction (G). Thirty days post-surgery (H).
Comparison of initial (I) and final results after 1 (J) and 5 (K, L) years
of follow-up. Surgical procedure: Dr Fausto Frizzera and Dr Mateus
Tonetto.
REFERENCES

1. Frizzera F, Tonetto M, Kabach W, et al. Escultura gengival:

abordagem cirúrgica em alterações gengivais estéticas. Revista
Clínica 2012;8: 388–400.
2. Frizzera F, Tonetto M, Cabral G, Shibli Jawad E, Marcantonio JR.
Periodontics, implantology, and prosthodontics integrated: the
zenith-driven rehabilitation. Case Rep Dent 2017;2017:1070292.
3. Buser D, Martin W, Belser UC. Optimizing esthetics for implant
restorations in the anterior maxilla: anatomic and surgical
considerations. Int J Oral Maxillofac Implants 2004;19 Suppl:43–
61.
4. ZanettI GR, Frizzera, FBF. Análise e abordagem integrada das
alterações gengivais estéticas. In: Ottoni JMP et al. Manipulação
Tecidual: Possibilidades e Realidade. Nova Odessa, Brazil: Ed
Napoleão, 2011:338–379.
5. Chu SJ, Karabin S, Mistry S. Short tooth syndrome: diagnosis,
etiology and treatment management. J Calif Dent Assoc
2004;32:143–152.
6. Levine RA, McGuire M. The diagnosis and treatment of the
gummy smile. Compend Contin Educ Dent 1997;18:757–762,
764.
7. Pithon MM, Santos AM, Campos MS, et al. Perception of
laypersons and dental professionals and students as regards the
aesthetic impact of gingival plastic surgery. Eur J Orthod
2014;36:173–178.
8. Pinho T, Bellot-Arcís C, Montiel-Company JM, Neves M. Esthetic
assessment of the effect of gingival exposure in the smile of
patients with unilateral and bilateral maxillary incisor agenesis. J
Prosthodont 2015;24:366–372.
9. Fowler P. Orthodontics and orthognathic surgery in the combined
treatment of an excessively “gummy smile”. N Z Dent J
1999;95:53–54.
10. Kokich VO, Kokich VG, Kiyak HA. Perceptions of dental
 professionals and laypersons to altered dental esthetics:
asymmetric and symmetric situations. Am J Orthod Dentofacial
Orthop 2006;130:141–151.
11. Zanetti GR, Brandão RCB, Zanetti LSS, Castro GC, Borges Filho
FF Integração orto-perio-prótese para correção de assimetria
gengival: relato de caso. R Dental Press Estet 2007;4:50–60
12. Rigsbee OH, Sperry TP, BeGole EA. The influence of facial
animation on smile characteristics. Int J Adult Orthodon
Orthognath Surg 1988;3:233–239.
13. Burstone CJ. Lip posture and its significance in treatment
planning. Am J Orthod 1967;53:262–284.
14. Humayun N, Kolhatkar S, Souiyas J, Bhola M. Mucosal coronally
positioned flap for the management of excessive gingival display
in the presence of hypermobility of the upper lip and vertical
maxillary excess: a case report. J Periodontol 2010;81:1858–
1863.
15. Mangano A, Mangano A. An innovative cosmetic technique called
lip repositioning: a less invasive treatment possibility for dentists
and surgeons. J Indian Soc Periodontol 2013;17:287.
16. Indra AS, Biswas PP, Vineet VT, Yeshaswini T. Botox as an
adjunct to orthognathic surgery for a case of severe vertical
maxillary excess. J Maxillofac Oral Surg 2011;10:266–270.
17. Vent J, Lemperle G. Prevention and treatment of complications
after polymethyl methacrylate-microspheres injection. Facial Plast
Surg 2014;30:628–634.
18. Beer K, Glogau RG, Dover JS, et al. A randomized, evaluator-
blinded, controlled study of effectiveness and safety of small
particle hyaluronic acid plus lidocaine for lip augmentation and
perioral rhytides. Dermatol Surg 2015;41(Suppl 1):S127–136.
19. Perenack J. Treatment options to optimize display of anterior
dental esthetics in the patient with the aged lip. J Oral Maxillofac
Surg 2005;63: 1634–1641.
20. Lindhe J, Lang, NP, Karring, T. Tratado de Periodontologia
Clínica e Implantologia Oral, ed 5. Rio de Janeiro, Brazil:
 Guanabara Koogan, 2010.
21. Angelopoulos AP, Goaz PW. Incidence of diphenylhydantoin
gingival hyperplasia. Oral Surg Oral Med Oral Pathol
1972;34:898–906.
22. Fletcher JP. Gingival abnormalities of genetic origin: a preliminary
communication with special reference to hereditary generalized
gingival fibromatosis. J Dent Res 1966;45:597–612.
23. Bozzo L, de Almedia OP, Scully C, Aldred MJ. Hereditary gingival
fibromatosis. Report of an extensive four-generation pedigree.
Oral Surg Oral Med Oral Pathol 1994;78:452–454
24. Kather J, Salgado MA, Salgado UF, Cortelli JR, Pallos D. Clinical
and histomorphometric characteristics of three different families
with hereditary gingival fibromatosis. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 2008;105:348–352.
25. Gottlieb B, Orban B. Active and passive continuous eruption of
teeth. Abstract in J Dent Res 1933;13:214.
26. Garber DA, Salama MA. The aesthetic smile: diagnosis and
treatment. Periodontol 2000 1996;11:18–28.
27. Evian CI, Cutler SA, Rosenberg ES, Shah RK. Altered passive
eruption: the undiagnosed entity. J Am Dent Assoc
1993;124:107–110.
28. Coslet JG, Vanarsdall R, Weisgold A. Diagnosis and classification
of delayed passive eruption of the dentogingival junction in the
adult. Alpha Omegan 1977;70:24–28.
29. Borghetti A, Monnet-Corti V. Fisiopatologia e exame clínico do
complexo mucogengival. In: Cirurgia Plástica Periodontal. Porto
Alegre, Portugal: Artmed, 2002:57–97.
30. Gargiulo AW, Wentz FM, Orban B. Dimensions and relations of
the dentogingival junction in humans. J Periodontol 1961;32:261–
267.
31. Weinberg MA, Eskow RN. An overview of delayed passive
eruption. Compend Contin Educ Dent 2000;21:511–514, 516–
518.
32. Januário AL, Barriviera M, Duarte WR. Soft tissue cone-beam
 computed tomography: a novel method for the measurement of
gingival tissue and the dimensions of the dentogingival unit. J
Esthet Restor Dent 2008;20:366–373.
33. Oakley E, Rhyu IC, Karatzas S, Gandini-Santiago L, Nevins M,
Caton J. Formation of the biologic width following crown
lengthening in nonhuman primates. Int J Periodontics Restorative
Dent 1999;19:529–541.
34. Carranza JR, Fermin A, Newman MG. Periodontia Clínica, ed 11.
Rio de Janeiro, Brazil: Guanabara Koogan, 2007.
35. Frizzera F, Medeiros MC, Zanetti GR, Cirelli, JA, Marcantonio
JRE. Interação Estética Periodontal. Programa de Atualização
em Odontologia Estética. Porto Alegre, Portugal:
Artmed/Panamericana, 2013;4:95–167.
36. Carvalho P, Silva R, Joly J. Aumento de coroa clínica estético
sem retalho: uma nova alternativa terapêutica. Rev Assoc Paul
Cir Dent Ed Esp 2010;1:26–33.
37. Paolantoni G, Marenzi G, Mignogna J, Wang HL, Blasi A,
Sammartino G. Comparison of three different crown-lengthening
procedures in the maxillary anterior esthetic regions.
Quintessence Int 2016;47:407–416.
38. Abou-Arraj RV, Souccar NM. Periodontal treatment of excessive
gingival display. Semin Orthod 2015;19:267–278
39. Herrero F, Scott JB, Maropis PS, Yukna RA. Clinical comparison
of desired versus actual amount of surgical crown lengthening. J
Periodontol 1995;66:568–571.
40. Hempton TJ, Dominici JT. Contemporary crown-lengthening
therapy: a review. J Am Dent Assoc 2010;141:647–655.
41. Pontoriero R, Carnevale G. Surgical crown lengthening: a 12-
month clinical wound healing study. J Periodontol 2001;72:841–
848.
42. Deas DE, Moritz A J, McDonnell HT, Powell CA, Mealey BL.
Osseous surgery for crown lengthening: a 6-month clinical study.
J Periodontol 2004;75:1288–1294.
43. Frizzera F, Nepomuceno R, Roman-Torres C, et al. Tratamento
 do sorriso gengival: como esta-belecer proporção e harmonia.
Clínica (São José) 2014;10:272–284.
44. Frizzera F, Tonetto MR, Pigossi S, Kabach W, Marcantonio E Jr.
Predictable interproximal tissue removal with a surgical stent. J
Prosthet Dent 2014;112:727–730.
45. Coachman C, Van Dooren E. An integrated cosmetic treatment
plan: soft tissue management and metal-free restoration. Pract
Proced Aesthet Dent 2009;21:29–33.
46. Ottoni, J, Serrao CR, Frizzera FBF, Schmidt EB, Barcelos K,
Zanetti GR, Magalhaes LF. Manipulação Tecidual: Possibilidades
e Realidade. Nova Odessa, Brazil: Editora Napoleão, 2011, v1.
47. Tao J, Wu Y, Chen J, Su J. A follow-up study of up to 5 years of
metal-ceramic crowns in maxillary central incisors for different
gingival biotypes. Int J Periodontics Restorative Dent 2014;34:85–
92.
48. Fradeani M, Barducci G. Tratamento Protético: Uma Abordagem
Sistemática à Integração Estética, Biológica e Funcional, São
Paulo, Brazil: Quintessence, 2009, v.2.
49. Frizzera F, Tonetto MR, Pigossi S, Calderero LM, Andrade MF,
Marcantonio JR E. Interação Odontologia Restauradora e
Periodontia. Parte 1: Planejamento e Protocolo cirúrgico. Revista
Clínica 2014;10:98–106.
50. Tonetto MR, Frizzera F, Pigossi S, Bandeca M, Andrade MF.
Interação Odontologia Restauradora e Periodontia. Parte 2:
Reanatomização dentária. Revista Clínica 2014;10:152–160.
 CHAPTER 3
ROOT COVERAGE
IN ESTHETIC REGIONS:
treatment of long clinical crowns
Fausto Frizzera, Cristiano H. Pascoal, Jamil A. Shibli Luis M. Calderero, Rodrigo
Nahas, Giuseppe A. Romito
1. INTRODUCTION

Most patients now require dental changes that are not carious due to
the general information available about oral health and how they
should clean their teeth. An increase in the prevalence of gingival
recession (GR) in adults and young peoplehas been observed. This
may be due to inadequate brushing associated with factors that
predispose or trigger the occurrence of GR.
Teeth with long clinical crowns impair the look of the smile. The
height/width ratio is unsatisfactory due to a change that occurred at
the cervical level. In addition to esthetic issues, the patient may
present1 carious or non-carious cervical lesions, cervical dentin
hypersensitivity, difficulty in cleaning, and progressive loss of
periodontal attachment (Figs 01A–I).
01. A–I Patient presenting with a complaint about GR. The treatment
previously proposed in his home country was extraction to eliminate
cervical dentin hypersensitivity. To resolve his clinical situation,
surgery was proposed to cover the root surfaces.

Due to injuries to the periodontal tissue, the level of the gingival

margin migrates apically, exposes the cementoenamel junction (CEJ),
and characterizes the occurrence of GR2. Depending on the type of
recession, it is possible to perform surgical procedures to manipulate
the gingival margin coronally and obtain a better positioning of the
gingival zenith.
Correct diagnosis, careful planning, and careful manipulation of soft
tissues around the GR are crucial for a favorable and predictable
prognosis of root coverage. Thus, some factors must be analyzed
before the surgical procedure to determine the best procedure to be
 adopted.

OBJECTIVES
At the end of the chapter the reader should be able to:
Identify the types of GR.
Establish the predictability of root coverage surgery.
Choose the most suitable technique for the treatment of GR.

2. SCIENTIFIC BACKGROUND

2.1. ETIOLOGY AND CLASSIFICATION OF GINGIVAL

RECESSION TYPES

The first step for correcting GR and preventing future relapse is to

determine its etiology. Most of the adult population has at least one
site with GR3 and its cause is multifactorial. The factors that cause
recession can be divided into predisposing and triggering factors
(Table 01 and Figs 02A–G). Three factors are strongly associated
and deemed crucial for the occurrence of GR:
1. Bone dehiscence.
2. Thin gingival biotype.
3. Inflammatory process caused by periodontal infection or mechanical
trauma.

PREDISPOSING FACTORS TRIGGERING FACTORS

Bone dehiscence or fenestration Traumatic brushing

Reduced bone and gingiva in the Dental movement outside the bone
free and proximal surfaces socket

Lack of attached gingiva Plaque-induced inflammation

 Inappropriate teeth positioning Violation of the biologic width

Abnormal insertion of the frenulum Trauma to the soft tissues due to

and vestibule removable partial denture , piercing,
or habits

Table 01. Predisposing and triggering factors for gingival recession

02. A–G Patient with a thin biotype diagnosed due to gingival color
change with insertion of a probe into the sulcus (A–C). Inflammation in
the periodontium generates the release of collagenases, which
degrade gingival connective tissue; epithelial ridges migrate to the
resorbed space until the ridges of the oral epithelium merge with those
of the sulcular epithelium (D–E). Consequently, the periodontal tissue
no longer receives nutrition (F) from the connective tissue; the cells
initially enter a hypoxic condition, which is followed by anoxia and,
consequently, programmed cell death. Apoptosis of these cells leads
to desquamation of the most coronal portion of the periodontium,
resulting in GR in areas of thin biotype (G). D–G images have been
adapted from Novaes and Novaes1.

GR may occur in any periodontal site. Usually, patients with

periodontitis and inadequate control of dental biofilm have recessions
on all faces4. Patients with a low plaque index can also present GR
but GR is usually found on the free surfaces and is associated with
mechanical brushing or flossing trauma5. Both periodontal disease
and mechanical trauma have the potential to cause periodontal
damage (Figs 03A, B to 05A–C). It is essential to eliminate this
aggressive process before performing a surgical procedure.
03. A, B Mechanical trauma due to flossing.

04. A–C Patient with a history of periodontal disease with generalized

attachment loss associated with loss of papillae and gingival
recessions.

05. A–C Patient with early gingival recessions due to brushing, and
buccal and lingual trauma.

Miller6 proposed a classification for GR where, besides defining the

design of the defect, it offers a prognosis of root coverage procedures
based on the presence or absence of intact interproximal periodontal
tissues. The classification states that in class I and II GR, 100% of
coverage can be achieved. This is because of the presence of intact
interproximal periodontal support and consequent blood and structural
supply to the flap. In class III and IV GR, where interproximal tissues
are partially or entirely lost, compromising the tissue support
positioned over the GR, the same results cannot be expected (Table
02 and Figs 06A–D).

CLASS I Gingival recession that does not extend beyond the

mucogingival line and shows no loss of interproximal
support tissues: full coverage is predictable.

CLASS II Gingival recession that reaches or exceeds the

mucogingival line and shows no loss of interproximal
support tissues: full coverage is predictable.
 CLASS III There is loss of interproximal support coronal to the
extension of the buccolingual recession: predictability of
partial coverage.

CLASS IV There is loss of interproximal support at the same level or

apical as the extent of the buccolingual recession: no cover
predictability.

Table 02. GR types according to Miller6

06. A–D GR types according to Miller6.

The presence of interproximal bone is not the only factor that should
be considered to obtain favorable results7. Several systemic,
environmental, and local aspects, as well as the choice of different
coverage techniques, may influence the outcome (Figs 07A–D).
07. A–D Treatment of periodontal disease is not currently limited to
achieving periodontal health only. Corrective surgical procedures may
be necessary to reconstruct part of the lost tissue.

Traumatic brushing is one of the leading causes of GR and may

occur due to excessive force, frequency, and time of brushing, type of
bristles, and toothpaste8. Oral hygiene techniques should be reviewed
to prevent GR relapse (Figs 08A–C). An alternative to control the
pressure is to instruct the patient to start brushing the lingual surfaces,
finishing brushing in regions with more severe GR. Electric
toothbrushes may also be indicated to prevent excessive trauma to
the periodontal tissue. A randomized clinical trial demonstrated that
the use of these toothbrushes showed better stability of the gingival
margin after root coverage9.

08. A–C Patient with short and long clinical crowns who presented
with mechanical trauma on the left side. In tooth 22 the trauma was
caused by both brushing and flossing. The patient was properly
oriented before periodontal plastic surgery to correct the present
changes.

The periodontal biotype should be taken into consideration in

surgical planning to correct GR. Baldi et al10 assessed the thickness of
the flaps (Figs 09A, B) for root coverage. The results showed that
when the flap was thicker than 0.8 mm, a prognosis of total coverage
was higher than when the tissue was thinner. Other clinical studies
corroborate with these results but emphasized the difficulty in
measuring the thickness of the flap during the surgery11,12.
09. A, B Successful treatment of GR depends on the thickness of the
flap, which may be thin (A) or thick (B).

The dimensions of the papillae adjacent to the defect are crucial

since they are responsible for stabilization and nutrition of the flap.
Long papillae favor the stabilization and nutrition of the flap, favoring
the outcome13. Methods to predict the amount of root coverage, taking
into consideration the architectureof the papillae and its relationship to
the CEJ, were proposed by Zucchelli14 (Figs 10A–I). Poorly positioned
teeth, reduced papilla height and volume, prominent roots, and
cervical lesions can make it challenging to cover the root surface
entirely, choose the appropriate surgical procedure, and combine it
with restorative or orthodontic procedures.
10. A–I The height of the papillae and its relationship to the CEJ (x)
can be used to predict the amount of root coverage. When the papillae
are intact, it is possible to obtain complete coverage (A–C). If one of
the papillae is partially lost, partial coverage can be achieved and the
zenith will usually be directed to the compromised papilla (D–F).
Partial loss of the two papillae will limit the treatment of gingival
recession; root coverage is expected to be approximately 70% (G–I).

2.2. TECHNIQUE SELECTION

The technique for treating GR is sensitive to the operator and the
surgical procedures adopted. Different types of root coverage surgery
have been described in the literature15,16. However, despite some
technical differences, several universal principles help define a better
prognosis and determine which technique should be employed
according to the characteristics of GR.

2.2.1. ROOT SURFACE TREATMENT

After case selection and planning, the first question that emerges is
how to treat the root surface exposed to bacteria, acids, and different
substances. The exposed root surface should be decontaminated
before positioning the flap that will correct the GR. This
decontamination can be done by prophylaxis, manual scaling with
periodontal curettes, or ultrasonic decontamination; however, there is
no clinically significant difference between these techniques17,18. We
prefer the use of curettes or ultrasonic instruments because they are
less aggressive to the gingival margin. Surface biomodification can be
done with 24% ethylenediaminetetraacetic acid, citric acid, or
tetracycline. There is no proven clinical advantage and its use is not
necessary19,20.
The association of root coverage techniques to enamel matrix-
derived proteins—enamel matrix derivative (EMD) has shown
promising results (Figs 11A–C). Spahr et al21, in a clinical study with a
2-year follow-up, concluded that both treatment modalities presented
satisfactory results, with better results when the technique was
associated with EMD. Complete GR correction showed more stable
results in cases treated with EMD, whereas recurrence of GR was
more frequent in cases treated with surgery alone. In theory, the use
of EMDs may allow the formation of not only the long junctional
epithelium in the covered defect but also partial regeneration of
support tissues at the base of the defect. This hypothesis would justify
greater predictability and stability for the treatment of long-term GR
but needs to be scientifically proven22,23. Another advantage found in
the association of EMD with surgery is the anti-inflammatory potential
of this biomaterial, where earlier healing can be found.
11. A–C Use of EMD-derived proteins on the root and flap surface.
Surgical procedure: Dr Cristiano Pascoal.

2.2.2. SURGICAL TECHNIQUES

Regardless of the technique chosen for root coverage, the flap should
always be positioned over the gingival defect and kept completely free
of tension. Pini-Prato et al24, in a clinical study, stated that the tension-
free flap contributes to a higher percentage of root coverage. This
elimination of tension is achieved by releasing the flap in the alveolar
mucosa region. The techniques initially described suggest a partial-
thickness flap from the gingival margin; however, it is recommended to
keep a full-thickness flap in the gingival margin to maintain tissue
volume. The flap should be divided only from the mucogingival
junction, with scalpel blades or dissectors, where the alveolar mucosa
allows the elimination of tension promoted by its collagen fibers (Figs
12A–C). It is possible to see absence of tension when the
manipulation of the lip does not cause the flap to move when the flap
is covering the root surface.

12. A–C Flap release at the mucogingival junction. An incision is

made at the base of the periosteum inserted into the bone tissue and
then the flap is carefully divided to avoid lacerations.
 Another maneuver that seeks to eliminate tension is the making of
divergent relaxing incisions. The flap can be made into a trapezoidal
or triangular shape (Figs 13A, B). Zucchelli et al25 demonstrated a
higher incidence of scars when performing trapezoidal flaps. A
triangular shape is recommended in areas or for patients with higher
esthetic demand. Although allowing a full-thickness flap release, this
maneuver can compromise the blood supply of the flap and impair
healing. Thus, the need to include releasing incisions will depend on
the amount and extent of GR18,26.

13. A, B Triangular (A) or trapezoidal (B) vertical incisions may be

made for coronal flap repositioning.

Elimination of flap tension is a critical factor in achieving another

essential variable for root coverage prognosis: the final position of the
flap. Pini-Prato et al27 evaluated the influence of the final location of
the gingival margin after surgery. They concluded that a 2-mm coronal
positioning of the flap in relation to the CEJ considerably increases the
prognosis of full coverage of the GR (Figs 14A–C and 15A–D).
Another factor to be considered is the position of the connective tissue
graft in relation to the CEJ. In general, the graft should be stabilized at
the level or up to 1 mm apical to the CEJ. If it is necessary to increase
the amount of keratinized tissue, in addition to root coverage,
approximately 20% of the graft can be left exposed since there will be
nutritional support for the remnantof the graft under the flap28.

14. A–C Flap sutured apically (A), at the level (B), and coronal to the
CEJ (C). The flap should not be sutured beyond the CEJ if there is
interproximal bone loss or a restorative treatment plan to be followed,
where coverage beyond the established level will cause an esthetic
change.
15. A–D A different result is expected in relation to root coverage
when repositioning the flap at the level (A, B) or beyond the CEJ (C,
D). If full coverage is desired, it is important to reposition the flap 1–2
mm coronal to the CEJ.

The main histological difference between a thin and a thick gingival

biotype is the volume of connective tissue. Thus, the association of
the subepithelial connective tissue graft (SCTG) with techniques for
root coverage aims to increase gingival thickness and obtain a biotype
to prevent GR relapse10. The SCTG is adapted between the surgical
bed and the flap and can be stabilized separately with bioabsorbable
sutures or in adjacent areas or in the flap/adjacent tissue with
conventional sutures (Figs 16A–C).

16. A–C The graft can be sutured to the flap (A), recipient area (B), or
adjacent areas (C). Only in situations where the sutures will be inside
the tissue, there is a real need to use bioabsorbable sutures.

Research showed similar results between the two techniques

(isolated flap vs flap associated with SCTG). Short-term follow-up
showed that the correct flap manipulation determines root coverage16.
However, due to modification in tissue biotype, the region that
received the tissue graft is more resistant to trauma and injuries,
reducing the risk of relapse in the medium or long term. Thus, it is
suggested that GR with a gingival margin thickness of less than 1 mm
should be treated with the associated technique29–31.
The treatment of GR still represents a challenge to the clinician due
to the extension of the surgical field, severity of the lesion (Table 03),
and limited amount of connective tissue at the donor site32.

EXTENSION SEVERITY

Isolated Shallow (height < 4 mm)

Multiple Deep (height ≥ 4 mm)

Table 03. Types of recession according to extension and severity

Another important factor is compromised vascularization in the

grafted area due to the height and width of exposed root surfaces in
cases of multiple recessions33.
Some systematic reviews concluded that SCTG demonstrated
greater predictability for complete root coverage and increased
thickness and width of keratinized tissue after treatment of multiple
Miller class I and II recessions32,33. This surgical technique can be
considered a “gold standard” (Figs 17A–H) for the treatment of
localized Miller class I and II GR31.
17. A–H Types of GR according to its extent and severity. Shallow
and isolated (A), shallow and multiple (B), outcomes (C, D); deep and
isolated (E), deep and multiple (F), outcomes (G, H) after surgical
treatment through coronally positioned flap associated with connective
tissue graft. Cases partially published by Ottoni et al15 and Frizzera et
al64,67. Surgical procedures: Dr Fausto Frizzera.

Even with the benefits described in the literature, SCTG is often

associated with patient morbidity due to postoperative complications
related to the donor area, usually the hard palate34,35. Additionally
longer surgical time, pain, and discomfort are associated with this
technique36,37. These factors are aggravated in cases of treatment of
multiple adjacent recessions, where more graft tissue is required.
Some alternative surgical techniques are being compared to SCTG for
the treatment of GR.
 Collagen matrix from pigs—Mucograft (MC)—has been marketed as
a possible alternative to soft tissue grafts in increasing the range of
keratinized tissue around teeth and implants36. Some studies have
also used MC in the treatment of localized38,39 or multiple40 Miller class
I and II GR. The benefits described are often related to the patient’s
lower morbidity because graft removal is not necessary39,41. When
used for the treatment of localized GR, the percentage of root
coverage was 75.29% (6 months), 88.5% (12 months), and 77.6% (5
years)37–39. In the treatment of multiple GR, the percentage of root
coverage was 93.25% at 12 months40; however, clinical studies on the
performance of this type of treatment in both intact and severely
damaged root surfaces are still limited.
Non-carious cervical lesions are common findings in regions of GR
because the exposed root surface is less resistant to abrasion. Thus,
simple brushing leads to wear of the exposed root cement and even
on dentin. In most of these cases, in an attempt to eliminate
hypersensitivity, lesions are restored. Scientific studies support the
positioning of the flap over restorations, whether in glass ionomer
cement or composite resin42,43. If optimal polishing and a well-matched
tooth restoration margin cannot be achieved, replacement of the
restoration is recommended. The cervical lesion should be treated
using an SCTG.

2.2.3. SURGICAL TECHNIQUES TO TREAT GR

To correct GR, several techniques of periodontal plastic surgery have
been described and analyzed in the literature. The choice of surgical
procedure will depend on the extent and severity of the GR. Several
procedures have a good prognosis of coverage but their success
depends on the correct selection and indication of the technique44.
Periodontal plastic surgery for root coverage can be classified into45:
I. Free grafts
II. Surgical techniques with pediculated flaps:
a. Rotated flaps;
b. Coronally positioned flap.
FREE GRAFTS
An incision is made on the recipient area by the mucogingival junction
and the buccal flap is divided. The epithelium on the coronal portion of
the recipient area is removed. The gingival graft from the palatal
masticatory mucosa is then sutured (Figs 18A–F). The graft can have
epithelial and connective tissues or just connective tissue (SCTG); a
collagen (CM) matrix can also be used in specific clinical cases. This
technique can be performed directly, with a single procedure, where
the graft covering the GR is stabilized. It can also be used primarily to
increase the height and thickness of the gingival tissues apical to the
GR. As a second step, a coronally positioned flap can be
performed46,47.
18. A–F Increased amount of attached gingiva through deepening of
the vestibule and a free gingival graft by conventional technique. Two
years after surgery, color and texture changes were observed, which
were exacerbated by the presence of melanin pigments. Surgical
procedure: Dr Fausto Frizzera.

Free gingival graft is a technique widely studied in the literature.

Despite presenting long-term stable results48, it is associated with
limited outcomes regarding root coverage. It depends directly on graft
nutrition by the recipient area and graft thickness, ideally 2 mm thick.
On average, root coverage ranges from 39% to 100% and is the
most predictable technique for shallow defects. However, esthetic
results are not satisfactory due to the discrepancy of shape and color
between the grafted tissue and the tissues of adjacent areas (Figs
19A–I and 20A–H). While most patients expect esthetic excellence,
this technique has been recommended for cases of GR in regions with
low esthetic demands, with no attached gingiva, and shallow vestibule
depth49.
19. A–I Technique for the removal of free gingival graft in a
mannequin from Study Models.
20. A–H Removal of a free gingival graft. The dimensions of the graft
are defined. A guide is made using the suture envelope (A–C). An
incision parallel to the gingival tissue is initiated in the graft’s coronal
portion for its release. A suture thread or tissue plier can be used to
manipulate the graft during its removal and stabilization in the surgical
bed (D, E). After removal, the graft must be under constant hydration.
The adipose tissue layer must be removed (F–H). Surgical procedure:
Dr Elcio Marcantonio Jr.

SCTG can be used as an alternative to a free gingival graft to gain

keratinized tissue (Figs 21A–D to 27A–I). This therapeutic modality
has some advantages such as smaller wound area in the palate and
better color between the grafted area and adjacent tissues50. This
surgical procedure was used by Orsini et al51, who reported an
average contraction of 40% of the SCTG at 1 year, obtaining a
keratinized tissue width of around 5 mm. When the esthetic pattern
was evaluated, the grafted area presented a better color, which was
compatible with the adjacent gingival tissue. Although considered the
gold standard for periodontal grafting procedures, autogenous grafting
has disadvantages.
21. A–D SCTG removal. An incision perpendicular to the ridge to the
desired sizeshould be made (A). Next, an incision is made parallel to
the ridge to divide the connective tissue epithelium (B–D).
22. A–E The graft is released laterally with inclined incisions at its
mesial and distalportions (A). Depending on the desired graft
thickness, it may be necessary to do a full- or partial-thickness flap
(B). Apical release is performed through an incision that will delimit the
height of the graft, made carefully to avoid damage to the vascular
structures (C, D). Sutures are then performed (E).
23. A–F After graft removal, it is necessary to perform region
compression, suturing, and protection (A–C). X and U suturing with
buccal knot to allow good coaptation of the surgical wound edges in
the donor area (D–F). Mannequin from Study Models.
24. The graft may also be prepared to cover an area larger than its
size.
25. A–K The region of tooth 41 presented a thin biotype, no attached
gingiva, and shallow vestibule depth. During orthodontic treatment, the
patient reported difficulty in cleaning the region and the defect
increased (A–C). Surgery to increase the attached gingiva band
began with an incision in the vestibule (D, E). In the surgical bed the
preparation of the receiving area was extended and regularized with
scalpel blade and scissors (F–H). A guide corresponding to the
extension of the graft was cut according to the area prepared to
receive the graft (I, J). A saline-soaked gauze was placed in the
receiving area. (K).

26. A–L According to the guide’s size, an incision was made

perpendicular to the gingival tissue with a depth of 1.5 mm. Then an
incision parallel to the gingival tissue was made, with a height equal to
that predetermined by the guide. The tissue was incised in its mesial,
distal, and apical portion to release the graft.
27. A–I The graft adipose tissue layer was removed and the graft
stabilized with sutures. After graft suturing, compression was
performed for 2 minutes and the area was protected with surgical
cement (A–F). Tissue appearance 4, 8 and 24 months after the
procedure (G–I). In addition to deepening of the vestibule and gingival
thickening, note the coronal migration of gingival tissue. Surgical
procedure: Dr Fausto Frizzera.

The amount of graft that can be removedis limited, and trans or

postoperative complications may occur (Figs 28A–E and 29A–L).
New materials have been developed to avoid the need to perform a
second surgical procedure for SCTG removal; they have similar
results to short-term autogenous grafting but are not yet available in
the market52. Despite having limited results for volume increase and
consequent modification of the gingival biotype, CM can be used to
increase the inserted gingival band, replacing or limiting the amount of
autogenous graft required53.
28. A–E Transoperative bleeding due to injury of the major palatal
artery. Initially the area was compressed and infiltrated with anesthetic
with vasoconstrictor (A–C). In this situation, it was possible to clamp
the artery because the lesion occurred in the most anterior region (D).
Regardless of the region, sutures can be done in the posterior region
to reduce bleeding (E).
29. A–L Because the artery could be accessed, it was sutured with
resorbable sutures (A–C). Compressive and approximation sutures
were performed and the oxygen-rich bluem oral gel was applied to the
donor region (D–F). Before surgery, a removable acrylic appliance
was made to ensure greater postoperative patient comfort (G–I). In
addition to protecting the palate, this appliance can also exert
additional compression and prevent complications.

The SCTG and CM were compared for the increase of keratinized

tissue around teeth and implants36. At 12 months, the mean height
obtained from the keratinized tissue with the SCTG was 2.60 mm; for
the CM, it was 2.5 mm. Most of the treated sites were teeth/implants in
posterior regions that had shallow vestibules and high muscle
insertion. These characteristics of the operated areas justified the
limited height gain of keratinized tissue. The authors described greater
graft contraction in the first 30 days of healing for both SCTG (60%)
and CM (67%).

II. PEDICULATED FLAPS

Due to the low predictability of free grafts to cover the root surfaces,
techniques aimed to position the remaining gingival tissue on the root
surface with a pedicle that would allow nutrition of the grafted area
were developed28. In addition to presenting greater nutritional support
to the grafted avascular root surface, the tissue aspect is similar to the
areas adjacent to the GR.

A) ROTATED FLAPS
Rotated flap techniques depend on extremely favorable anatomy
around them and are indicated in a few situations. The laterally rotated
flap was initially described by Group and Warren54; it consists of a full-
thickness flap on the tooth adjacent to the lesion, followed by a partial-
thickness flap to release tissue and minimize bone exposure (Figs
30A–C). The keratinized gingiva of the adjacent tooth serves as a
donor area for the compromised region. This technique was indicated
for isolated GR in the mandible, but GR in the donor area were
frequent. Double papilla flaps (Figs 31A–C) aim to de-epithelize the
entire gingival margin of the tooth with GR and rotate large papillae
adjacent to the defect to treat it28.

30. A–C Flap laterally rotated. After incision (A), the gingival margin
opposite from where the flap is going to be rotated should be de-
epithelialized and the flap should be divided (B). The flap is then
displaced and stabilized over the GR leaving part of the bloody donor
area (C).
31. A–C Double papilla flap. After incision (A), the flap should be
released and then divided (B) to be repositioned over the gingival
recession (C).

Rotated flaps should be correctly indicated and this is not the

treatment of choice for patients with high esthetic demands since
scarring may occur in the donor region due to secondary-intention
healing and a low root coverage index16.
Currently, these techniques are not often used or studied. Due to
the good results obtained with a coronally positioned flap, it was
possible to verify a large gap in scientific research about rotated flaps
until a new proposal by Zucchelli et al55 to combine these two
techniques. These flaps may have the best biologic plausibility among
rotated flaps since they can be shifted horizontally and vertically. The
combination of lateral and coronal displacement of the flap and its
stabilization in a position beyond the CEJ showed a 96% coverage
rate in isolated GR. In this technique, it is necessary to create a flap
that presents a mesiodistal extension 6 mm more extensively than the
width of the GR and a cervical-apical dimension that starts 3 mm
apically to the buccal probing depth of the donor tooth. The flap should
initially be divided into the surgical papilla region, displaced to full
thickness in the region that will cover the recipient surface, divided
from the mucogingival junction, and released from muscle insertions;
the epithelium of the papillae should be removed and the coronally
stabilized flap should be joined to the CEJ by a suspensory suture55.

B) CORONALLY POSITIONED FLAPS

Norberg56 first published the coronally positioned flap technique with
the aim of root coverage for esthetic correction. Since then, several
techniques for coronally positioned flaps have been described and
modified to improve the final result of root coverage of different types
of GR.
Tarnow57 described the semilunar flap technique, where an incision
is made parallel to the gingival margin. The tissue contained between
the incision and the margin is shifted and repositioned coronally,
covering the previous GR. This technique is not currently
recommended because it presents a high degree of GR recurrence.
Besides, there is a risk of necrosis and loss of this tissue if the region
has a thin or intermediate gingival biotype.
To treat GR, Raetzke58 proposed tissue release via the gingival
margin. With a sharp and delicate instrument, the gingival margin, the
attached gingiva, and alveolar mucosa are released to create a pouch
flap to accommodate a connective tissue graft. In the original
technique, the graft was slightly exposed to cover the root surface.
This technique may be indicated for the treatment of isolated and
shallow GR; whenever possible, one should try to manipulate the flap
coronally to cover the entire graft. Coronal positioning of the flap is
achieved in situations where there is a small amount of attached
gingiva and when the tissue is properly released (Figs 32A–G and
33A–R).
32. A–G Pouch flap technique for covering isolated and shallow GR.
Bed preparation should go beyond the mucogingival junction and
involve the buccal interdental papillae (A, B); the removed graft (C)
must have adequate thickness to accommodate under the gingival
tissue. The whole set should be repositioned over the gingival
recession (D). Area with buccal depression due to lingually positioned
tooth (E–G).
33. A–R Increasing the volume of the connective tissue graft region is
recommended. The tunnel technique, with specific and delicate
instruments, was performed (A–E). The graft was removed from the
maxillary tuberosity, carefully prepared, inserted, and stabilized to
allow better tissue healing (F–O). Note the increased volume obtained
30 days after surgery (P–R). Surgical procedure: Dr Fausto Frizzera.

Langer and Langer59 described the coronally positioned flap

technique, where an intrasulcular incision is made and extended
through the base of the papilla, followed by bilateral vertical incisions.
The divided flap is folded in the buccal region and the papillae are
then de-epithelialized and the flap is stabilized coronally with isolated
sutures.
Allen and Miller60 demonstrated a 97.8% coverage of the GR, with
an average of 3.18 mm of coverage. This technique is currently
indicated for isolated and deep recessions and has been modified to
allow better healing and predictability. The modifications consist of the
release of a total-thickness flap in the gingival margin to the
mucogingival junction, where the flap should be divided into the
muscle insertions released. Stabilization should be performed 1–2 mm
coronal to the CEJ with sutures anchored in the palatal region of the
tooth (Figs 34A–E).
34. A–E Technique for covering isolated and deep gingival recession
with two vertical incisions (A, B). A mixed flap of partial and total
thickness should be prepared (C, D). The graft should be stabilized
over the gingival recession and positioned coronally (E).

The “L”-modified, coronally positioned flap is recommended for

shallow single recessions in regions where tension elimination of the
flap is not possible without vertical incisions (Figs 35A–E and 36A–
N). Due to esthetic concerns when using vertical incisions in the
anterior region, a single releasing incision distal to the defect is
included in the flap. The apical-cervical extension of the GR is
measured and increased by 1 mm. Then this measure is transferred to
the distal papilla, parallel to the tooth, from the tip of the papilla, which
is the reference point between the incisions and should mimic the tip
of the papilla. A 45-degree vertical incision is extended from the
papilla to beyond the mucogingival junction. A full-thickness flap is
reflected at the mucogingival junction and then the flap is divided and
released. The distal papilla and the margins of the releasing incision
are then de-epithelialized and the coronally positioned flap is
stabilized with sutures61.
35. A–E Technique for covering isolated and shallow GR with a
vertical incision. This technique is indicated when there is a large
amount of attached gingiva (A, B). A mixed flap, of partial-total-partial
thickness, must be prepared (C) while the distal papilla must be
reflected internally with a tunneling device. The graft must be
stabilized (D) and coronally repositioned (E).
36. A–N Clinical reproduction of the technique to cover isolated and
shallow gingival recession with only one distal vertical incision (A–D).
The flap is reflected up to the mucogingival junction and then divided
to eliminate its tension (E, F). The lateral borders and distal papilla
were de-epithelialized and the flap was positioned coronally (G–L).
Postoperative aspect at 45 and 90 days (M, N). Surgical procedure: Dr
Cristiano Pascoal.

Several shallow and adjacent recessions can be addressed by

performing a pouch release in each region and joining it to create a
tunnel (Figs 37A–F). The recommended technique is a modification of
the original, where the flap is prepared via gingival margins. This
technique requires high operational dexterity and the use of different
instruments but allows nutrition of the entire buccal flap by maintaining
the interproximal papillae. The gingival graft should be of adequate
size, between 1 mm and 1.5 mm thick, and be carefully inserted via
the gingival margin, avoiding trauma or disruption of the flap Figs
38A–F and 39A–R). After graft stabilization, the flap should be
coronally positioned. In this technique, it is possible to obtain complete
coverage of Miller class I and II GR. Favorable results in class III
recessions can be obtained by advancing both the flap and papillae
coronally.
37. A–F Modified tunnel technique for covering multiple and shallow
GR. The surgical bed must go beyond the mucogingival junction and
involve the interdental papillae (A–C). The graft must have adequate
thickness to be accommodated under the gingival tissue (D). The
flap/graft set must be positioned over the GR (E). One-year
postoperative follow-up (F).
38. A–F The surgical bed must involve the teeth with recession (A–D)
and the buccal-proximal angle of the adjacent teeth (E, F).
39. A–R A tunnel must be created and checked for interferences (A–
F). Sutures will position and stabilize the graft in the surgical bed. The
needle penetrates the tissue in the direction of the epithelium toward
the connective tissue, in the mesial papilla, and exits coronal to the
gingival margin (G); then, the needle passes through the other papilla
without perforating the tissue (H). The graft is positioned with its
smoothest part (I) in contact with the roots and the roughest part (J) in
contact with the flap. The needle then passes through the graft and
returns through the prepared papilla without perforating the tissue (K,
L). Then, the needle penetrates the papilla, from the connective tissue
to the epithelium. The needle should exit coronally to its entrance (M).
The suture thread is then pulled to insert the graft into the surgical
bed; as soon as the graft is in the desired position, the suture is
tightened (N–P). A similar suture is performed in the distal portion of
the graft, without penetrating the central papilla, as the graft is already
close to the sutured area (Q). Finally, vertical sling mattress sutures
must be performed to reposition the flap coronally (R).

Zucchelli and De Sanctis62 described an envelope technique for the

treatment of multiple recessions with greater ease of execution and
flap release. The proposed design was to perform angled incisions in
the papillae facing the tooth with more significant GR to create
surgical papillae that, when positioned coronally, present better
adaptation (Figs 40A–E). If two adjacent teeth have an equal
recession, the incision should be straight or V-shaped (Figs 41A–F).
A total-thickness flap should be reflected up to the mucogingival
junction. At this point, it should be released, repositioned, and sutured
coronally over the de-epithelized papillae. Incisions in the papilla
between the central incisorsshould be avoided and a tunnel flap
should be performed (Figs 42A–P). This technique, and its
association with growth factors, has been extensively researched and
is indicated for both shallow and deep multiple recessions showing
high rates of root coverage and full coverage of GR.
40. A–E Envelope flap technique for covering multiple and deep GRs.
Inclined incisions should be performed on the papillae (A, B) and a
mixed (partial-total-partial) flap is used (C). The connective tissue graft
should be stabilized in regions with a thin biotype (D). The flap should
be repositioned over the gingival recessions (E).

VIDEO OF THE TREATMENT OF MULTIPLE AND DEEP RECESSIONS USING

A CONNECTIVE TISSUE GRAFT
41. A–F Patient with multiple recessions with equal height between
adjacent teeth (A). Incision planning was performed by directing them
to the tooth with the deepest recession. In the canine and first
maxillary premolar, a V-incision was performed (B). After the flap was
reflected and released, a collagen matrix was sutured and the flap
was positioned coronally (C–E). One-year postoperative follow-up (F).
Surgical procedure: Dr Rodrigo Nahas.
42. A–P Patient with multiple recessions covering the maxillary central
incisors where the envelope technique was indicated (A, B). The flap
was made by preserving the papilla between the maxillary central
incisors (C, D). Roots with thicker buccal volume were reduced with
the Perioset drill kit, the flap was released, and a connective tissue
graft was stabilized (E–H). The patient’s blood had been collected
before the surgical procedure for leukocyte- and platelet-rich fibrin
production, which was prepared and inserted in the operated region to
enhance soft tissue repair (I–O). Two-year follow-up of the operated
area (P). Clinical case done at the Periodontal Plastic Surgery Clinicl
supervised by Dr Claúdio Marcantonio and Dr Fausto Frizzera.

By comparing the techniques of Zucchelli and De Sanctis62 with

tunnel techniques for the treatment of multiple and shallow GRs,
Gobbato et al63 demonstrated similar clinical results between the two
techniques. However, in terms of surgical and postoperative time, the
tunnel technique had inferior performance. After the tunnel technique,
patients required a higher use of analgesic medications and reported
more pain and edema than patients receiving the envelope technique.
Thus, from a clinical point of view, tunneling should preferably be used
in situations where there are narrow papillae or those that have lost
part of their height, and in the region between central incisors.

3. CLINICAL APPLICATION

Several types of surgical techniques are described in the literature and

choosing between them should take into account a number of factors.
These include the number of teeth affected, size of the GR, amount of
attached gingiva, tissue biotype, and the training and experience of
the surgeon. Less experienced surgeons can benefit from more
invasive techniques with larger flaps and vertical incisions that allow
for greater flap release and range of motion. In situations where the
recession is isolated, it is necessary to create devices to promote
greater flap release for its coronal positioning (Figs 43A–R and 44A–
G).
43. A–R Patient with single and deep recession (A). The root surface
was prepared with a bur and then smoothed with a periodontal curette
to reduce the buccal volume (B). The mixed flap was made, the
epithelium of the papillae and the edges of the vertical incisions were
removed (C–E). Periosteum incisions allowed extensive flap release;
defect dimensions in height and width were measured to cut and
stabilize an acellular dermal matrix (F–J). The coronal repositioned
flap with simple interrupted suspensory suture (K–M). Lateral view
before (N), immediately after (O), and 6 months after the surgical
procedure (P). Frontal view 7 days (Q) and 1 year (R) after root
surgery. Surgical procedure: Dr Fausto Frizzera.
44. A–G Vertical sling mattress sutures used to reposition the flap
coronally.

3.1. TRAPEZOIDAL FLAP

In this way, we can make divergent relaxing incisions, always

beveled to avoid scar formation, in deep recessions (double—mesial
and distal) or shallow (single — mesial or distal) with large amounts of
attached gingiva in the presence of a shallow isolated recession with
an inserted gingival height of 3 mm or less; the pouch technique (Figs
45A–F and 46A–F).
45. A–F Shallow and single GR. The patient had esthetic and
functional complaints (A). A pouch flap was performed. The tissue
was released on the buccal in the attached gingival region, surpassing
the mucogingival junction (B, C) and in the papillae (D–F).
46. A–F A 1-mm-thick graft was removed from the palate, inserted into
the recipient region and stabilized with sutures (A–E). At the 1-year
follow-up it was possible to notice the stable outcome (F). Case
previously published by Frizzera et al64.

3.2. POUCH FLAP

The presence of Miller class III recessions or buccalized teeth can

impair the full coverage of the root surface. To obtain satisfactory
results, surgical and restorative procedures can be combined (Figs
47A–P).
47. A–P The maxillary central incisor was recommended for extraction
due to root fracture; an implant and a provisional crown were placed at
the time of the extraction along with tissue regeneration procedures
(A–C). A shallow and isolated Miller class I recession on tooth 13 was
treated with a pouch flap together with a connective tissue graft
removed from the palate; complete coverage and increased tissue
volume were obtained after 6 months (D–H). Tooth 23 was
buccalized, presenting an isolated and deep GR with distal bone loss
and a non-carious cervical lesion (I–K). The root was restored with
composite resin, and a trapezoid flap combined with a connective
tissue graft was done; partial coverage and increased buccal
thickness were obtained after 6 months of follow-up (L, M). Anterior
region appearance 6 months after surgery (N) and 12 months after
restorative treatment (O, P). The surgical procedure was performed as
part of the Course in Periodontal Plastic and Peri-implant Guided
Surgery by Dr Fausto Frizzera and Dr Elcio Marcantonio Jr.
Restorative procedure: Dr Camila Lorenzetti.

3.2.1. SHALLOW AND DEEP GR

 In cases of multiple deep recessions, where the tooth with the
deepest recession is at one of the extremes, an envelope flap may not
allow the complete coronal positioning of the flap. This type of defect
is classified as “stair-shaped” recessions; the design of the flap should
involve a vertical incision close to the tooth that presents the deepest
GR associated with oblique incisions in the other regions. The area of
the vertical incision will show greater mobility compared to the rest of
the flap so that it will be possible to cover all root surfaces without
tension. When treating multiple recessions, it is possible to promote a
more significant flap release due to its horizontal extension. The
techniques of choice will range from tunnel flap, L-incision (stair-
shaped recessions), or sloping incision in the papillae. The technique
proposed by Zucchelli and De Sanctis62 is very versatile in treating
both shallow and deep multiple recessions. The tunnel technique is
indicated in shallow recessions where there is concern about the
postoperative prognosis of the interproximal papillae (Figs 48A–L and
49A–M). Vertical incisions are indicated in multiple recessions when
the tooth on the edge of the area to be treated presents the deepest
GR.

3.3. ENVELOPE AND TUNNEL FLAPS

48. A–L Patient with multiple recessions and gingival unevenness.
Planning to correct the position of the gingival margins included root
cover with the envelope technique on the right side, a tunnel on the
left side, and crown lengthening on the left maxillary central incisor
(A–E). In the teeth on the right side, angled incisions were made in the
papillae. A mixed-thickness flap was reflected. A connective tissue
graft was removed from the hard palate (F–J). The graft was stabilized
over the region with a gingival thickness of less than 1 mm and the
flap was positioned coronally (K–L).
49. A–M In the teeth on the left, a tunnel flap was made in teeth 23
and 24. A connective tissue graft was removed from the hard palate,
internally placed into the flap and coronally stabilized (A–E). It was
possible to obtain a satisfactory result at an early stage after gingival
grafts and the procedure for clinical crown augmentation of tooth 21
was planned (F, G). The teeth were whitened with combined in-office
and at-home technique (H, I). After 5 years of follow-up it was possible
to verify the stability of the results (J–M). Case previously published
by Frizzera et al; see als 66–68.

* In stair-shaped recessions, make a vertical incision at the most extreme tooth.

† If the amount of attached gingiva is greater than 4 mm, use an L-flap (unit recession) or
envelope (multiple recessions).

REFERENCES
1. Novaes AB, Novaes Jr AB. Cirurgia Periodontal com Finalidade
Protética. São Paulo, Brazil: Editora Artes Médicas 1999: 204.
2. American Academy of Periodontology. Glossary of Periodontal
Terms, ed 4. Chicago, IL: American Academy of Periodontology,
2001.
3. Kassab MM, Cohen RE. The etiology and prevalence of gingival
recession. J Am Dent Assoc 2003;134:220–225.
4. Albandar JM, Kingman A. Gingival recession, gingival bleeding,
and dental calculus in adults 30 years of age and older in the
United States, 1988–1994. J Periodontol 1999;70:30–43.
5. Addy M, Mostafa P, Newcombe RG. Dentine hypersensitivity: the
distribution of recession, sensitivity and plaque. J Dent
1987;15:242–248.
6. Miller PD. A classification of marginal tissue recession. Int J
Periodontics Restoriative Dent 1985;5:8–13.
7. Zucchelli G, Stefanini M, Ganz S, Mazzotti C, Mounssif I,
Marzadori M. Coronally advanced flap with different designs in
the treatment of gingival recession: a comparative controlled
randomized clinical trial. Int J Periodontics Restorative Dent
2016;36:319–327.
8. Rajapakse PS, McCracken GI, Gwynnett E, Steen ND, Guentsch
A, Heasman PA. Does tooth brushing influence the development
and progression of non-inflammatory gingival recession? A
systematic review. J Clin Periodontol 2007;34:1046–1061.
9. Acunzo R, Limiroli E, Pagni G, Dudaite A, Consonni D, Rasperini
G. Gingival margin stability after mucogingival plastic surgery.
The effect of manual versus powered toothbrushing: a
randomized clinical trial. J Periodontol 2016;87:1186–1194.
10. Baldi C, Pini-Prato G, Pagliaro U, Nieri M, Saletta D, Muzzi L,
Cortellini P. Coronally advanced flap procedure for root coverage.
Is flap thickness a relevant predictor to achieve root coverage? A
19-case series. J Periodontol 1999;70:1077–1084.
11. Huang LH, Neiva REF, Wang HL. Factors affecting the outcomes
of coronally advanced flap root coverage procedure. J Periodontol
2005;76:1729–1734.
12. Hwang D, Wang HL. Flap thickness as a predictor of root
 coverage: a systematic review. J Periodontol 2006;77:1625–
1634.
13. Saletta D, Pini-Prato G, Pagliaro U, Baldi C, Mauri M, Nieri M.
Coronally advanced flap procedure: is the interdental papilla a
prognostic factor for root coverage? J Periodontol 2001;72:760–
766.
14. Zucchelli G, Mele M, Stefanini M, et al. Predetermination of root
coverage. J Periodontol 2010;81:1019–1026.
15. Ottoni J, Serrao CR, Frizzera FBF, et al. Manipulação Tecidual:
Possibilidades e Realidade. Nova Odessa, Brazil: Ed Napoleão,
2011: 612.
16. Zucchelli G, Mounssif I. Periodontal plastic surgery. Periodontol
2000 2015;68:333–368.
17. Pini-Prato GP, Baldi C, Pagliaro U, et al. Coronally advanced flap
procedure for root coverage. Treatment of root coverage surface:
root planing versus Polishing. J Periodontol 1999;70:1064–1076.
18. Zucchelli G, Mele M, Mazzotti C, et al. Coronally advanced flap
with and without vertical releasing incisions for the treatment of
multiple gingival recessions: a comparative controlled randomized
clinical trial. J Periodontol 2009;80:1083–1094.
19. Mariotti A. Efficacy of chemical root surface modifier in the
treatment of periodontal disease. A systematic review. Ann
Periodontol 2003;8:205–226.
20. Bittencourt S, Ribeiro EDP, Sallum EA, et al. Root surface
biomodification with EDTA for treatment of gingival recession with
semilunar coronally repositioned flap. J Periodontol
2007;78:1695–1701.
21. Spahr A, Haegewald S, Tsoulfidou F, et al. Coverage of Miller
class I and II recession defects using enamel matrix proteins
versus coronally advanced flap technique: a 2-year report. J
Periodontol 2005;76:1871–1880.
22. Hägewald S, Spahr A, Rompola E, et al. Comparative study of
Emdogain and coronally advanced flap technique in the treatment
of human gingival recessions. A prospective controlled clinical
 study. J Clin Periodontol 2002;29:35–41.
23. Castellanos A, De la Rosa M, De la Garza M, Cafesse RG.
Enamel matrix derivative and coronal flaps to cover marginal
tissue recessions. J Periodontol 2006;77:7–14.
24. Pini-Prato GP, Pagliaro U, Baldi C, et al. Coronaly advanced flap
procedure for root coverage. Flap with tension versus flap without
tension: a randomized controlled clinical study. J Periodontol
2000:71:188–201.
25. Zucchelli G, Stefanini M, Ganz S, Mazzotti C, Mounssif I,
Marzadori M. Coronally advanced flap with different designs in
the treatment of gingival recession: a comparative controlled
randomized clinical trial. Int J Periodontics Restorative Dent
2016;36:319–327.
26. De Sanctis M, Zucchelli G. Coronally advanced flap: a modified
surgical approach for isolated recession-type defects. Three-year
results. J Clin Periodontol 2007;34:262–268.
27. Pini-Prato GP, Baldi C, Nieri M, et al. Coronally advanced flap:
the post-surgical position of the gingival margin is an important
factor for achieving complete root coverage. J Periodontol
2005;76:713–722.
28. Ottoni J. Manejo de Tejidos: Posibilidades y Realidad. Nova
Odessa, Brazil: Editora Napoleão, 2013: 614.
29. Silva RC, Joly JC, Lima AF, Tatakis DN. Root coverage using the
coronally positioned flap with or without a subepithelial connective
tissue graft. J Periodontol 2004;75:413–419.
30. Cortellini P, Tonetti M, Baldi C, et al. Does placement of a
connective tissue graft improve the outcomes of coronally
advanced flap for coverage of single gingival recessions in upper
anterior teeth? A multicentre, randomized, double-blind, clinical
trial. J Clin Periodontol 2009;36:68–79.
31. Chambrone L, Sukekava F, Araujo MG, Pustiglioni FE,
Chambrone LA, Lima LA. Root-coverage procedures for the
treatment of localized recession-type defects: a Cochrane
systematic review. J Periodontol 2010;81:452–478.
32. Graziani F, Gennai S, Roldán S, et al. Efficacy of periodontal
plastic procedures in the treatment of multiple gingival recessions.
J Clin Periodontol 2014;41(Suppl 15):S63–76.
33. Hofmänner P, Alessandri R, Laugisch O, et al. Predictability of
surgical techniques used for coverage of multiple adjacent
gingival recessions – a systematic review. Quintessence Int
2012;43:545–554.
34. Griffin TJ, Cheung WS, Zavras AI, Damoulis PD. Postoperative
complications following gingival augmentation procedures. J
Periodontol 2006;77:2070–2079.
35. Zucchelli G, Mazzotti C, Tirone F, Mele M, Bellone P, Mounssif I.
The connective tissue graft wall technique and enamel matrix
derivative to improve root coverage and clinical attachment levels
in Miller class IV gingival recession. Int J Periodontics Restorative
Dent 2014;34:601–609.
36. Sanz M, Lorenzo R, Aranda JJ, Martin C, Orsini M. Clinical
evaluation of a new collagen matrix (Mucograft prototype) to
enhance the width of keratinized tissue in patients with fixed
prosthetic restorations: a randomized prospective clinical trial. J
Clin Periodontol 2009;36:868–876.
37. McGuire MK, Scheyer ET. Xenogeneic collagen matrix with
coronally advanced flap compared to connective tissue with
coronally advanced flap for the treatment of dehiscence-type
recession defects. J Periodontol 2010;81:1108–1117.
38. Jepsen K, Jepsen S, Zucchelli G, et al. Treatment of gingival
recession defects with a coronally advanced flap and a
xenogeneic collagen matrix: a multicenter randomized clinical
trial. J Clin Periodontol 2013;40:82–89.
39. McGuire MK, Scheyer ET. Long-term results comparing
xenogeneic collagen matrix and autogenous connective tissue
grafts with coronally advanced flaps for treatment of dehiscence-
type recession defects. J Periodontol 2016;87:221–227.
40. Cardaropoli D, Tamagnone L, Roffredo A, Gaveglio L. Coronally
advanced flap with and without a xenogenic collagen matrix in the
 treatment of multiple recessions: a randomized controlled clinical
study. Int J Periodontics Restorative Dent 2014;34(Suppl 3):S97–
102.
41. Cardaropoli D, Tamagnone L, Roffredo A, Gaveglio L. Treatment
of gingival recession defects using coronally advanced flap with a
porcine collagen matrix compared to coronally advanced flap with
connective tissue graft: a randomized controlled clinical trial. J
Periodontol 2012;83:321–328.
42. Santamaria MP, Feitosa DS, Nociti Jr, et al. Cervical restoration
and the amount of soft tissue coverage achieved by coronally
advanced flap. A 2-year follow-up randomized controlled clinical
trial. J Periodontol 2009;36:434–441.
43. Lucchesi JA, Santos VR, Amaral CM, Peruzzo DC, Duarte PM.
Coronally positioned flap for treatment of restored root surfaces: a
6-month clinical evaluation. J Periodontol 2007;78:615–623.
44. Ishikawa I, McGuire M, Mealey B, et al. Consensus report:
mucogingival deformities and conditions around teeth. Ann
Periodontol 1999;4:101.
45. Lindhe J, Lang NP. Clinical Periodontology and Implant Dentistry,
ed 6. Hoboken, NJ: Wiley-Blackwell, 2015: 1480.
46. Maynard JG, Oschenbein C. Mucogingival problems, prevalence
and therapy in children. J Periodontol 1975;46:543–552.
47. Vieira BS, de Oliveira AR, Rodas MR, Maia LP, Dos Santos PL,
Silveira EMV. Comparison of two screw-retained free gingival
grafting techniques. J Craniofac Surg 2017;28:746–749.
48. Agudio G, Chambrone L, Pini Prato G. Biologic remodeling of
periodontal dimensions of areas treated with gingival
augmentation procedure: a 25-year follow-up observation. J
Periodontol 2017;88:634–642.
49. Bouchard P, Malet J, Borghetti. Decision-making in aesthetics:
root coverage revisited. Periodontol 2000 2001;27:97–120.
50. Edel A. Clinical evaluation of free connective tissue grafts used to
increase the width of keratinised gingiva. Periodontal Clin Investig
1998;20:12–20.
51. Orsini M, Orsini G, Benlloch D, Aranda JJ, Lázaro P, Sanz M.
Esthetic and dimensional evaluation of free connective tissue
grafts in prosthetically treated patients: a 1-year clinical study. J
Periodontol 2004;75:470–477.
52. Zeltner M, Jung RE, Hämmerle CH, Hüsler J, Thoma DS.
Randomized controlled clinical study comparing a volume-stable
collagen matrix to autogenous connective tissue grafts for soft
tissue augmentation at implant sites: linear volumetric soft tissue
changes up to 3 months. J Clin Periodontol 2017;44:446–453.
53. Urban IA, Lozada JL, Nagy K, Sanz M. Treatment of severe
mucogingival defects with a combination of strip gingival grafts
and a xenogeneic collagen matrix: a prospective case series
study. Int J Periodontics Restorative Dent 2015;35:345–353.
54. Group J, Warren R. Repair of gingival defects by a sliding flap
operation. J Periodontol 1956;27:290–295.
55. Zucchelli G, Cesari C, Amore C, Montebugnoli L, De Sanctis M.
Laterally moved, coronally advanced flap: a modified surgical
approach for isolated recession-type defects. J Periodontol 2004:
75: 1734–1741.
56. Norberg O. Ar en utlakning utan vovnadsfortust otankbar vid
kirurgisk behandling av. S. K. Alveolarpyorrhoe? Svensk
Tandlaekare Tidskrift 1926;19:171.
57. Tarnow DP. Semilunar coronally positioned flap. J Clin
Periodontol 1986;13:182–185.
58. Raetzke PB. Covering localized areas of root exposure employing
the “envelope” technique. J Periodontol 1985;56:397–402.
59. Langer B, Langer L. Subepithelial connective tissue graft
technique for root coverage. J Periodontol 1985;56:715–720.
60. Allen EP, Miller PD. Coronal positioning of existing gingiva: short
term results in the treatment of shallow marginal tissue recession.
J Periodontol 1989;60:316–319.
61. Pascoal CP. Retalho em L: uma nova alternativa para o
tratamento de recessões gengivais isoladas. Dissertação.
Campinas, Brazil: Faculdade de Medicina e Odontologia São
 Leopoldo Mandic, 2012: 86.
62. Zucchelli G, De Sanctis M. Treatment of multiple recession-type
defects in patients with esthetic demands. J Periodontol
2000;71:1506–1514.
63. Gobbato L, Nart J, Bressan E, Mazzocco F, Paniz G, Lops D.
Patient morbidity and root coverage outcomes after the
application of a subepithelial connective tissue graft in
combination with a coronally advanced flap or via a tunneling
technique: a randomized controlled clinical trial. Clin Oral Investig
2016;20:2191–2202
64. Frizzera F, Vieira GH, Molon RS, Esteves JC, Pecanha MM,
Sampaio JEC. Recobrimento radicular para o tratamento de
hipersensibilidade dentinária cervical persistente. Perionews
2013;7:26–33.
65. Frizzera F, Tonetto M, Kabach W, et al. Escultura gengival:
abordagem cirúrgica em alterações gengivais estéticas. Revista
Clínica 2012;8:388–400.
66. Frizzera F, Medeiros MC, Zanetti GR, Cirelli JA, Marcantonio Jr
E. Interação estética periodontal: programa de atualização em
odontologia estética. Porto Alegre, Portugal:
Artmed/Panamericana, 2013;4:95–167.
67. Frizzera F, Molon RS, Kabach W, Verzola MHA, Orrico SRP,
Sampaio JEC. Tratamento de recessões gengivais múltiplas:
uma abordagem cirúrgica mais conservadora. Perionews
2012;6:18–28.
68. Zabalegui I, Sicilia A, Cambra J, Gil J, Sanz M. Treatment of
multiple adjacent gingival recessions with the tunnel subepithelial
connective tissue graft: a clinical report. Int J Periodontics
Restorative Dent 1999;19:199–206.
 CHAPTER 4
TREATMENT PLANNING IN
IMPLANT DENTISTRY:
the search for predictable results
Fausto Frizzera, Bianca Vimercati, Marco Masioli, Jamil A. Shibli, Camila C.
Marcantonio, Elcio Marcantonio Jr
1. INTRODUCTION

Before implant treatment, it is essential to diagnose and plan each

case appropriately. Several tools can be used to make this critical
phase of treatment more predictable.
Many clinicians extract teeth because implant rehabilitation will
provide greater predictability for their treatment. However, dentists
should aim to preserve teeth because it has been scientifically
established that implants have survival rates similar to those of teeth1.
A detailed anamnesis, followed by clinical, laboratory, radiographic,
and photographic examinations, is fundamental to define the best
surgical and rehabilitation strategy. Specialties involved in treatment
should perform their procedurescarefully. Biologic failure may
compromise tooth viability and require the placement of an implant.
The patient must be healthy and without any pathological condition
that impairs the osseointegration process or must not take
medications that interfere with bone metabolism2.
One of the factors that must be taken into account before
performing implant rehabilitation is the patient’s bone age. To avoid
severe discrepancies between teeth and implants due to
maxillomandibular growth, implants should be placed after bone
growth is completed3.
In young patients, children, or adolescents, the treatment protocol is
to extract the tooth and maintain the prosthetic space to install the
implant later on after the patient reaches bone maturity. In adult
patients, this window is not necessary and it is possible to place the
implant at different times after the extraction. Establishing an
adequate diagnosis, surgical–prosthetic planning, and adequate
implantation chronology are critical factors for the successful
rehabilitation with implants.

OBJECTIVES
At the end of the chapter the reader should be able to:
Determine the reason for extraction and its repercussions on bone
and soft tissue.
Determine the ideal three-dimensional position of the implant.
Select implants for surgical–prosthetic rehabilitation.

2. EVIDENCE-BASED LITERATURE

2.1. TOOTH IMPAIRMENT

Dental caries, advanced periodontal disease, root resorption,

fractures, and recurrent endodontic lesions can lead to tooth loss4. A
recommendation of extraction should consider the extent of the
present pathology and if there is no possibility of maintaining the tooth
in function with an appropriate esthetic (Figs 01A–L). Depending on
the case, there may be more significant impairment of the remaining
bone tissue and sometimes the installation of an implant in the bone
socketmay be contraindicated. Clinical and radiographic examinations
are usually necessary to establish this diagnosis5.
01. A–L Mandibular left central incisor with a facial gingival recession
from an endoperiodontal lesion (A). Clinical and radiographic
evaluation (B) shows that the tooth has slight extrusion, grade 1
mobility, and sufficient periodontal support in the interproximal and
lingual region. Extraction is not recommended as long as the
endoperiodontal lesion is resolved. After periodontal and endodontic
treatment (C–H), a mixed flap was used to perform apicectomy and
root coverage surgery with a connective tissue graft (I, J).
Postoperative follow-up at 3 and 12 months after surgery was without
periodontal pockets (K, L). Surgical procedure: Dr Fausto Frizzera;
endodontic treatment: Dr Victor Valentim and Dr Igor Daroz under the
guidance of Dr Jaílson Vitali in the FAESA Integrated Clinics course.
 The integrity and thickness of support tissues are essential in
surgical planning6. A tooth may have extensive caries with no
significant gingival or bone impairment. In these cases when
restoration is not feasible, placement of an implant is recommended.
Similarly, teeth that need to be extracted due to root resorption share
this same feature, unless it is associated with the periodontium.
Endoperiodontal lesions have the potential to destroy support tissues
in height and thickness and should be diagnosed and controlled
before surgery.
Endodontic lesions are usually present near the root apex, with
bone loss restricted to this region. The possibility of lesion resolution
by endodontic treatment should be verified. Extraction should only be
recommended if the endodontic treatment presents a poor prognosis
(Figs 02A–K). The presence of bone defects makes it challenging to
install the implant in the socket due to the higher risk of not obtaining
apical anchorage of the implant since the lesion is often
underestimated or not detected by conventional radiographic
examinations7.
02. A–K Patient with a gummy smile and lesion in the periapical
region of tooth 22 (A–D). Radiographically, we note how periapical
radiography underestimated the size of the lesion. The indicated
treatment (E–G) involved periodontal and endodontic surgical
procedures. The right maxillary first molar clinical crown was enlarged
to its left counterpart, except for tooth 22, which underwent curettage
of the periapical lesion, apicectomy, retrograde obturation, and bone
grafting. After 1 year of follow-up, it was possible to observe the repair
of the periapical lesion of tooth 22 and an adequate periodontal
support, where the minimum ratio between crown and root should be
1:1, without the presence of pockets or tooth mobility (H–K). Surgical
procedure: Dr Fausto Frizzera; endodontic treatment: Dr João Batista
Gagno Intra.

Concerns about placing implants in areas with periapical or

periodontal lesions have resulted in several studies8–10; the current
consensus recommends not to install implants in regions with acute
processes. As long as the area is debrided during the surgical
procedure before implant placement, chronic lesions do not impair
osseointegration11.
Extensive loss of periodontal support can compromise the function
and esthetics of a tooth and immediate implant placement (Figs 03A–
G). In these cases, an adequate treatment plan to recover the lost
tissues and obtain more favorable results is needed12. In patients with
more significant tissue loss, it is often necessary to perform staged
implant rehabilitation. If tissue gain is still limited, grafting procedures
may be performed or a dentogingival restoration may be
recommended13. In these patients, oral hygiene instructions,
periodontal treatment before implant placement, and periodic follow-
up are of great importance to prevent future peri-implant problems14,15.
03. A–G This patient complained about the maxillary anterior teeth,
especially tooth 21 (A). Radiographically, there is an unfavorable
crown/root ratio and extensive bone loss (B–D). Clinically tooth 21
presents with mobility and severe attachment loss (E–G). Even though
there is sufficient apical bone, implant placement at this moment is
contraindicated due to the present defect and the need for its
resolution.

Root fractures and cracks are a significant dilemma in the diagnosis

and clinical treatment. They can occur in the vertical, horizontal, or
oblique direction and the recommendation for tooth extraction
depends on its extension and direction. Horizontal and oblique
fractures in the cervical third can be treated by orthodontic or
periodontal procedures, or by a combination of both. However, if there
is a vertical or oblique fracture extending to the middle or apical third,
tooth extraction should be considered16.
Vertical fractures and cracks are difficult to diagnose and may not
be noticed for months or years. Their presence implies the need for
extraction since no treatment is effective for vertical fractures17,18.
Maintaining the tooth will cause an infectious process. Additionally, the
micromovement of fragments further stimulates the inflammatory
response and bone resorption, which may cause extensive bone
defects and make future implant placement difficult or unfeasible.
Early diagnosis is essential for preserving bone tissue and avoiding
bone grafts and higher morbidity for the patient19. Currently, no
noninvasive diagnostic method can confirm the presence of a vertical
root discontinuity, so a number of clinical and radiographic findings are
taken into consideration to establish this diagnosis. Clinical,
radiographic, and periodontal evaluation, as well as transillumination,
fistula tracking, pulp vitality testing, and mobility are used to diagnose
vertical root fractures18. The presence of a periodontal pocket in an
isolated surface of a tooth is a common sign of a root fracture.
Radiographic signs of fracture may include increased periodontal
ligament, periapical radiolucency, bone loss, and separation of root
fragments20.
Even after these evaluations, doubt may persist; in these situations,
exploratory surgery may be performed to verify the actual presence of
a crack or fracture, or cone beam computed tomography (CBCT) can
be requested. If the diagnosis is confirmed, the tooth should be
extracted. Depending on the amount of bone, it is possible to place an
implant and grafts during the same procedure (Figs 04A–G).
04. A–G Presence of extensive bone defect in the buccal surface of
tooth 11 (A). In addition, the tooth had an unfavorable crown/root ratio
and a broad intraradicular post (B). Clinical evaluation showed the
presence of a deep and isolated pocket only in the facial surface of
tooth 11, with presence of suppuration (C). The diagnosis of root
cracks on the facial surface was established and the tooth was
removed (D–G).

2.2. IMPLANT PLACEMENT TIMELINE

The timing of implant placement after extraction was established by

consensus21; different types were classified according to the timing of
implant placement (Figs 05A–D).
05. A–D Different implant placement types defined based on tooth
extraction. Type I: implant placed in fresh socket (A); type II: early
implant placement, after complete soft tissue healing, between 4 and
8 weeks after extraction (B); type III: immediate implant placement,
after considerable bone healing assessed by radiographs, between 12
and 16 weeks after extraction (C); type IV: late implant placement,
installed in healed ridges, 16 or more weeks after extraction (D).

If the treatment aims to rehabilitate the patient immediately after

extraction, care should be taken. Any problems in diagnosing or
planning can lead to future complications. The individualized
rehabilitation planning begins after initial assessments of the patient
and their systemic and local conditions are performed.
Surgical installation of an implant aims to rehabilitate one or more
teeth. Taking into account the current rehabilitative philosophy where
reverse planning is performed before surgical procedures, a number
of factors (Figs 06A–D) regarding the tooth and site to be implanted
and their maxillomandibular relationship should also be considered14.
06. A–D Fracture of tooth 21 due to occlusion trauma in protrusion; a
balanced occlusion should be established to allow adequate
rehabilitation with an implant (A). Before implant placement,
orthodontic, surgical, or combined treatment may be required to
balance the occlusion (B), convergence of the roots of the teeth
adjacent to the edentulous area (C), and inadequate prosthetic or
interocclusal space (D).

Orthodontic and oral rehabilitation should be employed to verify the

need to reestablish the patient’s vertical dimension, anterior guide,
and lateral and protrusion movements. Stable occlusion is critical to
successful rehabilitation and is of paramount importance in situations
where an immediate provisional is placed without occlusal
contacts22,23. If the patient has loss of posterior occlusal support or
parafunctional habits, the provisional and implant may receive
excessive loads and the success of the treatmentis compromised24,25.

2.3. BONE EVALUATION

Implant placement in the ideal three-dimensional(3D) position will

depend on bone availability. Therefore, it is essential to request a
CBCT scan before surgery. This radiographic method allows the
visualization of the existing bone and gingival contour (if a soft tissue
retractor is used during the computed tomography scan) and whether
immediate implant placement is possible, reducing the patient’s total
treatment time. The CBCT also allows us to verify the need for bone
regeneration before implant placement (Figs 07A–H).
07. A–H Assessment of bone and gingival condition in the soft tissue
using CBCT: socket with sufficient apical bone for immediate implant
placement (A); socket with limited apical bone that does not allow
immediate implant placement (B); healed socket with enough bone for
implant installation (C); healed socket with limited thickness with need
for bone regeneration, which may or may not be combined with
implant placement (D); healed socket with limited height and thickness
with the need for bone regeneration before implant placement (E). It is
possible to detect bone defects with three (F), two (G), or only one (H)
remaining wall.
 The CBCT scan is essential for diagnosis and individualized
treatment planning with dental implants5. Individual treatment planning
of each patient increases the predictability of treatment. For excellent
outcomes, such as those required by patients, errors from inaccurate
diagnosis or treatment planning must be avoided26. Besides being an
essential tool for diagnosis, the CBCT scan allows us to accurately
assess bone height and thickness and their relationship with
anatomical structures. It also allows virtual planning for guided
surgeries27. It is possible to classify the dentulous or edentulous ridge
into six types (Figs 08A–L and 09A–F) according to Benic and
Hämmerle28.
08. A–L Classification of bone defects according to Benic and
Hämmerle28.
09. A–F Clinical images of the six classes of bone defects according
to Benic and Hämmerle28.
0 Slight loss of bone tissue
1 Intact socket
2 Narrow buccal defect
3 Wide buccal defect
4 Defect in thickness
5 Defect in height and thickness

When indicated, CBCT should be used in a way that favors patients

and facilitates surgical procedures. In many situations the clinician
may have questions about the thicknessof the bone ridge or the
prognosis of a tooth with a radiolucent apical lesion.
Evaluation by panoramic or periapical radiographs is indicated to
evaluate teeth, periodontal condition, bone ridge, and their relationship
with anatomical structures in a general context (Fig 10).
10. Panoramic radiographs allow to assess the patient’s general oral
condition and evaluate the distance from the ridge to anatomical
structures such as the maxillary sinus (1), nasal fossa (2), incisive
foramen (3), mandibular canal (4), mental foramen (5), and basilar
process (6). It is still possible to verify the relationship between the
edentulous area and the roots of the adjacent teeth and plan the
rehabilitation.

The patient must have periodontal and dental health before implant
placement (Figs 11A–C to 13A–C). Conventional radiographs are
good tools for initial planning but are limited due to overlapping
images and may not allow true visualization of the extent of the defect
present at or around the tooth. CBCT allows the verification of the
dimensions of the defect and the density and topography of the
existing bone. Therefore, the ideal position of the implant placed
immediately after tooth removal can be determined. Such a concern
exists because the position the implant is placedinto influences the
amount of soft tissue around it.
11. A–C Patient with periodontal and dental health, except for tooth
24. The patient complained of the esthetics. Deep periodontal
pockets, mobility, and painful sensitivityare present.
12. A–J Radiographic examination demonstrates the presence of a
bone defect around the root of tooth 24 (A). Tomographic evaluation
of the defect demonstrates extensive buccal bone loss with sufficient
apical bone for immediate implant placement (B–J).

13. A–C This patient had high esthetic demands and reported
dissatisfaction with gingival staining in the buccal region of tooth 24.
Radiographic and photographic protocol done by Odontopixel.

2.4. SOFT TISSUE EVALUATION

Due to the different clinical and histological characteristics of gingival

tissue, the soft tissue surrounding the implant is called the peri-implant
mucosa. In esthetic areas, it is essential that visually this tissue is
similar to the adjacent mucosa. If there is adequate keratinized
mucosa around the implant, it should be pink and firm (Figs 14A–E);
otherwise, it may appear red and loose29.

14. A–E The tooth was extracted and an implant placed in the ideal
3D position (A). Due to the adequate primary stability, an immediate
provisional was made. The socket was regenerated and a connective
tissue graft (B) was added to increase the soft tissue volume and
prevent exposure of the peri-implant margin. Clinical and radiographic
follow-up at 6, 12, and 36 months after surgery (C–E). Surgical
procedure: Dr Fausto Frizzera; restorative procedure: Dr Marco
Masioli; laboratory technician: Igor Hand.

Like the periodontium, the peri-implant tissue will also have a sulcus
(Fig 15).

15. Schematic illustration of the difference between dental and peri-

implant tissues.

The depth of the sulcus will vary depending on several factors such
as implant position, prosthetic component, region, and bone anatomy.
The presence of peri-implant pathology should be diagnosed by the
presence of recession or bleeding on probing (Figs 16A–C)30.
16. A–C Presence of recession around the implant, with exposure of
the implant surface, limited amount of attached gingiva, presence of
biofilm, and peri-implant bleeding, which may result in peri-implantitis.

Histologically, peri-implant tissue is similar to gingival tissue. An

epithelial tissue adhesion with hemidesmosomes to the prosthetic
component is present, similar to teeth31. In contrast, the peri-implant
mucosa has reduced blood supply and collagen fibers do not adhere
directly to the implant, as occurs on the root surface of teeth. Most of
them are parallel to the implant, forming a collar around the implant,
providing tonicity and consistency to the mucosa32.
The orientation of collagen fibers is also related to the quality of the
periimplant mucosa33. It is also possible to find fibers oriented in
different directions, especially in thicker tissues with more keratinized
mucosa (Figs 17A–F).
17. A–F Clinical differences between thin (A–C) and thick (D–F) peri-
implant biotype.
 It is necessary to consider these aspects when working with
implants because there may be a ridge deficiency after tooth
extraction. Seibert and Lindhe34 classified ridge defects into three
types (Figs 18A–C):
Class I: there is thickness loss but no height loss.
Class II: there is height loss but no loss in thickness.
Class III: there is combined height and thickness loss.

18. A–C Clinical classification of ridge defects: class I—loss in

thickness (A); class II— loss in height (B); class III— combined loss in
height and thickness (C).

In addition to presenting loss in height and thickness, there may be

changes in color and texture. The patient has a high perception for
assessing color changes; in some situations, this is more easily
perceived than small discrepancies (≈ 0.5 mm) between gingival
margins35.
As with the attached gingiva, the alveolar ridge may present
pigmentation. Removal of these spots should be performed by
complete excision of the affected epithelial tissue; their indication will
depend strictly on the patient’s wishes. Other color changes may
come from particles of metallic materials that have impregnated the
soft tissue or from the implant or prosthetic component due to the
presence of thin tissue. The etiology of tissue color modification
should initially be identified to define its treatment, either by removing
the pigmented tissue or by increasing tissue volume (Figs 19 and
20A–C).

19. Defining the etiology of color alteration is the first step in

establishing its treatment. The tissue may be thin and change in color
may be associated with a discolored root or may have endogenous
(eg, melanin pigmentation) or exogenous (eg, metal pigmentation)
pigmentation.

20. A–C The peri-implant region may also present a change in color
when the implant or prosthetic component shows through the thin peri-
implant mucosa (A). If the change is restricted to the metal prosthetic
component (B), it can be replaced by an esthetic abutment (C) or a
connective tissue graft may be performed to increase tissue thickness.

Changes in texture may be due to improperly designed incisions or

changes in alveolar mucosa position. Scar tissue can be peeled using
scalpel blades, high-power laser, or burs. If the scar affects the
gingival margin with limited tissue thickness and there is a concern
about the recession of this margin after the procedure, a connective
tissue graft is recommended before scar removal (Figs 21A–C).
Regions with altered alveolar mucosa position resulting from surgical
grafting procedures can be treated by an apically positioned flap, with
a minimum of 2 mm of keratinized tissue. When there is no keratinized
tissue, a free gingival graft is recommended. A free gingival graft, from
the palate or tuberosity, usually has a different color and texture (Figs
22A–C) when compared to adjacent teeth. Thus, it is not
recommended in esthetic regions. In these cases, synthetic or animal
collagen matrices are recommended. These biomaterials tend to
result in a more uniform color of keratinized tissue36.

21. A–C Anterior region with postoperative scars due to incorrect

incision planning (A). In the edentulous region, which has greater
tissue thickness, a gingival peel with diamond burs was performed
(B); on tooth 22, a connective graft was performed before the peeling
due to the thin biotype and to avoid a greater recession in the
compromised area (C).

22. A–C Region with limited amount of attached gingiva (A). Region
with large amount of attached gingiva (B). Region that received a free
gingival graft to increase the amount of attached gingiva (C); notice
the change in color and texture.

The esthetic resolution of dental losses with dental implants

demands a high degree of planning and excellent execution of
surgical and restorative procedures. The evolution of implant systems,
restorative materials, surgical techniques, as well as the possibility of
achieving excellent results, increased the level of demand of patients
who want the implants to look similar to their adjacent teeth.
Placement of the implant in the correct position is crucial to achieve
positive outcomes. An error in 3D implant positioning may
compromise peri-implant tissue architecture and impair esthetics and
function.

2.5. IMPLANT PLACEMENT

Every implant placement procedure aims to rehabilitate the patient
permanently. The time this implant will be in function in the oral cavity
is still undetermined. Thus, it is necessary to define the ideal position
of the implant and use quality materials, with clinical evidence
supported by the scientific literature, to allow long-lasting results with
long-term follow-up.
In the early stages of rehabilitation with single implants, there was
no ideal protocol for the implant position and implants were placed
according to bone availability37. It is important to note that improper
implant selection or placement can impair the esthetics and prosthetic
rehabilitation38–40. Placement of implants according exclusively to bone
availability should be avoided, given the possibility of catastrophic
results.
The ideal prosthetic position of the implant should be determined
before any surgical procedure.
To enable prosthetic rehabilitation, the planning for ideal implant
installation needs to be established before any type of surgical
procedure. An evaluation of the edentulous space, the remaining
bone, and the interocclusal relationship must be done by analyzing the
patient’s smile, by clinical and radiographic examination, and by
creating study models. These are fundamental factors in the
establishment of an adequate treatment plan.
A thorough clinical and radiographic examination associated with
the smile analysis and study models is necessary. This analysis will
determine the edentulous space and remaining bone availability and
the interocclusal relationship. These are critical factors in establishing
an appropriate treatment plan.
Establishing the position of the gingival edge is the first step when
planning implant placement. All rehabilitation must be guided by the
desired edge41; large horizontal movements imply the need for
orthodontic procedures to create a space for ideal implant
placement42. For smaller horizontal and vertical changes, restorative
or surgical procedures may be enough.
Placement of the implant in the ideal position may require prior or
simultaneous tissue regeneration. Regenerative techniques should be
employed to improve the quantity and amount of tissue around the
 implant, favoring effective prosthetic rehabilitation with adequate
esthetics and function28. Tissue regeneration before implant
placement should be preferred when it is not possible to place the
implant in the correct position; otherwise, the simultaneous approach
(implant placement combined with bone and gingival reconstruction) is
recommended. To guide the implant position and bearing in mind the
physiological bone remodeling that occurs around it, three spatial
positions must be respected (Figs 23A–E and 24A–F):
1. Mesiodistal (MD): Takes into account the horizontal relationship
between the implant and the adjacent teeth or implants.
2. Cervical-apical (CA): Regards the vertical positioning of the implant
in relation to the bone crest, the desired gingival margin, and the
cementoenamel junction (CEJ) of the adjacent teeth.
3. Buccolingual (BL): Considers the inclination and position of the
implant in the ridge in an occlusal view.
23. A–E Correct 3D implant placement in the MD (A), CA (B), and BL
(C) positions. Areas in red: danger zone; green area: comfort zone.
Clinical distances between MD, CA (D), and BL (E) that must be
respected: 1 mm apical to the CEJ of the contralateral tooth (blue
line); 3–5 mm from the desired gingival margin (green line); and 1.5
mm from the adjacent teeth (yellow line).
24. A–F In areas with tissue deficiency (A–C), placement of the
implant should only happen if the ideal 3D position can be achieved.
The surgical guide is used during bone preparation and after implant
placement to verify implant position (D, E); then, tissue regeneration is
performed (F).

A minimum MD distance of 1.5 mm between implant and tooth, or 3

mm between implants, should be respected to allow the correct
emergence profile and avoid damage to the bone crest and
interproximal papilla43. The interproximal bone crest, periodontal
fibers, and cervical contour of the tooth or restoration hold the papilla
in position. The height of the soft tissue depends on the type of
relationship between the implant ideally positioned in the bone tissue
(Figs 25A–Q) and the tooth, implant, or bone ridge44. A change in
bone crest height may lead to loss of interproximal tissue and
consequent interdental black space (Figs 26A–D and 27A–L).
25. A–Q Clinical case where it was not possible to place the implant in
the proper position due to bone limitation (A–D). A bone graft was
removed from the ramus of the mandible with a bur and mixed with a
bone substitute (Straumann cerabone). A membrane (Straumann
Jason) was placed over the defect and fixed with a fixation pin (E–N).
Six months after surgery, it was possible to detect proper soft tissue
healing with considerable bone augmentation, allowing the implant to
be placed in the proper position (O–Q).
26. A–D The minimum distance between implants must be of 3 mm
(A). The height of the papilla between implants is usually shorter (B)
even when respecting this distance; when this change is present in
the midline, the esthetic risk is lower (C, D).
27. A–L Patient who presented a high smile line and missing teeth 11
and 12 with soft tissue impairment (A–C). The placement of two
adjacent implants will only worsen the condition of the soft tissue;
surgical planning involved the placement of one implant on the region
of tooth 11 and bone and gingival regeneration. Postoperative follow-
up at 4 months, where a provisional cantilever prosthesis was
delivered for tissue conditioning (D–L). Surgical and restorative
procedure: Dr Edielson Mattos under the guidance of Dr Fausto
Frizzera, Umberto Ramos, and Everaldo Del Caro Filho.

After placement of a prosthetic component and formation of the

peri-implant biologic width, physiological bone remodeling may occur
around the implant.
Bone remodeling around the implant is also called the saucer effect.
It can be verified in the interproximal region on periapical radiographs.
When the implant is placed in the correct position, bone loss does not
affect the papilla since the proximal bone crest will be in a more
coronal position43. If an implant is placed too close to a tooth or other
implant, the saucer effect can cause interproximal bone loss and
represent a challenge when treating the interproximal soft tissue (Figs
28A, B).
28. A, B Implant installed behind the mesial root of the maxillary first
molar (A); the tooth was extracted at the same surgical moment and
the implant was placed in the appropriate 3D position (B).

Bone remodeling occurs around the entire implant, causing a loss in

the buccal and lingual surfaces; Thus, apical migration of the
buccogingival margin may occur due to the involvement of the buccal
bone43. It is necessary to differentiate bone remodeling to establish
biologic width (saucer effect) and peri-implantitis, where bone loss is
associated with infection and bleeding (Figs 29A–H). The implant can
be placed under three different conditions in relation to the CA position
and bone crest: suprabony, at bone level, or infrabony (Fig 29I).
29. A–I The bone around the implant (A) may undergo physiological
bone remodeling. This process is called the saucer effect (B, D–G)
and should not be confused with peri-implantitis (C, H). Peri-implantitis
is associated with increased probing depth, bleeding, and extensive
bone loss around the implant. The implant can be placed in a
suprabony position (1), at bone level (2), or infrabony position (3) (I).

The implant should be installed in a suprabony position only if

vertical tissue regeneration is planned to create tissue around the
exposed threads. Implant placement at the bone level is the gold
standard position for most dental implant systems43. Placement of the
implant in an infrabony position has been recommended mainly in
esthetic areas to favor the soft tissue contour and maintenance of
bone tissue around the implant. For these cases, a Morse taper
connection implant and narrow prosthetic abutments are
recommended.
For the correct CA positioning of the implant, it is necessary to take
into account the desired gingival margin height. The implant platform
should be positioned 3–5 mm apically to the desired gingival margin.
In systems that recommend the placement of the implant at the bone
level, the implant should be placed approximately 3 mm from the
future gingival margin43. For implant systems that recommend the
infrabony placement of the implant, the manufacturer’s
recommendations must be followed. If the recommendation is that the
implant is installed 2 mm intraosseously, the distance between the
desired gingival margin and the implant platform will be 5 mm.
The prerogative to install the implant in an infrabony condition is
also to reduce physiological bone remodeling around Morse taper
implants. Morse taper connections present excellent tissue stability,
allowing for a more apical placement without compromising the bone
walls around the implant. When the saucer effect occurs around apical
placements, regardless of their type of connection, a significant
amount of the soft tissue will be without bone support, which is a
concern. Kois45 stated that the gingival margin is less stable when
there is a distance greater than 4 mm to the bone crest. The absence
of this support makes the tissue more susceptible to recession,
especially in patients with a thin biotype (Figs 30A–F).
30. A–F The gingival margin tends to be more stable when the
distance to the bone crest is 3–4 mm (A); if this distance is higher,
there is a risk of peri-implant margin recession due to lack of bone
support (B). Less bone remodeling can be achieved around the Morse
taper implant compared to external hex implants (C). Histological
evaluation of Morse taper implant with a prosthetic component with a
reduced platform show an intimate contact of the bone tissue on the
implant platform (D–F) (ON = new bone; OR = residual bone). Figs D–
F: courtesy of Dr Adriano Piattelli, Marco Degidi, and Jamil Shibli.
Adapted from Degidi et al45.

The buccolingual position of the implant from an occlusal view must

be considered, as well as its angulation. The buccal bone wall should
be 1–2 mm thick. It is usually necessary to place the implant in a
lingual position. The implant should be placed around 1 mm more
lingual than the center of the adjacent teeth43. If the implant is placed
too lingually, it may lead to an inadequate emergence profile of the
prosthesis impairing speech and periodontal control. If the implant is
placed too buccally, it may cause bone dehiscence and marginal
recession (Figs 31A–C).
31. A–C Improperly placed implant in the edentulous area with
compromised tissues around it and adjacent tooth.

Implant inclination must respect an emergence between the incisal

edge and the cingulum in the anterior teeth and should be installed in
the center of the occlusal table of the posterior teeth. The type of
prosthetic retention is determined by the angulation of the implant and
may influence the length of the prosthetic crown. Buccalized implants
will usually have longer clinical crowns, while lingualized implants will
have shorter crowns. These cases may require the removal of the
implant and placement of a new implant in the appropriate 3D
position. Periodontal plastic surgery will not have satisfactory results in
the short or long term because the cause of the problem (short or long
clinical crown) is due to an incorrect position of the implant.
The ideal implant position is essential to achieve satisfactory
esthetic and functional results in implant dentistry. Additionally, it is
necessary to plan the number, height, and width of implants to be
placed according to each clinical situation respecting the clinical,
biologic, and biomechanical principles.

2.6. DENTAL IMPLANT SELECTION

Planning for a definitive implant-supported rehabilitation needs to take

into consideration the length, diameter, and region where the implant
will be placed. The knowledge of fixed prostheses was initially applied
to implantology to guide surgical–prosthetic planning. However, the
support comes no longer from the root surface, periodontal ligament,
and alveolar bone. It is provided by the direct contact of the implant
surface with the bone.
The selection of implant diameter should take into account factors
such as bone thickness and height, region, and prosthetic space (Fig
32). Implants can be divided into three categories, taking into account
their diameter and length.

32. Implants can be classified according to their diameter into narrow

neck (I), which have a diameter less than or equal to 3.5 mm, regular
neck (II), having a diameter between 3.6 mm and 4.4 mm, and wide
neck (III), with a diameter greater than or equal to 4.5 mm.
 The choice of implant diameter must carefully respect the distances
between teeth and implant. It must be at least 2 mm smaller than the
width of the alveolar ridge to prevent bone dehiscence soon after
placement. If this occurs after the implant has been placed in the
appropriate 3D position, bone grafting can be performed (Fig 33). It is
necessary to avoid damage to the roots of neighboring teeth; this must
be previously checked and, if necessary, orthodontic treatment is
recommended to correct the angulation of the roots.

33. Preparation for implant placement inside the bone socket.

Implant length is defined by bone availability. Radiographic

examination is used to verify the distance between the bone ridge and
the apical limit (Figs 34A–J). In the maxillary arch, the implant apex
should be at least 1 mm away from the bone limit; some authors even
advocate that the apex should be in contact with this limit without
major risks of complications. However, in the mandibular posterior
region, a greater safe distance of at least 2 mm should be established
to avoid neurologic complications.
34. A–J Assessment of posterior bone thickness and height: socket
with sufficient apical bone for immediate implant placement (A);
socket with limited apical bone that does not allow the immediate
placement of an implant (B); healed ridge large enough for implant
placement (C); healed ridge with limited thickness and height
demonstrating the need for bone regeneration, which may or may not
be associated with simultaneous implant placement (D); healed ridge
with limited bone height demonstrating the need for bone regeneration
before implant placement (E). Bone thickness and height: socket with
sufficient apical bone for immediate implant placement (F); socket with
limited apical bone that does not allow immediate implant placement
(G); healed ridge large enough for implant placement (H); healed ridge
with limited thickness demonstrating the need for bone regeneration,
which may or may not be associated with simultaneous implant
placement (I); healed ridge with limited bone height demonstrating the
need for surgical procedure to enable implant placement (J).

Implants can be considered as long, regular, or short depending on

size (Fig 35A). Long implants, with a length greater than or equal to
13 mm, are recommended in extraction sockets; when there is bone
thickness limitation, a narrow implant is recommended. Implants of
regular length, with a height greater than or equal to 8.5 mm or less
than 13 mm, are recommended in various clinical situations for single
or multiple rehabilitations. Short implants have a height of less than or
equal to 8 mm. They are recommended on short ridges, in situations
of multiple teeth losses with adequate bone thickness. Note the need
to establish a good relationship between diameter and length in
implant selection to favor its biomechanics. The shorter the implant,
the wider it should be. On the other hand, the longer the implant, the
narrower it can be.

35. A, B According to their length, implants can be classified as: short

(I) with a length less than or equal to 8 mm; regular (II) length greater
than or equal to 8.5 mm and less than 13 mm; and long (III) length
greater than or equal to 13 mm (A). Implants may have different
prosthetic connections: external hex (IV); internal hex (V); Morse taper
(VI) (B).
 Implant rehabilitation involves the installation of a dental prosthesis.
The implant platform can basically have three connection types:
external hex, internal hex, and Morse taper (Fig 35B). Each type of
connection has its advantages and disadvantages. Professionals have
preferences for a certain type of connection. In esthetic areas, the use
of a Morse taper connection is indicated because it tend to present
less bone remodeling around the implant, better distribution of
chewing forces and excellent stability of prosthetic components46,47.
36. A–D An area with thickness and height deficiency (A) has been
grafted to allow implant placement in the ideal 3D position (B). Even
after a considerable increase in bone thickness, it was necessary to
create a dentogingival prosthesis to provide a better esthetic result (C,
D).

3. CLINICAL APPLICATION

Partially edentulous patients who have poor dental positioning require

orthodontic treatment for better distribution of prosthetic spaces, or
restorative procedures to allow proper function and esthetics. When
the extensive bone and soft tissue defects are present, it may be
necessary to make a prosthesis that has artificial gums even after
performing bone and gingival grafts. Tissue reconstruction may not be
able to restore the entire architecture of previously lost tissue but will
enable implant placement at the ideal 3D position (Figs 36A–D).
37. A–F Placement of two implants in the region of the incisors for
rehabilitation with a fixed four-element prosthesis: implants placed in
the region of the maxillary lateral incisors—allows excellent amount of
soft tissue (A, B); implants in the lateral and maxillary central incisor
region— recommended when there is extensive defect in the region of
one of the laterals, has less amount of soft tissue in the region
between central incisors (C, D); implants in the central maxillary
incisor region—indicated when there is extensive loss in the lateral
incisor region, with even less soft tissue in the region between central
incisors (E, F).

In esthetic regions, one of the primary factors that need to be

addressed is the amount of soft tissue around the implant in the
interproximal region. Soft tissue height will depend on the relationship
between the implant and the tooth, a pontic area, or another implant
adjacent to it (Table 01).

Table 01. Classification based on the height of the papillae in relation

to the teeth, implants, and pontic(Salama et al4)

The prosthetic space should be rehabilitated with as few implants as

possible, with a 3D conformation capable of distributing all chewing
force. This way, providing the right amount of soft and bone tissue
around the implant can be performed easily. Under these conditions,
the 3 × 2 rule can be used in the posterior region. A three-teeth
prosthetic space can be rehabilitated with a fixed three-element partial
prosthesis supported by two implants. In the anterior region, the rule
becomes 4 × 2. A space of four teeth can be rehabilitated with two
implants that will support a fixed four-element partial prosthesis (Figs
37A–F).

38. A, B The condition that presents the least amount of soft tissue is
when four implants are installed in the anterior region, which is
recommended only in patients who ask for this type of rehabilitation
(and are aware of possible soft tissue changes) with a low smile line
and prosthetic space greater than 26 mm and satisfactory amount of
peri-implant tissue.

According to the patient’s demands, such as a low smile line, a

sufficient amount of peri-implant tissue and ample prosthetic space, a
1 × 1 ratio can be used where each implant will support a prosthetic
element (Figs 38A, B to 40A–L). In these situations, it is necessary to
guide the patient as to the esthetic limitations that can occur and pay
even more attention to the placement of implants since minor changes
can lead to significant complications43.
39. A–S Patient with a low smile line and fixed partial prosthesis in the
region of teeth 11 and 22, where tooth 11 presented vertical fracture
and tooth 22 presented violation of the biologic width and persistent
endodontic lesion (A–C). Tomographic evaluation showed
intraosseous lesions that were considered in the implant length
planning (D–H). The remaining teeth were extracted and the
preparations for the four implants of 3.5 mm diameter following the
surgical guide (I–N). Due to adequate primary stability in the regions
of teeth 12, 11, and 21, narrow abutments and a provisional
prosthesis were installed (O–Q). The ridge was reconstructed with
bone and gingival graft (R, S).
40. A–L Four months after surgery, all implants were clinically
osseointegrated. The tissue was conditioned to make individualized
and screwed prostheses. Surgical procedure: Dr Fausto Frizzera;
restorative procedure: Dr Marco Masioli; laboratory technician: Igor
Hand.

3.1. MULTIPLE AND ADJACENT IMPLANTS

The macroscopic anatomy of the implant, as well as the type of bone

present and the bone preparation, will allow its proper anchorage at
the moment of surgery, being responsible for primary bone stability.
The micrometric and nanometric characteristics of the surface of the
implant influence secondary bone stability and osseointegration.
Depending on the type of surface treatment, it is possible to reduce
osseointegration time and increase the quality and amount of bone in
contact with the implant (Figs 41A–G to 46A–M).

3.2. SINGLE IMPLANTS

41. A–G Patient with periodontal abscess in tooth 11 who complained
of acute pain; the abscess was drained; curettage of the pocketwas
performed and drug therapy was started (A). Tomographic
examination showed partial loss of the buccal bone wall and presence
of an oblique fracture (B–D). Seven days after the initial intervention,
the patient returned with recurrent abscess on tooth 11, complaining
of severe pain and buzzing in the ear and requesting tooth extraction
(E–G).
42. A–I The tooth was extracted and the socket was curetted; neither
implant nor grafts were used due to active infection and patient
choice.
43. A–H Three months after extraction, it was possible to observe
healing of the alveolus with a considerable reduction in the width of
the ridge (A, B). The rim was sequentially instrumented (C–H).
44. A–J A 3.5 × 11 mm implant was placed in the ideal 3D position
using the provisional as a surgical guide (A–F). Bone grafting was
performed by combining scraped autogenous bone from the adjacent
region (on the implant surface) and xenogenous bone (to create the
contour of the shoulder) (G, H). The gingival graft was removed from
the tubercle region and sutured to the vestibular region of the implant
(I, J).
45. A–V Seven days after the sutures were removed (A–C). Three
months after implant placement, surgery was performed to reopen the
incision on the palate and the tissue was positioned on the buccal side
(D–F). The polyvinyl siloxane impression was made and two ceramic
crowns were formed on teeth 11 and 21 (G–V).
46. A–M Final adjustments to the ceramics prior to in-mouth try-in (A–
I). After the surgical procedures and tissue conditioning it was possible
to reconstruct the ridge volume (J–L). Clinical appearance one year
after installation of the definitive (M). Surgical procedure: Dr Fausto
Frizzera; restorative procedure: Dr Bianca Vimercati, laboratory
technician: Igor Hand.

REFERENCES

1. Chércoles RA, Sánchez-Torres A, Gay-Escoda C. Endodontics,

endodontic retreatment, and apical surgery versus tooth
extraction and implant placement: a systematic review. J Endod
2017;43:679–686.
2. Renouard F Ranger B. Risk factors in implant dentistry: simplified
clinical analysis for predictable treatment, ed 2. Chicago, IL:
Quintessence International, 2008.
3. Sharma AB, Vargervik K. Using implants for the growing child. J
Calif Dent Assoc 2006;34:719–724.
4. Sanz I, Garcia-Gargallo M, Herrera D, Martin C, Figuero E, Sanz
M. Surgical protocols for early implant placement in post-
extraction sockets: a systematic review. Clin Oral Implants Res
2012;23(Suppl 5):67–79.
5. Saavedra-Abril JA, Balhen-Martin C, Zaragoza-Velasco K,
Kimura-Hayama ET, Saavedra S, Stoopen ME. Dental
multisection CT for the placement of oral implants: technique and
applications. Radiographics 2010;30:1975–1991.
6. Januario AL, Barriviera M, Duarte WR. Soft tissue cone-beam
computed tomography: a novel method for the measurement of
gingival tissue and the dimensions of the dentogingival unit. J
Esthet Restor Dent 2008;20:366–373.
7. Lofthag-Hansen S, Huumonen S, Gröndahl K, Gröndahl HG.
Limited cone-beam CT and intraoral radiography for the diagnosis
of periapical pathology. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2007;103:114–119.
8. Fugazzotto P. A retrospective analysis of immediately placed
implants in 418 sites exhibiting periapical pathology: results and
clinical considerations. Int J Oral Maxillofac Implants
2012;27:194–202.
9. Crespi R, Cappare P, Gherlone E. Immediate loading of dental
implants placed in periodontally infected and non-infected sites: a
4-year follow-up clinical study. J Periodontol 2010;81:1140–1146.
10. Novaes Jr AB, Marcaccini AM, Souza SL, Taba Jr M, Grisi MF.
Immediate placement of implants into periodontally infected sites
in dogs: a histomorphometric study of bone-implant contact. Int J
Oral Maxillofac Implants 2003;18:391–398.
11. Montoya-Salazar V, Castillo-Oyague R, Torres-Sanchez C, Lynch
CD, Gutierrez-Perez JL, Torres-Lagares D. Outcome of single
immediate implants placed in post-extraction infected and non-
infected sites, restored with cemented crowns: a 3-year
prospective study. J Dent 2014;42:645–652.
12. Miyamoto I, Funaki K, Yamauchi K, Kodama T, Takahashi T.
Alveolar ridge reconstruction with titanium mesh and autogenous
particulate bone graft: computed tomography-based evaluations
of augmented bone quality and quantity. Clin Implant Dent Relat
Res 2012;14:304–311.
13. Schneider D, Grunder U, Ender A, Hammerle CH, Jung RE.
Volume gain and stability of peri-implant tissue following bone
and soft tissue augmentation: 1-year results from a prospective
cohort study. Clin Oral Implants Res 2011;22:28–37.
14. Coachman C, Salama M, Garber D, Calamita M, Salama H,
Cabral G. Prosthetic gingival reconstruction in fixed partial
restorations. Part 3: laboratory procedures and maintenance. Int J
Periodontics Restorative Dent 2010;30:19–29.
15. Salama M, Coachman C, Garber D, Calamita M, Salama H,
Cabral G. Prosthetic gingival reconstruction in the fixed partial
restoration. Part 2: diagnosis and treatment planning. Int J
Periodontics Restorative Dent 2009;29:573–581.
16. Diangelis AJ, Andreasen JO, Ebeleseder KA, et al. International
Association of Dental Traumatology guidelines for the
management of traumatic dental injuries: 1. Fractures and
luxations of permanent teeth. International Association of Dental
Traumatology. Dent Traumatol 2012;28:2–12.
17. Taschieri S, Rosano G, Weinstein T, Del Fabbro M. Replacement
of vertically root-fractured endodontically treated teeth with
immediate implants in conjunction with a synthetic bone cement.
Implant Dent 2010;19:477–486.
18. Kahler W. The cracked tooth conundrum: terminology,
classification, diagnosis, and management. Am J Dent
2008;21:275–282.
19. Berman LH, Kuttler S. Fracture necrosis: diagnosis, prognosis
assessment, and treatment recommendations. J Endod
2010;36:442–446.
20. Özer SY, Ünlü G, Değer Y. Diagnosis and treatment of
endodontically treated teeth with vertical root fracture: three case
reports with two-year follow-up. J Endod 2011;37:97–102.
21. Hammerle CH, Chen ST, Wilson Jr TG. Consensus statements
and recommended clinical procedures regarding the placement of
implants in extraction sockets. Int J Oral Maxillofac Implants
2004;19 Suppl:26–28.
22. Chu SJ, Salama MA, Salama H, et al. The dual-zone therapeutic
concept of managing immediate implant placement and
provisional restoration in anterior extraction sockets. Compend
Contin Educ Dent 2012;33:524–532, 534.
23. Kan JY, Rungcharassaeng K, Morimoto T, Lozada J. Facial
gingival tissue stability after connective tissue graft with single
immediate tooth replacement in the esthetic zone: consecutive
case report. J Oral Maxillofac Surg 2009;67(Suppl11):40–48.
24. Degidi M, Nardi D, Daprile G, Piattelli A. Nonremoval of
immediate abutments in cases involving subcrestally placed
postextractive tapered single implants: a randomized controlled
clinical study. Clin Implant Dent Relat Res 2014;16:794–805.
25. Weber HP, Morton D, Gallucci GO, Roccuzzo M, Cordaro L,
Grutter L. Consensus statements and recommended clinical
procedures regarding loading protocols. Int J Oral Maxillofac
Implants 2009;24 Suppl:180–183.
26. Ganz SD. Cone beam computed tomography-assisted treatment
 planning concepts. Dent Clin North Am 2011;55:515–536.
27. Drago C, Carpentieri J. Treatment of maxillary jaws with dental
implants: guidelines for treatment. J Prosthodont 2011;20:336–
347.
28. Benic GI, Hämmerle CH. Horizontal bone augmentation by
means of guided bone regeneration. Periodontol 2000
2014;66:13–40.
29. Araújo M, Lubiana NF. Características dos tecidos
periimplantares. Periodontia 2008;18:8–13.
30. Lang K, Wetzel AC, Stich H, Caffesse R. Histologic probe
penetration in healthy and inflamed peri-implant tissues. Clin Oral
Implant Res 1994;5:191–201.
31. Berglundh, T, Lindhe J, Ericsson I, Marinello CP, Liljenberg B,
Thomsen P. The soft tissue barrier at implants and teeth. Clin
Oral Implant Res 1991;2:81–90.
32. Berglundh, T, Lindhe J Dimensions of the peri-implant mucosa.
Biological width revised. J Clin Periodontol 1996;23:971–973.
33. Dhir S, Mahesh L, Kurtzman GM, Vandana KL. Peri-implant and
periodontal tissues: a review of differences and similarities.
Compend Contin Educ Dent 2013;34:69–75.
34. Seibert J, Lindhe J. Esthetics and periodontal therapy. In: Lindhe
J (ed). Textbook of Clinical Periodontology, ed 2. Copenhagen,
Denmark: Munksgaard, 1989: 477–514.
35. Zucchelli G, Mounssif I, Mazzotti C, et al. Does the dimension of
the graft influence patient morbidity and root coverage outcomes?
A randomized controlled clinical trial. J Clin Periodontol
2014;41:708–716.
36. Sanz M, Lorenzo R, Aranda JJ, Martin C, Orsini M. Clinical
evaluation of a new collagen matrix (Mucograft prototype) to
enhance the width of keratinized tissue in patients with fixed
prosthetic restorations: a randomized prospective clinical trial. J
Clin Periodontol 2009;36:868–876.
37. Garber DA, Belser UC. Restoration-driven implant placement with
restoration-generated site development. Compend Contin Educ
 Dent Aug 1995;16:796, 798–802, 804.
38. Chu SJ, Tarnow DP. Managing esthetic challenges with anterior
implants. Part 1: midfacial recession defects from etiology to
resolution. Compend Contin Educ Dent 2013;34:26–31.
39. Chung S, Rungcharassaeng K, Kan JY, Roe P, Lozada JL.
Immediate single tooth replacement with subepithelial connective
tissue graft using platform switching implants: a case series. J
Oral Implantol 2011;37:559–569.
40. Gehrke SA. Correction of esthetic complications of a
malpositioned implant: a case letter. J Oral Implantol
2014;40:737–743.
41. Frizzera F, Tonetto M, Cabral G, Shibli JA, Marcantonio Jr E.
Periodontics, implantology, and prosthodontics integrated: the
zenith-driven rehabilitation. Case Rep Dent 2017;2017:1070292.
42. Clavijo VGR, Carvalho PMF, Da Silva RC, Joly JC, Flores VHO.
Achieving excellence in smile rehabilitation using
ultraconservative esthetic treatment: a multidisciplinary vision.
Quintessence of Dental Technology 2012;35:2–20.
43. Buser D, Martin W, Belser UC. Optimizing esthetics for implant
restorations in the anterior maxilla: anatomic and surgical
considerations. Int J Oral Maxillofac Implants 2004;19 Suppl:43–
61.
44. Salama H, Salama MA, Garber D, Adar P. The interproximal
height of bone: a guidepost to predictable aesthetic strategies and
soft tissue contours in anterior tooth replacement. Pract
Periodontics Aesthet Dent 1998;10:1131–1141.
45. Degidi M, Perrotti V, Shibli JA, Novaes AB, Piattelli A, Iezzi G.
Equicrestal and subcrestal dental implants: a histologic and
histomorphometric evaluation of nine retrieved human implants. J
Periodontol 2011;82:708–715.
46. Kois JC. Predictable single-tooth peri-implant esthetics: five
diagnostic keys. Compend Contin Educ Dent 2004;25:895–896.
47. Pessoa RS, Sousa RM, Pereira LM, et al. Bone remodeling
around implants with external hexagon and Morse-taper
connections: a randomized, controlled, split-mouth, clinical trial.
Clin Implant Dent Relat Res 2017;19:97–110.
 CHAPTER 5
SOCKET
PRESERVATION:
how to maintain tissue architecture
Fausto Frizzera, Vítor M. Sapata, Ronald E. Jung, Elcio Marcantonio Jr, Jamil A.
Shibli
1. INTRODUCTION

The health of the population may be affected by tooth loss, which can
cause esthetic and functional changes, in addition to compromising
quality of life1,2. Extraction leads to a process of bone remodeling in
the alveolar ridge, where part of its initial architecture is lost3,4. The
ridge architecture can be preserved through gingival and bone
grafting, allowing the rehabilitation of the lost tooth with esthetic and
functional implant treatment.
The teeth are in close relationship with the alveolar ridge and its
extraction promotes changes in the shape of the ridge5,6. To preserve
the tissue, the implant is placed and a provisional installed at the
moment of the extraction7,8. The final result is dependent on tissue
reconstruction and correct implant positioning, which requires
excellent surgical precision9. A systematic literature review showed no
clinical or biologic differences between the techniques used for single
rehabilitation with implants10.
Although not demonstrating a significant difference between
approaches, the studies do not take into account one crucial factor:
the patient’s desire to receive a fixed implant rehabilitation in a shorter
time frame. Immediate rehabilitation is a technique with high technical
demands, which depends on patient cooperation and is often not
routinely performed by clinicians. The literature tends to favor a
delayed approach, where the socket is first grafted, and in a second
surgical procedure, the implant is placed11.

OBJECTIVES
At the end of this chapter, the reader should be able to:
Know the clinical and biologic events that occur after extraction.
Select the biomaterials recommended to minimize bone remodeling.
Use soft tissue grafts to compensate for volumetric ridge change.
2. EVIDENCE BASED ON THE LITERATURE

2.1. BONE CHANGES AFTER EXTRACTION

Socket remodeling begins immediately after tooth removal. Then a

series of biologic events will occur, resulting in the filling of the socket,
which loses part of its total volume. Studies in animals showed that
the bone socket loses about 35% of its volume after an extraction12,13.
In humans, approximately 50% of the thickness of the ridge is lost and
may exceed 4 mm of horizontal reduction in the first 6 months14–17.
Depending on the architecture of the ridge, the remaining bone may
be insufficient for implant placement in the optimal position (Figs
01A–R). This remodeling can lead to esthetic difficulties or the need
for grafts, thereby causing higher morbidity18. Socket grafting attempts
to avoid the tissue resorption that occurs naturally after extraction due
to loss of function and nutrition to the bone.
01. A–R Biologic events that occur after extraction: sagittal (A–F),
frontal (G–L), and transverse (M–R) planes. Reducing the socket
volume may impair future implant placement.

The extraction must be a minimally traumatic procedure to prevent

or decrease the alveolar bone loss that occurs after extraction.
Gingival detachment should be performed with a scalpel blade or
delicate periosteal elevator. The instrument used for the extraction will
depend on the remaining tooth structure (Figs 02 to 05A–F). Devices
such as the tooth extraction system, modified forceps, and periotomes
can be used for this purpose19. Maintenance of the socket architecture
also depends on the preservation of its walls. The use of grafting
material facilitates socket preservation20–23.
02. Devices used for minimally traumatic extraction. In the presence of
root tips, the dental extraction system and periotomes may be used. If
the crown is intact, extraction may be performed with a periotome; in
conical or circular roots extraction, forceps can be used by gentle
rotational motion.
03. A–F The dental extraction system works by preparing the root
canal with a bur, screwing in the device for extraction, and removing
the root by means of a wire and pulley system.
04. A–F Extraction with a periotome works by inserting the instrument
in the periodontal ligament and using a wedge movement on the
proximal and palatal surfaces. Flexible periotomes allow a slight
rotational movement to dislocate the tooth or root. After rupture of the
periodontal fibers, the remaining tooth structure should be carefully
removed.
05. A–F For extraction with forceps, the instrument needs to be
adapted at the cervical area and a gentle rotation movement must be
performed. Rupture of the periodontal fibers with this movement
allows the tooth to be removed.

Socket repair occurs even in the absence of grafts, where the blood
clot will regulate the process of bone remodeling. Araújo and Lindhe3
described the three phases of the histologic changes occurring after
extraction:

2.1.1. INFLAMMATORY PHASE

Early after extraction, blood from the alveolar walls forms a clot to stop
the bleeding. This clot is gradually replaced by a granulation tissue
composed of fibroblasts, vascular structures, and inflammatory cells
that migrate to the socket to remove impurities and microorganisms.
During this phase, osteoclasts are present inside and outside the
socket, especially on the cancellous and bundle bone.

2.1.2. PROLIFERATIVE PHASE

The maintenance of cell types present in granulation tissue leads to
collagen production and vascular neoformation. A provisional matrix is
formed, which will be mineralized later. Osteoblasts stay close to the
newly formed bone tissue, where they are linearly grouped. In this
phase, the primary bone that fills the socket is formed. This bone has
low mechanical strength. Tissue mineralization occurs from the lateral
walls of the socket and toward its center, as well as in the most apical
portion of the socket, followed by the central and coronal portion.

2.1.3. MODELING AND REMODELING PHASE

In a more advanced phase of the alveolar healing process, it is
possible to verify the formation of a more significant amount of
secondary and medullary bone, as well as limited areas of osteoclast-
mediated bone resorption in the Howship lacunae. Bone remodeling is
known as bone turnover, where bone resorption and formation
processes occur together to renew and maintain the tissue in
homeostasis. Alteration of the alveolar ridge shape is called bone
modeling and can be verified mainly in the buccal wall, both in height
and thickness3.
The alveolar process undergoes several tissue changes in the first
year after extraction. The highest amount of bone loss is concentrated
in the first 3 months6. When the buccal bone wall has a thickness of 2
mm or more, there is reduced remodeling. However, this only happens
in around 2.6% of the anterior teeth. The average thickness of the
buccal bone wall tends to be less than or equal to 0.5 mm24–27.

2.2. SOCKET PRESERVATION

After extraction, a horizontal reduction of the alveolar ridge between

2.6 mm and 4.6 mm is expected11,22,28,29. Socket preservation is
recommended to limit this remodeling. The technique consists of filling
the socket with grafting material, reducing its loss to between 0.5 mm
and 1.5 mm20–23,29–31 (Figs 06A–D).
06. A–D Dry skull image with post-extraction alveolar bone remodeling
on tooth 21 (image taken at the Anatomy Laboratory of Faesa
University) (A). Clinical appearance of a fresh socket and healed
ridge, demonstrating the intensity of ridge remodeling (B). Occlusal
view of the central incisor region with a buccal bone defect where only
extraction (C) and extraction associated with socket preservation were
done (D).

Osteointegration of the graft will provide incorporation and union

between the grafted material and bone neoformation32. Its occurrence
and the formation of new bone depend on the mechanism of action of
the chosen graft (Tables 01, 02, and Figs 07A–H). There are three
fundamental elements to bone regeneration: osteogenesis,
osteoinduction, and osteoconduction. The autogenous bone graft is
the only one that presents all three elements. For small and medium
defects, intraoral donor areas are recommended, usually the ramus,
tuberosity, chin, or palate. For extensive reconstructions such as
severely resorbed jaw or bone defects caused by tumors or trauma,
removal of a block graft from extraoral regions such as the skull, iliac
bone, tibia, and rib may be necessary, as well as intraoral regions.
However, the use of block grafts is becoming very restricted due to the
evolution of biomaterials.

Table 01. Grafts can be classified according to their origin33

Table 02. Bone grafts can influence new bone formation in three ways
07. A–H Grafts that can be used for guided bone regeneration.
Autogenous block-shaped graft (A), large particle xenograft (B), and
small particle alloplastic graft (C); a xenograft may also be a
combination of material from animals of different species (bovine
inorganic graft plus 10% porcine collagen) (D) hydrated with serum (F,
G) and blood (H).

2.2.1. AUTOGRAFTS AND ALLOGRAFTS

Autogenous bone is considered a gold standard, although it has
higher morbidity than other grafts and limited effectiveness in
maintaining the architecture of the dental socket. Araújo et al34
demonstrated no histologic difference in healing between grafted and
non-grafted sockets using autografts. Research also showed that an
autograft did not favor alveolar bone repair and was ineffective in
maintaining the shape of the ridge, with a reduction of approximately 2
mm in the height of the buccal crest and 25% of the ridge volume.
Demineralized, frozen, and dried bone allograft and frozen and
dried bone allograft demonstrate excellent results in maintaining
socket volume35,36. However, this material cannot be commercialized
in some countries due to laws prohibiting the commercialization of
human tissues. In contrast, there is a limited number of scientific
papers proving the predictable use of allografts from national bone
banks.

2.2.2. XENOGRAFTS
Xenografts were first used decades ago to reduce bone turnover37.
The inorganic bovine bone, a slow resorption osteoconductive
material, is the most commonly used xenograft38. Studies about this
graft in humans and animals show its effectiveness in maintaining the
alveolar ridge shape, implant osseointegration, absence of
inflammatory reactions, and gradual resorption of its particles, mostly
surrounded by bone tissue37,39,40–42.
The incorporation of 10% of purified porcine type I collagen into
inorganic bovine bone gave the product its trading name (BOC). The
addition of collagen promotes cohesion between the particles of the
biomaterial, facilitating manipulation and incorporation into the
receptor area. The biomaterial preserves alveolar architecture,
reducing the amount of bone loss and is superior to extraction without
grafting4. Numerous studies have been conducted in humans and
animals proving its efficacy compared to other bone grafts43–46.
The use of inorganic bovine bone combined with porcine collagen in
a fresh socket increases the amount of bone formation. It can maintain
the alveolar architecture, demonstrating the benefits of using this graft
when compared to non-grafted sockets. Additionally, approximately
half of the alveolar ridge of non-grafted sockets is composed of bone
marrow. In contrast, in those grafted with the biomaterial, this amount
represented only 27%. Following the use of BOC in fresh sockets, the
formation of dome-shaped mineralized bone tissue was verified and
the new bone formed was in direct contact with the biomaterial, the
lingual and buccal bone wall12.
Histologically, in the initial weeks after extraction and grafting with
inorganic bovine bone plus 10% porcine collagen, the portion
corresponding to collagen is reabsorbed and alveolar remodeling
occurs gradually. The bone graft has an osteoconductive function. It
maintains the framework to allow the migration of cells of bone tissue
and provide bone neoformation. As the biomaterial is reabsorbed, new
bone tissue is formed. Part of this material can still be verified in
histologic evaluations years after the grafting procedure, which
characterizes it as a slow resorption material4.
The use of inorganic bovine bone in a bone defect that has all walls,
such as in a socket, leads to the formation of hard tissue. However,
alveolar healing time is increased47–50. Comparative studies in humans
showed that when an inorganic bovine bone was used in the socket,
maintenance of the alveolar architecture was more significant than
when it was not used43,51,52.

2.2.3. SYNTHETIC GRAFTS

Synthetic grafts are available and are cheaper, but their efficacy is
questioned. A systematic review of the literature showed that
autografts and xenografts have better results in post-extraction
compared to synthetic grafts or non-grafted sockets. Histologically,
alloplastic grafts presented a significant amount of vital bone, a
smaller amount of biomaterial, and connective tissue. However,
among the evaluated grafts, they presented the highest resorption rate
and loss of height and thickness of the alveolar ridge53.

2.2.4. MEMBRANES
Usually, if defects are present in the walls, placement of grafts and
membranes is indicated to prevent the occurrence of alveolar defects,
making future implantation complicated3,54,55. Studies that evaluated
the filling of this space with such a combination showed a more
significant amount of bone formation and preservation of bone
architecture4,44,56,57.
Treating defective sockets requires a different approach than
alveolar preservation because tissues need to be reconstructed. The
socket (Figs 08A–I) can be classified into55:
Type I: When bone and gingival tissues are intact.
Type II: There is a buccal bone defect, but the gingival margin is
properly positioned.
Type III: There is a buccal bone defect and gingival margin
recession.
08. A–I Types of socket: I intact; II with a bone defect; and III with a
bone and gingival defect.
In esthetic areas, bone loss requires tissue reconstruction using
membranes, bone, and gingival grafts55. Membranes function as a
barrier, keeping the grafted material inside the socket, preventing graft
particles from lodging into the gingival tissue, and migration of soft
tissue cells into the grafting material58–60. To reduce surgical and
biologic trauma to the remaining bone walls, periosteum detachment
should be avoided. The membrane should be cut and adapted
according to the existing defect and slightly positioned inside the
socket, covering 1–2 mm of bone55. Bone cells will migrate through the
resorbable membrane and other walls of the socket to allow graft
incorporation. Membrane resorption time, and the number of cells and
vessels that will pass through it, will depend on their physicochemical
characteristics.
Most membranes used in dentistry are of xenogenous or synthetic
origin. One of the essential precautions regarding their use is to
prevent them from being exposed to the oral environment since
exposure leads to contamination of the grafted material by oral
bacteria, resulting in a decrease in regenerated tissue61,62. The first
membranes used were nonresorbable and had a high exposure index,
requiring a second surgery to remove them. For these reasons, their
use was severely reduced after the development of resorbable
membranes (Figs 09A–K). These membranes are safe and
predictable when performing guided bone or tissue regeneration, as
demonstrated by animal and human studies63–66. Even when exposed,
the soft tissue usually has no infection because exposed collagen is
easily degraded67,68.
09. A–K Synthetic membrane (A) that can be cut in the form of an “ice
cream cone” (B) or cone (C) and has greater consistency after
hydration. Membrane of porcine origin (D) that can be cut according to
the defect and has better adaptation after hydration (E). Cone-shaped
membrane adaptation for correction of buccal bone defect and filling
of the socket with large particle xenograft (F–K).

Reabsorption of collagen membranes is associated with their

chemical processing, the type of tissue, and the cross-linking
collagen69. Membranes can be classified into cross-linked or non-
cross-linked based on this structure. Membranes with more cross-links
are more difficult for the organism to resorb. One study that compared
the use of these two membrane types in peri-implant defects
demonstrated that cross-linked membranes have more exposure than
non-cross-linked membranes because they trigger a higher immune-
mediated inflammatory response64.
Although collagen membranes have a faster rate of degradation,
they have the capacity for hemostasis, clot stabilization, and
semipermeability, allowing nutrient transfer to the grafted area70,71.
Formation of new vessels precedes bone neoformation. These
processes are closely related, so it is essential to use a membrane
that allows early angiogenesis60.
Geistlich Bio-Gide is a non-cross-linked, double-layered native
porcine collagen type II membrane. The smooth layer should face the
flap and the porous layer should be in contact with the grafted
area72,73. The fact that it has a faster resorption rate than cross-linked
membranes is not a concern since most tissue is newly formed in the
early weeks after the grafting procedure74,75. Schwarz et al71 evaluated
the immunohistochemical and histologic characteristics of the
angiogenesis of cross-linked and non-cross-linked membranes in rats.
The results of this study proved the superior capacity of angiogenesis
through the native collagen membrane compared to the other cross-
linked membranes.
One study demonstrated that the combination of native collagen
membrane with inorganic bovine bone and repositioned flap allowed
the formation of a higher bone volume compared to a graft without a
membrane. Flaps improperly performed on esthetic areas may
compromise the results of treatment and should be carefully
planned76.
Performing grafts with a buccal bone defect without a flap allows a
better postoperative period for the patient by reducing pain and
edema, decreasing the amount of bleeding and surgery time, and
preventing the formation of tissue scarring. It does not alter the
position of the mucogingival line, favoring nutrition of the bone
remnant and graft, besides preserving the architecture of the ridge15.
An advantage of using the membrane on the buccal surface is that it
allows the graft to be adequately compressed so as to push the buccal
soft tissue to maintain the contour of the ridge (Figs 10A–F).

10. A–F Compromised socket that received grafting with a native

collagen membrane and inorganic bovine bone plus porcine collagen.
Note the possibility of projecting the tissue volume to the buccal side
with the use of a membrane and maintaining the volume obtained
after its healing.

Due to the characteristics of the bone graft used, alveolar

remodeling is dependent on the remaining bone after extraction. A
socket with a bone defect will have a different bone remodeling
pattern than the intact socket, presenting a more significant loss of the
alveolar area77. A study in primates evaluated the use of a metallic
device (SocketKAGE) to stabilize the alveolar structure with complete
loss of the buccal bone wall associated with inorganic bovine bone or
clot77. One year after surgery, use of the device combined with a bone
graft showed better results in bone height and thickness compared to
the other group.
Tan-Chu et al15 evaluated the contour of the alveolar ridge after
treating sockets with buccal bone defect using the “ice cream cone”
technique described previously55. The lower part of the membrane
was cut according to the buccal defect (similar to a cone). The upper
part was cut according to the entrance of the socket (similar to ice
cream) (Figs 11A–I and 12A–N). After tomographic analysis of ridge
thickness, intraoral scanning, and measurement of the cast model, an
average loss of 1.32 mm in thickness was observed 6 months after
surgery. Sufficient buccal wall and the remaining bone structure
allowed for implant placement15.
11. A–I Adaptation of the “ice cream cone” membrane to correct a
buccal bone defect and filling the socket with a large particle
xenograft. Sealing the socket is performed by folding and suturing the
membrane over it.
12. A–C Sequence of images for alveolar extraction and preservation
by “ice cream cone” technique (A–C)..
12. D–N The socket should be curetted, irrigated, and the inner edges
of the soft tissue should have the epithelium removed (D–N)The
height and width of the socket should be measured so that the
membrane is cut according to the size of the defect (F–I). The
membrane and bone graft must be inserted into the socket and a
suture is used to stabilize the grafting material (J–N).

2.3. SOCKET SEALING WITH SOFT TISSUE GRAFT

The socket submitted to the alveolar preservation technique should

receive a bone graft and cervical sealing with a membrane or soft
tissue graft to prevent graft particle migration and contamination of the
grafted area, also allowing an increased volume of gingival tissue78–80.
A buccal flap is not indicated unless there is root involvement that was
not determined after radiographic and clinical examinations,
culminating in the need for exploratory surgery to close the diagnosis.
Elevation of the buccal flap and closure of the socket by releasing this
flap is not recommended because of increased morbidity, a decrease
in the amount of attached gingiva, changes in the position of the
mucogingival junction, and damage to the buccal bone wall81.
Autogenous, xenogenous, or allogenous soft tissue graft can be used
as a socket seal. The gingival grafts (subepithelial connective tissue
and connective tissue combined with epithelium) and collagen matrix
(Figs 13A–F) are the most commonly used.
13. A–F Types of socket preservation with different types of grafts
depending on the integrity of the alveolus (A) and papillae. Socket
sealed with collagen matrix (B) and epithelium-connective tissue graft
(C). Sealed buccal bone loss with connective tissue graft (D), collagen
matrix (E), and epithelium-connective tissue graft (F).

2.3.1. GINGIVAL GRAFTS (EPITHELIUM-CONNECTIVE

TISSUE AND SUBEPITHELIAL CONNECTIVE
TISSUE)
Autogenous gingival grafts are usually removed from the hard palate,
maxillary tuberosity, or edentulous areas. The surgical technique for
removal and tissue content are the differences between the
epithelium-connective tissue and subepithelial connective tissue grafts
(Figs 14A–I).
14. A–I Removal of epithelium-connective tissue graft. A guide with
the diameter of the socket is made with a suture. Using a delicate
scalpel blade, the donor area is traced, the guide is then removed and
a 2–2.5-mm-deep incision is made around the traced area (A–C).
Graft removal is performed with an incision parallel to the periosteum
(D–F). The donor area is then sutured and protected with a
mechanical barrier. The graft is tested in the socket to verify the need
for size adjustment (G–I).

VIDEO OF SOCKET PRESERVATION WITH EPITHELIUM–CONNECTIVE

TISSUE GRAFT

These grafts can be used to: increase the attached gingiva;

increase tissue thickness on flanges, teeth, or implants; coverage of
Miller class I and II gingival recession; maintenance of gingival margin
position in the socket when associated with immediate implant,
provisional, and biomaterials; and alveolar sealing where socket
preservation is used82–85 (Figs 15A–F to 18A–L).
15. A–F After graft testing and adaptation, simple sutures are
performed to stabilize and coaptate the edges.
16. A–E Patient sample from clinical research conducted by Dr. Jamil
Shibli, where alveolar preservation with recombinant human bone
morphogenetic protein-2 and free gingival graft was performed. Study
performed by Dr Leda Marina Lima and Walterson M. Prado.

17. A–E In this research, volumetric evaluation of the reconstructed

ridge with this material gave satisfactory results, with greater volume
loss in the external 5 mm of the alveolar ridge in the vestibular region.
Study performed by Dr Leda Marina Lima and Walterson M. Prado.
18. A–L After removal and testing of the connective tissue, a
stabilizing suture on the buccal and lingual is performed. If necessary,
simple sutures can be made by attaching the graft to the gingival
tissue for better coaptation.

These grafts increase morbidity by creating a new surgical area that

can have complications during its removal and healing (Figs 19A–U
to 26A–I)86. Another disadvantage when working with autogenous
grafts is due to the limited amount of donor tissue (Tables 03 and
04)82.
19. A–U Patient with a gummy smile and history of trauma in the
region of the maxillary central incisors. Before orthodontic treatment,
tooth 11 had internal resorption. Orthodontic treatment was approved
and followed by the endodontistin charge of treatment. During
treatment, the tooth presented a fistula and a periodontal pocket (A–
M). Minimally traumatic extraction of tooth 11 and socket preservation
(N–P). The granulation tissue was removed and the socket irrigated
with saline; then, the socket was inspected with a periodontal probe,
which showed extensive loss in its distal portion (Q–U).
20. A–Y The socket margins were de-epithelized with a bur and a
fistulectomy was performed with the appropriate instruments (A–D).
Socket preservation was performed with Bio-Oss Collagen; the
epithelium-connective tissue graft was removed from the palate with a
scalpel and 15C blade (E–N). To protect the donor area, a removable
acrylic orthodontic appliance and surgical cement were used. In the
recipient area, the gingival graft was stabilized at the gingival margins
using simple sutures (O–S). Postoperative condition after 14 days
presented a good integration between graft and socket (T–Y).
21. A–J Four months after socket preservation, the results were
verified and flapless surgery was performed to place the implant (A–
H). A circular scalpel was used to allow access to the ridge and a 3.5
× 11 implant (Drive Acqua; Neodent) installed in the ideal three-
dimensional position, considering the result from orthodontic treatment
(I, J).
22. A–I The area was prepared and received a connective tissue graft
removed from the tuberosity region (A–E). Sutures were removed 7
days after surgery. A tomography was performed to confirm correct
implant placement (F–I).
23. A–F Digitally planned image demonstrating the need to intrude the
maxillary incisors and crown lengthening on the incisors (A).
Appearance after provisional installation tooth 11 (B, C) and
orthodontic appliance removal (D). Final outcome after treatment (E,
F). Orthodontic procedure: Deise Cunha; surgical procedure: Dr
Fausto Frizzera; restorative procedure: Dr Marco Masioli; laboratory
technician: Igor Hand.
24. A–J Presence of buccolingual vertical fracture in tooth 25 (A–F).
Due to the presence of an extensive lesion and loss of interproximal
tissue, a flap for access, debridement, and grafting of the region with
large particles of inorganic bovine bone graft was performed (G–J).
25. A–F The grafted area was protected with an acellular dermal
matrix and a connective tissue graft was stabilized over the ridge to
facilitate flap closure and increase volume in the free and
interproximal surfaces (A, B). Clinical appearance after 15 (C, D) and
180 days (E, F).
26. A–I A graft tissue biopsy was performed and flapless implant (A–
G) placement surgery was done. The histologic analysis revealed
remodeling of the biomaterial and its intimate contact with the vital
bone tissue (5× and 40×) (H, I). Surgical procedure: Dr Elcio
Marcantonio; restorative procedure: Dr Rogério Margonar.

EPITHELIUM– SUBEPITHELIAL
TYPE OF GINGIVAL CONNECTIVE CONNECTIVE
GRAFT: ADVANTAGES TISSUE TISSUE

Increase in tissue thickness + +++

Increase in attached gingiva +++ +

Coverage of gingival * +++

recession
 Maintenance of gingival * +++
margin post-extraction
Implant placement and
immediate provisional

Socket sealing ++ +

*Not indicated

Table 03. Comparison of the results obtained between the various

indications for autogenous gingival grafts

EPITHELIUM– SUBEPITHELIAL
TYPE OF GINGIVAL CONNECTIVE CONNECTIVE
GRAFT: ADVANTAGES TISSUE TISSUE

Graft removal ++ +

Time for graft removal + ++

Morbidity +++ +

Need for protection of the +++ +

donor area

Color and texture of grafted – +++

area

Table 04. Comparison between gingival grafts with regard to their

main disadvantages

2.3.2. COLLAGEN MATRIX GRAFT

The three-dimensional collagen matrix (Geistlich Mucograft;
Straumann Mucoderm) has a xenogenous origin and consists of two
layers. One compact layer, which helps structural maintenance of the
graft and facilitates its suturing and cell adhesion, and one porous
layer, which aids fluid absorption, clot organization, and graft
integration into the recipient bed (Figs 27A–S). Few studies have
evaluated its use. Human and animal studies have been conducted
and have demonstrated the effectiveness of this collagen matrix to
treat areas with no or limited amount of attached gingiva87,88,
increased alveolar ridge volume89,90, treatment of Miller class I and II
gingival recession39, and socket sealing91 and may also be used as a
dermal substitute92. Histologically, in 3–4 months the graft was
incorporated, showing no histologic differences when compared to a
non-grafted area or one that has received a free gingival graft88,90.
27. A–S Tooth 14 presented extensive subgingival caries, a fracture in
the pulpal floor, gingival recession, and absence of buccal bone (A–
C). Minimally traumatic extraction was performed. The socket was
grafted with a collagen membrane on the buccal surface. A slow
resorption graft biomaterial and sealing with porcine collagen matrix
(D–I) were used. Four months after alveolar preservation, soft tissue
height gain and buccal bone regeneration were verified; surgery was
performed to remove bone for biopsy and install a 3.5 × 11 implant
(Drive Acqua; Neodent) (J–Q). Histologic analysis (R, S) showed slow
remodeling of the biomaterial and intimate contact with vital bone
tissue (20× magnification). Surgical procedures: Dr Keila Soares and
Dr Mariana Buaiz with orientation from Dr Fausto Frizzera.
3. CLINICAL APPLICATION

The literature presents several materials and techniques used to

change the quantity or quality of tissues. However, a grafting material
that provides satisfactory results with minimal biologic cost has yet to
be deemed as ideal90. The material of choice for alveolar bone grafting
is inorganic bovine bone containing 10% porcine collagen. Although
autogenous tissue grafts are considered the gold standard, socket
preservation has a number of disadvantages such as increased
morbidity and surgical time. Allografts are banned from
commercialization in some country and ethical issues regarding their
use and potential for disease transmission remain87.
The use of heterografts has a number of advantages compared to
other types of grafts.
When considering the different types of sockets, grafts, and clinical
situations, a unified treatment protocol for all cases is difficult to
establish (Tables 05, 06 and Figs 28A–L to 33A–H). To facilitate
socket preservation aimed at maintaining bone volume, a surgical
technique was proposed for esthetic areas and is shown on the right.
Table 05. Flowchart for socket treatment when an immediate implant
is not recommended
Table 06. Decision-making regarding the type of gingival graft to be
used for socket sealing

SURGICAL TECHNIQUE
1. Anesthesia of the operative region
2. Minimally traumatic extraction with the appropriate devices
3. Clockwise or counterclockwise curettage of the entire socket
4. Abundant irrigation with saline
5. Inspection of the socket with a periodontal probe to assess the
remaining bone on the free and interproximal surfaces*
6. Removal of the epithelium from the edges of the alveolus with a
blade or drill
7. Alveolus grafting with resorption biomaterial and membrane if
necessary
8. Sealing of the alveolus with gingival graft
* Flap elevation is indicated when it is not possible to sufficiently clean via the alveolus
entrance.

3.1. SOCKET SEALING WITH CONNECTIVE TISSUE

GRAFT
28. A–L Minimally traumatic tooth extraction on tooth 11 and ridge
preservation with Geistlich Bio-Oss Collagen associated with
connective tissue graft to seal the socket and increase tissue height
and thickness (A–D). Tissue aspect 4 months after surgery for
alveolar preservation at the time of implant placement (E–H). Implant
placement (Straumann Bone Level) associated with guided bone
regeneration (I, J). Before and after treatment (K, L). Surgical and
restorative procedures: Prof Ronald E. Jung.

3.2. SOCKET SEALING WITH COLLAGEN MATRIX

29. A–I Tooth n had a mesiodistal vertical fracture. Minimally traumatic
extraction and bone regeneration were performed with Bio-Oss
Collagen adapted inside the socket (A–E). The socket was sealed
with a Geistlich Mucograft collagen matrix cut with a surgical punch (F,
G). Four months after the procedure, the result of the first surgery for
alveolar preservation was verified and the surgery for implant
installation was performed (H, I).
30. A–F Implant placement (Straumann Bone Level) combined with
guided bone regeneration. Surgical and restorative procedure: Prof
Ronald E. Jung.

3.3. SOCKET SEALING WITH EPITHELIUM-CONNECTIVE

TISSUE GRAFt

31. A–F Longitudinal root fracture on the lingual surface of tooth 11,
with severe resorption of the buccal bone plate in the apical region of
teeth 11 and 12. The coronal surface of the buccal wall was intact.
32. A–H Ridge preservation in tooth 11 with Bio-Oss Collagen and
epithelium-connective tissue graft. Follow-up 4 months after ridge
preservation (A–D). Appearance of the alveolar ridge at the time of
implant placement (Straumann Bone Level) in the ideal prosthetic
position for a screwed prosthesis. Presence of bone dehiscence in the
cervical third of the implant (E–H).
33. A–H Guided bone regeneration procedure with Bio-Oss Collagen.
Bio-Oss Collagen positioned vertically and horizontally in L93 and Bio-
Gide (A–D). Feldspar porcelain prosthetic rehabilitation with zirconia
esthetic abutment (Straumann CARES abutment) (E–H). Surgical and
restorative procedure: Prof Ronald E. Jung.

REFERENCES

1. Berretin-Felix G, Nary Filho H, Padovani CR, Machado WM. A

longitudinal study of quality of life of elderly with mandibular
implant-supported fixed prostheses. Clin Oral Implants Res
2008;19:704–708.
2. Saintrain MV, de Souza EH. Impact of tooth loss on the quality of
life. Gerodontology 2012;29:632–636.
3. Araújo MG, Lindhe J. Dimensional ridge alterations following
tooth extraction. An experimental study in the dog. J Clin
Periodontol 2005;32:212–218.
4. Araújo MG, Lindhe J. Ridge preservation with the use of Bio-Oss
collagen. A 6-month study in the dog. Clin Oral Implants Res
2009;20:433–440.
5. Johnson K. A study of the dimensional changes occurring in the
maxilla following tooth extraction. Aust Dent J 1969;14:241–244.
6. Schropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing
and soft tissue contour changes following single-tooth extraction:
a clinical and radiographic 12-month prospective study. Int J
Periodontics Restorative Dent 2003;23:313–323.
7. Spear F. Maintenance of the interdental papilla following anterior
tooth replacement. Pract Periodontics Aesthet Dent 1999;11:21–
28.
8. Cosyn J, Eghbali A, De Bruyn H, Collys K, Cleymaet R, De Rouck
T. Single-tooth implants in the anterior maxilla: 3-year results of a
case series on hard and soft tissue response and aesthetics. J
Clin Periodontol 2011;38:746–753.
9. Buser D, Wittneben J, Bornstein MM, Grutter L, Chappuis V,
Belser UC. Stability of contour augmentation and esthetic
outcomes of implant-supported single crowns in the esthetic
 zone: 3-year results of a prospective study with early implant
placement postextraction. J Periodontol 2011;82:342–349.
10. Esposito M, Grusovin MG, Polyzos IP, Felice P, Worthington HV.
Interventions for replacing missing teeth: dental implants in fresh
extraction sockets (immediate, immediate-delayed and delayed
implants). Cochrane Database Syst Rev 2010;9:CD005968.
11. Hammerle CH, Araujo MG, Simion M. Evidence-based knowledge
on the biology and treatment of extraction sockets. Clin Oral
Implants Res 2012;23(Suppl 5):80–82.
12. Araújo M, Linder E, Wennström J, Lindhe J. The influence of Bio-
Oss collagen on healing of an extraction socket: an experimental
study in the dog. Int J Periodontics Restorative Dent
2008;28:123–135.
13. Araújo MG, da Silva JC, de Mendonca AF, Lindhe J. Ridge
alterations following grafting of fresh extraction sockets in man. A
randomized clinical trial. Clin Oral Implants Res 2015;26:407–
412.
14. Nevins M, Camelo M, De Paoli S, et al. A study of the fate of the
buccal wall of extraction sockets of teeth with prominent roots. Int
J Periodontics Restorative Dent 2006;26:19–29.
15. Tan-Chu JH, Tuminelli FJ, Kurtz KS, Tarnow DP. Analysis of
buccolingual dimensional changes of the extraction socket using
the “ice cream cone” flapless grafting technique. Int J
Periodontics Restorative Dent 2014;34:399–403.
16. Tan WL, Wong TL, Wong MC, Lang NP. A systematic review of
post-extractional alveolar hard and soft tissue dimensional
changes in humans. Clin Oral Implants Res 2012;23 Suppl 5:1–
21.
17. Van der Weijden F, Dell’Acqua F, Slot DE. Alveolar bone
dimensional changes of post-extraction sockets in humans: a
systematic review. J Clin Periodontol 2009;36:1048–1058.
18. Miyamoto I, Funaki K, Yamauchi K, Kodama T, Takahashi T.
Alveolar ridge reconstruction with titanium mesh and autogenous
particulate bone graft: computed tomography-based evaluations
 of augmented bone quality and quantity. Clin Implant Dent Relat
Res 2012;14:304–311.
19. Saund D, Dietrich T. Minimally-invasive tooth extraction:
doorknobs and strings revisited! Dent Update 2013;40:325–326,
328–330.
20. Kan JY, Morimoto T, Rungcharassaeng K, Roe P, Smith DH.
Gingival bio-type assessment in the esthetic zone: visual versus
direct measurement. Int J Periodontics Restorative Dent
2010;30:237–243.
21. Kan JY, Rungcharassaeng K, Morimoto T, Lozada J. Facial
gingival tissue stability after connective tissue graft with single
immediate tooth replacement in the esthetic zone: consecutive
case report. J Oral Maxillofac Surg 2009;67(Suppl 11):40–48.
22. Lekovic V, Kenney EB, Weinlaender M, et al. A bone regenerative
approach to alveolar ridge maintenance following tooth extraction.
Report of 10 cases. J Periodontol 1997;68:563–570.
23. Pieri F, Aldini NN, Marchetti C, Corinaldesi G. Influence of
implant-abutment interface design on bone and soft tissue levels
around immediately placed and restored single-tooth implants: a
randomized controlled clinical trial. Int J Oral Maxillofac Implants
2011;26:169–178.
24. Sanz M, Cecchinato D, Ferrus J, Pjetursson EB, Lang NP, Lindhe
J. A prospective, randomized-controlled clinical trial to evaluate
bone preservation using implants with different geometry placed
into extraction sockets in the maxilla. Clin Oral Implants Res
2010;21:13–21.
25. Belser UC, Buser D, Hess D, Schmid B, Bernard JP, Lang NP.
Aesthetic implant restorations in partially edentulous patients – a
critical appraisal. Periodontol 2000 1998;17:132–150.
26. Huynh-Ba G, Pjetursson BE, Sanz M, Cecchinato D, Ferrus J,
Lindhe J, Lang NP. Analysis of the socket bone wall dimensions
in the upper maxilla in relation to immediate implant placement.
Clin Oral Implants Res 2010;21:37–42.
27. Spray JR, Black CG, Morris HF, Ochi S. The influence of bone
 thickness on facial marginal bone response: stage 1 placement
through stage 2 uncovering. Ann Periodontol 2000;5:119–128.
28. Covani U, Cornelini R, Barone A. Bucco-lingual bone remodeling
around implants placed into immediate extraction sockets: a case
series. J Periodontol 2003;74:268–273.
29. Iasella JM, Greenwell H, Miller RL, Hill M, Drisko C, Bohra AA,
Scheetz JP. Ridge preservation with freeze-dried bone allograft
and a collagen membrane compared to extraction alone for
implant site development: a clinical and histologic study in
humans. J Periodontol 2003;74:990–999.
30. Roe P, Kan JY, Rungcharassaeng K, Caruso JM, Zimmerman G,
Mesquida J. Horizontal and vertical dimensional changes of peri-
implant facial bone following immediate placement and
provisionalization of maxillary anterior single implants: a 1-year
cone beam computed tomography study. Int J Oral Maxillofac
Implants 2012;27:393–400.
31. Simion M, Dahlin C, Trisi P, Piattelli A. Qualitative and
quantitative comparative study on different filling materials used in
bone tissue regeneration: a controlled clinical study. Int J
Periodontics Restorative Dent 1994;14:198–215.
32. Giannoudis PV, Dinopoulos H, Tsiridis E. Bone substitutes: an
update. Injury 2005;36(Suppl 3):S20.
33. Mellonig JT, Nevins M, Sanchez R. Evaluation of a bioabsorbable
physical barrier for guided bone regeneration. Part I. Material
alone. Int J Periodontics Restorative Dent 1998;18:139–149.
34. Araújo MG, Linder E, Lindhe J. Bio-Oss collagen in the buccal
gap at immediate implants: a 6-month study in the dog. Clin Oral
Implants Res 2011;22:1–8.
35. Monea A, Beresescu G, Boeriu S, Tibor M, Popsor S, Antonescu
DM. Bone healing after low-level laser application in extraction
sockets grafted with allograft material and covered with a
resorbable collagen dressing: a pilot histological evaluation. BMC
Oral Health 2015;15:134.
36. Tal H. Autogenous masticatory mucosal grafts in extraction
 socket seal procedures: a comparison between sockets grafted
with demineralized freeze-dried bone and deproteinized bovine
bone mineral. Clin Oral Implants Res 1999;10:289–296.
37. Berglundh T, Lindhe J. Healing around implants placed in bone
defects treated with Bio-Oss. An experimental study in the dog.
Clin Oral Implants Res 1997;8:117–124.
38. Perrotti V, Nicholls BM, Horton MA, Piattelli A. Human osteoclast
formation and activity on a xenogenous bone mineral. J Biomed
Mater Res A 2009;90:238–246.
39. Cardaropoli D, Tamagnone L, Roffredo A, Gaveglio L. Treatment
of gingival recession defects using coronally advanced flap with a
porcine collagen matrix compared to coronally advanced flap with
connective tissue graft: a randomized controlled clinical trial. J
Periodontol 2012;83:321–328.
40. Carmagnola D, Adriaens P, Berglundh T. Healing of human
extraction sockets filled with Bio-Oss. Clin Oral Implants Res
2003;14:137–143.
41. Indovina Jr A, Block MS. Comparison of 3 bone substitutes in
canine extraction sites. J Oral Maxillofac Surg 2002;60: 53–58.
42. Santos FA, Pochapski MT, Martins MC, Zenobio EG, Spolidoro
LC, Marcantonio Jr E. Comparison of biomaterial implants in the
dental socket: histological analysis in dogs. Clin Implant Dent
Relat Res 2010;12:18–25.
43. Frizzera M, Moreno R, Munoz CO, Cabral G, Shibli J. Impact of
soft tissue grafts to reduce peri-implant alterations after
immediate implant placement and provisionalization in
compromised sockets. Int J Periodontics Restorative Dent
2019;39:381–389.
44. Troiano G, Zhurakivska K, Lo Muzio L, Laino L, Cicciù M, Lo
Russo L. Combination of bone graft and resorbable membrane for
alveolar ridge preservation: a systematic review, meta-analysis
and trial sequential analysis. J Periodontol 2017;12:1–17.
45. Degidi M, Nardi D, Daprile G, Piattelli A. Nonremoval of
immediate abutments in cases involving subcrestally placed
 postextractive tapered single implants: a randomized controlled
clinical study. Clin Implant Dent Relat Res 2014;16:794–805.
46. Sculean A, Windisch P, Keglevich T, Gera I. Clinical and
histologic evaluation of an enamel matrix protein derivative
combined with a bioactive glass for the treatment of intrabony
periodontal defects in humans. Int J Periodontics Restorative
Dent 2005;25:139–147.
47. Maiorana C, Poli PP, Deflorian M, et al. Alveolar socket
preservation with demineralised bovine bone mineral and a
collagen matrix. J Periodontal Implant Sci 2017;47:194–210.
48. Araujo MG, Carmagnola D, Berglundh T, Thilander B, Lindhe J.
Orthodontic movement in bone defects augmented with Bio-Oss.
An experimental study in dogs. J Clin Periodontol 2001;28:73–80.
49. Hammerle CH, Chiantella GC, Karring T, Lang NP. The effect of a
deproteinized bovine bone mineral on bone regeneration around
titanium dental implants. Clin Oral Implants Res 1998;9:151–162.
50. Lundgren D, Slotte C. Reconstruction of anatomically complicated
periodontal defects using a bioresorbable GTR barrier supported
by bone mineral. A 6-month follow-up study of 6 cases. J Clin
Periodontol 1999;26:56–62.
51. Cardaropoli D, Tamagnone L, Roffredo A, Gaveglio L. Coronally
advanced flap with and without a xenogenic collagen matrix in the
treatment of multiple recessions: a randomized controlled clinical
study. Int J Periodontics Restorative Dent 2014;34(Suppl 3)S:97–
102.
52. Nevins M, Camelo M, De Paoli S, et al. A study of the fate of the
buccal wall of extraction sockets of teeth with prominent roots. Int
J Periodontics Restorative Dent 2006;26:19–29.
53. Jambhekar S, Kernen F, Bidra AS. Clinical and histologic
outcomes of socket grafting after flapless tooth extraction: a
systematic review of randomized controlled clinical trials. J
Prosthet Dent 2015;113:371–382.
54. Cardaropoli G, Araujo M, Lindhe J. Dynamics of bone tissue
formation in tooth extraction sites. An experimental study in dogs.
 J Clin Periodontol 2003;30:809–818.
55. Elian N, Cho SC, Froum S, Smith RB, Tarnow DP. A simplified
socket classification and repair technique. Pract Proced Aesthet
Dent 2007;19:99–104.
56. Novaes AB, Jr., Suaid F, Queiroz AC, et al. Buccal bone plate
remodeling after immediate implant placement with and without
synthetic bone grafting and flapless surgery: radiographic study in
dogs. J Oral Implantol 2012;38:687–698.
57. Polyzois I, Renvert S, Bosshardt DD, Lang NP, Claffey N. Effect
of Bio-Oss on osseointegration of dental implants surrounded by
circumferential bone defects of different dimensions: an
experimental study in the dog. Clin Oral Implants Res
2007;18:304–310.
58. Annen BM, Ramel CF, Hämmerle CH, Jung RE. Use of a new
cross-linked collagen membrane for the treatment of peri-implant
dehiscence defects: a randomised controlled double-blinded
clinical trial. Eur J Oral Implantol 2011;4:87–100.
59. Bunyaratavej P, Wang HL. Collagen membranes: a review. J
Periodontol 2001;72:215–229.
60. Wang Y, Wan C, Gilbert SR, Clemens TL. Oxygen sensing and
osteogenesis. Ann N Y Acad Sci 2007;1117:1–11.
61. Nemcovsky CE, Artzi Z, Moses O, Gelernter I. Healing of
marginal defects at implants placed in fresh extraction sockets or
after 4–6 weeks of healing. A comparative study. Clin Oral
Implants Res 2002;13:410–419.
62. Simion M, Rocchietta I, Fontana F, Dellavia C. Evaluation of a
resorbable collagen matrix infused with rhPDGF-BB in peri-
implant soft tissue augmentation: a preliminary report with 3.5
years of observation. Int J Periodontics Restorative Dent
2012;32:273–282.
63. Hockers T, Abensur D, Valentini P, Legrand R, Hammerle CH.
The combined use of bioresorbable membranes and xenografts
or autografts in the treatment of bone defects around implants. A
study in beagle dogs. Clin Oral Implants Res 1999;10:487–498.
64. Tal H, Kozlovsky A, Artzi Z, Nemcovsky CE, Moses O. Cross-
linked and non-cross-linked collagen barrier membranes
disintegrate following surgical exposure to the oral environment: a
histological study in the cat. Clin Oral Implants Res 2008;19:760–
766.
65. Tal H, Pitaru S, Moses O, Kozlovsky A. Collagen gel and
membrane in guided tissue regeneration in periodontal
fenestration defects in dogs. J Clin Periodontol 1996;23:1–6.
66. Zitzmann NU, Naef R, Scharer P. Resorbable versus
nonresorbable membranes in combination with Bio-Oss for
guided bone regeneration. Int J Oral Maxillofac Implants
1997;12:844–852.
67. Friedmann A, Strietzel FP, Maretzki B, Pitaru S, Bernimoulin JP.
Histological assessment of augmented jaw bone utilizing a new
collagen barrier membrane compared to a standard barrier
membrane to protect a granular bone substitute material. Clin
Oral Implants Res 2002;13:587–594.
68. Moses O, Pitaru S, Artzi Z, Nemcovsky CE. Healing of
dehiscence-type defects in implants placed together with different
barrier membranes: a comparative clinical study. Clin Oral
Implants Res 2005;16:210–219.
69. Goissis G, Marcantonio Jr E, Marcantonio RA, Lia RC, Cancian
DC, de Carvalho WM. Biocompatibility studies of anionic collagen
membranes with different degree of glutaraldehyde cross-linking.
Biomaterials 1999;20:27–34.
70. Postlethwaite AE, Seyer JM, Kang AH. Chemotactic attraction of
human fibroblasts to type I, II, and III collagens and collagen-
derived peptides. Proc Natl Acad Sci USA 1978;75:871–875.
71. Schwarz F, Rothamel D, Herten M, Sager M, Becker J.
Angiogenesis pattern of native and cross-linked collagen
membranes: an immunohistochemical study in the rat. Clin Oral
Implants Res 2006;17:403–409.
72. Alpar B, Leyhausen G, Gunay H, Geurtsen W. Compatibility of
resorbable and nonresorbable guided tissue regeneration
 membranes in cultures of primary human periodontal ligament
fibroblasts and human osteoblast-like cells. Clin Oral Investig
2000;4:219–225.
73. Bornstein MM, Heynen G, Bosshardt DD, Buser D. Effect of two
bioabsorbable barrier membranes on bone regeneration of
standardized defects in calvarial bone: a comparative
histomorphometric study in pigs. J Periodontol 2009;80:1289–
1299.
74. Dickinson DP, Coleman BG, Batrice N, et al. Events of wound
healing/regeneration in the canine supraalveolar periodontal
defect model. J Clin Periodontol 2013;40:527–541.
75. Susin C, Wikesjo UM. Regenerative periodontal therapy: 30 years
of lessons learned and unlearned. Periodontol 2000
2013;62:232–242.
76. Perelman-Karmon M, Kozlovsky A, Liloy R, Artzi Z. Socket site
preservation using bovine bone mineral with and without a
bioresorbable collagen membrane. Int J Periodontics Restorative
Dent 2012;32:459–465.
77. Min S, Liu Y, Tang J, Xie Y, Xiong J, You HK, Zadeh HH. Alveolar
ridge dimensional changes following ridge preservation procedure
with novel devices: part 1 – CBCT linear analysis in non-human
primate model. Clin Oral Implants Res 2016;27:97–105.
78. Thalmair T, Fickl S, Schneider D, Hinze M, Wachtel H.
Dimensional alterations of extraction sites after different alveolar
ridge preservation techniques – a volumetric study. J Clin
Periodontol 2013;40:721–727.
79. Jung RE, Siegenthaler DW, Hämmerle CH. Postextraction tissue
management: a soft tissue punch technique. Int J Periodontics
Restorative Dent 2004;24:545–553.
80. Fickl S, Zuhr O, Wachtel H, Stappert CF, Stein JM, Hürzeler MB.
Dimensional changes of the alveolar ridge contour after different
socket preservation techniques. J Clin Periodontol 2008;35:906–
913.
81. El Chaar ES. Soft tissue closure of grafted extraction sockets in
 the posterior maxilla: the rotated pedicle palatal connective tissue
flap technique. Implant Dent 2010;19:370–377.
82. Chambrone L, Sukekava F, Araujo MG, Pustiglioni FE,
Chambrone LA, Lima LA. Root-coverage procedures for the
treatment of localized recession-type defects: a Cochrane
systematic review. J Periodontol 2010;81:452–478.
83. Miller PD Jr. A classification of marginal tissue recession. Int J
Periodontics Restorative Dent 1985;5:8–13.
84. Orsini M, Orsini G, Benlloch D, Aranda JJ, Lazaro P, Sanz M.
Esthetic and dimensional evaluation of free connective tissue
grafts in prosthetically treated patients: a 1-year clinical study. J
Periodontol 2004;75:470–477.
85. Tsuda H, Rungcharassaeng K, Kan JY, Roe P, Lozada JL,
Zimmerman G. Peri-implant tissue response following connective
tissue and bone grafting in conjunction with immediate single-
tooth replacement in the esthetic zone: a case series. Int J Oral
Maxillofac Implants 2011;26:427–436.
86. Oates TW, Robinson M, Gunsolley JC. Surgical therapies for the
treatment of gingival recession. A systematic review. Ann
Periodontol 2003;8:303–320.
87. Sanz I, Garcia-Gargallo M, Herrera D, Martin C, Figuero E, Sanz
M. Surgical protocols for early implant placement in post-
extraction sockets: a systematic review. Clin Oral Implants Res
2012;23(Suppl 5):67–79.
88. Nevins M, Nevins ML, Kim SW, Schupbach P, Kim DM. The use
of mucograft collagen matrix to augment the zone of keratinized
tissue around teeth: a pilot study. Int J Periodontics Restorative
Dent 2011;31:367–373.
89. Thoma DS, Jung RE, Schneider D, et al. Soft tissue volume
augmentation by the use of collagen-based matrices: a volumetric
analysis. J Clin Periodontol 2010;37:659–666.
90. Simon BI, Von Hagen S, Deasy MJ, Faldu M, Resnansky D.
Changes in alveolar bone height and width following ridge
augmentation using bone graft and membranes. J Periodontol
 2000;71:1774–1791.
91. Meloni SM, Tallarico M, Lolli FM, Deledda A, Pisano M, Jovanovic
SA. Postextraction socket preservation using epithelial connective
tissue graft vs porcine collagen matrix. 1-year results of a
randomised controlled trial. Eur J Oral Implantol 2015;8:39–48.
92. Wehrhan F, Nkenke E, Melnychenko I, et al. Skin repair using a
porcine collagen I/III membrane-vascularization and epithelization
properties. Dermatol Surg 2010;36:919–930.
93. Mir-Mari J, Benic GI, Valmaseda-Castellón E, Hämmerle CHF,
Jung RE. Influence of wound closure on the volume stability of
particulate and non-particulate GBR materials: an in vitro cone-
beam computed tomographic examination. Part II. Clin Oral
Implants Res 2017;28:631–639.
 CHAPTER 6
IMPLANT PLACEMENT
IN FRESH SOCKETS:
how to get an ideal position
Fausto Frizzera, Luiz Guilherme Freitas de Paula, Ana Carolina M. Marcantonio,
Camila C. Marcantonio, Jamil A. Shibli, Elcio Marcantonio Jr
1. INTRODUCTION

There is a significant concern with implant placement in the socket

and tissue thickness in the anterior region. There is an association
with the occurrence of prosthetic and biologic complications1. One of
the goals of performing immediate implant placement is to shorten
treatment time and surgical procedures. The success of the technique
is based on the ideal three-dimensional (3D) position of the implant2.
This position is the most challenging aspect of the technique. If the
implant is installed in an inappropriate position, treatment may
become more complicated and time-consuming than conventional
treatment. The chosen technique must be performed by experienced
professionals, with appropriate theoretical and psychomotor training3.
Both immediate (type I) and early (type II) implant placement
present the challenge of preparing and positioning the implant since
there is not enough time for the newly formed bone to fill the socket. If
it is not possible to heal an infection associated with the tooth to be
extracted or if the bone defect present in the socket is too extensive,
early implant placement is recommended. It will take 4–8 weeks for
soft tissue healingof the socket. Subsequently, surgery is performed
with a large flap to allow bone and gingival grafting along with implant
installation.
Minimally invasive procedures without flap elevation make it difficult
to visualize the alveolar bone; however, it is a current approach and
should, whenever possible, be applied to fresh sockets4. Flapless
immediate implant placement is advantageous because it avoids
scarring and keloid scarring, reduces buccal bone loss, surgical
morbidity, and the number of sutures but requires absolute knowledge
of the anatomy of the region5–10.

OBJECTIVES
At the end of this chapter the reader should be able to:
 Identify the anatomy of the socket before implant placement.
Select the ideal implant to be installed immediately after extraction.
Avoid implant positioning errors in fresh sockets.

2. SCIENTIFIC BACKGROUND

2.1. ALVEOLAR BONE ANATOMY IN THE ANTERIOR

REGION

The possibility of immediate implant placement depends on the

anatomy of the socket and the bone remnant. Tomographic evaluation
allows us to verify the position of the root and its relationship with the
maxillary bone ridge (Figs 01A–D). This relationship has been
classified into four distinct classes11:
Class I: The root is positioned in contact with the buccal cortical
bone. Prevalence of 81.1%.
Class II: The root is centered on the ridge, not maintaining contact
with the buccal or lingual bone. Prevalence of 6.5%.
Class III: The root is in contact with the lingual bone. Prevalence of
0.7%.
Class IV: At least two-thirds of the root are in contact with the buccal
and lingual bone. Prevalence of 11.7%.
01. A–D Classifications of the root/ridge relationship11.

The class IV type of defect is the least favorable for placement of

immediate implants. It can often make it unfeasible to properly place
the implant in the ideal 3D position. Immediate implant placement after
extraction requires the presence of lingual/palatine bone and at least 3
mm of bone apical to the bottom of the socket to provide adequate
stability and lock in the implant12 (Figs 02A–D).
02. A–D Bone anatomy and remaining apical bone are important in
determining the possibility of immediate implant placement. Clinical
and tomographic examinations should be performed to assess bone
availability and palate angulation, which may be narrow (A, B) or wide
(C, D).

The challenge in immediate implant placement in anterior teeth is

due to the characteristics of the area. The palatal bone wall should be
prepared to place the implant from 2 mm to 3 mm away from the facial
bone wall, creating a gap for the grafting biomaterials. In sockets
without the facial bone wall, this distance should be 3–4 mm to the
facial gingiva13,14. Preparation of the palatal wall, however, is hindered
by the depth and inclination of the socket. Burs tend to escape toward
the bottom of the socket, which may tilt the preparation toward the
buccal side15–17. During surgical preparation, it is necessary to use a
bur protractor, have a stable fulcrum for the handpiece, and place the
implant with pressure toward the palatal bone wall. Several techniques
have been described to facilitate the preparation of the socket;
however, the procedure is still sensitive and maximum precision must
be aimed for.

2.2. SOCKET PREPARATION FOR THE IMPLANT

Before the use of helicoidal burs, preparation of the palatal bone wall
was performed with a 2 mm diameter round bur to smooth the bone in
the apical-coronal and buccolingual (BL)15 direction (Figs 03A–F). A
flat area is created in the socket, where other burs are used to prepare
the bone accurately. The use of a long side-cut bur may also be
recommended to rectify the socket walls. The use of a lance pilot bur
angled to the face is another option; as the bur is introduced, its
angulation is corrected, directing it to the palate (Figs 04A–F). In both
techniques, knowledge of the socket and bone topography is
necessary. Thus, tomographic evaluation before the surgical
procedure is crucial (Figs 05A–J). Depending on the length of the
socket, the presence of apical lesions, and the anatomy of the
remaining bone, immediate implant placement may not be indicated.
03. A–F The palatine bone can be regularized with a round bur before
using helicoidal or conical burs. The space between the implant
platform and buccal bone wall should be at least 2 mm.
04. A–F Use of the lance pilot bur should be started at the central
portion of the socket using buccal inclination. As the bur is inserted
into the bone, correction of its angle is necessary. The same care
should be taken with any other subsequent burs and during implant
insertion to prevent buccal repositioning of the implant. Note that in
sockets without buccal bone wall, it is necessary to install the implant
1 mm more palatally and apically.
05. A–J Patient presenting with tooth impairment on tooth 11 (A). The
tooth was extracted and the socket was initially prepared with a lance
pilot bur (B–E). The preparation followed the protocol for implant
placement in the ideal 3D position (F–J).

The ideal 3D positioning of the implant in the socket resembles that

of the edentulous ridges. It may change in the cervical-apical (CA) and
BL directions to compensate for bone remodeling. Special care should
be taken when installing immediate implants in posterior sockets,
especially molars. It is challenging to position the implant in an area
with unfavorable anatomy and at risk of damaging noble anatomic
structures (Figs 06A–G).
06. A–G Tooth 36 was extracted and an immediate implant placed in
the ideal 3D position. After osseointegration, the implant was
rehabilitated with a screwed porcelain crown. Surgical procedure: Dr
Fausto Frizzera; restorative procedure: Dr Marco Masioli.

In esthetic areas, to obtain a more significant amount of tissue on

the facial surface, the implant should be placed in a more palatal and
apical position. For each millimeter that the implant is placed palatally,
it should be placed 1 mm deeper in the socket18. A significant amount
of bone formation around the implant and increased initial stability
occurs when the implant is installed 1 mm apical to the buccal bone
crest19. When the gingival margin is in the correct position, the implant
should be installed 4 mm apically to the soft tissue margin. Even in the
presence of a buccal bone defect or in the absence of such a wall, the
ideal 3D position should be maintained and the tissue reconstructed18
(Figs 07A–C).

07. A–C Images demonstrating the ideal 3D positioning of the socket

in the BL (A), CA (B), and MD (C) directions.

A study in dogs described the ideal position of narrow implants

placed immediately after extraction19. The control group was treated
with implants placed at the bone level and in the center of the socket.
The test group was treated with implants with lingual anchorage and
positioned 0.8 mm infrabone. The results of this study showed that the
implants placed in an infrabony and lingual position presented biologic
advantages. The degree of bone thickness and height after healing
and osseointegration was higher in the test group. Additionally,
infrabony implant placement minimizes the risk of thread exposure
and allows for a more appropriate emergence profile7,9,20.
Success in immediate implant placement is dependent on treatment
planning, evaluation of imaging, and the ability of the surgeon. In this
surgical technique, it is necessary to select the implant accurately.
Individual implant characteristics such as length, diameter, type of
prosthetic connection, thread design, and shape will influence
osseointegration, post-extraction bone maintenance and
21
reconstruction, implant placement, and primary stability .
2.3. SELECTION OF THE IDEAL IMPLANT

Several authors have previously argued against immediate implant

placement in anterior teeth with an intact or defective facial bone wall
due to esthetic changes3,22,23. Initial studies demonstrated that
recession of the facial gingival margin of the peri-implant tissue may
lead to treatment failure1. In the 1990s, the recommendation was to
place implants with a diameter compatible with the size of the socket.
This would maintain the anatomy of the ridge without performing bone
grafts. In several cases, large implants were placed in contact with the
buccal bone wall to reduce the gap or space between the implant
surface and the bone wall. Gingival migration reported in these studies
is related to limited tissue thickness, buccal implant placement, and
the presence of buccal bone dehiscence24 (Figs 08A–C).

08. A–C Incorrect implant selection or placement can lead to esthetic

and functional complications.

2.3.1. IMPLANT DIAMETER

The diameter of the implant influences the amount of bone around the
implant and its primary stability25. Diameter selection should take into
account both mesiodistal (MD) and BL distances. A common mistake
is to select the implant only by the interproximal space present or the
tooth to be rehabilitated. The BL distance from the shoulder and root
should be considered to position the implant away from the buccal
bone plate and create a gap of at least 2 mm between bone and
implant. Bearing in mind that in the cervical region of central incisors
the BL distance from the root is around 6 mm26, an immediate implant
installed in this region should have a diameter less than or equal to 4
mm. The MD distance should only be used as a reference if it is
smaller than the BL distance.
Immediate implants placed close to the buccal bone wall showed
bone loss of about 50% after healing27. According to the literature,
wide neck implants tend to have a bone loss rate higher than narrow
neck implants19,20. Current clinical studies show that even if the socket
is grafted, a small loss of buccal bone, around 1.5 mm, can be
expected28–31.
By combining grafting with the immediate placement of a narrow
implant away from the buccal wall, it is possible to maintain buccal
bone after its osseointegration32–35 (Figs 09A–D and 10A–H). In an
animal study, bilateral distal root removal of the lower fourth premolar
was performed and a narrow implant was placed in the socket in
contact with the lingual bone wall, leaving a gap of 1–2 mm32. In the
test group, the gap was filled with bone graft; in the control group, this
space was not grafted. The results showed that filling the gap with
biomaterial reduced alveolar bone loss. In the test group, the buccal
bone was thick and at the level or slightly apical in relation to the
implant platform (loss of 0.1 ± 0.5 mm). In the control group, there was
a bone defect on the buccal surface (loss of 1.3 ± 0.7 mm) and the
bone was apically thin.
09. A–D The selection of implant diameter should take into
consideration the MD and BL (A) distances to allow buccal bone
regeneration or preservation. Wide implants (B) should not be used in
anterior regions, where implants with a regular (C) or narrow (D)
diameter are recommended instead.
10. A–H Previously it was suggested that implants with a wide
diameter would fill the socket and maintain the buccal wall (A–D). The
current literature recommends that a minimum space should remain
and be filled with bone graft (E–H).

2.3.2. IMPLANT LENGTH

Longer implants should be used in fresh sockets, to achieve stability in
the palatal wall, and should be positioned apically in the socket21. Root
length is a good predictor of implant length; teeth that have short roots
have a more significant amount of apical bone, which facilitates
visualization and preparation of the socket. In contrast, teeth with long
roots represent a surgical challenge and immediate implant placement
may not be recommended even when adequate apical bone is present
(Figs 11A, B). The required length of the implant may not be
available, and a longer implant would be positioned very apically.

11. A, B Long roots may complicate or prevent immediate implant

placement.

A clinical study demonstrated that tapered and narrow implants

used in maxillary incisor sockets were 13 mm long in 79% of cases,
11.5 mm in 4%, and 15 mm in 17% of cases. All of the cases
presented satisfactory primary stability, on average higher than 50
N/cm236. The primary stability obtained is influenced by several factors
and the patient should be informed regarding the possible types of
treatment (Figs 12A–F and 13A–I).
12. A–F Sequential socket preparation (A–D) and implant placement
should be performed with caution (E). If performed, it is necessary to
reposition the implant (F). Patient operated on by Dr. Betina
Malacarne in the Residency Course in Implant Dentistry at ABO ES
supervised by Dr Fausto Frizzera.
13. A–I Extraction of a maxillary anterior tooth can be followed by
different treatments. Implant preparation should be performed to verify
that the implant can be placed in the ideal 3D position. If possible and
the implant is placed higher than 32 N/cm2, an immediate provisional
may be placed (A); otherwise a fixed provisional should not be placed
on the implant (B). If it is not possible to place the implant in the ideal
3D position (allowing a screw-type prosthesis), alveolar preservation
and subsequent implant placement (C) should be chosen. A
tomographic exam allows one to determine if the prosthesis should be
cemented (D–F) or screwed in (G–I).

2.3.3. IMPLANT SHAPE

The anatomy of the implant used in sockets is essential to increase
stability during implant placement. The design of the implant should
allow adequate stability in the walls of the socket21. The surgical area
should be underprepared with a difference of 0.5 mm or more than the
diameter of the last bur used and the implant37 (Figs 14A–F). A
tapered implant provides higher initial stability compared to cylindrical
implants in regions of lower volume and bone density38,39. A split-
mouth controlled clinical trial was performed where a cylindrical
implant was placed on one side and a tapered implant on the other40.
Both implants received immediate loading. The results of the study
demonstrated higher primary stability with tapered implants and
lowered interproximal bone loss after 3 months.
14. A–F For greater implant stability, it is necessary to underprepare
the area and use tapered implants.

A study in dogs investigated the influence of the three types of

prosthetic connections (external, internal, and Morse taper) in bone
remodeling7. The results of the study showed that both bone height
and bone-implant contact are favored by a Morse taper implant
combined with a reduced platform.
The type of implant platform and thread and underpreparation of the
cervical third of the socket have to be carefully approached because
these factors can be directed to the buccal during implant placement
(Fig 15). Evaluation of the placement of implants installed in a human
cadaver showed that implants with square tapping threads are more
likely to be positioned buccally compared to implants with V-shaped
cutting threads41. This study demonstrated that in implants with
compacting threads, the buccal inclination after preparation was
higher than 1 mm in 63.6% of the sockets. This was approximately 0.6
mm higher than in sharp thread implants. One of the advantages of an
implant with compact threads is its significant stability. The risk of
positioning the implants buccally is reduced with the use of hybrid
implants. These implants have compacting threads in the coronal half
and cutting threads in the apical half.
15. There is a tendency for the implant to be buccalized during
placement37. To compensate for this change in positioning, the
perforation should be slightly palatal. Green circle: ideal position of the
implant; yellow circle: implant very close to the buccal wall; red circle:
implant installed in the defective area.

An alternative to reduce the risk of misplacing the implant is guided

surgery. The guide reduces the risk of errors during implant
preparation. Implant insertion can be performed using the surgical
guide or not (Figs 16A–K). More experienced surgeons usually prefer
to insert the implant without a surgical guide in position because it is
possible to support the head of the handpiece more firmly. Decreasing
this change in implant position is essential since buccalized implants
have three times more recession than lingualized implants42. The
initial 5 mm of the palatal wall should be prepared with a bur slightly
smaller than the diameter of the implant.
16. A–K Tooth 12 with crown and radicular fracture (A–C). Digital
surgery planning and a surgical guide were made for immediate
implant placement (D–F). With the guide in position, preparations
were made; the positioning with the parallelism pin was checked after
the use of the 2.0 helicoidal bur (G, H) and with the radiographic
preparation guide after the use of the last tapered bur (I). Then a 3.5 ×
13 mm tapered implant was placed in the ideal 3D position with
primary stability greater than 32 N/cm2; an immediate provisional was
placed (J, K).

3. CLINICAL APPLICATION
 The aforementioned studies demonstrate how it is possible to
increase both precision and biologic results when placing immediate
implants. The characteristics of the implant must be determined before
surgery. It is necessary to consider the aspects evaluated in the
clinical and radiographic examination (conventional and tomographic).
The implant selected for the IIP technique must be conical, long,
narrow, and with a Morse taper connection. Implants with purely
compacting threads should be avoided since there is a higher risk of
tilting them toward the buccal side during insertion (Table 01). The
ideal position of the implant must be one of the trans-surgical
objectives and it must be achieved to obtain satisfactory results. The
surgical sequence for immediate implant installation must follow the
following principles:
1. Perform minimally invasive extraction.
2. Perform socket curettage and irrigation.
3. Carry out initial preparation of the lingual wall with a round or lance
bur.
4. Perform preparation with a 2.0 bur and check the implant position
and its relationship with the adjacent teeth and surgical guide.
5. Carry out preparation with additional burs depending on the implant
selected.
6. Check the position of the preparation and its relationship with the
adjacent teeth and surgical guide.
7. Place implant with pressure toward the lingual bone wall in the ideal
implant position.
8. Leave a buccal gap of 2–3 mm in an intact socket and 3–4 mm in
defective sockets.

CLINICAL AND ANATOMICAL

CHARACTERISTICS IMPLANT CHARACTERISTICS

Presence of lingual and apical bone Long implants

(> 3 mm)
 Gingival margin discrepancy with Narrow or regular diameter implants
contralateral tooth < 3 mm if MD and BL space is present

Adequate clearance between Avoid implants with exclusively

implants and adjacent teeth roots compact or sharp threads

Absence of acute infection Morse taper connection

Table 01 Checklist of the clinical, anatomical, and implant

characteristics in esthetic areas

3.1. IMPLANT WITH IMMEDIATE PROVISIONAL

17. A–K Patient with a low smile line, thick biotype and tooth 11 with
crown and radicular fracture to the middle third of the root (A–E). After
minimally traumatic extraction, the socket was cleaned and inspected
(F–K).
18. A–O The preparation was done with a 2.0 round bur (A–C), with a
total length of 17 mm (implant length = 13 mm + CA implant
positioning = 4 mm below the gingival margin). A 2.4/2.8 mm diameter
lance pilot bur (D, E) was used up to the middle third of the
preparation and a 2.8/3.2 bur was used only in the cervical third (F,
G). A 3.5 × 13 mm tapered implant was placed 4 mm apically to the
gingival margin with a final torque of 45 N/cm2 (H–L). An impression
was taken for provisional laboratory-manufactured provisional and
regeneration with collagen membrane and biomaterial (M–O).
19. A–K An adhesive prosthesis was placed on the adjacent teeth
until the provisional screwed prosthesis was ready (A, B). The
provisional was delivered 48 hours after surgery. At this point, the
patient reported pressure even after reduction of the palatal portion of
the provisional prosthesis (C, D). Six months after surgery, the patient
returned and it was noted that the provisional was more buccal than
the adjacent teeth, the peri-implant margin had a discrepancy of
approximately 0.5 mm, and a small loss of volume was present (E–G).
These changes may have occurred due to interference of the palatine
bone, the provisional component, and the nonuse of a connective
tissue graft. The buccal bone wall was regenerated, but in the
transition zone between the implant and the prosthesis (cemented on
zirconia abutment) a slight discrepancy was present, although hidden
by the patient’s smile line (H–K). Surgical procedure: Dr Fausto
Frizzera; restorative procedure: Dr Camila Lorenzetti.

3.2. IMMEDIATE IMPLANT WITH TOOTH-SUPPORTED

PROVISIONAL
20. A–N Patient with a high smile line showing discrepancy between
the gingival margins of the anterior teeth and tooth 13 with recent
history of fracture (A–E). Tooth 13 was carefully extracted using a
tooth extraction system and an implant was placed immediately (F–H).
The implant was inserted twice but eventually moved to the buccal; in
both situations, the implant was removed and the palatal bone
prepared. At the third attempt the implant was ideally positioned but its
torque was lower than 32 N/cm2. To avoid risking osseointegration of
the implant, the patient chose to receive provisional prosthesis fixed to
the adjacent teeth. The socket was filled with a xenograft biomaterial
and sealed with a gingival graft (I–N).
21. A–N During osseointegration, a gingivectomy on the anterior teeth
was done to equilibrate the gingival contour (A–C). Four months after
the implant surgery, there was a satisfactory amount of tissue. A
temporary (provisional) was placed over the implant-conditioned soft
tissue. Later, a ceramic crown was made and screwed over the
implant (D–N). Surgical procedures performed in the Periodontal and
Peri-implant Plastic Surgery Course supervised by Dr Fausto Frizzera.
Restorative treatment: Dr Mateus Tonetto and Dr Luiz Guilherme
Freitas de Paula.

REFERENCES

1. Kan JY, Rungcharassaeng K, Morimoto T, Lozada J. Facial

gingival tissue stability after connective tissue graft with single
immediate tooth replacement in the esthetic zone: consecutive
case report. J Oral Maxillofac Surg 2009;67(11 Suppl):40–48.
2. Buser D, Martin W, Belser UC. Optimizing esthetics for implant
restorations in the anterior maxilla: anatomic and surgical
considerations. Int J Oral Maxillofac Implants 2004;19(suppl):43–
61.
3. Hammerle CH, Araujo MG, Simion M. Evidence-based knowledge
on the biology and treatment of extraction sockets. Clin Oral
Implants Res 2012;23(5 Suppl):80–82.
4. Chu SJ, Tarnow DP. Managing esthetic challenges with anterior
implants. Part 1: midfacial recession defects from etiology to
resolution. Compend Contin Educ Dent 2013;34(7 Spec):26–31.
5. Ataullah K, Chee LF, Peng LL, Tho CY, Wei WC, Baig MR.
Implant placement in extraction sockets: a short review of the
 literature and presentation of a series of three cases. J Oral
Implantol 2008;34:97–106.
6. Calvo GJL, Ortiz RA J, Negri B, Lopez ML, Rodriguez BC,
Schlottig F. Histological and histomorphometric evaluation of
immediate implant placement on a dog model with a new implant
surface treatment. Clin Oral Implants Res 2010;21:308–315.
7. Calvo GJL, Perez AC, Aguilar SA, et al. Narrow- versus mini-
implants at crestal and subcrestal bone levels. Experimental
study in beagle dogs at three months. Clin Oral Investig
2015;19:1363–1369.
8. Hassan KS, Kassim A, Al Ogaly AU. A comparative evaluation of
immediate dental implant with autogenous versus synthetic
guided bone regeneration. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2008;106:8–15.
9. Negri B, Calvo-Guirado JL, Pardo-Zamora G, Ramirez-Fernandez
MP, Delgado-Ruiz RA, Munoz-Guzon F. Peri-implant bone
reactions to immediate implants placed at different levels in
relation to crestal bone. Part I: a pilot study in dogs. Clin Oral
Implants Res 2012;23:228–235.
10. Negri B, Calvo-Guirado JL, Ramirez-Fernandez MP, Mate
Sanchez-de Val J, Guardia J, Munoz-Guzon F. Peri-implant bone
reactions to immediate implants placed at different levels in
relation to crestal bone. Part II: a pilot study in dogs. Clin Oral
Implants Res 2012;23:236–244.
11. Kan JY, Roe P, Rungcharassaeng K, et al. Classification of
sagittal root position in relation to the anterior maxillary osseous
housing for immediate implant placement: a cone beam
computed tomography study. Int J Oral Maxillofac Implants
2011;26:873–876.
12. Tupac RG. When is an implant ready for a tooth? J Calif Dent
Assoc 2003;31: 911–915.
13. Frizzera F. Alterações teciduais após instalação imediata de
implante, provisório e enxertos em alvéolos comprometidos.
Araraquara. Tese [Doutorado em Ododntologia] – Faculdade de
 Odontologia de Araraquara, 2015.
14. Ortega MJ, Perez PT, Mareque BS, Hernandez AF, Ferres PE.
Immediate implants following tooth extraction: a systematic
review. Med Oral Patol Oral Cir Bucal 2012;17:251–261.
15. Hwang KG, Park CJ. Ideal implant positioning in an anterior
maxillary extraction socket by creating an apico-palatal guiding
slot: a technical note. Int J Oral Maxillofac Implants 2008;23:121–
122.
16. Koh RU, Oh TJ, Rudek I, et al. Hard and soft tissue changes after
crestal and subcrestal immediate implant placement. J
Periodontol 2011;82:1112–1120.
17. Landsberg CJ. Socket seal surgery combined with immediate
implant placement: a novel approach for single-tooth
replacement. Int J Periodontics Restorative Dent 1997;17:140–
149.
18. Potashnick SR. Soft tissue modeling for the esthetic single-tooth
implant restoration. J Esthet Dent 1998;10:121–131.
19. Caneva M, Salata LA, de Souza SS, Baffone G, Lang NP,
Botticelli D. Influence of implant positioning in extraction sockets
on osseointegration: histomorphometric analyses in dogs. Clin
Oral Implants Res 2010;21:43–49.
20. Caneva M, Botticelli D, Rossi F, Cardoso LC, Pantani F, Lang
NP. Influence of implants with different sizes and configurations
installed immediately into extraction sockets on peri-implant hard
and soft tissues: an experimental study in dogs. Clin Oral
Implants Res 2012;23:396–401.
21. Javed F, Romanos GE. The role of primary stability for successful
immediate loading of dental implants. A literature review. J Dent
2010;38: 612–620.
22. Elian N, Cho SC, Froum S, Smith RB, Tarnow DP. A simplified
socket classification and repair technique. Pract Proced Aesthet
Dent 2007;19:99–104; quiz 6.
23. Lang NP, Pun L, Lau KY, Li KY, Wong MC. A systematic review
on survival and success rates of implants placed immediately into
 fresh extraction sockets after at least 1 year. Clin Oral Implants
Res 2012;23(5 Suppl):39–66.
24. Chen ST, Buser D. Clinical and esthetic outcomes of implants
placed in postextraction sites. Int J Oral Maxillofac Implants
2009;24(Suppl):186–217.
25. Ferrus J, Cecchinato D, Pjetursson EB, Lang NP, Sanz M, Lindhe
J. Factors influencing ridge alterations following immediate
implant placement into extraction sockets. Clin Oral Implants Res
2010;21:22–29.
26. Stanley NJ, Ash M. Wheeler’s Dental Anatomy, Physiology, and
Occlusion, ed 9. St Louis, MO: Saunders Elsevier, 1974.
27. Araujo MG, Lindhe J. Dimensional ridge alterations following
tooth extraction. An experimental study in the dog. J Clin
Periodontol 2005;32:212–218.
28. Iasella JM, Greenwell H, Miller RL, et al. Ridge preservation with
freeze-dried bone allograft and a collagen membrane compared
to extraction alone for implant site development: a clinical and
histologic study in humans. J Periodontol 2003;74:990–999.
29. Lekovic V, Kenney EB, Weinlaender M, et al. A bone regenerative
approach to alveolar ridge maintenance following tooth extraction.
Report of 10 cases. J Periodontol 1997;68:563–570.
30. Roe P, Kan JY, Rungcharassaeng K, Caruso JM, Zimmerman G,
Mesquida J. Horizontal and vertical dimensional changes of peri-
implant facial bone following immediate placement and
provisionalization of maxillary anterior single implants: a 1-year
cone beam computed tomography study. Int J Oral Maxillofac
Implants 2012;27:393–400.
31. Simon BI, Von HS, Deasy MJ, Faldu M, Resnansky D. Changes
in alveolar bone height and width following ridge augmentation
using bone graft and membranes. J Periodontol 2000;71:1774–
1791.
32. Araújo MG, Linder E, Lindhe J. Bio-Oss collagen in the buccal
gap at immediate implants: a 6-month study in the dog. Clin Oral
Implants Res 2011;22:1–8.
33. Araújo MG, Lindhe J. Ridge preservation with the use of Bio-Oss
collagen: a 6-month study in the dog. Clin Oral Implants Res
2009;20:433–440.
34. Novaes AB, Suaid Junior F, et al. Buccal bone plate remodeling
after immediate implant placement with and without synthetic
bone grafting and flapless surgery: radiographic study in dogs. J
Oral Implantol 2012;38:687–698.
35. Polyzois I, Renvert S, Bosshardt DD, Lang NP, Claffey N. Effect
of Bio-Oss on osseointegration of dental implants surrounded by
circumferential bone defects of different dimensions: an
experimental study in the dog. Clin Oral Implants Res
2007;18:304–310.
36. Frizzera M, Moreno R, Munoz CO, Cabral G, Shibli J. Impact of
soft tissue grafts to reduce peri-implant alterations after
immediate implant placement and provisionalization in
compromised sockets. Int J Periodontics Restorative Dent
2019;39:381–389.
37. Kan JY, Roe P, Rungcharassaeng K. Effects of implant
morphology on rotational stability during immediate implant
placement in the esthetic zone. Int J Oral Maxillofac Implants
2015;30:667–670.
38. Elias CN, Rocha FA, Nascimento AL, Coelho PG. Influence of
implant shape, surface morphology, surgical technique and bone
quality on the primary stability of dental implants. J Mech Behav
Biomed Mater 2012;16:169–180.
39. Wu SW, Lee CC, Fu PY, Lin SC. The effects of flute shape and
thread profile on the insertion torque and primary stability of
dental implants. Med Eng Phys 2012;34:797–805.
40. Torroella SG, Mareque BJ, Cabratosa TJ, Hernandez AF, Ferres
PE, Calvo GJL. Effect of implant design in immediate loading: a
randomized, controlled, split-mouth, prospective clinical trial. Clin
Oral Implants Res 2015;26:240–244.
41. Koticha T, Fu JH, Chan HL, Wang HL. Influence of thread design
on implant positioning in immediate implant placement. J
 Periodontol 2012;83:1420–1424.
42. Evans CD, Chen ST. Esthetic outcomes of immediate implant
placements. Clin Oral Implants Res 2008;19:73–80.
 CHAPTER 7
IMMEDIATE PROVISIONAL
ON TEETH OR IMPLANTS:
determining chronology and restoration contouring
Mateus Rodrigues Tonetto, Fausto Frizzera, Eduardo Fernandez, Camila
Lorenzetti, Matheus Coelho Bandéca
1. INTRODUCTION

After extraction of an anterior tooth, the patient usually requests its

immediate replacement. A provisional prosthesis can be made to
supply the esthetics of the region. This has a direct influence on tissue
remodeling after surgery to maintain or reconstruct tissue architecture.
Before extraction, it is essential to plan the type of provisional
restoration that the patient will receive. Ideally, the implant and the
provisional are placed immediately after tooth extraction. However, it
is necessary to explain to the patient that other alternatives may be
necessary.
The condition of the adjacent teeth should be analyzed before
surgery because it will not always be possible to immediately place a
provisional over the implant. The provisional restoration can be fixed
or bonded to the adjacent teeth. Primary implant stability, occlusion,
and tissue appearance are some of the factors that will determine the
possibility of an immediate provisional restoration over the implant.
Regardless of which temporaryis going to be used, it must be
customized to prevent changes and improve soft tissue conditions.
Incorrect contouring of the provisional restoration can compromise all
surgical efforts to achieve adequate tissue contour and a natural
emergence profile.
Given the possibility of tissue manipulation, an understanding of and
integration between surgical and restorative procedures are necessary
to obtain more predictable results.

OBJECTIVES
At the end of the chapter the reader should be able to:
Determine if the immediate provisional will be tooth- or implant-
retained.
Understand the techniques and indications for making an immediate
provisional.
 Know the ideal provisional anatomy to obtain a suitable gingival
contour.

2. SCIENTIFIC BACKGROUND

The use of provisional restorations aims to prepare, contour, and

stabilize peri-implant soft tissues during and after osseointegration
and graft incorporation. It aims to provide comfort to patients in their
day-to-day life and allows evaluation of esthetic parameters before the
final restoration is made1–3. In esthetic areas, a provisional should be
placed immediately after extraction. In non-esthetic regions, it can be
done according to the expectations of the patient. Placement of an
immediate provisional over teeth or implants will depend on the
surgical and restorative treatment plan.
For the immediate provisionalization of the implant, we must
consider the type of soft tissue defect, the final implant torque, and the
patient’s occlusion. Torque should be measured on completion of
implant placement and, if less than 32 N/cm2, immediate provisional
restoration is not recommended4,5 (Figs 01A–F). Initial studies on the
technique demonstrated a high risk of implant loss if primary stability
was lower than this value6. Failure in osseointegration is due to micro
and macromovement that can occur when the provisional is placed.
Instead of establishing direct contact between implant and bone,
fibrous tissue is formed around the implant, characterizing its failure7,8.
To avoid this type of complication, which increases treatment time,
placement of a provisional on the adjacent teeth or a provisional
device is recommended during osseointegration and graft
incorporation.
01. A–F Immediate implant installation after extraction with final
installation torque (A–C). Immediate provisional confection (D).
Screwed on provisional restoration (E). Tissue appearance after 6
months, showing maintenance of the tissue contour (F).

In addition to implant stability, it is necessary to assess occlusal and

tissue aspects before immediate provisional restoration (Figs 02A–C
and 03A–C). The patient should have a stable occlusion, no signs of
parafunction, and no loss of posterior occlusal stability. In the
presence of extensive bone or gingival defects, a provisional should
not be installed directly in the implant. The closure provided by the
graft-associated flap aids the reconstruction of lost tissues. In different
cases, it is necessary to correctly indicate the type of provisional and
be prepared for complications that may occur during surgery, which
will change the initial planning (Table 01).
02. A–C Lack of occlusal stability can lead to tooth damage. Patient
with impaired tooth 12 and absent molars.

03. A–C Patient without occlusal stability, with little interocclusal space
due to deep bite. Initial fracture on tooth 22 and, after 8 months,
fracture on tooth 21.

PROVISIONAL
RESTORATION SUPPORT TECHNIQUE

Orthodontic appliance Removable or fixed

appliance with provisional in
the edentulous region

Tooth-supported Adjacent teeth Adjacent teeth are used as

support and the provisional
is attached with a fixed or
adhesive partial denture
 Teeth and ridge The edentulous region is
provisionally rehabilitated
with a removable partial
denture

Implant- Prosthetic abutment Placement of abutment and

supported provisional restoration

Table 01. Different provisionalrestoration techniques for different

clinical situations

2.1. TOOTH-SUPPORTED IMMEDIATE PROVISIONAL

RESTORATION

Before an extraction in an esthetic area, it should be determined if it is

possible to immediately place a provisional and what type of retention
the provisional will have. Implant placement, whether immediate or
delayed, should be performed in the ideal three-dimensional position.
If there are bone or soft tissue deficiencies that impair the correct
positioning of the implant or proper tissue healing is not feasible, the
delayed approach should be used (Figs 04A–E). Also, if rehabilitation
planning involves the need for orthodontic movement, the timing of
implant placement should be determined by all the professionals
involved in the treatment (Figs 05A–C).
 04. A–E Patient with a porcelain chip in the crown of tooth 21, with the
presence of a fracture and large periapical lesion in tooth 22, that
does not allow immediate implant placement (A, B). Minimally
traumatic extraction and bone graft were performed; a provisional
fixed partial prosthesis (C) on teeth 21 (abutment) and 22 (cantilever)
was made. After 6 months, an adequate soft tissue contour and bone
regeneration were observed (D, E). Surgical procedure: Dr Fausto
Frizzera; restorative procedure: Dr Quézia Godinho.

05. A–C Patient requiring extraction of tooth 23, with inadequate

occlusion and prior orthodontic treatment. There is a defect with
presence of adequate soft tissue and palatine bone. The implant
should be installed only after orthodontic treatment and tissue
regeneration.

Provided that the proper conditions are present, the implant can be
placed immediately after extraction. The stability of the implant and
the characteristic of the socket defect will indicate which type of
surgical approach will be performed:
1. Cover screw and implant coverage
2. Standard or custom healing abutment
3. Interim implant
When adequate primary stability is not achieved, with less than 10 N,
or an extensive bone defect of more than 1 wall is present, the ridge
should be grafted, and the implant covered. If stability exceeds 15 N, it
is possible to install the healing abutment, which allows the
maintenance of soft tissue or even promotes tissue gain and should
be totally free of masticatory function or any type of load9–11 (Figs
06A–I). The healing period will depend on the implant surface
treatment and the recommendations of the system used. If bone and
gingival grafts are required, the time for reopening and loading the
implant should be 3–6 months for tissue maturation.
06. A–I Patient with abscess on tooth 15 and extensive bone loss.
Clinical and tomographic evaluation, verifying the possibility of
immediate implant placement (A–E). Immediate implant placement
and healing abutment (45 N/cm2 stability) and bone and gingival graft
(F–H) were performed. A provisional was made supported by the
restoration of the adjacent tooth. Six months after surgery with the
implant-supported provisional (I). Surgical procedure: Dr Fausto
Frizzera; restorative procedure: Dr Marco Masioli.

In these situations, the immediate provisional is supported by

adjacent teeth with a fixed partial prosthesis or by a fixed or
removable orthodontic appliance (Figs 07A–I to 09A–G). A fixed
partial prosthesis is recommended when adjacent teeth are already
prepared for a fixed restoration. Healing abutments may be
recommended instead of covering the implant because it avoids a
second surgical procedure and assists in maintaining the tissue
contour12.
07. A–I Extraction of tooth 11 and initial provisional manufactured with
the extracted tooth crown (A–E). After soft tissue healing, tooth 21
was prepared due to the presence of extensive restorations and a
fixed partial prosthesis (F, G) was made. This type of restoration
allows better conditioning of gingival tissue (H, I).
08. A–C Absence of lateral incisor and provisional restoration
supported by mobile orthodontic appliance. This type of restoration
provides good esthetic results. However, it does not condition the soft
tissues and can still become a patient complaint for the inconvenience
of using a removable prosthesis.

09. A–G Extraction of tooth 11 due to root resorption and active

infection, followed by socket preservation with bone and gingival graft.
Because the patient was undergoing orthodontic treatment, the
extracted tooth was prepared for use as a provisional in the appliance.

2.1.1. REOPENING OF THE IMPLANT

After a period of graft incorporation and implant osseointegration, it is
necessary to evaluate the condition of the tissue (ideal, deficient, or
excess) and implant positioning to define how to reopen the implant.
A circular scalpel technique can be used. Initially, the center of the
implant is located with a probe. The circular scalpel is then adapted,
the incision made, and the mucosal tissue cap removed. This
technique is recommended when there is adequate tissue thickness,
and there is no need to improve the peri-implant tissues (Figs 10A–L
and 11A–G). This technique allows immediate manufacture of the
provisional over the implant, which favors gingival healing in an
adequate contour. If there is excess tissue, it may be surgically
removed or the tissue can be conditioned using the provisional.
10. A–L Implant installed inside the socket, where a bone and gingival
graft had been performed and sealed with a provisional made using
retention and reinforcement tape (Ribbond) (A–C). Due to the
satisfactory amount of soft tissue (D, E), a circular scalpel was used to
reopen the implant (F–I).
11. A–G Removal of the healing abutment and preparation of the
provisional abutment (A). The gingival margin of tooth 13 was more
coronal than tooth 23; an overcontour was made to compress and
condition the gingival tissue (B–E). Final photo after conditioning the
temporary gingival tissue (F, G).

A technique indicated for defective regions is to reopen them with a

lingual incision, where the flap is moved to the buccal area with the
objective of promoting an increase in volume13. At this point, a healing
abutment (Figs 12A–G and 13A–K) or the provisional itself can be
placed (Figs 14A–D). Depending on the magnitude of the defect, a
connective tissue graft may also be used (Figs 15A–G to 17A–P).
Regardless of the technique used, it is essential that the provisional
has satisfactory esthetic characteristics, an adequate contour, and a
high degree of adaptation and polishing to allow a better response of
the peri-implant tissue14.
12. A–G After osseointegration, palatal incision and placement of the
healing abutment follows, thus conditioning the buccal soft tissue (A–
D). Appearance 1 week after reopening, on the day of suture removal
(E–G).
13. A–K Fourteen days after reopening the implant, tissue
conditioning was started by adding flowable composite resin around
the healing abutment, which enabled compression and an outline of
the gingival contour (A–C). After 3 weeks of healing, a provisional was
placed (D–H) and the tissue was progressively conditioned to allow a
natural contour (I–K). Surgical procedure: Dr Fausto Frizzera;
restorative treatment: Dr Bianca Vimercati.
14. A–D A provisional can be placed immediately after reopening the
implant using a palatal incision to assist with tissue support. Surgical
procedure: Dr Fausto Frizzera; restorative procedure: Dr Gabriela
Cassaro.
15. A–G Previously implanted area with buccal volume deficiency. An
arched incision is made and the palatal tissue is divided (A–C). The
palatal tissue is then released and enveloped (D–G).
16. A–I Region of tooth 21 with buccal volume deficiency (A–C). The
implant was reopened and the volume increased with a thick
connective tissue graft (D–F). Clinical aspect after tissue healing and
abutment installation (G–I).
17. A–P An impression was taken to make the copings and ceramic
crowns (A–O). Four-year follow-up (P). Surgical procedure: Dr Jamil
Shibli; restorative treatment: Dr Susana D’Avila.

2.2. IMMEDIATE IMPLANT-SUPPORTED PROVISIONAL

RESTORATION

An immediate implant-supported provisional can be understood as a

provisional placed within 48 hours after the surgical procedure15.
Benefits of this technique include cost savings, no second surgical
procedure, preservation of the interdental papillae, and psychological
comfort for patients16.
In the delayed technique, the implant is already osseointegrated.
However, in the case of an immediate provisional restoration,
osseointegration has not been established17. For predictable results, it
is essential that several occlusal, surgical, and prosthetic standards
are met. Restoration of the provisional should be free of occlusal
contacts. The patient should be asked not to chew in the area since
this may impair osseointegration18. The patient should present
occlusal stability and no signs of bruxism or parafunctional habits19. If
these conditions are present, it is possible to place a custom healing
abutment that will maintain the tissue contour and favor the
manufacture of the definitive prosthesis (Figs 18A–E to 20A–E).

18. A–E Patient with loss of posterior support, deep bite, and limited
interocclusal space on tooth 21.
19. A–L Minimally invasive extraction was performed. The socket was
prepared and a 4.3 × 13 mm implant was placed in the palatal wall
(approximately 3 mm away from the buccal gingiva) with a torque of
60 N/cm2 (A–E). Due to the patient’s occlusion, installation of an
immediate provisional over the implant was contraindicated. A
provisional was added to the removable partial prosthesis that the
patient already used. To assist in maintaining the soft tissue contour
and seal the grafts (bone and gingival) placed in the socket, a custom
healing abutment was placed (F–L).
20. A–E Postoperative images at 14 (A), 60 (B), and 120 days (C–E)
when the implant was ready for prosthetic rehabilitation. Surgical
procedure: Dr Fausto Frizzera; restorative procedure: Dr Pablo
Delazare.

If a primary stability of 32 N/cm2 or more is achieved, it is possible to

use a prosthetic component to make a cemented or screwed
provisional, which will depend on the preferences of the professional
and implant positioning15. It is possible to place an immediate
provisional or take an impression of the implant for a laboratory-
manufactured provisional restoration to be delivered within 48 hours.

2.3. TYPES OF RETENTION OF IMPLANT-SUPPORTED

PROVISIONALS

The type of retention on the prosthetic abutment will depend on the

position of the implant. If implant emergence is in a lingual position, a
screw-retained prosthesis is possible; otherwise, a cemented
prosthesis is recommended because the screw hole would be on the
buccal18 (Figs 21A–F to 23A–I).
21. A–F Emergence profile of cemented (A–C) and screwed (D–F)
prostheses.
22. A–F After extraction of tooth 12 and immediate implant placement.
The immediate provisional was made (before grafting). The
provisional was subsequently cemented and the excess cement was
completely removed. (A–E) 6 months after the procedure (F). Surgical
procedure: Dr Fausto Frizzera; restorative procedure: Dr José
Maurício Reis.
23. A–I Implant previously installed on tooth 22, with adequate soft
tissue (A–C). A minimally invasive reopening was performed to
expose the implant and the provisional was manufactured using
flowable resin (D–H). Two-week follow-up (I). Surgical procedure: Dr
Fausto Frizzera; treatment performed at the Implant Dentistry Clinic of
FAESA by Drs Mariana Itaboraí, Yasmim Ferreira, and Allan Caetano
supervised by Dr Gabriela Cassaro de Castro.

The disadvantage of performing a temporary cemented prosthesis

is the possibility of contamination of the operated area due to cement
overflow. In situations where the implant is slightly buccal, it is
possible to tilt the provisional slightly to buccal or have the screw
emerging on the incisal edge. In both situations, the esthetics of the
provisional may be compromised. The implant should be positioned
between the incisal edge and the cingulum20.
The provisional can be made directly, in the patient’s mouth, or
indirectly, by the laboratory. For laboratory-manufactured provisionals,
impressions should be taken, which allows the making of a temporary
with less porosity and excellent polishing. However, another clinical
session would be necessary to deliver the restoration of the
provisional. The indirect technique is recommended in cases of
multiple implants or where high esthetics are required.
The direct technique requires capturing the prosthetic abutment.
Chemically activated acrylic or composite resin may be used.
However, color stability and the degree of polish and porosity of
acrylic resins are inferior to light-cured composite resins21–23. The
characteristics of the material and ease of handling favors
manufacturing conventional or flowable composite resins. Additionally,
acrylic resin monomer is cytotoxic and should be used with extreme
caution, especially when performed during surgery24.

2.4. ABUTMENT AND PROVISIONAL ANATOMY

Depending on the selected connection (external hex, internal hex, or

Morse taper) it is possible to obtain a better distribution of chewing
forces, with less microspace at the prosthetic/abutment junction and
greater stability of the prosthetic components25,26. Among the factors
mentioned, we can classify external hex as having the worst
properties and Morse taper the best. Besides, bacterial colonization
occurs in the microspace between the implant and the abutment,
which, when associated with occlusal forces, may lead to unwanted
bone remodeling around the implant27.
The use of reduced platforms or platform switching in implants has
been currently recommended. The objective is to increase the
distance from the implant/abutment junction to the bone crest, thus
reducing its remodeling27. Also, the small diameter components favor
the prosthetic procedures since the platform is distant from the bone.
When installing immediate implants with an external connection, a
procedure for the removal of bone tissue from the socket around its
platform is necessary to allow passive seating of the prosthetic
components (Figs 24A–C).
24. A–C UCLA abutment placed in the implant showing contact with
the bone (A, B). Currently, use of a reduced platform is recommended
to preserve bone contour and reduce bone remodeling around the
implant. (C).

Placement of the definitive abutment at the time of surgery is a

technique that is currently being used. However, it makes
rehabilitation restrictive because, in most cases, it directs rehabilitation
to a cemented prosthesis. Also, the distance between the cementation
line and gingival margin can vary, making it difficult to remove the
cement. Tissue changes due to excess cement require customization
or replacement of the prosthetic component.
Most implant systems do not provide a premanufactured abutment
that will have optimal distances between the gingival margin or
papillae and the cementation line. It is recommended to use a custom
prosthetic abutment for the definitive restoration. The appropriate
subgingival profile is one with a supragingival margin that favors
cement removal. Failure to remove excess cement may lead to
mucosal inflammation and peri-implantitis24,28–31. Therefore, installing
an immediate permanent abutment as well as cemented implant-
supported prostheses requires care. In such cases, excess cement,
either temporary or definitive, should be removed before placement
using an analogous abutment18,32 (Figs 25A–F).
25. A–F Isolation before the cementation procedure (A). Use of the
die with the analogous abutment for cement overflow before the
cementation procedure (B, C). Thin layer of cement present in the
crown (D). Cementation of the ceramic crown in the mouth (E).
Minimally invasive extraction (F).

The contour of the provisional restoration influences the

maintenance of soft tissue support33. It is necessary to differentiate the
prostheses on teeth and implants. Tissue characteristics are distinct.
In teeth, the provisional will have a straight or convex contour34. In
implants, the contour of choice in esthetic areas will depend on the
three-dimensional position of the implant and on the volume of soft
tissue14,35 (Table 02). The transition zone between the implant, peri-
implant tissue, and prosthesis should be in harmony to provide
excellent soft tissue stability.

EMERGENCE
PROFILE OF
PROSTHETIC
IMPLANT LOCATION ABUTMENT OBJECTIVE

Slightly buccal Concave Avoid marginal

recession

Centralized Slightly concave or Maintain soft tissue

straight position

Lingual Convex Tissue conditioning

Table 02. Provisional contour types for proper tissue conditioning
according to clinical condition of osseointegrated implant

The contour of the provisional in the subgingival region will influence

the soft tissue around the implant (Figs 26A–H). Tissue compression
causes ischemia and its persistence will lead to compromised peri-
implant tissue nutrition, which may be accompanied by programmed
cell death (apoptosis) and even recession of the gingival margin16,33.
This procedure can be performed on purpose when it is necessary to
increase the length of the clinical crown or to condition the soft tissue
for the buccal or interproximal region. In these situations, the region
should have adequate soft tissue and the implant must have been
placed in an ideal position.
26. A–H Design of the definitive abutment should follow the tissue
contour (A, B). Anatomical design of the implant prosthesis depending
on the positioning of the implant: slightly to buccal (C, D), centralized
(E, F), and palatal aspects (G, H).

By avoiding peri-implant soft tissue compression and consequent

mechanical and inflammatory trauma, it is possible to reduce apical
tissue migration. Reducing the contour of the restorative material from
the buccal subgingival portion at surgery allows for adequate soft
tissue thickness and reduction of the length of the clinical crown when
associated with connective tissue grafting14.

3. CLINICAL APPLICATION

3.1. TECHNIQUE FOR DIRECT SCREWED

RESTORATION OF PROVISIONAL

Manufacturing of a screwed provisional begins with installing the

abutment; the need to reduce the height must be evaluated and
marked. The abutment is removed and prepared to allow interocclusal
space for restorative material. Then a stock or provisional tooth is
worn internally, maintaining the contour of the cervical region. The
abutment and provisional are cleaned, conditioned with 37%
phosphoric acid and the adhesive system is used for later capture with
flowable resin. The provisional can be taken into position and screwed
to the torque indicated by the manufacturer (Figs 27A–I and 28A–Q).
27. A–I Patient with abscess due to oblique root fracture. Diagnosis
was confirmed on radiographs and soft-tissue cone beam tomography
(A–E). First, the fractured fragment was removed and antibiotic
therapy started. It was possible to notice great loss in the volume of
gingival tissue. Tissue regeneration was recommended with the
extraction (F, G). Placement of 3.5 × 13 mm Morse taper implant and
provisional prosthetic abutment (H, I).
28. A–Q Preparation of the abutment to allow the correct adaptation
and occlusal height of the provisional tooth (A, B). Try-in of the
denture tooth on the abutment. The denture tooth was captured with
flowable resin (C, D). In the same session, while the provisional was
made, the necessary grafts (E–G) were performed. Adjustments and
polishing of the provisional (H, I). Temporary installation after grafting,
not compressing the grafts (J). Tissue contour obtained after the
healing period (K–M). Definitive prosthesis manufacture with hybrid
abutment in zirconia and lithium disilicate after impression (N, O).
Computed tomography scan and clinical aspect after cementation of
ceramic crown on tooth 22 and ceramic veneers on teeth 11, 21, and
12 due to present restorations and dental disharmony (P, Q). Surgical
procedure: Dr Fausto Frizzera; restorative procedure: Dr Camila
Lorenzetti and Dr Maria Silvia Rigolin.

3.2. TECHNIQUE FOR DIRECT CEMENTED

 RESTORATION OF PROVISIONAL

An abutment for a cemented restoration of the provisional is placed

and the need of the preparation is assessed. Then a denture tooth is
internally prepared, maintaining the cervical contour. The abutment
and the provisional are cleaned. After placing the screwretained
prosthesis, the interior of the restoration of the provisional is filled with
chemical cure acrylic resin. After curing, the provisional and abutment
are removed. Correct finishing and polishing result in an adequate
subgingival contour of the provisional. The abutment should be placed
with the manufacturer’s recommended torque and the temporary
restoration should be cemented. Excess cement should be carefully
removed (Figs 29A–H and 30A–H).
29. A–H After the implant was placed in the socket, a preparation
sleeve was placed in position and marked on the buccal and palatal
faces to perform the necessary wear, and checking the interocclusal,
buccal, and palatine spaces (A–F). The crown of the extracted tooth,
which was a ceramic crown, was used and reworked to make a
cemented provisional (G, H).
30. A–H A provisional with subcontouring in the cervical space was
performed to favor gingival coronal migration (A–E). Result after 3
months of provisional, where it was possible to notice coronal
migration of the soft tissue margin position (F–H). Surgical procedure:
Dr Fausto Frizzera; restorative procedure: Dr Bianca Vimercati.

3.3. TECHNIQUE FOR INDIRECT CEMENTED

RESTORATION OF PROVISIONAL

The position of the implant is evaluated to check for the possibility of a

cemented restoration. The prosthetic component is chosen and tested
(to verify correct seating) according to the implant configuration and
depth that it was placed. An impression of the implant or prosthetic
component is performed for a laboratory-manufactured provisional
(Figs 31A–I and 32A–I).
31. A–I Patient with root fracture and buccal bone defect. Minimally
invasive extraction (A–D) was performed. Implant was placed in the
lingual bone wall. Due to the shape of the ridge, the implant had to be
inclined to the buccal aspect and it was necessary to make a
cemented prosthesis (E–F). Impression for a temporary was taken
and the healing abutment was placed (G–I).
32. A–I Before taking an impression, the surgical area should be
isolated to avoid contact with the impression material. The impression
must be disinfected. Wax-up of the provisional restoration (A).
Manufacture of provisional restoration with light-curing composite
resin using a putty matrix (B, C). Placement of the metal abutment
and cementation of provisional restoration (D, E). Six-month follow-up
(F, G). A new impression was taken and a laboratory-manufactured
zirconia abutment was made; teeth 12 and 21 were prepared for a full
crown due to leakage and large extension of the previous restorations
(H). One year after cementation (I). Surgical procedure: Dr Fausto
Frizzera; restorative procedure: Dr Camila Lorenzetti.

3.4. TECHNIQUE FOR INDIRECT SCREWED

RESTORATION OF PROVISIONAL

A provisional component is selected and an impression is made for a

laboratory-manufactured restoration of provisional. The provisional is
made to match the shape and color of the adjacent teeth. The
provisional is placed in position and screwed with the torque indicated
by the manufacturer. In all described situations, occlusal contacts
should be removed during mandibular movements (Figs 33A–H to
38A–D).
33. A–H Patient with fractured tooth 11 (A–E) with limited tissue
thickness (F, G). Digital planning showed the need for midline and
gingival contour correction. The fractured fragment was removed (H).
34. A–K Two weeks later, extraction and placement of a 3.5 × 15 mm
implant, according to the position of the digital planning.
35. A–O An impression was made for a laboratory-manufactured
provisional restoration. Tissue regeneration and immediate adhesive
provisional bonded to the adjacent teeth (A–E). The grafted area was
isolated to avoid contamination when preparing tooth 21 (F–O).
36. A–J Placement of implant-supported (tooth 11) and tooth-
supported (tooth 21) provisional restorations (A–H). Healing after 30
and 120 days (I, J).
37. A–T After 4 months, the clinical crown was increased to correct
the gingival discrepancy.
38. A–D Tissue around the implant (A, B). Initial and postoperative
appearance of clinical crown lengthening. The patient is ready for the
definitive restorative treatment (C, D).

REFERENCES

1. Poggio CE, Salvato A. Bonded provisional restorations for

esthetic soft tissue support in single-implant treatment. J Prosthet
Dent 2002;87: 688.
2. Donos N, Horvath A, Mezzomo LA, Dedi D, Calciolari E, Mardas
N. The role of immediate provisional restorations on implants with
a hydrophilic surface: a randomised, single-blind controlled
clinical trial. Clin Oral Implants Res 2018;29:55–66.
3. Attard NJ, Zarb GA. Immediate and early implant loading
protocols: a literature review of clinical studies. J Prosthet Dent
2005;94:242–258.
4. Satwalekar P, Satwalekar T, Bondugula V, Bhuvaneshwari B,
 Harshavardhan KV, Pasula K. Creating esthetic harmony with
nonloading, fixed provisional restoration using extracted teeth
after immediate implant placement. J Contemp Dent Pract
2016;17:344–346.
5. Ortega MJ, Pérez PT, Mareque BS, Hernández AF, Ferrés PE.
Immediate implants following tooth extraction. A systematic
review. Med Oral Patol Oral Cir Bucal 2012;17:251–261.
6. Ottoni JM, Oliveira ZF, Mansini R, Cabral AM. Correlation
between placement torque and survival of single-tooth implants.
Int J Oral Maxillofac Implant 2005;20:769–776.
7. Brunski SB. Biomaterials and medical implant science. Int J Oral
Maxillofac Implants 1995;10:649–650.
8. Maniatopoulos C, Pilliar RM, Smith DC. Threaded versus porous-
surfaced designs for implant stabilization in bone-endodontic
implant model. J Biomed Mater Res 1986;20:1309–1333.
9. Francischone CE, Sartori IAM, Nary Filho H. Carga imediata em
arco total. In: Cardoso RJA, Macha-Do MEL. Odontologia,
Conhecimento e Arte: Dentística, Prótese, ATM, Implantodontia,
Cirurgia, Odontogeriatria. São Paulo, Brazil: Artes Médicas, 2003:
453.
10. Meredith N. Assessment of implant stability as a prognostic
determinant. Int J Prosthodont 1998;11:491–501.
11. Sennerby L, Ross J. Surgical determinants of clinical success of
osseointegrated oral implants: a review of the literature. Int J
Prosthodont 1998;11:408–420.
12. Misch CE, Perel ML, Wang HL, et al. Implant success, survival,
and failure: the International Congress of Oral Implantologists
(ICOI) Pisa Consensus Conference. Implant Dent 2008;17:5–15.
13. Nemcovsky CE, Moses O. Rotated palatal flap. A surgical
approach to increase keratinized tissue width in maxillary implant
uncovering: technique and clinical evaluation. Int J Periodontics
Restorative Dent 2002;22:607–612.
14. Redemagni M, Cremonesi S, Garlini G, Maiorana C. Soft tissue
stability with immediate implants and concave abutments. Eur J
 Esthet Dent 2009;4:328–337.
15. Cochran DL, Morton D, Weber HP. Consensus statements and
recommended clinical procedures regarding loading protocols for
endosseous dental implants. Int J Oral Maxillofac Implants
2004;19 (Suppl):109–113.
16. Trimpou G, Weigl P, Krebs M, Parvini P, Nentwig GH. Rationale
for esthetic tissue preservation of a fresh extraction socket by an
implant treatment concept simulating a tooth replantation. Dent
Traumatol 2010;26:105–111.
17. Noelken R, Kunkel M, Jung BA, Wagner W. Immediate non-
functional loading of Nobel perfect implants in the anterior dental
arch in private practice – 5-year data. Clin Implant Dent Relat Res
2014;16:21–31.
18. Chu SJ, Salama MA, Salama H, et al. The dual-zone therapeutic
concept of managing immediate implant placement and
provisional restoration in anterior extraction sockets. Compend
Contin Educ Dent 2012;33:524–532, 534.
19. Weber HP, Morton D, Gallucci GO, Roccuzzo M, Cordaro L,
Grutter L. Consensus statements and recommended clinical
procedures regarding loading protocols. Int J Oral Maxillofac
Implants 2009;24(Suppl):180–183.
20. Tupac RG. When is an implant ready for a tooth? J Calif Dent
Assoc 2003;31:911–915.
21. Kamonkhantikul K, Arksornnukit M, Takahashi H, Kanehira M,
Finger WJ. Polishing and toothbrushing alters the surface
roughness and gloss of composite resins. Dent Mater J
2014;33:599–606.
22. Rutkunas V, Sabaliauskas V, Mizutani H. Effects of different food
colorants and polishing techniques on color stability of provisional
prosthetic materials. Dent Mater J 2010;29:167–176.
23. Silame FD, Tonani R, Alandia RCC, Chinelatti M, Panzeri H,
Pires SFC. Colour stability of temporary restorations with different
thicknesses submitted to artificial accelerated aging. Eur J
Prosthodont Restor Dent 2013;21:187–190.
24. Santos RL, Pithon MM, Carvalho FG, Ramos AA, Romanos MT.
Mechanical and biological properties of acrylic resins manipulated
and polished by different methods. Braz Dent J 2013;24:492–497.
25. Coelho GM, Pesqueira AA, Falcón ARM, Santos DM, Haddad
MF, Bannwart LC, Moreno A. Stress distribution in implant-
supported prosthesis with external and internal implant-abutment
connections. Acta Odontol Scand 2013;71:283–288.
26. Sotto MBS, Lima CA, Senna PM, Camargos GV, Del Bel CAA.
Biomechanical evaluation of subcrestal dental implants with
different bone anchorages. Braz Oral Res 2014;28:S1806-
83242014000100235.
27. Lazzara R, Porter S. Platform switching: a new concept in implant
dentistry for controlling postrestorative crestal bone levels. Int J
Perio Rest Dent 2006;26:9–17.
28. Pauletto N, Lahiffe BJ, Walton JN. Complications associated with
excess cement around crowns on osseointegrated implants: a
clinical report. Int J Oral Maxillofac Implants 1999;14:865–868.
29. Piñeyro A, Tucker LM. One abutment – one time: the negative
effect of uncontrolled abutment margin depths and excess
cement: a case report. Compend Contin Educ Dent 2013;34:680–
684.
30. Wilson Junior TG. The positive relationship between excess
cement and peri-implant disease: a prospective clinical
endoscopic study. J Periodontol 2009;9:138892.
31. Quaranta A, Lim ZW, Tang J, Perrotti V, Leichter J. The impact of
residual subgingival cement on biological complications around
dental implants: a systematic review. Implant Dent 2017;26:465–
474.
32. Wadhwani C, Piñeyro A. Technique for controlling the cement for
an implant crown. J Prosthet Dent 2009;102:57–58.
33. Tarnow DP. Commentary: replacing missing teeth with dental
implants: a century of progress. J Periodontol 2014;85:1475–147.
34. Fradeani M. Esthetic Analysis: A Systematic Approach to
Prosthetic Treatment. Chicago, IL: Quintessence Publishing
 Company 2004: 352.
35. Steigman M, Monje A, Hsun-Liang C, Wang HL. Emergence
profile design based on implant position in the esthetic zone. Int J
Periodontics Restorative Dent 2014;34:559–563.
 CHAPTER 8
IMMEDIATE REHABILITATION
OF INTACT AND
COMPROMISED SOCKETS:
a predictable protocol
Fausto Frizzera, Jamil A. Shibli, Ana Carolina M. Marcantonio, and Elcio
Marcantonio Jr
1. INTRODUCTION

About 12 million implants are placed annually worldwide1 according to

the implant placement chronology that follows tooth extraction as
proposed by Hammerle et al2 at the Gstaad conference in Switzerland
(Fig 01). The different chronologies of implant placement vary mainly
regarding time and surgical morbidity. Satisfactory biologic and clinical
results, associated with safety and long-term stability, have always
been the objective of scientific research carried out in implantology.
Although these are primary treatment factors, patient satisfaction and
the number of surgeries are underassessed.

01. Among the types of implant placement, the one that requires the
most training is type I; its biggest advantage is reduced treatment
time, morbidity, and number of procedures.

Results have centered on patients’ expectations; total treatment

time, cost, number of surgical procedures, safety, and clinical
outcomes should all be taken into account. From the patient’s point of
view, treatment should be done as quickly as possible least painfully,
and least costly, providing an excellent outcome.
The major concern regarding the technique for implants and
immediate provisionals (IIP) is the position the gingival margin (GM)
will assume after surgery and in the long term. Different clinical
situations may require maintaining or modifying this process. In the
past, a gingival recession (GR) of approximately 1 mm in the first year
was expected3; to reduce the chance of recession, soft and bone
tissue regeneration4 (Table 01) is recommended. The initial step to
maintaining or modifying the position of the GM is correct three-
dimensional (3D) placement of the implant in the socket. If the implant
cannot be placed in the ideal position, delayed implant placement is
recommended.

Table 01 Studies on immediate implant placement according to

different protocols. Bone and gingival grafts, flapless surgery, and
immediate implant-supported provisional restoration increase the risk
of GR around the implant. The use of these techniques for immediate
implant placement allows the reduction or even prevention of
recessions (adapted from Chen and Buser5)
 Gingival biotype and the type of bone defect are predictive factors of
possible alterations that may occur after extraction and will be
addressed in this chapter. A protocol to increase esthetic predictability
in the treatment of intact and compromised sockets will be presented.

OBJECTIVES
At the end of the chapter the reader should be able to:
Understand the treatment of intact and compromised sockets.
Learn the methods to avoid esthetic complications after surgery.
Comprehend the proposed surgical protocol.

2. SCIENTIFIC BACKGROUND

2.1. GINGIVAL BIOTYPE

Gingival biotype is characterized by the quantity and quality of

periodontal and peri-implant tissue, which is initially described as thin
or thick6. The ideal method for classifying the gingival biotype has not
yet been developed. It is possible to use the visual and translucency
methods, direct gingival perforation with ultrasonic devices, or cone
beam computed tomography (CBCT) with lip retractor7.
A gingival thickness of 1 mm or less around the teeth is classified as
a thin biotype. A thick biotype presents a thickness of 1 mm or more.
Around implants, soft tissue thickness greater than 2 mm is classified
as thick; it is considered thin if it is equal to or less than 2 mm8,9.
Assessing the thickness of tissue around the teeth is complex. In
implants, thickness can be measured with a caliper after removal of a
screwed in crown.
Measurement of soft tissue thickness can be performed 2 mm
apically to the GM through tissue perforation. This is an invasive
procedure that requires anesthesia. The compression caused by the
probe or needle may affect measurement accuracy10. The use of an
ultrasonic device is a noninvasive method; however, its use to verify
soft tissue thicknessis limited because its accuracy in detecting the
low thickness of gingival tissue is low7. The assessment of tissue
thickness by CBCT with soft tissue retraction is a noninvasive and
accurate method but it is costly and emits ionizing radiation. It is
indicated when CBCT is already required for treatment planning when
placing an implant or evaluating a graft.
The simplest but no longer accurate clinical diagnosis of biotype is
done by inserting a probe into the gingival sulcus. In a thick biotype,
the instrumentwill not show through the soft tissue; on the other hand,
in a thin biotype it will11. The visual method is not reliable to determine
biotype because it tends to overestimate tissue thickness8,12.
The occurrence and magnitude of changes in periodontal/peri-
implant tissue will depend mainly on the patient’s gingival biotype
(Figs 02A–D and 03A–F). Clinically, tissue trauma and a defective
buccal bone wall may lead to esthetic complications, such as
recession of the soft tissue margin or a volume defect on the ridge13.

02. A–D Clinical aspects of thin biotypes, with longer triangular or

rectangular (A, B) crowns. Thick biotype with shorter, usually
quadrangularped clinical crowns (C, D).

03. A–F Tissue characteristics of thick (A–C) and thin (D–F) biotype.
2.1.1. THIN GINGIVAL BIOTYPE
Patients with a thin biotype have an extremely delicate gingival tissue,
with a scalloped architecture of soft tissue and bone. Gingival tissue
and bone are thin. Bone fenestration or dehiscence may be present14
(Figs 04A–F). The tissue has lower resistance to injuries and is often
associated with GR15. In patients with a thin biotype, greater care is
required when planning and performing surgical procedures to avoid
esthetic and biologic complications16-18.
04. A–F Characteristics of the buccal bone wall: intact (A, D),
fenestration (B, E), and dehiscence (C, F).

GM recession after IIP is more frequent in patients with a thin

periodontal biotype compared to those with a thick biotype19. Although
the difference is a few millimeters, be aware that discrepancies in the
position of the GM in the anterior region cause esthetic complaints.
Surgery usually does not recover all lost tissue20. Another factor that
should be taken into consideration is that these values represent the
change that occurs in the early years after implant placement. Gingival
tissue recession tends to increase over time, especially in individuals
with a thin biotype15,21 (Figs 05A–H and 06A–F).
05. A–H Immediate implant and provisional rehabilitation (without
bone or gingival graft) performed on tooth 22 after 18 years (A–C).
After osseointegration, a zirconia abutment and a ceramic crown were
placed (D, E). Four years after treatment, the patient returned and
complained of peri-implant margin recession with exposure of the
zirconia abutment and presence of thin tissue (F–H).
06. A–F A connective tissue graft was used to treat these changes.
Surgical procedure: Dr Elcio Marcantonio Jr; restorative procedure: Dr
Rogério Margonar.

To avoid extensive changes in soft tissue architecture when

planning for IIP in patients who have thin, modifying tissue thickness,
a soft tissue graft is recommended. Studies show that modification on
the biotype around implants with subepithelial connective tissue grafts
demonstrated greater long-term stability in GM levels and better
esthetic results19,22. Additionally, it is possible to create a more
favorable ridge contour, using the soft tissue graft to compensate for
the buccal bone loss that occurs after extraction even after performing
guided bone regeneration23 (Figs 07A–J to 09A–I).
07. A–J Connective tissue graft to be placed on the buccal region of
the socket (A–C). The area was prepared (D–F) to receive the graft
that was stabilized by sutures (G–J).
08. Sequence for connective tissue graft suturing.
09. A–I Tooth 21 with vertical fracture and absence of buccal bone
wall (A, B). The tooth was carefully extracted and the socket was
prepared to receive a tapered implant stabilized in the lingual bone
wall. A temporary and a slightly exposed subepithelial connective
tissue graft was done (C–G). Note the gain in height requiring
conditioning of the tissue to the level of the gingival margin with the
homologous tooth (H, I). Surgical procedure: Dr Elcio Marcantonio Jr;
restorative procedure: Dr Rogério Margonar.
2.1.2. THICK GINGIVAL BIOTYPE
Patients with a thick gingival biotype present a flat soft tissue and
bone architecture. The buccal bone wall and gingiva are thick,
presenting greater resistance to mechanical, pathological, and
surgical injuries14. Faced with aggressive inflammation, the tissue
tends to form a periodontal pocket rather than a GR. Surgical
procedures performed in thick biotypes are favored due to greater
vascularization, easier closure of the flap by first intention, and
protection of the area7.
A thick gingival biotype around an implant ensures greater stability
of long-term results. In IIP situations, it is important that there is
abundant tissue in the region, both in height and thickness, because
this may prevent future surgical procedures. Excess tissue in height
can be eliminated by simple tissue conditioning with provisional
restoration or by gingivoplasty.
Studies evaluating IIP in intact sockets where the buccal gap was
filled with bone graft material and had a thick gingival biotype showed
stability of the GM in the first years of evaluation. Remodeling the
buccal bone wall is a concern because of the volumetric changes of
the ridge. In such situations, it is possible to perform a connective
tissue graft to increase the volume of this region24. In teeth that have a
buccal bone defect and a thick biotype, a connective tissue graft at the
moment of implant placement is recommended. The defect will affect
bone remodeling and a greater GR; a decrease in buccal volume can
be expected.

2.2. CLINICAL ASPECT OF THE SOCKET

The socket condition will determine the recommended treatment as

well as possible tissue changes that may occur. The socket itself can
be considered a defect surrounded by bone walls. Its self-limiting
healing causes 3D tissue loss. The use of biomaterials may reduce
this volumetric contraction but the presence of bone defects may lead
to a worse prognosis regarding preservation of tissue architecture.
 Different surgical approaches can be traced to obtain an adequate
contour of the bone and gingival tissue. The type of bone defect
present should be evaluated for immediate implant placement and to
avoid complications during the healing period. A loss of one of the
alveolar walls may change the pattern of bone formation after
extraction, reducing its 3D volume and increasing the risk of GR and
loss of papillae25. The absence of buccal bone does not prevent
immediate implant placement. It is possible to achieve primary stability
and osseointegration because it will be anchored in the lingual wall.
However, it is important to evaluate the bone defect after extraction
and perform the necessary interventions to ensure appropriate
esthetic and functional results for the patient.

2.2.1. INTACT SOCKET

An intact socket presents the most favorable situation for immediate
implant. If there is sufficient remaining bone structure to place the
implant in the ideal 3D position, the IIP technique can provide
excellent results. Currently, minimally invasive procedures are
frequently used. A flapless IIP favors healing, treatment time, the
number of surgeries, and morbidity without compromising the final
result11,26–28.
A thick biotype favors the long-term maintenance of the ideal
position of the GM. A thin biotype should be grafted to modify it into a
thick biotype. Buccal bone thickness in the anterior region of the
maxilla is usually a concern because the buccal bone wall tends to be
thin. Horizontal reduction of the alveolar ridge is expected after
extraction, which may require a gingival graft24.
Volume loss occurs mainly in the coronal third of the buccal bone
crest after IIP in intact sockets29. In addition to the expected post-
extraction bone remodeling, a saucer effect also occurs around the
implant. An immediately placed implant does not prevent alveolar
remodeling30, even if a bone graft and membrane are used31.
The GM tends not to migrate apically in the presence of a thick
biotype because even when losing part of its volume, the height of the
buccal bone crest is maintained. A study by Kois32 demonstrated that
the soft tissue margin tends to be stable when the distance from the
buccal bone crest to the GM is less than or equal to 3 mm. Buccal
bone reconstruction is possible as long as the implant is properly
positioned in the socket, taking into account the bone loss that occurs
after extraction. A sufficient gap between the implant and the buccal
bone wall needs to be respected and filled with a slow resorption
biomaterial5. Presence of the buccal bone wall at the time of implant
placement favors graft placement and incorporation.
Initial studies on IIP demonstrated no concern about implant
diameter and placement, features of the provisional implant, use of
grafts, or delicate flapless surgery5. Long-term follow-up showed GR
and its recommendations were limited to patients without risk factors
(nonsmokers, with a buccal bone thickness greater than 1 mm and
thick biotype) only in the premolar region33.
Due to limited scientific evidence, the consensus
33
recommendations were not to perform immediate implants in
esthetic areas due to the high risk of GM recession. The
recommendation was to perform alveolar ridge preservation and
implant placement after 4–8 weeks34,35. However, with the evolution
and application of the technique, studies with appropriate surgical
techniques22,36,37 have demonstrated that in intact sockets it is possible
to maintain the GM. The technique consists of IIP combined with bone
graft to fill the gap and modification of soft tissue biotype (Figs 10A–E
to 12A–G).
10. A–E In patients with intact sockets and a thin biotype, there is a
need to modify the gingival biotype to thick when performing
immediate implants. A careful detachment is performed on the cervical
third of the socket to place the gingival graft into the buccal surface.

PLACEMENT OF AN IMMEDIATE MORSE TAPER IMPLANT COMBINED WITH

CONNECTIVE TISSUE GRAFT AND CERABONE
11. A–J Patient with provisionals and impaired tooth 11 (A–C). The
tooth had a long post and deep subgingival caries in the interproximal
surface; after post removal, the presence of a buccal and lingual
fracture was detected. Minimally traumatic extraction was performed.
The socket was intact (D, E). The region was cleaned and prepared to
receive a 3.5 × 13 mm tapered implant with Morse taper connection
(F, G). The gap was grafted with inorganic bovine bone and the buccal
surface received a connective tissue graft (H–J).
12. A–G Appearance immediately after gingival graft suture and
provisional installation (A–C). Postoperative situation at 14 (D) and
180 days (E–G). Surgical procedure: Dr Fausto Frizzera; restorative
procedure: Dr Marco Masioli.

Recent clinical and preclinical studies38,39 have suggested that the

socket shield technique, which intentionally maintains the root
fragment in the buccal portion of the socket, combined with immediate
implant placement may favor volume maintenance in the esthetic
region. These findings are based on the fact that bone tissue is
maintained by the periodontium and its vascularization, avoiding the
bone and tissue collapse normally observed after tooth removal. This
procedure requires high technical dexterity; maintaining a buccal root
fragment in position is not always easy.
The technique advocates root removal with the aid of rotatory
instruments and periotomes, as well as removal of any soft tissue
present in the periapical portion or soft tissue lesions adjacent to the
fragment to be maintained (Figs 13A–K to 15A, B). It is important that
the implant is positioned at the same level as the dental fragment; if
necessary, a bone graft should be used to fill the gap. It is also
necessary to avoid this technique in regions with higher occlusal
demand.
13. A–K Tooth 21 with subgingival fracture associated with a short
root. The socket shield technique, with immediate placement of a 4.3
× 13 mm implant and immediate placement of the provisional,
maintaining the buccal root fragment (A–D). Two months after the
procedure it was possible to verify a satisfactory contour of the buccal
tissues (E–H), which was maintained after 3 years of follow-up (I–K).
Surgical procedure: Dr Jamil Shibli; restorative procedure: Dr Susana
D’Avila.
14. A, B In the socket shield technique, the compromised tooth is
extracted and the root fragment in contact with the vestibular bone is
maintained.
15. A, B The implant and provisional are placed and the fragment
assists in the nutrition and maintenance of the buccal bone wall.

2.2.2. COMPROMISED SOCKET

The literature does not agree on the best treatment option for
defective sockets. Most studies assume that IIP after extraction should
be restricted to intact sockets27. However, from a clinical perspective,
most teeth that should be extracted in the anterior region have a thin
buccal wall40.
The involvement of one of the socket walls makes it difficult to
maintain the tissue architecture after extraction. It is essential to
identify the type of defect present before performing any surgical
procedure and alert the patient to possible tissue changes that may
occur. Implant placement in regions with a bone defect should only be
performed if the defect is treatable; otherwise a delayed approach is
recommended. The morphology of the bone defect in the free
surfaces (buccolingual) is classified according to its 3D characteristics
(Figs 16A–F and 17A–D).
16. A–F Types of socket defects: shallow and deep V (A, B), shallow
and deep U (C, D), and shallow and deep wide U (E, F).
17. A–D Buccal bone neoformation after guided bone regeneration
depends on the defect and bone envelope characteristics. This can be
difficult if the bone envelope is narrow (A, B) or facilitated if it is wide
(C, D). The buccal portion of the implant should be positioned 3–4 mm
from the inner portion of the buccogingival tissues.

According to the vertical extent of the defect, the defect may be

classified as shallow, when less than half of the wall has been
damaged cervically/apically, or deep if more than half of the alveolar
wall is compromised. Guided bone regeneration of shallow defects is
more predictable41–43 but horizontal and vertical enlargement of bone
and gingival tissue is possible in both situations.
Defects in width prompt more postoperative tissue changes than
defects in height. The mesiodistal morphology of the defect can be
classified19 as: V-shaped, where there is a narrow defect with a
pointed apex and closed angle; U-shaped, wider defect with a
rounded apex and open angle; wide U-shaped, defect with greater
amplitude and width and rounder angle with extension of loss to the
adjacent tooth. In the latter, immediate implant placement should be
avoided. For V-shaped or U-shaped defects, an immediate implant
may be placed after extraction provided that guided bone regeneration
is performed and the implant is positioned within the bone envelope44.
The horizontal extent of the defect in the buccolingual direction is a
predictor of new bone formation on the buccal surface of the implant.
The size of the bone envelope should be measured by creating a line
that joins the proximal bone ridges; from this line, the distance to the
end of the palatine bone is measured. The bony envelope may be
classified as narrow if it is less than 7.5 mm or wide if greater than 7.5
mm45. The higher this value, the greater the possibility of placing the
implant within the bone envelope to maintain a distance of 3–4 mm
from the implant platform and the inside of the buccogingival tissue.
To aid buccal bone formation, a smaller diameter implant can be
selected and installed 4–5 mm from the buccal GM, which allows a
larger gap to be filled with biomaterials.
New studies have demonstrated the possibility of reconstructing the
buccal bone after immediate implant placement in defective sockets
and limiting soft tissue apical migration40,46–49. After placing 18 Nobel
Perfect Groovy implants, sockets with complete buccal bone loss were
grafted with autogenous bone particles removed from the mandibular
ramus region. Complete reconstruction of the buccal bone was
demonstrated even without using membranes47. In a later study40, IIP
was combined with autogenous bone grafting but performed in intact
sockets or with buccal bone defects; it was possible to obtain
satisfactory esthetic results and a bone wall in the buccal region of 1
mm when measured 1 mm below the implant platform. In these two
studies, a buccal volume discrepancy was also reported in the region
receiving the implant and bone graft; these defects presented as a
depression in the ridge contour after extraction.
Sockets with buccal bone defects were treated with a modified IIP
approach by using a block-shaped bone graft removed from the
tuberosity and adapted in the socket (Figs 18A–J to 20A–F). Rosa et
al48 demonstrated how to reconstruct the buccal bone without using
membranes and maintaining the position of the GM. The proposed
technique was called immediate dentoalveolar restoration, showing
stability of long-term results after 58 months in 18 patients.
18. A–J Patient with fractured tooth 21; minimal traumatic extraction
was performed and an implant was placed with torque allowing the
placement of an immediate provisional restoration.
19. A–N To reconstruct the defective buccal wall, a block bone graft
(A–D) was collected. The graft was placed in the buccal region and
the spaces filled with autogenous bone and inorganic bovine bone (E–
H). The provisional was made on the same day and installed over the
implant without occlusal contacts (I). Postoperativeimages at 7 and 30
days (J, K). Radiographic (L) and initial clinical appearance and after
180 days (M–N). Surgical procedure: Dr Elcio Marcantonio Jr;
restorative procedure: Dr Rogério Margonar.
20. A–F In the immediate dentoalveolar restoration technique, the
compromised tooth is extracted and the implant placed in the ideal
position. Then bone particles removed from the tuberosity are inserted
into the socket and the remaining space. A provisional is placed
without occlusal contacts; after a period of osseointegration and graft
incorporation, final case resolutionis reached.

Sarnachiaro et al49 performed a study to verify the increase in bone

thickness after treating maxillary sockets with buccal bone defects
with an immediate implant combined with a resorbable membrane,
particulate autogenous bone graft, and a custom healing abutment.
Ten cases were treated in this study; five implants were placed in the
premolar, three in the canine, and two in the incisor region. A CBCT
immediately after surgery and after graft incorporation, between 6 and
9 months, demonstrated the reconstruction of the buccal bone wall
with an average thickness of 3.7 mm and 3 mm, respectively, in its
coronal portion.
Kan et al25 presented a similar proportion of cases where there was
recession of the GM greater than 1.5 mm regardless of whether
surgery was performed with or without a flap; the recession was
associated with the type and width of the bone defect. The worst
results were found in patients with wide U-type defects. In addition,
flap elevation in regions with a bone defect may further impair alveolar
involvement. An improperly designed and sutured flap may increase
the risk of gingival and papillary recession in the implant region and
adjacent teeth.
These studies showed favorable results in relation to bone tissue
but they do not clarify why they did not use gingival grafts and what
might occur in peri-implant soft tissue in long-term follow-up (Figs
21A–F to 25A–L). Research performed on intact sockets has shown
that minimizing or avoiding recession of the peri-implant margin when
a connective tissue graft is used together with with IIP24,50–52 is
possible; it is also possible to move the tissue margin coronally,
leaving soft tissue slightly exposed, and use a provisional with a
concave subgingival profile36,53. The space created by the
subcontouring of the provisional prosthesis allows the thickness of the
buccal soft tissue to be increased, making it less prone to buccal
recession, as demonstrated after short-term and long-term follow-
up37,46,52,54.
21. A–F Initial clinical presentation of the patient showing a
periodontal pocket on the distal surface of tooth 21 due to
cementum/dentin resorption. This was in addition to a periapical fistula
and gingival harmony with a maximum Pink Esthetic Score score of
14.
22. A–P Computed tomography images showing buccal bone
fenestration, apical lesion, and internal resorption (A–F). After years of
monitoring by an endodontist and no definitive resolution of the apical
problem and presence of a periodontal pocket, the patient decided to
replace her tooth with an implant. The treatment plan was explained to
the patient, together with the rehabilitation options. Tooth 21 was
carefully extracted with forceps to maintain the integrity of the crown
(G–J). Alveolar dehiscence and the presence of a gingival thickness
of 1.3 mmwere clinically confirmed. The socket was instrumented on
its palatal wall and a 3.5 × 13 mm implant was installed with a torque
of 50 N/cm2 (K–M). The Ostell device confirmed the high primary
stability for the immediate installation of a provisional (N, O).
According to the ridge anatomy, a cemented prosthesis was planned.
The extracted tooth was reshaped with resin and used as the
provisional over the prepared prosthetic component (P).
23. A–O Inspection of the socket confirmed distal bone loss and the
implant’s ideal positioning (A–D). A collagen membrane (Geistlich Bio-
Gide) (E–G) was placed under the alveolar defect, and a bone graft
(Geistlich Bio-Oss Collagen) (H, I) filled the socket to the level of the
gingival margin. The prosthetic component was installed with a torque
of 20 N/cm2. The provisional crown was cemented and fine occlusal
adjustments (J–L) were performed. Postoperative aspect at 7 (M, N)
and 30 (O) days; healing was extremely favorable.
24. A–P At the time of manufacturing the definitive prosthesis, a slight
color change of the tissue was noticed due to the metallic abutment. It
was suggested to the patient to use connective tissue grafting to
increase the tissue volume or to use a zirconia abutment (A–D). The
patient chose the less-invasive option, and a lithium disilicate veneer
(tooth 11) and crown (tooth 21) were fabricated and cemented; note
the improvement in tissue staining (E–P).
25. A–L Tomographic examinations at 6 and 12 months showed total
reconstruction of the buccal bone (A–C). At the 3-year (D–I) and 4.5
year (J–L) follow-up, tissue staining was maintained. Still, a small
discrepancy between the gingival margin of the two maxillary central
incisors and a loss of volume in the buccal region of the implantwere
observed, which reduced the Pink Esthetic Score score to 12.
Although the patient had no complaints regarding this alteration, it was
attributed to the nonuse of a gingival graft to compensate for the
ridge’s physiologic remodeling. Surgical procedure: Dr Fausto
Frizzera; restorative treatment: Dr Laerte Mattos.

In a randomized controlled trial45, the IIP technique was performed

on maxillary incisors with buccal bone defect to evaluate peri-implant
changes 1 year after surgery. After extraction, a narrow implant was
placed. Patients were randomly divided into three groups: control, no
soft tissue graft; MUCO, 3D collagen matrix (Geistlich Mucograft); and
CONJ, subepithelial connective tissue graft removed from the palate.
All sockets were reconstructed with bone graft (Geistlich Bio-Oss
Collagen) and resorbable membrane (Geistlich Bio-Gide); a
provisional with undercontoured cervical and absence of occlusal
contacts was installed over the implants. Migration of the GM was
0.72 mm (± 0.57), 0.42 mm (± 0.60), and –0.04 mm (± 0.3),
respectively in the control, MUCO, and CONJ groups. Results showed
that recession was significantly lower in the CONJ group compared to
the control group. In addition to limiting the migration of the GM, the
connective tissue graft promoted better ridge contour and greater soft
tissue thickness in the buccal region of the implant (Figs 26–28).
26. A–C This patient had subgingival fracture in tooth 24 at the middle
third of the root, with fistula and buccal bone loss.
27. A–O The tooth was extracted with the aid of a periotome and the
socket was cleaned and prepared to receive a 3.5 × 13 mm tapered
implant (Flash, Prosthetic Systems Connection).
28. A–T The implant was placed with a primary stability of
approximately 50 N/cm2; a titanium UCLA abutment was manually
installed and marked 2 mm apically at the occlusal level of tooth 25
(A). The prosthetic component was removed, worn, and reinstalled to
verify its interocclusal relationship; then a denture tooth was relined
with flow resin (B–D). The socket was then filled with a collagen
membrane (Geistlich Bio-Gide), bone graft (Geistlich Bio-Oss
Collagen) and a 3D collagen matrix (Geistlich Mucograft) (D–H). The
provisional was adjusted, polished, and then screwed with a torque of
20 N/cm2 (I, J). Six months after surgery, the gingival margin was in
harmony with the adjacent teeth but a slight loss of volume was noted.
The prosthetic rehabilitation was completed with a screwed ceramic
crown (K–P). At the 4-year follow-up (Q–T). Surgical procedure: Dr
Fausto Frizzera; restorative procedure: Dr Luiz Guilherme Freitas de
Paula.

The porcine collagen matrix is capable of maintaining the height of

the GM. Although the best results are obtained by using a connective
tissue graft (Figs 29A–G), new biomaterials have been researched
and developed to effectively replace the subepithelial connective
tissue graft, showing promising results for increased tissue volume55.
29. A–G After performing surgery to treat compromised sockets, it
was possible to obtain satisfactory and stable clinical and radiographic
results after 5 years (initial (A, D), 6 months (B, E), and 12 months (C,
F). Follow-up of the clinical case was previously described in Chapter
1. Surgical procedure: Dr Fausto Frizzera; restorative procedure: Dr
Mateus Tonetto.

3. CLINICAL APPLICATION

Although an ideal treatment protocol for sockets is sought, it is

necessary to assess the risks and benefits of each type of treatment
and respect the biologi changes that occur after extraction. The
immediate approach presents considerable benefits if the proper
protocol is followed (see Figs 30–34 and Tables 02 and 03). Even in
situations where there is compromised buccal bone, it is possible to
reconstruct defects in V and U as long as the implant is installed in the
ideal 3D position. It is still possible to limit short- and long-term peri-
implant and papillary margin height loss by using a connective tissue
graft.
30. A–D Protocol for immediate implant placement in compromised
sockets. The implant should be positioned toward the lingual, at least
3 mm from the inner portion of the buccal gingiva (A). A slow
resorption biomaterial is placed in the socket to completely fill the gap;
it is still possible to slightly extend the buccal gingiva to increase its
volume (B). A 2–3 mm thick connective tissue graft should be sutured
at or beyond the gingival margin (only 20% of the graft can be
exposed), its height should be greater than or equal to 5 mm, and its
width should correspond to the distance between the mesial and distal
papilla (C). A provisional with cervical undercontour should be placed
without compressing the graft (D).

Table 02 Decision-making for the treatment of intact sockets

Table 03 Decision-making for treating a compromised socket

The treatment protocol used to prevent complications in the

treatment of these clinical situations consists of:
 Clinical and tomographic evaluation
Minimally traumatic surgery and flapless extraction
Placement of a narrow implant in the ideal 3D position.
Temporary confection with cervical undercontour and without
occlusal contacts
Placement of a connective tissue graft on the buccal surface
Guided bone regeneration with inorganic bovine bone with 10%
porcine collagen

TREATMENT PROTOCOL FOR COMPROMISED

SOCKETS
31. A–O Patient had fractured tooth 11 with suppuration and buccal
bone loss (A–I). A minimally traumatic extraction was done and the
socket was inspected, cleaned, and irrigated (J–O).
32. A–N A 4.3 × 13 mm tapered implant was installed in the ideal 3D
position and a prosthetic component was prepared to receive a
provisional crown (A–F). The buccal aspect was then prepared with
an elevator (G–J). Then, the bone and gingival grafts (removed from
the maxillary third molar region) were placed (K–N).
33. A–P The gingival graft was sutured in the buccal region and the
provisional graft was installed without occlusal contacts and with a
concave subgingival profile to allow coronal migration of the soft tissue
margin (A–I). Postoperative images at 7 (J), 90 (K), and 180 days (L–
P).
34. A–I 3D reconstruction of the grafted area (A). The teeth were
prepared and an impression was taken to make the pure porcelain
prosthetic restoration (B–E). One-year follow-up after surgery (F–I).
Surgical procedure: Dr Fausto Frizzera; restorative procedure: Dr
Bianca Vimercati; laboratory technician: Igor Hand.

REFERENCES

1. Albrektsson T, Dahlin C, Jemt T, Sennerby L, Turri A,

Wennerberg A. Is marginal bone loss around oral implants the
result of a provoked foreign body reaction? Clin Implant Dent
 Relat Res 2014;16:155–165.
2. Hammerle CH, Chen ST, Wilson TG, Jr. Consensus statements
and recommended clinical procedures regarding the placement of
implants in extraction sockets. Int J Oral Maxillofac Implants
2004;19(Suppl):26–28.
3. Evans CD, Chen ST. Esthetic outcomes of immediate implant
placements. Clin Oral Implants Res 2008;19:73–80.
4. Martin WC, Pollini A, Morton D. The influence of restorative
procedures on esthetic outcomes in implant dentistry: a
systematic review. Int J Oral Maxillofac Implants
2014;29(Suppl):142–154.
5. Chen ST, Buser D. Esthetic outcomes following immediate and
early implant placement in the anterior maxilla – a systematic
review. Int J Oral Maxillofac Implants 2014;29(Suppl):186–215.
6. Seibert J, Lindhe J. Esthetics and periodontal therapy. In: Lindhe
J (ed). Textbook of Clinical Periodontology, ed 2. Copenhagen,
Denmark: Munksgaard, 1989: 477–514.
7. Fu JH, Lee A, Wang HL. Influence of tissue biotype on implant
esthetics. Int J Oral Maxillofac Implants 2011;26:499–508.
8. Kan JY, Morimoto T, Rungcharassaeng K, Roe P, Smith DH.
Gingival bio-type assessment in the esthetic zone: visual versus
direct measurement. Int J Periodontics Restorative Dent
2010;30:237–243.
9. Saadoun AP, LeGall M, Touati B. Selection and ideal
tridimensional implant position for soft tissue aesthetics. Pract
Periodontics Aesthet Dent 1999;11:1063–1072; quiz 74.
10. Greenberg J, Laster L, Listgarten MA. Transgingival probing as a
potential estimator of alveolar bone level. J Periodontol
1976;47:514–517.
11. De Rouck T, Eghbali R, Collys K, De Bruyn H, Cosyn J. The
gingival biotype revisited: transparency of the periodontal probe
through the gingival margin as a method to discriminate thin from
thick gingiva. J Clin Periodontol 2009;36:428–433.
12. Eghbali A, De Rouck T, De Bruyn H, Cosyn J. The gingival
 biotype assessed by experienced and inexperienced clinicians. J
Clin Periodontol 2009;36:958–963.
13. Garber DA, Salama MA, Salama H. Immediate total tooth
replacement. Compend Contin Educ Dent 2001;22:210–216, 218.
14. Kao RT, Pasquinelli K. Thick vs. thin gingival tissue: a key
determinant in tissue response to disease and restorative
treatment. J Calif Dent Assoc 2002;30:521–526.
15. Olsson M, Lindhe J. Periodontal characteristics in individuals with
varying form of the upper central incisors. J Clin Periodontol
1991;18:78–82.
16. Baldi C, Pini-Prato G, Pagliaro U, et al. Coronally advanced flap
procedure for root coverage. Is flap thickness a relevant predictor
to achieve root coverage? A 19-case series. J Periodontol
1999;70:1077–1084.
17. Pontoriero R, Carnevale G. Surgical crown lengthening: a 12-
month clinical wound healing study. J Periodontol 2001;72:841–
848.
18. Romeo E, Lops D, Rossi A, Storelli S, Rozza R, Chiapasco M.
Surgical and prosthetic management of interproximal region with
single-implant restorations: 1-year prospective study. J
Periodontol 2008;79:1048–1055.
19. Kan JY, Rungcharassaeng K, Morimoto T, Lozada J. Facial
gingival tissue stability after connective tissue graft with single
immediate tooth replacement in the esthetic zone: consecutive
case report. J Oral Maxillofac Surg 2009;67(11 Suppl):40–48.
20. Burkhardt R, Joss A, Lang NP. Soft tissue dehiscence coverage
around endosseous implants: a prospective cohort study. Clin
Oral Implants Res 2008;19:451–457.
21. Albandar JM, Kingman A. Gingival recession, gingival bleeding,
and dental calculus in adults 30 years of age and older in the
United States, 1988–1994. J Periodontol 1999;70:30–43.
22. Tsuda H, Rungcharassaeng K, Kan JY, Roe P, Lozada JL,
Zimmerman G. Peri-implant tissue response following connective
tissue and bone grafting in conjunction with immediate single-
 tooth replacement in the esthetic zone: a case series. Int J Oral
Maxillofac Implants 2011;26:427–436.
23. Schneider D, Grunder U, Ender A, Hammerle CH, Jung RE.
Volume gain and stability of peri-implant tissue following bone
and soft tissue augmentation: 1-year results from a prospective
cohort study. Clin Oral Implants Res 2011;22:28–37.
24. Cosyn J, De Bruyn H, Cleymaet R. Soft tissue preservation and
pink aesthetics around single immediate implant restorations: a 1-
year prospective study. Clin Implant Dent Relat Res 2013;15:47–
57.
25. Kan JY, Rungcharassaeng K, Sclar A, Lozada JL. Effects of the
facial osseous defect morphology on gingival dynamics after
immediate tooth replacement and guided bone regeneration: 1-
year results. J Oral Maxillofac Surg 2007;65(7 Suppl 1):13–19.
26. Block MS, Mercante DE, Lirette D, Mohamed W, Ryser M,
Castellon P. Prospective evaluation of immediate and delayed
provisional single tooth restorations. J Oral Maxillofac Surg
2009;67(11 Suppl):89–107.
27. Lin GH, Chan HL, Wang HL. Effects of currently available surgical
and restorative interventions on reducing midfacial mucosal
recession of immediately placed single-tooth implants: a
systematic review. J Periodontol 2014;85:92–102.
28. Raes F, Cosyn J, Crommelinck E, Coessens P, De Bruyn H.
Immediate and conventional single implant treatment in the
anterior maxilla: 1-year results of a case series on hard and soft
tissue response and aesthetics. J Clin Periodontol 2011;38:385–
394.
29. Roe P, Kan JY, Rungcharassaeng K, Caruso JM, Zimmerman G,
Mesquida J. Horizontal and vertical dimensional changes of peri-
implant facial bone following immediate placement and
provisionalization of maxillary anterior single implants: a 1-year
cone beam computed tomography study. Int J Oral Maxillofac
Implants 2012;27:393–400.
30. Araujo MG, Sukekava F, Wennstrom JL, Lindhe J. Ridge
 alterations following implant placement in fresh extraction
sockets: an experimental study in the dog. J Clin Periodontol
2005;32:645–652.
31. Favero G, Lang NP, Romanelli P, Pantani F, Caneva M, Botticelli
D. A digital evaluation of alveolar ridge preservation at implants
placed immediately into extraction sockets: an experimental study
in the dog. Clin Oral Implants Res 2015;26:102–108.
32. Kois JC. Predictable single-tooth peri-implant esthetics: five
diagnostic keys. Compend Contin Educ Dent 2004;25:895–896,
8, 900 passim; quiz 6–7.
33. Hammerle CH, Araujo MG, Simion M. Evidence-based knowledge
on the biology and treatment of extraction sockets. Clin Oral
Implants Res 2012;23Suppl 5:80–82.
34. Belser UC, Grutter L, Vailati F, Bornstein MM, Weber HP, Buser
D. Outcome evaluation of early placed maxillary anterior single-
tooth implants using objective esthetic criteria: a cross-sectional,
retrospective study in 45 patients with a 2- to 4-year follow-up
using pink and white esthetic scores. J Periodontol 2009;80:140–
151.
35. Buser D, Wittneben J, Bornstein MM, Grutter L, Chappuis V,
Belser UC. Stability of contour augmentation and esthetic
outcomes of implant-supported single crowns in the esthetic
zone: 3-year results of a prospective study with early implant
placement postextraction. J Periodontol 2011;82:342–349.
36. Chung S, Rungcharassaeng K, Kan JY, Roe P, Lozada JL.
Immediate single tooth replacement with subepithelial connective
tissue graft using platform switching implants: a case series. J
Oral Implantol 2011;37:559–569.
37. Kan JY, Rungcharassaeng K, Lozada JL, Zimmerman G. Facial
gingival tissue stability following immediate placement and
provisionalization of maxillary anterior single implants: a 2- to 8-
year follow-up. Int J Oral Maxillofac Implants 2011;26:179–187.
38. Hürzeler MB, Zuhr O, Schupbach P, Rebele SF, Emmanouilidis
N, Fickl S. The socket-shield technique: a proof-of-principle
 report. J Clin Periodontol 2010;37:855–862.
39. Bäumer D, Zuhr O, Rebele S, Hürzeler M. Socket Shield
Technique for immediate implant placement – clinical,
radiographic and volumetric data after 5 years. Clin Oral Implants
Res 2017;28:1450–1458.
40. Cosyn J, Eghbali A, De Bruyn H, Collys K, Cleymaet R, De Rouck
T. Immediate single-tooth implants in the anterior maxilla: 3-year
results of a case series on hard and soft tissue response and
aesthetics. J Clin Periodontol 2011;38:746–753.
41. Dahlin C, Andersson L, Linde A. Bone augmentation at
fenestrated implants by an osteopromotive membrane technique.
A controlled clinical study. Clin Oral Implants Res 1991;2:159–
165.
42. Dahlin C, Lekholm U, Becker W, Becker B, Higuchi K, Callens A,
van Steenberghe D. Treatment of fenestration and dehiscence
bone defects around oral implants using the guided tissue
regeneration technique: a prospective multicenter study. Int J Oral
Maxillofac Implants 1995;10:312–318.
43. Jovanovic SA, Spiekermann H, Richter EJ. Bone regeneration
around titanium dental implants in dehisced defect sites: a clinical
study. Int J Oral Maxillofac Implants 1992;7:233–245.
44. Gelb DA. Immediate implant surgery: three-year retrospective
evaluation of 50 consecutive cases. Int J Oral Maxillofac Implants
1993;8:388–399.
45. Frizzera F, Moreno R, Munoz CO, Cabral G, Shibli J. Impact of
soft tissue grafts to reduce peri-implant alterations after
immediate implant placement and provisionalization in
compromised sockets. Int J Periodontics Restorative Dent
2019;39:381–389.
46. Frizzera F. Alterações teciduais após instalação imediata de
implante, provisório e enxertos em alvéolos comprometidos.
Araraquara. Tese [Doutorado em Odontologia] – Faculdade de
Odontologia de Araraquara, 2015.
47. Noelken R, Kunkel M, Wagner W. Immediate implant placement
 and provisionalization after long-axis root fracture and complete
loss of the facial bony lamella. Int J Periodontics Restorative Dent
2011;31:175–183.
48. Rosa JC, Rosa AC, Francischone CE, Sotto-Maior BS. Esthetic
outcomes and tissue stability of implant placement in
compromised sockets following immediate dentoalveolar
restoration: results of a prospective case series at 58 months
follow-up. Int J Periodontics Restorative Dent 2014; 34:199–208.
49. Sarnachiaro GO, Chu SJ, Sarnachiaro E, Gotta SL, Tarnow DP.
Immediate implant placement into extraction sockets with labial
plate dehiscence defects: a clinical case series. Clin Implant Dent
Relat Res 2016;18:821–829.
50. Hsu YT, Shieh CH, Wang HL. Using soft tissue graft to prevent
mid-facial mucosal recession following immediate implant
placement. J Int Acad Periodontol 2012;14:76–82.
51. Tupac RG. When is an implant ready for a tooth? J Calif Dent
Assoc 2003;31:911–915.
52. Yoshino S, Kan JY, Rungcharassaeng K, Roe P, Lozada JL.
Effects of connective tissue grafting on the facial gingival level
following single immediate implant placement and
provisionalization in the esthetic zone: a 1-year randomized
controlled prospective study. Int J Oral Maxillofac Implants
2014;29:432–440.
53. Lee YM, Kim DY, Kim JY, et al. Peri-implant soft tissue level
secondary to a connective tissue graft in conjunction with
immediate implant placement: a 2-year follow-up report of 11
consecutive cases. Int J Periodontics Restorative Dent
2012;32:213–222.
54. Cabello G, Rioboo M, Fabrega JG. Immediate placement and
restoration of implants in the aesthetic zone with a trimodal
approach: soft tissue alterations and its relation to gingival
biotype. Clin Oral Implants Res 2013;24:1094–1100.
55. Zeltner M, Jung RE, Hämmerle CH, Hüsler J, Thoma DS.
Randomized controlled clinical study comparing a volume-stable
collagen matrix to autogenous connective tissue grafts for soft
tissue augmentation at implant sites: linear volumetric soft tissue
changes up to 3 months. J Clin Periodontol 2017;44:446–453.
 CHAPTER 9
TREATMENT
OF ESTHETIC COMPLICATIONS
AROUND IMPLANTS:
the decision between keeping or removing an
implant
Guilherme J. P. Lopes de Oliveira, Fausto Frizzera, Adriano Piattelli, Jamil A.
Shibli, Elcio Marcantonio Jr
1. INTRODUCTION

The appearance of the soft tissue in the anterior region after

osseointegration and placement of the definitive prosthesis reflects the
quality of the planning and execution of the surgical and prosthetic
procedures. Failures in the transition zone between prosthesis and
implant usually represent inadequate biologic integration among
tissues or errors in implant positioning.
The dilemma is to maintain or remove an osseointegrated implant.
Implants placed in the ideal three-dimensional (3D) position and
presenting tissue deficiencies due to the absence or failure of a graft
or long-term tissue remodeling can be treated with surgery to recover
the lost tissue.
Poorly placed implants, resulting from technical errors at the time of
the surgery or insufficient bone tissue for their optimal positioning,
should be removed if the patient has esthetic complaints or
pathological changes. This presents a challenging situation for the
patient since it involves returning to a toothless condition as well as
financial, time, and biologic costs.
Implant removal instead of a bone or gingival graft in esthetic areas
occurs because of lack of space for the peri-implant tissues (soft and
hard). Grafts in areas with poorly positioned implants will not solve
esthetic complications but may aid peri-implant health.
In general, mucogingival procedures can be performed around
implants to increase the band of attached gingiva and tissue volume.
For the loss of papillae or recession around implants, it is necessary to
combine orthodontic or restorative and surgical procedures.

OBJECTIVES
At the end of the chapter, the reader should be able to:
Determine when to graft or when to remove implants.
Treat tissue defects on the buccal surface of the implant.
 Establish the best way to treat papillary defects around implants.

2. SCIENTIFIC BACKGROUNG

Esthetically pleasing and functional outcomes result from an adequate

quantity and quality of peri-implant tissues1. During treatment with
implants, tissue manipulation promotes an adequate transition zone.
After osseointegration and healing of the grafts, adequate peri-
implant tissues are expected. The provisional prosthesis will condition
and maintain the tissue before a definitive prosthesis is made2 (Figs
01A–D).
01. A–D After osseointegration and tissue conditioning in multiple or
single rehabilitations, the tissue may present an adequate (A, C) or
inadequate contour (B, D).

It is common for esthetic complaints to occur after the final

prostheses and implants are placed. At this time, dealing with these
defects is a challenge, especially if the implant is not in the ideal
position3. Although minor corrections are predictable, major defects
require more than just surgical methods.
Soft tissue grafts can be used for a thickness gain of less than 2
mm, for fenestrations, or recessions4.
Bone grafts can be used for bone fenestration or dehiscence or
defects from the progression of peri-implant disease. These
interventions should be made before placement of the final
prosthesis5–7.
2.1. TISSUE MANIPULATION AROUND
OSSEOINTEGRATED IMPLANTS

2.1.1. SUBMERGED IMPLANTS

If the site presents volume deficiencies and the implant is submerged,
techniques to increase volume at the time of reopening can be
performed. A simple lingual incision, aimed at displacing the flap to the
buccal or a subepithelial connective tissue graft can be done. The
graft may be sutured to the buccal flap, palatal flap (around the
healing abutment), or to the healing abutment itself (Figs 02A–L and
03A–F).
02. A–L Implant installed on tooth 24 with volume deficiency and
narrow band of attached gingiva (A). A more lingual incision was
made and the flap was shifted to the buccal to increase tissue volume
and the amount of attached gingiva (B). Then a thick connective
tissue graft was removed from the tuberosity (C–I). The graft was
placed in the appropriate position and the graft was sutured to the
healing abutment itself. The graft was placed to verify its most
appropriate positioning, with fixation of the graft to the planned healing
path (J–K). The graft was punctured with a disposable irrigation
needle to create a space for insertion of a tipped instrument (such as
a dissector) (L).
03. A–F The graft fenestration was extended with the instrument itself
and a narrow healing abutment was used to fix the graft to the
operated region (A–E). Final aspect of the region (F). Surgical
procedure: Dr Mariana Gratz supervised by Dr Fausto Frizzera.

2.1.2. UNSUBMERGED IMPLANTS

Patients may have complaints regarding the appearance of soft tissue
during the provisional phase or even after the definitive prosthesis is
installed. In these situations, it is important to evaluate the condition of
the soft and hard tissue around the implant. The patient should be
informed about the limitations, risks, and treatment options before any
type of interventionis performed8. To treat the present complication, it
may be necessary to perform new restorative, orthodontic, and
surgical procedures, especially if there is tissue loss (Figs 04A–C to
07A–R).
04. A–C Change in height, thickness, and color of the peri-implant
mucosa in the region of tooth 21 (A). It is possible to improve the
height and thickness of the tissue with a gingival graft as long as the
implant is well positioned. The buccal region should be prepared to
receive an internally positioned connective tissue graft (B, C).
05. A–I Defect in the region of tooth 21 without change in the height of
the papillae. The prosthetic component must have a cervical
undercontour (A, B). The facial tissue should be prepared using
microelevators and microblades (C, D). A thick connective tissue graft
should be inserted into the prepared region and sutured at the base of
the mesial and distal papillae (E, F). A horizontal suture should be
performed to coronally pull the flap and allow wound closure and
defect resolution (G–I).
06. A–S A patient undergoing temporaries presented with a complaint
regarding the contour of her gingival tissue (A, B). Two narrow
implants had been installed in the region of teeth 7 and 10 due to
tooth agenesis. The surgical planning involved clinical crown
augmentation on the anterior teeth, with the exception of the the
implant region, which received a connective tissue graft to increase
gingival volume and coronal repositioning of the peri-implant margin.
After removal of the provisionals, it was observed that both abutments
were at different heights and had their ends at the gingival level (C–F).
The abutments were inverted to keep a portion of the end of the 12th
abutment exposed and to facilitate its veneering; the temporaries were
then relined and worn in the cervical region (G–L). The clinical crown
augmentation was performed on anterior teeth up to the level of the
cementoenamel junction of the maxillary central incisors (M). The flap
was detached, released, and a thick connective tissue graft was
removed from the hard palate region using the two-incision technique
(N–S).
07. A–R The epithelial component of the graft was excised with
Castroviejo microscissors and the graft sutured in the palatal flap; the
facial flap was repositioned coronally in the implant region (A–D).
Three months after surgery (E–G), the restorative procedures to treat
the black spaces were performed; they consisted of the re-
anatomization of the interproximal contour of the provisional
restorations and distal portion of the maxillary incisors (H–O).
Because of a trip, it took the patient 1 year to return. Note the
improvement of the interproximal region. Appearance before the
replacement of the restorations (P), immediately after (Q) and on the
patient’s last follow-up (R). Surgical procedure: Dr Fausto Frizzera;
restorative procedure: Dr Bianca Vimercati.

The primary condition for performing any bone and mucogingival

graft in the implanted area is that the implant is in the correct 3D
position. The papillae between adjacent implants usually present
height limitations (Figs 08A–F and 09A–K). To avoid this
complication, a reduced number of implants is recommended or teeth
in the anterior region should be moved orthodontically to avoid
adjacent implants. Even so, recovery of all lost tissue may not be
possible and interventions in adjacent teeth or papillae may be
necessary to enhance esthetic outcomes.
08. A–F Loss of interproximal tissue around teeth 11 and 12 due to
two adjacent and misplaced implants (A–E). A flap with two vertical
incisions was performed and the actual position of the implants was
verified (F).
09. A–K The implant of tooth 12 was submerged and a thick
connective tissue graft was removed from the hard palate and sutured
to the facial and occlusal areas (A–D). Postoperative situation at 14
(E, F) and 60 days (G, H) when the pontic area was conditioned using
a provisional prosthesis. After conditioning the interproximal region, a
fixed pontic partial prosthesis was installed over the implant on tooth
11, allowing a more satisfactory result (I–K). Surgical procedure: Dr
Elcio Marcantonio Jr; restorative procedure: Dr Wagner Nunes de
Paula. Case partially published in the Journal of General Dentistry2.

Studies showed that, on average, it is possible to cover 66–96.5%

of the exposed implant area with a coronally repositioned flap and
connective tissue graft1,6. The best results (96.3% coverage of the
exposed area and complete coverage in 75% of cases) were obtained
in the study by Zucchelli et al1, where implants were placed inside the
bone envelope and a prosthetic–surgical procedure was done (Figs
10A, B).
10. A, B The position of the implant and its relationship with the bone
ridge is one of the factors that most influences the decision whether
the implant can be maintained or not. Other factors that influence
coverage are the integrity of the papillae, the diameter of the implant,
and the restorative condition. An implant positioned outside the bone
and gingival envelope requires removal.

The prosthetic phase should consist of removal of the crown, facial

preparation of the abutment to allow room for soft tissue neoformation,
and a new provisional with cervical undercontour, respecting the
critical and subcritical area of the restoration. The provisional
prosthesis should be in position for 1 month to check the tissue
response; then the appropriate surgical procedure should be
recommended. The conventional technique is to perform two vertical
incisions around the peri-implant recession, flap detachment and
division, removal of the epithelium on the papillae, suturing of the
connective tissue graft, and coronally reposition the flap (Figs 11A–
K).
11. A–K Implant installed on tooth 21 with clinical crown longer than
its homologous tooth and cervical darkening due to a thin biotype (A–
C). The crown and prosthetic abutment were replaced and the
abutment was terminated 1 mm apically to the gingival margin of tooth
11 (D–F). A flap with two vertical incisions was made and a connective
tissue graft sutured over the abutment (G, H). The flap was coronally
repositioned and sutured to cover the abutment surface (I). The
technique used covered the abutment and established a stable result
(J, K).

Apical migration of the peri-implant margin may expose the

prosthetic component, the implant platform, or its threads. The
affected region may not yet have a prosthetic component or implant
exposure, but the gingival margin may not be even. Tissue recession
occurs due to facial bone loss associated with the presence of a thin
biotype9. It is possible to increase tissue volume with bone and
gingival grafting around the implant in the ideal position. If the implant
is misplaced, removal is recommended.

2.2. IMPLANT REMOVAL

In cases where it is clinically and radiographically determined that the

implant is not in the ideal position, a surgical intervention for bone or
soft tissue correction may in reality consist of an unnecessary “heroic”
act. Corrections of this kind are extremely complicated and can
undermine the professional–patient relationship by promoting
discouraging results. In these cases, the removal of the implant and
placement of a new implant and grafts is recommended (Figs 12A–
N).
12. A–N Implant on tooth 11 with soft tissue recession due to its
inadequate position (A–F). The implant was removed and a bone and
gingival graft was performed. Six months after graft incorporation, a
total flap procedure was performed to install a new implant in the
adequate position (G–L). Note the result obtained after implant
osseointegration and provisional manufacture (M) and 3 years after
the final prosthesis (N). Surgical procedure: Dr Elcio Marcantonio Jr;
restorative procedure: Dr Felipe Coletti, Dr Luiz Guilherme de Paula
and Dr Mateus Tonetto.

Implant removal using burs can produce major bone destruction and
interfere with the integrity of the facial bone wall (Figs 13A–V).
Additionally, implant placement interferes with the height of the facial
bone wall and it is not uncommon for post-implant removal to result in
major bone defects, which may impair the placement of an immediate
implant. In these cases, the bone cavity should be filled with a bone
substitute biomaterial; this area should be covered with a membrane10.
13. A–V Implant positioned too buccally and apically on tooth 11 (A–
C). The implant was removed using drills, elevators, and forceps (D,
E). At the time, there were no devices for less traumatic removal of an
already osseointegrated implant; note the ridge defect (F). Two
months later the remaining ridge was regenerated with autogenous
bone and membrane (G–J). A flap was performed to install an implant
and perform bone and gingival regeneration (K–O). Four months later,
the implant was reopened and the healing abutment (P–S) was
installed. The patient was then rehabilitated and showed stable
results, even after 5 years of treatment (T–V). Surgical procedure: Dr
Elcio Marcantonio; restorative treatment: Dr Rogério Margonar.

An interesting alternative to implant removal is the use of a high

torque wrench. Implant removal is performed with a retriever that
generates minimal damage to the bone tissue. This is of utmost
importance, especially in areas where there is limited bone availability
(Figs 14A–Q). This technique is preferred over other techniques such
as using a bur to prepare the area around the implant or using a low-
speed trephine bur. However, using a high torque wrench has
limitations, such as incompatibility with all types of implants and the
likelihood of implant fractures due to the application of excessive
force, especially on narrow implants or with high density bone11,12
(type I or II). If this technique fails, removal of implants with burs or
trephines can be performed.
14. A–Q This patient presented with malocclusion and a poorly
positioned implant, with suppuration and peri-implantitis (A–F). To
improve the maxillomandibular relationship, orthodontic and
periodontal planning determined the removal of the implant placed on
tooth 31. Due to the loss of attachment present in the adjacent teeth, a
minimally invasive technique using a retriever was made to remove
the implant (G–K). After removal of the implant, a tunnel was prepared
in the facial portion and access was created in the mucosa, between
teeth 41 and 42, for a mixed soft tissue graft (L, M). After insertion of
the connective tissue graft, the socket was filled with a slow resorption
bone substitute and the epithelial portion of the graft was sutured to
seal the socket (N). The palate was sutured with compressive sutures
(O) and the patient was instructed to use a removable acrylic device
for protection. Postoperative images at 45 and 180 days (P, Q).
Surgical procedure: Dr Fausto Frizzera; orthodontic planning and
procedure: Dr Deise Cunha; restorative procedure: Dr Quézia
Godinho.

3. CLINICAL APPLICATION

Often, esthetic complications occur around implants; even so, few

clinical studies have been conducted to determine the most
appropriate treatment for these defects. There is a lack of consensus
in the scientific literature as to what to do in relation to each clinical
situation, especially for interproximal tissue losses. The clinical
consensus (Table 01) is that well-placed implants have a higher
chance of achieving satisfactory results after grafting procedures.
Table 01 Correction of defects after osseointegration

Volume increases with connective tissue and free gingival grafts are
predictable techniques to be performed around implants. These
techniques allow for improved gingival contour and better biofilm
control, apart from conversion into a thick biotype13.
A coronally repositioned flap around the peri-implant margin of well-
placed implants offers a higher chance of success when the
interproximal tissue is intact, especially if the appropriate emergence
profile of the prosthetic crown has been established1. Clinical crown
lengthening may also be performed on adjacent teeth to enable better
esthetic results14.
The greatest challenge in periodontics and implantology is the
treatment of interproximal defects. The peak of the papilla is
determined by the bone level and its relationship with the interdental
contact point15. Correcting interproximal defects often requires slow
orthodontic extrusion or dental re-anatomization. The relationship
between the implant and tooth or pontic areas should be preferred
because it presents a greater likelihood of obtaining adequate
papillary height.
When removing an implant, the clinician needs to be confident that
it will be beneficial to the patient. The final outcome should achieve
superior esthetic and functional results compared to the initial
condition. When planning for the removal of a misplaced implant, a
soft tissue graft may be recommended in patients with a thin gingival
biotype or gingival recession. Thus, later on the implant will be
installed in the ideal 3D position in a more favorable clinical condition.
The timing of the placement of a new implant in the compromised
area will depend on the remaining bone structure and the possibility of
placing it in the ideal 3D position5. Immediately after removal of the
implant, a new implant may be placed if there is enough bone to
anchor an implant, similar to implant placement in a fresh socket. If
the ideal 3D position cannot be achieved, the bone must be
regenerated. In both situations, the guided bone regeneration
technique and a subepithelial connective tissue graft should be
employed.
At the time of implant placement, regardless of the torque obtained,
it is preferable to submerge it to achieve more predictable results. A
provisional should be installed on the adjacent teeth, being careful not
to compress the operated area. After the graft has been incorporated,
the tissue should be conditioned to improve the position of the soft
tissue margin and papillae16. The need to perform periodontal plastic
procedures on adjacent teeth will depend on the patient’s wishes
(Figs 15A–L to 20A–E).

3.1. SURGICAL AND RESTORATIVE APPROACH

15. A–L Presence of generalized recession on the left side, especially
around the implant on tooth 12, which presents a color change (A–E).
The implant was slanted toward the facial aspect and was removed
with a retriever (F–J). Due to the presence of adequate bone
structure, the region was instrumented to install an implant anchored
in the palatine bone (K, L).
16. A–D For bone reconstruction, biomaterial of heterogeneous origin
and a resorbable membrane were used; a subepithelial connective
tissue graft was used to reposition the gingival margins and increase
tissue volume.
17. A–E After 4 months, a new gingival graft was removed from the
hard palate and positioned over the occlusal edge to submerge the
implant and improve the condition of the interproximal tissue.
18. A–H A bonded prosthesis was installed and proximal sutures were
performed to suspend the soft tissue, showing a satisfactory
appearance 14 days after this procedure (A, B). Finally, a minimally
invasive reopening was performed 2 months after grafting and a
provisional was placed (C, D). The patient was satisfied with the
results obtained and did not wish to undergo new procedures for
gingival correction; therefore, rehabilitation was completed (E–H).
Surgical procedure performed in the course on Periodontal and Peri-
implant Plastic Surgery supervised by Dr Fausto Frizzera and Dr Elcio
Marcantonio Jr; restorative procedure: Dr Felipe Coletti.
3.2. SURGICAL, ORTHODONTIC, AND RESTORATIVE
APPROACH
19. A–L Rehabilitation with prosthesis and artificial gingiva without
space for hygiene. The presence of tissue hyperplasia and a
misplaced implant (A–E) can be seen. The implant was removed and
another implant was placed immediately. The area was regenerated
with xenograft bone, nonresorbable membrane and bone tacks (F–K).
Orthodontic extrusion of tooth 12 was performed to improve the
condition of the papilla between the tooth and implant. (L).
20. A–E Subsequently, a provisional was made over tooth 13 and a
connective tissue graft and clinical crown lengthening were performed
on the remaining anterior teeth (A). Final image of the area 1 year
after surgery (B–E). Clinical procedures: Dr Ulisses Dayube and Dr
Jamil Shibli.

REFERENCES

1. Zucchelli G, Mazzotti C, Mounssif I, Mele M, Stefanini M,

Montebugnoli L. A novel surgical-prosthetic approach for soft
tissue dehiscence coverage around single implant. Clin Oral
Implants Res 2013;24:957–962.
2. Valente ML, Marcantonio E Jr, Faeda RS, de Paula WN, Dos
Reis AC. Esthetic solution to malpositioned implants with
remodeling of soft tissue: a case report. Gen Dent 2016;64:56–
59.
3. Domínguez GC, Fernández DA, Calzavara D, Fábrega JG.
Immediate placement and restoration of implants in the esthetic
zone: trimodal approach therapeutic options. Int J Esthet Dent
2015;10:100–121.
4. Shibli JA, D’avila S, Marcantonio Junior E. Connective tissue graft
to correct peri-implant soft tissue margin: a clinical report. J
Prosthet Dent 2004;91:119–122.
5. Buser D, Sennerby L, De Bruyn H. Modern implant dentistry
based on osseointegration: 50 years of progress, current trends
and open questions. Periodontol 2000 2017;73:7–21.
6. Burkhardt R, Joss A, Lang NP. Soft tissue dehiscence coverage
around endosseous implants: a prospective cohort study. Clin
Oral Implants Res 2008;19:451–457.
7. Sculean A, Chappuis V, Cosgarea R. Coverage of mucosal
recessions at dental implants. Periodontol 2000 2017;73:134–
140.
8. Khzam N, Arora H, Kim P, Fisher A, Mattheos N, Ivanovski S.
Systematic review of soft tissue alterations and esthetic outcomes
 following immediate implant placement and restoration of single
implants in the anterior maxilla. J Periodontol 2015;86:1321–
1330.
9. Zhang L, Ding Q, Liu C, Sun Y, Xie Q, Zhou Y. Survival, function,
and complications of oral implants placed in bone flaps in jaw
rehabilitation: a systematic review. Int J Prosthodont
2016;29:115–125.
10. Cardo VA Jr, Koschitzki E, Augenbaum N, Polinsky JL.
Replacement of an implant and prosthesis in the premaxilla due
to a malposition and prosthetic failure: a clinical case letter. J Oral
Implantol 2014;40:751–754.
11. Anitua E, Orive G. A new approach for atraumatic implant
explantation and immediate implant installation. Oral Surg Oral
Med Oral Pathol Oral Radiol 2012;113:19–25.
12. Stajčić Z, Stojčev SLJ, Kalanović M, Đinić A, Divekar N, Rodić M.
Removal of dental implants: review of five different techniques. Int
J Oral Maxillofac Surg 2016;45:641–648.
13. Bassetti RG, Stähli A, Bassetti MA, Sculean A. Soft tissue
augmentation around osseointegrated and uncovered dental
implants: a systematic review. Clin Oral Investig 2017;21:53–70.
14. Stern JK, Bingham CM, Pumphrey BJ, Chiche GJ, Britton E.
Novel approach to managing malsequenced and malpositioned
immediately placed implants in the esthetic zone. Int J
Periodontics Restorative Dent 2017;37:273–280.
15. Salama H, Salama MA, Garber D, Adar P. The interproximal
height of bone: a guidepost to predictable aesthetic strategies and
soft tissue contours in anterior tooth replacement. Pract
Periodontics Aesthet Dent 1998;10:1131–1141; quiz 1142.
16. Su H, Gonzalez-Martin O, Weisgold A, Lee E. Considerations of
implant abutment and crown contour: critical contour and
subcritical contour. Int J Periodontics Restorative Dent
2010;30:335–343.
 CHAPTER 10
LONG-TERM
FOLLOW-UP OF IMPLANTS:
what should be expected
Judith M. P. Ottoni, Susana d’Avila, Gabriela C. de Castro, Fausto Frizzera,
Ulisses Dayube, Jamil A. Shibli
1. INTRODUCTION

The scientific knowledge associated with the constant advancement of

biomaterials has provided dentistry with a wide range of rehabilitation
options in the past decades. Implants and the advancement of tissue
engineering have allowed the replacement of one or more missing
teeth with high biologic and esthetic predictability. Developments in
science and medicine have increased the longevity of human beings.
Before Brånemark established osseointegration, the survival rate of
implants was much lower than today. Additionally, the indication for
implants was restricted to complete edentulous patients. However,
different treatment modalities today have variable survival and
success rates for total, partial, and single rehabilitation ranging above
90%.
Nevertheless, new technologies have been employed to reduce the
number of surgical and restorative procedures, often concerned only
with short-term outcomes. The longevity of dental treatment and
possible future changes that may occur, both biologically and
technically, must be considered during a treatment plan. It is also
necessary to consider how the patient ages and the systemic and
local repercussions caused over time.
The focus of implantology has evolved from mainly achieving
osseointegration and not considering soft tissues to contemporary
implantology, which encompasses both the functional and esthetic
aspects of treatment. Implant-supported restorations should mimic the
natural dentition associated with longevity. However, there are no
systematic studies that present consistent data on follow-up, survival,
and success rates after 10 or 20 years of masticatory function. This
raises the following question: What should we expect from our
treatments after this time?

OBJECTIVES
At the end of the chapter the reader should be able to:
Understand the long-term success and survival rate of implants.
Characterize the types of failures in implant-supported prostheses.
Identify possible tissue modifications around teeth and implants.

2. SCIENTIFIC BACKGROUND

2.1. LONG-TERM SURVIVAL AND SUCCESS RATES OF

IMPLANTS

Currently, the option of restoring function and esthetics with the use of
implants is routine in dental offices; therefore, patients and clinicians
should expect complications from the biologic behavior of these
implants as well as mechanical responses of the materials used.
Success in implant dentistry initially characterized by Albrektsson et
al1 consisted of a clinical and radiographic evaluation of an
asymptomatic implant (Table 01). The exclusive analysis of these
characteristics is now considered as assessment of survival. The
concept of success encompasses broader aspects of the implant
system, prosthesis, and peri-implant tissues, in addition to patient
satisfaction (Table 02). Figures 01A–C to 04A–D, respectively show
implants classified as unsuccessful and successful.

SURVIVAL CRITERIA

Clinically stable implant

Absence of pain, infection, discomfort, or paresthesia

Absence of radiolucent image around the implant

Bone loss < 0.2 mm annually after first year

Table 01. Success criteria initially proposed by Albrektsson et al1,

which are now considered as implant survival criteria
 SUCCESS CRITERIA2

IMPLANT – No pain, mobility, or suppuration

– Bone loss < 1.5 mm in the first
year
– Bone loss < 0.2 mm annually after
the first year
– No radiolucent imaging around the
implant

PERI-IMPLANT SOFT TISSUES – Probing depth < 3 mm

– No bleeding, suppuration, edema,
or recession
– Plaque index < 20%
– Thickness of keratinized mucosa
> 1.5 mm

IMPLANT-SUPPORTED – No complications or prosthetic

RESTORATION failures
– Adequate esthetics and function

PATIENT SATISFACTION – No discomfort and paresthesia

– Satisfaction with esthetics
– Adequate chewing and gustatory
function
– Overall satisfaction

Table 02. Criteria commonly used to define success after implant

rehabilitation. Adapted from Papaspyridakos et al2
01. A–C This patient had an immediate implant placed in the anterior
maxilla that did not osseointegrate. Six months after the surgical
procedure, the implant and provisional presented mobility, presence of
a facial fistula, and the patient reported pain (A). Radiographically, it
was possible to verify a radiolucent image around the implant,
indicating failure (B, C).
02. A–J Implant in the anterior region with 10 years of follow-up in a
21-year-old patient. Initial clinical aspect of facial defect (A–C). Aspect
of the remaining bone tissue (D). Fixation of autogenous bone
fragment removed from the ascending ramus of the mandible (E).
Covering of autogenous graft with synthetic graft and collagen
membrane (F). After 6 months, it was possible to observe the
improvement of the defect with (G) and without the provisional (H).
Periapical radiograph after the healing period (I); note full integration
of the autogenous graft (J).
03. A–J A 4.1 × 13 mm implant placed with nano-topography (A).
Three-dimensional positioning (B). Silk suture (C). After 4 months of
healing (D, E). Occlusal aspect with considerable increase in facial
volume (F). Removal of healing abutment and healthy conditions of
peri-implant tissues (G). Placement of the metal-ceramic abutment
(H). Abutment control radiograph (I). Try-in of the zirconia copings (J).
04. A–D Placement of ceramic crowns (A). Clinical aspect of the 1-
year follow-up (B). Lateral view of the 5-year follow-up with
maintenance of the facial contour (C). Peri-implant bone crest after 5
years. Tooth-implant diastema after 10 years (D).

Longevity rates and biologic and technical risks should be

considered for the treatment planning of unitary, partial, or total
arches3. The durability of treatments is not based in how many years
implants remain in the oral cavity, but how they work, remain esthetic,
and allow proper maintenance and hygiene. Longitudinal studies
evaluating survival rates of osseointegrated implants show rates
above 85% in the first 5 years and 80% after 10 years of function.
These data are based on the absence of mobility, clinically apparent
disease, and bone loss of 0.2 mm radiographically detected annually1.
Considering other elements of evaluation of effectiveness and
esthetic excellence, such as papillary height and the color of the peri-
implant mucosa, single implants are an efficient treatment method,
with survival rates of 98% over 5 years and 95% over 10 years4. It is
necessary to consider the differences between the definitions of
survival and success. Gallucci et al5 demonstrated 95.5% survival in a
group of patients. When considering the success criteria regarding
peri-implant tissue, prosthetic aspects, and subjective parameters, the
same index dropped to 86.7%. The treated sites must be biologically
prepared and healthy. Implant-supported restorations should have
designs favorable to long-term maintenance, that is, the presence of
interproximal contact points, hygiene areas, and an adequate
emergence profile. Prior planning, mastery of the restorative
techniques and materials employed (Figs 05A–D), as well as periodic
maintenance, are crucial to achieving longevity in implant-supported
rehabilitations.
05. A–D Adequacy of the vertical occlusion dimension concomitantly
with placement of an implant-supported complete denture. Note the
large discrepancy between before (A, B) and after the rehabilitation
(C, D).
 This chapter describes the problems most frequently reported in
systematic reviews that address a follow-up period of 5–10 years and
clinical observations of the authors with a follow-up of 10–20 years.
First, the preventive procedures before implant placement are
addressed, then the biologic risks and technical complications. Finally,
the biologic role of residual maxillomandibular growth and occlusal
changes in areas with previously placed implants is considered (Table
03).

Table 03. Aspects covered in this chapter

2.2. PREVENTION BEFORE IMPLANT PLACEMENT

2.2.1. SOFT TISSUE-RELATED ASPECTS

The gingival biotype is directly related to the longevity and stability of
the tissue around the implants because they react differently to
inflammatory aggression. A thin biotype around implants increases the
risk of peri-implant margin recession. A thick biotype has excellent
tissue stability in long-term follow-up6; therefore, in the anterior region,
the presence of a thick biotype is essential to maintain soft tissue
architecture over time (Figs 06A–C).
06. A–C Patient without attached gingiva and vestibule depth (A),
without attached gingiva and with adequate vestibule depth (B), and
with attached gingiva and adequate vestibule depth (C).

Many implants are placed in regions that have only alveolar

mucosa, which differs from the attached gingiva in several ways. In
addition to the absence of keratinized epithelium, this mucosa is frail,
in part because of its low collagen content and the presence of large
amounts of elastic fibers7,8. The parallel orientation of the fibers in the
peri-implant tissue favors the rapid progression of peri-implant
disease, affecting bone tissue and promoting its resorption.
Numerous studies argued that the presence or absence of
keratinized tissue does not interfere with the health of peri-implant
tissues provided that there is good hygiene9–11. On the other hand, our
clinical experience shows that the presence of keratinized mucosa
facilitates biofilm control around peri-implant tissues, especially the
junctional epithelium, which remain free of inflammation. If all fresh
sockets were submitted to regenerative procedures to maintain bone
and gingival contour before being rehabilitated with implants, a high
number of reconstructions could be avoided (Figs 07A–H to 11A–H).
07. A–H Single implant and temporary unit with tissue regeneration to
maintain tissue architecture: initial clinical aspect (A); initial
tomographic images, with sagittal (B), frontal (C), and axial (D) cuts.
Clinical aspect after removal of the provisional (E). Oblique and
longitudinal root fracture with a history of amalgam retrograde filling
(F). Probing after the extraction; the depth (G) and presence of a
defect on the buccalaspect are verified (H).
08. Position of a guide pin to check the depth and inclination of the
perforation (A). A 3.5 × 13 mm tapered implant, with Morse connection
(B). Occlusal view after implant installation (C). Immediate provisional
screwed in after tissue regeneration (D). Clinical aspect 6 months after
surgery (E). Removing the temporary abutment (F) and installing a
zirconia abutment (G). Radiographic image of the abutment in position
(H) and 12 months after surgery (I).
09. A–H Patient with loss of maxillary teeth and the entire structure of
the maxillary ridge. Initial aspect of the patient’s smile (A), who had
undergone orthognathic surgery, extraoral graft, and implant
installation (B, C). Lip muscle insertion at the implant level due to the
previous procedures (D–F). Due to the present condition, the
prosthesis was not made. There was an indication of the deepening of
the vestibule associated with the epithelial graft. For higher stability of
the vestibule deepening procedure, and protection of the donor and
recipient areas, a surgical drain was constructed. An impression of the
distal implants was taken (G). A reduction was madeon the plaster
model (H).
10. A–H Two UCLA abutments were placed in the distal implants (A,
B) to make the surgical drip where the cement could flow through; this
device was fixed by the distal implants (C, D). The muscle insertion
was then removed, the vestibule was deepened (E, F), and the
epithelium was removed from the tissue adjacent to the implants (G).
A free gingival graft was removed from the hard palate and received
vertical cuts to increase its extension (H).
11. A–H Due to the large extent of the area to be grafted, the graft
was divided into two and stabilized at the buccal surface of the
implants (A). The surgical drip was loaded with surgical cement and
screwed into the distal implants to protect the recipient and donor
regions (B). Tissue aspect at 15 (C) and 30 (D) days postoperatively.
Note the increased attached gingiva around the implants 4 months
after surgery (E, F). Appearance after maxillary rehabilitation: due to
peri-implant problems, removal of the left mandibular implants was
recommended (G). Control radiograph 3 years after the gingival graft
(H). Gingival graft procedure: Dr Fausto Frizzera; rehabilitation
procedure: Oral Surgery Residency Program at FOAr-UNESP.

Soft tissues around single implants are more stable and predictable
than around multiple contiguous implants. In single implants, the
position of soft tissue in proximal areas is maintained by the
periodontal support of the adjacent tooth. In multiple implants,
papillary formation only becomes predictable and with better esthetic
results where there is a broad section of keratinized tissue.
2.2.2. OCCLUSION-RELATED ASPECTS
Occlusion-related aspects may influence the longevity of implant
restorations. The existing clinical situation should be visualized from a
rehabilitation point of view. Timely interventions that only aim to
resolve the patient’s complaint may neglect the presence of
comorbidities and the need for other treatments that would favor long-
term stability. A clinical example is multiple teeth fractures at relatively
short time intervals; occlusal trauma is the probable cause (Figs 12A–
C).

12. A–C Oblique fracture of tooth 21 (A). Clinical examination

revealed loss of posterior support due to multiple tooth loss and deep
overbite with limited interocclusal space (B). Occlusal alteration
resulted in the altered contour of the lingual surface of tooth 11 and
fracture of tooth 21 (C).

Patients with loss of posterior occlusal support or occlusal instability

should be treated for mutually protected occlusion. To stabilize the
patient’s occlusion, orthodontic treatment and full-mouth rehabilitation
may be recommended. All rehabilitation has the same occlusal
objectives, whether tooth-supported, implant-supported, or mucosa-
supported. The objectives are: (1) Establish the correct vertical
dimension of occlusion, intermaxillary relationship, and stable bilateral
occlusal contacts; (2) Avoid premature contact and occlusal
interference; (3) Reestablish function, health, and esthetics.
In the posterior segment, maxillary bone resorption occurs mostly in
the buccal wall, whereas in the mandible it occurs in the lingual wall.
This leads to a challenge to correct positioning during implant
placement, favoring deleterious loads and manufacture of
overcontoured crowns. Another aspect that can be altered is the
occlusal surface of the prosthetic crowns in the posterior segment12,13.
Important changes may be made by decreasing the occlusal table
extension, contact points, and cusp angulation. Sometimes these
imbalances can result in implant fracture (Figs 13A–C).

13. A–C Metal-ceramic prosthesis over five external hexagon

cylindrical implants in function for 19 years. Note the distal extension
on both sides. Tomographic aspect of the implants in function and fully
anchored in bone tissue (A, B); after 11 years in function, all implants
fractured due to occlusal stress (C).

Occlusal imbalance maintained even after implant placement may

delay treatment. Necessary adjustments should be evaluated before
and not during treatment.
2.3. COMPLICATIONS AFTER IMPLANT PLACEMENT

2.3.1. BIOLOGIC RISKS

A mixed dentition of implants and teeth is a concern because of
changes in the oral microbiota. In periodontally compromised patients,
periodontal pathogens present or remaining after basic periodontal
therapy may contaminate or colonize implants. If there is an
imbalance between host and microbiota, peri-implantitis may occur. If
left untreated, it may accelerate bone resorption, leading to increased
probing depth or peri-implant margin recession (Figs 14A–C). Signs
of periodontal and peri-implant diseases, such as changes in tissue
coloration, bone resorption, papillary loss, and gingival or peri-implant
recessions, need to be monitored.

14. A–C Intraoral view of a patient with periodontal disease who had
dental absences treated with implants (A). Radiographic image
showing bone loss and involvement of tooth 21 (B). Image overlap to
verify the clinical and radiographic relationships, favoring periodontal
involvement and causing esthetic and functional defects (C).
 Periodontal disease, when untreated, contraindicates treatment with
implants. Probing depths and a biofilm index greater than 20% should
be addressed and the disease fully controlled before implants are
considered. A meta-analysis14–16 revealed that the survival rate for
implants is higher when placed in patients with no history of
periodontal disease. In these studies, it was suggested that 1 implant
out of 20 installed is lost after 10 years due to peri-implant disease.
The prevalence of peri-implant disease is 10% of implants, and 20%
of patients rehabilitated with implants, after a period of 5–10 years.
These numbers represent the prevalence of the disease in both
systemically healthy patients and smokers, patients with a history of
periodontal disease, and a low return for follow-up appointments3. A
systematic review3 indicated that high survival and longevity in
implants placed in partially or fully edentulous patients who adhere to
supportive periodontal therapy may be achieved.
The incidence of peri-implant disease is controversial due to the
different definitions in the conditions that represent the disease and
the clinical magnitude presented in different populations. We present
definitions using the suggested criteria17,18:
Peri-implant mucositis: Reversible inflammatory lesions restricted
to superficial soft tissues.
Hyperplastic mucositis: Reversible inflammatory lesions related to
loosening or loose prosthetic components.
Mucosal abscess: Restricted to supracrestal soft tissues and related
to food retained in the peri-implant sulcus.
Mucosal fistula: Related to loosen prosthetic components or
remnants of cement in the peri-implant sulcus. It is the result of an
untreated mucosal abscess.
Peri-implantitis: Progressive loss of supporting bone around the
implant, induced by bacterial biofilm. Inflammation causes bleeding
and suppuration on probing. Marginal tissue may be swollen and
reddened; however, pain is not commonly reported. The peri-implant
bone defect is cup-shaped around the implant and can progress
without implant mobility.
Parameters to be used to assess the presence and severity of
periodontal and peri-implant disease include19: bacterial biofilm
accumulation; peri-implant mucosal conditions (quality and quantity of
keratinized mucosa); presence of bleeding and suppuration; increased
probing depth and evaluation of bone–implant interface aspects by
radiographic examinations (Figs 15A, B to 17A–D).

15. A, B At the follow-up appointments, apart from hygiene

orientation, clinical evaluation with probing (A) and radiographs (B)
were recommended.
16. A, B Presence of bleeding (A) and suppuration (B).
17. A–D Radiographic examination of both implants at the time of
placement (A). Radiographic examination of both implants on the day
of prosthetic crown installation (B). Radiographic examination of both
implants after 5 years in function, showing peri-implantitis (C). Clinical
view after 5 years with peri-implant disease. Note the recession of the
peri-implant tissue margin in the maxillary arch and hyperplasia in the
mandibular arch (D).

Like periodontitis, peri-implantitis is also a multifactorial disease; in

addition to biofilm, other risk factors should be noted:
Inadequate surgical instrumentation
Quantity and quality of the peri-implant mucosa
Absence of passivity of implant-supported restoration
Prosthetic components not fitting correctly
Occlusal overload
Inadequate or insufficient space for cleaning
Inappropriate three-dimensional position
Characteristics of implants regarding their surface
Smoking and diabetes
A wide variety of surgical and nonsurgical protocols for the
treatment of peri-implant disease are available. However, no
comparative studies have examined these protocols. Despite
improvement in clinical parameters after treatment, complete
resolution according to the success criteria is not achieved in all
patients with peri-implantitis. Recurrence and disease progression
after treatment determine implant loss; based on the extent of the
defect, the recommendation is to remove the implant20,21.
Peri-implant disease is associated with the presence of bacterial
biofilm around the implant22. Proper oral hygiene is the most efficient
prevention. The treatment aims to remove the cause and
decontaminate the implant to treat the infection. This therapy can be
effective without a surgical approach as long as the lesion is initial and
restricted to the soft tissues, that is, in cases of peri-implant
mucositis21. It is possible to remove biofilm, calculus, and
decontaminate the implant surface without reflecting a flap. Plastic or
titanium curettes, abrasive air blasting, photodynamic therapy, and
chemical agents can be used alone or in combination (Figs 18 to
20A–E).
18. Mucositis treatment using a sodium bicarbonate jet in an area with
severe peri-implant mucosal recession with a history of peri-
implantitis.
19. A–E Large build-up under resin prosthesis resulting in mucosal
inflammation and peri-implant margin recession.
20. A–E Removal of calculus with curettes, implantoplasty (removal of
threads and smoothing of the treated surface of the implant), and
chemical decontamination (A, B). Appearance 5 days after removal of
local factors (C). Access for hygiene and clinical appearance after 180
days (D, E).

The presence of bone defects around the implant, bleeding on

probing, or suppuration are signs of peri-implantitis. The surgical
approach allows access to sites and bone defects, removal of
granulation tissue, and decontamination of the implant. With this
therapy, it is possible to reduce probing depth, bleeding, and tissue
edema, with the consequent recession of the peri-implant margin17.
Peri-implantitis is associated with apical migration of the peri-
implant margin due to changes in underlying bone topography.
Despite being the most logical treatment option, guided bone
regeneration (GBR) is not yet the option of choice for the treatment of
peri-implantitis. The literature demonstrates similar results between
regenerative and non-regenerative treatment. These data may be
related to the heterogeneity of the studies, characteristics of the peri-
implant defect, peri-implant soft tissue, surgical protocol, and type of
biomaterials used. Additionally, the effectiveness of GBR is unclear
because of the challenge of osseointegrating a previously
contaminated implant (Figs 21A–L and 22A–J).
21. A–L Patient with impairment of tooth 11 due to advanced root
resorption (A–D). An immediate implant was placed 11 years ago
along with bone and gingival graft, as well as an immediate provisional
(E–J). Clinical appearance after 6 months (K, L).
22. A–J A porcelain crown was cemented over the prosthetic
component and excess cement was removed (A–C). Clinical and
radiographic aspect after 8 years. Note the presence of a pocket and
suppuration (D, E). Peri-implantitis was treated with surgical access,
mechanical debridement, grafting with biomaterial, and leukocyte- and
platelet-rich fibrin (F–I). At the 2-year follow-up (J). Clinical case
conducted by Dr Jamil A. Shibli and Dr Alberto Blay.

The use of systemic antibiotics, like amoxicillin and metronidazole,

is used to eradicate pathogenic bacteria. Tetracycline can also be
used locally to decontaminate the implant surface. Mechanical therapy
associated with low-intensity laser and photosensitizing agents, like
toluidine blue or methylene blue (photodynamic therapy),
demonstrated promising results. Further research to establish a more
comprehensive protocol regarding intensity and exposure are
needed23–25. Another protocol uses high-power laser such as
Er,Cr:YSGG to decontaminate the implant surface, as well as
removing soft tissue around the peri-implant lesion.
Depending on the morphology of the defect26, decontamination of the
implant surface, implantoplasty, GBR, or even implant removal may
be indicated (Figs 23A–D). A factor usually not considered in studies
is the use of a connective tissue graft. The purpose of this graft is to
increase gingival thickness and prevent or limit the recession of peri-
implant tissues (Figs 24A–J and 25A–I).
23. A–D Options for treating peri-implantitis: scaling with titanium or
plastic curettes (A), implantoplasty (B), photodynamic therapy (C),
implant removal (D).
24. A–J Patient with peri-implantitis presenting a deep peri-implant
pocket (A, B). Surgical incision for access (C). Granulation tissue
within the bone (D). Bone regeneration after removal of inflamed
tissue (E). Area of tuberosity where the connective graft (F) was
removed. Connective graft to modify tissue biotype (G). Sutures (H).
Seven-year follow-up (I, J).
25. A–I Radiographic image after implant osseointegration (A) and
clinical aspect 1 year after prostheses installation (B). The patient was
later diagnosed with peri-implantitis (C) and treated with a similar
surgical protocol (D, E) to that described in Fig 22. However, this
patient did not have attached gingiva and received no connective
tissue graft. It was possible to obtain an excellent result at the peri-
implant bone level (F, G). Stability of the clinical and radiographic
results after 9 years of follow-up (H, I).

Graph 01 Peri-implant maintenance program based on periodontal

support therapy and risk factors associated with each individual.

Follow-up appointments after crown placement should be planned,

with more frequent visits in the first year. The first follow-up should be
within 15 days of crown placement, then at 3, 6, and 12 months. At the
first two appointments, in addition to checking gingival health, implant
and abutment stability, and occlusal contacts, patient adaptation to the
prosthesis and hygiene instructions should be reinforced. After this
period, the recommended frequency is a follow-up appointment every
3 or 6 months according to the complexity of the treatment and
susceptibility to peri-implant disease— annual radiographic control is
recommended (Graph 01).
Initially, an at-home biofilm control program should be instituted,
where the professional will suggest the various hygiene devices that fit
the patient’s motor capacity and the design of the prosthetic structure.
During subsequent appointments, the importance of biofilm control
should be reinforced; if necessary, new techniques should be
introduced. The maintenance schedule for implants must be
individually determined; the patient must understand their
responsibility in the treatment; the motivation and ability to clean the
prosthesis can influence the choice of the type of rehabilitation27.

VIDEO OF ER,CR:YSGG HIGH-INTENSITY LASER USED TO TREAT PERI-

IMPLANTITIS

2.3.2. TECHNICAL RISKS

Despite the high success rates reported in the literature on implant
therapy, high percentages of prosthesis-related failures are observed.
In implant-supported prostheses, due to the absence of periodontal
ligament, masticatory forces will affect the entire prosthesis, prosthetic
abutment, implant, and bone system. The success of treatment
depends on the behavior of each one of these components and their
relationship to each other.
The use of implants in esthetic areas is relatively new. Restoring
lost anterior teeth with implants has created new biomechanical
challenges in balancing this with natural dentition. If following the
previous recommendation for implant placement, guided by bone
availability rather than ideal position, angled prosthetic components,
cemented or overcontoured crowns, and narrow implants with
inadequate anatomy and strength may be required28, which can lead
to failure.
Technical and mechanical complications include29: loosening,
fracture or delamination of the ceramic; fracture of the infrastructure;
loosening or fracture of the screw; loosening or fracture of the
prosthetic component; fracture or damage of the prosthetic platform;
and fracture of the implant. Some of these complications were
observed in 24.7% of implant prostheses (single and fixed) during an
average follow-up of 10 years.
Possible causes of failure of the ceramic of implant-supported
prosthesis:
Absence or reduced proprioception of implants
Presence of a screw access opening, limiting the thickness of the
ceramic
Ceramic without support or excessive thickness
Difference between the thermal expansion coefficients of restorative
materials
In a systematic review that assessed the survival of single implant
prostheses, a prosthesis with external hexagon connection presented
more technical complications compared to those with an internal
connection, in a ratio of 3:1(ref. 28). In 5 years, 4.8% of single prosthesis
will show screw loosening, which is the most prevalent complication.
Screw fracture is less common and affects only 0.2% of single
prosthesis. Both complications are associated with lack of adaptation
and occlusal forces and may cause changes in peri-implant tissue3.
It is important to clarify that, in single prostheses, the rotational
freedom between the abutment and prosthetic platform can influence
the stability of the screw. To reduce the micromovement of prosthetic
components, premanufactured components from the same implant
company should be used. In addition, manual and radiographic
verification of adaptation is necessary and if there is no rotation of
prosthetic components and parts. Clinical and radiographic follow-up
is essential to identify mechanical or biologic problems:
 Fracture of the prosthesis infrastructure or esthetic material
Screw or abutment fracture
Loss of occlusal contacts
Exposure of the implant screws
Hyperplasia or presence of fistulas in the peripheral mucosa
surrounding the implant
Loss of implant-supported restoration or provisional
Presence of bacterial biofilm and calculus causing mucositis and/or
peri-implantitis
Design fault in the restorations
Any prosthesis that has a screw at some point will become loose since
continuous friction, added to occlusal tensions, will smash the contact
regions, reduce the pre-torque, and favor loosening of the retaining
screws. Overfusion in metal straps can create a bonding interface
between different metals, concentrating stress in the prosthetic
component.
Fractures of the prosthetic component are less common; however,
the use of narrow implants seems to predispose to this failure28. In
these situations, the component diameteris reduced. The screw does
not follow this reduction, so the component wall is thinner and frail
(Figs 26A–D).
26. A–D After 8 years of function, gingival inflammation was observed
around the implant (A). Fracture of the prosthetic component can be
observed (B). The fractured component was removed and a new
prosthesis manufactured (C, D).

When evaluating single and fixed prosthesis, delamination of the

covering ceramics was observed in 1 out of 5 of the metal-ceramic
pieces after 10 years of function29. In multiple fixed prostheses beyond
the larger occlusal contact area, deflection may occur. Other possible
causes are internal ceramic failures, differences in coefficients of
thermal expansion, poor ceramic adherence, and parafunctional
habits (Figs 27A–D). The latter is described as a risk factor because
tooth wear due to parafunctional habit may overload the implant
prosthesis, which does not have neuromuscular receptors to absorb
excessive force29.
27. A–D Initial aspect after the installation of maxillary and mandibular
implant-supported complete dentures made of layered milled zirconia
(A). On the day of prosthesis delivery, the patient was asked to wear
an occlusal guard at night (B). Two years after delivery, the patient
presented delamination of the ceramic (C). Demarcation showing the
places where delamination occurred (D).

When comparing a single prosthesis with metallic or ceramic

components, no difference was observed in a follow-up for at least 3
years; however, the quality of the system used and the specific design
for all-ceramic components should be taken into account30. When
comparing only cemented crowns, all-ceramic components failed
more often compared to metal-ceramics. The type of cement used had
no influence on porcelain fractures. The main complication arising
from a cemented prosthesis is due to excess of cement in the peri-
implant sulcus, which promotes gingival inflammation and even fistula
formation. During treatment planning, the soft tissue height determines
the adequate transmucosal height of the prosthetic components, so
that the margin is located 0.5–1.0 mm apically to the gingival margin.
Previous studies3,21 suggested a clearer definition of which technical
complications may manifest, such as mechanical complications from
premanufactured components or technical complications arising from
component customization (manufacturing or laboratory modifications).
Another approach would be to classify technical and mechanical
complications according to severity, as follows: (1) Major: fractured
implants, fractured infrastructure, fractured prosthetic component, loss
of prosthesis; (2) Intermediate: component screw loosening, ceramic
or infrastructure fracture, phonetic complications; (3) Minor:
component screw loosening, loss of retention, loss of adhesion, loss
of resin restoration over screw access hole, delamination of cover
ceramic (can be polished), and occlusal adjustment.

2.3.3. FACIAL GROWTH AND OCCLUSAL CHANGES

The longevity of an implant prosthesis can be influenced by a number
of related factors. Due to the high success rate and longevity of the
single prosthesis and scientific data on the follow-up of these
prostheses, alterations in the positioning of the teeth adjacent to the
implant have been observed. The residual growth of the alveolar bone
interferes esthetically and functionally with the implant-supported
prosthesis.
Implants, when osseointegrated, promote ankylosis of the adjacent
bone tissue; therefore, placement of implants in young patients in the
growing phase is not recommended. Modifications from facial growth
and dental positioning could justify these skeletal and esthetic
changes.
Aging, which is accompanied by muscle changes and physiologic or
pathological tooth wear, can promote changes in dental positioning31.
These changes may not be apparent in natural dentition. Among the
changes that can be noticed are the presence of occlusal wear,
anterior crowding, and extrusion or mesialization of teeth (Figs 28A–
C). Opening of contact points and gingival and incisal embrasures
may occur adjacent to implants as a result of tooth movement for
occlusal reasons32.
28. A–C Clinical aspect of patient with occlusal alteration due to
absence of posterior support (A). It is possible to verify the presence
of an open proximal contact on tooth 12 due to the alterations (B, C).

In addition to occlusal changes, skeletal changes may also be

expected. In a longitudinal controlled study in adults, Behrents33
observed residual growth, demystifying the statement that adults do
not grow. These findings were surprising because most long-term
follow-up studies do not take into account the role of this residual
growth. Although slow and steady, this growth becomes relevant,
once again, when there is a fixed reference as in single and partial
implant rehabilitations. In cases where growth is evident, an implant-
supported prosthesis in infraocclusion and diastema between the
adjacent natural tooth and implant crown are evident (Figs 29A–F).
29. A–F Adaptation of ceramic crowns over the implant on tooth 11
and over teeth 21 and 22 (A). Smile after crown delivery (B). Clinical
and radiographic follow-up of 12 years. Observe dental migration and
diastema between the crowns of the maxillary central incisors (C–E).
Occlusal view where downward and palatal movement of crowns can
be observed (F).

To understand this finding, it is important to know maxillary and

mandibular growth: in the maxilla, vertical and horizontal growth
occurs backward and upward but its displacement is forward and
downward; in the mandible, growth occurs by apposition in the
condylar region and posterior edge of the ascending ramus, causing
its displacement and horizontal sliding forward and rotation downward
(Figs 30A–E).
30. A–E Migration due to residual jaw growth (A–C), which shows
different areas of apposition and continuous bone resorption (D, E).

Not all have the same rate of change in an implant’s spatial position
relative to the adjacent teeth; growth potential can be influenced by
several hormones, such as growth and parathyroid hormones, which
continue to be released throughout life34. In addition, in women,
hormonal variations from the age of menarche, the number of
pregnancies, and age at menopause influence development and facial
and body changes not observed in men.
Clinically, the results of these modifications may cause discomfort
and biologic changes due to food impaction and masticatory
inefficiency of the implants35–38.
A single implant, if placed too early, can act as a focus of
malocclusion. Although esthetic changes are generally observed by
professionals, loss of proximal contact also bothers the patient due to
food impaction.
Correction depends on the degree of alteration and location of the
prosthesis. Screwed prostheses facilitate adjustment or even crown
replacement. However, it is worth remembering the importance of the
availability of components, even for implants that are more than 10
years old.

3. CLINICAL APPLICATION

The increase in the life expectancy of our patients, which usually

exceeds 80 years, determines the need to perform treatments with
excellent results respecting biologic and functional aspects. Implant
treatment planning should address time and longevity factors, along
with the changes that patients and tissues undergo and the materials
used in their treatment (Table 04).

Table 04. Treatment options for peri-implant disease and occlusal

changes/facial growth.

REFERENCES

1. Albrektsson T, Zarb G, Worthington P, Eriksson AR. The long-

term efficacy of currently used dental implants: a review and
proposed criteria of success. Int J Oral Maxillofac Implants
1986;1:11–25.
2. Papaspyridakos P, Chen CJ, Chuang SK, Weber HP, Gallucci
GO. A systematic review of biologic and technical complications
with fixed implant rehabilitations for edentulous patients. Int J Oral
Maxillofac Implants 2012;27:102–110.
3. Heitz-Mayfield LJ, Needleman I, Salvi GE, Pjetursson BE.
Consensus statements and clinical recommendations for
prevention and management of biologic and technical implant
complications. Int J Oral Maxillofac Implants 2014;29(Suppl):346–
350.
4. Zembic A, Kim S, Zwahlen M, Kelly JR. Systematic review of the
survival rate and incidence of biologic, technical, and esthetic
complications of single implant abutments supporting fixed
prostheses. Int J Oral Maxillofac Implants 2014;29(Suppl):99–
116.
5. Gallucci GO, Grutter L, Chuang SK, Belser UC. Dimensional
changes of peri-implant soft tissue over 2 years with single-
implant crowns in the anterior maxilla. J Clin Periodontol
2011;38:293–299.
6. Kan JY1, Rungcharassaeng K, Lozada JL, Zimmerman G. Facial
gingival tissue stability following immediate placement and
provisionalization of maxillary anterior single implants: a 2- to 8-
year follow-up. Int J Oral Maxillofac Implants 2011;26:179–187.
7. Lekholm U, Adell R, Lindhe J, et al. Marginal tissue reactions et
osseointegrated titanium fixtures. (II) A cross-sectional
restrospective study. Int J Oral Maxillofac Surg 1986;15:53–61.
8. Berglundh T, Lindhe J, Ericsson I, Marinello CP, Liljenberg B,
 Thomsen P. The soft tissue barrier at implant teeth. Clin Oral
Implants Res 1991;2:81–90.
9. Stetler KJ, Bissada NF. Significance of the width of keratinized
gingiva on the periodontal status of teeth with submarginal
restorations. J Periodontol 1987;58:696–700.
10. Wennström J, Lindhe J. Plaque-induced gingival inflammation in
the absence of attached gingival in dogs. J Clin Periodontol
1983;10:266–276.
11. Strub JR, Gaberthüel TW, Grunder U. The role of attached
gingiva in the health of peri-implant tissue in dogs. 1. Clinical
findings. Int J Periodontics Restorative Dent 1991;11:317–333.
12. Weinberg LA. Reduction of implant loading with therapeutic
biomechanics. Implant Dent 1998;7:277–285.
13. Weinberg LA. Therapeutic biomechanics concepts and clinical
procedures to reduce implant loading. Part II: therapeutic
differential loading. J Oral Implantol 2001;27:302–310.
14. Hardt CR, Gröndahl K, Lekholm U, Wennström JL. Outcome of
implant therapy in relation to experienced loss of periodontal bone
support: a retrospective 5-year study. Clin Oral Implants Res
2002;13:488–494.
15. Mengel R, Flores-de-Jacoby L. Implants in regenerated bone in
patients treated for generalized aggressive periodontitis: a
prospective longitudinal study. Int J Periodontics Restorative Dent
2005;25:331–341.
16. Gatti C, Gatti F, Chiapasco M, Esposito M. Outcome of dental
implants in partially edentulous patients with and without a history
of periodontitis: a 5-year interim analysis of a cohort study. Eur J
Oral Implantol 2008:1:45–51.
17. Mombelli A, Lang NP. The diagnosis and treatment of peri-
implantitis. Periodontol 2000 1998;17:63–76.
18. Esposito M, Hirsch JM, Lekholm U, Thomsen P. Biological factors
contributing to failures of osseointegrated oral implants. (II).
Etiopathogenesis. Eur J Oral Sci 1998;106:721–764.
19. Lang NP, Berglundh T, Heitz-Mayfield LJ, Pjetursson BE, Salvi
 GE, Sanz M. Consensus statements and recommended clinical
procedures regarding implant survival and complications. Int J
Oral Maxillofac Implants 2004;19 Suppl:150–154.
20. Mombelli A, Müller N, Cionca N. The epidemiology of peri-
implantitis. Clin Oral Implants Res 2012;23 Suppl 6:67–76.
21. Shibli J, Ivanovski S, Park YB, et al. Group D. Consensus report.
Implants-peri-implant (hard and soft tissue) interactions in health
and disease: the impact of explosion of implant manufacturers. J
Int Acad Periodontol 2015;17(1 Suppl):71–73.
22. Shibli JA, Melo L, Ferrari DS, Figueiredo LC, Faveri M, Feres M.
Composition of supra- and subgingival biofilm of subjects with
healthy and diseased implants. Clin Oral Implants Res
2008;19:975–982.
23. Shibli JA, Martins MC, Nociti FH Jr, Garcia VG, Marcantonio E Jr.
Treatment of ligature-induced peri-implantitis by lethal
photosensitization and guided bone regeneration: a preliminary
histologic study in dogs. J Periodontol 2003;74:338–345.
24. Shibli JA, Martins MC, Theodoro LH, Lotufo RF, Garcia VG,
Marcantonio EJ. Lethal photosensitization in microbiological
treatment of ligature-induced peri-implantitis: a preliminary study
in dogs. J Oral Sci 2003;45:17–23.
25. Shibli JA, Martins MC, Ribeiro FS, Garcia VG, Nociti FH Jr,
Marcantonio E Jr. Lethal photosensitization and guided bone
regeneration in treatment of peri-implantitis: an experimental
study in dogs. Clin Oral Implants Res 2006;17:273–281.
26. Schwarz F, Sahm N, Schwarz K, Becker J. Impact of defect
configuration on the clinical outcome following surgical
regenerative therapy of peri-implantitis. J Clin Periodontol
2010;37:449–455.
27. Chen S, Darby I. Dental implant: maintenance, care and
treatment of peri-implant infection. Aust Dent J 2003;48:212–220;
quiz 263.
28. Zembic A, Kim S, Zwahlen M, Kelly JR. Systematic review of the
survival rate and incidence of biologic, technical, and esthetic
 complications of single implant abutments supporting fixed
prostheses. Int J Oral Maxillofac Implants 2014;29 Suppl:99–116.
29. Wittneben JG, Buser D, Salvi GE, Bürgin W, Hicklin S, Brägger U.
Complication and failure rates with implant-supported fixed dental
prostheses and single crowns: a 10-year retrospective study. Clin
Implant Dent Relat Res 2014;16:356–364.
30. Wismeijer D, Bragger U, Evans C, et al. Consensus statements
and recommended clinical procedures regarding restorative
materials and techniques for Implant Dentistry. Int J Oral
Maxillofac Implants 2014;29 Suppl:137–140.
31. Brandão RCB, Brandão LBC. Ajuste oclusal na Ortodontia: por
que, quando e como?. Revista Dental Press de Ortodontia e
Ortopedia Facial (Impresso) 2008;13:124–155.
32. Jemt T. Single-implant survival: more than 30 years of clinical
experience. Int J Prosthodont 2016;30:551–558.
33. Behrents RG. Growth in the aging craniofacial skeleton. In:
Craniofacial Growth Series, Monografy no 17. Ann Arbor, MI:
Center for Human Growth and Development, The University of
Michigan 1985: 1–145.
34. Guyton AC, Hall JE. Os hormônios hipofisários e seu controle
pelo hipotálamo. In: Guyton e Hall Tratado de Filosofia Médica.
Philadelphia, PA, 1996;75: 847–857.
35. Ottoni J, Gabriella M. Dental implants three-dimensional position
affected by late facial growth: follow up of 12 to 15 year. Journal
of Osseointegration 2011;3:61–68.
36. Oesterle LJ, Cronin RJ. Adult growth, aging, and the single-tooth
implant. Int J Oral Maxillofac Implants 2000;15:252–260.
37. Jemt T. Measurements of tooth movements in relation to single-
implant restorations during 16 years: a case report. Clin Implant
Dent Relat Res 2005;7:200–208.
38. Daftary F, Mahallati R, Bahat O, Sullivan RM. Lifelong craniofacial
growth and the implications for osseointegrated implants. Int J
Oral Maxillofac Implants 2013;28:163.
 CHAPTER 11
AVOIDING ESTHETIC AND
FUNCTIONAL DEFECTS ON
IMPLANTS:
how to condition the transition zone
Fausto Frizzera, Guilherme J. P. Lopes de Oliveira, Deise L. Cunha, Daniel S.
Thoma, Jamil A. Shibli, Elcio Marcantonio Jr
1. INTRODUCTION

In recent years, the use of dental implants has increased.

Complications can lead to esthetic and functional defects if the
necessary surgical steps for tissue reconstruction are not followed1.
Patients expect the outcome to be the most similar to their natural
dentition. The increased complexity of implant treatment2 is related to
the need to achieve harmony between white and pink esthetics.
In white esthetics, a restorative material can be manipulated to
mimic the adjacent teeth. On the other hand, pink esthetics will
depend on the architecture of soft and hard tissues. The transition
zone represents the area between the prosthetic crown and the
implant3. The complicating factor in implantology is obtaining pink
esthetics in areas that have bone and gingival (mucosal) deficiencies.
The treatment plan has to include possible grafting procedures to
maintain the tissue architecture or recover what was lost4.
Taking into account an individual’s characteristics, soft and hard
tissue grafting can be performed before, simultaneously, or after
implant placement5. Soft tissue defects present a varied etiology. The
cause of the defect determines the approach to correct it.
Defects caused by limited bone availability, gingival biotype, and
altered dental position are simpler to resolve before implant
placement. Tissue defects caused by implant mispositioning may
require implant removal, tissue regeneration, and placement of
another implant in the proper three-dimensional(3D) position.

OBJECTIVES
At the end of the chapter the reader should be able to:
Understand the techniques needed to improve peri-implant tissue.
Determine the appropriate treatment(s) for tissue changes.
Determine the appropriate time for grafting and implant placement.
2. SCIENTIFIC BACKGROUND

Correction of peri-implant esthetic defects (Figs 01A–C) should be

performed only after the cause has been determined. In fact,
prevention of defects is more predictable; however, it is possible to
correct peri-implant defects at the time of reopening or with the
prosthesis in place6.

01. A–C Soft tissue defects peri-implant (A). Comparison between

contralateral teeth shows complications that are difficult to treat (B, C).

Changes in the architecture, color, contour, or texture of peri-

implant tissues may represent complications around implants and
require treatment. Surgery is often unable to address these defects
alone and should be combined with restorative and orthodontic
procedures, especially when there is loss of interproximal tissue (Figs
02A–F). Correction of these defects is necessary to achieve adequate
quantity and quality of peri-implant tissues. Failures usually occur due
to incorrect placement of the implant, lack of gingival and bone tissue
grafts, or because of altered healing after surgery6.

02. A–F Patient with a gummy smile and history of multiple implant
losses on tooth 21. The implant was clinically stable but with recession
of the peri-implant margin and papillae (A–C). Due to previous implant
loss, the patient opted to try to maintain the implant at first. The
limitations of this case were properly explained. A multidisciplinary
approach was planned and the first surgical step to increase tissue
thickness began (D–F).

Bone grafts have been extensively used in implant dentistry to allow

for implant placement in the correct position7,8 or correct minor peri-
implant defects9. Thus, the grafting procedure has great value when
attempting to obtain a favorable peri-implant esthetic.
Similarly, soft tissue grafts aim to improve the transition zone for
more favorable results. Free gingival grafts may be indicated for
volume increase, vertical gain, and the creation of a band of attached
gingiva6.
Corrections to the ridge or around implants can be classified
according to the indicated time for implant placement. Thus,
regenerative procedures can be performed preventively, before
implant placement, at the same time as surgery, or after implant
osseointegration.

2.1. CORRECTIVE PROCEDURES BEFORE IMPLANT

PLACEMENT

Changes in tissue architecture represent horizontal, vertical, or

combined defects. The predictability of regeneration will depend on
the interproximal and buccolingual remaining bone structure.
Orthodontic or surgical procedures may be necessary.

2.1.1 ORTHODONTIC TREATMENT

Implant placement is difficult in patients with dental misplacement
(Figs 03A–L). In many cases, lack of space between teeth, a narrow
interocclusal space, and excessive buccal or palatine displacement of
neighboring teeth prevent implant placement in the proper position. If
this type of dental malposition is present, orthodontic treatment is
necessary to allow the implant to be placed in the correct position10.
03. A–L Patient with a history of trauma in the anterior region of the
deciduous dentition, which resulted in poor dental positioning (A).
Orthodontic treatment repositioned the teeth in the maxillary arch and
tractioned the impacted tooth (B–I). After orthodontic movement and
traction of tooth 12, loss of the mesial papilla and absence of
adequate prosthetic space on tooth 11 (J–L) were noted. These
changes are most easily diagnosed during treatment, when
professionals from different specialties directly participate in treatment.
Orthodontic treatment: Dr Deise Cunha.
 Controlled orthodontic movement may promote vertical bone
growth, while slow extrusion of a tooth combined with occlusal wear
can prevent occlusal trauma11. A thick gingival biotype maximizes the
results.
In the past, orthodontic extrusion was used on a compromised tooth
to position the buccogingival margin at least 1 mm coronal to the
contralateral tooth. After extraction and rehabilitation with implants, the
same amount of buccal recession was expected12. Maintenance or
indication for extraction will depend on root shape, dental and
periodontal condition, remaining bone structure, and prosthetic
planning. If an extraction or any other surgical procedure involving the
interproximal tissue is necessary, a minimum of 4–8 months must be
allowed to stabilize the newly formed bone tissue13.
Currently, orthodontic extrusion is recommended when there is loss
of papillae or extensive periodontal defects (Figs 04A–U). If there is
gingival recession of up to 3 mm in the compromised tooth, a
minimally invasive approach can be performed to reposition the
margin coronally at the time of implant placement. The combination of
optimal implant positioning, use of a slightly exposed connective
tissue graft, and manufacture of a provisional prosthesis with concave
subgingival profile will improve gingival level14 (Figs 05A–F and 06A–
F).
04. A–U Patient with a history of chronic trauma on tooth 11 with
painful sensitivity and presence of buccal fistula (A, B). Exploratory
surgery was performed and a dye used to diagnose the presence of
an oblique fracture. Extensive buccal, mesial, and distal bone loss
was detected (C–E). After discussing the treatment options with the
patient, they opted for an attempt to maintain the tooth through slow
orthodontic extrusion to improve the interproximal tissue condition (F).
If the dental condition was poor after the orthodontic therapy, the
patient agreed to undergo extraction and implantation. The tooth was
slowly extruded and a considerable bone increase occurred in the
interproximal region (G–P). Tomographic aspect before and after
orthodontic extrusion (Q, R). Note the improvement in the condition of
the buccal bone and limited amount of periodontal attachment at the
end of therapy. The patient opted to keep tooth 11 and its
rehabilitation with a ceramic crown (S–U).

05. A–F Ten-year follow-up of the previous case where maintenance

of the interproximal papillae can be noted; after this period, the root
presented a buccal fracture (A–C). The tooth was carefully removed to
maintain the crown that would serve as a temporary tooth (D). The
implant was placed in the ideal 3D position and the buccal region was
grafted with biomaterials and connective tissue grafts (E, F).

06. A–F Implant stability in the socket was 50 N; a provisional with an

undercontour on the cervical was manufactured from the crown of
tooth 11 (A–C). Postoperative follow-up, where it was possible to note
an increase in heightof approximately 2 mm (D–F). The complete
surgical staging is presented in Chapter 8. Orthodontic procedure: Dr
Deise Cunha; restorative procedure: Dr Bianca Vimercati; surgical
procedure (implant and grafts): Dr Fausto Frizzera.

2.1.2. SURGICAL PROCEDURES FOR BONE

IMPROVEMENT
The use of grafts is recommended when it is not possible to place
implants in the correct position; this may occur in severely resorbed
ridges, posterior regions of the maxilla with maxillary sinus
pneumatization, or in post-extraction sockets with severe bone defects
and poor remaining bone structure7,15,16. In such cases, a healing
period after grafting (4–8 months depending on the defect, type, and
graft) is necessary before the implant is placed (Figs 07A–G to 12 A–
E).
07. A–G Region of tooth 22 with tissue deficiency in thickness (A).
The bone defect (B) was treated with a block bone graft removed from
the retromolar region, adjusted, and fixed with a screw (C). The
spaces between the block and the receiving area were filled with
autogenous particulate bone (D) and the grafted area was covered
with a membrane. Postoperative aspect after 8 months with implant
and healing abutment in place; note the volume increase obtained (E).
Frontal and sagittal views of the use of the autogenous block graft (F,
G). Surgical procedure: Dr Jamil Shibli.
08. A–L The region of tooth 22 was previously grafted; the patient
reported having received a fresh and frozen homogenous bone graft
(A, B). A flap was created to remove the fixation screw (C) and install
the implant; note the appearance of the grafted tissue as it is different
from the patient’s native bone (D). Postoperative aspect 6 months
after the implant was installed (E), soft tissue contour (F), and proof of
the metal infrastructure (G); rehabilitation was completed and the
patient had no complaints. Three years later, the patient returned
complaining about a whitish area around the implant. Clinically, there
was evidence of bone tissue exposure (H). The necrotic fragment was
removed. This event was correlated with the absence of remodeling,
vitality, and vascularization of the homogeneous bone graft (I, J).
Frontal and sagittal views of the use of the homogeneous graft in a
block (K, L). Surgical procedure: Dr Samy Tunchel and Dr Jamil
Shibli.
09. A–H A patient with ectodermal dysplasia reported that no teeth
had erupted in his mouth and could not use removable dentures (A).
Absence of teeth formation led to the nondevelopment of the ridge
and consequent severe atrophy of the maxillary bones (B, C). Before
implant placement, bone grafting with xenograft material was planned
using bilateral maxillary sinus elevation and thick bone grafting in the
region of the canine eminence (D–F). The procedure was started by
collecting blood to produce L-PRF to aid soft tissue healing (G, H).
10. A–E A total flap covering the maxilla was created note the limited
amount of tissue (A, B). The maxillary sinus was lifted bilaterally and
filled with inorganic bovine bone particles (C–E).
11. A–I The canine eminence was perforated bilaterally and received
the xenograft bone to increase thickness; the bone graft was covered
with a resorbable collagen membrane (A–F). On the left, the
membrane was fixed with titanium tacks; on the right, this fixation was
not performed because the bone tissue was very thin and there were
microfractures that prevented its fixation. The L-PRF membranes were
positioned in the regions with these microfractures and over the
collagen membranes to enhance healing (G). Postoperative images
after 1 (H) and 7 (I) months when graft exposure was not verified.
12. A–E Tomographic aspect of the grafted region; note that the
region that received membrane fixation showed better results after
graft incorporation. In the canine eminence regions, it was possible to
place the implant in the correct position, although it requires additional
bone grafting. In the maxillary sinus regions, it was possible to obtain
a satisfactory result in only one surgery (A–C). Frontal and sagittal
views of the xenograft and membrane stabilized with tacks (D, E).
Surgical procedure: Dr Fausto Frizzera and Dr Judith Ottoni.
 Bone grafts can be used during implant placement to correct bone
defects or fill gaps between implants and post-extraction alveolar bone
walls17 (Figs 13A–F). Due to the lower potential of bone neoformation
and reduced nutrition, a ridge that has a cortical component will
present a greater biologic challenge to be regenerated than one that
also has medullary bone. Increase in thickness is more easily
achieved than height18.
13. A–F Bone defect in thickness (A, B), height (C, D), and combined
or 3D (E, F).

The option to perform 3D reconstructions to increase height is

determined by the height of the interproximal bone (Figs 14A–D and
15A–F). The height of the interproximal bone crest will also determine
the presence and provide mechanical support to the interdental
papilla18. Due to the limitations and risks of this type of reconstruction,
it is recommended that the implant be installed only after graft
incorporation.
14. A–D The potential for bone neoformation is defined by the
interproximal bone ridges and alveolar ridge envelope.
15. A–F Combined defect (height and thickness) on tooth 13; note
preservation of the interproximal bone ridges of teeth 12 and 14
allowing for 3D reconstruction of the ridge (A). A screw was placed
vertically to support the nonresorbable palatine-fixed, titanium-
reinforced membrane (B). The region was prepared by bone
perforations and received a mixture of autogenous bone and
biomaterials; the membrane was then fixed on the buccal area (C, D).
Then 8–12 months after the grafting procedure, the membrane and
screws were removed and the implant was placed. Frontal and sagittal
views of the use of titanium-reinforced membrane to stabilize
xenograft and autograft (E, F).

Autogenous grafts combined with biomaterials (50% each) are

recommended to treat complex height and thickness defects before
the placement of implants. The feasibility of a combined approach with
the growth factor recombinant human bone morphogenetic protein-2
or leukocyte- and platelet-rich fibrin (L-PRF) should be verified (Figs
16A–E to 18A–H). Post-extraction and peri-implant bone defects,
maxillary sinus lift, and horizontally resorbed ridges with or without
fenestration can be resolved satisfactorily with the use of
osteoconductive biomaterials2.
16. A–E Absence of tooth 21; note the loss of papillary heightin this
region (A). In the tomographic exam, it was possible to notice
extensive bone loss in height and thickness, requiring a 3D
reconstruction (B). One flap was elevated, the bone defect was
verified, and the nasopalatine foramen was deflated (C).
Demonstration with periodontal probes of the intended reconstruction
(D, E).
17. A–J For tissue reconstruction, inorganic bovine bone was mixed
with liquid L-PRF and recombinant human bone morphogenetic
protein-2 was prepared (A–E). The titanium mesh was initially fixed on
the buccal and the defect was filled with bone graft; the mesh was
then fixed on the palatal (F). L-PRF (G) membranes were placed over
the mesh. The flap was then sutured (H) and showed no exposure
during the healing period (I) with considerable bone gain (J).
18. A–H Removal of the titanium mesh (A–C). Reconstruction of the
alveolar ridge was apparent, allowing the implant to be placed in the
ideal 3D position (D). Final aspect immediately after prosthetic
rehabilitation (E, F). Frontal and sagittal representation of the use of
titanium mesh to stabilize the grafts (G, H). Surgical procedure: Dr
Elcio Marcantonio Jr; Prosthetic rehabilitation: Dr Lelis Nicoli.

Regardless of the type of bone defect present, it is important that

the area that will receive the graft and implant presents quantity and
quality of soft tissue compatible with the desired esthetic result.
Changes in color, volume, texture, or absence of attached gingiva
may hinder or make the esthetic resolution of the case difficult and
should be corrected before grafting and implantation19.
2.1.3. PROCEDURES FOR SOFT TISSUE IMPROVEMENT
The treatment of chromatic changes of the ridge or teeth is considered
a challenge and will depend on the etiology. The color of the tissue
may be altered due to hyperpigmentation and require its complete
removal. In addition, changes in soft tissue color may occur due to thin
tissue thickness that shows the color of the underlying implant,
biomaterial, or tooth. In these situations, a connective tissue graft
increases tissue volume and masks the color change6 (Figs 19A–C).
19. A–C Change in color, volume, and texture due to limited presence
of attached gingiva (A), gingival thickness, pigmentation by
exogenous substances (B), and thickness limitation (C).

To treat changes in texture, such as scarring, it is first necessary to

evaluate the volume of soft tissue present. If the tissue is thick, it is
possible to perform gingival peeling20. On the other hand, if the tissue
is thin, a volume increase with a connective tissue graft is indicated
before peeling.
Absence of attached gingiva combined with a shallow vestibule can
be a complicating factor in anterior regions that need an implant or
graft. Conventional surgery to increase the attached gingival band with
a free gingival graft usually results in changes in color and texture. To
avoid this type of alteration, porcine collagen matrix (Geistlich
Mucograft has been used with satisfactory results in cases where
there is a minimum of 2 mm of keratinized gingiva. The mucograft can
be combined with a narrow and long free gingival graft (Figs 20A–F)
and sutured around and apically to a soft tissue graft18,21.
20. A–F Technique for increasing the attached gingival band (A) by
combined free gingival graft and collagen matrix (Geistlich
Mucograft)21. A divided flap at the mucogingival junction is apically
sutured (B). Then a long narrow free gingival graft is removed from
the hard palate region and sutured to the lateral and apical portion
joining the attached gingival region of the adjacent teeth (C). The
collagen matrix is cut and stabilized with sutures (D). The graft is
progressively incorporated (E, F), allowing for increased vestibule
depth and an attached gingival band with more satisfactory esthetic
results compared to the free gingival graft alone.

2.2. CORRECTIVE PROCEDURES AT THE TIME OF

IMPLANT PLACEMENT

Bone and gingival grafts may be required at the time of implant

placement (Figs 21A–G and 22A–K). Determining which graft to use
will depend on the extent of the defect, the gingival biotype, and flap
thickness. The bone defect present should be treated by bone
augmentation techniques18. Bearing in mind that it is often not possible
to fully regenerate the bone ridge, soft tissue grafts compensate for
ridge remodeling after grafting and provide a thicker and better-quality
tissue6,22. Flaps less than 2 mm thick and cases of thin biotype should
receive a connective tissue graft.
21. A–G Ridge augmentation by combining expanders and
biomaterials (A–C). An appropriate flap should be performed; lance
drill used at the height determined during preoperative planning (D–
G).
22. A–K Expanders are then progressively used for ridge expansion
and placement of an implant of the appropriate diameter.

2.2.1. SOFT TISSUE GRAFT

Soft tissue grafts used around implants should be thicker than those
around teeth. Subepithelial connective tissue is the gold standard
material due to the favorable esthetic result. The area of choice for
graft removal is the hard palate or maxillary tuberosity. Graft
integration with the surrounding tissues is easy to achieve due to the
blood supply from the periosteum and flap that will cover the graft
(Figs 23A–I), which makes this procedure predictable and favorable6.
23. A–I Absence of tooth 21 with loss of facial volume (A). Flap
elevation showing enough bone to place an implant (B–D). To
compensate for loss of facial volume, a thick connective tissue graft
was removed and sutured to the facial flap (E, F). Postoperative
outcome at 1 (G) and 6 months (H); after tissue conditioning with a
provisional, it was possible to obtain an adequate tissue contour (I).
Prosthetic–surgical procedure: Dr Jamil A. Shibli, Dr Renan Dalla
Soares and Dr Jose D. Pasqua-Neto.

The thickness increase obtained with an autogenous soft tissue

graft ranges from 2 mm to 2.5 mm. Both grafts, from the tuberosity
and palate, presented similar thickness loss in a long-term follow-up
study23. The advantage of using the graft removed from the tuberosity
is a better postoperative period and the option to remove thicker
grafts. Over time, small changes in texture of the grafted area may be
noted.
Recently, a new xenogenous biomaterial (Geistlich Fibro-Gide) was
developed to increase tissue volume without the need to remove the
graft from another intraoral region, which reduces procedure time and
surgical morbidity22. The biomaterial consists of resorbable and
biocompatible porcine collagen, which has volumetric stability (Figs
24A–K and 25A–G). Thoma et al22 in a study comparing this
biomaterial to autogenous connective tissue grafts demonstrated
similar and satisfactory results with 3 months of follow-up. New
studies are being conducted to evaluate the stability of this new type
of graft over time.
24. A–K Implant previously installed on #8 with tissue volume
deficiency where it is possible to notice grayness through the mucosa
(A–C). Geistlich Fibro-Gide adaptation (15 × 20 × 6 mm) according to
defect size and use of palatal flap to facilitate closure without tension
on the graft (D–G). Postoperative of 7 (H) and 60 days (I). Clinical
procedures for reopening and fabricating a provisional restoration to
condition the tissue (J, K).
25. A–G After tissue stabilization, an impression was taken to make
two porcelain crowns (A–E). Situation at the 6-month follow-up (F, G).
Surgical and restorative procedure: Dr Daniel Thoma. Case kindly
provided by Geistlich Pharma, which owns all image rights.

The graft removed from the palate has excellent clinical results. It
can be removed extensively but its thickness is limited by the
characteristics of the palate. It is best indicated for situations where an
implant, bone graft, and membrane will be used together; this area is
preferred to the tuberosity because the graft will have lower density
and greater vascularization. If suture dehiscence occurs, the part
initially exposed will be the gingival graft, protecting the guided bone
regeneration area24 (Figs 26A–P).
26. A–P Patient had uncontrolled type 2 diabetes mellitus with root
fracture and active infection on tooth 11 (A–C). Extraction and early
implant placement were planned. Bone tissue aspect 2 months after
extraction (D). The implant was installed using the provisional
prosthesis as a surgical guide (E, F), the defect was regenerated with
inorganic bovine bone (G) and collagen membrane (H), and a
connective tissue graft was stabilized over the ridge and sutured (I–K).
Seven days after surgery, the flap showed satisfactory healing.
However, after 14 days the patient returned, complaining of pain;
suture dehiscence with exposure of connective tissue graftwas noted
(L). Topical application of chlorhexidine gel to the affected region was
recommended and chlorhexidine mouthwash was used until the fourth
week, when total wound closure was verified. Clinical and
tomographic appearance after 1 year of follow-up, when the patient
was still unable to control his diabetes mellitus; they return to
periodontal and peri-implant maintenance every 4 months (M–P).
Surgical procedure: Dr Fausto Frizzera; restorative treatment: Dr
Marco Masioli.

2.2.2. BONE GRAFTS

When the soft tissues present favorable characteristics, and it is
possible to place the implant in the ideal 3D position, regeneration of a
bone defect can be done with a combined approach. For more
favorable results, a gingival graft and bone regeneration may be
performed in combination with implant placement. Single-step
procedures reduce the need of multiple surgeries, which is interesting
from the point of view of patient recovery but increases the length of
surgery25.
 Bone graft stability was demonstrated by a series of studies26,27.
Buser et al28 showed stable results after 6 years of follow-up of
implants placed 4–8 weeks after extraction (type 2) combined with a
collagen membrane and inorganic bovine bone. No implant had
recession greater than or equal to 1 mm from the buccal peri-implant
margin and the buccal bone presented an average thickness of 1.9
mm in the computed tomography evaluation28.

3. CLINICAL APPLICATION

Initial planning is, in fact, the best time to predict possible esthetic
deficiencies around implants and determine hard and soft tissue
deficiencies. The approach at this time promotes more predictable
results with regard to obtaining the correct esthetics. 3D implant
positioning is perhaps the most important factor for esthetic excellence
(Figs 27A–Y to 36A–K).
27. A–Y This patient reported a history of trauma in the anterior region
and periapical surgery on tooth 22 for over two decades. Clinically,
color and volume changes were observed in the gingival tissue around
teeth 21 and 22 (provisional). Tooth 21 was prepared and received a
provisional fixed partial prosthesis (A–G). The pigmented area was
delineated with a scalpel blade and a flap was performed to remove
the entire area (H–M). Removal of tissue pigmentation resulted in the
removal of all attached gingiva. The remaining ridge was punctured to
stimulate bleeding and nourish a collagen matrix sutured over the
surgical area (N–S). Postoperative situation at 2 and 6 weeks. The
clinical and histopathological diagnosis was of amalgam tattoo (T–Y).
28. A–W Before grafting and implant placement on teeth 21 and 22, a
connective tissue graft was used to increase gingival thickness,
reduce volume loss, and mask the color change.
29. A–H Clinical steps for graft suture.
30. A–L A mixed flap was initially made with total thickness and then
divided into the buccolingual bone defect area. After the flap’s
passivity was confirmed, two connective tissue grafts were removed
from the hard palate region and sutured on teeth 21 and 22. After 1
week, the sutures were removed and the provisional was reduced in
the region between tooth 21 and tooth 22 to allow better papillary
accommodation (A–D). After 3 weeks, a satisfactory tissue contour
was verified (E). Two months after surgery, tissue conditioning was
started by adding resin to the provisional (F–H). During this phase, the
patient reported an incident where the temporary came loose along
with the post and a fracture with subgingival extension occurred (I, J).
A new post was cemented and a new provisional was made
respecting the new tissue arrangement (K, L).
31. A–O After corrections in the soft tissue, implant installation and
tissue regeneration on tooth 22 (A–L) were planned. A total-thickness
flap was reflected and the bone fenestration was curetted, creating
communication between the buccal and palatal parts (M–O).
32. A–J A round bur was used to make a flat area for initial
preparation with the lance bur (A). The perforations were guided by
the patient’s own provisional and a narrow implant was placed in the
ideal 3D position, obtaining primary stability of 45 N/cm2 (B–J).
33. A–I Finally, the root volume of tooth 21 was reduced, the
periosteum was incised for flap release, and the grafts were
performed.
34. A–F Sutures on the donor area; the receiving area was sutured to
close the flap by first intention. The provisional was relieved to avoid
compression of the surgical area.
35. A–G Two weeks after surgery, the sutures were removed. The
postoperative of the grafted area (A–F) was verified. Three months
after surgery, a periapical radiograph (G) was performed; a circular
incision was made to reopen the implant for immediate manufacture of
the provisional; then the flap was apically repositioned on tooth 23 for
clinical crown lengthening.
36. A–L Clinical and radiographic aspects after healing (A, B). An
impression of tooth 21 and implant on tooth 22 was taken for the
definitive porcelain crowns (C). Porcelain try-in and appearance after
adjustments (D–F) and installation (G, H). Patient’s smile after
treatment (I) and comparison between the initial presentation (J, K)
and the final result (L). Surgical procedures: Dr Fausto Frizzera;
laboratory technician: Anderson Hirle. Treatment performed in the
Integrated Clinics and Implantology Course at FAESA Centro
Universitário; restorative procedures supervised by Prof Conceição
Moulin and Prof Gabriela Cassaro de Castro.

Reductions in buccal bone height or thickness and change in

gingival biotype may be achieved previously to or in combination with
implant placement through soft and hard tissue grafts. Interventions at
these stages promote more predictable esthetic results than future
corrections (Tables 1 and 2).
Table 1 Correction of bone or soft tissue defects before or during
implant placement
Table 2 Treatment strategies to correct teeth and ridge alterations

Peri-implant defects after implant placement can be corrected using

soft and hard tissue grafts but only minor defects can be corrected.
Major defects are usually associated with a thin biotype and a
misplaced implant that cannot be resolved without replacing it with a
new implant.

REFERENCES

1. Slagter KW, Meijer HJ, Bakker NA, Vissink A, Raghoebar GM.

Immediate single-tooth implant placement in bony defects in the
esthetic zone: a 1-year randomized controlled trial. J Periodontol
2016;87:619–629.
2. Buser D, Sennerby L, De Bruyn H. Modern implant dentistry
based on osseointegration: 50 years of progress, current trends
and open questions. Periodontol 2000 2017;73:7–21.
3. Domínguez GC, Fernández DA, Calzavara D, Fábrega JG.
Immediate placement and restoration of implants in the esthetic
zone: trimodal approach therapeutic options. Int J Esthet Dent
2015;10:100–121.
4. De Bruyckere T, Eghbali A, Younes F, De Bruyn H, Cosyn J.
Horizontal stability of connective tissue grafts at the buccal aspect
of single implants: a 1-year prospective case series. J Clin
Periodontol 2015;42:876–882.
5. Kuchler U, Chappuis V, Gruber R, Lang NP, Salvi GE. Immediate
implant placement with simultaneous guided bone regeneration in
the esthetic zone: 10-year clinical and radiographic outcomes.
Clin Oral Implants Res 2016;27:253–257.
6. Sculean A, Chappuis V, Cosgarea R. Coverage of mucosal
recessions at dental implants. Periodontol 2000 2017;73:134–
140.
7. Spin-Neto R, Stavropoulos A, Coletti FL, Faeda RS, Pereira LA,
Marcantonio Junior E. Graft incorporation and implant
osseointegration following the use of autologous and fresh-frozen
allogeneic block bone grafts for lateral ridge augmentation. Clin
Oral Implants Res 2014;25:226–233.
8. Dos Anjos TL, de Molon RS, Paim PR, Marcantonio E,
Marcantonio Junior E, Faeda RS. Implant stability after sinus floor
 augmentation with deproteinized bovine bone mineral particles of
different sizes: a prospective, randomized and controlled split-
mouth clinical trial. Int J Oral Maxillofac Surg 2016;45:1556–1563.
9. Felice P, Soardi E, Piattelli M, Pistilli R, Jacotti M. Esposito M.
Immediate non-occlusal loading of immediate post-extractive
versus delayed placement of single implants in preserved sockets
of the anterior maxilla: 4-month post-loading results from a
pragmatic multicentre randomised controlled trial. Eur J Oral
Implantol 2011;4:329–344.
10. Patil PG, Karemore V, Chavan S, Nimbalkar-Patil SR, Kulkarni R.
Multidisciplinary treatment approach with one piece implants for
congenitally missing maxillary lateral incisors: a case report. Eur J
Prosthodont Restor Dent 2012;20:92–96.
11. Nazzal AM, Trojan TM, Green M. Uprighting and periodontally
accelerated osteogenic orthodontics as an alternative to surgical
crown lengthening. J Clin Orthod 2016;50:507–511.
12. Salama H, Salama M. The role of orthodontic extrusive
remodeling in the enhancement of soft and hard tissue profiles
prior to implant placement: a systematic approach to the
management of extraction site defects. Int J Periodontics
Restorative Dent 1993;13:312–333.
13. Buskin R, Castellon P, Hochstedler JL. Orthodontic extrusion and
orthodontic extraction in preprosthetic treatment using implant
therapy. Pract Periodontics Aesthet Dent 2000;12:213–219; quiz
220.
14. Spinato S, Agnini A, Chiesi M, Agnini AM, Wang HL. Comparison
between graft and no-graft in an immediate placed and immediate
non- functional loaded implant. Implant Dent 2012;21:97–103.
15. Mordenfeld A, Lindgren C, Hallman M. Sinus floor augmentation
using Straumann® BoneCeramicTM and Bio-Oss® in a split
mouth design and later placement of implants: a 5-year report
from a longitudinal study. Clin Implant Dent Relat Res
2016;18:926–936.
16. Scheyer ET, Heard R, Janakievski J, et al. A randomized,
 controlled, multicentre clinical trial of post-extraction alveolar ridge
preservation. J Clin Periodontol 2016;43:1188–1199.
17. Felice P, Zucchelli G, Cannizzaro G, et al. Immediate, immediate-
delayed (6 weeks) and delayed (4 months) post-extractive single
implants: 4-month post-loading data from a randomised controlled
trial. Eur J Oral Implantol 2016;9:233–247.
18. Urban IA, Monje A, Lozada JL, Wang HL. Long-term evaluation of
peri-implant bone level after reconstruction of severely atrophic
edentulous maxilla via vertical and horizontal guided bone
regeneration in combination with sinus augmentation: a case
series with 1 to 15 years of loading. Clin Implant Dent Relat Res
2017;19:46–55.
19. Khzam N, Arora H, Kim P, Fisher A, Mattheos N, Ivanovski S.
Systematic review of soft tissue alterations and esthetic outcomes
following immediate implant placement and restoration of single
Implants in the anterior maxilla. J Periodontol 2015;86:1321–
1330.
20. Basha MI, Hegde RV, Sumanth S, Sayyed S, Tiwari A, Muglikar
S. Comparison of Nd: YAG laser and surgical stripping for
treatment of gingival hyperpigmentation: a clinical trial. Photomed
Laser Surg 2015;33:424–436.
21. Urban IA, Lozada JL, Nagy K, Sanz M. Treatment of severe
mucogingival defects with a combination of strip gingival grafts
and a xenogeneic collagen matrix: a prospective case series
study. Int J Periodontics Restorative Dent 2015;35:345–353.
22. Thoma DS, Zeltner M, Hilbe M, Hämmerle CH, Hüsler J, Jung
RE. Randomized controlled clinical study evaluating effectiveness
and safety of a volume-stable collagen matrix compared to
autogenous connective tissue grafts for soft tissue augmentation
at implant sites. J Clin Periodontol 2016;43:874–885.
23. Spain ER. Soft-tissue volume gain around dental implants using
autogenous subepithelial connective tissue graft from the or
tuberosity preliminary results of a randomized prospective clinical
study. Osteology Monaco 2016 Apr.
24. Zuhr O, Hürzeler M. Cirurgia Plástica Estética Periodontal e
Implantar. São Paulo, Brazil: Quintessence, 2013.
25. Kolerman R, Nissan J, Mijiritsky E, Hamoudi N, Mangano C, Tal
H. Esthetic assessment of immediately restored implants
combined with GBR and free connective tissue graft. Clin Oral
Implants Res 2016;27:1414–1422.
26. Aludden HC, Mordenfeld A, Hallman M, Dahlin C, Jensen T.
Lateral ridge augmentation with Bio-Oss alone or Bio-Oss mixed
with particulate autogenous bone graft: a systematic review. Int J
Oral Maxillofac Surg 2017;46:1030–1038.
27. Benic GI, Hämmerle CH. Horizontal bone augmentation by
means of guided bone regeneration. Periodontol 2000
2014;66:13–40.
28. Buser D, Chappuis V, Kuchler U, et al. Long-term stability of early
implant placement with contour augmentation. J Dent Res
2013;92(12 Suppl):176S–182S.