Giovanni Zucchelli Claudio Mazzotti

Mucogingival
esthetic surgery
around implants

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 To our families
Giovanni Zucchelli, Claudio Mazzotti
FOREWORD

Thi s book from Giovanni Zucchelli, as well as the previous one, Mucog ingival Esthetic Surgery, is a
marvelous opportunity to take a journey through biology, esthetics, and surgery.
Prof Zucchelli has been able to put all the passion and the science that guides him in his profession-
from research to teaching to clinical practice - in this volu me, wh ich provides the attentive reader useful
technical information and a guide for surgical decision making.
Meticulous application of biologic foundations and a refined technique-achieved after many years of
study, research, and dedication to cl inical practice - along with perfect step-by-step documentation of
all of the techniques, allow the readers to follow the path outlined by the author, to share the importance
of the mucogingival techniques applied to implantology, and to make them th eir own .
In summary, this is a magical book in which science meets art and poetry, a book that makes us explore
the secrets of soft tissue surgery around implants, but also tells us so much about its author and of his
professional comm itment and passion.
The clinicians who are about to browse through th is book will not be able to refrain from reading it pas-
sionately, as if it were a rousi ng novel, and turn it into a guide for their surg ical choices, as I have done.

Massimo de Sanctis
FOREWORD

This work by Giovanni Zucchelli and Claudio Mazzotti , with Carlo Monaco and Martina Stefan ini as
co-authors, represents a milestone in modern implantology that will survive the physiologic obsoles-
cence of printed paper in the scientific field due to its strong subliminal eth ical message and for the
coherence of the educational path expressed in a masterful flow of chapters. The ethical message
derives from the countless emotions and reactions that this work will provoke in all of the clinicians,
scholars, and educators that care about the oral and psychologic health of the patients they treat.
After immersing themselves in this book, after a carefu l evaluation of the clinical cases presented that
were solved with innovative and predictable approaches due to their long follow-up , the following
question will arise: How did we get to this point?
The "subliminal ethical message" derives from the warning enclosed in this work: the lack of knowl-
edge and tendency for improvisation in medicine inevitably create a series of physical and psychologic
problems for our patients.
After this caution notice, by going into scientific detail and treating the topic exhaustively, this book
offers all of the educational tools for the clinicians to perform implantology correctly.
The classification of peri-implant esthetic defects provides a practical tool that allows the cl inician to
establish the best-suited therapy.
This volume offers an innovative vision regarding the proposed therapeutic solutions and at the same
time presents a balanced perspective about when to use traditional options, such as bone augmenta-
tion, along with masterful techniques for soft tissue management; it offers a modern and interdisciplinary
vision of implant treatment in wh ich periodontology and restorative dentistry fuse together in a rational
and effective stream to solve "impossible" clinical cases.
Through this book we have confirm ation that thorough knowledge of the different fields of dentistry is
the critical foundation for ethical and modern implant treatment. The sequence of the chapters al lows
not only the expert clinician but also the student to enter the world of modern implantology through a
coherent learning path .
This work serves the objectives of both a textbook for students and a valid instrument to update the
professional knowledge of experienced clinicians .
Lastly, I express my appreciation toward the authors and co-authors who, thanks to their efforts, have
allowed the creation of a piece that wi ll contribute to improving the health of our patients-which should
be the ultimate goal for all clinicians.
Furthermore , I am sure that this work wi ll endure the passage of time unaffected thanks to its strong
ethical advice along with an undisputed educational value.

Tiziano Testori

v
PREFACE

As a periodontist, I have witnessed the birth of implantology feeling somewhat detached and, I must
adm it, also a bit disturbed since I was faithful to the teaching "better to have a tooth even if in a terminal
stage than any kind of implant". They spoke of surfaces and bone, that is to say "osseointegration".
Not that this is not important; on the contrary, if osseointegration had not become a certainty I wou ld
not be here writing the preface for this book.
My interest in implantology began when "keratinized tissue" came onto the scene, and its importance
for the hygiene maintenance and long-term survival of implants started to be acknowledged. The term
peri -implant soft tissues had not been coined yet, a term that for most is still synonymous with kera-
tinized tissues, but there was talk of soft tissues useful for the sole purpose of protecting the bone.
However, there was never a mention of that which could be most appreciated by the patient: the shape
and size of the tooth (clinical crown for the experts), the color and texture of the gingiva (peri-implant
mucosa for the experts), and how the tooth emerges from the gingiva (emergence profile for the experts) .
What is the patient aware of? What does the patient want? These are the questions that triggered my
interest in implantology and gave impetus to the birth of this book.
To make it simple, patients don't want to perceive any difference between the implant and their tooth.
The shape of the tooth's clinical crown on its apical half depends on the contour of the gingival mar-
gin and the height of the papillae; the remaining coronal half depends, so to speak, on the skill of th e
dental technician in reproducing the shape of the neighboring teeth. The clinica l crown length of the
implant depends on the distance between th e incisal edge (responsibility of the dental techni cian) and
the mucosal margin, wh ich should be at the same height and have the same scall op as the gingival
margin of the contralateral tooth. The papi llae, very important for the patient, are also made up of soft
tissues and should fill up the entire interdental space up until the contact point, which should also match
the contact point of the contralateral tooth.
The patient is also able to see the buccal mucosa, which should be indistinguishable from the ging iva
on the adjacent teeth , as much or as little keratinized as it may be.
The emergence profile of the implant crown shou ld also draw inspiration from the natural tooth. Th e
ideal seagull wing-shaped profile, which we consider pretty and natural, is created by the convexities
of th e buccal enamel and of the buccal soft tissues. However, the latter convexity does not extend
more than 3 to 4 mm apical from the gingival margin ; more apically, the soft tissues follow the profile
of the underlying bone, which proceeds in a palatal direction. If we consider that the buccal bone is
found at least 3 to 4 mm from the mucosal margin of the implant crown, it is difficult to thin k that bone
reconstruction techniques can be done to augment th e buccal soft tissue profile when the soft tissues
around adjacent teeth do not have a convex buccal profile but follow a palatal inclination.
This right here is how this book was born, from the understanding that peri-implant soft tissues playa
decisive role in our patient 's esthetic satisfaction. No longer do soft tissues serve the sole purpose of
preserving bone; soft tissues must please the patient. More specifically, the soft tissues that determ ine
patient satisfaction are suprabony; they are found several millimeters coronal to the buccal bone crest
(mucosal margin of the implant crown) and interproximally (the papillae) , and their stability depends
mostly on the thickness of the connective tissue of wh ich they are composed rather than on the position
and thickness of the underlying bone.
Faithful to the old definition of keratinized tissue, we have the supraperiosteal soft tissues that should
protect the bone crest and improve plaque control performed by the patient. The difference between
suprabony soft tissues and supraperiosteal keratinized tissue is related to the surgical techniques.
Bilaminar techniques are meant to augment the thickness of the suprabony soft tissues with the
main goal of improving esthetic patient satisfaction . The free gingival graft technique has the goal of
augmenting the height of the keratinized tissues to improve hygiene maintenance and peri-implant
health .
The sequence of this book 's chapters follows my personal path when approaching implantology and
express my somewhat personal vision of it. I started with the treatment of peri-implant soft tissue
dehiscences (PSTDs) , most of which affected implants without buccal bone defects or even those
previously treated with bone reconstruction techniques. In other words , I started with patients who
complained about esthetic defects around the implant crown despite good implant osseointegration .
The esthetic and functional long-term success of a procedure that combined prosthetics and surgery
led me to think that perhaps the role of the soft tissues was being underestimated and maybe the
role of the integrity of the buccal bone was being overestimated.
The next step, regarding the very successful treatment of soft tissue dehiscences associated with
buccal bone defects, confirmed my suspicions about the key role of the soft tissues and the pros-
thetic restoration in spite of the lack of integrity of the buccal bone.
The successful treatment of peri-implant esthetic defects encouraged me toward the next step: What
can be done at the time of or before implant placement to avoid these esthetic defects?
That's how the mucogingival approach to implant insertion was born , applied both to the immediate
and delayed implant and changing depending on the extent of the ridge defect and of the reason
(dental or periodontal) that led to tooth extraction.
The esthetic and functional success of the mucogingival approach led to the following step: appli -
cation of soft tissue surgery for the treatment of borderline esthetic cases in which other more
"conventional" approaches could have been applied.
It is a sort of challenge to the alleged limits of soft tissue management for the treatment of esthetic
implant cases with the goal of encouraging the reader toward the "future direction" of peri-implant
soft tissue surgery, which nowadays cannot be considered "predictable" by the standards of scientific
evidence but that is evidently possible and can give great satisfaction to our patients. Th e long-term
stability of the outcome, an increased number of treated cases, and the confirmation of the results
by the scientific literature wi ll tell if these alleged limits can be overcome in a predictable manner.
One of the special features of this book of which I am most proud is the treatment plan and decision
tree for implant therapy in esthetic areas, starting with the reason for tooth extraction. Despite having
abandoned the periodontal "romanticism" in wh ich the implant is always the last option with respect
to the conservation of a tooth, even at the expense of esthetics and function, one cannot consider
the extraction of a tooth for dental reasons (endodontic problems, fracture , internal/ external root
resorption, invasive carious lesions) to be the same as the extraction of a tooth for periodontal rea-
sons. In the latter case, the patient is affected by a disease (periodontitis) that should be treated (both
from a nonsurgical and, if needed , surgical point of view) before starting implant-related therapies.
VI I
Postextraction implant placement is almost always "forbidden" either because th e patient hasn't com -
pletely healed from periodontitis or because the extent of the bone loss (sometimes also at the level of
the adjacent tooth) is such as to prevent immediate implant placement.
This book is meant to promote the need for a periodontal background in order to strive for successful
implant therapy for our patients. Not only because implants cannot be successfu l in patients with peri-
odontal disease, but because periodontal, and mucogingival in particular, surg ical skill is fundamental
for the management of peri-implant soft tissues.
That is why we chose a title almost entirely identical to the one of my previous book. The same bio-
logic principles and techniques that apply to mucogingival th erapy around teeth are applied today to
peri-implant soft tissue surgery, and th ey make it possible to achieve once unexpected esthetic and
functional results.
The gingiva does not exist around implants and, therefore , mucogingival surgery around implants cannot
exist; my wish is that this "mistake," already mentioned in the book title, can be an incentive for the
astute reader to apply around implants the same mucog ingival surgical principles and techniques they
have learned to apply around teeth.

Giovann i Zucchelli
ACKNOWLEDGMENTS

Rereading the acknowledgments from my past book, I can confirm every single word that was written
10 years ago. This is a very beautiful thing, an accomplishment, in my life. It shows that the dearest
and most important people have remained the same after so much time and are even more so today.
A huge thank you to my wife Claudia, our love and her support have allowed me to achieve in these 10
years so many other professional gratifications that I cou ld not have mastered without her closeness
and assistance. Thanks again for having made me proud of our wonderfu l children.
A different thank you to my ch ildren , Alessia and Alessandro, now young adults. Now, it 's not only their
loving glances and th eir smiles that give me peace of mind; them having become serious and fine (and
beautiful) adults is the main incentive and motivation for my professional success and for my dedication.
I am so proud of you guys, and I want you to be proud of me.
I renew, with all my heart , my thanks to my role models who are no longer with us and whom I miss
more and more each day: my father and Prof Marcello Calandriello.
My friendship and unconditional esteem for Prof Massimo De Sanctis have led me to ask him once again
to write the foreword for this book, and it is thanks to his teachings that this second book could be born.
I particularly want to thank Claudio Mazzotti , my true disciple. His talent as a clinician , his scientific rigor,
and his stability are an added value to this work. Having him alongside me as an author fill s me with pride.
A heartfelt thank you to my co-authors, Carlo Monaco, for his unparalleled skill and expertise on the
prosthetic work done for the cl inical cases presented in this book, and Martina Stefanini , for the help
in drafting and preparing this book and for the unconditional (and unwavering) effort to give scientific
value and rigor to all (or almost all) of the words written .
I reiterate my thank you to my "guys" that help me every day in my professional activities and at the
University: Monica Mele, Matteo Marzadori, IIham Mounssif, Matteo Sangiorgi , Pietro Bellone, and
Alexandra Rendon. Without you r help, I would not have been able to do this book.
I particularly thank Alexandra Rend6n for the English translation of this book, a truly huge task.
A heartfelt thank you to Tiziano Testori , a true friend and mentor in implantology, but above al l a "vision-
ary" and the first one to understand the key role of the peri-implant soft tissues when people were still
thinking about other things. Thanks for having honored me by writing the preface to this book.
I wou ld also like to th ank my friend Guido Gori; thanks to his drawings this book became more "artis-
tic" and beautiful and hopefully made it easier to understand the various steps of the peri-implant soft
tissue surgeries.
Finally, I want to than k Maria Grazia Monzeg lio for allowing me to make this book like I wanted to even
if it was unconventional for the publishing company.
I also thank Alessio Buono for his techn ical assistance and professionalism for this book' s graphic
design .

Giovanni Zucchelli

IX
ACKNOWLEDGMENTS

This moment, wh ile I prepare to write the acknowledgments, is a special moment in wh ich I feel very
proud and light-hearted. I finally reached the end of this incredible adventure , made up of efforts, sac-
rifices, endless hours of work, and vacations and weekends spent in front of the computer, but always
aware that only he who sows may one day reap the fruit of his hard labor.
I clearly remember the day in which my "maestro" asked me to write this book alongside him; it 's
hard to describe the emotions that I felt, ones that made that moment unique and special and that wi ll
remain engraved in my mind for all my life. For this reason , my first heartfelt thank you goes to you,
Prof Giovanni Zucchelli , my teacher and mentor, who has honored me and continues to honor me with
his teachings, and who has made me grow in my profession and in life by conveying his passion for
periodontics , professional ethics, the love for teaching, and the sacrifice and ambition to never limit
oneself. To you, I express my immense gratitude.
A huge thank you to the love of my life, my wife and colleague IIham Mounssif, for her essential aid in
the elaboration of this book, a wonderful and special woman who supports me and helps me every
day both at work and in my private life, the pillar of my life without wh ich I cou ldn't have achieved any
of this. To you, the center of my universe, I will be eternally and lovingly grateful.
To my large family, my mother Maria Laura, my sister Simona and my best friends, thanks for the support
and encouragement that is ever present in the brightest and darkest moments. Our closeness makes
my life sim pler and more enjoyable. I love you from the bottom of my heart.
Thanks to my frie nds and colleagues, Martina Stefanini , Matteo Marzador, Monica Mele, and Valentina
Bentivogli , for their support and advice throughout the making of this book. In particular, I want to thank
Martina Stefanini for the enormous help given during the elaborati on of thi s work.
A heartfelt thanks to my colleagues and friends Giovanni Polizzi and Tomasso Cantoni for having wel-
comed me many years ago in "their" Verona, a city in wh ich I have grown professionally and personally
by their side.
I thank the doctors from Prof Zucchelli's department, in particular Riccardo Zambaldi and Francesco
Maiani, two young motivated and promising periodontists who helped us prepare the countless pictures
presented , and Alexandra Rendon for her extraordinary work in translating the entire book into English.
To Guido Gori, thanks for you r creativity and for your artistic vei n, reflected in your beautiful designs,
which are an added value for th is book.
Finally, I wou ld like to thank Alessio Buono and Maria Grazia Monzeg lio for bearing with and supporting
our cou ntless modifications and requests and for the passion that you put into making this publication.

Claudio Mazzotti
ABOUT THE AUTHOR

Prof Giovanni Zucchelli DDS, PHD

Graduated in 1988 with a degree in dentistry from the University of Bologna, Italy.
He was awarded a PhD in medical biotechnology from the same university.
Professor of periodontology at the University of Bologna, Italy.
Head of the Department of Peri odontology and Dental Hyg iene at the University of Bologna, Italy.
Coordinator of the degree course in Dental Hyg iene at the University of Bologna, Italy.
Honorary member of the American Academy of Periodontology (AAP).
President of the Italian Academy of Osseointegration (lAO).
Member of the editori al boards of the International Journal of Periodontics and Restorative Dentistry,
the Journal of Periodontology, and the International Journal of Oral Implantology.
Associate editor of the International Journal of Esthetic Dentistry.
Active member of the European Academy of Esthetic Dentistry (EAED), the Italian Society of
Periodontology (SldP), th e Italian Academy of Osseointegration (lAO), and the European Federation
of Periodontology (EFP).
Author of more than 130 scientific publications in the field of periodontics and implantology.
Winner of various awards in Europe and the United States for scientific research in the field
of periodontology.
Co-author of two illustrated textbooks on periodontal plastic surgery (Ed. Martina) and of the chapter
"Mucog ingival Therapy- Periodontal Plastic Surgery" in Clinical Periodontology and Implant Dentistry
(Lindhe J, Lang NP , Karring T reds]; Wi ley-Blackwell).
Author of the book Mucogingival Esthetic Surgery, published by Quintessence Publishing
and translated into 12 languages .
Speaker at major Italian and international conferences on the topics of periodontics
and implantology.
XI
ABOUT THE AUTHOR

Dr Claudio Mazzotti
Graduated in 2005 with a degree in dentistry. In the year 2010, he obtained a master's degree
in periodontology from the University of Siena.
Active member of the Itali an Society of Periodontology (SldP) since 2011 .
Coordinator of th e "young SldP" group for the 2020-202 1 period.
Co-author of the chapter "Root Coverage Techniques for Treating Multiple Recessions"
in the Atlas of Periodontology and Implant Therapy of the SldP (Quintessence Pu blishing Italia).
Collaborates in research and clinical activities with Prof G. Zucchelli at the Department
of Periodontology of the University of Bologna.
Tutor and faculty member for the master's degree program in periodontology and clinical
implantology and tutor in the international master's program for soft tissue management around
teeth and implants at the University of Bologna.
Comm ittee member of the Board of Dentistry of the State Medical Board of Ravenna
(from 2018 to date).
Author of scientific publications in Italian and international journals and speaker at courses
and conferences.
ABOUT THE CO-AUTHORS

Prof Carlo Monaco

Graduated in 1992 with a degree in dentistry from the University of Bologna, Italy, where he was
subsequently adjunct professor from 1997 to 2000.
Visiting researcher at the Department of Cariology, directed by Prof Ivo Krejci, at the University of
Geneva between the years 2000 and 2004.
Obtained a master's degree in science (2003) and a PhD in dental materials (2005) at the University
of Siena with Prof M. Ferrari.
Researcher at the University of Bologna since 2006.
Up to 2020, taught undergraduate courses on fixed prostheses on natural teeth and implants and
prosthodontics at the University of Bologna.
Italian Academy of Prosthetic Dentistry (AIOP) award winner for best research in the field of
prosthodontics in the years 2005, 2008, and 2009.
Obtained a PhD in material science in 20 13 from the Faculty of Engineering , University of Bologna.
Associate professor at the University of Modena and Reggio Emilia, teaching the courses of implant
prosthodontics and removable prosthodontics in the school of dentistry.
Dean of the master's degree program in prosthodontics and implant prosthetics with advanced
technologies , University of Bologna.
Since 2004 collaborating with Prof G. Zucchelli in the development of clinical and research protocols
related to implant-supported restorations, soft tissue management, and the interrelationship between
prosthodontics and periodontics in the natural dentition .
Active member of the AIOP and the Italian Academy of Osseointegration (lAO).
Fellow of the International Team for Implantology since 20 18.

Dr Martina Stefanini, PhD

Graduated in 2005 w ith a degree in dentistry from the University of Bologna, Italy. Attended Prof G.
Zucchelli's department at the University of Bologna since 2005 as a scholarship holder.
Obtained a master's degree in periodontology from the University of Siena in 2011 , in collaboration
with the Italian Society of Periodontology (SldP). Obtained a PhD in medical science in 2016 from the
University of Bologna.
Since 2018, she is a researcher in the Department of Biomedical and Neuromotor Sciences (DIBINEM),
University of Bologna.
She is responsible for the teaching activities for the degree in dental hygiene at the University of Bologna.
Faculty member for the international master's program in soft tissue management around teeth and
implants at the University of Bologna.
Active member of the SldP since 2012.
Fellow of the International Team for Implantology since 2018.
Member of the Osteology Foundation Council since 2020.
Board member of the National Osteology Group Italia (NOGI).
Author and co-author of scientific publications in international journals and speaker at multiple Italian
and international conferences.
XIII
CONTENTS

VOLUME 1
FOREWORDS IV

PREFACE V

ACKNOWLEDGMENTS VI

ABOUT THE AUTHORS XI

D ETIOLOGY AND CLASS IFI CATION OF PERI-IMPLANT ESTHETIC DEFECTS 2

. : . PROSTHETI C -SURGICAL TREATMENT 32

~ OF PERI -IMPLANT SOFT TISSUE DEHISCENCES

II HARVEST OF A CONNECTIVE TISSUE GRAFT 174

II IMPLANT REPLAC EMENT IN THE ESTH ETI C ZONE 202

~ MUCOGINGIVALAPPROACH FOR IMPLANT PLACEMENT

. : . . TO REPLACE A SING LE TOOTH IN THE ESTHETIC AREA 286
II MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT 300

MUCOGINGIVAL APPROAC H FOR THE IMMEDIATE 416

II POSTEXTRACTION IMPLANT

VOLUME 2
II SOFT TISSUE MANAGEMENT IN NON -ESTHETI C AREAS 538

r.w MUCOG ING IVALAPPROACH FOR THE REPLACEMENT 656

-.:.II OF A TOOTH EXTRACTED FOR PERIODONTAL REASONS

rJi' MUCOGINGIVAL APPROAC H TO MULTIPLE TOOTH REPLACEMENT 776

1.1:.1 WITH DENTAL IMPLANTS

m SOFT TISSUE MANAGEMENT AT THE SECOND-STAGE SURGERY 912

If) SOFT TISSUE MANAGEMENT IN COMPLEX CAS ES 962

m ESTHETI C EVALUATION OF IMPLANT-PROSTHETIC THERAPY 1064

xv
 I
1\

"~ I'

I
.'
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)
I
" "

\
JI

Etiology
and Classification
of Peri-implant
Esthetic Defects
t~LC
ETIOLOGY AND CLASSIFICATION OF PERI-IMPLANT ESTHETIC DEFECTS
The goal of intraoral implant restorations in the
esthetic area is to reestablish adequate function
while creating a prosthesis that blends in with the
natural dentition. Not being able to identify the
"real" tooth from the "fake" one is fundamental
when striving for full satisfaction of patient de-
mands. In ideal situations in the esthetic zone, th e
buccal aspect of the rough im plant portion should
be positioned 3 to 3.5 mm apical to the muco-
sal margin of the future prosthetic crown , which
must be at the same level and have the same
scallop as the gingival margin of the contralateral
Courtesy of: ' John Wiley and Sons. Periodontal 2000. 2018 Jun;77(J):JSO-J64.
tooth (red dotted line) . Correspondingly, in the
natural dentition , the buccal bone crest is at a
distance of around 3 to 3.5 mm from the gingival
margin. In healthy conditions, the gingival margin
is placed around 1 mm coronal to the cemen-
toenamel junction (CEJ), wh ile the buccal bone
crest is located about 2 mm apical to the CEJ.
On a natural tooth, soft tissues are attached to
the root surface through a connective tissue
attachment made up of perpendicularly insert-
ed fibers that are mineralized inside of the root
cementum .
 ETIOLOGY AND CLASS IFICATI ON OF PERI-IMPLANT ESTHETIC DEFECTS
Supracrestal
soft tissue
Transmucosal
path
There are several clinical and histologic char-
acteristics that peri-implant mucosa and gin-
giva share, but there are also some important
differences.
Just li ke the gingiva, the external surface of the
peri-implant mucosa is also lined with a kerati-
nized oral epithelium , which is continuous with a
sulcu lar epitheliu m and a thin barrier epithelium
(with similar characteri stics to those of the peri-
odontal junctional epithelium) that ends approxi-
mately 1 to 1.5 mm coronal to the bone crest and
whose length depends on the health statu s of
the ti ssues. Unlike the supracrestal fibers around
teeth that are inserted into th e radicular cement
through the connective tissue attachment, the
collagen fibers of th e connective tissue in th e
peri-implant suprabony compartment originate
from the periosteum at th e bone crest and run
in a direction parallel to the implant surface to-
ward the soft tissue margin , creating only a con-
nective tissue ad hesion. The term peri-implant
............. ....... .... .......... .. j .... j ......... .
Supracrestal
soft tissue
I Transmucosal
/J.-,f.. .. ·..Hf·"".. ...... .... ·•·...... J.... !.......... path
supracrestal soft ti ssues (PSTs) refers to the soft
tissues th at surround a dental implant and whose
vertical dimension corresponds to the distance
from the bone crest to the mucosal margin . Th e
so-called transmucosal path is th e tissue th at
runs from the most coronal aspect of the bone
judged to be in contact with the im plant to the
gingival margin; in an apicocoronal direction, it in-
cludes the su lcu lar epitheliu m, th e junctional ep-
ithelium , and an area of connective tissue adhe-
sion. In the esthetic zone, the transmucosal path
and the supracrestal soft tissues almost always
co incide, so the terms co uld be considered syn-
onyms. On the other hand , the mucosal channel
(or mucosal tunnel), on ly visible after crown re-
moval, corresponds to th e internal aspect of the
peri-implant soft ti ssues that are not adhered to
the implant-prosthetic surface. Th e latter defini-
tion was introduced to differentiate this zone from
th e transmucosal path , which comprises the tis-
sues adhered to the implant-prosthetic surface.
5
ETIOLOGY AND C LASS IFICATION OF PERI -IMPLANT ESTHETI C DEFECTS
Th e type of im plant-bone- or tissue-Ievel- can influence the depth of the mucosal tunnel but not the
height of the supracrestal soft ti ssues.
MU.COSAL TUNNEL
To prevent recession of th e mucosal margin
(peri -implant soft ti ssue dehiscence [PSTDJ)
or grayish soft ti ssue discoloration due to the
underlying implant-prosthetic structures, su-
pracrestal soft ti ssues should be augmented.
Th e challenge is to establish th e minimum soft
tissue thi ckness th at will allow th e transmu-
cosal path to remain stable and not undergo
recession w hen faced w ith bacterial co loniza-
ti on or traumati c tooth brushing. Taking into
co nsideration th at, in the natural dentition, the
area occupied by the inflammatory infiltrate
(dotted white line) induced by subgingival bac-
teri al plaque accumulation or trauma from tooth
bru shing is about 1 to 1.5 mm , it follows that
th e thi ckness of th e connective ti ssue co m-
prised between the external oral epitheli um
and th e intern al sulculari juncti onal epith elium
Courtesy of: • Edra . Oental Cadmos. 2020;88(9):1-21 .
should be more than 1.5 mm . In this way, an
area of healthy co nnective tissue (black dotted
arrow) will persist, ensuring vasc ular support
to the mucosal margin (black arrows) and thu s
preventing recession. In addition, several stud -
ies have highlighted the need for at least 2 to 3
mm of peri -im plant ti ssue thi ckness, depend-
ing on th e prostheti c materials used , in order
to avoid soft tissue discolo ration caused by the
proximity of the underlying implant-prosth etic
components-a situation that would negatively
affect the esth eti c outco me. These co nsider-
ations lead to the co nclusion th at th e soft tis-
sues (epith elium plus co nnective ti ssue) at th e
level of the supracrestal portion req uire a thi ck-
ness of at least 2 mm to prevent both the oc -
currence of mucosal recession and unestheti c
ti ssue discolorati on.
 ETIOLOGY AND CLASS IFI CATION OF PERI-IM PLANT ESTHETIC DEFECTS

Keratinized ti ssues are measured from the muco -
sal margin of the implant-supported crown to the
mucog ingival junction. Both their color and height
change fro m one patient to another and from one
area to another in th e same pati ent 's mouth; in
some cases, th ey are easily identifiable, while in
others it can be hard to recognize the mucog in-
gival line demarcation. The position of th e latter
is geneti cally determin ed and is not in any way
affected by the type of implant or prosthetic co n-
necti on. Th e height of the keratinized tissues, by
itself, is not correlated with the development of
PSTD, but it can help mask the implant-prosth et-
ic components thanks to the characteri stics of its
underlying connective tissue. However, the height
of the keratinized tissues does influence the es-
thetic outcome and plaq ue co ntro l, making tooth
brushing more effi cient. The amount of kerati-
nized tissue at th e level of the implant-supported
crown should not differ from that present on the
adjacent teeth: either a lack or an excess of kera-
ti nized ti ssues could lead to an esth etic problem.

Mucosal margin

Keratinized tissues

Mucogingival junction

**
7
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ETIOLOGY AND C LASSIFICATION OF PERI-IMPLANT ESTHETIC DEFECTS
The term peri-imp/ant soft tissue dehiscence
(PSTD) describes the recession of the buccal
mucosal margin at an implant site. Whi le in natu-
ral dentition the definition of gingival recession is
universally accepted as the apical displacement
of the gingival margin with respect to the CEJ,
there is no agreement on the definition of PSTD
due to the lack of a fixed reference point around
implants. Some authors use the mucosal gingival
margin at the moment of final restoration place-
ment as a reference point, wh ile others use the
exposure of the metallic surface of the implant
or prosthetic abutment. In the authors' opinion,
these choices aren't always appropriate because
they don't take into account the position of the
gingival margin of the co rresponding natural
PSTD may result in one or several esthetic/ bio-
logic complications, including:
• Increase in the apicocoronal clin ical dimen-
sions of the prosthetic crown in comparison
to the corresponding natural tooth.
• Exposure of the metallic surface (of the im-
plant or prosthetic abutment), which further
worsens the already unesthetic aspect of the
restoration due to the increased height of the
implant prosthesis and to th e negative visual
Courtesy of: • Quintessence Publishing. Eur J Orallmplanto!. 2018;11(2):215-224 .•• Quintessence Publishing. Int J Periodontics Restorative
Dent. May-Jun 2013;33(3):327-35 . ... John Wiley and Sons. Periodontal 2000. 2018 Jun;77(1):256-272.
tooth. As a matter of fact, an increased height of
the prosthetic clinical crown with respect to that
of the homologous natural tooth is often the main
concern for patients with esthetic comp laints. For
this reason, we define a PSTD as any apical migra-
tion of the peri-implant mucosal margin in relation
to its ideal esthetic position, which is represented
by the gingival margin of the corresponding natu-
ral tooth . Previously described anatomical consid-
erations lead to the conclusion that early stages
of PSTD development might entirely depend on
the thickness of the soft tissues at the level of the
transmucosal path, wh ile exposure of the implant's
rough surface is a result of the progression of the
PSTD and can only happen in the absence of in-
tegrity of the buccal bone plate.
impact caused by the color of the implant
and/or prosthetic abutment.
• Discoloration of the buccal soft tissues due to
the shine-through effect of the gray-colored
implant-prosthetic components.
• Exposure of the implant body, which-be-
cause of its macro/micro surface roughness-
tends to accumulate bacterial plaque, favoring
further apical migration of the soft tissues and/
or the onset of mucositis or peri-implantitis.
 ETIOLOGY AND CLASSIFICATION OF PERI-IMPLANT ESTHETIC DEFECTS

The reason for development of PSTD on the Implant Position

buccal aspect remains controversial. There
are several anatomical/predisposing factors
(buccally positioned implant, buccal bone de-
hiscence, insufficient keratinized tissues, thin
gingival phenotype, coronally inserted frenula
or muscle pull) and other pathologic/precipi-
tating factors (plaque-induced inflammation,
trauma induced by tooth brushing or by the
incorrect use of dental fl oss) that concur and
eventually cause apical migration of the soft
tissue margin.
The most important predisposing factor associ-
ated with the development of peri-implant soft
tissue dehiscence is incorrect implant position-
ing. An excessively buccal position creates ana-
tomical cond itions that favor apical migration of
the marginal soft tissues. Whenever an implant is
placed outside of the alveolar bone housing, the
implant platform acquires a marked buccal posi-
tion, putting stress on the soft tissues, which in
turn become thinner and are more prone to the
development of mucosal recession .

Similarly, excessive buccal inclination of the implant-even if placed inside the bony envelope-can
also lead to the formation of a dehiscence, since a very facially displaced implant platform can also
cause stretching and thinning of the buccal soft tissues and result in the same outcome.

9
ETIOLOGY AND CLASSIFICATION OF PERI-IMPLANT ESTHETIC DEFECTS

An excessively apical position of the implant
platform can also favor development of a PSTD
characterized by an increased clin ical height of
the implant-supported crown. In these situations,
the transmucosal path has increased ve rtical di-
mensions, and if th e peri-implant soft tissues are
not thick enough, they will more easily undergo
recession. In addition, shallow vestibular depth
common ly associated with this condition makes
plaque control more difficult. For these reasons,
it is considered a predi sposing factor for PSTD
without metallic exposure.

Soft Tissues In our opinion, the minimum soft tissue thick-

The most important predisposing factor for PSTD ness at the level of the peri-im plant transmuco -
development, in addition to implant malposition, sal path needed to prevent formation of PSTD or
is red uced thickness of the buccal soft ti ssues. unesthetic translucency of the im plant-prosth eti c
Just as in natural dentition, implant-supported components is at least 2 mm.
crowns with a thin/scal loped phenotype have a
higher predisposition for development of margin-
al soft tissue recession. What has yet to be es-
tablished is th e minimum th ickness of the buccal
soft tissues that would be capable of preventing
formation of PSTD and whether that thickness is
the same as the one needed to prevent gingival
recession in natural dentition.
In the authors' opinion , given the considerable
difference between the quality of adhesion of
soft tissues onto the natural root surface (con-
nective tissue attachment) and that of soft tis-
sues in the transmucosal path onto the suprabo -
ny implant-prosthetic structure (no attachment),
the minimum thi ckness of the buccal soft tissues
needed to redu ce the ri sk of recession of the
marginal tissues cannot be the same for natural
teeth and implant-supported restorations.

Courtesy of: • John Wiley and Sons. Periodonto/2000. 2018 Jun;77(1):256-272.

 ETIOLOGY AND CLASSIFICATION OF PERI-IMPLANT ESTHETIC DEFECTS
Buccal keratinized tissue (KT) height also seems
to influence the stability of the peri-implant soft
tissues. Cases in which the buccal soft tissues
possess a reduced band of KT, probably due to
the lesser quantity of dense connective tissue,
seem to have a higher predisposition to the devel-
opment of PSTD over time. Additionally, reduced
depth of the vestibule, wh ich is often associated
with this anatomical condition, makes it harder for
the patient to maintain good plaque control, and
so it becomes a predisposing factor for PSTD.
Hard Tissues
Buccal bone and its relationship with the den-
tal implant have an influence on the overlying
soft tissues. Presence of a thick buccal bone
wall is important to support the soft tissues,
which w ill be less inclined to migrate apical-
ly. Th e opposite is tru e for a thin buccal bone
wall.
However, given that the buccal bone crest is
located at a distance of 3 to 3.5 mm from the
implant crown's marginal soft ti ssues (length
of the peri-implant transmucosal path), for the
purpose of PSTD formation, buccal soft tissue
thickness at the transmucosal path (white dot-
ted line) is more important than the thickness
of the buccal bone crest; however, the latter is
still cruc ial to prevent exposure of the surface
of the implant affected by PSTD.
11
ETIOLOGY AND C LASSIFICATION OF PERI-IMPLANT ESTHETIC DEFECTS

The superim position of the

clinical and radiographic im-
ages shows the distance (3
to 3.5 mm) between the pros-
thetic crown's marginal soft tis-
sues and the underlyi ng buc-
cal bone crest (transmucosal
path). Therefore, to prevent de-
velopment of PSTD, it is nec-
essary that a minimum soft tis-
sue thickness of 2 mm extends
apical ly throughout the length
of the peri-im plant transmuco-
sal path (3 to 3.5 mm).

Absence of the buccal bone wall (bone dehiscence) is a condition that favors apical progression of th e
PSTO, with consequent pathologic exposure and contamination of the implant surface .

Integrity of the buccal bone

wall happens to be critical, es-
pecially in the case of postex-
traction implant placement. In
those circumstances, defects
of the buccal wall can signifi-
cantly increase the ri sk for
development of PSTO with
patholog ic exposure of the im-
plant 's buccal surface .
 ETIOLOGY AND CLASSI FICATION OF PERI-IM PLANT ESTHETIC DEFECTS

Th e position of the interproximal bone crest can also influence the position of the implant-supported
crown's marginal soft tissues. Integrity of the interdental bone peaks is important for the support of the
interproximal soft tissues, which in tu rn can affect the position of the buccal soft tissues.

Loss of peri-implant papillae frequ ently goes hand in hand with the formation of buccal PSTD.

**
13
Courtesy of.' • J ohn Wiley and Sons. Clin Oral Implants Res. 2021 Mar;32(3):349-358. '" John Wiley and Sons. J Periodontal. 2019
Oct;90(10):1116-1124.
ETIOLOGY AND CLASSIFICATION OF PERI -IMPLANT ESTHETIC DEFECTS
Implant
Certain factors related to the characteristics
of the implant itself can contribute to the de-
ve lopment of PSTD. Amongst them, implant
diameter is one of the most important since
large-diameter implants are more frequent-
ly associated w ith PSTD. This happens even
in the absence of positioning errors because
Some types of implant-abutment connections
seem to playa protective role regarding the
risk for PSTD. The use of platform-switching
systems as we ll as the more recent conical
an implant w ith a diameter that is too large
is anatomically constrained to an excessively
buccal position , which leads to stretching and
thinning of the buccal soft tissues and eventu -
ally also recession . Additionally, large-diameter
implants are more likely to be associated with
bone dehiscences-a factor that favors apical
progression of PSTD.
connections seem to reduce marginal bone
loss, favoring maintenance of the buccal bone
crest and therefore positively affecting the sta-
bility of the overlying soft tissues.
 ETIOLOGY AND CLASSIFICATION OF PERI-IMPLANT ESTHETIC DEFECTS

The goal of buccal dehiscence treatment on osseointegrated implants is to obtain complete dehiscence
coverage (CDC), keeping in mind that the reference point has to be the gingival margin of the contra-
lateral natural tooth. Achievement of a CDC will result in the recovery of soft tissue harmony, with a
noticeable improvement in the esthetic impact of the implant-supported restoration.

To facilitate the accomplishment of comp lete coverage and to avoid visibility of the implant-prosthetic
components through the mucosal tissues (grayish discoloration), soft tissue thickness must be aug-
mented, especially in the most coronal millimeters (peri- implant transmucosal path) where the tissues
are not supported by the underlying bone, transforming a medium or thin phenotype into a thick one.

Therefore, another goal of the treatment is to
site-specifically modify the patient's pheno-
type, creating a marginal soft ti ssue thickness
of at least 2 mm that is continuous for 3 to
4 mm apicocoronally. This wil l be achieved by in-
creasing the thickness of the dense connective
tissue found between the external oral epitheli-
um and the junctional/sulcular epithelium of the
peri-implant transmucosal tissues. Therefore,
if the thickness of the connective tissue found
between the two epithelial layers is greater than
the area occupied by the inflammatory infiltrate
(black dotted line) induced by subgingival bac-
terial plaque (black arrow) or tooth-brushing
trauma (blue arrow), then an area of healthy
connective tissue wi ll remain to support the
mucosal margin and prevent dehiscence of the
peri-implant soft tissues (histologic sections
published with permission from Prof Massimo
De Sanctis).

15
Courtesy of: • Quintessence Publishing. Int J Periodontics Restorative Dent. May-Jun 2013;33(3):327-35.
ETIOLOGY AND CLASSIFICATION OF PERI-IMPLANT ESTHETIC DEFECTS
CLASSIFICATION OF BUCCAL PERI-IMPLANT SOFT TISSUE
DEHISCENCE/DEFICIENCIES
by Martina Stefanini
In addition to provid ing a standard system, the
goal of the classification of buccal peri-implant
soft tissue dehiscence/deficiencies at single im-
plant-supported crowns in the esthetic zone is to
propose a decision tree that wi ll guide the clini-
cian during the choice of the appropriate thera-
peutic approach . As previously mentioned , de-
hiscence of the peri-implant mucosa is defined
as an apical displacement of th e implant-sup-
ported crown's soft tissues with respect to their
ideal position, which in the presence of adjacent
teeth is represented by the position of the gin-
gival margin of the natural correspond ing tooth.
It follows that the objective of the mucogingival
therapy should be to achieve complete coverage
of the dehiscence by the replacement of the gin-
gival margin in the ideal position.
Thi s classificati on is intended for correctly
placed , osseointegrated dental implants without
Class I: The buccal soft tissue margin of the
implant-supported crown is in an esthetically
correct position (at the same level of the ide-
al gingival marg in of th e natural corresponding
Class II: Th e buccal soft tissue margin of th e
implant-supported crown is in a more apical
position than th e ideal gingival margin of the
natural contralateral tooth, but the profile of the
implant-supported crown is positioned with in
Courtesy of.' • John Wiley and Sons. J Periodontal. 2019 Oct;90(10):1116-1124.
signs of peri -implantitis. According to the 2017
World Workshop on Periodontal and Peri-
implant Diseases and Conditions, diagnosis of
peri -implantitis is based on the following criteria:
implants th at show signs of inflammation (bleed-
ing or exudate), radiographic bone loss in com-
parison to initial healing, and increased probing
depth with respect to values registered after
implant restoration. In the absence of previous
radiographs or probing depth measurements, a
radiographic bone loss of ~3 mm in association
with bleeding and probing depths of ~ 6 mm are
indicative of peri-implantitis.
The classification we propose comprises four
classes and three subclasses. The class is es-
tab lished by th e position of the implant crown
and implant platform. Subclasses, on the other
hand, are defined accord ing to th e height of the
interproximal soft tissues (peri-implant papillae).
tooth), but the implant and/or abutment is visible
through the mucosa, there is a lack of keratin ized
tissue, and/or the thickness of the buccal soft
tissue is insufficient.
*
(palatal to) the imaginary curved line (black dot-
ted line) th at passes through the buccal soft ti s-
sue profiles of the adjacent teeth at the level of
the gingival margin.
 ETIOLOGY AN D CLASSIFICATION OF PERI-IMPLANT ESTHETIC DEFECTS

Class III and IV: The buccal soft tissue mar-

gin of the implant-supported crown is in a more
apical position than the ideal gingival margin of
the natural corresponding tooth, and the crown's
profile is located outside (buccal to) the imagi -
nary curved line (black dotted line) that passes
through the buccal soft tissue profiles of the ad-
jacent teeth at the level of the gingival margin.
For these classes, it is imperative to remove the
implant crown in order to evaluate the position of
the implant platform .

When the implant platform lies within (palatal to

or at the level of) the straight imaginary line (red
dotted line) that passes through th e profile of the
adjacent teeth at the level of the gingival margin,
the dehiscence is classified as Class III .

When the implant platform lies outside (buccal

to) the red dotted line that passes through the
profile of the adjacent teeth at the level of the
gingival margin, the dehiscence is classified as
Class IV.

17
Courtesy of.- • John Wiley and Sons. J Periodontal. 2019 Oct;90(10):1116-1124.
ETIOLOGY AND CLASSIFICATION OF PERI-IMPLANT ESTHETIC DEFECTS

Each of the classes (except for Class I, in which subclass C does not apply) can be further divided into
the following subclasses in relation to the ve rti cal dimension and position of the peri-implant papillae:

C-.)--
I.
; f .•

a) The vertex of both papillae is positioned at a distance of ~3 mm coronal to the ideal position of
the soft tissue margin of the implant-supported crown.

b) The vertex of at least one of the papillae is positioned at a distance of <3 mm coronal to the ideal
position of the soft tissue margin of the implant-supported crown.

c) The vertex of at least one of the papillae is positioned at the same level as or apical to the ideal
position of the soft tissue margin of the implant-supported crown.

It follows that multiple combinations can
arise between the classes and subclass-
es. However, according to the authors, th e
therapeutic approaches that can be imple-
mented for the treatment of dehiscence/de-
ficiency of the peri-implant soft tissues are
essentially three:
• Coronally advanced flap plus a connective tissue graft
(without removing the existing implant-supported crown).
• A combined prosthetic-surgical-prosthetic approach
(see chapter 2).
• Soft tissue augmentation with submerged healing and
subsequent tissue punch to uncover the implant (see
chapter 12).

Courtesy of.' • Quintessence Publishing. Eur J Orallmplantol. 2018;11(2);215-224 . .. Quintessence Publishing. Int J Periodontics Restorative
Dent. May-Jun 2013;33(3);327-35. ... John Wiley and Sons. J Periodontol. 2019 Oct;90(10):1116-1124.
 ETIOLOGY AND CLASSIFICATION OF PERI-IMPLANT ESTHETIC DEFECTS
DECISION TREE
Class la
Th e implant-supported crown in the maxillary
right lateral inc isor position shows a soft tis-
sue margin th at is located in an esthetically
correct position when compared to the corre-
spond ing lateral incisor. Sti ll , when analyzing
the profile, a buccopalatal vo lume defic iency
is evident, causing the grayish tissue discol-
oration from the abutment/implant showing
through the thin mucosa. This deficiency can
be classified as Class I.
The distance between the vertex of both papil-
lae and the horizontal line that passes through
the mucosal margin of the implant crown (which
coincides with that of the contralateral incisor) is
~3 mm. Therefore, this represents subclass a.
The suggested therapeutic approach is a coro-
nally advanced flap with an underlying connec-
tive tissue graft. The treatment goal is to obtain
an increase in soft tissue thickness in order to
improve the emergence profi le and avoid the
underlying implant-prosthetic components from
showing through the buccal soft tissues.
19
ETI OLOGY AND CLASSIFI CATION OF PERI-IM PLANT ESTH ETIC DEFECTS
Class Ib
Th e soft tissue margin of the implant c rown in
th e maxillary left central incisor position is lo-
cated in an estheti cally correct position w hen
co nsidering th e gingival margin position of the
adjacent central incisor. W hen analyzing the
profil e, a bu cco lingual vo lu me defic it, w hic h
allows for visibility of th e abutment/im plant
To improve the quantity and quality of the in-
terprox imal soft tissues and ensure a better
vascular supply to the co nnective tissue graft,
it is advised to implement a combined pros-
th eti c-surgical- prosthetic approach. Thi s ap-
proach makes it possible to obtain , by means
of crown removal and subsequent reducti on
Courtesy o f: • Edra. Dental Cadmos. 2020;88(9):1-21.
throu gh the thin alveo lar mucosa, becomes
apparent. Th e horizontal soft ti ssue defi cien-
cy g ives the prostheti c crown an inadeq uate
em ergence profil e, both fro m an esth etic and
hyg ienic point of view. Th e height of th e im-
pl ant 's d istal papilla is <3 mm , w hich makes
thi s a Class Ib defi ciency.
of th e prosthetic abutm ent and placement of a
short provisional crown, interproximal soft ti s-
sue growth , w hich w ill fill up the space former-
ly occupied by th e initial abutm ent and crown.
(For a detailed description of the prosthetic -sur-
gical-prostheti c approach, please refer to chap-
ter 2).
 ETIOLOGY AND CLASSI FICATION OF PERI-IM PLANT ESTH ETIC DEFECTS
Class lIa
The position of the mucosal margin of the im-
plant-supported crown in th e maxillary right lat-
eral incisor position is api cal to its ideal position,
which constitutes a buccal soft tissue dehiscence
(PSTD). The crown's profile is within (palatal to)
Thanks to the adequ ate dimensions of the
interproximal soft tissues and to the co rrect
position of the crow n, it is possible to treat
the dehiscence without having to remove the
restoration . Surgical treatment co nsists of a
the imaginary curved line that passes th rough the
soft ti ssue margins of the adjacent teeth. Papilla
height is ::c3 mm, even if th e mesial papilla seem s
in a worse condition co mpared to the distal one.
For these reasons, the PSTD belongs to Class lIa.
co ronally advanced flap w ith an underlying
connective tissue graft. Th e goal, besides
cove rin g th e PSTD, is to mask the abutment
by increasing the thickness of th e buccal soft
tissues.
5 YEARS
21
ETIOLOGY AND CLASSIFICATION OF PERI-IMPLANT ESTHETIC DEFECTS
Class lib
The mucosal margin of the implant-supported
crown in the maxillary left lateral incisor position
is more apical with respect to the gingival mar-
gin of the corresponding lateral incisor (which
presents altered passive eruption), thus con -
stituting a buccal soft tissue dehiscence. The
profile of the crown lies within (palatal to) the
Even if the crown's emergence profile is deemed
correct, in the presence of inadequate papillae
(both in height and in thickness due to their tri-
angular shape with very thin vertices) it is advis-
able to remove the prosthetic crown and place a
shorter provisional on an abutment with reduced
mesiodistal dimensions in order to promote inter-
proximal soft tissue growth. Additionally, improve-
ment of the cleft on the mucosal margin of the im-
plant-supported crown is also expected with this
presurgical prosthetic phase. After the maturation
imaginary curved line that passes through the
soft tissue margins of the adjacent teeth. The
height of the papillae mesial and distal to the
implant-supported crown is <3 mm if the ide-
al position of the mucosal margin is taken into
consideration. For these reasons, the PSTD be-
longs to Class lib.
phase (around 2 months), the interproximal soft
tissues appear thicker, and there is continuity
between the buccal and palatal surfaces thanks
to the formation of isthmuses (black lines). This
will allow an extended de-epithelialization of the
papillae in a palatal direction, therefore increasing
the vascular bed for the surgical papillae of the
coronally advanced flap that will cover the con-
nective tissue graft. (For a detailed description
of the prosthetic-surgical-prosthetic approach,
please refer to chapter 2).
 ETIOLOGY AND CLASSIFICATION OF PERI-IMPLANT ESTHETIC DEFECTS

Class lie

The position of th e mucosal

margin of the implant-sup-
ported crown in the maxillary
right lateral incisor position
is apical to the gingival mar-
gin of the corresponding lat-
eral incisor, a situ ati on that
constitutes a PSTD. The im-
plant-supported crown has
an appropriate emergence
profile (Class II); however, the
interproximal papillae are in-
adequate for the obtain ment
of complete dehiscence cov-
erage without crown removal.
Th e im plant crown's mesial
papilla is even located api-
cal to the ideal position of th e
buccal mucosal marg in (black
dotted line). For these reasons,
the PSTD belongs to Class Ilc.

Subclass c represents the most unfavorable
clinical scenario, the one that many times leaves
the clinician undecided between removing the
im plant or not. The on ly factors that cou ld lead
the clinician to propose treatment of the PSTD
are the following: the implant, once the crown is
removed, is within the straight imaginary line that
connects the gingival margins of the adjacent
teeth (from an occlusal view), and it is possible
to submerge the implant entirely or partial ly after
abutment removal and placement of a closure
screw. If the space between the closure screw
and the adjacent teeth is filled with soft tissues, it
is possible to treat the implant site like an eden-
tulous area and use a submerged healing ap-
proach (connective tissue platform technique)
to obtain an apicocoronal and buccolingual in-
crease in the soft tissues. After soft tissue mat-
uration, implant uncovering is done by means
of an occlusal punch, and the soft tissue condi-
tioning phase is started with the placement of a
provisional crown. (For a detailed description of
the submerged healing approach for treatment
of PSTD, please refer to chapter 12).

23
ETIOLOGY AND CLASSIFI CATION OF PERI-IMPLANT ESTHETIC DEFECTS

Class ilia

A buccal soft tissue dehiscence (PSTD) is pres-
ent at the level of the im plant-supported crown
in the maxillary ri ght central incisor position , with
the mucosal margin being in an apical position
with respect to the gingival margin of the adja-
cent incisor. The profile of the implant-supported
crown lies outside of the imaginary curved line
that connects the buccal profiles of the adjacent
teeth, which makes crown removal necessary
in order to evaluate the position of the implant
platform. When the implant platform is with in the
straight imaginary line that connects th e gingival
margins of the adjacent teeth, the PSTD is con -
sidered a Class III. Given that the papillae dimen-
sion is ~3 mm , th e PSTD can be further classified
into subclass a. Once the crown is removed and
a provisional with reduced dimensions is placed,
coverage of the PSTD can be achieved with a
coronal ly advanced flap in conjunction with an
underlying connective tissue graft.

After the cond itioning phase with the provisional restoration and maturation of the soft tissues, the final
restoration can be placed.
 ETIOLOGY AND CLASSIFICATION OF PER I-IMPLANT ESTHETIC DEFECTS
Class IIIb
Th e implant-supported crown in the maxillary
right lateral incisor position presents a soft
ti ssue deh iscence (PSTD), given that th e mu-
cosal margin is apical to its ideal position. The
crown's buccal profi le lies outside (buccal to)
the imaginary curved line th at passes through
the profiles of the adjacent teeth ; therefore,
In the presence of papillae inadequate both in
height and thickness due to their triangular
shape with very narrow vertices, it is advisable to
remove the implant-supported crown and place
a short provisional restoration on an abutment
with reduced mesiodistal dimensions in order
to allow interproximal soft tissue improve ment.
Around 2 months afterwards, the interproximal
soft tissues will be mature and thicker, and there
crown removal is necessary for adequate eval-
uation of the implant platform 's position. Th e
implant platform barely lies w ithin th e imagi-
nary dotted line that connects the gingival mar-
gins of th e adjacent teeth , and the distal papilla
dimensions are <3 mm. Therefore, this PSTD
belongs to Class Illb.
wi ll be continuity between the buccal and palatal
surfaces thanks to the formation of isthmuses.
This will allow the palatal de-epithelialization of
the papillae, providing larger vascu lar beds for
the surgical papillae of the coronally advanced
flap, also destined to cover the connective tissue
graft. (For a detailed description of th e prosthet-
ic-surg ical-prosth etic approach, please refer to
chapter 2).
25
ETIOLOGY AND CLASSIFICATION OF PERI -IMPLANT ESTHETIC DEFECTS
Class lIIe
The position of the mucosal margin of the im-
plant-supported crown in the maxillary right
central incisor position is apical to the gingival
margin of the corresponding central incisor,
rendering this a buccal soft tissue dehiscence
(PSTD). The im plant-supported crown's profile
lies outside (buccal to) the imaginary curved
line that passes through the profiles of the ad-
jacent teeth, making crown removal necessary
Inadequate papillae are an indication for the
implementation of a submerged surgical ap-
proach . After crown removal and placement
of a closure screw, treatment of the implant
site as an edentulous site is possible, and the
connective tissue platform can be used to aug-
ment the soft tissues both apicocoronally and
Courtesy of: • John Wiley and Sons. J Periodontol. 2019 Oct;90(10):1116-1124 . .. Quintessence Publishing. Int J Periodontics Restorative Dent.
Mar/Apr 2020;40(2):213-222.
to evaluate the position of the implant plat-
form. The implant platform is within (palatal
to) the imaginary straight line that connects
the gingival margins of the adjacent teeth.
Interproximal papillae have reduced heights,
with the distal papilla being even more apical
than the ideal position of the buccal mucosal
margin. For these reasons , this PSTD belongs
to Class Illc.
buccolingually. After soft ti ssue maturation, im-
plant uncovering is done by means of an oc-
clusal tissue punch, allowing for the start of the
soft tissue cond itioning phase with a provision-
al restoration. (For a detailed description of the
submerged surgical approach for treatment of
PSTD, see chapter 12).
 ETIOLOGY AND CLASSI FICATION OF PER I-IMPLANT ESTH ETIC DEFECTS

Class IVa

The implant-supported crown in th e maxillary necessary in order to evaluate the position of

left central incisor position presents a peri-im -
plant soft ti ssue dehiscence (PSTD). The
crown's profile lies outside of (buccal to) the
imag inary curved line that co nnects th e pro-
files of the adjacent teeth, making its removal
th e implant platform, w hich also lies outside of
(bu ccal to) the straight imaginary line that pass-
es through the gingival margins of the adjacent
teeth . Fi nally, papillae dimension is ~3 mm,
making thi s case a Class IVa PSTD.

The crown's buccal prominence makes its removal
necessary. The implant platform 's buccal position
is an indication for th e placement of a short pro-
visional restoration along with a palatally angulat-
ed abutment of reduced mesiodistal dimensions
to allow th e maximum growth of the interproxi-
mal soft tissues. Once maturati on of said tissues
is achieved (around 2 months), papillae wi ll be
larger mesiodistally and thicker, and there wi ll be
continuity between the buccal and palatal surfac-
es thanks to the formati on of wide isthmu ses. The
latter will allow a more palatal de-epith elialization
of the papillae, consequently increasing the vascu-
lar beds for the surgical papillae of the coronally
advanced flap, intended to cove r the connective
tissue graft as well. (For a detailed description of
the prosthetic-su rg ical-prosthetic approach, see
chapter 2).

27
Courtesy of: • John Wiley and Sons. Periodontal 2000. 2018 Jun;77(1):256-272.
ETIOLOGY AND CLASSI FICATION OF PERI-I MPLANT ESTHETIC DEFECTS
Class IVb
Th e mucosal margin of the implant-supported
crown in th e maxillary right central incisor posi-
tion is in a more apical position than the gi ngival
margin of the contralateral incisor, resulti ng in a
peri-implant soft tissue dehiscence (PSTD). The
profile of th e implant-supported crown is buccal
to the imaginary curved li ne that passes through
Whenever a buccally displaced implant pl at-
form and loss in papillae height are present
simultaneously, the treatment of choice is a
soft tissue augmentati on proced ure with sub-
merged implant healing. The goal is to trans-
form th e implant site into an edentu lous site by
removing the prosth etic abutment and plac-
ing a closure screw. Once a buccolingual and
th e profiles of the adjacent teeth, which makes
its removal mandatory in ord er to assess the po-
sition of the implant platform . The latter lies buc-
cal to the imaginary straight line that connects
the gingival margins of the adjacent teeth, and
papill ae dimensions are <3 mm. All of these fac-
tors render this a Class IVb PSTD.
apicocoronal increase in the soft tissues is ob-
tained at the edentu lous ridge, implant uncov-
ering can be done, and soft tissue conditioning
is started w ith a provisional restoration . (For a
detailed description of th e submerged heal-
ing approach for th e treatment of peri -implant
PSTD, see chapter 12. Case images provided
by Or Roberto Pistilli).
 ETIOLOGY AND CLASSIFICATION OF PERI-IMPLANT ESTHETIC DEFECTS
Class IVe
The implant-supported crown on the maxillary
left central incisor position presents a peri-im-
plant soft tissue dehiscence (PSTD). Both the
profile of th e implant-supported crown and
the implant platform lie outside of (buccal
to) the imaginary lines that pass through the
adjacent crown profiles (curved line) and the
gingival margin of the adjacent teeth (straight
Another clinical situation in wh ich treatment of
PSTD is not possible is when implant malposition
is so severe that the abutment screw hole exits
more than 1 mm apical to the ideal position of
the soft tissue margin of the implant-supported
line). The vertices of both papillae are apical
to the ideal position of the soft tissue mar-
gin for the implant-supported crown . These
conditions make this a Class IVc PSTD. In
this c linical scenario treatment of the PSTD
is not feasible; therefore, in order to fulfill the
patient's esthetic requests implant removal is
advised.
crown. According to the proposed classification,
we are dealing with a Class IVb dehiscence, but
the buccal displacement of the implant platform
renders any treatment, especially prosthetic,
unfeasible.
29
ETIOLOGY AND CLASSIFICATION OF PERI-IMPLANT ESTHETI C DEFECTS
SUGGESTED READINGS
Adell R, Lekholm U, Rockier B, Branemark P I,
Lindhe J, Eriksson B, Sbordone L. Marginal tissue
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A 3-year longitudinal prospective study. Int J Oral
Maxillofac Surg. 1986;15:39 -52.
Bengazi F, Wennstrbm JL, Lekholm U. Recession
of the soft tissue margin at oral implants . A 2-year
longitudinal prospective study. Clin Oral Implants
Res. 1996;7:303-10.
Benic GI, Mokti M, Chen C-J , Weber H-P,
Hammerle CHF, Gallucci GO. Dimensions of buccal
bone and mucosa at immediately placed implants
after 7 years: a cli nical and cone beam computed
tomography study. Clin Oral Implants Res.
2012;23:560-6.
Canu llo L, lurlaro G, Ian nello G. Double-blind
randomized controlled trial study on post-extraction
immediately restored implants using the switching
platform concept: soft tissue response. Preliminary
report. Clin Oral Implants Res. 2009;20:414-20.
Cardaropol i G, Lekholm U, Wennstrbm JL. Tissue
alterations at implant-supported single-tooth
replacements: a 1-year prospective clinical study.
Clin Oral Implants Res. 2006;17:165-71.
Chen ST, Buser D. Clinical and esthetic outcomes
of implants placed in postextraction sites. Int J Oral
Maxillofac Implants. 2009;24 Suppl:186-217.
Cosyn J, Hooghe N, De Bruyn H. A systematic
review on the frequency of advanced recession
fo llowing single immed iate implant treatment. J Clin
Periodontol 2012;39:582-9.
Cosyn J, Sabzevar MM , De Bruyn H. Predictors of
inter-proximal and midfacial recession fol lowing single
implant treatment in the anterior maxilla: a multivariate
analysis. J Clin Periodontol. 2012;39:895-903.
De Rouck T, Collys K, Cosyn J. Immediate single-
tooth implants in the anterior maxi lla: A 1-year case
cohort study on hard and soft tissue response. J
Cl in Periodontol. 2008;35:649-57.
Evans CDJ , Chen ST. Esthetic outcomes of
immediate implant placements. Clin Oral Implants
Res. 2008; 19:73-80.
Grunder U, Gracis S, Capelli M. Influence of the
3-D bone-to- implant relationsh ip on esthetics . Int J
Periodontics Restorative Dent. 2005;25:1 13-9.
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 maxi ll a in relation
to immed iate impl ant placement. Clin Oral Implants
Res. 2010;21 :37-42.
Jemt T, Ahlberg G, Henriksson K, Bondevik O.
Changes of anterior cli nical c rown height in patients
provided with sing le- implant restorations after
more than 15 years of follow-up. Int J Prosthodont.
2006;19:455-61.
Jung RE, Sailer I, Hammerle CH, Attin T, Schmidlin
P. In vitro color changes of soft tissues caused by
restorative materi als. Int J Periodontics Restorative
Dent. 2007;27:251-7.
Kan JY, Rungcharassaeng K, Lozada J. Immediate
placement and provisionalization of maxillary anterior
single implants: 1-year prospective stu dy. Int J Oral
Maxillofac Im plants. 2003;18:31-9.
Kan JY, Rungcharassaeng K, Lozada
JL, Zimmerman G. Facial gingival tissue
stabi lity following immediate placement and
provisionalization of maxillary anterior single
implants: a 2- to 8-year follow-up. Int J Oral
Maxillofac Implants. 2011 ;26:179-87.
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 Maxil la. J Periodontol.
2015;86:1321-30.
Lin GH, Chan HL, Wang HL. The significance of
keratin ized mucosa on implant health: a systematic
review. J Periodontol. 2013;84:1755 -67.
 ETIOLOGY AND CLASSIFICATION OF PERI -IMPLANT ESTHETI C DEFECTS
Mazzotti C, Stefanini M , Felice P, Bentivog li V,
Moun ssif I, Zucchel li G. Soft-tissue dehiscen ce
cove rag e at peri -i mplant sites. Peri odontol 2000.
2018;77:256 -272.
Miyamoto Y, Obama T. Dental cone beam
computed tomography analyses of postoperative
labial bone thickness in maxillary anterior implants:
co mparing immediate and delayed implant
placement. Int J Periodontics Restorati ve Dent.
2011 ;31:215-25.
Ni sapakultorn K, Suphanantachat S, Silkosessak 0,
Rattanamongkolgul SFactors affecting soft tissue
level around anterior maxillary single-tooth implants.
Clin Oral Implants Res. 2010;21:662-70.
Pieri F, Aldini NN , Marc hetti C, Corin aldesi G.
Influence of implant-abutment interface design on
bone and soft tissue levels around immed iately
placed and restored single-tooth implants: a
randomized controlled clinical trial. Int J Oral
Maxillofac Implants. 2011 ;26: 169-78.
Qahash M, Susin C, Polimeni G, Hall J, Wikesjb
UME. Bone healing dynamics at buccal peri -implant
sites. Clin Oral Implants Res. 2008; 19:1 66 -72.
Roccuzzo M, Grasso G, Oalmasso P. Keratin ized
mu cosa around implants in partially edentu lous
posteri or mandible: 10 -year resu lts of a prospective
comparative study. Clin Oral Implants Res.
2016; 27:491-6.
Ross SB, Pette GA, Parker WB, Hardi gan P.
Gingival marg in changes in maxillary anterior sites
after single immediate implant placement and
provisionalization: a 5-year retrospective study
of 47 patients. Int J Oral Maxillofac Implants.
2014;29:127-34.
Schrott AR, Jimenez M, Hwang J-W, Fiorellini J,
Weber H-P W. Five-year evaluati on of the influ ence
of keratinized mucosa on peri -implant soft-tissue
health and stabi lity around impl ants supporting
fu ll-arch mandibular fixed prostheses. Clin Oral
Implants Res. 2009;20:11 70-7.
SUGGESTED READINGS
Small PN , Tarn ow DP, Cho SC. Gingival recession
aroun d wide-d iameter versus standard -di ameter
implants: a 3- to 5-year longitudinal pros pective
study. Pract Proced Aesthet Dent. 2001;13:1 43 -6.
Small PN , Tarnow DP. Gingival recession around
implants: a 1-year longitudinal prospective study.
Int J Oral Maxillofac Implants. 2000;15:527-32.
Spray JR , Black CG, Morri s HF, Ochi S. The
influence of bone th ickness on facial marginal
bone response: stage 1 placement through stage
2 uncoverin g. Ann Periodontol. 2000;5: 11 9-28.
van Brakel R, Noord mans HJ, Frenken J, De
Roode R, de Wit GC, Cune MS. The effect of
zi rconia and titan ium implant abutments on light
reflection of the supportin g soft ti ssues. Clin Oral
Implants Res. 2011;22:11 72-11 78 .
Zigdon H, Machtei EE. The dimensions of
keratinized mucosa aroun d implants affect clinical
and immunological parameters. Clin Oral Implants
Res. 2008;19:387-92.
Zucchelli G, Tavelli L, Stefanini M, Barootchi S,
Mazzotti C, Gori G, Wang H-L. Classification
of fac ial peri-impl ant soft ti ssue dehi scence/
defi ciencies at single implant sites in the estheti c
zone. J Periodontol. 2019;90:111 6-11 24.
Zuiderveld EG, den Hartog L, Vissi nk A,
Rag hoebar GM, Meijer HJA. Significance of
buccopalatal implant position, biotype, platform
switching, and pre-implant bone augmentation
on the level of the mid buccal mu cosa . Int J
Prosthodont. 2014;27:477-9.
31
 ., .
~ '((~
Prosthetic-Surgical
Treatment
of Peri-implant
Soft Tissue
Dehiscences
PROSTHETIC -SURG ICAL TREATMENT OF PERI-IMPLANT SOFT TI SSUE DEH ISCENCES

Th erapy for treatment of buccal dehiscences
on osseointeg rated im plants foresees a pros-
theti c-surgical-prosth eti c approach. The sur-
gical technique, which relies on th e placement
of a connective tissue graft covered by a cor-
onally advanced fl ap, is preceded by a provi-
sional prosth etic phase and then fo llowed by
a secon d provisional phase and placement of
th e fin al restoration. With thi s approach, de-
hiscence coverage is predictably obtained,
and masking of th e grayish hue of th e under-
lying implant- prosthetic co mponents is also
achieved . A prereq uisite for surg ical cove rage
of peri -im plant dehiscences is th e absence of
peri -im plantitis, co nfirmed both cl inically and
rad iographically.

Since dehiscence coverage and soft

tissue augmentation should take place
at th e level of the gingival margin of th e
contralateral tooth , the connective ti s-
sue graft should be positioned 1 mm ____________~___ I1mm
co ronally to th e reference tooth's gingi-
val margin . This is done to co mpensate
for potential tissue shrinkage and also
to obtain a surplus of marginal soft tis-
sue, both in height and thickness, th at
can later be adeq uately conditioned
during th e postsurg ical prosthetic
phase.
*

Courtesy of: • Quintessence Publishing. Eur J Orallmplantol. 2018;11(2):215-224.

 PROSTHETIC-SURGI CAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

A free gingival graft would hardly survive

in this position because of the wide avas-
cular area (ie, implant-supported crown)
that must be covered. Likewise, a partially/
completely de-epithelialized connective
tissue graft inserted into a pouch flap and
placed at the level of the desired muco-
sal margin wouldn't have the best chanc-
es of surviving on top of the avascular
implant-supported crown, or at least it
wouldn't be able to maintain an adequate
thickness (>2 mm). Even in case of surviv-
al and integration, the grafted area would
probably differ from the adjacent soft tis-
sues in color and surface texture, there-
fore not satisfying the patient's esthetic
demands. For these reasons, a connective
tissue graft must be used , and it should
be completely covered by a coronally
advanced flap . The implant's mesial and
distal papillae represent the only vascular
area coronal to the graft. These papillae,
once de-epithelialized, will become vas-
cular beds onto which the surgical papil-
lae of the coronally advanced flap will be
anchored. However, very small and trian-
gular papillae resulting from adaptation to
the morphology of the implant-supported
crown, and not always supported by an
intact osseous crest (as in the case of an-
atomical papillae in recession type 1 [RT1]
gingival recessions according to the Cairo
classification), wouldn't provide enough
vascular supply for the stabilization of the
surgical papillae of the coronally advanced
flap. In these conditions , there would be
a very high risk of early flap shrinkage
with consequent exposure of the under-
lying connective tissue graft, reducing or
nullifying the potential for coverage of the
buccal dehiscence. Presurgical prosthet-
ic treatment makes it possible to increase
the space between the abutment and the
adjacent teeth by means of crown removal
and exchanging the prosthetic abutment
with a so-called surgical abutment that is
as narrow and thin as possible, which al -
lows growth in the width, thickness , and
volume of the interproximal soft tissues.
35
Cour tesy of: • Quintessence Publishing. Eur J Ora//mp/anto/. 2018;11(2):215-224.
 PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

The papillae, growing into the

space formerly occupied by
the crown and prosthetic abut-
ment, will acquire a trapezoidal
shape with a coronal isthmus
(white lines) instead of the for-
mer triangular shape with a
coronal vertex (black arrows).
The presence of an isthmus
will allow occlusal de-epithe-
lialization of the papillae in a
palatal direction, further in-
creasing the vascu lar bed for
the surgical papillae of the cor-
onally advanced flap, which
are also trapezoidal.
The time needed for the soft
tissues to fill th e space former-
ly occupied by the prosthesis
and for their maturation in or-
der to proceed to the surgical
phase varies from one case to
another but wi ll never be less
than 2 months.

The clinical image showing the

superimposition of the initial
prosthetic crown and the aug-
mented soft tissues resulting
from the presurgical prosthetic
treatment emphasizes the bio-
logic and clinical advantages of
this phase: Transformation of an
area that wou ld otherwise be oc-
cup ied by the avascu lar surface
of the implant-supported crown
into wide vascu lar beds for the
surgical papillae of the coronal lY
advanced flap that wi ll cover the
connective tissue graft.

Courtesy of' • Quintessence Publishing. Eur J Oral lmplantol. 2018;71(2):2 15-224.

 PROSTHETIC-SURGICAL TREATMENT OF PERI -IMPLANT SOFT TISSUE DEHISCENCES

The presurgical prosthetic phase foresees
the removal of the implant-supported crown
and substitution of the prosthetic abutment
with a surgical abutment that is as narrow
as possible while being compatible with the
abutment screw and also thin , being made
from a material that can be reduced w ithout
risk of fracture. Both factors contribute to an
increase in the distance between the abut-
ment and the adjacent teeth. The soft tissue
maturation phase requires a short provisional
that doesn't interfere with soft tissue growth
apical ly and lateral ly to the abutment, and the
patient shou ld be instructed to perform tooth
brushing with a "roll" technique in an apico-
coronal direction .

As little as 7 days later, the

smooth and undercontoured
surface of the surgical abut-
ment has already allowed cor-
onal migration of the apical soft
tissues, which spontaneously
almost reach the position of
the gingival margin of the cor-
responding adjacent incisor.
This leads to a reduction of the
dehiscence and to a qualitative!
quantitative improvement of
the keratin ized tissues apical
to the surgical abutment. After
2 weeks the dehiscence has
practically disappeared thanks
to an subsequent improvement
of the keratinized tissues. At
least 2 months are needed in
order to allow complete mat-
uration and stabilization of the
soft tissues lateral to the sur-
gical abutment, so that they
come in close contact with it.
During this phase, the patient
should be seen at the dental
office every 3 weeks to make
sure that the provisional does
not interfere with soft tissue
growth at any given moment.
37
PROSTHETIC-SURG ICAL TREATMENT OF PER I-IMPLANT SOFT TISSUE DEHISCENCES
The surgical abutment should be buccally in-
clined the least amount possible in order to
compensate, at least partially, for the incorrect
angulation that implants with buccal soft tissue
dehiscences usually have. In thi s phase, the use
of titanium abutments is very useful because
they allow a greater compensation than can be
achieved with more esthetic abutments, such as
those made in zirconia. As a matter of fact, in
In co mparing th e baseline situation w ith the
presurgical one, it becomes evident th at this
prosthetic phase has led to coronal migration
of the buccal soft tissues, resolving the buccal
dehiscence, and to the interproximal soft tissues
filling the entire space formerly occupied by the
implant-supported crown. During the presur-
gical prosthetic phase, the patient must agree
Courtesy of: • Quintessence Publishing. Eur J Orallmplantol. 2018;11(2):215-224.
order to avoid weaken ing their resistance, zirco-
nia abutments should have a greater thickness
at the level of the implant platform, wh ich limits
changes in their inclination and consequently the
growth of peri-implant soft ti ssues.
The surgical procedure can be scheduled when-
ever there are no further changes in the volume
of the soft tissues apical and lateral to the abut-
ment between follow-up visits.
to an esthetic co mpromise due to the use of a
short provisional crown that leaves the underly-
ing metallic surgical abutment partially exposed.
Th is, along with the fragility of the provisional
and its dim inished esthetics in comparison with
the definitive crown, are among the main disad-
vantages of the phase preceding the surgical
procedure.
 PROSTHETIC-SURGICAL TREATM ENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES
Once peri-implant soft tissue maturation is com -
plete, it is possible to proceed to the surgical
phase. Thi s procedure consists of a coronally
advanced fl ap with vertical incisions (trapezoidal
flap) and placement of an underlying connective
tissue graft. Flap design is executed with the
surgical blade by creating bleeding lines that will
guide the incisions. The trapezoidal flap design
consists of two 3-mm horizontal incisions and
two verti cal incisions that extend as little as pos-
sible into the alveolar mucosa while being slight-
ly divergent in a coronoapical sense. Horizontal
incisions, on the other hand , are placed at a
distance from the anatom ical papilla (black ar-
rows) th at corresponds to th e desired coronal
advancement of the fl ap over th e surgical abut-
ment. In this particular case, given that the con-
nective ti ssue graft must be placed 1 mm more
coronal than th e gingival margin of the adjacent
tooth, coronal advancement of the flap is around
2 to 3 mm . The possibility of de-epithelializing
the papillae palatally on their occlusal surface al-
lows a more coronal positioning of the horizontal
incisions, ie, placing th em on keratin ized tissue.
The flap's surgical papilla is made up of the soft
tissue in the area delimited by th e horizontal and
ve rtical incisions and an imaginary line (red dot-
ted line) traced horizontally at the level of most
apical probing depth of th e buccal soft ti ssues.
Thi s papilla is elevated with a split-thickness in-
cision performed by keeping the blade parallel
to the external mucosal surface, taking care to
keep a uniform connective tissue thickness. On
the other hand , full -thi ckness fl ap elevation is
done at the level of the probeable soft tissues
apical to the surg ical abutment by inserting a
periosteal elevator into the su lcus. Full-thickness
elevation is continued until overcom ing the bone
crest, or if the latter is not identified, full-thi ck-
ness elevati on should stop when the soft tissues
become adherent to the underlying stru ctures
in order not to lose connective tissue adhesion.
Th e most apical portion of the verti cal incisions
is elevated with a split-thickness incision, taking
care to leave the periosteum in place for the pro-
tection of the underlying bone. Once the lining
mucosa of the lip is reached apically, flap ele-
vation proceeds in a split-thickness fashion in
order to al low its coronal advancement. Two dif-
ferent incisions shou ld be performed: one deep
and one superficial split-thickness incision. Th e
deep incision , performed with the surgical blade
parallel and close to the osseous plane, allows
detachment of th e muscle insertions from the
periosteum and the elevation of the alveo lar
mucosa.
39
PROSTHETIC-SURGICAL TREATMENT OF PERI -IMPLANT SOFT TISSUE DEHISCENCES

Once the alveolar mucosa has been elevated,
the blade inclination can be changed to proceed
apical ly in a direction parallel to the external sur-
face of the lining mucosa. This superficial inci-
sion allows detachment of the muscle insertions
from the inner aspect of the alveolar mucosa.
Th e muscle fibers, detached both from the su-
perficial and deep tissues, contract apically, thus
allowing the coronal advancement of the surgical
flap.

Remnants of non-osseointegrated biomaterial , blade in order to expose th e underlying perioste-

scar tissue, and submucosal tissues found in um. This wi ll aid in stabilization of the connective
the surgical site are dissected with the surgical tissue graft and the overlying flap.

De-epithelialization of the anatomical

papillae is done to create connective
tissue beds that will serve as anchor-
age for the connective tissue graft
and the surgical papillae of the coro-
nally advanced flap. The bases of the
anatom ical papillae are de-epithelial -
ized with the tip of the blade, which
is inserted into the connective tissue
at th e level of the split-thickness inci-
sion previously made when creating
the surg ical papillae. Once the ep-
ithelium has been separated at the
base, de-epithelialization of the papil-
la vertex is continued with microsurgi-
cal scissors by following the incision
made with the blade. On th e occlusal
aspect, papillae de-epithelialization is
also done in a palatal direction.
 PROSTHETIC-SURGICAL TREATMENT OF PERI -IMPLANT SOFT TI SSUE DEHISCENCES

Afterward s, th e recip ient bed is ready to re-

ceive the connective ti ssue graft. The graft's
mesiod istal dimensio ns should be 6 mm great-
er than the width of the surg ical abutment, and
its height shou ld extend from 1 mm coronal
to the gingival margin of the adjacent tooth up
to 2 to 3 mm apical to the buccal bone c rest.
The thickness of the connective tissue graft wil l
vary according to the thickness of the flap, but
their combined thi cknesses should amount to
>2 mm .
In particular, the connective tissue graft should
be thicker at its central portion, w hich w ill be
placed on top of the surgical abutment, and
thinn er at the lateral portions, w hich w ill be
sutured to the base of th e de-epithelialized
anatomical papillae. Suturing is done by per-
forming simple interrupted sutures with a 7-0
polyg lycolic acid (PGA) material with a short
(8-mm) needle. It is important that the closing
knots are placed on top of the graft, and not
the papillae, so that the knot fi xes the graft at
the base of the papilla. This method avoids an dimension of the graft (in compari son to di-
excessively coronal position of the co nnective mensions normally used w hen treating gingival
tissue graft, w hich would wrongly occupy the recessions) lead to a suboptimal adaptation of
area of the de-epithelialized anatom ical papil- the connective tissue graft's apical portion to
lae destined to anchor the su rgical papillae of th e underlying periosteal bed. The black arrow
the coronally advanced flap. indicates the outward projection of the graft
The significant buccal displacement of the sur- apically, w hich makes it necessary to fix it to
gical abutment and the larger apicocoronal the periosteum at its most apical portion.

41
PROSTHETIC-SURGICAL TREATMENT OF PERI -IMPLANT SOFT TISSUE DEHISCENCES

~--

To fac ilitate periosteal anchorage at the level of

the mesial and distal apical angles of the graft,
a vertical mattress suture with external perios-
teal anchorage is used. With the 7-0 suture, the
needle perforates the graft passing under the
vertical incision and exits on the adjacent soft tis-
sues. Ap ical to the previous exit point, th e needle
reenters the tissues, taking periosteal anchorage
(see illustrations), passes under the vertical inci-
sion line, and exits apical to the graft; the suture
is finished with a surgical knot that is placed on
top of the connective tissue graft. The two re-
sulting apical knots (a mesial and a distal one)
allow for optimal adaptation of the graft onto the
periosteum.
 PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

This minimizes the thickness of the coagu lum formed

between the graft and the underlying tissues, reduc-
ing the risk of graft shrinkage.
Sutures are performed in a sequence that gradually
reduces flap tension, making stabilization of the sur-
gical papillae on top of the anatomical papillae easi-
er. For this reason , suturing is done at the level of the
vertical incisions first. In order to start suturing along
the vertical incisions, the surgical papilla is placed in
its final position over the anatomical papilla with the
help of tissue forceps; the first suture is placed at
the most apical aspect of the mesial vertical incision,
consisting of a simple interrupted suture made from
th e flap toward the adjacent soft tissues in an apico-
coronal direction. If the adjacent tissues are attached
gingiva, there is no need to seek periosteal anchor-
age. In this case, the short (8-mm) needle (with 7-0
PGA) is capable of remaining inside the span of the
connective tissue, and the suture is called intramural
(see illustrations). The rest of the sutures along the
vertical incision are performed in the same fashion:
intramural, from the flap toward the adjacent tissues
in an apicocoronal direction. After closing the verti-
cal incisions, the surgical papillae are now passively
lying on top of the anatomical papillae. Each surgi-
cal papilla is fixed to the corresponding anatomical
papilla with a sling suture that is suspended around
the cingulum of the adjacent tooth. The needle
(11-mm, 6-0 PGA) enters buccally at the base of
the surgical papilla, perforates the de-epithelial-
ized anatomical papilla, and reaches the palatal
side. The thread is positioned under the cingulum
of the adjacent correspond ing tooth, and then the
needle returns buccally, without perforating the
tissues but only passing under the contact point.
Here, the needle perforates the tooth's distal papil-
la and exits, again, palatally. The thread is once
more placed under the cingu lum , and the needle
returns to the starting position, where the suture is
finished with a surgical knot. It is important that the
compression exerted by the suture is directed to-
ward the adjacent teeth (black arrow) with healthy
bone crests and not toward the surgical abutment.

43
PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEH ISC EN CES

After performing the sling sutures, first inten-

tion closure between the surgical and anatom-
ical papillae is completed in the proximity of the
surgical abutment, completely tension free, with
simple interrupted sutures using 7-0 PGA (8-mm
needle).

Upon comp letion of the sutures, it is important that the coronally advanced flap comp letely covers the
connective tissue graft while adapting to the convex and smooth surface of the surgical abutment.
 PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES
The flap should completely cover the connec-
tive tissue graft, and the marginal keratinized tis-
sues should tightly adhere to the surgical abut-
ment's convex surface. This provides stability
to the surgical wound and reduces the risk for
early flap shrinkage. From an occlusal view, it
is essential to assure absence of bleeding or of
Profile and occlusal images demonstrate how
the buccopalatal deficiency has been complete-
ly corrected at the end of the surgical procedure.
Afterwards, the provisional is reduced so that it
Sutures are removed 2 weeks after the surgery.
At 14 days postoperatively, it is possible to notice
the stability of the flap, which hasn't experienced
coagulum formation between the marginal kera-
tinized tissues and the surgical abutment. Early
flap shrinkage could lead to failure in dehiscence
coverage or, in the best-case scenario, graft ex-
posure with a subsequent whitish/ keloid appear-
ance, typical of a free gingival graft and therefore
far less esthetic.
won 't interfere with the soft tissue healing pro-
cess. Particular care must be taken during its
cementation to avoid cement overflow that could
infiltrate under the flap.
shrinkage from its immediate postsurgical posi-
tion, and the complete resolution of the bucco-
palatal soft tissue defect.
45
PROSTHETI C-S URGICAL TREATMENT OF PER I-IMPLANT SOFT TISSUE DEHISCENCES

During a 4-month period, referred to as the
maturation phase, the soft tissues must
be free to mature both in height and th ick-
ness. The phenomenon by which soft tissues
migrate coronally, after being thickened , is
known as creep ing. In th is period , the patient
is seen at monthly appointments, during w hich
th e provisional is removed and further reduced
wherever it comes in contact with the soft tis-
sues, wh ile the surgical abutment is polished
with a rubber cup; this is done to avoid hinder-
ing soft tissue growth .

Four months after the surgery, soft tissues

are stable and mature enough to start the
• • •
conditioning phase. Soft tissue condi-
tioning is done with a new, screw-retained
provisional crown. In th is phase, the goal
is to apically reposition the marginal soft
tissues until th ey reach the same lev-
el as the gingival margin of the adjacent
teeth and at the same time reshape the
peri-implant papillae so that they become
triangular and fill the interproximal spaces
completely. Repositioning of the soft ti s-
sue margin is accomplished through api-
cal compression by progressive addition
of fluid composite resin to the provisional.
Meanwhile, the "squeezing" at the inter-
proximal areas is achieved with progres-
sive modifications of the provisional with
a continuous coronal displacement of its
contact points; the aim is to leave small
interproximal spaces that the soft tissues
can fill in a short period of time. Therefore,
3 to 4 weeks should pass between ap-
pointments for modification of the pro-
visional crown. The definitive restoration
can be placed when the marginal scallop
of the provisional crown resembles that of
the contralateral tooth and th e height and
shape of th e peri-implant papillae are as
similar as possible to those of the corre-
sponding natu ral tooth .
 PROSTHETIC-SURGICAL TR EATMENT OF PERI -IMPLANT SOFT TI SSUE DEHISCENCES
Soft tissue augmentation results in a significant
increase at the transmucosal path between the
implant head and the soft tissue margin. Th e
patient must be instructed in adequate hygiene
maintenance of the implant site so that the
Th e occlusal images show
the increase in peri-implant
soft tissue thickness. This al-
lows for three-d imensional
compensation of the bucco-
lingual and apicocoronal soft
tissue defi cit, treatm ent of the
peri-implant buccal dehis-
cence, masking of the metallic
implant structure, and creation
of a new transmucosal path
that will give the implant-sup -
ported crown an entirely natu-
ral emergence profile.
increase in soft tissue volume does not trans-
late into non-physiologic probing depths, wh ich
cou ld lead to an increased risk for developing
biologic complications such as mucositis or
peri-implantitis.
As a result of implant malposi-
tion, it is rarely possible to place
a screw-retained definitive resto-
ration in these cases. Therefore,
it is almost always necessary to
fabricate a personalized pros-
thetic abutment that will be
placed and screwed onto the im-
plant fixture. The surface of this
abutment shou ld be as smooth
as possible so that it can favor
epithelial adhesion and at the
same time minimize subgingival
bacterial plaque accumu lation.
The prosthetic abutment can be
made from an esthetic material
(zirconia), wh ich can further re-
duce the risk of color alterations
at the level of the soft ti ssue
margin related to the difference
in light refl ection in comparison
to natural teeth.
47
PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

It is important for the prosthetic

abutment to accurately repro-
duce the shape of the screw-re-
tained provisional at the internal
aspect of the transmucosal
path, given that its task is to
maintain the shape and height
of the transmucosal path that
was attained through soft tissue
cond itioning. Adequate support
will allow the maintenance of
peri-implant soft tissue esthet-
ics over time.
It is of crucial importance that
the finishing line of the pros-
thetic crown is positioned the
least subgingival as possible
(0.5 to 1 mm buccally and in-
terproximally, respectively) or
even juxtagi ngival in non-es-
thetic areas (palatally). This
serves a threefold purpose:
making cementum removal
easier (aided also by the place-
ment of retraction cords during
cementation), better control of
the crown's margin closure by
the dentist and hygienist, and
facilitating patient-performed
plaque control.
 PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TI SSUE DEHISCENCES
The cl inical result 1 year after final restoration
placement shows complete coverage of the
peri -implant soft tissue dehiscence and absence
of th e grayish discoloration that was present as a
result of the reduced tissue thickness. The scal-
lop of the peri-implant mucosal margin resem-
bles that of the gingival margin of the adjacent
natural tooth, thus creating symmetry and har-
mony of the soft tissues, which are fundamen-
tal for evaluation of the esthetic outcome. The
stability of the coronally advanced flap with an
The esthetic result (blending of the treated area
with the adjacent elements) remains stable even
3 years after cementation. Unexpected ly, fur-
ther increase in buccal soft tissue thickness can
be observed; this phenomenon , wh ile reducing
Courtesy of: • Quintessence Publishing. Eur J Oral Implantol. 2018;11(2):215-224.
*
underlying connective tissue graft makes for an
esthetically pleasing result; as a matter of fact,
none of the typical signs of graft exposure, which
would alter the esthetic resu lt, are present. The
definitive crown blends in well with the adjacent
natural dentition, as does the surgical treat-
ed area with the neighboring soft tissues. The
emergence profile is well represented, protect-
ing the soft tissue margin from potential trauma
during mastication and making the patient's oral
hygiene maneuvers easier.
the risk of future dehiscence relapse, modifies
the crown's emergence profile. Th e augmented
vo lume buccal to th e implant surface success-
fu lly hides the underlying prosthetic structure
(restorative therapy done by Or Astrid Razem).
49
PROSTHETIC-SURGICAL TREATMENT OF PERI -IM PLANT SOFT TISSUE DEH ISCENCES

A subsequent unplanned increase in buccal established goal, ie, hindering versus favoring
soft tissue thickness , even after 1 year, is a tissue creep ing over time, it is advisable for
frequent finding whenever this type of con- the crown to have an over- or undercontoured
nective tissue graft is used with this surgical emergence profile.
procedure (ie, extraorally de-epithelialized free
gingival graft with a coronally advanced flap).
The biologic explanation for this phenomenon
cou ld be the change in the vascular supply
of the grafted connective tissue, which goes
from an area of reduced terminal vascu lariza-
tion like the palate to a vastly irrigated area like
that underneath the highly vascularized buccal
mucosa.
The increase in buccal soft tissue thickness
can induce further coronal migration of the mu-
cosal margin on top of the implant-supported
crown due to the "creeping" phenomenon. On
the one hand, this cond ition can allow com-
plete coverage of areas that previously were
only partially covered, but on the other hand , it
can also lead to shortening of the implant-sup-
ported crown. This is hardly ever noticed by
the patient, and only a direct comparison be-
tween the clinical images over time makes this
observation possible. Based on the previously
*

Courtesy of.' • Quintessence Publishing. fur J Orallmplantol. 2018;11(2):215-224.

 PROSTHETIC-SURGICAL TR EATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

The esthetic result (blending in of the treated area in buccal thickness is maintained, with a very low
with the adjacent structures) appears stable at 5 risk of buccal dehiscence recurrence. The periapi-
years after final restoration placement, with high cal radiograph shows stability of the peri-implant
patient-reported satisfaction . Even the increase bone support and radiopacity of the bone crest.

51
Courtesy of.' • Quintessence Publishing. Eur J Orallmplantol. 2018;11(2):215-224.
PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE OEHISCENCES

Comparison of the marginal scallop, emer-
gence profile, and clinical crown length at
the implant site at 1, 3, and 5 years after final
restoration placement shows an increase in
buccal soft tissue th ickness and the creeping
*
phenomenon over time. These considerations
have led the authors to reduce graft thickness
during surgery; the added th ickness of the graft
and the flap together shou ld amount to, but not
surpass, 2 mm.

Courtesy of.' • Quintessence Publishing. Eur J Orallmplantol. 2018;11(2):215-224.

 PROSTHETIC-SURGICAL TREATMENT OF PERI -IMPLANT SOFT TISSUE DEHISCENCES

53
Courtesy of.' • Quintessence Publishing. Eur J Orallmplantol. 2018;11(2):215-224.
PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES
As previously described, incorrect implant place-
ment, specifically in an excessively buccal posi-
tion, is one of the main factors associated with
the development of peri-implant buccal soft tissue
dehiscences. The CBCT scan reveals the errone-
ous buccal placement, even if th e scattering ef-
fect of the metallic structure makes it difficu lt to
accurately measure th e extent of the buccal bone
dehiscence. The latter, along with the degree of
implant malposition and probing measure ments
of the buccal soft tissues apical to the dehis-
cence (white arrow), are the determining factors
for the cli nician's decision between treatm ent of
the dehiscence or implant removal. The CBCT
scan allows diagnosis of the buccal bone deh is-
cence with co nsequent exposure of the implant
surface, while probing (without anesthesia) apical
to the soft tissue dehiscence allows differentiation
between an anatomical or pathologic exposure of
the buccal implant surface (ie, without increased
probing depths versus with increased probing
depths and contamination of the implant surface,
respectively). Due to the difficulty and lack of as-
surance regarding the possibility of attaining com-
plete decontamination of the implant surface, the
absence of path ologic probing depths at the level
of the implant's osseointeg ratable portion (white
arrow) is a key factor for choosing to perform
surgical coverage of the peri-implant soft tissue
dehiscence.
 PROSTHETIC-S URGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES
The short provisionals, cemented onto thin and
narrow surgical abutments, are app lied at least 2
months before su rgery in order to favor buccal and
interproximal soft tissue growth. This prosthetic
provisional phase is crucial, given that it creates the
required clinical co nditions for the successful exe-
cution of the subsequent surgical phase. Taking into
consideration the ideal position for the con nective
tissue graft, ie, more coronal than the ging ival mar-
gin of the central incisors, the increase in thickness
and height of the mesial and distal papi llae ob -
tained by the presurgical prosthetic phase can be
appreciated. Now, these deeper and wider papillae
can be de-epithelialized in a palatal direction, there-
fore augmenting the vascu lar bed for the surgical
papillae of the coronal ly advanced flap.
55
PROSTHETIC-SURGICAL TREATMENT OF PERI -IMPLANT SOFT TI SSUE DEHISCENCES
Th e surg ical procedure will cons ist of a coronal-
Iy advanced trapezoidal flap with an underlying
connective tissue graft at the level of both maxil-
lary lateral incisors. In the presence of thin, bare -
ly keratinized tissues and severe implant malpo-
sition, it is advised to perform the split-thickness
The absence of buccal probing depths renders
the elevation of the soft tissues apical to the de-
hiscence rather compl icated. In fact, this tissue,
firmly adhered to the implant surface, should be
elevated at a split-thickness with the tip of the
blade and never w ith a periosteal elevator due to
the risk of lacerating it and removing the connec-
tive tissue found between the implant threads.
Separation of the alveolar mucosa from the un-
derlying deep structures allows the execution of
the superfi cial inc ision, parallel to the external
surface of the lining mucosa, wh ich w ill allow
tension -free coronal advancement of the flap.
elevati on of the fl ap, and especially that of the
surgical papillae, without the surg ical abutment.
This provides more space for correct position-
ing of the blade in order to provide an adequate
shape (trapezoidal) and thickness (epithelial-con-
nective) to the surgical papillae.
Th e absence of buccal keratinized tissues and
reduced tissue thickness increase the risk of
flap perforation . Th erefore, the flap is entirely
elevated at a deep split-thickness from the ver-
tical incisions toward the soft tissues apical to
the implant dehiscence until meeting the alveolar
mucosa, where a superficial split-thickness inci-
sion is performed .
 PROSTHETI C-SURGICAL TREATMENT OF PERI -IMPLANT SO FT TISSUE DEHI SCENCES
After th e surgical abutm ent is replaced ,
de- epith elializati on of th e mesial and distal
anatomical papill ae can p roceed ; in thi s way,
vasc ular beds are c reated to receive both th e
co nnective ti ssue graft and th e surgical papil-
lae of th e co ron ally advanced fl ap . Th e epi -
th elium at th e base of th e anatomical papill ae
is elevated w ith the use of th e surgical bl ade
and subseq uently removed w ith th e mic ro -
surgical scissors, p roceeding toward th eir
ve rtex. Th e presence of an isthmu s at the ve r-
tex of th e papill ae permits d e -epith elializati on
of th eir occl usal surface in a palatal directi on.
Thi s increases th e vasc ular area avail abl e
for th e surgical papill ae of th e co ronally ad-
vanced flap.
57
PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES
The graft is procured from the palate as an epithe-
lial-connective tissue graft and de-epithelialized
extraorally with a surgical blade. The apicocoro-
nal dimension needed for the graft is measured
with the periodontal probe starting 1 mm coronal
to the gingival margin of the central incisor and
ending 2 mm apical to the buccal bone crest. It
is important that the central portion of the graft
remains th icker, as it wi ll be placed on top of an
avascular surface (implant and abutment), while
the lateral parts can have a reduced thickness to
facilitate suture and adaptation of the graft to the
underlying surgical abutment.
The connective tissue graft is sutured to the base
of each anatomical de-epithe li alized papi lla with
a horizontal mattress suture anchored to the soft
tissues palatal to the de-epithelialized area. When
performing the suture, the needle perforates the
graft and de-epithelialized papilla and exits pala-
tally (black arrow in photo; illustration B).
Here, the needle reenters the tissues horizon -
tally to the exit point and comes out at the base
 PROSTHETI C-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

of the de-epithelialized papilla, barely coronal correct adaptation of the graft to the base of
to the graft (white arrow in photo; illustrations C th e de-epithelialized papilla without displ acing it
and 0) ; the suture is closed with a surgical knot coronally, as would happen with a simple inter-
(illustration E). This particu lar suture allows the rupted suture.

59
PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES
In its apical portion, the graft is fixed with ex-
ternal vertical mattress sutures with periosteal
anchorage. The use of thin , manageable grafts
like those derived from de-epithelialization of a
free gingival graft is fundamental for their ade-
quate adaptation to the involved structures: the
prominent surface of the implant-abutment, the
base of the anatomical papillae, and the perios-
teal bed. Before proceeding to flap closure, it is
In cases in which the abutment has a marked
buccal displacement, it is often necessary to
perform a second suture at the base of the
papilla to improve graft adaptation at the level of
th e line angles of the surgical abutment.
necessary to close the abutment screw access
channel with flowable composite (after having
protected the screw with polytetrafluoroethylene
[PTFE] or a cotton pellet). This will allow the mar-
ginal tissues of th e coronally advanced flap to
adapt onto a hard and smooth convex surface,
preventing blood seepage that cou ld destabilize
the surgical wound and lead to failure of the sur-
gical procedure.
After the graft has been sutured in place, it is
possible to proceed with flap closure. Suturing
begins at the level of the vertical releasing in-
cisions with simple interrupted sutures, each of
which is performed in an apicocoronal sense,
starting from the flap toward the adjacent tis-
sues, while keeping the surg ical papilla in th e
desired position on top of the anatomical papil-
lae with the help of tissue pliers. Once suturing
along the vertical incisions is finished, the surgi-
cal papillae will find themselves passively lying
on top of the anatomical de-epithelialized papil-
lae. First intention wound closure between the
surgical and the anatomical papilla is achieved
with two sutures: first a sling suture (6-0 PGA,
11-mm needle) suspended around the cingulum
of the adjacent tooth and then a simple inter-
rupted suture (7-0 PGA, 8-mm needle) close to
the surgical abutment. At the end, it is crucial
that the flap's marginal tissues adapt perfectly
to the surgical abutment, in th is way blood from
seeping outside of the wound.
 PROSTHETI C-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TI SSUE DEHISCENCES

The same procedure is performed for treatment of the buccal dehis-

cence on the implant in the maxillary left lateral incisor position. The
presurgical prosthetic treatment wil l improve the papillae both mesial
and distal to the abutment, wh ich used to be rather compressed by the
presence of the original crown and implant abutment. In this case, the
very distal position of the implant and its proximity with the lateral incisor
had greatly reduced the soft tissues present at the level of the distal
papi lla. At the end of the soft tissue maturation phase, it is possible to
find even at the distal aspect a well-represented anatomical papi lla that
can be de-epithelialized on its occlusal aspect in a palatal direction. Due
to the inherent difficulty, it is advised to perform papilla de-epithelializa-
tion without the surgical abutment, wh ich on the other hand becomes
essential for the adequate placement of the graft at the level of the gin-
gival margin of the adjacent tooth. The kind of graft that derives from the
de-epithelialization of a free gingival graft, thin and plastic, together with
a thin and soft suture (7-0 PGA) allows an all -arou nd optimal adaptation
of the graft onto the surgical abutment, the base of th e de-epithelialized
anatomical papillae, and the periosteal bed apically.

Before proceeding to fl ap closure, it is crucial to the fl ap to adapt onto a hard, smooth, and convex
close the abutment screw access with flowable surface no matter where its fin al position ends up
composite. This will allow the marginal tissue of being .

In case of multiple implants affected by buccal
soft tissue dehiscences, it is advisable to perform
all surgeries during the same session in order to
favor a symmetric and esthetic final result. Before
dismissing the patient , it is important to control
the stability of the surgical wounds, verifiable
cl inical ly by the foll owi ng characteristics: the
absence of bleeding or coagul um formation be-
t ween the fl ap's marginal tissues and the surgical
abutment and primary wound closu re between
the surgical papillae and the corresponding
de-epithelialized anatomical papillae.
61
PROSTHETIC-SURG ICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEH ISCENCES

During the first 4 postsurgical months it is essen-
tial to let the soft tissues heal undisturbed, without
prosthetic interferences. For this reason, provi-
sionals should be cemented and left short with re-
gard to the soft tissues. This wi ll make it possible
for the grafted connective tissue, under the cover-
age of the flap, to mature and attain adequate sta-
bility for the subsequent conditioning phase. The
main disadvantage during these first months is the
unesthetic appearance of the treated area due to
the exposure of the metallic abutment apically to
the margin of the provisional . In cases of highly
demanding patients or in the absence of markedly
malpositioned implants, this negative aspect can
be reduced with the use of more esthetic abut-
ments such as those made from zirconia.
 PROSTHETIC-SURGICAL TREATMENT OF PERI -IMPLANT SOFT TISSUE DEH ISCENCES
After 4 months of undisturbed healing , it is
possible to proceed to the soft tissue condi-
tioning phase with the use of new screw-re-
tained provisionals. The goals are to create a
scallop on the marginal gingival tissues of the
prosthetic crowns that corresponds apicocor-
onally with those of the adjacent teeth (the gin-
gival margin of the lateral incisors should have
a more coronal position than that of the central
incisors) and also to promote coronal growth
of the interdental papillae, conferring a triangu-
lar shape. The latter is achieved by progres-
sively modifying the emergence profi les of the
provisional crown (ie, the "squeezing" effect)
and gradually displacing the contact points
coronal ly. This further contributes to the de-
velopment of harmony that w ill guarantee the
best esthetic result. Also during this phase,
any possible differences in position and shape
of the mucosal margins resulting from healing
subsequent to the multiple procedures are
corrected or improved.
Concurrently, it is important to establish ade-
quate emergence profiles that are easy to clean
by the patient and that protect the marginal tis-
sues from food impaction during mastication.
63
PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

Soft tissue conditioning can be considered comp leted when there are no clinically evident chang-
es in the gingival margin scallop or in interdental papillae growth in between follow-up visits. The
tim e frame varies from patient to patient, but this is the moment at wh ich the final prosthetic phase
can be started.

Comparison between the images at the time of final restoration placement and 12 months afterward
shows how some degree of tissue remodeling still takes place afterward . Therefore, it is recommend-
ed to leave small interdental voids in order to favor furth er growth of the interdental papillae.
 PROSTHETIC-SURGICAL TR EATME NT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

The final restorative phase

is very sensitive and fund a-
mental for the maintenance
of the results obtained by the
modifications performed on
the provisionals. In fact, it is
not uncommon to lose part of
the morphology and esthet-
ic results achieved at th e end
of the provisional prosthetic
phase when placing the final
restorations (restorative thera-
py done by Or Enrico Fabris).
65
PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISC ENCES

The clinical images 2 years after the surgical-prosthetic treatment demonstrate the stability of the
obtained esthetic resu lt. The site-specific change in the soft tissues, noticeable on the occlusal and
profile views, reduces the risk of dehiscence recurrence and avoids translucency of the underlying
implant-prosthetic structures.

Comparison between the baseline periapical radiographs and those done 2 years after treatment high-
lights not only the stability of the peri-implant bone levels but also a further increase in radiopacity of the
interproximal bone crest for both treated implants. This, together with the absence of clinical signs of
mucositis or peri-implantitis, is a sign of stability and peri-implant health.
 PROSTH ETIC-SURG ICAL TR EATMENT OF PERI-IM PLANT SOFT TISSUE DEHISCEN CES

..

Long-term stability of th e es-

thetic result achieved with the
described surgical-prosthetic
approach is demonstrated in
the cl inical image of the 5-year
follow-up.
Th e site-specific change in
soft ti ssue thickness, notice-
able on both th e occlusal and
profil e views, proves to be sta-
ble compared at the 2-year
follow-up.
67
PROSTHETIC-SURGICAL TREATMENT OF PER I-IMPLANT SOFT TI SSUE DEHISCENCES

Comparison of the occlusal images at 1 and 5 years after treatment highlights th e increase in volume/
thi ckness of the soft tissues buccal to the implant-supported crowns. It is interesting to notice that out
of the two implants, the one that shows a larger increase in tissue thi ckness over tim e is the implant
in the maxillary right lateral incision position , which was the one that originally had th e most marked
malposition and the largest soft ti ssue-osseous dehiscence.

Before and after comparison of the buccal soft tissues of the implant at the maxillary right lateral incisor
position.

Before and after comparison of the buccal soft ti ssues of the implant at the maxillary left lateral incisor
position.
PROSTHETIC-SURGICAL TREATMENT OF PERI -IMPLANT SOFT TISSUE DEHISCENCES

Side by side comparison of the base-

line smile view and the one 5 years
after the end of treatment shows the
achieved esthetic resu lt. Analysis of
the intraoral baseline situation and of
the several follow-up visits over time
co nfirms the stability of the treatment
in terms of the morphology, color,
and surface texture of the soft tis-
sues buccal to the implant-supported
crowns.
The periapical radiographs taken 5
years postoperatively show the stabil-
ity of the peri-implant bone support.

69
PROSTHETIC-SURGICAL TREATMENT OF PERI- IMPLANT SOFT TISSUE DEHISCENCES

The 7-year follow-up shows the stabi lity of the
obtai ned results regarding both esthetics and
th e increased thickn ess of the buccal soft tis-
sues. The occlusal and profile images show
the good integration of the implant-supported
crowns w ith the buccal soft tissues, ren-
dering the implant mal positions com pl etely
imperceptible.
Periapical rad iographs done at 7 years show
stability of the peri- im plant bone support.
PROSTHETI C-SURG ICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

71
PROSTHETI C-SURG ICAL TREATM ENT OF PER I-IMPLANT SO FT TI SS UE DEHISC EN CES

Implant rehabilitati on in the anterior mandible area
is quite demanding from an esth etic point of view
because of the reduced th ickness of the bone
and soft ti ssues, which often leads to the devel-
opment of peri -implant dehiscences . This cl inical
case shows an implant in the mandibular left cen-
tral incisor position in which the development of
a peri -implant soft tissue dehiscence (PSTO) has
caused esth etic discomfort for the patient. An in-
crease in patients' esthetic demands is evidenced
by the fact that, ever more frequently, there are
complaints invo lving areas of the oral cavity th at
are not visible during smiling. Add itionally, the
risk of dehiscence progression, which entails a
greater possibility of pathologic exposure of the
implant surface and of developing peri-implantitis,
increases the indications for treatm ent of buccal
soft ti ssue dehiscences affecting im plants placed
in anterior mandibular areas, regardless of the pa-
tient 's esth etic demands.

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 PROSTH ETIC -SURG ICAL TR EATMENT OF PER I-IMPLANT SOFT TISSUE DEHISCENCES

Removal of th e prosthetic crown makes it easier to appreciate the

relationship between th e im plant platform and the adjacent tissues.
The implant, even if correctly placed in an apicocoronal sense,
is buccally displ aced. Thi s, however, is necessary in order not to
ri sk creatin g lingual bone and/or soft tissue deh iscences, which
are equally difficult to treat and much more difficu lt to keep clean
by the patient. The presence of a thin biotype makes the color of
th e underlying implant surface visible th rough the soft tissues. The
very thin soft tissues and th e absence of keratinized tissue, along
w ith a high frenum insertion and a red uced depth of the vestibule,
render th e surgical procedure a very comp lex one.
Treatment of buccal dehiscences on im plants placed in the ante-
ri or mandible is also done with the prosthetic-surgical-prosthetic
approach, but with some surg ical modificati ons related to the ana-
tomical characteristics of this site.

73
PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE OEHISCENCES

The surgery requ ires the execution of a coronally

advanced trapezoidal flap and the placement of
a connective ti ssue graft. Absence of patholog-
ic buccal probing depths (1 mm), lack of kerati-
nized ti ssues, and the firm adherence of th e buc-
cal soft tissues to the implant surface mandate
split-th ickness elevation of the whole flap , insert-
ing the surgical blade into the buccal sulcus (illus-
tration A). The split-thickness incision allows the
conservation of the connective tissue adhered
onto the implant surface. The deep split-thick-
ness incision (with the blade parallel to the bone
surface) proceeds apically until 4 to 5 mm of peri-
osteum are exposed apical to the bone dehis-
cence (illustration B).

After the deep split-thickness incision, a super- For this reason, a strip of submucosa (formed
ficial split-thickness incision is performed in or- by muscle and fibrous, adipose, and glandular
der to allow coronal advancement of the flap. tissues) always remains between the deep and
The presence of the lower lip, whose muscular superficial incisions; this should be excised with
structure inserts coronally and perpendicularly to a coronoapical incision extending from the most
the implant surface, forces the execution of the apical part of the superficial incision to the most
superficial split-thickness incision in an almost apical part of the deep incision (illustration 0).
horizontal plane, starting from the vertical inci-
sions. For this reason, in the anterior mandibular
region, the vertical incisions should extend much
more apically into the alveolar mucosa than is re-
quired in the maxilla. During the superfi cial inci-
sion , the blade proceeds horizontally, parallel to
the external surface of the lining mucosa of the
lip (illustration C). The reduced depth of the vesti-
bule in the mandibular anterior area prevents the
retraction of the muscle fibers that are dissected
from the deep and superficial anatomical struc-
tures, contrary to what happens in the maxilla.
 PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES
Removal of the submucosal tissues is facilitat-
ed by pulling them toward the external aspect
with the tissue forceps, which allows detection
of the muscle insertions. Once the submuco-
sal tissue is removed, the periosteum apical to
the bone dehiscence wi ll be available for the
periosteal anchorage sutures, which are per-
formed at the most apical aspect of the vertical
incisions and are fundamental for restoring the
vertical ity of the vestibule (illustration E). This
verticality wi ll be completed with a coronal sling
suture anchored to the papillae (illustration F).
The use of the connective tissue graft, apart
from stabilizing the flap devoid of marginal ke-
ratinized tissues, is meant to act as a barrier
against the coronal reinsertion of the muscle
fibers removed during surgery. When the im-
plant surface is found to be covered by firmly
adhered connective tissue, it is important not
to remove or alter it during the surgical proce-
dure. This tissue is indicative of adequate fibro-
integration, which in the absence of osseointe-
gration guarantees a clean, uncontaminated
implant surface.
75
PROSTHETIC -SU RGICAL TREATMENT OF PERI- IM PLANT SOFT TISSUE DEHISCENCES
The connective tissue is sutured with simple
interrupted sutures (7-0 PGA, 8-mm needle)
to the base of the anatomical de-epithelialized
papillae. The characteristics of this graft, ie, thin
The implant 's buccal malposition calls for
periosteal anchorage sutures to improve the
adaptati on of the graft's apical portion onto
th e periosteal bed . In th e presence of very
deep implant exposure, it is not necessary
for the graft to reach the bone crest because
the li p, w ith its thick submucosal ti ssues, w ill
Flap closure starts with the periosteal anchor-
age sutures at th e most apical of the vertica l
incisions: a fundamental step for the restoration
of the verticality of th e vestibu le and depth of
the vestibu lar fornix (6 -0 PGA, 11-mm needle).
After the vertical incisions are completely closed ,
and plastic con nective tissue, allow its precise
adaptation to th e implant surface (in spite of its
buccal prominence) and to the interdental vas-
cular bed .
prevent any possible discolorati on due to the
exposed apical im plant threads . The height
of the graft (6 to 8 mm) is chosen based on
the need to restore the depth of the vestibul e,
given that it w ill act as a barrier against future
reinsertion of the muscle fibers exci sed during
th e surgery.
stabilization of th e surgical papillae on top of the
corresponding anatomica l papillae is accom-
plished with sling sutures suspended around the
cing ulum of the adjacent teeth and simple inter-
rupted sutures placed in proximity to the surgical
abutment.
 PROSTHETIC-SURGICAL TR EATMENT OF PERI-IMPLANT SOFT TISSUE DEHI SCENCES

After soft tissue maturation (4 months), at which
point an increase in height and thi ckness of th e
soft tissues can be appreciated , it is possible to
proceed to the cond itioning phase. This phase
is carried out with a screw-retained provisional
that can be modified in order to condition both
the marg inal ti ssues until ach ieving a height and
morphology similar to that at the contralateral
tooth and the interdental papillae until they en-
tirely fill the interproximal spaces.

77
PROSTHETIC-SURG ICAL TREATMENT OF PERI-IMPLAN T SO FT TI SS UE DEH ISC ENCES

6 MONTHS

When soft tissue conditioning

is done, it is time for final res-
toration placement. Whenever
possible, it is preferable to
place a screw-retained resto-
ration, even if most of the time
one is obliged to opt for a ce-
mented restorati on due to th e
implant's malposition causing
• a buccal position of the screw
access hole.
Many tim es, the adjacent teeth
require th e addition of restor-
ative material s in ord er to har-
monize shapes, spaces, and
dimensions for an improved
final esthetic result.

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 PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHI SCENCES

Th e clinical result 1 year after the surgery is esthetically pleasing thanks to the treatm ent of th e mu-
cosal dehiscence and closure of the interdental spaces, obtained through the co nditioning of the
interdental papillae and the adhesive restorations placed on the teeth adjacent to the implant. The
periapi cal rad iograph shows stability of the peri-implant bone levels.

The superimposition of
the baseline clinical situ-
ation and th e i-year fol-
low-up image evidenc-
es th e vertical increase
of the soft tissues with
the coronal displace-
ment of the mucosal
margin into an area with
no bone support.
79
PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

Th e clinical images at 1 year

after definitive restoration show
the stability of the results and
the good hygiene maintenance
by the patient. Tissue thi ck-
ness is maintained, which pre-
vents apical migration of the
margin and unpleasant grayish
discoloration of the soft tissues
due to the metallic structures.
*

Follow-up at 3 years after final restoration placement shows maintenance of the outcomes: the overall
esthetic harmony and the increase in soft tissue thickness. The latter is essential for redu cing th e ri sk
of recurrence of the peri-implant soft tissue dehiscence.

Courtesy of.' • Quintessence Publishing. Eur J Orallmplantol. 2018;11(2):215-224.

 PROSTHETI C-SURGICAL TREATMENT OF PERI -IMPLANT SOFT TISSUE DEHI SCENCES

..... ..
-~--.-•.-. .•~:~ mm
.~J: .

Comparison of the profile im-

ages of the various follow-ups
done over time shows a slig ht
but gradual increase of the
buccal soft tissue thickness.
This unexpected increase,
even years after the surgery,
can lead to subsequent cor-
onal migration of the mucosal
margin thanks to the "creep-
ing" phenomenon.
*

*
At the 9-year follow-up, the clinical resu lt remains stable both in terms of the complete coverage of the
PSTD and in relation to the increase in buccal soft tissue th ickness. Comparison of the profile images
shows th e long-term maintenance of the deepened vestibular forn ix.

81
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PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

From the fifth to the ninth year

there does not appear to be
any additional increase in the
buccal soft tissue thickness,
whi le the vertical increase in the
soft tissues and the position of
the mucosal margin of the im-
plant-supported crown (coro-
nal to the gingival margin of the
adjacent tooth) remain stabl e.
The superimposition of the
baseline clinical situation and
th e 9-year follow-up highlights
the relocation of the mucosal
margin in a more coronal posi-
tion and the long-term stability
of the surgically reconstructed
supracrestal soft tissues. Side-
by-side comparison of the ini-
tial periapical radiograph and
the one done at 9 years shows
stability of the peri-implant
bone levels. This, together with
the absence of cl inical signs of
mucositis or peri-implantitis,
confirms the good health sta-
tus of the peri-implant tissues.
The long buccal peri-implant
transmucosal path (4 mm) has
not represented an obstacle
for the patient's plaque control.

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 PROSTHETI C-S URGICAL TREATMENT OF PER I-IMPLANT SO FT TISSUE DEHISCENCES

83
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PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES
A pathologic exposure of the implant sur-
face (clinically exposed or probeable) does
not constitute a contraindication for the treat-
ment of the soft tissue buccal dehiscence.
There are a series of titanium microbrushes
available on the market for the mechanical
The difference between the contamination of an
implant surface as the result of a buccal soft
tissue dehiscence versus peri-implantitis is sig-
nificant. In the case of peri-implantitis, there is
a primary infection on the implant surface that
leads to bone loss with a subsequent buccal
soft tissue dehiscence in the presence of thin
soft tissues. In this case, bone loss is not lim-
ited to the buccal surface but also affects the
interproximal bone with a circumferential pat-
tern of bone resorption and vertical defects.
In these cases, particularly in the presence of
narrow and deep defects, access to the con-
taminated implant surface is much more diffi-
cult, and some areas tend to remain hidden and
Courtesy of." • John Wiley and Sons. Periodontol2000. 2018 Jun;77(I):256·272 . .. John Wiley and Sons. J Periodon tol. 2020 Jan;91(I):9·16.
treatment of contaminated surfaces, which,
added to the easy access to the exposed
buccal surface, render decontamination of the
exposed implant surface much more predict-
able than can be expected for the treatment of
peri-implantitis.
inaccessible to the instruments for mechanical
decontamination. On the other hand, contami-
nation of the implant surface secondary to the
formation of a buccal soft tissue dehiscence is
limited to the implant's buccal aspect. Direct
access and the absence of infrabony compo-
nents make it much easier to use instruments
for decontamination.
Presurgical prosthetic treatment entails removal
of the implant-supported crown , exchange of
the prosthetic abutment for a surgical (straight
and narrow) one, and the placement of a ce-
mented provisional that does not interfere with
growth and maturation of the implant 's buccal
and interproximal soft tissues.
 PROSTHETIC-SURGICAL TREATMENT OF PERI-I MPLANT SOFT TI SSUE DEHISCENCES

Mechanical treatment of the co ntaminated im- roughness-both important co nditions for con -
plant surface requires the use of titan ium mi- nective tissue adhesion .
crobrushes placed on a low-speed handpiece
with abundant irrigation . The tree-shaped one
is used on the exposed buccal surface, w hile
the pointy one is used in th e area where th e im -
plant surface comes in close co ntact with the
buccal bone and in between implant threads .
Th e use of these instruments allows remov-
al of the superficial ro ugh layer of th e implant
surface, practically turning it into a machined
surface. This, in contrast to implantoplasty
performed with diamond burs, allows preser-
vation of the shape of th e threads and surface

Chemical treatment of th e implant surface is
always done following mechanical instrumen-
tation and requires th e use of 24% EOTA gel ,
applied locally for 2 minutes and th en rinsed
abundantly, and 1% chlorh exidine gel, also
for 2 minutes but not rin sed afterwards. The
formation of interproximal soft tissue isthmu s-
es allows extension of papi llae de-epithelial-
ization on their occlusal surface in a palatal
direction.

85
 PROSTHETIC-SURGICAL TREATMENT OF PERI -IMPLANT SOFT TISSUE DEHISCENCES

As opposed to in th e mandible, where the lip's submucosal tissue covers the most apical part of the
implant surface affected by bone dehiscence, in the maxilla it is necessary for th e graft to entirely cover
th e buccal dehiscence, extending 2 to 3 mm apically on top of the buccal bone crest in order to avoid
visibility of the im plant th rough the thin soft tissues.

The palatally extended de-epithelialization of the papillae provides a w ide vascu lar bed for the
surgical papillae of th e trapezoidal coronally advanced flap even after th e placement of the con-
nective tissue graft in a more coronal position, ie, 1 mm coronal to th e gingival margin of the
co ntralateral tooth.

The provisional should be shortened so that it
doesn't interfere with soft tissue healing.
Primary healing of the soft ti ssues (surgical papil-
la over the de-epithelialized anatom ical papilla)
and the presence of the underlying connective
tissue graft allows for limited or nonexistent early
shrinkage of the marginal soft tissues, even if they
are placed on top of an avascu lar surface (surgical
abutment and implant surface). After 14 days, at
the moment of suture removal, th e marginal tis-
sues are practically in the same position as they
were at the end of the su rgery.

Courtesy of: • John Wiley and Sons. J Periodontal. 2020 Jan;91(1):9-16.

 PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHI SCENCES

After both the postsurgical

soft tissue maturation phase (4
months) and the prosthetic con-
ditioning phase (screw-retained
provisional), the increase in soft
tissue thickness can be ob-
served in correspondence with
the new peri-implant transmuco-
sal portion. If the thickness of the
graft is compared to the thick-
ness of the buccal soft tissues
at the moment of final restoration
placement, it is possible to un-
derstand the importance of the
synergy between the connective
tissue graft and the coronally ad-
vanced flap in determining the
final volume of the buccal soft
tissues. This means that it is not
necessary to harvest thick grafts
from the palate, a great advan-
tage in terms of patient morbidity.

The 1-year recall shows the comp lete coverage (gingival margin at the same level as that of the adja-
cent incisor) of the buccal dehiscence and the overall good esthetic result thanks to good integration
of the new implant-supported crown and the corresponding soft tissues with the rest of the dentition
(restorative therapy done by Or Alessandro Marchetti).
87
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PROSTH ETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

*
The increase in buccal soft tissue thickness, ev-
ident in the clinical images, confers an adequate
emergence profile to the im plant-supported
crown, which seems to emerge in a natural fash-
ion from the buccal soft tissues, and guarantees
long-term stability of the results, reducing the risk
of recurrence. Th e periapical radiograph captured
at the 1-year follow-up visit shows remineraliza-
tion of the osseous crest, wh ich appears more
rad iopaque with respect to the initial situation.

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 PROSTHETI C-SURGICAL TREATMENT OF PERI -IMPLANT SOFT TISSUE DEHISCENCES

89
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PROSTHETIC-SURGICAL TR EATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

Comparison between the baseline situation and the 3-year recall shows a slightly shorter clinical crown
with respect to the adjacent incisor; this is due to the creeping , ie, coronal migration, of the marginal
soft tissues because of their increased thickness.

The occlusal and profile imag-

es confirm th e buccal soft tis-
sue increase, which continues
even years after th e surgery.
Th e periapical radiograph
shows stability of the bone
crest, which appears radi-
opaque. Th is, togeth er with
the absence of clinical signs of
mucositis or peri-implantitis, is
a sign of peri-implant health.

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 PROSTHETIC-SURG ICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

Stability of the PSTD coverage and the radiographic improvement over the years are evident, even in
the case of a buccal dehiscence associated with pathologic exposure of the implant 's buccal surface.

91
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PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

At the 5-year follow-up the results seem stable,
both in terms of the complete coverage of the
PSTD and in relation to the increased thickness
of the buccal soft tissues. Before and after (5-
year) images show complete coverage of the
PSTD and long-term stability of the surgically
reconstructed peri-implant transmucosal path.
Comparison between the baseline periapical
radiograph and the one done at 5 years shows
stability or even some improvement in the levels
of the peri-implant bone support. This, in addi-
tion to the lack of clinical signs indicating muco-
sitis or peri -implantitis, confirms the continued
healthy status of the peri-implant tissues.

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 PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

93
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PROSTHETIC-SURGICAL TREATMENT OF PER I-IMPLANT SOFT TISSUE DEHISCENCES

The majority of peri-implant dehiscences requ ire surgical

treatment cons isting of a coronally advanced flap with ver-
tical incisions. Thi s is because conditions like severe implant
malposition or loss of the interproximal soft tissue height re-
quire extending de-epithelialization of the papillae, previous-
ly augmented during the presurgical prosthetic therapy, in a
palatal direction. In cases of minor buccal displacement of
the implant platform and in the presence of good height and
width of the peri-implant papillae, it is possible to perform a
coronallY advanced envelope flap- a technique widely used
in mucogingival surgery for the treatment of multiple adjacent
gingival recessions. This technique also al lows treatment of
any ging ival recession present on teeth adjacent to the PSTD,
maximizing the overall esthetic resu lt.
 PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES
Presurgical prosthetic therapy remains a funda-
mental step for increasing the vascu lar beds me-
sial and distal to the surgical abutment in prepa-
ration for the anchorage of the surgical papillae
of the coronally advanced flap. The presence of
triangular-shaped papillae on the envelope flap
makes the increase in width and height of the ana-
tom ical papillae to be de-epithelialized even more
critical. This is obtained by the removal of the im-
plant-supported crown, the change in the mor-
phology of the abutment, and the placement of a
short provisional that does not interfere with soft
tissue growth. The superimposition of the clinical
images allows appreciation of the difference in
shape between the prosthetic and surgical abut-
ments, which provides space for the growth of
the interproximal soft tissues. Comparison of the
peri-implant papillae dimensions in the presence
of the initial restoration and after the presurgical
soft tissue maturation shows the importance of
the presurgical prosthetic phase. Considering
that the ideal position of the connective tissue
graft should be about 1 mm coronal to the gin-
gival margin of the contralateral tooth, when the
papillae mesial and distal to the abutment are tall
and wide enough , which eliminates the need to
perform de-epithelialization in a palatal direction,
it is possible to resort to an envelope flap.
95
PROSTH ETIC-SURG ICAL TREATM ENT OF PER I-IMPLANT SOFT TISSUE DEHISCENC ES

Th e fro ntal approac h fo r the executi on of the
coronally advanced fl ap without vertical incisions
(from canine to can ine) requ ires interproximal
submarg inal incisions that are ob lique, directed
toward the fl ap's center of rotation (the implant
in this case). These incisions start from th e gi n-
gival margin of th e teeth adjacent to the implant
and end at a distance from th e papilla vertex th at
corresponds to the coronal advancement of th e
marginal tissues, which will be greater at th e level
of th e PSTD and lesser at th e adjacent teeth. Th e
flap is th en elevated in a sp lit-fu ll-split thickness,
as described for the trapezoidal flap, until obtain-
ing adequate passivity.
 PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE OEHISCENCES

The presence of a thin

labial bone plate at the
implant 's buccal surface
doesn't always avoid
the metallic gray tissue
discoloration.

The abutment's screw access hole must be
closed with fl owable composite to provide a con-
vex surface that is hard and smooth in order to al-
low optimal adaptation of the coronally advanced
flap's marginal tissues. In the presence of deep
bone dehiscences or metallic discolorations with
a large apical extension, instead of using a sin-
gle tal l graft-more painful for the patient- it is
advisable to opt for two grafts: one placed coro -
nally and anchored to the base of the anatomical
de-epithelialized papillae, and the second one
placed apically and anchored to the periosteum.

97
PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

The flap is sutured coronally, placing the surgical papillae on top of the anatomical de-epithelialized
papillae, with sling sutures that are suspended around the cingu la of the teeth included in the flap de-
sign . Improved primary closure mesial and distal to the surgical abutment is achieved with additional
simple interrupted sutures .

At the end of the surgery, it is very important movements of the lip. During the first 6 months,
for wound stabi lity that there is no blood seep- the provisional should be left slightly short so
ing through the soft tissue margin and the un- as not to interfere with healing and maturation
derlying surgical abutment, even during forced of the coronal soft tissues .

•
 PROSTHETIC-SURGICAL TREATMENT OF PERI -IMPLANT SOFT TISSUE DEHISCEN CES
At the end of the soft tissue maturation phase
(4 to 6 months) it is possible to proceed to soft
ti ssue co nditioning with a new screw-retain ed
provisional.
The main goals are to push the implant's mar-
ginal soft tissues apically so that they resemble
those of the adjacent tooth in terms of thei r po-
sition and scallop and also to gradually fill the
interproximal spaces with triangular papillae by
progressively displacing th e contacts points in a
more coronal position.
When all of these objectives have been achieved,
it is time to place the final restoration. Both the
final abutment and crown should maintain the
soft tissue morphology obtained at the end of
the provisional prosthetic phase.
99
PROSTHETIC-SURGI CAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES
Th e increase in height and thickness of the
im plant's buccal soft tissues allows an opti-
mum esthetic result, masking the underlying
implant-prosthetic co mponents and favoring
blending of the restoration withi n the treated
area.
Th is technique allows the creation of a new
transmucosal path on ly on the buccal side,
w hich can be easily cleaned by the patient.
The periapical radiograph captured at the end
of the cond ition ing phase shows stability of the
peri-implant bone support levels.
The clinical image at 1 year
after the surgery shows how
the grafted area blends in w ith
th e adjacent soft tissues whi le
achieving comp lete coverage
of the buccal dehiscence.
Even the apical discoloration
is masked th anks to th e in-
creased thickness of the buc-
cal soft tissues.
PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEH ISCENCES

101
PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEH ISCENCES
PROSTHETI C-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE OEHISCENCES

The periapical radiograph

at the 7-year follow-up
shows stability of the
peri-implant bone sup-
port levels and radiopac-
ity of the osseous crest.
103
PROSTHETIC-SURGICAL TREATMENT OF PER I-IMPLANT SOFT TISSUE DEHISCENCES

Comparison of th e tissues over time allows confirmation of the stability of the esthetic result and the
slight, but important, increase in buccal soft tissue th ickness that will help reduce the risk of recu rrence
to a minimum .

Courtesy of: • Quintessence Publishing. Int J Periodontics Restorative Dent. May-Jun 2013;33(3):327-35.
 PROSTHETI C-SURG ICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

105
Courtesy or • Quintessence Publishing. Int J Periodontics Restorative Dent. May-Jun 2013;33(3):327-35.
PROSTHETI C-SURG ICAL TREATMENT OF PER I-IMPLANT SOFT TISSUE DEHISCENC ES

The free gingival graft is a poorly predictable root coverage technique that provides unsati sfactory
esthetic results due to the white scarli ke aspect of the treated area, which contrasts with the adjacent
tissues. Its limitations regarding esthetics and degree of coverage become even more evident when
th e technique is used for the treatment of buccal PSTD on osseointegrated im plants.

The main challenge when treating implant de- (conical if possible) could increase the inter-
hiscences is not related to th e buccal implant proximal space in order to allow spontaneous
position but is highly dependent on the deg ree growth of the affected tissues. In such unfa-
of mesiodistal malposition; that is, when the im- vorable circumstances, the presurgical soft
plant is placed in close proximity to an adjacent tissue maturation phase could last longer than
tooth , th e height and width of the peri-implant the customary 2 to 3 months (i e, up to 6 to 8
papilla are drastically reduced. Before consid- months).
ering implant removal as the only alternative, it
would be wise to evaluate th e response of the
soft ti ssues to th e presurgical prosth etic phase.
Often these changes are greater than could be
expected , taking into account the baseline cl in-
ical and radiog raphic evaluations. This is par-
ticularly tru e in cases in which th e tooth adja-
cent to the implant needs prosthetic treatm ent.
A marked subgingival preparation of the tooth
surface facing the implant in association with
th e placement of a narrow and thin abutment

Courtesy of: 'John Wiley and Sons. Periodontol2000. 2018 Jun;77(I):150- 164.
 PROSTHETIC-SURGICAL TREATMENT OF PERI -IMPLANT SOFT TISSUE DEHISCENCES

The absolute need to extend de-epithelialization
palatally, especially at the level of the distal implant
papilla, requires the performance of a coronally
advanced flap with vertical incisions. The pres-
ence of a recession on the adjacent tooth (left lat-
eral incisor) requires placing the releasing incision
distal to it. The good quality of the lateral incisor's
distal papilla and the absence of indications for
placement of a connective tissue graft for its treat-
ment (given that its keratinized tissues had been
previously augmented with the free gingival graft)
make it possible to perform a triangular-shaped
releasing incision that will be better camouflaged
with the adjacent tissues.

107
PROSTH ETI C-S URG ICAL TREATMENT OF PER I-IMPLANT SO FT TISSUE DEHI SCENCES

The criti cal step for th e success of this surgery is th e de-epithelialization of the im plant 's distal papilla
on its occlusal aspect until th e palatal surface is reac hed .

The triangular releasing incision allows extension of the de-epith elialization lateral to the verti cal inci-
sion, favorin g its concealment within th e adjacent soft tissues .

The lack of path ologic probing depth s apical with simple interrupted sutures placed along th e
to th e dehiscence indicates an anatom ical ex- vertical incisions and then stabilized coro nally,
posure of th e implant surface, which th erefore adapting to the abutment and to the crown of
should not be co ntaminated. Split-thickn ess flap the adjacent tooth with sling sutures at the level
elevati on at the level of the im plant allows pres- of the papillae. The provisional is shortened so it
ervati on of th e integ rity of th e connective tissue wo n't interfere with soft tissue healing.
fi ber adhesion on the bone-deprived
implant surface. The co nnective tissue
graft should cove r the whole area of
the implant exposure and overcome
the buccal crest api cally by 2 to 3 mm ;
this prevents th e risk of unesthetic out-
co mes due translucency of th e metallic
portion th ro ugh the mucosal tissues .
In order to minimize the patient 's pain
and discomfort, it is advised to harvest
th e graft from th e palate with its lon-
gest dimension placed mesiod istally
and th e shortest porti on positioned
apicocoronally. Th e flap is th en sutured
 PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

Soft tissues are allowed to mature undisturbed for 6 months, Following this period, the soft tissue con-
ditioning phase is started and lasts approximately 4 months before placement of the final restoration,
The latter will require a personalized abutment and a cemented definitive restoration,

109
PROSTH ETIC-SURG ICAL TREATMENT OF PERI -IMPLANT SOFT TISSUE DEHISCENCES

The fin al estheti c outcome is extremely sat-
isfying for th e pati ent. Both the im plant-sup-
ported crown and the treated soft ti ssues
blend in beaut ifully w ith th e adjacent teeth
and soft tissues. Th e most remarkab le feat is
th e improvement of the im plant 's distal papil-
la, w hose height and shape don't differ muc h
fro m th ose of th e reference tooth . The periapi-
cal rad iog raph shows stab ility of th e peri-im-
plant bone support.

Courtesy of: '"John Wiley and Sons. Periodontal 2000. 2018 Jun;77(I):150-164.
 PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SO FT TI SSU E DEH ISCENCES

111
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PROSTH ETI C-SURG ICAL TREATMENT OF PER I-IMPLANT SO FT TISS UE DEHISCENCES

The refin ement of the prosth eti c pro-

ced ures and surgical techniques has
significantly expanded the indicati ons
for th e prosthetic -surgical-prosthet-
ic treatm ent of peri-im plant soft tis-
sue dehiscences . Th e case shown
represents a bo rd erlin e situation, th e
successful resolution of w hich fur-
ther increases future expectations for
treatm ent of peri-impl ant soft ti ssue
defects. The peculiarity of th is clinical
case co nsists in th e co mbinati on of
the buccal dehiscence w ith the reces-
sion of the implant's mesial and distal
papillae, w hich in turn are associated
w ith loss of attachment on neighboring
teeth . Th e loss of bone support , par-
ti cularly at th e level of the distal papilla,
results in a large bu cco lingual thick-
ness deficiency. Thi s defi cit is evident
extern ally by th e deep invag inati on of
the epithelium into th e buccal soft tis-
sues (black arrow).
 PROSTHETIC-SU RGICAL T REATM ENT OF PER I-IMPLANT SO FT TI SSUE DEHISC ENCES

Substitution of the implant-supported resto-
ration and modification of the abutment has led
to a noticeable improvement of the interproximal
soft tissues, but, as shown on the periapical ra-
diograph , the space potentially available for soft
ti ssue growth is still limited by the shape of th e
surgical abutment, w hich does not foll ow the im-
plant's outline.
This required the elimination of any convexities
and an additional 2-month waiting period in or-
der to allow co mplete fill of the opened space by
matu re soft tissues.

11 3
PROSTHETIC-SURG ICAL TREATMENT OF PER I-IMPLANT SOFT TISSUE DEHI SCENCES

Th e presurg ical prosthetic treatment allows th e

obtention of soft ti ssue mesial and distal to the
im plant that, even if not supported by an intact
attachment or bone of the adjacent teeth, is ve ry
w ide and mature w ith interproximal isthmu ses
(white lines) that allow de-epithelialization of the
anatomical papillae on their occlusal plane in a
palatal directi on. Th e severe buccopalatal soft tis-
sue defi ciency in correspondence w ith the distal
papilla remains an im portant factor th at infl uences
surgical difficulty.
 PROSTHETIC-SURGICAL TR EATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

Th e presence of non -osseointegrated bioma- Another difficult factor relates to the decision of
terial, employed in previous bone regeneration when to stop the removal of biomaterial from
interventions, is a frequent fin ding duri ng buc- th e implant 's buccal surface. Clinically, the de-
cal flap incision and elevation. Occasionally, cision is made when the material appears in-
some particles of the biomaterial can be found tegrated into the hard tissues and is no longer
at the level of the papillae, interferi ng with prop- easily removed with the blade or microsurgical
er split-thickness elevation (white arrow) . This scissors . Obviously, thi s does not guarantee in
is can be attributed to th e supracrestal place- any way th at the biomaterial left in place is truly
ment of biomaterial during th e bone regener- osseointegrated, wh ich is another reason why
ation procedure. Coronally, th ose free parti- it is recommended to extend the graft's dimen-
cles co uld easily become vehicles for bacterial sions so that it covers 2 to 3 mm of bone apical
contamination because of their rough surface to the buccal bone dehiscence.
and proximity to th e oral cavity. Apically, the
excess biomaterial that did not take part in
the osseointegration process on the implant's
buccal surface becomes incapsulated inside
th e connective ti ssue, which in turn becomes
scar-like tissue with a hard consistency (black
arrow) . This tissue makes freeing the flap from
muscle insertions more difficu lt, interfering with
the execution of the superficial split-thickness
incision. The connective tissue that harbors the
incapsulated biomaterial should be removed in
order to achieve adequate coronal advance-
ment of th e flap.
Another problem in th ese cases is the presence
of biomaterial on th e flap's internal surface,
whether it is elevated full - or split-thickness. As
previously mentioned, th ese particles are en-
gulfed in the co nnective tissue (yel/ow arrows)
at the flap's inner surface, and their removal
poses the risk of excessively thinning the flap
itself. For this reason, microsurgical scissors
are recom mended for th e elimination of these
particles rather than using the surgical blade.
115
PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

The use of connective tissue grafts obtained
from the de-epithelialization of a free gingival
graft harvested from the palate is fundamental
for regulating the graft's thickness. It shou ld be
made thi cker in the area that wi ll sit on top of
the surg ical abutment as well as at the site of
the buccopalatal defect above the distal papil-
lae, and thinner in the areas that wi ll be sutured
to the base of the anatomical de-epithelialized
papillae. Despite the coronal position of the
connective tissue graft, the presence of wide
vasc ular beds that extend palatally provides a
stable anchorage for the papil lae of the flap,
guaranteeing first intention wound healing
between the surg ical papillae and the corre-
sponding anatomical pap illae.
 PROSTHETIC-SURGICAL TREATMENT OF PER I-IMPLANT SOFT TISSUE DEHISCENCES

In cases as complex as this one, postsurgical soft tissue maturation should be left undisturbed for at
least 6 months.

After 6 months, the buccal soft ti ssue dehiscence has been covered, and the buccopalatal soft tissue
defect at the level of th e distal papillae seems resolved to a large extent. In order to achieve th e maximum
coronal growth of the papilla during the conditioning phase, augmentation in excess of the buccal soft
tissue thickness is recommended-both at the level of the surgical abutment and at the distal papillae.
11 7
PROSTHETIC-SURGICAL TREATMENT OF PER I-IMPLANT SOFT TISSUE DEH ISCENCES

For this reason, a second surgical intervention was performed. Given the minimum amount of coronal
advancement needed, the flap design corresponds to that of an envelope flap, wh ich will cover a con-
nective tissue graft placed over the surgical abutment and at the level of the distal papilla.

After the second surg ical procedure, soft tissues are left to mature undisturbed for at least 4 months.
 PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

At the end of the postsurgical maturation phase, the th ickness of the soft tissues buccal to the abut-
ment and the distal papilla has been augmented in excess and is now ready to start the prosthetic
conditioni ng phase.

119
 PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

Soft tissue conditioning for 4 months allows remodeling of the marginal tissues, conferring height and
contour similar to that of the adjacent central incisor wh ile obtaining interproximal papilla growth . The
implant's distal papilla, with suboptimal bone support and formerly reduced height and thickness,
appears sim ilar in height and shape to the central incisor's distal papi lla.

The radiographic comparison between the baseline

situation and the recall 1 year after the start of thera-
py shows stability of the supporting bone levels and
radiopacity of the osseous crest, even at the distal
aspect, where there was greater bone and attach-
ment loss on the adjacent tooth . This, along with the
absence of clin ical signs of mucositis or peri-implan-
titis, is indicative of healthy peri-implant tissues.
 PROSTHETIC-SURGICAL TREATMENT OF PERI -IMPLANT SOFT TISSUE DEH ISCENCES

The final restoration is esthetically satisfying for
the patient. Coverage of the soft tissue dehis-
cence was achieved, meeting the level of the
gingival margin of th e adjacent tooth, and there
is excellent soft tissue integration between the
treated area and the adjacent tissues. The papilla
distal to the implant restoration highly resembles
the one distal to the target reference tooth and is
in a much more coronal position in comparison
with the baseline situation, even in the absence
of the integrity of underlying bone support and
despite th e clinical attachment level On the ad-
jacent lateral incisor. The implant crown has a
proper and natural-appearing emergence profile.

121
PROSTHETIC-SURGICAL TREATM ENT OF PERI -IMPLANT SOFT TISSUE DEH ISCENCES

The occlusal and profile views highlight the increase in soft tissue th ickness, particu larly significant at
the level of the implant's distal papilla.
 PROSTHETI C-SURGICAL TR EATMENT OF PERI-IMPLANT SOFT TISSU E DEHISCENCES

Two years after delivery of the fin al restoration, the general esthetic outcome appears stable, along w ith
coverage of the soft tissue dehiscence and blending of the treated area w ith the adjacent soft tissues.

123
PROSTHETI C-SURGICAL TR EATMENT OF PERI -IMPLANT SOFT TISSUE DEHI SCEN CES

Soft ti ssue gain is also stable, which reduces the risk for recurrence of peri -implant dehiscence. Th e
emergence profil e of th e implant crown is estheti cally pleasing and protects th e marginal soft ti ssues.
PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSU E DEHISCENCES

125
PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

A less frequent findin g, in comparison to buccal dehiscence of the

peri -implant soft ti ssues, is th e occurrence of mucosal fenestrations. A
fenestration is th e pathologic exposure of the im plant (or implant- prosthet-
ic) surface with integrity of the marginal soft ti ssues. Implant malposition
and red uced thickness of the buccal soft tissues playa crucial role in the
etiology of this type of lesion.
The goal of the surgical treatm ent in thi s case is not coverage but aug-
mentation of the thi ckness of the soft tissues buccal to the implant-pros-
theti c surface. The exposed implant surface should be decontaminated,
and the surgical proced ure aims at preserving th e integ rity of the stri p of
marginal soft tissues coro nal to th e perforati on for enhance ment of the
fin al estheti c result.
 PROSTHETIC-SURGICAL TREATMENT OF PERI -IMPLANT SOFT TISSUE DEHISCENCES

The epithelial margin of the per-

foration is excised in preparation
for first intention wound closure
of the fenestration with thin su-
ture material (7-0 PGA, 8-mm
needle). From here on, the surgi-
cal technique consists of a cor-
onally advanced trapezoidal flap
and placement of an underlying
connective tissue graft, obtained
from de-epithelialization of a free
gingival graft harvested from the
palate. The apicocoronal dimen-
sion of the graft should be enough
to cover the implant-prosthetic
exposure as well as 2 to 3 mm
of crestal bone apical to the buc-
cal bone dehiscence. The plas-
tic properties of the graft and its
reduced thickness allow an op-
timal adaptation onto both the
exposed implant surface and the
base of the anatomical de-epi-
thelialized papillae. Since we are
dealing on ly with the abutment
and the smooth implant col lar,
decontamination is performed
with rubber points to polish the
metal , 24% EDTA gel, and 1% ch-
lorhexidine gel (both left in place
for 2 minutes each).

Th e comparison between the image obtained from the CBCT scan and the intrasurgical situation
shows how unreliable 3D radiographic images can be for diagnosis of buccal bone dehiscences. Th e
presence of a th in buccal plate usually is masked due to the scattering effect generated by the metallic
surfaces.
127
PROSTHETIC-SURGICAL TREATMENT OF PERI -IMPLANT SOFT TISSUE DEHISCENCES

The flap is closed with sim-

ple interrupted sutures along
the vertical incis ions and with
a coronal sling suture at the
level of th e papillae. The pres-
ervation of th e integ rity of the
marginal soft tissues and clo -
sure of the perforation allow
enhancement of the esthetic
result, avoiding exposure of
the graft and th e resulting dif-
ference in color and texture
with respect to the adjacent
soft tissues.
 PROSTHETIC-SURGICAL TREATMENT OF PER I-IM PLANT SOFT TISSUE DEHISCENCES

Years after the treatment, the stability of the outcome can be ap-
preciated, in terms of both esthetic blending of the treated area
with the adjacent soft tissues and gain in buccal soft tissue thick-
ness. At the 7-year recall there is a considerable increase in the
dimension of the buccal keratinized tissue as a result of the realign-
ment of the mucogingival junction. In the event that the integrity
of the strip of marginal soft tissues coronal to the perforation had
been lost, the implant-prosthetic structures cou ld have hardly re-
mained covered . Furthermore, graft exposure would have resulted
in an increase in the dimensions of the keratinized tissues, with
the un esthetic appearance that characterizes the healing of free
gingival grafts.
The periapical radiograph taken 7 years after the surgery shows
stability of the supporting bone levels.
129
PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEH ISCENCES
PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

131
PROSTHETIC-SURGICAL TREATMENT OF PER I-IM PLANT SOFT TI SSUE DEHISCENCES

One of the worst mistakes regarding implant po-

sition is the extremely coronal placement of an
implant in a patient who wasn 't diagnosed with
altered passive eruption of the teeth neighboring
the implant site. Thi s mistake happens most fre-
quently with flapless implant placement, mainly
postextraction cases. Given that in the esthet-
ic zone the gingival margin of the contralateral
tooth is used as a reference point for the position
of the implant platform, if this margin is coronal
to the cementoename l junction (CEJ) because it
is affected by altered passive erupti on and the
implant experiences gingival recession , th en it are coronally displaced due to the altered pas-
cou ld lead to th e appearance of a peri-implant sive eruption . Therefore, the implant crown is
soft tissue "pseudo-dehiscence." In this clinical not "long," but rather the teeth are "short." If the
scenario, the mucosal margin on the implant's implant platform was placed coronal to the CEJ
facial aspect cou ld be in a correct position, and bone crest of the reference tooth, the im-
whi le the gingival margins of the adjacent teeth plant should be removed.
 PROSTHETIC-SURGICAL TREATMENT OF PERI -IMPLANT SOFT TISSUE DEHISCENCES

A very buccal position of the implant is an additional complicating factor that renders treatment of the
pseudo-dehiscence of the implant's facial tissues even less predictable.

Diagnosis of altered passive eruption is made crown . Altered passive eruption is diagnosed
w ith the aid of a periapical radiograph taken when the difference between th e clinical and
with a radiopaq ue reference point, such as anatomical crown is ~3 mm.
a gutta-percha point , placed on the clinical
crown so that it coincides w ith the ging ival
margin on one side and w ith the incisal edge
on the other. By measuring intraorally the
length of the clinical crown and radiographi -
cally the length of the gutta-percha point and
the anatom ical crown (d istance from CEJ to
incisal edge), it is possible to calcu late the
amount of radiographic distortion and con-
sequently the real length of the anatom ical
133
PROSTHETIC-SURGICAL TREATMENT OF PER I-IMPLANT SOFT TISSUE DEHISCENCES
In some cases, like the one presented, in ad-
dition to resolving the altered passive eruption
of the neighboring teeth , it is necessary to cor-
onally advance the mucosal margin at the im-
plant site. In fact, since the implant is in a lateral
incisor site and being that the implant platform
is at the level of th e CEJ of the central incisor, it
is necessary to create a tran smucosal path that
covers the implant platform in excess in such
a way that the mucosal margin of the implant
crown is coronal to the gingival margin of the
central incisor, w hich will be located almost at
the level of (s;1 mm from) the tooth 's CEJ after
treatment of the altered passive eruption. In a
single surgical procedure, it is possible to treat
th e altered passive eruption and at the same
time increase th e height and thickness of the
implant's buccal soft tissues by combining the
esthetic crown lengthening w ith a coronally ad-
vanced flap plus a con nective tissue graft. Given
the need for some degree of coverage of th e
implant's soft tissue dehiscence, the presurgi-
cal prosthetic treatment (crown removal and re-
placement/modification of the abutment) must
be done to improve the quality and quantity of
the implant's mesial and distal soft tissues. The
flap's design cons ists of a series of scalloped
paramarginal incisions, except at the level of the
im plant. In order to obtain coro nal advancement
of the flap at th e implant site it is necessary to
make a distal vertical incis ion. Since both teeth
adjacent to the implant (right canine and central
incisor) must also sustain the coronal advance-
ment of the flap and at the same time undergo
treatment of th e altered passive eruption, the
submargin al incisions should be slightly more
apical with respect to their counterparts on the
left side. Obviously, this is only possible in the
presence of an adequate band of buccal kerati-
nized tissue.
 PROSTHETIC-SURGICAL TR EATM ENT OF PERI -IMPLANT SOFT TISSUE DEHISCENCES

The flap is elevated w ith a variable thickness: split at the level of the surgical papilla, and full at the
level of the buccal parabolas, where a periosteal elevator will be used to expose the buccal bone
crest.

Freeing of the flap with deep and su-

perficial split-thickness incisions is
done only at the level of the implant
in order to achieve coronal advance-
ment of that portion. Once the flap
is entirely elevated, bone remodeling
is done for treatment of the altered
passive eruption: osteoplasty of the
buccal surface and ostectomy only
whenever the minimum space (1 to
2 mm) for the supracrestal soft tissue
attachment is not present between
the buccal bone crest and the CEJ
(black arrows). Ostectomy is carried
out with a surgical blade after bone
volume has been reduced by th in-
ning it with a round diamond bur.

135
PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

The connective tissue graft is sutured (7-0 corresponding to the paramarginal incision on
PGA) facially at the implant and right cen- the central incisor and give a uniform thick-
tral incisor. The latter has a double purpose: ness to the buccal soft tissues at the level of
compensate for the loss of keratinized tissue the implant crown and the adjacent tooth.

The apically repositioned flap is sutured with simple interrupted sutures (7-0 PGA) anchored to the
base of the anatomical de-epithelialized papi llae. The portion of the flap that is coronally advanced is
fixed with simple interrupted sutures along the vertical incision and with a sling suture (6 -0 PGA) at the
level of the implant's papillae.
 PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

Soft tissues are left to mature undisturbed for 4 months. A grayish discoloration due to the underlying
metallic structure is still visible, especially during smiling because of the shadow cast by the lip.

At the end of the maturation phase the dark
color of the underlying implant-prosthetic struc-
tures is still visible through the implant's buc-
cal soft tissues, even after their height and
thickness has been increased . The patient
acknowledges this unesthetic outcome during
smiling. Furthermore, a misalignment between
the gingival margins of the central incisors has
become evident due to the increased thickness
of the soft tissues after graft placement, which
has caused creeping of the right central inci-
sor's gingival margin.

137
PROSTHETIC-SURGICAL TREATMENT OF PERI -IMPLANT SOFT TISSUE DEHISCENCES

Realignment of the gingival margin of both to extend de-epithelialization of the anatom i-

central incisors can be easily achieved with
gingivectomy and gingivoplasty, whi le a cor-
onally advanced flap and connective tissue
graft must be done to mask the underlying
metallic structures . Given that the transparen-
cy is located coronally, the graft must also be
placed in th is position; this makes it necessary
cal papillae onto their occlusal aspect, in a
palatal direction, to create vascular beds that
wi ll match the position of the surgical papillae
once the flap is coronally advanced . In order
for the flap to be advanced in a palatal direc-
tion, it must be of trapezo idal design with two
vertical incisions.
 PROSTHETIC-SURGICAL TREATMENT OF PERI -IMPLANT SOFT TISSUE DEHISCENCES

Given that the right ce ntral incisor is in a more
palatal position than the left central incisor, it
is advisable to place a provisional restoration
that accentuates the crown's emergence pro-
file. This wi ll prevent/reduce excessive soft tis-
sue rebound and favor symmetry of the gingi-
val margin of both teeth . Once the soft tissue
condition ing phase of the peri-implant soft tis-
sues is fini shed , it is possible to proceed with
the final prosthetic restoration. In this case, due
to the patient's esthetic demands, the restor-
ative phase included placement of veneers on
the teeth adjacent to the implant- supported
crown.

139
PROSTHETIC-SURGICAL TREATMENT OF PERI -IMPLANT SOFT TISSUE DEHISCENCES

Compari son between th e baseline and final images shows how harmonization of th e gingival mar-
gins was achieved, in some part , thanks to coverage of the peri-implant soft tissue dehiscence and ,
most im portantly, due to th e treatment of the altered passive eruption on adjacent teeth (restorative
therapy by Or Elisabetta Pastorino).
 PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

Radiographic control reveals stability of the peri-implant supporting bone levels, with an increased ra-
diopacity of the bone crest. The smile views show good blending of the implant site within the anterior
segment, both in terms of the prosthetic restoration and also regarding the soft tissues.

141
PROSTH ETIC-SURG ICAL TREATM ENT OF PER I-IMPLANT SOFT TISSU E DEHISCENCES

The 2-year recall images show stability of the esthetic result and maintenance of volume at the aug-
mented peri-im plant soft tissues.

Follow-up at 3 years confirms stability of th e esthetic result and shows a slight increase in th e thickness
of th e peri-im plant soft ti ssues, typical of thi s proced ure. This does not cause esth eti c discomfort to
the pati ent and reduces the risk of peri-im plant dehiscence recurrence to a minimum.
 PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

Radiographic control also at 3 years confirms stability of the peri-implant supporting bone levels. The
profile view highlights further growth of the buccal soft tissu e thi ckness, a frequent finding when de-ep-
ithelialized epithelial-connective tissue grafts are placed along with a coronally advanced flap.

143
PROSTHETI C-SURGICAL TREATMENT OF PER I-IMPLANT SOFT TISSUE DEH ISCENCES
PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

145
PROSTH ETIC-SURG ICAL TR EATMENT OF PER I-IM PLANT SOFT TI SSUE DEHI SCENCES

Lack of diagnosis of altered pas-

sive eru pti on and wrong ly posi-
tioned implants in patients with
agenesis of th e maxillary lateral in-
cisors can lead to esth etically un-
pleasant outcomes. Ad ditionally,
inadequate thickness of the
peri-im plant buccal soft ti ssues
can lead to peri-implant patholo-
gies due to contamination of th e
exposed implant surface. When
th e implant is osseointegrated
and there are no cl inical or rad io-
graphic signs of peri-implantiti s,
implant removal becomes ex-
tremely complex, risky, and not
well accepted by the patient.
 PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

Also in this case, treatment entai ls correction of the prosthetic-surgical-prosthetic approach .

the altered passive eruption of the teeth neigh-
boring the implants as well as an increase in
thickness and height of the transmucosal path
at its midfacial aspect. The need to shorten the
implant-supported crowns requires treatment
of the buccal soft tissue dehiscences with
Therefore, surgical therapy is preceded by a
prosthetic phase that consists of removal of
the implant-supported crowns and placement
of a surgical abutment and short provisional
crowns that wi ll not interfere with peri-implant
soft tissue growth.

147
PROSTHETIC-SURGICAL TREATMENT OF PERI- IMPLANT SOFT TISSUE DEHISCENCES

For the simultaneous treat-

ment of altered passive erup-
tion and implant soft tissue
dehiscences, it is necessary
to design a flap with paramar-
ginal incisions and intrasu lcu lar
incisions, respectively ; the soft
tissues apical to the implants
should be elevated full thick-
ness, and two vertical releasing
incisions should be placed dis-
tal to the can ines. The latter are
mandatory in order to ach ieve
apical positioning of the flap on
the teeth affected by altered
passive eruption and at the
same time coronal position ing
of the flap at the level of th e im-
plants' surgical abutments.

Bone remodeling for the treat-

ment of altered passive eruption
consists of buccal osteoplasty
and osteotomy at sites lacking
the minimum required space for
the supracrestal soft tissue at-
tachment (ie, 1 to 2 mm between
the buccal bone crest and the
CEJ). Ostectomy is performed
with the surgical blade after the
bone volume has been reduced
with a round diamond bur.
 PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

Connective tissue grafts are

placed on top of the surgical
abutments, covering the buccal
dehiscences coronally and 2 to
3 mm of the buccal bone crest
apically.
The flap is sutured in an apical
position at the level of the teeth
with altered passive eruption
and is coronally advanced at
the level of the implant sites.
The provisional restorations are
shortened so that soft tissues
can heal freely.

Sutures are removed 2 weeks

after the surgery.
149
PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE OEHISCENCES

Soft tissues are left to heal undisturbed for 6 months. Small corrections in the morphology of the soft
tissues can be obtained with gingivoplasty performed with diamond burs and abundant irrigation. Final
restorations are to be placed once soft tissue healing is completed (9 months after surgery).
 PROSTHETIC -SURG ICAL TREATMENT OF PERI -IMPLANT SOFT TISSUE DEHISCENCES

The final outcome fully satisfies the patient's es-
thetic demands.
Comparison between th e baseline and final
images evidences th e harm ony of the gingival
margins obtained mostly due to treatment of
the teeth affected by altered passive eru ption
and to a lesser degree thanks to coverage of
the peri-implant soft tissue dehiscences (restor-
ative therapy by Or Fabio Fusconi and Or Giulia
Graziani).

151
PROSTHETIC-SURGICAL TREATMENT OF PERI -IMPLANT SOFT TISSUE DEHISCENCES
PROSTHETI C-SURGICAL TREATMENT OF PERI -IM PLANT SOFT TISSUE DEHISCEN CES

153
PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

Treatment of PSTDs at single implants has
been found to be predictable. In most cases it
is not possible to perform the surgical proce-
dure immediately while retaining the patient's
implant-supported crown, either because it lies
outside of the imaginary curved line that pass-
es through the buccal aspect of the anatomical
crowns of the adjacent teeth or because the
papillae are not ideal and must be increased in
height and thickness with presurgical prosthetic
therapy. Much less explored and documented
is the treatment of PSTDs on multiple adjacent
implants. The main limiting anatomical factor is
implant proximity, which, even after crown re-
moval and placement of surg ical abutments,
does not allow formation of peri-implant papillae
that are wide or deep enough to serve as vascu-
lar beds for both the connective tissue graft and
th e surgical papillae of th e coronally advanced
flap. Th e case presented here shows a 28-year-
old female patient whose central incisors had to
be extracted because they were afflicted with
root resorption and ankylosis due to a previous
traumatic incident.

Following is the timeline of the patient's previous treatments: Extraction of the maxillary left central
incisor with socket preservation with deproteinized bovine bone particles and collagen membrane.
 PROSTHETIC -SURGICAL TREATMENT OF PER I-IMPLANT SOFT TISSUE DEHISCENCES

After 4 months, guided bone regeneration with an autogenous bone block, deproteinized bovine bone
particles, and a collagen membrane.

155
 PROSTHETIC-SURGICAL TREATMENT OF PERI -IMPLANT SOFT TISSUE DEHISCENCES

Im plant placement in th e maxillary left central incisor position 6 months later.

Four months later, immediate

postextraction implant place-
ment in the maxillary right cen-
tral incisor position. In spite of
deferred tooth extraction and
bone regeneration surgeries,
the final resu lt was not very suc-
cessful, leaving the patient highly
unsatisfied and worried because
the only solution seemed to be
removal of both implants.
 PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES
At the time when the authors were contacted by
the referring dentist, the patient had two provi-
sional crowns in place, esthetically unpleasant and
First, the referring dentist was asked to replace
the current prosthetic abutments w ith custom-
ized zirco nia abutments th at wou ld allow proper
hyg iene maintenance by the patient and at th e
same time the placement of short provisionals
that didn't impinge on buccal or interproximal
soft ti ssues.
functionally unsatisfactory, wh ile the implants, even
though malpositioned, did not present clinical or
rad iographic signs of peri -implantitis. Removal of
the provisional crowns allowed visualization of the
considerable distance (>4 mm) between the pros-
thetic abutments, wh ich allowed the presence of
an interimplant papilla that, although quite flat , was
very wide mesiodistally and deep buccopalatally.
Thi s, along with absence of signs of peri-implanti-
tis, was the determining factor for the decision to
treat the PSTDs of both implants with the prosthet-
ic-surg ical-prosthetic approach described for sin-
gle implants.
Thi s wou ld provide ideal quantity and quality
of the soft ti ssues at the time of surgery, to be
done 2 months afterwards, wh ich wou ld al-
low execution of the coronally advanced flap
w ith an underlying connective ti ssue graft for
the treatment of the PSTD on the adjace nt
implants.
157
PROSTHETI C-SURG ICAL TREATMENT OF PERI -IMPLANT SOFT TISSUE DEH ISCENCES

Two months after removal of the implant-sup-
ported restorations and replacement of th e
abutments, the soft tissues seem healthy and
have come to occupy the whole peri-implant
space. This was possible because during th is
period th e patient was properly motivated and
instructed to brush using the roll technique,
clean interproximally with a spongy floss, and
use a chlorhexidine-based (0.12%) rinse once a
day for 1 minute.
 PROSTH ETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE OEHISCENCES
The surgical techniqu e consists of a trapezoi -
dal flap with horizontal incisions at the level of
the papillae and two slightly divergent vertical
incisions that extend into the alveolar mucosa.
Placement of the horizontal incisions should take
into consideration th at, with the interimplant and
Th e flap is elevated split-thickness in order to
preserve the integrity of the con nective tissue
adhesion on the buccal aspect of the exposed
implant surfaces.
Only the probeable tissues apical to the sur-
gical abutments are elevated full-th ickness
with the periosteal elevator. Freeing of the flap
right central incisor's distal papillae being rather
flat, the surgical papillae should be replaced in a
prevailingly palatal direction in order to be super-
imposed on top of the correspondi ng anatomical
papillae. For thi s reason, the horizontal incisions
should be placed in a more coronal position.
is achieved w ith two incisions: a deep one, to
separate muscle insertions from the perioste-
um , and a superficial one, to remove muscle in-
sertions from the inner surface of th e flap. Flap
mobility is considered adequate when each
surgical papilla is capab le of being positioned
palatally w ithout ten sion .
The soft tissues found co ronal and occlusal
to th e horizontal incisions are de-epithelialized
until the palatal surface is reached; this area
w ill represent the anatomical papilla that with
provide vascular supply to the surgical papillae
of the coronally advanced flap. Presence of a
consi derable distance between the abutments
results in a ve ry wide peri-implant vascular bed
that makes up for the insuffi cient height of the
interim plant papilla and for the most likely ab-
sent bone peak.
159
PROSTHETIC-SURGICAL TREATMENT OF PERI -IMPLANT SOFT TISSUE OEHISCENCES

The profile images show the buccal promi-

nence of the implant platforms, especially that
of the transmucosal implant in the maxillary
left central incisor position . The morphology of
the transmucosal implant portion reduces the
effectiveness of the treatment because it ap-
proximates the implant to the adjacent tooth/
implant, reducing the amount of soft tissues
available between them and making coverage
of the implant platform very difficult because it
protrudes buccally with respect to the position detachment of the abutment, implant fracture)
of the fixture. Reducing the prom inence of the that cou ld render the success of the PSTD cov-
im plant co llar w ith a feather-edge preparation erage useless. However, the transmucosal im -
is not recommended due to the risk of poten - plant collar shou ld be polished w ith metal-pol -
tial prosthetic or implant-related problems (eg, ishing silicon points.

A connective tissue graft, obtained from the
de-epithelializati on of a free gingival graft, is fixed
coronally to the base of the papillae with internal
mattress sutures anchored to the palatal aspect
of the de-epithelialized anatomical papillae (see
drawing) and apically with simple interrupted
sutures anchored to the periosteum . The latter
are necessary because the prominence of the
implant platforms cou ld impede the graft from
adapting to the apical periosteal bed. Th e api-
cocoronal dimension of the graft should be such
that it allows coverage of 3 mm of periosteum api-
cal to the implants' buccal bone crest. It is crucial
to take care not to obliterate the vascu lar supply
of the de-epithelialized anatomical papillae with
excessively coronal placement of the graft.

./

t"
/
 PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES .i••_
The coronally advanced flap is closed with simple
interrupted sutures along the vertical releasing in-
cisions. Sling sutures placed at the level of the
papillae and suspended around the cingula of the
adjacent teeth favor positioning of the surgical
papilla on top of the corresponding anatomical
papillae, de-epithelialized in a palatal direction,
and contribute to a tight adaptation between the
flap's keratinized tissue and the convex surface of
the surgical abutment. Simple interrupted sutures
are used to achieve primary intention closure be- occlusal view shows adaptation between the sur-
tween the surgical and anatomical papillae, es- gical and anatomical papillae without areas heal-
pecially at the level of the interim plant papilla. The ing by secondary intention.

The provisional restoration is shortened so that it doesn't interfere with buccal and interproximal soft
tissues during healing. Sutures are removed after 2 weeks.

The patient is recalled on a monthly basis during the first 3months; if the provisional comes in contact
with the soft tissues, it is shortened to avoid interference with tissue maturation.
161
PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

During the maturation phase,

soft tissues are left undisturbed
for 6 months. At the recall ap-
pointment, adequate coverage
of the buccal dehiscences can
be appreciated , while at the
level of the peri-implant papilla
a small deficit is still present.

The slight deficit involves only

papilla height, as the buccolin-
gual defect has been resolved.
The profile and occlusal views
evidence how optimal cover-
age was achieved in spite of
the prominence of the implant
platforms.
 PROSTHETIC-SURG ICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEH ISCENCES _1___
The superimposed images highlight the amount of coverage of the surgical abutments that was obtained.

A second surgery was performed to further im-
prove th e height of the interim plant papilla and
root coverage of the right lateral incisor. The
technique involved a palatal , slightly semilunar,
beveled incision at th e base of th e interimplant
papilla and elevation of th e supracrestal tissues,
which are to be coronally positioned, along with
a buccal envelope flap. The thickness of the
palatal soft tissues makes it possible to create
a long bevel by tilting the blade until reaching
the palatal bone. Thi s maneuver increases the
amount of con nective tissue on the surfaces that
come in contact at the time of flap closure. The
supracrestal ti ssues return to th eir initial position,
while covering a "saddle" co nnective tissue graft
placed in the interimplant area.

163
PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES
The buccal flap is designed as a coronally ad-
vanced envelope flap. Coronal advancement of
the flap serves a double purpose: compensate
for the volume occupied by the connective tissue
A connective tissue graft (white arrow) as wide as
the interimplant space and 15 mm in length was
placed as a saddle over the interimplant bone
crest. Posteriorly, 3 mm of the graft was inserted
under the palatal flap, and the remaining 12 mm
A second connective tissue graft was placed
at the level of the CEJ of the right lateral in-
cisor to improve root coverage and increase
the buccal soft tissues so that there would
be a uniform thickness between this site and
the implants' buccal aspect, which was pre-
viously augmented in the first surgical phase.
graft placed at the interimplant area and improve
coverage of the right lateral incisor. In order to
obtain greater coronal advancement on the right
side, an additional surgical papilla was elevated .
covered the interimplant area and ended under the
buccal flap (white dotted line). The length of the
graft allowed its stabilization under the palatal and
buccal flaps without the need for additional sutures
to keep it in place.
Both grafts were obtained from the extraoral
de-epithelialization of palatally harvested free
gingival grafts.
Coronal advancement of the flap allowed first
intention wound healing along the palatal inci-
sion line in spite of the additional connective
tissue graft placed between the implants.
 PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE OEHISCENCES
--

Flap closure was done with simple interrupted sutures along the semilunar palatal incision and at the
papillae distal to the implants; sling sutures are done at the remaining teeth.

The provisional has been subsequently shortened as a result of the insignificant tissue shrinkage.
so that it does not interfere with healing of the Soft tissues are left to mature undisturbed for 6
buccal and interproximal tissues. After 2 months, months, after which the soft tissue conditioning
soft tissues are at the same postsurgical position phase is started with new provisional restorations.

The goal of cond itioning is to manipulate soft tis-
sue height and give the desired contour to the
facial mucosal margins of the implant crowns
while favoring papilla growth by compression. In
agreement with the patient, the provisionals were
shortened incisally, and the shape of the lateral in-
cisors was also modified to redistribute the widths
and shapes of the teeth in the anterior segment.
After 2 months there already was significant tissue
remodeling guided by the provisional restorations.

165
PROSTHETIC-SURGICAL TREATMENT OF PERI -IMPLANT SOFT TISSUE DEHISCENCES

Comparison between the presurgical image and

the image 2 months into the soft tissue condi-
tioning phase shows the distinct improvement
regarding coverage of the PSTD and height!
thickness of the interimplant papilla.

Four months after the start of soft tissue conditioning, significant improvements in the morphology of
the peri-implant tissues are visible and also appreciated by the patient. However, soft tissue maturation
is not quite complete.

When the soft tissues appear

stable and the patient is sat-
isfied with the esthetics of the
smile, it is possible to proceed
with final restoration place-
ment. In this case, this took
place 8 months after the start
of soft tissue conditioning.
 PROSTHETIC-SURGICAL TR EATM ENT OF PERI -IMPLANT SOFT TISSUE DEH ISCEN CES • • •_

Comparison and superimposition of the presurgi-
cal and final image at the end of soft tissue con -
ditioning highlights the significant coverage of the
PSTD and improvement of the shape and height
of the interimplant papilla. Once more, this has
been achieved without altering the supporting
bone levels. The distance between the implants
allowed the execution of techniques for increasing
soft tissue thickness as well improvement of the
interproximal tissues, which, thanks to the provi -
sional prosthetic phase, were able to mature in a
coronal direction.

167
PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES

Right after delivery, the definitive crowns leave small interdental spaces in order not to hinder further
growth of the peri-implant papillae, wh ich goes on for years after final restoration placement.

One year after final restoration, the result is stable, and the patient is highly satisfied with the esthetic
outcome. There has been further growth of the interproximal soft tissues.
 PROSTHETI C-SU RGICAL TREATMENT OF PER I-IMPLANT SOFT TISSU E DEHISCENCES
--

Comparison between the baseline image and the situation 1 year after final restoration shows the es-
thetic improvement as a result of the prosthetic-surgical -prosthetic approach.

The profile views from before sur-

gery and 1 year after delivery of the
final restorations show the bucco-
lingual and apicocoronal soft tissue
gain that allowed the creation of
prosthetic crowns with adequate
emergence profiles and appropri-
ate dimensions in correspondence
with neighboring teeth .
The before and after occlusal views
highlight the increased soft tissue
thickness at the level of the inter-
implant papilla, which, thanks to
the conditioning done with the pro-
visional crowns, has allowed fur-
ther vertical papilla gain due to the
creeping phenomenon.

169
PROSTHETIC -SURGICAL TREATMENT OF PER I-IMPLANT SO FT TISSUE DEHISCENCES

The 2-year follow-up co nfirms stability of the results.

Comparison between the baseline situation and the 2-year recall after delivery of the fin al restorations
shows improvement of the esthetic outcome achieved with th e prosthetic-surgical- prosth etic approach .

Th e occlusal views highlight the buccal soft tissue increase at the level of the interimplant papilla, which
has allowed further co ronal papilla growth due to compression of th e restorations and th e creep ing
phenomenon.
PROSTHETIC-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TISSUE DEHISCENCES _1___

171
 PROSTHETI C-SURGICAL TREATMENT OF PERI-IMPLANT SOFT TI SSUE DEHISCENCES
Anderson LE, Inglehart MR , EI-Kholy K, Eber R,
Wang H-L. Implant associated soft tissue defects
in the anterior maxill a: a rand omized control trial
comparing su bepithelial con nective tissue graft
and acel lular dermal matrix allograft. Implant Dent.
2014;23:416-25 .
Burkhardt R, Joss A, Lang NP. Soft tissue
dehiscence coverage around endosseous
implants: a prospective cohort study. Clin Oral
Implants Res. 2008;19:451-7.
Le B, Borzabadi-Farahani A, Nielsen B. Treatment
of Lab ial Soft Tissue Recession Around Dental
Implants in the Esthetic Zone Using Guided
Bon e Reg eneration With Mineralized Allograft:
A Retrospective Clinical Case Series. J Oral
Maxil lofac Surg. 2016;74:1552-61.
Mazzotti C, Stefanini M, Felice P, Bentivogli V,
Mounssif I, Zucchelli G. Soft-tissue dehiscence
coverage at peri -impl ant sites. Period ontol 2000.
2018;77:256-272.
Mele M, Felice P, Sharma P, Mazzotti C, Bellone P,
Zucchelli G. Esthetic treatment of altered passive
eruption. Periodontol 2000. 2018;77:65-83.
Roccuzzo M, Gaudioso L, Bunino M, Dalmasso P.
Surgical treatment of buccal soft tissue recessions
around single implants: 1-year results from a
prospecti ve pi lot stud y. Clin Oral Implants Res.
2014;25:641-6.
Roccuzzo M, Dalmasso P, Pittoni D, Roccuzzo A.
Treatment of buccal soft tissue dehiscence around
single implant: 5-year results from a prospective
stud y. Clin Oral lnvestig . 2019;23:1977-1 983 .
Schall horn RA , McClain PK, Charles A, Clem D,
Newman MG . Evaluation of a porcine collagen
matrix used to augment keratinized tissue and
increase soft tissue th ickness around existing
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_1
__-
SUGGESTED READINGS
Stefanini M, Rendon A, Zucchelli G. Porcine-
Deri ved Acellular Dermal Matrix for Buccal Soft
Tissue Augmentation at Single Implant Sites: A
1-Year Follow-up Case Series. Int J Periodontics
Restorative Dent. 2020;40:121-128.
Zucchelli G, Fel ice P, Mazzotti C, Marzadori
M, Mounssif I, Monaco C, Stefanini M. 5-year
outcomes after coverage of soft tissue dehiscence
around single implants: A prospective cohort
study. Eur J Orall mplantol. 2018; 11:215 -224.
Zucchelli G, Mazzotti C, Mounssif I, Marzadori
M, Stefanini M. Esthetic treatment of peri-implant
soft tissue defects: a case report of a modified
surgical-prosthetic approach. Int J Periodontics
Restorati ve Dent. 2013;33:327- 35 .
Zucchell i G, Mazzotti C, Mounssif I, Mele M,
Stefan ini M, Montebugnoli L. A novel surgical-
prosthetic approach for soft tissue dehiscence
coverage around single implant. Clin Oral Implants
Res. 2013;24:957-62.
Zucchelli G, Tavelli L, Stefanini M, Barootchi S,
Mazzotti C, Gori G, Wang HL. Classification
of facial peri-implant soft ti ssue dehiscence/
deficiencies at single implant sites in the esthetic
zone. 2019;90:11 16-11 24.
173
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HARVEST OF A CONNECTIVE TISSUE GRAFT
~K·· )
~\
Connective tissue grafting implies the harvest-
ing of connective tissue from a certain location
(donor site) and its placement on a different
location (recipient site). The palate is by far the
most common intraoral donor site; its fibromu-
cosa is characterized by a dense connective
tissue (lam ina propria) that is covered with an
orthokeratinized epithelium. Between the pal-
atal fi bromucosa and the periosteum lining the
palatal bone, there is a layer of submucosa with
variable thickness made up mainly of ad ipose
and glandu lar tissues.
EPITHELlU-MM---~~ ~
ADIPOSE AND GLANDULAR TISSUE
PER IOSTEUM ~
0000
Palatal soft tissue thickness varies from one
patient to another and also w ithin a single
patient depending on the site. Clinical ly, this
can be assessed by penetrating the tissues
perpend icu larly to the bone surface with an
~ , -~\
~
From an anatomical point of view, if we look at a
cross section of the palate (schematic represen-
tation) and imagine harvesting an epithelium-con-
nective tissue graft (drawing), it is noticeable how
the thickness of the adipose-glandular tissues is
greater in the anterior area (canine and premolars)
and is reduced toward the posterior area (molars),
where these tissues are rather scarce and in any
case located more apically, ie, toward the pala-
tal vau lt. On the other hand, the th ickness of the
dense connective tissue increases proceeding
from the anterior to the posterior area.
DE NSE CT
anesthesia needle and placing a silicone stop
(such as those used with endodontic fil es)
in tight contact with the tissues. Penetration
depth can then be measured with a digital cal-
iper, from the silicone stop to the needle tip.
 · HARVEST OF A CONNECTI VE TISSUE GRAFT . ,• •_

PREMOLAR AREA MOLAR AREA

(ANTERIOR PALATE) (POSTERIOR PALATE)

Th e depth of needle penetration varies from

patient to pati ent and fro m site to site, but it w ill
usually be greater on th e palatal aspect of the
premolars (especially the first premolar) and
minimal at the level of the palatal root of th e
fi rst molar. Whenever a third molar is present,
it is not uncommon to encounter a significant
palatal thickness (almost entirely constituted
by dense connective tissue le T]) at th at level.

PREMOLAR AREA (ANTERIOR PALATE)

PALATAL RUGAE ---------lH~--____::::.,____- ..

EPITHELIUM

DENSE CT

ADIPOSE AND GLANDULAR TISSUE

Palatal rugae often extend into

th e premolar area, and here
the adipose-glandu lar ti ssues
are notably thick, while the
dense connective ti ssue layer
is barely present.
On the other hand , distal to the
premolars the adipose-glan-
dular layer is thinn er or entirely
absent. Th erefore, th e width of
the palatal ti ssues consists al-
most entirely of dense con nec -
tive tissue (lamina propria).

MOLAR AREA (POSTERIOR PALATE)

EPITHELI UM

DENSE CT

ADIPOSE AND GLANDULAR TISS UE

177
HARVEST OF A CONNECTIVE TISSUE GRAFT
\) ~
DE-EPITHELlA~ IZED F: EE GINGIVAL GRAFT HARVESTING
There are two kinds of techniques for harvesting
a connective tissue graft from the palate:
1. de-epithelialized free gingival graft harvest-
ing, in which the donor area heals by second-
ary intention;
2. subepithelial connective tissue graft harvest-
ing, in wh ich the palatal wound heals by pri-
mary intention due to the preservation of an
access flap that, after graft harvest, is sutured
covering the donor area.
The main goal of the latter techn iques is to re-
duce patient morbidity by improving the post-
operative course. Secondary intention pala-
tal wou nd heali ng, typical of free ging ival graft
harvesting, has always been associated with a
worse postoperative course for the patient due
to postsurgical pain and/or bleeding. However,
postsurgical pain is more dependent on the
"
~
SUBEPITHEliAL GNNECTIVE TISSUE HARVE
depth and apicocoronal dimensions of the graft
than on the type of healing (ie, primary or sec-
ondary intention). The de-epithelialized free
gingival graft technique allows a more shallow
harvesting depth, therefore reducing possible
postsurgical pain and bleeding . The illustrations
exemplify how, cons idering same-thickness con-
nective tissue grafts (area between the blue sur-
gical blades), epithelium-connective tissue graft
harvesting is done at a lesser depth with respect
to the harvest of a subepithelial connective tis-
sue graft. When th is second technique is used,
harvesting extends deeper into the palatal soft
tissues, approaching the periosteum and leav-
ing a th inner layer of tissue to cover the bone.
Additionally, given that some dense connective
tissue must be left on the access flap to avoid
risking its necrosis, it follows that the final graft
w ill include more ad ipose-glandular tissue.

In peri-impl ant plastic surgery, the de-epitheliali-
zed free gingival graft harvesting technique is to
be considered as the first choice because of the
need for connective tissue grafts void of adipose/
glandular ti ssues and th at are capable of pro-
viding an adequate thickness to the peri- implant
soft ti ssues in order to mask the im plant-pros-
thetic components and prevent development of
peri-implant soft tissue dehiscences (PSTDs).
Palatal anesthesia should be performed api cally
to the harvest area, toward the palatal vault, in a
zone where the presence of thicker submuco -
sal tissues can allow for certain mobility of the
palatal fi bromucosa with respect to the underly-
ing tissues. These conditions will render needle
penetration and liquid diffusion less painful (al-
most painless), as opposed to infiltration on the
HARVEST OF A CO NNECTI VE TISSUE GRAFT
--
harvest site, which is more painful. Fu rthermore,
administerin g anesthesia away from the harvest
site will avoid creating perforations or vascu lar
alterations in the future graft. The technique for
obtaining a de-epithelialized free gingival graft
starts by tracing, with the ti p of the surgical blade
(15C), a coro nal horizontal incision (without im-
pinging on the gingival sulcus of the adjacent
teeth) and two vertical incisions (mesially and
distally) that delimit the harvest site. Th e distal
vertical incision is done first, and then, only after
co nfi rming with th e periodontal probe that th e
mesiodistal dimensions are correct, th e mesial
vertical incision is performed . It is advised not to
trace the apical horizontal incision at this point
in order to avoid excessive bleeding during graft
harvesti ng.
179
HARVEST OF A CONNECTIVE TISSUE GRAFT

Once the incisions are traced, graft thickness is parallel to the external mucosal surface, wh ile
calibrated by inserting the blade along the coro- taking care to maintain a uniform thickness api-
nal horizontal incision (internal bevel) and along cocoronally and mesiodistally. The beveled cor-
the mesial vertical incision (perpendicularly) up onal horizontal incision serves to avoid marginal
to the desired depth; afterward, the mesiocoro- bone exposure, even in the presence of thin pal-
nal angle of the graft can be elevated split-thick- atal soft tissue.
ness, keep ing the blade parallel to the external
surface. The same thickness is kept along the
horizontal incision up to the distal verti cal inci-
sion. After elevati ng the distocoronal angle of the
graft, the split-thickness incision is continued
apical ly as previously described: with the blade

Th e last incision (apical horizontal incision) is performed whi le hold-

ing the graft with the microsurgical tissue pliers: it is first traced
with the tip of the blade and then deepened, keeping the blade
perpendicular to the external mucosal surface until the epithelium-
connective tissue graft is fully detached.

Extraoral de-epithelialization is performed by
position ing the blade at approximately half of
the graft 's mesiodistal length, so that the free
half closest to the operator can be used to hold
it in place by applying gentle pressure with one
finger. Epithelium removal is done with a brand
new 15C blade, which is initially used at an an-
gie (beveled incision) until reaching the base
of th e epithelial layer (epithelium thickness is
around 0.3 mm).
At th is point, the blade can be seen through the
transparency of the epithelial layer. Once epi-
thelial thi ckness is established, the blade is kept
parallel to the external surface wh ile removing
the epithelium (horizontal de-epithelialization).
The graft is then rotated, and its second half is
de-epithe lialized in th e same fashion. For thi s
step it is not necessary to start with the blade at
'" -
HARVEST OF A CONNECTIVE TISSUE GRAFT
--
an angle; it is enough to place the blade on top
of the epithelium-free half and proceed horizon-
tally to remove th e epithelium of the untreated
half.
Th e last portion of epithelium to be removed
after horizontal de-epithelialization will cor-
respond to the beveled coronal incision per-
form ed during graft harvest, which consists of
a narrow band of epithelium without underlying
co nnective tissue. Removal of this area is done
with a perpendicular excision (vertical de-epi-
thelialization). Graft de-epithelialization should
be performed with magn ification and a direct
light source placed perpendicu lar to the graft.
Complete removal of the epithelium is controlled
by th e difference in the ti ssue's co lor (epithelium
is ye llowish, and co nnective tissue is whiter),
surface texture, and light reflection.
181
HARVEST OF A CONNECTIVE TISSUE GRAFT

The red uced and uniform thickness of the graft
makes hemostasis of the donor site easier. Th is
is achieved w ith the placement of a collagen
matrix or fibrin sponge fixed in situ with com-
pressive cross-mattress sutures that are sus-
pended around the buccal surface of the corre -
sponding neighboring teeth.
The cross- mattress suture starts apical to the
harvest site (image A), perforating the palatal fi-
bromucosa in a distomesial direction (image B).
Th e suture needle is then passed under the
distal contact point of the correspond ing tooth
(image C) and across its buccal surface . Then it
is passed back palatally under the mesial con-
tact point (image 0).
The thread crosses over the co llagen matrix/fi-
brin sponge (image E), and the sutu re is fini shed
with a surgical knot placed over the starting
point (image F). It is important for the knot to
be made distoapically to th e harvest site, where
the blood vessels originate, as it w ill contribute
to achieving hemostasis.

A graft harvested from the premolar area has a greater amount of ad ipose-glandular ti ssue on its in-
ternal aspect in comparison with a graft from the molar area, where th ese tissues are almost absent.

EXTERNAL SURFACE INTERNAL ASPECT

PREMOLAR AREA

MOLAR AREA
 HARVEST OF A CONNECTIVE TI SSU E GRAFT
--
PREMOLAR AREA

MOLAR AREA

Regard less of the area of graft harvesting ,
premolar or molar, the thickness of the dense
connective tissue remaining after de-epitheliali-
zation and removal of submucosal tissues is ba-
sically the same. The qualitative properties of the
subepithelial connective tissue (rich in collagen
fibers) give the graft dimensional stability and
plasticity, making it easy to handle and capable
of adapting to the underlying structures. These
characteristics are fundamental for the correct
positioning and suturing of the connective tis-
sue graft onto the recipient site.

The harvest site, protected by the collagen matrix, heals considerably fast. As early as 7 days
after the procedure, there is already advanced re-epithelialization of the harvest site. The speed
of healing and the postoperative co urse are positively influenced by the reduced thickness and
apicocoronal dimensions of the graft.

183
HARVEST OF A CONNECTIVE TISSUE GRAFT
For protection of the palatal wound, a cyano-
acrylate dressing can be applied. This mate-
rial, specifically designed for the oral cavity,
seems to decrease postoperative discomfort
and reduces the risk of possible destabiliza-
tion of the coagu lum by the patient's tongue.
Th anks to its adhesive characteristics , the cy-
anoacrylate can be used in place of the su-
tures, reducing significantly the duration of
the surgical procedure and contributing to
reduced postoperative discomfort. After plac-
ing a fibrin sponge at the palatal site, the use
of cyanoacrylate without sutures is indicated
w hen there is good control of bleeding at the
end of the surgery. App lication is done with a
specific single-use pipette, passing it over the
fibrin sponge and along the wound margins;
afterward, the surface is lightly patted with a
sterile wet gauze-this will make the cyanoac-
rylate acquire a stiff consistency. It is import-
ant to stabilize the dressing before it spreads
beyond the palatal wound. Whenever large
grafts have been harvested, it is possible to
apply and stabilize the first layer of cyanoacry-
late one area at a time. For improved stability
of the dressing and of the surgical wound , it is
advised to apply a second layer of material as
previously described.
 HARVEST OF A CONNECTIVE TISSUE GRAFT
--

A cyanoacrylate dressing can be applied after performing the compressive palatal sutures in case of
deeper wo unds with wider apicocoronal dimensions, or whenever bleeding is not completely under
control at the end of the surgery. Thi s reduces the risk of early bleeding due to involuntary trauma on
the harvest site.

185
HARVEST OF A CONNECTIVE TISSUE GRAFT
The mesiodistal dimension of the harvesting
procedure doesn't significantly influence the
postoperative course.
For this reason, whenever thick connective tis-
sue grafts are needed (as in the case of pre-im-
plant soft tissue ridge augmentation) it is pref-
erable to double the mesiodistal length of the
One of the most important advantages of the
de-epithelialized free gingival graft technique is
the possibility of procuring another graft that can
have the same thickness as the first one only a
few (3) months later. Thi s is due to the fact that,
especially in the molar area, the harvest site is
almost always confined to the layer involving the
palatal fibromucosa; this accelerates the healing
process because a substantial amount of tissue
PREMOLAR MOLAR
graft and then, taking advantage of the plas-
ticity of this tissue, fold it in half to double its
thickness. Deep palatal harvesting shou ld be
avoided because, apart from th e slower healing
and the pain inflicted on the patient, the result-
ing grafts have greater amounts of adipose and
glandular tissue.
remains covering the periosteum and palatal
bone. The cl inical case presented shows a situ-
ation in which two epithelium-connective tissue
grafts have been harvested contiguously, one
from the premolar area (white arrow) and the oth-
er from the molar area (black arrow). As a result,
after de-epithelial ization and removal of the sub-
mucosal tissues, a dense connective tissue thick-
ness of 1 and 2 mm , respectively, was obtained.
 HARVEST OF A CON NECTIVE TISSUE GRAFT _1.._
Three months later, another epithelium-connec-
3 MONTHS
tive tissue graft was harvested from the same
area . Images show how, after removing the ep-
ith elium and submucosal tissues, the thickness
of the dense connective tissue was the same as
that of the previous graft (around 2 mm).

This proves the rapid healing/regenerative poten-

tial of the palatal fibrom ucosa and has an impact
on daily practice as it allows the clinician to use
the same area of th e palate for a repeated graft
harvest after a waiting period of only 3 months.
187
HARVEST OF A CONNECTIVE TISSUE GRAFT

Clinically, the palate can be classified into different types according to the th ickness of the soft tissues:
average, thin , or thick.

AVERAGE PALATE

The difference between them is more related to
the thickness of the palatal submucosa than to
that of the fibromucosa.
The "average" palate is the one found more
frequently from a clinical point of view. In
this type of palate, the fibromucosa is thick
(>1.5 mm) and present along the whole palate,
both at the level of the premolars and molars.
The submucosa is mainly present at the level
of the premolars, wh ile in the molar area it is
only found apically. In thi s palate it is always
possible to obtain a 1.5- to 2-mm thick con-
nective tissue graft after de-epithelialization
and removal of adipose-glandular tissue.

EXTERNAL
ASPECT

INTERNAL
ASPECT

APICAL
PORTION

CORONAL
PORTION

The coronal part of the graft is beveled (black intention. Thi s reduces the risk of palatal gingi-
arrow) , which makes it possible to leave a lay- val recession even if the graft is taken in close
er of dense connective tissue next to the teeth proximity to the gingival margin .
neighboring the site that w ill heal by secondary

The submucosal tissue (mainly adipose and glan-
dular) and the dense connective tissue of th e fi -
bromucosa can be clinically distinguished based
on their color (adipose tissue is yell ow, wh ile con-
nective tissue is white), the appearance of their
surface (glandular tissue displays acini on its sur-
face), and their consistency (submucosal tissue
De-epithelialization is done with help of a mag-
nificati on system (at least 3.5x loupes) and a
direct light source placed perpendicular to the
graft. Th e graft must be held against a sterile
surgical drape to stop it from moving during
de-epithelialization. The epithelium and connec-
tive tissue can be cl inically distinguished based
on their color (epithelium is yellowish, and con-
nective tissue is w hiter), texture (epithelium is
coarse, and connective tissue is smooth), and
Once de-epithelialization of the external surface
of th e graft is fini shed, epithelial remains can be
seen at the coronal aspect where the beveled
horizontal incision was done at the tim e of the har-
vest. This portion is easily identified by observing
HARVEST OF A CONNECTIVE TISSUE GRAFT _1
___
is softer in comparison with con nective tissue,
which is firm and dense). Removal of the submu-
cosal tissue is done with the surgical blade placed
horizontally. In the authors' opinion, this can prove
to be more difficu lt than de-epithelialization be-
cause of the mobility of the adipose-glandular tis-
sue in relati on to the underlying ti ssue.
light reflection (epithelium is more reflective). De-
epithelialization is done w ith a new bl ade used
at an angle until the base of the epithelial layer
is reached (around 0.3 mm); this layer is translu-
cent, an d the blade is visible underneath . Once
the epithelial thickness is established, the blade
is held parallel to the external su rface for the
complete removal of the epithelium (horizontal
de-epithelialization). A drop of saline solution
helps the blade cut and sli de w ith more ease .
the graft from its internal surface because the
epithelium, lacking connective tissue support,
looks thin and transparent. This last strip of epi-
thelium is excised, keeping the blade perpendic-
ular to the graft (vertical de-epithelialization).
189
HARVEST OF A CONNECTIVE TISSUE GRAFT

After removal of the ad ipose-g landular tissues both mesiodistally and apicocoro nally. It is the
and de-epithelialization, the resulting graft authors' opinion that a graft w ith these charac-
consists entirely of dense subepithelial con- teri stics can be obtained only with the de-epi-
nective ti ssue and has a uniform thickness theli alized free gingival graft technique.

EXTERNAL
ASPECT

INTERNAL
ASPECT

APICAL
PORTION

CORONAL
PORTION

THIN PALATE

In a "thin" palate, t he fib romucosa is <1.5 mm
thick and becomes thinner in a coro noapical
direction, both at the premolar and molar ar-
eas. Th e submucosa is abundant at th e level
of the premolars and practically absent in the
molar area . In this type of palate it is possi-
ble to obtain 1-mm-thi c k dense con nective
ti ssue grafts after de-epithelialization and re-
moval of adipose-g landular ti ssues.
 HARVEST OF A CONNECTIVE TISSUE GRAFT _1
. ._

CORONAL PORTION

APICAL PORTION

INTERNAL ASPECT

Clinical images of the graft after removal of submucosal tissue (mainly adipose and glandular).

EXTERNAL ASPECT

INTERNAL ASPECT

CORONAL PORTION

APICAL PORTION

191
HARVEST OF A CONNECTIVE TISSUE GRAFT
CLINICAL IMAGES OF THE GRAFT AFTER DE-EPITHELIALIZATION
EXTERNAL ASPECT
CORONAL THICKNESS
APICAL THICKNESS
It is the authors' opinion that, in the presence
of a thin palate, on ly the use of the de-epitheli-
alized free gingival graft technique can resu lt in
a graft w ith a un iform 1-mm thickness along its
mesiodistal and apicocoronal dimensions. The
Once submucosal tissue
has been removed , de-ep-
ithelialization can be done.
Th e graft should be moist-
ened w ith a drop of saline in
order to facilitate the move-
ment of the blade during
de-epithelialization .
absence of adipose-glandular tissues and the
presence of denser connective tissue (subepi-
thelial) provide dimensional stability, rendering
the graft easier to handle and capable of adapt-
ing to the underlying structures.
 HARVEST OF A CONNECTIVE TISSUE GRAFT _i.._
THICK FATTY PALATE

A "thick" palate isn 't always synonymous with a
thi ck fibromucosa. On the contrary, it is almost
always the submucosal layer that is thickened
and, depending on the patient, the tissues can
be predominantly adipose or glandular. The layer
of dense con nective tissue found on this type of
palate can be similar to that found on the average
palate or, more rarely, to that of the thin palate.
Most of the time, th e final graft thickness at the
level of the premolar area is similar to that of the
thin palate (around 1 mm), but at the level of the
molar area, it is similar to that of the average pal-
ate (around 1.5 mm). For this reason, the de-epi-
thelialized free gingival graft technique is the only
one that allows the harvest of a graft that con-
tains dense connective tissue in its entire extent
(mesiodistally and apicocoronally). In th is type of
palate, it is absolutely useless to go deeper into
the tissues at the moment of the harvesting pro-
cedure because th is would only cause remov-
al of more submucosal tissue that if left in site
would favor a more comfortable healing.

AFTER REMOVAL OF SUBMUCOSAL TISSUE

After removing th e submucosal tissue and epithelium , the residual dense connective tissue is 1.5 mm
thick at the level of the molar area and 1 mm thick in th e premolar area.
193
HARVEST OF A CONNECTIVE TISSUE GRAFT
THICK GLANDULAR PALATE
In some rare cases, the palate can be thick due
to the presence of a prominent glandular layer.
In this case, it is more difficult to distinguish the
submucosa from the fibromucosa since there
is no difference in co lor as with adipose tissue.
However, the different consistency (less firm
compared to the connective tissue), the blue/
pale-white color, and the surface character-
isti cs (acinar structures) of glandular tissues
make possible both the distinction and the con-
sequent removal of th e submucosal glandular
THIN AND POORLY KERATINIZED PALATE
Th e least common ly found variation, w hich is
also the least favorable, is the thin palate with
a thin epithelium . It has a thinner fibromucosal
layer « 1 mm) and a reduced submucosal ti s-
sue thickness (almost exclusively present on
the premolar area). Another distinctive charac-
teristic is the presence of an epithelium that
ti ssue from the subepithelial con nective tissue.
Even in this type of palate, most of the tim e the
final graft thickness at the level of the premo-
lars is similar to that of th e thin palate (arou nd
1 mm), and at the molar area it is similar to that
of the average palate (around 1.5 mm). Also
in this case, the de-epithelialized free gingival
graft remains the only tech niq ue that allows the
harvest of a graft that contains dense connec-
tive tissue in all of its extent (mesiodistally and
apicocoronal ly).
seems thin and poorly keratinized, which gives
this type of palate a particular color (darker
hue) and su rface characteristi cs (shiny ap-
pearance). In order to obtain a connective
ti ssue graft of clinically useful thickness , it is
mandatory to perform the de-epithelialized
free gingival graft technique.
 HARVEST OF A CONNECTIVE TI SSU E GRAFT

When th ere is a need for very thick connective

A
ti ssue grafts (like in the case of pre-implant soft
tissue ridg e augmentation) or when th e type of
palate does not allow the harvest of a sufficiently
thick graft, it is possible to double the thickness
of the graft by doubling the mesiodistal dimen-
sion of the harvested tissue and folding it in half.
This is possible given the characteristic plasticity
and ease of manipulation of the subepithelial con-
nective tissue graft. Th e harvesting technique that
can be used is that of th e de-epithelialized free
gingival graft. The connective tissue graft is folded
in half, and internal mattress sutures (7-0 polygly-
co lic acid [PGA], 7-mm needle) are applied as fol-
lows: the needle perforates th e double layer from
one side (illustration A); returns horizontally from
the other side (illustration B), perforating th e dou-
ble layer once more; and a surg ical knot is made
on the starting point (illustration C). Thi s technique
avoids having to extend th e harvesting procedure
deep into th e palatal soft tissues, whic h wou ld
be useless in any case because the submucosal
tissues wou ld be removed from the graft, and it
wou ld only increase postoperative pain while also
making it harder to achieve hemostasis at the do-
nor site. This technique makes it possible to ob-
tain enough connective tissue thickn ess even in
the presence of a thin palate.

195
HARVEST OF A CONNECTIVE TISSUE GRAFT

The maxillary tuberosity often presents a fi-
bromucosal thickness that allows the harvest of
a very thick connective tissue graft (or two av-
erage-thickness grafts). Clin ically, the most fre-
quent concern is if, in the presence of second
molars, the retromolar mesiodistal dimension wi ll
be enough to obtain a graft of the desired length.
The harvest of a connective tissue graft from the
maxillary tuberosity can be done during a distal
wedge procedure for the elimination of a pocket
distal to the second molar. In this case, the ret-
romolar area heals by first intention due to the
approximation of the buccal and palatal flaps cre-
ated for the removal of the tissue wedge.

The tissue wedge on ly needs to be de-epithelialized occlusally (black arrow) and on the part that faced
the distal aspect of the second molar (where the pocket used to be, white arrow); the same techn ique
previously described for extraoral de-epithelialization is used . From such a thick connective tissue
graft, two grafts w ith a su itable average thickness can also be obtained .

Sometimes, the maxillary tuberosity is harvested solely for the obtainment of a thick graft, without any
prior periodontal cond itions being present on the distal aspect of the second molar.
 HARVEST OF A CONNECTIVE TISSUE GRAFT

In these cases, the maximum avai lable amount

of connective tissue can be harvested, but
wound healing will be by secondary intention
(usually not so painful). The tissues harvested in
thi s manner (full -thickness) have a rather thick fi-
bromucosal component, while the submucosa is
almost absent. De-epithelialization is performed
along all the surfaces containing epithelium.

In most cases, the residual thickness of th e

tuberosity graft after de-epithelialization is so
large that, if cut in half longitudinally, two thi ck
(2- to 2.5-mm) co nnective tissue grafts can be
obtained.

The graft is divided by holding it still with the mi-

crosurgical tissue pli ers and performing a sharp
cut perpendicularly, along its longitudinal axis,
with a new 15C blade.
197
HARVEST OF A CON NECTIVE TISSUE GRAFT

It is also possible to split the graft partially and open it (as if opening a book) to obtain a graft th at has
twice the length in comparison to the original dimensions of the tissue harvested from the tuberosity.

The de-epithelialized tuberosity graft measures 8 mm mesiodistally and is 5 mm th ick.

The sharp incision , as previously described, allows the connective tissue graft to be split in two. This
incision must end approximately 2 mm from the base to allow opening the two portions like a book.

Partially splitting and "opening " the graft helps to almost double the initial mesiodistal length of the
tissue harvested from th e tuberosity (around 15 mm long in the end). On the other hand, the final th ick-
ness will correspond to around half of that from the original tuberosity graft (varying from 2 to 2.5 mm).
HARVEST OF A CONNECTI VE TI SSUE GRAFT

199
 HARVEST OF A CONNECTIVE TISSUE GRAFT

Berti K, Pifl M, Hirtler L, Rendl B, Nurnberger S,
Stavropoulos A, Ulm C. Relative Compositi on of
Fibrous Connective and Fatty/G landu lar Ti ssue
in Connective Tissue Grafts Depends on the
Harvesting Technique but not the Donor Site of
the Hard Palate. J Periodontol. 2015;86:1331-9.
Monnet-Corti V, Santini A, Glise J-M , Fouque-
Deruelle C, Dillier F-L, Liebart M-F, Borghetti A.
Connective tissue graft for gingival recession
treatment: assessment of the maximum graft
dimensions at the palatal vau lt as a donor site. J
Periodontol. 2006;77:899 -902.
SUGGESTED READINGS
Zucchelli G, Mele M, Stefanini M, Mazzotti C,
Marzadori M, Montebugnoli L, de Sanctis M.
Patient morbidity and root coverage outcome
after subepith el ial connective tissue and de-
epitheli alized grafts: a comparative randomized-
controlled cl inical trial. J Clin Periodontol
2010;37:728-38.
Zucchelli G, Tavelli L, McGuire MK, Rasperini
G, Feinberg SE, Wang H-L, Giannobile Wv.
Autogenous soft tissue grafting for periodontal
and peri-implant plastic surgical reconstruction. J
Periodontol. 2020;91:9-16.

Reiser GM, Bruno JF, Mahan PE, Larkin LH . The Zuhr 0, Baumer D, Hurzeler M. The addition
subepithelial connective tissue graft palatal donor of soft tissue replacement grafts in plastic
site: anatom ic considerations for surgeons. Int J periodontal and implant surgery: critical elements
Periodontics Restorative Dent. 1996;16:130-7. in design and execution. J Clin Periodontol.
2014;41 SuppI1 5:S123-42.
Tavelli L, Barootchi S, Greenwell H, Wang H-L.
Is a soft tissue graft harvested from the maxillary
tuberosity the approach of choice in an isolated
site? J Periodontol. 2019;90:821-825.

Tavelli L, Barootchi S, Ravida A, Oh T-J, Wang

H-L. What Is the Safety Zone for Palatal Soft
Tissue Graft Harvesting Based on the Locations
of the Greater Palatin e Artery and Foramen? A
Systematic Review. J Oral Maxillofac Surg. 2019
Feb;77:271.e1-271.e9.

Tavelli L, Ravida A, Lin G-H, Del Amo FS-L, Tattan

M, Wang H-L. Comparison between Subepithelial
Connective Tissue Graft and De-epithelialized
Gingival Graft: A systematic review and a meta-
analysis. J Int Acad Periodontol. 20191;21:82-96.

Tavelli L, Ravida A, Saleh MHA, Maska B, Del Amo

FS-L, Rasperini G, Wang H-L. Pain perception
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2019;23:459-468.

201
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 Implant
Replacement in
the Esthetic Zone
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

Chapter in collaboration with Or Raffaele Cavalcanti and Or Egon Euwe.

Peri-implant soft ti ssue dehiscence (PSTD) is a much as possible. PSTD treatment is a long
complication of implant therapy that creates an and costly procedure that carries the burden
esthetic problem for the patient. Chapters 1 and of the patient's ve ry high expectations after
2 dealt with the factors that lead to formati on of the disappointment caused by the previously
PSTDs and their treatment through a prosthet- unsuccessful implant treatment. Not meeting
ic-surgical-prosthetic approach, focusing on patient expectations wou ld make the clinician
th e critical elements for achievi ng a successful treating th e PSTD the culprit in th e eyes of th e
esthetic outcome . The degree of implant mal- patient. On the other hand, it is just as dan-
position, depth of the soft ti ssue dehisce nce, gerous to guarantee an esthetically pleasing
buccal probing depth , and loss of hard and result in the case of implant removal and re-
soft interproximal ti ssues are th e most import- placement. Like in the previous scenario, the
ant factors that can lead the clinician toward patient should be informed about the uncer-
the treatment of the PSTD or im plant removal. tainti es related to th e treatment but also about
In addition , given that the primary goal of the the influence of the extent of ti ssue damage re-
treatm ent is to improve esthetics and satis- sulting from implant removal on th e comp lexity
fy patient expectations, the latter also greatly of the therapy and how it cou ld affect the sub-
influence the clin ician's decision. For exam- sequent esthetic outcome.
ple, there are cases in which implant esthetics
could be improved by coverage of the PSTD,
buccal increase in soft ti ssue th ickness (so as
to avoid discoloration from the underlying im-
plant/prosthetic compo nents), and placement
of a new implant-supported crown, but this
wou ld fail to fulfill expectations if th e patient's
point of reference is the adjacent teeth, whose
esthetics cannot be replicated with the treat-
ment of the PSTD. Knowledge of the esthetic
limits regarding the treatment of PSTDs is fun-
damental before deciding on treatment versus
removal of an estheti cally fai li ng im plant. These
limits should be explained to the patient in or-
der to share th e decision-making process as
 IMPLANT REPLACEMENT IN TH E ESTHETI C ZON E

revealed that th e excessively buccal implant

position was responsible for the issues identi-
fied by th e patient: PSTD buccal to th e implant
w ith consequent misalignment and asymmetry
of th e marginal soft tissues in compari son w ith
th e corresponding natural lateral incisor and
adjacent teeth ; discoloration of th e soft tissues
apical to the crown due to th e proximity of the
underlying implant-prosthetic structures; th e ir-
The estheti c outco me can vary significantly de-
regular buccal and palatal emergence profiles,
pending on the degree of im pl ant malposition
w hich led to impaired dai ly hyg iene, food im-
an d osseointegration, ie, if the implant can be
paction, and lack of protection of th e mucosal
"unscrewed" w ith implant removal tools or if it
margin during masti cation; and parti al loss of
needs to be surgically removed with more or
the ce ntral incisor's distal papilla, associated
less aggressive osteotomies. Unfortunately,
with a slight loss of interprox imal attachment,
attempting implant removal w ith the use of
responsible for th e black triangle mesial to the
designated implant extractors is not a revers-
implant crown.
ible maneuve r devo id of risks because most
of the time it leads to alterations at the level
of the implant platfo rm or the intern al screw
threads, w hich leave no option oth er than sur-
gical implant removal. Some of the PSTD de-
fects treated by the authors would have ended
differently had there been the opportunity to
try "unscrewing" th e im plant without creatin g
irreversible damage to the implant itself.
The case illustrated shows an implant-sup-
ported restoration in t he maxi llary left lateral
incisor position, still in th e provisional phase,
that didn 't satisfy th e patient 's expectati ons or
estheti c demands. The pati ent's com plaints
pertained to the length and w idth of the im -
plant-supported crown, presence of a "bl ack
triangle" between the implant crown and th e
central incisor, the discolored appearance of
the implant's buccal mucosa, and an exces-
sive buccal prominence of the prosth etic crown
compared to the co ntralateral lateral incisor.
Thi s led th e pati ent to develop a com pul sive
habit of runn ing the tongue over the im plant
crown's buccal surface. Clinical examinati on

205
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
The periapical radiograph showed good im-
plant osteointegration and slight bone loss
distal to the central incisor. Thanks to the
presence of a provisional, the crown cou ld
be removed , and an impression was made to
obtain a master cast, wh ich then was digitally
scanned in order to make an in-depth diag-
nostic analysis. By doing so, it was possible to
perform a three-dimensional evaluation with-
out exposing the patient to additional radiation .
The digital analysis confirmed excessive incli-
nation and buccal position of the implant and
allowed the identification of the im plant axis,
which served to establish the degree of cor-
rection needed for th e abutment in order to
compensate for the implant position . In cases
like this one, a computerized assessment done
thanks to the digitalization of the intraoral im-
pression gives useful information for diagnosis
and treatment planning. In cases in wh ich im-
plant malpositioning is such that the abutment
screw is placed more than 1 mm apical to the
ideal position of the crown's mucosal margin,
implant removal is the advised therapy. In the
case portrayed, digital analysis proved that it
was possible to correct implant malposition
with an abutment whose screw access was in
an adequate coronal position with respect to
the mucosal margin of th e lateral incisor (red
dotted line). Still, the marked buccal position
of the abutment (black arrow) would have re-
quired a sign ificant amount of vo lume increase
at the buccal aspect in order to cover and
mask the abutment. All of this is fundamental
to illustrate not only the technical feasibility of
the procedure, but also the limitations of the
planned resu lt to the patient.

Th e prosthetic-surgical-prosthetic treatment
plan was proposed to the patient, explaining
that the excessive crown length and the apical
gray discoloration could be resolved; the inter-
dental black triangl e co uld be significantly re-
duced, but the excessive buccal prom inence
wou ld still be a problem. The patient was told
that she wou ld not feel the prominence of the
prosthetic crown with her tongue anymore after
treatment, but as a consequence of the therapy
she would noti ce an increase in the vo lume of
the buccal soft ti ssues, especially in comparison
to the contralateral side. Even th ough rem oving
the implant seemed like a nightmare to the pa-
tient, she was also the kind of patient who never
could have been satisfied with a treatment that
would entail asymmetries- not only concerning
height and outline of the tissues but also regard-
ing their vol ume and thickness-between one
side and the other. For these reasons, implant
rem oval was strongly suggested . In case of im-
plant removal, the procedures and time required
for tissue reconstruction (hard and soft) and
implant placementlprovisionalization vary from
case to case. A very important variable is the
method used for im plant removal: either through
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
the use of specialized implant removers, which
exert a counterclockwise force that unscrews
the implant while preserving peri -implant bone,
or by surg ical implant extraction. As a general
rule, whenever th e im plant is successfull y un-
screwed, the preferred approach is the fol low-
ing: undisturbed healing of the site for 4 to 6
months, followed by soft ti ssue augmentation at
the edentu lous site to compensate for the ridge
deficiency.
After a healing period of about 6 months, im-
plant placement (preferably guided) can be
carried out with or without simultaneous bone
augmentation. In the case of surgi cal implant
extraction, it is advised to perform bone recon-
struction in the same procedure; implant inser-
tion (preferably gu ided) can be done 6 months
later, with simu ltaneous buccal soft tissue aug-
mentation. There are two reasons for perform-
ing bone reconstruction at the tim e of surgical
implant removal: fi rst, due to the nature of the
surgi cal implant extraction, the residual bone
defect is often larger; second, given that this is
by default a surgical intervention, simu ltaneous
bone reconstruction helps reduce the number of
su rgeries the patient must undergo.
207
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
In the case illustrated, surgical implant remov-
al was necessary because the internal implant
threads were damaged, which made atraumatic
unscrewing impossible. The surgical procedure
had to allow for complete exposure of the mal-
positioned implant, bone reconstruction of the
res idual defect, and recession coverage at the
level of the adjacent canine. For th is reason, a
coronally advanced buccal flap was done with
a vertical incision distal to the canine. Flap ele-
vation was performed w ith a split-full-split thick-
ness: split at the level of the surgical papillae
and throughout the vertical incision, full at the
central portion unti l the implant surface and
2 to 3 mm of bone apical to it were exposed,
and again split to free the flap from the muscle
structures and allow its coronal advancement.
Coronal advancement of the flap was deemed
necessary to achieve complete coverage of
the biomaterial used for bone reconstruction
and to treat the canine's buccal recession.
Piezoelectric instruments were used to facilitate
implant removal and reduce the extent of the
mesial and distal osteotomies, whi le making it
possible to co llect native bone that was mixed
with the bone graft substitute. Small periotomes
were used to finalize implant removal in an at-
raumatic fash ion. Protection of the soft tissues
with a gauze and/or periosteal elevator during
the extraction maneuvers is fundamental.

After implant removal, there was a purely hor-
izontal ridge defect, wh ich was fi lled w ith a
combination of biomaterial and autogenous
bone; the latter was obtained in some degree
from the peri-implant osteotomies, and the
rest was grafted with the use of a mini bone
scraper. Special care was taken not to overfi ll
the defect beyond th e outline establi shed by
the buccal bone profiles of the adjacent teeth ,
ie, the bone housing . Thi s decision was based
on the fact that, from a biolog ic standpoint,
bone reconstruction beyond the bone housing
is not predictable, so this measure wou ld pre-
vent the encapsulation of non -osseointegrated
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
particles with in the overlying soft tissues.
Furthermore, there is no esthetic need for de-
fect overfil l, since it 's not the hard but the soft
tissues that are responsible for the esthetic
outcome; on a side note, connective ti ssue
thickness at the buccal aspect can be in-
creased at the moment of implant placement.
The bone graft was covered w ith a resorbable
co llagen membrane in order to keep the graft
particles in place and act as a barrier between
them and the flap's internal surface. In the ab-
sence of the buccal bone wall , failure to place
a barrier membrane cou ld comprom ise the
osseointegration of the biomaterial.
209
IMPLANT REPLACEMENT IN TH E ESTHETIC ZONE
As part of the procedure, th e root surface of the
canine affected by gingival recession was instru-
mented with mini curets; the papillae and the
area corresponding to the transmucosal peri-im-
plant path were de-epithelialized. Once freed
from muscle insertions, the buccal fl ap was cor-
onally advanced, and clos ure was achieved with
sling sutures, suspended around the cingula of
the teeth adjacent to the edentu lous site, and
with simple interrupted sutures along the verti-
cal and crestal incisions. The goal was to obtain
perfect wound closure and, consequently, first
intention wound healing. The suturi ng sequence
prescribes that sutures at the level of the vertical
incision are done first, sling sutures next, and
crestal sutu res last. Thi s makes it possible to
obtain comp lete, tension-free closu re of the sur-
gical wound. At the end of the surgery, the miss-
ing lateral incisor was replaced with a provisional
adhesive restoration anchored to the neighbor-
ing teeth (ie, Maryland bridge). In this way, the
patient was given a functional and esthetically
pleasing provisional prosth esis to withstand the
healing period. Special attention was paid to re-
ducing th e intermediate pontic element to avoid
any contact with the buccal and interproximal
soft tissues.

Th e site was left to heal undisturbed for 6
months, at w hich tim e the good healing of
th e soft tissues can be appreciated . Th e fro n-
tal pictures show good maintenance of th e
apicocoro nal dimensions of th e edentulous
ridge and complete recession coverage at
the canine, w hile th ere was a sl ight shrink-
age of the central incisor's distal papilla due
to a slight attachment and interproximal bone
loss. The occlu sal and profil e views display
how th e bone reconstruction compensated
for th e greater porti on of the horizontal rid ge
defect that wo uld have formed as a result of
implant removal, but it was not able to treat
th e most coronal aspect of the defect (white
outlined area and black arrows) . Thi s defect is
IMPLANT REPLACEMENT IN T HE ESTHETI C ZO NE
at th e same height as the supracrestal portion
of th e adjacent teeth 's root surfaces . The su-
perim position of th e images at th e tim e of th e
postextraction bone reconstru ction and after
6 months of healing shows how th e area of
th e residual defect (white outlined area) corre-
sponds to the exposed roots of the adjacent
teeth (black outlined areas). Thi s is, th erefore,
an area deprived of buccal bone even at th e
level of the adjacent teeth , w hich means that
th e res idual defect can only be compensated
through buccal soft ti ssue aug mentation. The
latter can be achieved at the ti me of implant
placement, employing th e coro nally advanced
flap with a connective tissue surgical technique
(see chapter 6).
\...............
.......
\ ....
211
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
The surgical procedure requires a vari-
able-th ickness flap elevation in conjunction
with a crestal soft tissue "punch" (gray area in
the diagram) , guided by the surgical template,
in the site for implant placement. Flap design is
similar to the one used for the implant removal
procedure: a buccal envelope flap consisting
of a slightly curved horizontal incision at the
level of the edentu lous site and a vertical inci-
sion distal to the canine. On a technical note,
the vertical incision should start at a distance
from the tip of the papilla that corresponds to
the amount of coronal flap advancement de-
sired, and it wi ll follow the outline of the pre-
molar's mesial gingival margin up until the mu-
cog ingival junction; this wi ll result in a triangular
surgical papilla distal to the canine. The flap is
elevated at a variable thickness: split thickness
(8) at the leve l of the crestal soft tissues on the
edentulous site and surgical papilla distal to
the can ine; full thickness (F) at the bone crest
until 2 to 3 mm of buccal bone are exposed;
and again split (8) apically to achieve coronal
flap advancement. The soft tissues immediately
on top of the bone crest at the site for implant
bed preparation are removed by performing a
small punch guided by the surgical template
(gingivectomy; gray area in the diagram) . This
allows site-specific access to the crestal bone
whi le keeping the integrity of the future mesi-
al and distal "implant papillae" (white arrows),
whose width and buccolingual thickness are
fundamental for the stabilization of the coro-
nally advanced flap. The intraoperative images
show the successfu l outcome of the previous
reconstructive bone surgery, which allowed
prosthetically guided implant placement w ithin
the bounds of the grafted bone and without for-
mation of dehiscences or fenestration defects
buccal to the implant.

A connective tissue graft, obtained from a de-ep-
ithelialized free gingival graft harvested from the
palate, is sutured with horizontal internal mat-
tress sutures (black arrows) to the internal sur-
face of the flap, in a paramarginal position. The
choice to suture the graft in this manner, versus
suturing it to the base of the papillae, was made
After de-epithel ialization of the canine's distal
papilla and of the peri-implant papillae-the
latter on their occlusal aspect in a palatal di-
rection (red area in the diagram on the previous
page) -th e flap is sutured in a coronal position.
The sequence for flap closure requires begin-
ning with simple interrupted sutures at the level
of the vertical incision, followed by sling sutures
at th e level of the canine and central incisor,
and ending w ith si mple interrupted sutures at
the im plant site, which allow superimposition
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
due to th e limited dimension of the edentulous
space, which, once the impl ant was placed,
resu lted in peri-implant pap illae of reduced
width (see chapter 6). This allowed first intention
wound closure between the buccal flap's surgi-
cal papillae and the anatomical papillae without
interference of th e connective tissue graft.
of the surgical papillae over th e anatomical
de-epith elialized papillae mesial and distal to
the im plant platform. At th e end of the surgery,
th e adhesive bridge is cemented back in place
after reducing th e pontic element so as to avoid
comp ression or interference during soft tissue
healing. The postsurg ical periapical radiograph
shows correct implant positioning. The use of
computer-g uided systems, or at least of surgi-
cal stents to guide implant placement, is highly
advised in areas of high esthetic value.
213
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
Four months after the surgery, time needed for
adequate soft tissue maturation and implant
osseointegration, it is possible to proceed with
implant uncovering and provisionalization. With
the help of the same surgical guide used for im-
plant placement, a small tissue punch is made
through the crestal soft tissues to uncover the
implant. A screw-retained provisional is placed,
with the purpose of conditioning the peri-implant
soft tissues. This phase is dedicated to creating
peri-implant marginal tissue that is at the same
level as and whose shape resembles that of the
gingival margin of the contralateral natural tooth.
Once in place, the provisional should support
the marginal tissues while avoiding excessive
compression , which would lead to their apical
displacement. Another goal of prosthetic con-
ditioning is to achieve the maximum possible
growth of the papillae mesial and distal to the
provisional crown. This is promoted by leaving
slightly wider interproximal spaces at the be-
ginning and then progressively modifying the
mesial/distal profiles and continuously displac-
ing the contact point coronally every time the
papillae manage to fill the interproximal space
(squeezing effect). Modifications to the provi-
sional crown are done several times (every 1
to 2 months) until maximum papilla growth and
adequate position of the buccal mucosal mar-
gin are obtained.

Six months after placement of the provision-
al, esth etic improvement can already be ob -
served . Th e clinical image showcases th e
adequate position of the implant-supported
crown's mucosal margin , along w ith the im-
proved papillae. The initial buccolingual defect
was treated w ith the descri bed surg ical tech-
nique, w hich led to an increase in the th ick-
ness of the buccal soft ti ssues. This made it
Side-by-side comparison of the baseline situa-
ti on (before im plant extracti on) and th e clinical
image after soft tissue cond itioning high lights
the achieved esth etic outcome, as we ll as th e
increased thickness of th e soft ti ssues buccal
to th e transmucosal path of the correctly posi-
tioned implant. The latter is important to avoid
recurrence of th e PSTD and to mask the un-
derlying implant-prosthetic compo nents entire-
ly, preventing unpl easant soft ti ssue discolor-
ation. At the end of th e prosth eti c co nditioning
IMPLANT REPLACEMENT IN THE ESTHETI C ZONE
possible for the prosthetic crown to have a
proper emergence profi le, w hich is fun damen-
tal fo r the pati ent 's oral hyg iene maintenance.
The co nditioning phase ends w hen, after th e
last modifications of th e provisional, th ere is no
further papilla growth between recall visits and
the mucosal margin has a similar scallop and
position as the gingival margin on the natural
co ntralateral tooth.
phase with the implant-supported provisional,
the shape of the central incisor was slightly
mod ified distally with an ad hesive restorati on
to help redistribute the interdental space and
improve the shape of th e papilla. When doing a
comp rehensive treatment, most of the ti me it is
necessary to perform adhesive restorations on
the natural teeth neighborin g the implant-s up-
ported crown in order to improve the overall
esth etic outcome by manag ing th e spaces and
tooth morphology.
215
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
The esthetic result, even if still in a provisional
phase, satisfies the patient's expectations and
can be appreciated during smiling. The change
in implant position and increase in hard and
soft tissues allowed treatment of the preexist-
ing PSTD and resolved the grayish soft tissue
discoloration caused by the underlying implant
components. The black triangle that used to
bother the patient was also significantly re-
duced. Thanks to proper implant placement,
the patient was no longer able to perceive a
buccal prominence of the implant-supported
crown in comparison to the contralateral side;
after all, this had been the main reason that
led the authors to choose removal of the badly
positioned implant as opposed to just treating
it in situ. The final restoration can be placed at
the end of the prosthetic conditioning phase.
The periapical radiograph taken with the im-
pression coping shows good implant osse-
ointegration and stability of the peri-implant
bone level.
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

The goal of the final prosthet-

ic phase is to create a crown
with similar shape and col-
or as the contralateral tooth ,
while maintaining the con-
tour and position of the mar-
ginal soft tissues obtained in
the provisional phase. The
esthetic outcome at the end
of the treatment was greatly
appreciated when taking into
account the initial situation .
The marginal soft tissues at
the implant site have a scal-
lop and position that resem-
ble those of the contralater-
al target tooth; the papillae
fill the interproximal spaces
with a nice triangular shape.
Moreover, the patient finds the
outcome esthetically pleasing .
The comparison between the
baseline and final occlusal im-
ages highlights the buccopal-
atal change in the position of
the implant-supported crown .
In addition, it is possible to
see the curve created by the
profile of the buccal soft tis-
sues (black dotted line). If the
prosthetic-surgical- prosthetic
approach had been imple-
mented for treatment of the
PSTD, the esthetic outcome
probably still wou ld have been
satisfactory, but the buccal
soft tissues wou ld surely have
been more prominent as a re-
sult of the wrong implant po-
sition at baseline.

217
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
The successful esthetic outcome derives from
a series of equally important and fundamen-
tal factors: correct implant position, increased
soft tissue thickness at the level of the trans-
mucosal portion, and adequate management
of the peri-implant soft tissues with both the
provisional and definitive crowns. If a sing le one
of these factors is not carefully managed, the
outcome wi ll hardly satisfy a patient with high
esthetic expectations. A proper restorative
emergence profile is fundamental for adequate
hygiene maintenance and to favor self-cleans-
ing of the crown, preventing food impaction
between the crown and marginal soft tissues.
Th e emergence of the prosthetic crown from
the soft tissues resembles that of the natural
contralateral tooth and, contrary to the baseline
situation, is easy to clean . Oral hygiene mainte-
nance is the key element for the preservation
of periodontal and peri-implant tissue health,
which is why there should be ideal conditions
for the patient to perform appropriate plaque
control. Adequate emergence profiles, proper
interproximal spaces, and stable peri-implant
soft tissues give the patient the ability to clean
the implant-supported restoration efficiently.
 IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

The 8-year follow up shows maintenance of the outcome over time. The patient is highly satisfied
from both an esthetic and a functional point of view. It is important to emphasize that patient co-
operation with oral hygiene practices at home and compliance with professional oral hygiene recall
appointments are imperative for long-term success.
219
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

Comparison of the images at baseline and at the 8-year follow-up accentuates the great outcome.
Implant placement with simultaneous soft tissue augmentation allowed the creation of a suitable
peri-implant transmucosal path capable of masking the underlying implant-prosthetic components and
preventing PSTDs, wh ile making it possible for the prosthetic crown to have adequate emergence pro-
files that make it easy to clean. The periapical rad iograph shows stability of the peri-implant bone levels .
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

221
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
For decades, single-tooth replacement in the
esthetic zone has been considered one of the
least successfu l treatments in implantology.
This therapy entails surgical procedures for soft
ti ssue preservation/reconstruction as well as
prosthetic treatment planning. Recent develop-
ments in the field of CAD/CAM technology and
metal-free materials-like zirconia, aluminium
oxide, and lithium disilicate-have led to unparal-
leled esthetic resu lts, wh ile advances regarding
Such is the case of this patient, who complained
of bad esthetics due to the exposure of the im-
plant's buccal surface and dark discoloration
of the peri-implant mucosa; this created great
discomfort for the patient regarding her social
computer-g uided treatment planning for implant
placement have red uced positioning errors. The
massive increase in use of dental implants has
made the cli nician deal ever more frequently with
implant comp lications, whether biolog ic, bio-
mechanical, or esth etic. Th e latter are the most
common and also the ones for which the patient
has the least tolerance because of th e elevated
esthetic expectations (case courtesy of Dr Egan
Euwe).
interactions. The cl inical cond ition was wors-
ened by the lack of masti catory function caused
by the extrusion and mobility of the implant
crown , likely due to loosening of the abutment
screw.

The concurrence of several negative factors
associated with the PSTD drives the clinician
toward implant removal rather than its treat-
ment. In the case portrayed , the facial PSTD
associated with a marked buccal implant posi-
tion was further complicated by the presence
of a very thin and non-keratinized peri-implant
mucosa and deep pocket probing depths on
the buccal aspect.
Th e latter represented a clearly unfavorable
prognostic factor because it translates into a
contaminated implant surface completely de-
void of buccal bone. Additionally, the implant
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
platform was in a very coronal position, which
corresponded to the gingival margin of the lat-
eral incisor and was 1 mm more coronal than
the margin of the contralateral central incisor.
Shallow implant placement is one of the place-
ment errors that most frequently constrains the
cl inician to extract the implant. The periapical
radiograph shows a seemingly well osseointe-
grated implant without radiographic signs of
peri-implantitis, but with an excessive diameter
relative to the available interdental space that
resulted in close proximity of the implant and
the lateral incisor.
223
IMPLANT REPLACEMENT IN THE ESTHETIC ZO NE
In order to fulfill the patient's high esthetic demands,
a diagnostic wax-up was performed to allow anal-
ysis and distribution of the available interdental
space, evaluation of anterior tooth alignment, and
determination of the most suitable dental anatomy
As previously described , the treatment plan and
its execution sequence (first bone regeneration
and then soft tissue augmentation) are highly in-
fluenced by the ability to unscrew the implant
with implant extraction tools. Additionally, in
contrast with the case previously described, in
this case the presence of such unsuitable buc-
cal soft tissues-extremely thin, non-keratinized ,
and completely epithelialized on the internal as-
pect along the buccal probing depth-was a
contraindication for the execution of bone re-
generation procedures at the time of implant
removal; under such circumstances, complete
wound closure would have been hard to achieve,
for the restorations. The presence of a central in-
cisor with a preexisting crown was useful both for
space management and for the support of a pro-
visional restoration, obtained from the diagnostic
wax-up and placed after implant extraction.
putting a strain on the first intention wound clo-
sure needed to protect the bone graft material.
These considerations, along with successful at-
raumatic implant removal , led the clinician to opt
for simultaneous soft tissue augmentation and
to delay bone reconstruction to a second sur-
gical phase.
The system used to remove the implant consists
of a screw that fits into the implant's internal
threads, which then allows the use of the ratchet
to "unscrew" the implant by breaking the osse-
ointegration with counterclockwise movements.
This method allows maximum peri-implant bone
preservation.

Once th e im plant was removed , the site was
prepared in order to receive the soft ti ssue
graft. Thi s was accomplished by removing the
epithelium from the internal aspect of the buc-
cal pocket and from the transmucosal path,
with the help of both a 15C blade and rough-
grit diamond burs with cop ious irrigation. Given
the limited thickness of the buccal tissues ,
once their inner aspect was de-epithelialized
there was little to be preserved. As a resu lt, the
remaining facial deh iscence was much deeper
than the baseline situation.
Nonetheless, epithelium removal is cru cial if
we are wishing to achieve first intention wound
healing with co ntact between connective ti s-
sues, thus avoiding th e creation of dangerous
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
epithelial invaginations th at cou ld comp licate
surg ical management during the next phase.
The receiving bed was completed by tunneling
(with a 15C blade) mesially and distally to the
buccal dehiscence (black arrows), creating a
pouch to hold the de-epithelialized free gingival
graft. The buccal pouch increases th e vascu -
lar supply to the submerged part of the graft,
wh ich in turn increases the chances of survival
for the exposed part of the graft. On the oth-
er hand, the graft serves a double fun cti on: to
achieve primary closure of the former implant
site and to increase soft tissue thi ckness and
keratinized ti ssue height in preparation for
th e future implant and bone reconstruction
surgeries .
225
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

The epithelium-connective tissue graft was
harvested from the palate using a 15C blade.
A tinfoil templ ate can be useful to faithfully
transfer the dimensions of the recipient site
to the palate and harvest a graft of the ex-
act dimension and shape needed. With the
template on the palate, the tip of the blade is
used to circumscribe the area to be grafted.
Once the template is removed, the primary
incision is perform ed by deepening the blade
along the bleeding line; the designed area is
elevated with a uniform thickness until the ep-
ithelium-connective tissue can be complete-
ly removed. Th e same template was used to
trim a co llagen sponge that fit perfectly into
the harvest site, where it was sutured for he-
mostatic purposes w ith compressive cross
mattress sutures.

The epithelium-connective tissue graft is de-epithelialized extraorally over a surg ical drape with a 15C
blade. Epithelium was removed from the apical and lateral portions, wh ile the central and coronal por-
tions were left intact.

Once ready, the graft was fixed onto th e receiv-
ing bed w ith simple interrupted sutures, pl acing
the de-epith elialized apical portion inside th e
bu ccal soft tissue pocket and fitting th e coro-
nal porti on against th e de-epithelialized mar-
gins of the former transmucosal path . Removal
of th e epithelium from the part of the graft th at
will face the connective ti ssue of th e recipient
site is fundamental for graft assimilation and
Good soft tissue healing can be observed 3
months after th e surgery. Eve n if the parti ally
de-epith elialized epith elium-connective ti ssue
graft was of a slightly different co lor than the
surrounding ti ssues, its use allowed a reduction
of the residual defect that wo uld have followed
implant removal.
IMPLANT REPLACEMENT IN THE ESTHETI C ZONE
vascularization, and it w ill avoid formation of
epithelial invag inations along th e margins of
the surg ical wound. At th e end of th e surgery,
the provisional restoration obtained from th e
diag nostic wax-up (cantilever partial denture
anchored to maxillary right ce ntral incisor) was
cemented, taking care to avoid co mpression of
the underlying grafted ti ssue and keeping the
pontic crown out of occlusion .
Thi s is particularly true considering the dimin-
ished thickness of th e bu ccal soft ti ssues and
th e total absence of the implant's buccal bone
plate. The intraoral images show an edentulous
site w ith a slight apicoco ron al defect (fro ntal
view) and a more severe buccopalatal defect
(occlusal view).
227
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
Four months after implant removal, it is possi-
ble to proceed to the second surgical phase. A
three-dimensional diagnostic exam (cone beam)
allows evaluation of the residual defect resulting
from the extraction of the mal positioned im-
plant and is useful for planning the new im plant
placement. As opposed to what happens after
tooth extraction for dental reasons, bone re-
construction therapies are often required after
removal of a malpositioned implant. The mag-
nitude and the type of bone resorption (only
horizontal or also vertical) wil l guide the clinician
toward choosing to perform bone reconstruc-
tion simu ltaneously with implant placement or
opting for a deferred approach. In the presence
of vertical and/or horizontal defects so severe
that the placement of an implant with the ideal
The surgical flap design should allow am-
ple access to the buccal bone surface and
at the same time preserve the volume of the
soft tissues at the coronal and buccal aspects
(augmented in the first surgical phase) - key el-
ements for achieving first intention wound clo-
sure over the area of bone reconstruction. A
vestibular mucoperiosteal flap delimited by two
vertical incisions is elevated, and the palatal
length and diameter is not possible, only bone
reconstruction should be performed. Once
bone maturation has been comp leted, it w ill be
possible to proceed with implant placement,
wh ich, in these situations, cou ld be done with a
computer-guided flapless approach. In circum-
stances like the case illustrated , in the presence
of a vertical bone level that allows placement
of an implant of ideal length and a horizontal
defect that does not compromise proper im-
plant placement, it is advised to perform bone
reconstruction and implant placement simulta-
neously. This not on ly helps reduce the num-
ber of surgical phases but, most importantly, it
prevents the disruption of the osseointegration
process of the bone graft with a subsequent im-
plant placement.
flap is reflected until the correspond ing bone
crest is exposed. After obtaining surgical ac-
cess, it is possible to observe the entirety of
the residual bone defect from the removal of
the previous implant. The intraoperative clinical
images show that the height of the bone crest
was maintained, wh ile a severe horizontal de-
fect formed on the most coronal aspect, still not
compromising adequate implant placement.
 IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

After preparation of the site in an adequate

three-dimensional position, the implant is posi-
tioned, trying to achieve a primary stability that
allows simultaneous bone reconstruction . If this
is not possible, only bone reconstruction should
be performed , and implant placement should be
deferred to the next stage. With the implant in
place, the buccopalatal bone deficit becomes
evident by the presence of buccal implant expo-
sure greater than 5 mm ; treatment of this defect
must be addressed with bone reconstruction
techniques.

The defect was treated with a mixture of au-
togenous bone and xenograft, placed along
the exposed implant surface, and covered with
a nonresorbable expanded polytetrafluoroeth-
ylene (ePTFE) membrane.
After trimming the membrane to fit the treated
area, a hole was made in it with a rubber dam
punch to anchor it between the cover screw
and the implant. Before placement of the bone
graft, cortical perforations were made in the re-
cipient site in order to allow migration of cells
from the bone marrow toward the graft mate-
rial. With the membrane elevated, autogenous
bone (grafted from the nasal spine and adjacent
areas with a bone scraper) was placed in di-
rect contact with the exposed implant surface;
a second layer of mixed xenograft-autogenous
bone (in a 1:1 ratio) was placed externally.
229
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

Afterward, the membrane was placed upon the grafted area and stabilized on the buccal aspect with
fixation pins. The role of the barrier membrane is to stabilize and protect the xenograft-autogenous
bone and prevent ingrowth of soft tissue into the defect by isolating the filler material from the internal
aspect of the flap.

After releasing it from muscle pull, the buccal flap
was coronally advanced over the membrane and
sutured to the palatal flap with internal horizontal
mattress sutures. Flap closure was completed
with simple interrupted sutures along the vertical
and crestal incisions. Th en the provisional resto-
ration was reduced to avoid soft tissue compres-
sion and cemented, taking special care to not
leave behind excess cement that could interfere
with healing. The goal at the end of the surgery
is to obtain passive, first intention flap approxi-
mation and stability of the surg ical wound-the
latter being of utmost importance for achieving
bone regeneration . The intraoperative periapical
radiograph shows adequate placement of both
the implant and fixation pins.

Eig ht months after th e surgery, time need-
ed for healing and maturatio n of th e reco n-
structed hard ti ssues, it is possible to pro-
ceed w ith the third surgical phase w ith the
goal of removing t he nonresorbable mate-
rials employed in th e previous phase. The
surgical technique to provide access to t he
Hard and uninflamed tissue is to be expected
after successful bone regeneration. On the
contrary, presence of inflamed and soft tissue
indicates partial or com plete failure of th e bone
reconstruction procedure. Th e clinical imag-
es show that form ation of a false "root pro m-
inence" was possible th anks to the strategic
IM PLANT REPLACEMENT IN T HE ESTHETIC ZONE
mem brane and fi xation pins requires eleva-
tio n of a full -thic kn ess buccal fl ap, w ith two
releasing inc isions d istal to each of th e teeth
neigh borin g th e edentulous site. After peel-
ing the m embrane from th e underlying newly
formed tissue, it is possible to assess the out-
co me of t he bone reconstruction .
adaptati on of th e membrane; this w ill have a
positive effect on the final esthetic outco me
by helping the im plant-supported restoration
blend in w ith the surrounding teeth . The in-
traoperative profi le image demonst rates th e
opti mal thi ckness of th e newly formed hard
ti ssues.
231
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

After placing a sterile cover screw and suturing
the flap, it was possible to perform some plastic
surgery procedures on the soft tissues: a frenec-
tomy and gingivoplasty of the soft tissues buc-
cal to the edentulous site. The latter was done
to achieve a uniform color and surface texture
between the grafted soft tissues (at the time of
implant removal) and the adjacent tissues.
The occlusal image taken 3 months after the
surgery shows how the horizontal defect at the
edentulous site was successfully treated with
the described approach, even if a minimal differ-
ence in co lor is present as a result of the initial
soft tissue graft. Once ideal soft tissue shape
was achieved, it was possible to proceed with
implant uncovering with a soft tissue punch.
A cylindric portion of crestal soft tissues is re-
moved with the use of a dedicated rotary tis-
sue punch, exposing the underlying implant
platform .

Once the implant was uncovered, an impression was made for the fabrication of a screw-retained
provisional. A tall healing cap was placed to keep the transmucosal channel open.

Th e soft tissues are conditioned for sever-
al months with a screw-retained provisional
crown in order to obtain an ideal shape, us-
ing th e adjacent central incisor as a reference
point. The presence of a restoration on that
Once there are no further changes in th e po-
sition of the soft tissues, which means that the
facial marginal tissues are stable and the papil-
lae are no longer able to fill the interproximal
space left by th e previous modification of the
provisional's contact point, it is possible to pro -
ceed to the final prosthetic phase.
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
tooth makes it easier to achieve symmetric soft
tissue margins and crown shapes. Th e condi -
tioning phase consists of small adjustments to
the shape of the provisional crown every 1 or
2 months, wh ile tissues adapt accordingly. At
the level of the gingival margin, the provisional
crown has the purpose of gradually compress-
ing the buccal soft tissues until achieving a
shape and scallop simi lar to those of the ref-
erence tooth.
Interproximally, the goal is to obtain the maxi-
mum papillae growth possible. Thi s is achieved
by modifying the provisional's lateral profiles ,
leaving the interdental spaces slightly open ,
and progressively displacing the contact point
coronally whenever the tissues fill the space
between recall appointments.
Placement of a veneer on the right lateral in-
cisor, previously planned with a mock-up, al-
lowed adequate allocation of the available
spaces, realignment of the anterior teeth, and
overall harmony and symmetry among the
crown shapes, honoring the patient's esthetic
requests.
233
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

The final prosthetic phase has the purpose of
maintaining the shape of the soft tissues, ob-
tained w ith the cond itioning done on the pro-
visionals, while improving the esthetics of the
restoration through the use of biocompatible
materials with high esthetic value and managing
tint, value, chrome, translucency, and surface
texture-all of which contribute to the final es-
thetic outcome. In cases like these, close co l-
laboration with highly skilled dental technicians
is fundamental in order to obtain esthetically ex-
cellent restorations.

Proper surgical management of both soft and hard tissues, together with ade-
quate implant placement and overall prosthetic management, have allowed the
treatment of the PSTD with an outcome that completely satisfies the patient's
esthetic requests. The periapical radiograph taken at the end of the treatment
shows good impl ant osseointegration and good marginal fit of the restorations
placed on both central incisors.

Comparison between the baseline and final im-
ages highlights th e great treatment outcome,
even if the color and surface texture of the kera-
tinized peri-implant mucosa are slightly different
from the gingiva on adjacent teeth. The latter is
owed to the use of the partially de-epithelialized
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
graft for soft tissue augmentation at the moment
of implant removal. It is important to notice how
the peri-implant soft tissue marg in is placed at
the same level and has the same scallop as the
gingival margin of the contralateral tooth , despite
the severe defect present at baseline.
235
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

Images of the short- and long-term outcomes (6 months and 5 years, re-
spectively) show how the outcome is not only clinically stable but seems
to improve over time. The implant 's buccal marginal soft tissues appear to
be at the same level and have the same shape as the gingival margin of
the reference tooth. Performance of good oral hygiene by the patient is a
prerequisite for the maintenance of the result and health of the peri-implant
and periodontal tissues. The periapical radiograph taken at 5 years shows
stability of the interproximal bone. Th is, together with the absence of cl inical
signs of inflammation, is indicative of peri-implant health.
IMPLANT REPLACEMENT IN THE ESTHETIC ZON E

237
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
Th e case previously described has empha-
sized how an incorrect co ronoapical implant
placement (specifically, a shallow placement)
can represent a reason for implant rem oval,
sometimes eve n more so than an inco rrect
buccolingual placement. In the case of mu lti-
ple implants, incorrect mesiod istal placement
is the main reason for implant extracti on. In
fact, close proxim ity of adjacent implants
leads to loss of the interimp lant bone peak
w ith co nsequential loss of the corresponding
papi lla. A diminished peri-implant hard and
soft ti ssue heig ht entails th e remode ling of the
mucosa buccal to the im plants and develop-
ment of PSTDs.
Additionally, excessive implant-to- implant
proximity hinders the performance of ade-
quate hyg iene practi ces by th e patient, in -
creas ing th e ri sk for o nset of mucositis or
peri-im plantitis. Th e following case shows
two incorrectl y positioned im plants in the
maxillary right canine and fi rst premolar po-
sitions. The absence of adequate interimplant
space has led to the loss of interim plant soft
tissues and to the development of PSTD on
both implants, for w hich the previous treat-
ing clin icians tried to co mpensate by add ing
pink porcelain to th e restoration. Thi s, in turn ,
prevented th e patient from maintaining good
plaque co ntrol in th e area and favored the on-
set of peri -implantitis (particu larly on the me-
sial im plant) . Th e diag nosis of peri -implantitis
was made after radiograph ic evaluation of
bone loss, together w ith th e c linical finding s
of inc reased probing depth s and bleed ing/
suppuration .
To date, treatment of peri- im plantitis remain s
co mplex and is not always predictable. In ad-
dition to the uncertainty of effect ive decon-
tami nation of the affected implant surface,
c lose proxim ity of th e implants precl udes
th e presence of th e interimplant soft tissues
needed for first intentio n c losure of the flap . In
th ese co nditions, a regenerative approach for
treatment of peri-implantitis is not an option.
Having also excluded th e possibil ity of resec-
tive surgery, the only the rapeutic alternative
was implant extraction. Th e idea of remov-
ing on ly the mesial implant and treating the
remai ning one was taken into co nsideration,
but th e w ide range of unfavorable factors
such as buccopalatal malposition (very buc-
cal), loss of the mesial bone peak, and co n-
tam ination of the implant surface (affected by
peri -implantitis) led to the decision to extract
both im plants. As a result, removal of both im-
plants made it possible to take advantage of
the intact bone peaks mesial to the second
premolar and d istal to th e lateral incisor, thu s
making bone recon stru ction techniques more
pred ictab le and aiding in the execution of soft
ti ssue augmentation procedures (case cour-
tesy of Or Raffae/e Ca va/can ti).

As a general rule , treatment of extended eden-
tulous sites after removal of two implants shou ld
not differ from treatment of the same site after
multiple tooth extractions, with the exception
that management of the former entails a higher
level of complexity. This is due to th e fact that
the bone defect resulting from the extraction of
two adjacent implants is often more severe and
achievement of ideal esth eti cs is unquestion-
ably harder, especially in the area of the inter-
implant papil la. The span of the edentulous site,
the magnitude of the soft tissue deficit, and the
availability of connective tissue from the donor
areas are the most important variables that in-
fluence the choice of therapeutic approach, the
sequence of th e treatment phases (ie, increas-
ing soft or hard tissues first, simultaneously or
after implant removal), th e complexity of the
treatment, and the number of surgical proce-
dures needed.
After the removal of mu ltiple implants, there is
frequently a residual soft tissue defect that must
be treated at least partially in order to increase
the success of the bone reconstruction proce-
dures; th e latter, in contrast to the treatment of
edentul ous sites resu lting from multiple tooth
extractions (see chapter 10), are almost always
necessary, especially when PSTDs have been
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
exacerbated by peri-im plantitis as in the case
shown. Before surgery, the crowns and pros-
thetic abutments should be removed in order to
expedite flap incisions and implant removal. Th e
surgical technique requires the execution of a
coronally advanced envelope flap on the buccal
aspect, including one tooth mesial and distal to
the implants being removed . This flap is elevat-
ed with a varying thi ckness: split at the level of
the papil lae and until reaching the bone crest,
full th ickness until the whole implant surface is
exposed along with 2 to 3 mm of bone apically,
and again partial thickness to enhance flap mo-
bility. The palatal flap is elevated w ith an incision
that is internally beveled and reaches the palatal
bone wall as apically as possible. After debride-
ment of the surrounding bone defect, implants
were removed atraumatically w ith dedicated
extraction tools that use high reverse torque to
break the osseointegration and allow "unscrew-
ing" the implant while preserving peri-implant
bone. Only in the case that the implant cannot
be unscrewed should the cli nician resort to
peri-implant osteotomies, using a high-speed
handpiece or piezoelectric cuttin g instruments.
The presence of peri-implantitis usually increas-
es the chances of successful implant removal
w ith reverse-torque extraction tools.
239
 IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

The existence of a pronounced deficiency regarding

soft tissue volume and keratinized tissue presence,
both resu lting from the PSTD, is an indication for the
performance of soft tissue augmentation before bone
reconstruction. The rationale is that bone augmenta-
tion procedures can become more predictable and
less complex in the presence of adequate soft tissue
quantity and quality. The needed soft tissues can be
obtained from a thick epithelium-connective tissue
graft harvested from the retromolar area, ie, a soft tis-
sue wedge with connective tissue on all sides except
for the occlusal aspect, which keeps its epithelial layer.

The graft is sutured on top of the bone crest and from performing mechanical hygiene maneuvers,
stabilized between the buccal and palatal flaps resorting to chemical plaque control through the
with internal mattress and simple interrupted su- use of a 0.12% clorhexidine-based rinse kept
tures, keeping the epithelial portion exposed; the for 1 minute on the operated area and applied
surgical papillae corresponding to the adjacent three times a day. Afterward, mechanical plaque
teeth are coronally advanced and sutured onto control of the treated area is gradually reinstated,
the respective de-epithelialized anatomical papil- starting with an ultra-soft toothbrush and con-
lae with sling sutures anchored around the teeth tinuing with a soft and then a medium-bristled
bordering the edentulous site. This technique al- one, wh ile progressively reducing app lications of
lows an increase in volume and thickness of the the clorhexidine mouth rinse.
soft tissues with a simultaneous increase in ke-
ratinized tissue. Furthermore, the execution of an
envelope-type coronally advanced flap makes it
possible to also treat the gingival recessions of the
teeth adjacent to the edentulous site in the same
procedure. Suture removal is done after 14 days,
at which time the increase in volume and amount
of keratinized tissues already can be seen. For
these first 2 weeks, the patient should abstain

A period of at least 4 months should pass be-
fore proceeding w ith hard ti ssue reconstruc-
tion. This wi ll allow soft tissues to mature,
w hich in turn ensures their stability at the time
of th e surgery and guarantees first intention
wound healing over the bone graft material.
The preoperative periapical radiograph shows
a severe vertical ridge defect and might also
indicate the presence of an equally severe hori -
zontal defect given the rad iolucency at the level
of the implant extraction site.
The second surgical phase requires a flap de-
sign w ith a crestal incision and t wo vertical
releasing incisions perform ed buccally on th e
mesial and distal aspects of the teeth neigh-
boring the edentulous site, as shown.
IM PLANT REPLACEMENT IN THE ESTHETIC ZONE
A vari able thi ckness flap elevation is done: split
thi ckness at th e level of the surgical papillae
until reaching th e bone crest, ful l thickness to
full y expose the ridg e defect, and again partial
thickness to achieve ample flap mobilization. A
beveled incision is done at th e crestal aspect
until reaching the palatal bone crest; the palatal
flap is then elevated full thickness until exposing
3 to 4 mm of palatal bone, w hich w ill be useful
for membrane stabilization in thi s area. As fore-
seen, the ridge defect had both horizontal and
vertical compo nents, w hich were treated w ith
two autogenous bone blocks harvested from
the mandibular ramus and anchored buccally
and occlusally at the defect site w ith fixation
screws.
241
IMPLANT REPLAC EMENT IN THE ESTH ETI C ZONE
Th e remaining parts of t he defect were filled
w ith autogenous bone harvested from th e ad-
jacent areas w ith a mini bone scraper. In the
outermost layer, deproteinized bovine bone
was placed to achieve an ideal ridge mor-
ph ology. Special care was taken to not overfill
the defect w ith the bi omateri al. A double layer
of resorbable co llagen membranes was used
to protect and keep the biomateri al and au-
togenous bone in place, acting as a barri er
betwee n the filler materi al and th e connec-
t ive ti ssue on th e flap's intern al surface. Th e
buccal flap, free fro m th e muscle insertions,
was coro nally advanced and fixed w ith sli ng
sutures anc hored to th e palatal aspects of the
teeth adjacent to th e edentulous site; intern al
mattress sutures and sim pl e interru pted su-
tures were placed along t he crestal inc isions.
Finally, the vertical releasing incisions we re
cl osed with sim ple interru pted sut ures. During
th e postsurgical ph ase, it is c ru c ial that th e pa-
tient co mplies w ith postoperative inst ructions,
taking care to avoid any kind of mechanical
t rauma on th e treated area and keeping stri ct
chemical plaque control through t he use of
a 0.12% clorh exidine rin se three tim es a day
until suture removal. In th e following weeks,
as th e patient gradually reinstates mechanical
plaque contro l, it is important for the pati ent to
avoid chewing on th e treated side so as not to
destabilize the underlying materials used for
bone reco nstruction.

Implant placement should not take place unti l
6 to 8 months have passed following the bone
reconstruction surgery. In this case, implant
planning was done at 6 months. Th e diag-
nostic wax-up had already revealed that the
mesiodistal dimension of the edentu lous site
cou ld accommodate two implants to replace
the can ine and first premolar, but it would
have been nearly impossible to obtain enough
soft tissue between the im plants to simulate
an interdental papilla.
In cases like this one, it is preferable to place a
single implant that supports a cantilever par-
tial denture - as long as there are no contrain-
dications related to occlusion or parafunction-
al habits. If the single im plant is placed in the
premolar site, the mesial area would act as an
edentulous ridge whose soft tissues can be
predictably and effectively improved w ith soft
tissue augmentation techniques (see chapter
9) . Adequate management of the pontic res-
toration cou ld allow the simulation of an inter-
proximal papilla not on ly between the pontic
and the implant but also between the pontic
and the mesial tooth (lateral incisor) in an area
of high esthetic value. The surgical technique
requires a palatally displaced crestal incision
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
and a buccal envelope flap elevated w ith a
variable thickness and coronall y advanced.
The interdental incisions at the adjacent teeth
are paramarginal and convergent toward the
edentulous site . The horizontal crestal incision
is displaced palatally in order to position some
of the keratinized tissue on the buccal side.
The palatal flap is elevated in a split-th ickness
manner by performing a beveled incision until
reach ing the bone crest and then full-thick-
ness elevation to expose the reconstructed
bone crest and facilitate implant placement.
After obtaining full visibility of the bone ridge,
it was possible to appreciate the resu lt of the
bone reconstruction surgery: th e clinical intra-
operative images show comp lete resolution
of the horizontal ridge deficiency (occl usal
view) and a partial resolution of the vertical
deficiency (buccal view). Specifically, the ver-
tical reconstruction seems almost comp lete
at the premolar site and partial in the can ine
position. For this reason, in addition to esthet-
ic concerns regarding the possibi lity of cre-
ating an interimplant papilla, a decision was
made to place a single implant in the premolar
area and rep lace the canine w ith a cantilever
pontic.
243
IM PLANT REPLACEMENT IN THE ESTHETIC ZONE
Adequate implant placement
in the position of the fi rst pre-
molar was achieved by using
an acrylic stent obtained from
a model with the diagnostic
wax- up. Bone reconstruction
allowed insertion of an im-
plant w ith an ideal length and
diameter that cou ld support
a restoration with a mesial
cantilever.
A "saddle" co nnective tissue graft was placed
mesial to the implant in order to increase soft
ti ssue height in the area destined to become
th e interproximal papilla.
On one end , the graft is placed under the
buccal flap, and on the other it is tucked un-
der the palatal flap. Given the limited flap el-
evation, it was not necessary to suture the
connective ti ssue graft , because tension-free
The grafted tissue matures during the first
months, resulting in an increased volume of the
peri-implant soft tissues. There was also a no-
ticeable increase in the keratinized tissue buccal
to the healing cap thanks to the displacement of
the crestal soft tissues at the moment of implant
placement. Th e outcome of the surgery can be
evaluated after 3 to 4 months to establish if there
is a need for fu rther correcti ons. Th e clinical im-
ages show very coronal residual scarring and
flap approximation and primary closure could
guarantee graft stability. Th e buccal flap was
coronally advanced, and closure was achieved
with simple interrupted sutures around the
implant's transmucosal portion (ie, the collar
and a 2-mm-tall healing cap) and over the area
covering the connective tissue graft to ensure
primary intention wo und closure at th e eden-
tul ous area.
muscle insertions at the level of the edentulous
ridge. Apart from being unesthetic, these ana-
tomical cond itions reduced the vestibu le depth
and therefore would have limited the space need-
ed for adequate hygiene maneuvers. Additional ly,
a buccolingual deficiency was still present in
the area intended for the pontic restoration that
wou ld replace the can ine. For these reasons , an-
other soft tissue augmentation procedure was
performed in this site.
 IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

The surg ical technique required a

palatally displaced crestal incision
and a coronally advanced split-thick-
ness buccal fl ap . Th e palatal soft
tissues were undermin ed w ith a par-
tial-thickness incision for the sole
purpose of creating a pouch for the
saddle connective tissue graft, wh ich
was placed on top of the crestal con-
nective tissue left in situ . There was
no need to suture the graft in place,
since the limited flap elevation al-
lowed securing th e graft between the
tension-free buccal and palatal flaps,
once primary wound closure was
achieved, w ith a seri es of simple in-
terrupted sutures.
After flap closure, vestibuloplas-
ty was performed to address the
marked ly coronal mucosal inser-
ti ons. The procedure consisted of
a rhombus-shaped incision that re-
moved scars and fibrous insertions.
A superficial split-thickness incision
was done apically to free the buccal
mucosa from muscle pull, allowing
its spontaneous apical displacement.
No sutures were performed in this
area, and the exposed connective
tissue was left to heal by secondary
intention to avoid further scarring .
During the first 4 months of healing,
the soft tissues are left to mature un-
disturbed with out any interference
from the provisional restoration. This
allows a volumetric soft tissue in -
crease free from obstacles. After the
maturation phase, th e cond itioning
phase is started with a screw-re-
tained provisional, wh ich is period -
ically modified to mold the soft tis-
sues around the implant and on the
edentulous ridge.

245
 IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
The pontic site is prepared with a round, medi-
um-coarse-grit diamond bur on a high-speed
handpiece and copious irrigation. Tissue removal
should be done at the center of the edentulous
ridge, and an extra layer of flowable resin should
be added onto the pontic matching the space
created; the pontic shou ld exert light compres-
sion and create temporary ischemia when the
restoration is screwed in place. The goal of soft
tissue conditioning is to reshape the implant's
marginal tissues until achieving a level and scal-
lop similar to those of the gingival margin at the
reference tooth. Interproximally, the profiles of the
provisional crowns are progressively increased
by coronally displacing the contact points in or-
der to favor papillae growth (squeezing effect).
It is possible to proceed to the final prosthetic
phase when no further papilla growth is observed
after the previous modification of the provisional
restoration.
Side-by-side comparison of the occlusal views of
the site after healing from the bone reconstruction
surgery and at the end of soft tissue conditioning
shows how soft tissue augmentation techniques
can enhance the esthetic result and provide ad-
equate emergence profiles that favor hygiene
maintenance to the prosthetic restorations. These
images also confirm that bone reconstruction
surgery has the primary purpose of creating the
Comparison between the initial image and the
situation after soft tissue conditioning shows the
fundamental importance of adequate implant
positioning for the creation of ideal spaces that
wi ll allow formation and growth of an interimplant
papilla. By looking at the images portraying the
healed ridge after implant removal and the out-
come of the soft tissue conditioning phase, it be-
comes evident that correct management of both
hard and soft tissues is fundamental to accom-
plishing an esthetically pleasing result.
bone crest dimensions (height and width) need-
ed for the placement of implants of adequate
length and diameter; however, the optimization
of the esthetic outcome, in particular papilla for-
mation and creation of emergence profiles for the
restorations, is greatly dependent on soft tissue
thickness and volume. If the latter are augmented
accordingly, they can be effectively conditioned
during the provisional prosthetic phase.
 IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

Before and after images

highlight the success of the
treatments performed. The
outcome fully satisfies the
patient's esthetic and func-
tional demands. The com-
plexity, number of surgical
procedures, and overall treat-
ment time serve as caution-
ary advice to always perform
im plant therapy knowing its
possibilities and, most im por-
tantly, its limits. Adequate im-
plant placement and proper
soft tissue management, along
w ith a restorative therapy (both
provisional and definitive) that
favors hygiene maintenance,
are all essential for the success
of implant therapies (prosthet-
ic treatment done by Or Piero
Venezia) .

Knowledge of the limits of im plant treatment is implant with the adequate dimensions to replace
extremely important in order to avoid making er- a premolar and support a cantilever restoration .
rors with consequences that are hard to resolve. Crestal soft tissue augmentation made it possible
The case described is an example of how recog- to obtain well-shaped interproximal papillae and to
nizing the li mits of implant therapy can lead to a create mucosal margins for the prosthetic crowns
successfu l outcome; it is highly likely that if two that resembled those of their contralateral coun-
implants had been placed, even if correctly po- terparts. Th e buccolingual soft tissue increase
sitioned, the esthetic result wou ld not have been gave the prosthetic crowns a natural emergence
equally satisfying . profile, which aided in the blending of the treated
The goal of the fin al prosthetic phase is to cre- area with the surrounding elements and facilitated
ate two crowns with a shape and color sim ilar hygiene maintenance.
to those of th eir natural tooth counterparts whi le
maintaining the scallop and position of the mar-
ginal soft tissues obtained during the provisional
prostheti c phase. For long-term maintenance, it
is fundamental that the implant-supported resto-
ration can be mechanically cleaned with oral hy-
giene aids such as an interdental brush, "implant
floss ," and a toothbrush.
Treatment of both vertical and horizontal compo-
nents of the bone defect allowed placement of an
247
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

Radiographic analysis illustrates good implant
osseointegration and radiopacity of the bone
crest, which, along with the absence of signs
of inflammation, indicates peri-implant health.
Comparison with the radiograph taken before
the bone reconstruction surgery highlights the
successful outcome in terms of vertical bone
augmentation.
Four years after final restoration placement, the
result remains stable and is esthetically pleasing
for the patient. Good soft -tissue configuration
and the resulting emergence profile of the pros-
thetic crowns enables optimal integration of the
implant-supported restoration, which blends in
with the adjacent natural teeth.

Comparison between the baseline situation and the 1- and 4-year follow-ups after definitive restoration
placement gives proof of the great outcome that led to a complete resolution of the preexisting tissue
deficit in a way that ensured maintenance of peri -implant health and tissue stability over time.
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

249
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
Not every case of implant removal must be
treated with the placement of a new implant.
In some cases, for reasons pertaining to the
patient and/or clinical situation, other valid
treatment options can include an adhesive,
Maryland-type partial denture or even a tradi-
tional partial denture. It 's not uncommon for a
Th is patient's maxillary left central incisor had
been extracted for dental reasons (fracture of
an endodontically treated tooth) and replaced
with an implant 7 years before she came to
our office. The patient presented with pain and
showed signs of inflammation and peri-implan-
titis: spontaneous suppuration and pathologic
probing depths at the mesial , buccal, and dis-
tal aspects of the implant-supported crown. The
radiographic assessment supported the clinical
diagnosis by demonstrating loss of osseointe-
gration affecting almost 50% of implant length .
patient, disappointed by the failure of the pre-
vious treatment, to refuse undergoing implant
therapy once again. In other cases, the need
for more extensive prosthetic rehabilitation can
render therapy for rep lacement of the failing im-
plant unnecessary or pointless; this is the situa-
tion for the following patient.
As far as the patient cou ld tell , this had not been
the first time she presented with an abscess, but
in previous occasions the lesions were smaller
and the situation had been addressed with sys-
temic antibiotics.
When the patient was informed that the implant
had an unfavorable prognosis, she was over-
whelmed with disappointment and refused to
make any definitive therapeutic decision; for the
time being, only local antibiotics were adminis-
tered, and oral prophylaxis was performed to try
to postpone further treatments.

After antibiotic and cause-related therapy, the
patient's symptoms subsided, and both suppu-
ration and inflammation were resolved. However,
a significant soft tissue recession developed as
Once the patient was motivated and started col-
laborating, she was told that her problem was
not linked solely to the implant, but that a global
approach should be implemented because her
occlusion and loss of vertical dimension, linked
to the significant occlusal abrasions, could have
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
the inflammation disappeared, leading to buccal
exposure of the implant 's metallic surface. Even
if not visible during smiling, it became an import-
ant esthetic concern for the patient.
also influenced the progression of the peri-im-
plant lesion. The mere substitution of the fail-
ing implant with a new one, without modifying
the traumatic occlusion, could not ensure she
wou ldn't encounter a similar problem in the
future.
251
IMPLANT REPLACEM ENT IN THE ESTHETI C ZONE

The factors that helped the patient make a deci-
sion were the esthetic improvement that would
result from a more extensive prosthetic rehabi l-
itati on and th e possibility of avoiding the place-
ment of a second im plant to substitute the failing
one. In the authors' experience, patients who un-
dergo implant extractions are seldom in favor of
subsequent implant therapies . Due to economic
constraints, after implant removal a prefabricat-
ed acrylic resi n tooth was splinted to the adja-
cent teeth and left in place until more advanced
healing allowed the fabricati on of a long-term
fi xed provisional. The option of placing veneers
instead of fUll-cove rage crowns was discarded
because of th e presence of significant abrasions
(buccally, palatally, and occlusally) on virtually all
adjacent teeth .
When planning for the implant removal surgery,
th e authors took into consideration that the site
wo uld become an edentulous ridge that wou ld
accommodate a pontic restoration. This rep -
resented an advantage because it allowed the
first surg ical procedure to be less invasive, and
it made it easier to achieve a good esthetic
outco me; th e need for soft tissue augmenta-
tion-and th e type of procedure-remained un-
changed . In this regard, it is the authors' opinion
that there is no need to include autogenous bone
during the bone reconstruction surgery when the
extraction site is not destined to become an im-
plant site. This is because in such cases th e sole
purpose of the bone filler is to avoid soft tissue
collapse and maintain an adequate ridge volume
merely for esthetic reasons. Nevertheless, as
mentioned previously, bone reconstruction can
never take the place of soft tissue augmentation,
wh ich is the only procedure that can provide vol-
ume increase of th e most coronal tissues at the
level that corresponds to the suprabony part of
th e roots on adjacent teeth.

The access flap for the implant removal required a verti cal releasing incision distal to the maxillary left
canine, while mesial to the right central incisor the flap is freed from muscle insertions without the need
to open the distal interdental papilla (ie, sem i-tunnelization of the papilla between th e right central and
lateral incisors).
 IMPLANT REPLACEMENT IN THE ESTHETI C ZONE

A variable thi ckness flap was reflected:

split-thi ckness at th e level of the surgical papi llae,
full -thickness to obtain access to the exposed
im plant surface, and again split-thi ckness to al-
low th e co ronal advancement needed to cover
th e biomaterial and membrane used for bone
reconstru cti on. Implant removal was done with
instruments that exert a reverse-torque force
th at breaks the resid ual osseointegration and
makes it possible to unscrew the implant with
minimum trauma. Regard less, the extracti on of
an im plant affected by peri-i mplantitis often re-
sults in a severe ridge defect. In th e case shown,
only a very thin palatal wall remai ned at the ex-
tracti on site, with well-preserved bone peaks at
th e neighboring teeth.

The defect was filled with slow-resorption depro-
teinized bovine bone, taking care not to overfill
the defect beyond th e bone profil e of the adja-
ce nt teeth . A collagen membrane was used to
stabilize th e biomaterial and isolate it from the
flap's internal aspect. A co llagen matrix was
placed , covering the biomateri al in th e most
occlusal aspect. This kind of matrix can remain
partially exposed and is designed to increase th e
soft tissue volume.
253
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

The flap was coronally advanced to achieve
comp lete coverage of the biomaterial; only the
most occlusal part of the collagen matrix was
left exposed . Flap suturing consisted of sling
sutures anchored to the canine's palatal surface
and simple interru pted sutures at the vertical
incision and on the occlusal aspect to approx-
imate the buccal and lingual flaps as much as
possible. Ti ssues were left to heal undisturbed
by reducing the apical aspect of the provisional
tooth splinted to the teeth neighboring the eden-
tulous site.

After almost 3 months, the teeth in the maxilla were prepared , and provisional restorations were placed .
The pontic restorati on was progressively reduced to avoid contact with th e soft tissues, which were
still going through the healing/maturation phase.

As is always the case, despite

the bone reconstruction sur-
gery, there was a residual ti s-
sue deficiency in the coronal
area (white dotted line) that
was treated with a soft tissue
augmentation procedure per-
formed 6 months after implant
extraction. On the adjacent
teeth , the soft tissues corre-
sponding to the area of cor-
onal ridge deficiency are sup-
ported by (and attached to)
the suprabony root surfaces
(black dotted lines). Soft tissue
augmentation techniques can
also prove helpful to increase
tissue volume at the level of
th e papillae. Th e soft tissue
deficiency, w ith both horizontal

and vertical components, is mainly located in
th e coronal area of th e the ridge. Both compo -
nents are equally important when it comes to
the final esthetic outcome. The vertical deficien-
cy is responsible for the lack of papillae, while
the horizontal deficiency wou ld resu lt in an un-
natural emergence profile for the pontic. Bone
The most effective surg ical technique that can
achieve soft tissue increase in both the apicocoronal
and buccolingual directions is the connective tissue
platform technique (see chapter 9). Depending on
the dimension of the apicocoronal defect, the pro-
cedure can be performed with a buccal envelope
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
augmentation techn iques play a crucial ro le in
th e restoration of bone vo lume at a more api-
cal level , but they will never be able to substi-
tute soft tissue augmentation techniques w hen
trying to restore the height and thickness of the
papil lae and emergence profi les of the prosthet-
ic crowns.
flap (minor defects) or with vertical releasing inci-
sions (severe defects). In this case, the buccal flap
consisted of a buccal horizontal incision, connect-
ing the mesial line angles of the teeth delimiting the
edentulous site, and two vertical incisions that ex-
tend into the alveolar mucosa.
255
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
In the presence of a significant maxi llary labial fren-
ulum, it must be included in the buccal flap design
and passivated, along with other muscle inser-
tions, during the execution of the deep and super-
ficial sp lit-thickness incisions. Complete removal of
these kinds of frenula can be done either at least
2 months before the soft ti ssue augmentation sur-
gery, or afterward , at the end of the healing phase.
In the authors' point of view, early removal of the
frenulum shou ld be avoided whenever possible be-
cause the procedure wou ld entail scar formation
in response to the deep periosteal wound . As a
result, apart from being unesthetic, the scar can
reduce vascu lar supply from the flap to the con-
nective ti ssue grafts, therefore increasing the risk of
flap dehiscence and graft exposure. On the other
hand , postsurg ical removal of the frenulum at the
end of the soft-tissue maturation phase wi ll only
create a superficial wound with little risk of scar
After split-thickness elevation of the buccal flap, its
coronal advancement was achieved with a deep
incision to remove periosteal muscle insertions,
followed by a superficial incision to get rid of mus-
cle insertions on the internal aspect of the alveo lar
mucosa. Oeep and superficial muscle insertions
associated with the frenulum were also removed at
formation. However, there is one cond ition that re-
quires removal of the frenulum before the soft tis-
sue augmentation surgery: w hen there is less than
2 mm of keratinized ti ssue between the vertex of
the papilla and the frenal insertion. If possible, the
horizontal incision at the level of the affected sur-
gical papilla can be coronally displaced in order to
provide a distance of at least 2 mm between the
frenal insertion and the papilla vertex; in this way,
presurgical frenectomy is avoided. The buccal flap
design should create two wide trapezoidal papil-
lae, located between the horizontal and vertical
incisions, on keratinized tissue, and with a vertex
located at least 2 mm coronal to frenulum inser-
tions. Another beveled horizontal incision is done,
th is time connecting the palatal line ang les of the
teeth delimiting the edentulous site; the incision is
extended intrasulcularly at the adjacent teeth to al-
low split-thickness elevation of the palatal flap.
this stage. Coronal flap advancement was consid-
ered adequate when the buccal horizontal incision
was able to reach the palatal incision without ten-
sion. Th e crestal soft tissues between the horizon-
tal incisions were de-epithelialized with a surgical
blade -they wou ld become the connective tissue
platform onto wh ich the grafts were anchored .

A graft of greater thickness was required at
the distal half of the edentulous site to com-
pen sate for the greater verti cal soft tissue de-
ficiency next to the lateral incisor (blue arrows)
in compari son to the soft ti ssue level mesial
to the central incisor (green arrow). Th e easi-
est and most effective way to obtain different
graft thicknesses is to harvest, from the palate,
an epithelium-connective ti ssue graft whose
mesiodistal dimension is one and a half times
the length of the edentulous site. After extra-
oral de-epithelialization, one-third of th e graft
is folded to selective ly double its thickness on
one end; the two layers of tissue are secured
with an internal mattress suture. This tailored
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
graft is fixed onto the occlusal aspect of the
connective tissue platform with internal mat-
tress sutures as fo llows (see illustrations): the
needle penetrates the graft from its external
surface, takes anchorage on the platform's
connective tissue, and re-perforates the graft
from its internal surface; the suture is closed
w ith a surg ical knot that lies on the graft's ex-
ternal aspect.
A second graft, harvested and prepared as
previously described, is placed buccally; it is
fixed coronally with internal mattress sutures
anchored to the connective tissue platform
and apically with simple interrupted sutures
anchored to the periosteum .
257
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
The purpose of the occlusal graft is to treat the
vertical deficiency and to increase the height and
thi ckness of the papillae. As a comp lement to
thi s, th e goal of the buccal graft is to increase
soft tissue thickn ess in th e coro nal area- at th e
same level w here th e suprabony portion of the
The flap was coro nally advanced for co mplete
coverage of th e co nnective ti ssue grafts, and
primary wo und closu re was achieved along
th e palatal inc ision line. Th e verticality of the
vest ibular forni x was restored w ith periosteal
The provisional was modified so that it wouldn't interfere with healing and maturation of the soft tissues.
root is fou nd on adjacent teeth. After all , bone
augmentation techniques are not able to provide
the tissue thi ckness needed in this specific area
to create a natural emergence profil e that also
favors hyg iene maintenance of the prosthetic
crown.
anchorage sutures done at th e most apical
part of th e ve rti cal releasing inc isions. Simple
interrupted sutures were used along the rest
of the ve rti cal inc isions and palatal incision
line.
 IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

Wound healing was uneventful, and undisturbed soft tissue maturation took place for 6 months. During
this phase, periodic patient checkups were performed to reduce the provisional when it came into
contact with growing soft tissues.

Six months after the surgery, when soft tissue growth and maturation can be considered to be com-
plete, the provisional is modified by adding flowable composite to the pontic, thus starting the soft
tissue conditioning phase.

259
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

After nearly 2 months from the start of the soft
tissue conditioning, the decision was made to
perform small touch-ups (ie, tissue plasty) with
microsurgical scissors. The goal was to elimi-
nate the coronal muscle insertions, especially in
the area corresponding to the presence of the
maxillary labial frenulum . The frenulum's deep
and superfi cial muscle insertions were removed
as part of the buccal flap's passivation during
the previous surgery, reducing the risk of early
flap dehiscence. However, the frenulum's lining
mucosa remained an issue, since it stands out
from the adjacent keratinized tissues. For this
reason, once the site was healed, small super-
ficial cuts were made with the microsurgical
scissors to allow spontaneous apical displace-
ment of the alveolar mucosa; the wounds were
closed with 7-0 polyglycolic acid (PGA) sutures.
These touch -ups are so superficial that they can
be done under topical anesthesia and won't re-
su lt in scarring, as wou ld have happened with
a presurgical frenectomy. After only 2 days, the
treated area looks almost healed , and wounds
are almost imperceptible.

Comparison of the presurgical situation and images during the condition ing phase prove the effica-
cy of the platform technique in treating vertical and horizontal soft tissue deficiencies with a single
procedure.
 IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

The buccolingual soft-tissue increase allows the

creation of an adequate emergence profile for the
prosthetic crown that is also compatible with proper
hygiene maintenance. The apicocoronal augmenta-
tion created a tissue surplus that made it possible
to perform soft tissue conditioning with the provi-
sional restoration, resulting in the formation of inter-
proximal papillae and providing suitable anatomy to
the marginal tissues of the pontic restoration.

After 4 months of soft tissue conditioning , the pontic site has been adequately remodeled to create both
a natural emergence profile and a buccal mucosal margin that coincides with the gingival margin of the
adjacent central incisor.

261
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

After definitive cementation, the restoration fully satisfies the patient's esthetic demands.

The 2-year follow-up after final restoration placement shows further tissue remodeling around the pon-
tic, wh ich helped improve blending of the treated area with the adjacent tissues.
 IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

Comparison of the baseline and final images highlights how, in patients needing complex prosthetic res-
toration of the teeth adjacent to a failing implant, a partial denture with a pontic can be a vali d alternative
to implant therapy. Nonetheless, this does not preclude the need for soft tissue augmentation in order to
obtain an esthetic restoration that integrates harmoniously with the surrounding soft tissues.

263
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
Comparison of the images before soft tissue sur-
gery and those of the final outcome reiterate the
importance of soft tissue augmentation for the at-
tainment of an esthetic result. In fact, despite hav-
ing performed bone augmentation at the moment
of implant extraction , the soft tissues lacked the
adequate height and thickness needed to provide
an esthetic appearance to the pontic restoration-
not to mention a natural emergence profile fit for
proper hygiene maintenance.
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

265
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
Severe buccal malposition is one of the main in-
dications for implant removal. It is important to
point out that the concept of "buccal malposi-
tion " includes angulati on (or inclination) errors, as
well as positioning errors in wh ich the whole im-
plant body is placed too far buccally. Angu lation
defects resulting in a discrepancy of even more
than 20 degrees between the implant axis and
the ideal abutment axis can be corrected with
the use of angulated cast abutments (see chap-
ter 12). On the contrary, when the angulation er-
ror is associated w ith excessively buccal position
of the implant body, extraction is the first- choice
treatment. In these cases, implant removal is fre-
quently atraumatic, thanks to the use of dedicat-
ed tools that break the osseointegration by un-
screwing the implant, and the residual hard/soft
tissue defect often affects only the buccal aspect.
In fact, the lack of involvement of the interproximal
and palatal bone allows maintenance of papillae
and palatal soft tissue height. In cases like these,
even if the soft tissue defect looks alarming in the
beg inning , it can resolve almost entirely on its
own if the site is left to heal for several months (at
least 4 months) without performing any therapy
at the moment of implant removal.
 IMPLANT REPLACEMENT IN TH E ESTHETIC ZO NE

The following case portrays a patient who was greatly disappointed with the esthetics of an implant
placed in the maxillary left central incisor position. The occlusal and profile images show how the
malposition includes both an excessive buccal position and incorrect angulation of the implant fi xtu re.

267
IMPLANT REPLACEM ENT IN THE ESTHETIC ZONE
Implant extraction with dedicated reverse-torque instruments is predictable thanks to the implant's
morphology and its excessively buccal position.
Rem oval of th e implant-supported crown re-
vealed the presence of a reduced mesiod istal
space for a central incisor, especially consider-
ing that its dimensions should match th ose of
the co ntralateral incisor. Additionally, a periapi-
cal radiograph taken with a gutta-percha cone
showed slightly altered passive eruption on the
maxillary left lateral incisor-a distance of 3 mm
from the tip of th e co ne to the cementoenamel
junction. Thi s cond ition, however, seems more
evident on the maxi llary right lateral incisor. In ad-
dition to surgical correcti on of the altered passive
eruption, orthodontic treatment was proposed to
the patient in order to obtain th e ideal space for
the missing central incisor. The patient's refusal
of orthodontic therapy and th e specific request
for the maintenance of the overlap between the
central and lateral incisors urged the autho rs to
come up with an alternative, and perhaps more
complex, treatment plan.

When implants are so buccally displaced and
structures like the palatal bone, interproximal
bone peaks, and papillae at the adjacent teeth
are well preserved, the authors advise letting the
extraction site heal without performing hard or
soft tissue augmentation at the moment of im-
plant removal. Bone augmentation techniques
are contraindicated at this stage because of the
difficulty of providing coverage of the bone fill-
er materials given the marked recession of the
buccal soft tissues. On a similar note, soft tis-
sue augmentation techniques are also contrain-
dicated because of the risk of incomplete graft
coverage which , if left exposed, wou ld lead to a
different color or texture with respect to the adja-
cent soft tissues due to the nature of the palatal
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
graft. It is the authors' firm opinion that this type
of defect, almost entirely circumscribed to the
buccal aspect, can have good spontaneous
healing. The advantage of this approach is that,
by waiting, patient morbidity can be reduced be-
cause the dimensions of the soft tissue required
will be reduced compared to the amount needed
if the soft tissue augmentation was done simul-
taneously with implant extraction. Placement of
a carefully planned Maryland bridge gives the
patient the opportunity to have a restoration that
wi ll esthetically resemble the ideal final outcome.
This is particularly important when the patient
has specific requests, like in this case, in wh ich
the patient asked to keep the overlap between
the central and lateral incisors.
269
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

Only 3 months after the implant extraction, it is already possible to observe how the spontaneous healing
of the ridge led to a reduction of the defect, even if a significant buccolingual deficiency was still present.
Meanwhile, the patient was highly satisfied with the esthetic result achieved with the Maryland bridge.

After six months, hard and soft tissue healing is presumed to be complete. Along with the clinical
assessment, a three-dimensional rad iographic evaluation can be done at this point to plan the next
treatment phases.
 IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

Both clinical and radiographic evaluations reveal th e presence of a buccolingual defect that affects not
only the hard tissues but also the suprabony soft tissues that will give origin to the future transmucosal
path of the implant-supported crown.

The three-dimensional radiographic assess- for buccal bone augmentation to allow prosthet-
ment is necessary to plan implant placement ically gu ided and estheti cally adequate implant
through guided surgery. In the authors' opinion, placement.
computer-guided implant
placement in the esth etic
area is extremely helpful ,
even for expert clinicians;
its use is particularly in-
dicated w hen the thick-
ness of the ridge is less
than ideal and interden-
tal spaces are reduced.
In fact, the slightest er-
ror in implant positioning
can resu lt in irreversible
esthetic deformities if
the integrity of the bone
peaks and papillae delim-
iting the edentulous site
are compromised . Digital
planning reveals th e need
27 1
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
By creating a buccal flap, it is possible to per-
form implant placement, bone reconstruction ,
and soft tissue augmentation in a single pro-
ced ure. Because of the reduced mesiodistal
dimension of th e edentulous site, immediate
provisionalizati on was discarded to avoid inter-
ference of the provisional crown with soft ti s-
sue healing at the level of the papillae. On this
occasion, the authors opted for submerged
healing; after soft tissue maturation (approxi-
mately 6 months), the implant was uncovered
with a soft ti ssue punch to preserve the integri-
ty of the future peri-implant papi llae. The same
principles used in mucogingival surgery for th e
treatm ent of multiple adjacent gi ngival reces-
sions were applied to the buccal flap design:
split-thickness elevation at th e level of the sur-
gical papillae, full thi ckness until overcoming
th e bone crest, and again split thickness (first
deep and then superficial) to allow coronal flap
advancement. Given the presence of a wide
band of keratinized ti ssue, a paramarginal in-
cision was made at the right lateral incisor to
correct the altered passive erupti on . As estab-
lished during digital planning, th e implant plat-
form was placed 4 mm apical to the ideal po-
sition of the gingival margin at th e contralateral
central incisor.
 IMPLANT REPLACEMENT IN THE ESTHETI C ZO NE

Since a large portion of the implant's buccal
su rface was exposed, as foreseen during dig-
ital planning , buccal bone reconstruction was
deemed necessary. Th e periosteum , left in
place when freeing the flap from deep mus-
cle insertions, was removed entirely from the
area where the bone augmentati on would be
done.
In order to create a contai ned area to receive
the bone graft , placement of a barrier mem-
brane was done first, and the bone was ap-
plied afterwards . A slow-resorbing pericardi-
um membrane was chosen due to its stable
shape and resistance to tearing , which allowed
it to be sutured to the periosteum lateral to the
bone aug mentation area.

Autogenous bone was harvested with a mini bone scraper from the teeth adjacent to the implant site
that were affected by altered passive eruption. The autogenous bone was mixed with osteoconduc-
tive, slow-resorbing biomaterial at a percentage of 70% and 30%, respectively.

273
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
Previous membrane fixation facilitated the con-
trolled placement of the bone graft/biomaterial.
Afterward, a second membrane was placed
on top of the first one, resting on the buccal
plates of the teeth adjacent to the edentulous
Buccal bone reconstruction does not exclude
the need to increase soft tissue thickness at the
level of the future transmucosal path of the im-
plant restoration. For this reason, a connective
tissue graft, derived from the extraoral de-epi-
thelialization of a free gingival graft, was placed.
As per protocol, the graft was placed 1 mm
coronal to the esthetically ideal gingival margin
position at the adjacent central incisor and cov-
ered the entire area of bone augmentation, sur-
passing it by 2 to 3 mm apically. The horizontal
site. Coronally, simple interrupted sutures with
periosteal anchorage allowed membrane sta-
bilization to avoid graft dispersion into the su-
prabony area belonging exclusively to the soft
tissues.
graft dimensions coincided with the mesiodis-
tal dimension of the edentulous site. This would
al low a buccolingual increase in peri-implant
papillae thickness, wh ich in time wou ld lead
to their coronal growth during the soft tissue
conditioning phase. An ample amount of soft
tissue was available for suturing the graft at the
base of the anatom ical de-epithelialized papil-
lae of the adjacent teeth thanks to the choice of
submerged healing, ie, without the interference
of an immediate provisional crown.
 IM PLANT REPLACEMENT IN THE ESTHETIC ZONE

Great care should be taken to avoid excessively coronal placement of the graft, which would impede
primary wound closure between the coronally advanced fl ap and the co nnective tissue beds, resu lting
from the de-epitheli alizati on of the papillae delimiting the edentu lous site.

275
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

The coronally advanced flap was closed with simple interrupted sutures at the edentulous ridge area
and sling sutures on the adjacent teeth. The pontic element of the Maryland bridge was shortened
before recementation so it wou ld not interfere with soft tissue healing.

At suture removal, 2 weeks after surgery, the position of the soft tissues appears stable, and the bucco-
lingual deficiency seems to have almost entirely resolved.

The pontic element is further shortened to allow coronal growth of the augmented soft tissues. If space
allows it, it is possible to reduce the provisional without removing the bridge. Undisturbed soft tissue
maturation and bone healing continue for 6 months. The periapical rad iograph taken after this period
shows stability of the bone support and no signs of failed implant osseointegration.

Implant uncovering is done with a flapless punch
technique, guided by the same surgical stent
used for implant placement. The incision is done
with a microblade kept in contact with the wall
of the metal sleeve, which makes it a very con-
servative procedure, since only the soft tissues
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
covering the implant platform are removed . As a
result, the integrity of the future peri-implant papil-
lae is not affected . A transfer abutment is used to
avoid soft tissue collapse in the time needed to re-
finish the laboratory-made provisional restoration
obtained from the digital planning.
277
IMPLANT REPLAC EMENT IN THE ESTHETI C ZONE
A small gingivectomy guided by th e outline of
th e provisional restoration allows the place-
ment of th e restoration w ithout excessive co m-
pression of the bu ccal soft ti ssues. The mod-
ified and poli shed provisional is screwed in
One wee k after implant uncovering, the pa-
ti ent is highly sati sfied w ith th e esth etic result.
Comparison bet wee n th e baseline situati on
and the 1-week outcome after pl acement of th e
provisional shows th e estheti c improvement in
pl ace, makin g sure that th ere is not excessive
compression on the papill ae or bu ccal ti ssues.
The ischemia present immediately after crown
placement should disappear w ithin several
minutes.
line w ith th e patient request for th e mainte-
nance of the incisor overlap. The occlusal and
profil e images highlight th e soft ti ssue vo lume
increase, w hich confers a natural emergence
profile to th e prostheti c crow n.
 IMPLANT REPLACEMENT IN THE ESTHETIC ZO NE

At the time of fin al restoration placement, the buccal soft tissues appear thickened and follow the out-
line of the soft tissues at the adjacent teeth. Th is contributes to the creation of an adequate emergence
profile that is a very c lose match to that of the adjacent central incisor.

279
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE
One year after final restoration, the outcome
completely satisfies the patient's esthetic
demands, which included reproducing the
overlap between the contralateral central and
lateral incisors at the level of the implant site.
The periapical radiograph shows good implant
osseointegration and no signs of peri-implant
bone loss.
Comparison between the baseline images
and those from the 1-year follow-up after final
restoration placement demonstrate the es-
thetic improvement and the perfect integration
of the implant-supported crown, which seems
to emerge from the soft tissues in a complete-
ly natural way. The latter enables good pa-
tient-performed hygiene maintenance.
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

28 1
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

The recall appointment 28 months after definitive restoration placement proves the stability of the es-
thetic outcome. The patient is completely satisfied with this resu lt.
IMPLANT REPLACEMENT IN THE ESTHETIC ZONE

283
 IM PLANT REPLACEMENT IN THE ESTHETIC ZONE

Avi la G, Galindo-Moreno P, Soehren S, Misch CE,
Morelli T, Wang H-L. A novel decision-making
process for tooth retenti on or extraction. J
Peri odontol. 2009;80:476-91.
Araujo MG, Lindhe J. Dimensional ridge alterations
following tooth extraction. An experimental study
in the dog. J Clin Periodontol. 2005;32:212-8.
Botticel li D, Berglun dh T, Lindhe J. Hard-
tissue alterations foll owing immed iate implant
placement in extraction sites. J Cl in Periodontol.
2004;31 :820-8.
SUGGESTED READINGS
Nisapakultorn K, Suphanantachat S, Silkosessak
0, Rattanamongkolgul S. Factors affecting soft
tissue level aroun d anteri or maxillary single-
tooth implants. Clin Oral Implants Res. 2010
Jun;21 (6):662-70.
Zucchelli G, Mazzotti C, Bentivog li V, Mou nssif I,
Marzadori M, Monaco C. The connective tissue
platform technique for soft tissue augmentation.
Int J Periodontics Restorative Dent.
2012;32:665-75.

Bu ser 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.

Cardaropoli G, Lekholm U, Wennstrbm JL. Tissue

alterations at implant-supported single-tooth
replacements: a 1-year prospective cl inical study.
Clin Oral Implants Res. 2006;17:1 65-71.

Cardaropoli G, Wennstrbm JL, Lekholm U. Peri -

implant bone alterations in relation to inter-unit
distances. A 3-year retrospective study. Clin Oral
Im plants Res. 2003;14:430-6.

Grunder U, Gracis S, Capelli M. Influence of the

3-D bone-to-i mplant relationship on esthetics. Int
J Periodontics Restorative Dent. 2005;25:113-9.
Mazzotti C, Stefanini M, Felice P, Bentivog li V,
Mou nssif I, Zucchell i G. Soft-tissue dehiscence
coverage at peri-implant sites. Periodontol 2000.
2018;77:256-272.

Morton D, Chen ST, Marti n WC, Levine RA, Buser

D. Consensus statements and recommended
clinical proced ures regarding optimizing esthetic
outcomes in implant dentistry. Int J Oral Maxil lofac
Implants. 2014;29 Suppl:216-20.

285
 /
~ /
 Mucogingival
Approach
for Implant
Placement
to Replace
a Single Tooth
in the Esthetic Area
MUCOGINGIVAL APPROACH FOR IMPLANT PLACEM ENT TO REPLACE A SINGLE TOOTH IN THE ESTH ETIC AREA

Tooth Extracted for Dental Reasons

> ~
CBCT SCAN

( POSITIVE FINDINGS ) ( NEGATIVE FINDINGS )

J J
PROVISIONAL MARYLAND BRIDGE
POSTEXTRACTION IMPLANT
(GUIDED PLACEMENT)
+
IMMEDIATE PROVISIONALIZATION
+
SOFT TISSUE AUGMENTATION ASSESSMENT OF TISSUE LOSS

HORIZONTAL: MILD-MODERATE
VERTICAL: MILD
(NO LOSS IN PAPILLAE HEIGHT)

7 ~
CBCT SCAN

J
IMPLANT
SOFT TISSUE
RIDGE AUGMENTATION +
IMPLANT
SOFT TISSUE
(GUIDED PLACEMENT) I
4-6 MONTHS
AUGMENTATION
+
(SUBMERGED HEALING)
IMMEDIATE t I
PROVISIONALIZATION FLAPLESS IMPLANT
4 MONTHS
+ (GUIDED PLACEMENT)
SOFT TISSUE + t
IMPLANT UNCOVERING
AUGMENTATION IMMEDIATE
PROVISIONALIZATION t
PROVISIONAL CROWN

Courtesy of: • John Wiley and Sons. Periodontal 2000. 2018 Jun;77(I):150-164.
MUCOGINGIVAL APPROACH FOR IMPLANT PLACEMENT TO REPLACE A SINGLE TOOTH IN THE ESTHETIC AREA

Tooth Extracted for Periodontal Reasons

* *

PROVISIONAL MARYLAND BRIDGE

SOFT TISSUE
HORIZONTAL: RIDGE AUGMENTATION
SEVERE
VERTICAL:
MODERATE-SEVERE
(LOSS IN PAPILLAE DEFINITIVE
HEIGHT) MARYLAND 1+
'---~_~~
_ . CBCTSCAN . BRIDGE

r
I ADEGUATE BONE
HEIGHT
l INADEGUATE BONE
HEIGHT AND THICKNESS-
I
ADEGUATE BONE
HEIGHT AND THICKNESS
(INADEGUAT~ THICKNESS)

IMPLANT
t
HORIZONTAL AND

1
FLAP LESS IMPLANT
+
HORIZONTAL BONE
AUGMENTATION
VERTICAL
BONE AUGMENTATION
I
(GUIDED PLACEMENT) (SUBMERGED HEALING) 9-12 MONTHS

+ I t
IMMEDIATE 6 MONTHS FLAPLESS IMPLANT
PROVISIONALIZATION t (GUIDED PLACEMENT)
SOFT TISSUE PUNCH +
+ IMMEDIATE
PROVISIONAL CROWN PROVISIONALIZATION

_ Expert

Clinician 's expertise in realtion to the level of surgical difficulty Advanced

_ Less experienced

289
Courtesy of: • John Wiley and Sons. Periodontal 2000. 2018 Jun;77(1):150-164.
MUCOGINGIVAL APPROACH FOR IMPLANT PLACEMENT TO REPLACE A SINGLE TOOTH IN THE ESTHETIC AREA

The cho ice of a therapeutic approach for sin-
gle-tooth replacement in the esthetic area is
mainly influenced by the conditions that led to
tooth extraction. As a general ru le, there are two
different clinical situations th at may lead to tooth
extraction: one of a dental nature and the oth -
er of a periodontal nature. In the case of tooth
removal for dental reasons, the patient is peri-
odontally healthy, and th e cause of extraction
is related to the tooth itself: endodontic lesions,
root or crown-root fractures , internal or external
root resorption, or root caries. In these cases,
if bone loss is present, it is usually confined to
only one of the bone plates - buccal or palatal-
wh ich in most cases is only partially affected .
However, when teeth have to be extracted for
periodontal reasons, th e patient has an infec-
tious disease of bacterial origin , wh ich should be
treated prior to proceeding with implant therapy.
Furthermore, for the extraction to be indicated ,
bone loss should be so severe as to render peri-
odontal regenerative procedures unpredictable.
The decision tree here proposed represents the
authors' personal strategy based predominantly
on clin ical experience rather th an on scientific
evidence.

Tooth Extracted for Dental Reasons

In th e esthetic area, the therapeutic treatment of cho ice for a tooth that must be extracted for dental
reasons is a postextraction implant with immediate provisionalization and simultaneous soft tissue
augmentation (see chapter 7).

The reaso n for this choice is twofold: first, be-
cause it is the most straightforward solution
for the patient since it allows immediate sub-
stitution of the tooth to be extracted with an-
other "tooth" in a single procedure; second, it
immediately provides an esthetically pleasing
result (at the end of the surgical procedure) that
is kept throughout the healing phase and th at is
further improved with the placem ent of the final
restoration.
MUCOGINGIVAL APPROACH FOR IMPLANT PLACEMENT TO REPLACE A SINGLE TOOTH IN THE ESTHETIC AR EA

An accurate diagnosis, chiefly supported by
three-dimensional rad iographic studies (ie,
CBCT scan), is essential before arriving at
thi s decision . Th e necessary conditions for
the execution of a postextraction implant w ith
immediate provisionalization are mainly relat-
ed to the osseous tissue, in the sense that
there must be an ad equate quantity that w ill
allow obtention of th e needed primary stability
for immediate provisional ization. Additionally,
th e buccal bone plate must not be severely
compro mised. If present, buccal bone de-
hiscence must not exceed 5 mm in depth .
Computer-guided implant placement allows
im plant placement even in situ ati ons in w hich
bone availability is not ideal. The lack of a pal-
atal bone wall or presence of a deep palatal
dehiscence are contraindicati ons for postex-
traction im plant placement. However, pre-ex-
traction conditions relatin g to th e soft tissues
of th e tooth to be extracted suc h as a gingival
marg in at the level of or more apical th an th at
of the reference tooth or insufficient height!
thi ckn ess of th e buccal keratinized ti ssues
are no longer considered contraindications
for postextraction im plant placement with im-
mediate provisionalization. These unfavorable
scenari os can now be treated simultaneously
with implant placement if a soft ti ssue aug-
mentation technique is applied , as is the case
of the coronally advanced flap with an under-
lyi ng connective tissue graft obtained from the
de-epithelialization of a free gingival graft har-
vested from th e palate (see chapter 7) .
The only factor concernin g the soft tissues
th at cou ld be considered a contraindication
for postextraction implants with immediate
provisionalization is the prese nce of inad-
equate interdental papillae w ith insufficient
height, w idth , or thickn ess to provide vascular
supply and serve as anchorage for th e coro-
nally advanced flap. In th ese cases , it is rec-
ommended to perform tooth extracti on and
await complete healing (6 months) of th e soft
and hard tissues; in oth er wo rds, delayed im-
plant placement. Th e postextraction im plant
with immediate provisionalization therapy re -
quires experience and an elevated set of ski lls
on behalf of the clin ician, inc luding both the
surgeon and th e restorative dentist. Th e risk of
failure due to even minor mistakes during the
surg ical procedure or related to the prosth eti c
postsurgical management should always be
kept in mind.
The choice of delayed implant placement
could therefore be dependent on th e clinician's
learnin g cu rve if there is insufficient experi ence
to perform postextraction im plant placement
with immed iate provisionalization and simUlta-
neous soft-tissue augmentati on.

1ST CHO ICE

Postextraction implant placement with immediate provisionalization and simultaneous soft tissue aug-
mentation with a coronally advanced flap + connective tissue graft

SURGEON AND PROSTHODONTIST' S EXPERIENCE AND SKILL

INSUFFICIENT
I I
Delayed implant placement-that is, once th e
alveo lus has completely healed- is not a com-
promise regardin g th e fi nal esthetic result, but
it surely entails more treatment stages and lon-
ger waiting times for the patient (see chapter 6).
OPTIMUM
•
However, it represents a solution with a lower risk
of failure in comparison with th e postextraction
implant with immediate provisionalization, and
therefore is th e ideal choice for less experienced
clinicians.
291
MUCOGINGIVAL APPROACH FOR IMPLANT PLACEMENT TO REPLACE A SINGLE TOOTH IN THE ESTHETIC AREA

The authors define a "delayed" implant as one
that is placed only after complete healing of th e
extraction site, 6 or more months after tooth re-
moval. The reason for this waiting period is to
ensure the presence of comp letely healed soft
and hard tissues at the moment of the surgery
to allow maximum safety both regarding soft
tissue management and achievement of the
ideal primary stability needed to place a provi-
sional at the moment of implant placement. By
"delayed" implant, the authors refer to delayed
implant placement but also, w henever possi-
ble, immediate provisionalization and simulta-
neous soft tissue augmentation by means of a
coronally advanced flap and a connective tis-
sue graft.

2ND CHOICE

Delayed implant with immediate provisionalization and simultaneous soft tissue augmentation with a
coronally advanced flap and a connective tissue graft

SURGEON 'S EXPERIENCE AND SKILL

INSUFFICIENT OPTI MUM

• I

PROSTHODONTIST'S EXPERIENCE AND SKILL

INSUFFICIENT
I I
During the waiting period for healing of the ex-
traction site, the patient's esthetic and functional
demands should be provisionally attended. An
adhesive partial denture, such as the Maryland
bridge, represents by far the best provisional solu-
tion for the patient. If the patient's needs are met,
the clinician will not be under pressure to reduce
the waiting period required for tissue maturation.
For this reason, it is advised to avoid as much as
possible the use of precarious solutions in the
form of removable prostheses. In the vast majority
OPTIMUM
•
of cases, when a tooth has been extracted for
dental reasons, the edentulous site heals with a
horizontal (buccolingual) defect that involves both
soft and hard tissues. Th e presence of apicocoro-
nal soft tissue defects is much more rare and does
not represent a contraindication for the delayed
approach if the latter is accompanied by surgical
techn iques that allow soft tissue augmentation . It
does, however, increase the difficu lty of the pro-
cedure and therefore requ ires a higher level of skill
from the clinician.

A th orough appraisal of th e tissue deficit is (CBCT) radiographic studies are needed to

performed 6 months after th e tooth extraction. evaluate whether bone height and thickness
If the soft tissue loss is small to moderate in allow the placement of an esthetically/pros-
a buccolingual sense (with or without apico- thetically guided implant w ith ideal dimensions
coronal loss), standard and three-dimensional for the substitution of the m issing tooth .
MUCOGINGIVAL APPROACH FOR IMPLANT PLACEMENT TO REPLACE A SINGLE TOOTH IN THE ESTHETIC AREA
While bone height (apicocoronal dimension) is a
prerequisite for the execution of implant thera-
py (which is rarely a problem in the case of ex-
tractions done for dental reasons) , bone thick-
ness does not necessarily have to be ideal (ie, 2
mm of bone surrounding the implant buccally and
palatally). The presence of a reduced thickness of
The presence of reduced bone thickness to a
degree that wou ld not allow implant placement
or that would lead to the formation of a deep-
er buccal bone dehiscence (a rare finding in the
case of extractions done for dental reasons)
requires enhancement of the soft tissues previ-
ous to implant placement. In this case, implant
placement wou ld take place after complete
healing, around 6 months, along with guided
bone regeneration techniques at the buccal as-
pect. The same two-stage approach, soft tis-
sue augmentation first and subsequent implant
placement, is implemented whenever there is a
severe buccolingual soft tissue deficit (with an
add itional apicocoronal component) 6 months
after tooth extraction or if it is associated with
loss of papillae height. In these last scenari-
os, the most effective technique for soft tissue
Courtesy of.' • John Wiley and Sons. Periodontal 2000. 2018 Jun;77(I):150-164.
the buccal bone in the coronal aspect, such as to
lead to the formation of a small buccal dehiscence
«3 mm) after bone remodeling , is not considered
a contraindication for delayed implant placement
if soft tissue augmentation is performed simu lta-
neously by means of a coronally advanced flap
plus a connective tissue graft.
augmentation at the edentulous site is the con-
nective tissue platform (see chapter 9).
Delayed implants present some advantages with
respect to immediate implant placement, for
example:
1. regarding the soft tissues - the healed eden-
tulous site provides wider, th icker, and deeper
papillae for the implant and immediate pro-
visional (representing a larger vascular bed if
de-epithelialized in a palatal direction); in nar-
row edentulous sites, the healed ridge allows
verticalization of the supracrestal soft tissues
(see chapter 6);
2. regarding the hard tissues - a healed socket
improves the chances of achieving enough
primary stability for immediate provision-
alization and reduces the risk for implant
malposition .
293
MUCOG INGIVAL APPROACH FOR IMPLANT PLACEMENT TO REPLACE A SING LE TOOTH IN THE ESTHETIC AREA

In the case of delayed im plant placement, the
technique of choice is the coronally advanced
flap covering a con nective tissue graft simulta-
neously with implant placement and immed iate
provisionalization (see chapter 6). This proce-
dure, even if somewhat less risky than immedi-
ate postextraction implant placement, requ ires
a very skilled and experienced surgeo n and
prosthodontist.
Other options th at prove to be effective regard-
ing the fin al esth eti c resu lt- with decreased
technical difficu lty and minor risk of mistakes
that cou ld compromise th e success of the treat-
ment- requ ire longer treatment times and more
therape utic phases.
Th ey consist of two -stage approaches that can
be of two types:
1. Pre-im plant soft tissue augmentation (tech-
niques for the edentulous site) with a 6-month
healing period fo llowed by a flapless, comp ut-
er-g uided implant placement with immediate
provisionalizati on (see chapter 6).

3 RD CHOICE

Soft tissue augmentation at the edentulous ridge for buccolingual defects. After 6 months, flap less,
computer-guided implant placement with immediate provisional
SURGEON'S EXPERIENCE AND SKILL
INSUFFICIENT OPTIMUM

•
PROSTHODONTIST'S EXPERIENCE AND SKILL
INSUFFICIENT OPTIMUM
I I I
MUCOGINGIVAL APPROACH FOR IMPLANT PLACEMENT TO REPLACE A SINGLE TOOTH IN THE ESTHETIC AREA

2. Soft tissue augmentation simultaneous to
implant placement w ith submerged healing ;
once healing is completed (approximately 6
months), implant uncovering and subsequent
provisionalization. This therapeutic option
becomes the obligatory choice in the unfor-
tunate case that the primary stability is not
sufficient for immediate provisionalization of
the delayed implant and simultaneous soft
tissue augmentation (see chapter 6).

4TH CHOICE

Implant placement with soft tissue augmentation and submerged healing, followed by implant uncov-
ering and provisionalization

SURGEON 'S EXPERIENCE AND SKILL

INSUFFICIENT OPTIMUM
I I
•
PROSTHODONTIST' S EXPERIENCE AND SKILL
I
INSUFFICI ENT OPTIMUM
I I • I

Tooth Extracted for Periodontal Reasons

Periodontitis, along with dental caries, is one of
the main causes of tooth loss. The patient with
periodontal disease who is subjected to a den-
tal extraction in the esthetic area is much more
complex to manage from a therapeutic point of
view in comparison with a patient that has lost a
tooth for dental reasons (see chapter 9). First of
all, the patient affected by periodontitis has an in-
fection of bacterial etiology that should be treated
before even attempting to perform implant thera-
py. Additionally, the loss of a periodontally com-
promised tooth brings about anatomical sequelae
that resu lt in a more pronounced soft and hard
tissue deficit. Cause-related periodontal thera-
py, which also includes extraction of period on-
tally compromised teeth that have a "hopeless"
prognosis, and the subsequent surgical therapy,
should always be comp leted before embarking
on the treatment plan for substitution of the ex-
tracted tooth. At the time of the extraction of a
periodontally "hopeless" tooth , it is wise to re-
member that the radiolucency appreciated in the
periapi cal radiograph is caused by bone demin-
eralization. As is well known, bone is not directly
involved in the infection or inflammatory process
but recedes as a result of the infection present
on the root surface. As a consequence, the gran-
ulation tissue present in a postextraction socket
of a tooth removed for periodontal reasons actu-
ally contains demineralized bone that if removed
wi ll be lost and if left in place can remineralize
once the infection has subsided (ie, after tooth
extraction). Therefore, it is the authors' opinion
that debridement of the socket with sharp instru-
ments (eg , Lucas curet) should be avoided when
performing extractions of periodontally affected
teeth, especially because the proximity of natu-
ral teeth does not allow adequate distinction be-
tween loss of attachment or loss of bone on the
adjacent teeth.
295
MUCOGINGIVAL APPROACH FOR IMPLANT PLACEMENT TO REPLACE A SINGLE TOOTH IN THE ESTHETIC AREA
The extracted tooth is provisionally replaced by
an adhesive Maryland bridge bonded to the adja-
cent teeth. This gives the patient the opportunity
to have a provisional prosthetic solution that is
esthetically and functionally satisfying. It is essen-
tial that the patient doesn't have any kind of prob-
lem during the time needed to perform cause-re-
lated and corrective periodontal therapy in the
rest of the dentition. During this period, healing
In contrast with extractions performed for den-
tal reasons, in which the residual defect on the
edentulous site is mostly horizontal, in the case
of dental extractions due to periodontal reasons ,
the defect is almost always combined, ie, with
horizontal and vertical components. Thi s is due
to the major bone loss, wh ich most of the time
involves both the buccal and palatal bone plates,
and to the prevalent loss of attachment (loss of
interproximal bone peaks) that affects one or
both of the teeth adjacent to the periodontally
hopeless tooth . These two factors are also the
main reason for papilla loss at teeth neighbor-
ing the edentulous site. Six months after tooth
extraction, a soft tissue ridge augmentation
of the extraction site also takes place, enabling
reevaluation of the neighboring teeth 's periodon-
tal condition. The waiting time before proceeding
with implant placement varies from one patient to
another (eg, depending on the number of correc-
tive surgeries that must be performed for treat-
ment of periodontal sequelae) and from site to
site (depending on the severity of the bone loss),
but will always be at least 6 months.
technique is performed at the edentulous site
with the goal of correcting both the horizontal
and vertical components of the defect as well
as partially reconstructing the papillae of the ad-
jacent teeth . The availability of soft tissue at the
donor site (palate or tuberosity) is the main lim-
itation of these techniques and is the factor that
determines if the defect can be treated in one or
two surgical procedures. In the presence of an
adequate amount of tissue at the donor site, the
soft ridge augmentation procedure of choice is
the connective tissue platform technique since
it allows treatment of the vertical and horizontal
components of the defect with a single surgical
intervention (see chapter 9).
MUCOGINGIVAL APPROACH FOR IMPLANT PLACEMENT TO REPLACE A SINGLE TOOTH IN THE ESTHETIC AREA

Once healing and maturation of the soft tis- The periapical radiograph done 1 year after
sues has taken place (approximately 6 extraction of a periodontally affected tooth fre-
months), radiographic two- and three-dimen- quently shows a surprising bone remineraliza-
sional evaluations can be made with a peri- tion, especially at the level of the root surfaces
apical radiograph and a CBCT, respectively. In of the adjacent teeth. Thi s kind of bone fill can
the authors' opinion , pre-extraction three-di- only be observed if enough time is allowed for
mensional studies are of no value in cases of the complete healing of the socket; the amount
tooth removal due to periodontal reasons. The of time required will vary depending on the se-
rationale for this idea is the following: first of verity of the periodontal defect that led to tooth
all, postextraction implant placement should extraction. Nevertheless, this period must nev-
not even be considered a possibility for pa- er last less than 1 year in case of severe peri-
tients with periodontal disease because it odontal involvement.
would involve placing an implant in a site with
inadequate control of the periodontal infection;
secondly, if the tooth is being extracted for
periodontal reasons it means that bone loss
is so severe that it would not allow immediate
postextraction implant placement. On the oth-
er hand , a CBCT done after complete healing
of the extraction socket-approximately 1 year
after tooth removal-allows diagnostic evalu-
ation as well as treatment planning for guided
implant placement.
* *

The findings obtained from the three-dimensional radio-

graphic study can lead to different therapeutic choices:
1. Adequate bone for implant placement: Height and width
of the edentulous ridge allow placement of an implant
with the ideal length and diameter to replace the missing
tooth. In this case, the procedure of choice is flapless
implant placement (computer-guided) with immediate
provisionalization . Digital implant planning can provide
the clinician with a very precise provisional that can be
easily rebased. In addition , the flapless approach makes
it possible to leave the soft tissue morphology unaltered
and reduces postoperative patient morbidity.
*

297
Courtesy of.' ' John Wiley and Sons. Periodontol2000. 2018 Jun;77(1),150 -164.
 MUCOGINGIVAL APPROACH FOR IMPLANT PLACEMENT TO REPLACE A SINGLE TOOTH IN THE ESTHETIC AREA

2. Limited bone width (see chapter 12): Adequate bone

height; bone width allows implant placement with ade-
quate primary stability, but deep bone dehiscences (~5
mm) are expected. In this case, surg ical access through
a palatally placed incision is indicated, along w ith guid-
ed implant placement with simultaneous horizontal bone
reconstruction and submerged healing. Flapless implant
uncovering (soft tissue punch) and immediate provisional-
ization can be performed 6 to 9 months after the surgical
procedure, once comp lete bone healing/maturation has
been obtained.

3. Insufficient bone for implant placement: Both width and

height of the edentulous ridge are incompatible with
implant placement. In this case, the same palatally dis-
placed surgical access must be performed , but this time
only to perform bone reconstruction procedures. After
9 to 12 months, once soft and hard tissues are in ideal
condition, it is possible to proceed with computer-guided
(flapless) implant placement with immediate provisional-
ization. When the findings of the CBCT point to the need
for bone reconstruction to allow implant placement, it is
not uncommon that the patient w ill refuse additional sur-
gical treatment. If the soft tissue esthetic conditions are
ideal , both the patient and the clinician can decide on an
alternative option, such as a Maryland bridge.

Courtesy of: • Quintessence Publishing. Int J Periodontics Restorative Oent. 2012 Oec;32(6):665-75.
MUCOGINGIVAL APPROACH FOR IMPLANT PLACEMENT TO REPLACE A SINGLE TOOTH IN THE ESTHETIC AREA

It is essential to remember th at w hichever ap- Furthermore, a successful outcome can only

proach is chosen in case of a tooth extracted for be achieved w ith a nonsmoking, highly mo-
periodontal reasons, it can only be performed tivated and cooperative pati ent under strict
after complete reso lution of the periodontal supportive therapy w ith frequent maintenance
infection and treatment of th e periodontal de- recall appointments (no more than 3 months
fects present elsewhere. between visits).
299
Courtesy of: • Quintessence Publishing. Int J Periodontics Restorative Dent. 2012;32:665-675.
 I
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: I
\ ~
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i

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! \

Mucogingival
( Approach
for Delayed
Implant Placement
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
Long-term success of peri-implant soft tis-
sue dehiscence (PSTD) coverage techniques
around buccally misplaced implants, either with
or without anatomical or pathologic exposition
of the implant surface, leads to the conclu sion
that not enough importance has been given in
the past to the thickness of the buccal soft tis-
sues in terms of both esthetics and peri-implant
health. If the causes of the buccal PSTD were
really just implant malpositioning or lack of the
buccal bone plate, in cases treated on ly by aug-
menting the thickness and apicocoronal dimen-
sion of the buccal soft tissues-without mod-
ifying implant position or using guided bone
Courtesy of: • John Wiley and Sons. Periodontal 2000. 2018 Jun;77(I):150 -164.
regeneration to treat the osseous dehiscence-
recurrence of the PSTD shou ld be seen . Th e
question the authors have raised is whether an
esthetically valid and functional result can be
obtained even when the thickness of the buccal
bone is insufficient «2 mm) at the most coro-
nal portion of the implant sim ply through prop-
er im plant placement and adequate soft tissue
management. The purpose of this chapter is to
describe the surgical management of the soft
tissues in cases of delayed implant placement;
that is, after complete bone and soft tissue
healing (around 6 months) after tooth extraction
for dental reasons.
 MUCOGING IVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
The case presented shows a maxillary left cen-
tral incisor that, after receiving endodontic and
restorative treatments due to sports-related
dental trauma, suffered a vertical buccoligual
crown-root fracture in response to a second
traumatic injury (case done in collaboration with
Or Tommaso Cantoni).
The tooth was extracted, taking care not to
damage the surrou nding bone and soft tis-
sues, and the edentulous site was provisionally
restored with an adhesive Maryland type of
partial denture. This choice was made based
on clinical cond itions such as the presence of
deep probing depths on the buccal aspect (in-
dicative of a defect on the buccal bone plate),
presence of a thin and scalloped phenotype,
and on the information collected during patient
exam ination (medical history, patient requests,
and treatment goals) that advised against im-
mediate postextraction implant placement.
303
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

The vertical root fracture rendered the tooth hopeless, so it was extracted atraumatically to preserve
as much as possible the alveolar bone as well as the buccal and interdental soft tissues.

The provisional Maryland bridge

is fixed onto th e adjacent natural
teeth , allowing for the immediate
replacement of the extracted tooth.
Thi s provisional prosthesis, high-
ly appreciated by the patient from
an estheti c point of view, is kept in
place for th e entire healing period
of the extracti on site. It is the au-
thors' opinion that, once the patient
has been provided w ith a function-
ally and esth etically satisfying pro-
vis ional prosthesis, a period of at
least 6 months should be allowed
in order to obtain complete bone
healing.
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

Following tooth extraction , during the first
months of healing (3 to 6 months), th e soft tis-
sues undergo a remodeling process that can
result in horizontal, verti cal, or combined ridge
defects. In most cases of extracti ons done for
dental reasons, the defect is solely buccolingual
(horizontal defect). The formation of this defect is
due in part to the loss of the buccal bone plate,
which is mainly made up of alveolar bone prop-
er (bundle bone), and also to th e physiologic
remodeling of the alveo lar process that occurs
after tooth extraction.

Six months after tooth extraction, both soft and hard tissues from the edentulous site can be consid-
ered completely healed. Therefore, implant treatment planning can be started at th is point.

Soft tissues suffer changes in

their position that correspond
to the changes of the underlyi ng
bone, and they end up apicocor-
onally replacing part of the crestal
space previously occupied by the
tooth 's clinical crown (area within
white dotted line).
305
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLAC EMENT

A prosthetically guided radiographic stent is

made, and its correct positioning while perform-
ing the three- dimensional imaging is assured
with the use of a silico ne bite regi stration This
radiographic study is used to analyze the bone,
which in thi s case is deemed adequate for prop-
er apicocoronal implant placement. Regarding
the buccolingual placement, positioning th e
implant palatally in order to preserve 2 mm of
bone buccally wou ld require the implant crown's
emergence profile to have a very pronounced
angulation . In thi s scenario, th e stability of the patient and hyg ienist because of the deep hor-
gingival margin wou ld have to be sustain ed by an izontal probing distance (black arrow). This oc-
excessive thickness of the buccal soft tissues at curs frequently in the anterior teeth whenever the
the level of the peri-implant transmucosal path, implant insertion axis coincides with the palatal
rendering the area difficult to clean both by the cingu lum of the prosthetic crown.

A slightly more buccal implant position allows the placement of a prosthetic crown with an emergence
profile that has a similar angulation to that of th e natural tooth, thus requiring less thickness of the buccal
soft ti ssues to maintain the stability of the gingival margin. In this case, probing of the peri-implant trans-
mucosal path is mainly vertical and easily cleanable (white arrow) .

In these examples, th e implant insertion axis coincides with the palatal aspect of the incisal edge (es-
thetically guided implant placement). The use of angulated systems allows the placement of screw-re-
tained crowns in eith er situation.
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

The drawings exemplify how palatal positioning

(C) allows the preservation of a greater amount of
buccal bone, but also requires a greater thickness
of th e soft tissues at the level of th e peri-implant
transmucosal path to support the gingival margin ;
this also leads to a pronounced ang ulation of the
emergence profile of the implant-supported crown.
Hence, th e probeable area becomes so horizontal
that it is difficult to maintain from a hygienic point
of view, both by the patient and dental hyg ienist.
A more buccal implant placement (A and B), even th ickness needed to support the mucosal mar-
if reducing the thi ckness of the buccal bone, im- gin , and renders th e probing area at the level of
proves th e angu lation of the emergence profile of the peri-im plant transmucosal path vertical and
the implant-supported crown, reduces soft tissue easy to clean .

A provisional restorati on is made from the diag-
nostic wax-up and , in case of adequate prima-
ry implant stability (at least 35 Ncm), it can be
placed immediately following implant placement
(immediate provisionalization). The addition of
"positioning wings" on the provisional is very
helpful because it allows easy and accurate
seating of the restoration during the intraoper-
ative phase.
An access hole is drilled on the radiographic
stent, turning it into a surg ical stent to gu ide the
first drill during implant bed preparation .

307
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

The kind of defect that forms after tooth extraction determin es

th e choice of th e surgical approach to be implemented. In
th e presence of a small to moderate exclusively buccolingual
defect, with an adequate amount of bone both in height and
thickness for esth etically guided implant placement, it is pos-
sible to treat the defect simultaneously to im p lant placement
just by using soft tissue augmentation techniques.
The surg ical technique requires the creation of a buccal cor-
onally advanced envelope flap with a connective tissue graft
adapted onto a screw-retained provisional im plant restorati on,
wh ich is placed at the moment of implant placement (immedi -
ate provisionalization). Th e design of th e coronally advanced
flap is that of the envelope flap used in mucoging ival surgery
for the treatment of multiple gingival recessions. Whenever
the missing tooth is the central or lateral incisor, th e flap de-
sign is the one adopted for the "frontal approach" using the
coronal ly advanced envelope flap techn ique.
 MUCOGINGIVAL APPROAC H FOR DELAYED IMPLANT PLACEMENT
Th e incisions at th e level of the papillae adja-
cent to the edentul ous site are paramargin-
al and oblique, directed toward the center of
rotation of the flap, w hich corresponds to the
implant site. The interdental incisions start from
th e gingival margin distally and end mesial-
ly at a distance from the papilla vertex, which
correspo nds to the desired coronal advance-
ment of th e marginal ti ssues; this advancement
will be greater at the level of the implant site,
in which th e incision should be made slightly
scalloped and subcrestal , while on the adja-
cent teeth the advancement wil l be less. The
flap is reflected with a varying thickness: split
thickness at the level of the surgical papillae (in-
cluding those framin g th e edentulous site) until
th e buccal bone crest is reached , full thi ckness
for 2 to 3 mm in order to expose th e buccal
bone, and split thickness again apically to de-
tach muscle insertions onto the periosteum
(deep split-thickness incision) and from the in-
ternal aspect of the flap (superficial split-thi ck-
ness incision). The surgical stent must be tried
in before the surgery to assure its stability and
correct positioning. Once the flap has been el-
evated, a microblade is used to mark the out-
line of the drill hole on the crestal soft tissues.
By keeping the microblade in contact with the
walls of the access hole a cyl indric portion of
soft tissue is traced, wh ich can later be excised
full thickness, deli miting the site where the im-
plant will be placed.
309
MUCOGINGIVAL APPROAC H FOR DELAYED IMPLANT PLACEMENT
This all ows site-specific access to the crestal
bone as well as the maintenance of the integri-
ty of the future mesial and distal implant papil-
lae, whose width and buccolingual thickness are
fundamental in order to stabilize the connective
tissue graft and the surgical papillae from the cor-
onally advanced flap at the level of the edentu-
lous site. One great advantage of delayed implant
Once the supracrestal soft tissues are removed,
the surgical stent is used for an esthetically/pros-
thetically guided implant site preparation, thus
avoiding potential errors in position or inclination.
Before implant insertion, the laboratory-made
provisional crown with the same profile and shape
as the contralateral tooth can be of help to assess
placement (compared to an immediate implant)
is the availability at the time of the surgery of
wide, thick, and mature anatom ical papillae that
can be de-epithelialized palatally on their occlu-
sal aspect - exactly the same conditions that are
present when treating PSTDs 2 to 3 months after
removing the implant-supported crown and plac-
ing a narrow surgical abutment (see chapter 2).
the extent of the defect (distance from the buccal
bone to the profile of the provisional crown) and
to choose the thickness of the connective tissue
graft. The profile of the provisional wi ll playa fun-
damental ro le when it comes to supporting the
coronally advanced flap covering the connective
tissue graft.
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
After the last implant dri ll , and before implant
placement, th e thickness of the residual buccal
bone can be measured .
As foreseen in the three-d imensional study
during the diagnostic phase, the buccal bone
thickness is less than 2 mm at the most coro-
nal aspect but becomes progressively thicker
apically. Therefore, it can be anticipated that
fol lowing bone remodeling related to implant
placement, a buccal bone dehiscence wi ll
form, exposing the most coronal aspect of the
implant 's buccal surface.
At this point, it is valid to pose the following
questions:
1. Should this area of potential and limited
im plant exposure be treated with a bone
graft/biomaterial or with a connective tissue
graft?
2. How predictable is th e full coverage (up to
the implant platform) of small «3 mm) buc-
cal bone dehiscences treated with bone re-
generation techniques?
3. Is a successful bone regeneration technique
by itself enough to prevent the development
of PSTD on the implant-supported crown?
4. Does the future presence of a buccal bone
dehiscence represent a risk factor for im-
plant survival/success?
5. Will the eventual dehiscence render the im-
plant crown unesthetic?
Based on the limited knowledge regarding the
predictability of bone reconstructive surgery
in areas of shallow «3 mm) implant exposure
and their observations of PSTD etiopathogen-
esis, whose onset at the level of the soft tis-
sues marginal to the implant crown depends
on the thickness of the buccal soft tissues and
not on that of the buccal bone, the authors first
consider the thickness of the buccal soft tis-
sues that wi ll cover the prosthetic crown and
the confined zone of implant exposure before
seeking answers on the pred ictabi lity and effi-
cacy of the reconstructive bone surgery tech-
niques in reduced areas of implant exposure.
311
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

In ideal situation s, the rough implant surface

shou ld be placed 3 to 3.5 mm apical to the
future gingival margin of the prosthetic crown
(which should be at the same level and have the
same scallop as the gingival margin of the con-
tralateral tooth). This area, devoid of buccal bone
and with only soft tissue covering the prosthetic
components, is called the peri -implant transmu-
cosal path. It has been stated that, in order to
prevent formation of a PSTO, the thickness of
the soft tissues at the level of the transmucosal
portion must be at least 2 mm and have a min-
imum height of 3 mm . At this point, it is worth
questioning whether the buccal flap will reach a
thickness of 2 mm in its most coronal 3 mm. In
the vast majority of patients this is not the clinical
reality, even in those classified as having a thick
phenotype. As a resu lt, soft tissue augmentation thickness has led the authors to implement on ly
techniques that include the use of con nective soft tissue augmentation techniques in the pres-
tissue grafts frequently must be im plemented ence of limited areas «3 mm) of buccal implant
to obtain the desired 3- to 3.5-mm thickness of exposure.
the transmucosal path. The next question worth The connective tissue graft must be pOSitioned
asking is if, by using a connective tissue graft 1 mm coronal to the gingival margin of the adja-
w ith a height greater than the minimum requ ired cent tooth. Th e rationale for positioning the graft
at the transmucosal path (2 to 3 mm in add ition to coronally in excess is to compensate for poten-
the stated 3 to 3.5 mm) in order to cover the area tial contraction and, once healing is comp lete, to
of possible buccal bone dehiscence, it wou ld be have soft tissues that are positioned coronally
possible to prevent the problems that cou ld arise with respect to the contralateral tooth and that
from the presence of a confined area of buccal can then be prosth etically cond itioned to obtain
implant surface exposure due to the absence of a peri-implant mucosal margin that has the same
buccal bone. Data from th e literature does not shape as and is at th e same level as that of the
indicate differences in terms of survival, suc- contralateral tooth.
cess, or risk of peri-implantitis between implants
with or without buccal bone dehiscences, wh ich
most of the time are identified as casual findings
when radiographic examinations are done for
other sites or reasons. The on ly information th at
can be extrapolated from the analysis of the liter-
atu re relating to buccal bone dehiscences is the
greater risk for PSTO and th e esthetic problems
due to the visibility of the metallic components
through the soft tissues, issues wh ich can be
solved with soft tissue augmentation techniques,
particularly w ith th e coronally advanced flap and
connective tissue graft (see chapter 1). The lack
of data regarding the predictability of success-
ful bone regeneration in the presence of small
buccal bone dehiscences and the incapac ity of
bone grafts/ biomaterials to augment soft tissue
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
The apicocoronal dimension of the connective
tissue graft is therefore calcu lated, considering
that it must cover the area of the buccal bone
dehiscence present at the time of implant place-
ment as well as 2 to 3 mm of buccal bone apical
to it. This last apical area is destined to cover
the eventual exposure of the im plant's buccal
surface, which can develop during the healing
phase. The mesiodistal dimension of the graft
shou ld be 6 mm greater than the implant diam-
eter so that it can receive vascu lar supply both
mesially (3 mm) and distally (3 mm) to the implant
platform. On the other hand, graft thickness
will vary according to the distance between the
provisional crown's profile and the outline of the
buccal bone wall, after taking into account the
thickness of the covering flap as well. The sum
of flap and graft thickness must match, but not
exceed, the dimension of the buccolingual defect
at th e time the provisional crown is placed. The
reason not to exceed graft dimensions during
the surgery is that, with this surgical technique,
a further increase in soft tissues thickness takes
place over time.
Implant placement carried out in this manner
allows the possibility to have, both mesially and
distally to the implant platform, two trapezoidal
anatomical papillae that are wide, tall, and thick
in a buccopalatal sense, which means they can
be de-epithelialized not only on the vertical plane
but also palatally on the horizontal plane due to
the presence of wide isthmuses. Once implant
placement is done, the provisional is rebased
and adapted intraoperatively (immediate provi-
sionalization). It is of utmost importance to re-
duce the provisional interproximally so that it will
not interfere with healing between the surgical
papillae from the coronally advanced flap and
the corresponding de-epithelialized anatom ical
papillae.
313
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
One of the great advantages of delayed im-
plant placement (at 6 months, once bone heal-
ing has taken place) is th at it is easier and more
predictable to obtain the primary implant sta-
bility needed for immediate provisionalization.
From an esthetic point of view, this is a huge
advantage because the presence of the pro-
visional provides a stable support for the con-
nective tissue graft and prevents the collapse
of th e coronally advanced flap th at is covering
the graft. The anatom ical papillae mesial and
distal to the implant, as well as those of the
adjacent teeth included in the flap design, are
de-epithelialized first w ith the blade at the base
and then with the microsurgical scissors at the
vertex.
Th e convex surface of the provisional crown,
wh ich has the same profile at the buccal sur-
face as that of the adjacent tooth , starts 2 mm
coronal to the cementoenamel junction (CEJ)
of the latter (1 mm coronal to the presurgi-
cal position of the gingival margin). Ap ically,
toward the im plant platform, the provision-
al has a slightly concave buccal surface that
makes it easier to adapt and suture the graft;
this surface in additi on to the graft thickness
also compensates for the buccolingual defect.
Thu s, the graft w ill be positioned 1 mm coro-
nal to the presurgical level of the contralateral
tooth's gingival margin . Graft fixation cons ists
of simple interru pted sutures (polyglycolic acid
[PGA] 7-0, 8-mm needle) anchored at the base
of the de-epithelialized anatomical papillae.
 MUCOGINGIVAL APPROACH FOR DELAYED IM PLANT PLAC EMENT

Th e presence of mature, w ide, and tall ana-
tom ical papillae that can be de-epithelialized
palatally allows suturing the graft at th e base
of the papillae wh ile at the same ti me leaving a
suitable vasc ular bed coro nal to the graft , onto
w hich th e surgical papillae of th e coronally ad-
vanced flap can be fi xed.
This is of criti cal importance in order to avoid
flap dehiscence and early exposure of the con-
nective tissue graft. Th e flap is positioned cor-
on ally, suturing the surgical papi llae onto the
correspond ing anatomical papillae w ith sling
sutures suspended around the cingulu m of
the teeth adjacent to the implant (PGA 6-0, 11 -
mm needle). Th e last sling suture, suspended
around the cingulum of the provisional, posi-
tions th e flap's keratinized tissue coronal to
th e connective tissue graft and adapts it to the
provisional's convex surface. Before discharg-
ing the patient, it must be verified that blood
isn't seeping between the flap and the provi-
sional crown . This wil l ensure stability of th e
su rgi cal wound and prevent contraction of th e
covering flap .

Sutures are removed 14 days after the surgery. During the

first 3 weeks, the patient is asked to abstain from mechan-
ical hyg iene practices but instead must perform chem ical
plaque control at the surgical site with locally applied 0.12%
clorhexidine rinse (1 minute, three times a day). After the third
postoperative week, the patient starts brushing with an Ul-
tra-soft toothbrush and continues using the ch lorhexidine
rinse tw ice a day. The recommended brushing technique is
the roll technique, w ith the bristles kept in contact with the
tissues while performing an apicocoronal movement with the
toothbrush, ie, from the soft tissues toward the dental crown .
After 4 weeks of using the ultra-soft toothbrush, the patient
must change to a soft-bristled toothbrush wh ile rinsing only
once a day. The soft toothbrush is used for 2 months with
the same roll technique . Arou nd 3.5 months after the surgery,
the patient stops rinsing with ch lorhexidine and starts using
a medium toothbrush (always with the roll tech nique); at this
point use of dental floss (spongy floss) is reinstated.
315
MUCOGINGIVAL APPROAC H FOR DELAYED IMPLANT PLACEMENT
During the first postsurgical month, marginal tis-
sues should remain stable around the convex
surface of the provisional without undergoing
contracti on . For this reason, the patient shou ld
refrain from hygiene practices to avoid trauma-
tizing th e marginal soft tissues. The lack of con-
traction of the coronally advanced flap during
the early healing phase allows good blending of
the grafted area with the adjacent soft tissues
and the incorporation of the connective tissue
from the graft to that of the flap; this incorpo-
rati on is essential to achieve an increase in soft
tissue th ickness. An early exposure of the graft
would lead to a lesser increase in thickness and
to an unesthetic result due to the white, ke-
loid-type appearance that resembles the heal-
ing of a free gingival graft. Three months after
the surgery, the buccal increase in soft tissue
thickness becomes more evident thanks to the
integration of the connective tissue graft with
the covering flap. At th is point, stability of the
marginal soft ti ssues is guaranteed by their in-
creased thickness; therefore, the patient can
restart mechanical hyg iene practices (medi-
um-bristled toothbrush and dental floss) w ithout
the risk of traumatizing and damaging them.
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
Four months after th e surgery, th e incorpora-
tion and maturation process of th e buccal soft
tissue can be considered complete in most pa-
tients; the apicocoronal inc rease in thic kness
of th e soft tissues is clinical ly very significant
as well . Hence, it is possib le to start the phase
of prosthetic conditioning of the surgically
augmented soft tissues. In th e case of PSTD
treatment, soft tissue co nditioning is always
done 4 months after th e surgery. In fact, since
patients wear a short provisional during this
period, their estheti c demands lead c linic ians
to reduce waiting times to th e minimum possi-
ble (see chapter 1). On the other hand, in cas-
es of immediately provisionalized implants, the
patient does not have any issues with crown
estheti cs; for thi s reason, it is advised to wait
another 2 months before starting the soft tis-
sue conditioning phase (6 months after the
surgery).
317
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
The purpose of the soft tissue conditioning
phase is twofo ld:
1. to mold the soft tissues marg inal to the pros-
thetic crown apically, giving them a height
and scallop similar to that of the gingival
margin of the adjacent tooth;
2. to encourage the growth of the papillae me-
sial and distal to the implant crown so they
end up filling the interproximal spaces .
To favor papillae growth, the interpoximal pro-
fi les of the provisional are modified by pro -
gressively moving the contact points coronal-
Iy whenever the papillae fi ll the interproximal
spaces previously left open (ie, the squeezing
effect).
The soft tissues, augmented surgically both in
height and th ickness, can be cond itioned w ith
two different approaches depending on the
amount of vertical tissue increase achieved.
When the vertical increase results in the mar-
ginal soft tissues of the provisional crown be-
ing positioned coronally by only 1 mm or less
with respect to the contralateral tooth , condi-
tion ing is done by compression (adding flow-
able composite to the submarginal portion of
the provisional). On the other hand, when the
vertical increase resu lts in the marginal soft
tissues being 2 mm or more coronal to the
gingival margin, it is necessary to cond ition
the tissues through gingivoplasty with a dia-
mond bur.
Tissue remodel ing is done with a round dia-
mond bur of med ium-coarse grit on a high-
speed handpiece w ith abundant irrigation.
Soft tissue abrasion shou ld be done internally
on the occlusal surface, never on the buccal
aspect, and must not exceed 1 mm in depth.
In fact, buccal abrasion cou ld lead to the ex-
posure of the underlying connective tissue
graft, creating an unesthetic appearance.
After abrasion, tissues should always be more
coronal than the ging ival margin of the adja-
cent tooth, leaving the task of creating the final
shape and position of the gingival margin to
the compressive phase.
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
After reducing the marginal soft tissues occlu-
sally, flowable composite is applied to the inter-
nal aspect of the provisional; once polymerized,
thi s resin wi ll occupy th e space created by tis-
sue abrasion, creating a slight compression of
the marginal tissues. The clin ical parameter th at
guides the extent of th e compression is the isch-
emia induced on the marginal tissues (black ar-
row) by the modified provisional , wh ich should
not last more than 60 seconds; if this time is
exceeded, some composite should be removed.
Depending on how much the mucosal margin of
the implant crown needs to be displaced apical-
ly, the procedure may need to be repeated after
1 to 2 months. In fact, it is important not to try
to reach the level of the gingival margin of the
adjacent tooth in one step because afterwards,
whe n compression is done and the soft tissues
remodel from the gingivoplasty, there is the risk
that the margin will end up being too apical.
319
MUCOGINGIVAL APPROACH FOR DELAYED IM PLANT PLACEMENT
Th e other aim of prosthetic conditioning is to ob -
tain as much growth as possible of the papillae
mesial and distal to the implant provisional crown
(squeezing effect). This is achieved by progres-
sively modifying the interproximal profiles of the
crown and cont inuously displacing the contact
points coronally. Also in this case it is worth making
small changes, repeated ly if necessary, to obtain
greater papillae growth. When, after modifying the
Th e goal of th e final phase is to create a pros-
thetic element whose shape and color are sim -
ilar to the contralateral tooth wh ile maintaining
the soft tissue outline and position obtained
during the provisional phase. The emergence of
the restoration from the soft tissues must be as
provisional, at the next recall appointment there is
no further papillae growth and the open interprox-
imal space is no longer filled by the papillae, it is
time to start the final restorative phase. The tissue
cond itioning phase lasts around 3 to 4 months. At
this point, the initial horizontal defect is no longer
present and the soft tissues have the ideal height,
shape, and thickness needed to obtain an optimal
esthetic result with the definitive restoration.
similar as possible to that of the adjacent natural
teeth, making self-performed hygiene practices
easier for the patient.
Co llaboration with skilled dental technicians is
essential to achieve optimal esthetic and func-
tional resu lts.
 MUCOGINGIVAL APPROACH FOR DELAYED IM PLANT PLACEMENT

One year after placement of the definitive res-
toration , th e result is highly sati sfying for the
patient from an esthetic point of view; both the
implant-supported crown and its surrounding
soft tissues are we ll integrated with the adja-
cent natural teeth. The presence of an initial
buccolingual defect allowed the increase in
buccal soft ti ssue thickness obtai ned with th e
surgery to compensate for the defect without
creating an excessive vo lume increase on the
soft tissues at the level of the implant crown
with respect to the outline of the adjacent teeth .

321
MUCOGINGIVAL APPROAC H FOR DELAYED IMPLANT PLACEMENT

At 2 years, the esthetic result is stable, and circumferential prob-

ing depths are within physiologic limits with absence of bl eeding .
From the radiographic point of view, the typical peri-implant bone
remodeling that accompanies the reformation of the biologic width
can be appreciated as small areas of vertical bone resorption me-
sial and distal to the implant (white arrows) that remain stable over
time. The implant appears well osseointegrated, and there is ad-
equate radiopacity of the bone crest, wh ich, in conju nction with
absence of bleeding on probing, is a sign of peri-implant tissue
health. The frontal clinical image shows a whitish area apical to
the mucogingival junction of the implant-supported crown (black
arrow); this corresponds to the most apical part of th e connective
tissue graft that becomes visible because of the ischemia of the
alveolar mucosa when it is pu lled by the lip retractor used wh ile
taking the picture. Th is part of the graft was intended to cover
the most coronal aspect of the alveolar bone w hich, being thin
at the time of implant insertion, could have developed a dehis-
cence with subsequent exposure of the implant's buccal surface.
However, the aforem entioned whitish area disappears when the
lip retractor is removed, and th ere is no way to tell if in this area
there is an underlying exposure of the implant surface.

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 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
It could be speculated that, even in the presence
of a small buccal dehiscence, the grafted con-
nective tissue would be firmly adhered to the ex-
posed implant surface. This would create a small
area of connective tissue adhesion buccally that
can be defined as suprabony since it is coronal
to the buccal bone crest. Similarly, at the inter-
proximal areas, where physiologic remodeling of
the interproximal bone crest has occured, zones
of connective tissue adhesion have formed, and
these can be defined as intrabony because they
are associated with a vertical type of resorption .
It is interesting to notice how many authors are
more concerned with avoiding and preventing,
through surgical bone reconstruction techniques,
the formation of small areas of connective tissue
adhesion buccally and supracrestally (which
are easy to access by the patient for hygiene
maintenance), while at the same time consid-
ering physiologic the formation of equally small
areas of interproximal and intrabony connective
tissue adhesion, which are harder to reach by
the patient's hygiene maneuvers. The site-spe-
cific augmentation of the implant's buccal soft
tissues allows the treatment of the presurgical
horizontal defect without creating an excessive
and unesthetic volume increase; it also prevents
the development of PSTD and chromatic alter-
ations associated with visibility of the underlying
implant-prosthetic components. Additionally, it
allows simulation of a root prominence that is
very similar to that of the contralateral tooth and
creation of a proper emergence profile of the
prosthetic crown , fundamental for adequate hy-
giene maintenance by the patient while making
self-cleansing during mastication possible.
323
MUCOG INGIVAL APPROAC H FOR DELAYED IMPLANT PLACEMENT

Clinical and radiographic follow-up at 4 years shows th e stability of the

resu lts over tim e. Hygiene maintenance by the patient is essential for
the maintenance of peri-implant soft tissue health. The patient must
be provided the ideal cond itions to perform adequate plaque control:
proper emergence profiles, adequate interproximal spaces, and stable
peri -implant soft tissues allow the patient to clean the implant-support-
ed restoration easily and effective ly. Oelayed implant placement, done
after complete bone and soft tissue healin g (6 months after extracti on),
is not a compromise solution from the esthetic point of view if implant
placement (guided) is done concom itantly to buccal soft tissue aug-
mentation and immediate provisionalization.
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

On the contrary, this technique entails some surgi- 2. complete maturation and greater me-
cal advantages compared with postextraction im- siodistal and buccolingual dimension of
plant placement: the papillae mesial and distal to the implant
1. higher probability of obtaining the primary sta- platform, resulting from the cylindric tissue
bility needed for immediate provisionalization excision performed on a completely healed
because the implant is placed into healed bone; edentulous site.

Comparison between the occlusal images through the execution of a soft tissue augmenta-
(baseline, presurgery, and 4 years after definitive tion technique in conjunction with im plant place-
restoration placement) makes it possible to ap- ment. The emergence of the implant-supported
preciate the complete resolution of the horizontal crown from the soft tissues is still identical to that
defect, which formed following tooth extraction , of the contralateral tooth.
325
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

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 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

Clinical follow-up after 6 years shows stability
of the esthetic outcome. A sli ght "shortening" of
the clinical crown of the implant-supported res-
toration has taken place, although not perceived
by the patient, due to a coronal migration of the
mucosal margin . This confirms that not only are
the outcomes of soft tissue augmentation proce-
dures stable in time, but there can also be further
growth over the years that can lead to creeping
of th e marginal tissues.

327
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

Comparison of the periapical rad iographs taken at 2, 4, and 6 years after delivery of the final restoration
confirms the stability of the peri-implant supporting bone levels. After initial bone remodeling , bone
levels remained stable through time.

*
Side-by-side comparison of the initial and final profile views shows how the extraction-related defect
was not only resolved but almost overcompensated . The implant crown has adequate emergence
profiles that are easy for patient to clean.

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MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

329
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

The same surgical technique

is used to substitute a first pre-
molar extracted due to a verti-
cal fracture. Six months after
the extraction, a residual slight
to moderate horizontal defect
is present. In an apicocoronal
sense, the palatal outline of the
edentu lous site (black line) and
the gingival margin of the adja-
cent second premolar are at the
same level, wh ile the buccal out-
line is positioned more apically
(white dotted line). The papillae
delimiting the edentu lous site
are considerably flat, with ex-
posure of the can ine's CEJ in-
terproximally. It is the authors'
opin ion that implant placement
without simultaneous soft tis-
sue augmentation wou ld result
in an implant-supported crown
that is longer than the adja-
cent tooth, with an inadequate
emergence profile that wou ld
lead to further papillae contrac- *
tion . Ap icocoronal (in addition to buccolingual) thin, scall oped phenotype that has favored the
soft tissue augmentation is indicated to provide development of buccal gingival recessions on the
the restorative dentist an excess of soft tissues adjacent teeth (canine and central and lateral in-
that can be conditioned in order to position the cisors); recession at the level of the lateral incision
mucogingival margin of the implant-supported has been previously mistreated only with restor-
crown at the same level as that of the adjacent ative therapy. An advantage of the adopted surgi-
premolar and to improve the mesial and distal cal approach is the possibility of treating gingival
papillae so they become taller and more similar recessions on adjacent teeth with the execution
to those of the adjacent teeth. The patient has a of the coronally advanced flap.

Courtesy of.' • Quintessence Publishing. Implant Therapy. Nevins M, Wang H-L. 2019.

Th ree-d imensional radiographic
reveals an adequate amount of bone height
and th ickness for a prosthetically and esthet-
ically guided implant placement, with an ideal
diameter and length for replacing a premolar.
Th e axial view shows a buccoli ngual osseous
defect in the most coronal part of the edentu-
lous bone crest that does not impede implant
insertion but does significantly reduce the bone
thickness that can be left buccally at the level
of the implant platform. This poses the risk of
developing a small «3-mm) buccal bone dehis-
cence during or after (due to postsurgical bone
remodeli ng) im plant placement. Once again , for
the reasons previously described in th is chap-
ter, the decision is made to augment the soft
tissues (and not the bone) simultaneously to im-
plant placement. The cho ice to perform com-
puter-guided implant placement derives from
the advanced precision of the modern software
and hardware designed for guided implant
Courtesy of." • Quintessence Publishing. Implan t Therapy. Nevins M, Wang H-L. 2019.
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
*
examination placement, especially in cases of isolated eden-
tu lous sites. It is the authors' opinion that, in the
presence of barely sufficient bone dimensions
for correct implant positioning , guided implant
placement must be the chosen modality.
A surgical stent is created from the compute r
planning, which wi ll guide the use of all the burs
in the drilling sequence for implant bed prepara-
tion and also for implant placement; this reduc-
es implant positioning errors to the minimum.
Another advantage of computer-guided implant
planning is the possibility to create in advance a
provisional crown that will have a precise posi-
tion w ith respect to the implant platform, mak-
ing intraoperative rebasing particu larly quick
and easy. Even if these technologic innovations
are intended to assist the clin ician and reduce
the possibility of errors, it shou ld be noted that
they are not foo lproof and are subject to a learn-
ing curve in both the programming and execu-
tion phases.
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MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

After remaking the ce rvical restoration at the

level of the lateral incisior (placing the restoration
more coronal than the CEJ of the cani ne and
central incisor), it is possible to plan the design
of the surg ical flap to access the edentulous site
and for treatment of the gingival recessions on
the adjacent teeth. Th e chosen design is that of
the envelope flap for the treatment of multiple
recessions w ith a "lateral" approach. Al l of the
paramarginal oblique interproximal incisions,
placed on the papillae adjacent to the edentu - *
lous site, are convergent toward an imag inary future peri-implant papillae that can be de-epi-
line that passes through the center of the ca- thelialized palatally on the occlusal plane.
nine's buccal surface (axis of rotation). The in- Th e flap is then elevated at a variable thickness:
terproximal incisions start from the gingival mar- split thickness at the level of the surg ical papil-
gin of the adjacent tooth and end at a distance lae (including those delimiting the edentulous
from the papilla vertex that shou ld co incide with site) until reaching the buccal bone crest, full
the desired amo unt of coronal advancement of thickness to expose 2 to 3 mm of buccal bone,
the marginal tissues. This advancement will be and split thickness again apically to free the flap
greater at the level of the deeper recessions and from the periosteum (deep split-thickness inci-
at the future implant site, where the incision is sion) and from muscle insertions on the inner
slightly scall oped and paramarginal in order to aspect of the flap (superficial split-thickness
leave soft tissue coronally and at the level of the incision).

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 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

The surgical stent should be tried in before

surgery to check its stability and correct posi-
tioning. Once the flap has been elevated, a mi-
croblade is inserted through the access hole of
the surgical stent to trace the exact site where
the implant is to be placed. The microblade,
kept in contact with the walls of the drill-guid-
ing channel, designs a cylinder that will then
be excised at full thickness, allowing the selec-
tive removal of soft tissues only at the location
where the implant bed preparation will be done. hole dimensions do not allow the insertion of
After removing the crestal soft tissue cylinder, the implant in reduced interdental spaces). After
the drilling protocol is done with the stent, but implant placement, a small buccal dehiscence
the implant is placed manually without the help remains coronally as foreseen during treatment
of the stent (this is done because the access planning .

333
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MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
Transmucosal implants are the first choice
w hen performing thi s technique. Th e reason
for thi s is th at ti ssue-level implants make it
possible to displace the im plant-abutment
connection coronally, limiting c restal bone
De-epithelialization of the anatomical papillae of
the teeth adjacent to the implant site is done only
on the vertical pl ane, wh ile at the peri-implant
papillae the de-epithelialization can be extended
palatally on the horizontal plane (white arrows).
Th e main advantage of delayed implant place-
ment, in comparison to postextraction place-
ment, is the presence of wide, thick, and mature
trapezoidal papillae as a result of the complete
healing of th e edentul ous site. The connective
Courtesy of.' • Quintessence Publishing. Implant Therapy. Nevins M, Wang H-L. 2019.
resorption and facilitating hyg iene mainte-
nance by th e patient in an area in wh ic h the
dimensions of the peri-implant transmucosal
path have been augmented both apicocoro-
nally and buccolingually.
tissue graft, obtained from the de-epithelializa-
tion of a free gingival graft harvested from the
palate, is fixed onto the base of the anatom ical
papillae with simple interrupted sutures (PGA
7-0) . Wide vascu lar beds, needed for stabilization
of the surgical papillae of the coro nally advanced
flap, are left coronal to the graft. Th e apicocoro-
nal graft dimension should be such as to cover
comp letely the area of buccal bone dehiscence
and 2 to 3 mm of bone apical to it.
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

After relining the provisional, it is screwed onto the
implant, ensuring that excessive compression is not
exerted on the papillae and that there are no occlu-
sal contacts (infraocclusion). The flap is coronally
advanced and fixed with sling sutures suspend-
ed around the palatal cingulum of the provisional
crown and of the teeth included in the surgical
area (PGA 6-0, 11-mm needle). Simple interrupted
sutures (7-0, 8-mm needle) are used to complete
closure of the flap's surgical papillae on the ana-
tomical papillae that were de-epithelialized palatal-
ly (those mesial and distal to the provisional crown).

Suture removal is done 2 weeks postoperative ly. During this period, the patient performs chem ical
plaque contro l and avoids chewing in the treated area. Already at suture removal the increase in buc-
cal soft tissue thickness is evident, completely compensating for the preexisting horizontal defect.

335
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MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

During the first months of healing, it is

important that the patient maintains
optimal hygiene through the use of at-
raumatic ("rol l") brushing techniques,
which help in the maturation of the
soft tissues surrounding the provisional
crown . Tissues are allowed to mature
undisturbed for 6 months, without this
representing any esthetic concern for
the patient. After this phase follows the
prosthetic conditioning phase to realign
the mucosal margin with the gingival
margin of the adjacent tooth and to favor
papillae regrowth.

When the conditioning phase is completed, final restoration can be done.

 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEM ENT

Th e images at the time of definitive restoration placement show how marginal soft t issues of the im-
plant site are at the same level as the gingival margi n of the adjacent premolar, even if the latter was
also coronally advanced for recession coverage along with the cani ne and incisors. This is also evident
when the patient smiles.

*
The superimposition of the images at
baseline and at th e end of soft ti ssue
cond itioning demonstrates the ver-
tical growth of the papillae delimiting
the edentulous site, as wel l as the
recession coverage of the premolar,
canine, and lateral incisor. All of th is
was possible th anks to the verti cal
soft tissue augmentation achieved
w ith the su rg ery done simultaneously
to implant placement with immediate
provisionalization.
337
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MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

The horizontal soft tissue augmentation al lows

the treatment of the buccolingual baseline de-
fect, increasing the thickness of the buccal soft
tissues particularly at the level of the peri-im-
plant transmucosal path and not apical to it. In
this area, the increase in soft tissue thickness
is critical for the final esthetic result, to prevent
the development of PSTD, to mask the under-
lying implant-prosthetic metallic structures, and
to give the implant-supported crown adequate
emergence profiles that can be easily maintained
by the patient from a hygienic perspective.

The vertical and horizontal increase in the soft tissues obtained during implant placement and im-
mediate provisionalization allowed the creation of a definitive restoration that satisfies esthetic and
functional demands and that can also be properly cleaned by the patient (restorative therapy by Dr
Fabrizia Pierini).

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 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

The result appears stable after 2 years, both from an esthetic point of view and also in terms of soft
tissue thickness. The emergence profile of the prosthetic crown seems completely natural thanks to
the horizontal increase in the soft tissues that compensates for the presurgical horizontal defect. The
root coverage of the teeth adjacent to the implant-supported crown also appears stable.

339
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MUCOGIN GIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

Crown removal shows th e healthy state of th e peri -implant transmucosal ti ssues. Th e intraoral radio-
graph confirms the stability of th e peri-im plant bone levels.

Corrections in the shapes of the canine (distally) and
second premolar (mesially) were made with co m-
posite restorations after the 2-year follow-up. This
allowed a better distribution of the interproximal
spaces and further improvement of the morphology
of th e soft tissues coronal to the im plant-supported
*
crown. Th e 5-year follow-up after delivery of the
final restoration shows stability of the esthetic out-
comes. The augmented soft tissues remai n stable
and co nfer the im plant-supported crown a natural
emergence profile that is compatible with th e pa-
tient 's oral hygiene practi ces.

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 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

Comparison between the baseline and the

5-year recall images show the amount of
peri-implant soft tissue augmentation. The api-
coco ronal increase has allowed the placement
of a restoration with a buccal mucosal margin
that coincides with the gingival margin of the
adjacent premolar (whose crown was short-
ened as a result of recession coverage) and
comp lete fill of the interproximal spaces by the
peri-implant papillae.

*
The buccopalatal soft tissue augmentation al- connective tissue graft sutured at the base of the
lowed treatment of the initial horizontal defect surgical papillae at the time of the surgery and by
while also giving the prosthetic crown a natural the coronal creep ing induced by the compres-
emergence profile that is also easy to maintain sion from the implant restoration.
from a hygienic point of view.
Superimposition of the soft tissue images be-
fore surgery and 5 years after final restoration
placement not only highlights the apicocoronal
increase in the buccal soft tissues, it also shows
the vertical growth of the peri-implant papillae.
Since the latter is not associated with changes in
the height of the underlying bone peaks, it can be
attributed to the buccolingual increase of the soft
tissues at the level of the papillae. This growth
was favored by the mesiodistal extension of the
34 1
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 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

Follow-up at 7 years continues to show stability of the outcome, both in terms of esthetics and main-
tenance of buccal soft tissue volume.

Comparison between the periapical radio-

graphs at 1 and 7 years confirms stability of the
peri-implant bone levels. The implant's trans-
mucosal collar has allowed crown removal on
several occasions without altering the supracr-
estal attachment or leading to peri-implant bone
remodeling.

Courtesy of: ' Quintessence Publishing. Implant Therapy. Nevins M. Wang H-L. 2019.
 MUCOGI NGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

343
Courtesy of: • Quintessence Publishing, Implant Therapy. Nevins M, Wang H-L. 2019,
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

Th e limits of soft tissue augmentation for com-
pensation of inadequate bone th ickness buccal
to an implant have yet to be defined. However,
the authors' clinical experience seems to indicate
that, at least from an esthetic point of view, even
severe buccolingual deficiencies can be treated
solely with soft tissue augmentation techniques
if these are performed simultaneously with guid-
ed im plant placement and immediate provision-
alization. Whether there is indeed higher risk of
implant failure and/or peri-implantiti s or a differ-
ence in how stable the outcomes are over the
long term with use of this technique still needs
to be proven . The following case does not pres-
ent the traditional approach involving horizontal
bone regeneration, one of the gold standards for
ridge reconstruction, but the successful resu lt
expands the possibilities for its application in
different scenarios when dealing with manage-
ment of peri-implant soft tissues.

Th e patient had the maxillary right first premolar

extracted about 1 year previously. According to
th e patient's recounts, the tooth presented se-
vere mobility in spite of being otherwise healthy
and was most likely extracted due to periodontal
reasons, since there were other sites affected
by periodontitis at the time of consu ltation. As a
result of the dental extraction, there was a resid-
ual shallow apicocoro nal defect, which created
a 3-mm discrepancy between the edentulous
ridge and the gingival margin of the adjacent pre-
molar (black dotted line). Th e entity of the defect
was further worsened by the presence of gingi-
val recessions and loss of interproximal attach-
ment at the adjacent teeth (canine and second
premolar), with consequent loss of the papillae
delimiting the edentulous site. If placed in these
conditions, the implant restoration wou ld have
resulted in a long prosthetic crown with very flat
papillae, leading to a poor esthetic outcome.
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
Th e occlusal and profile views reveal a severe
buccolingual defect with an approximately
5-mm deficit between the buccal soft tissue
profile of the edentulous site and those of the
two adjacent teeth. In these conditions it would
have been impossible to give the implant crown
an adequate emergence profile that could be
kept clean easily. A thorough analysis of the
defect highlights the severe deficit (white dot-
ted line) in the area between the imag inary line
that connects the gingival margins (white line)
and the one that situated at the presumed level
of the alveolar bone crest (blue line) of the two
adjacent teeth .
In the authors' opinion, this area, wh ich should
correspond to the transmucosal path of the
im plant-supported restoration , pertains exclu-
sively to the soft tissues, whi le the most api-
cal part of the defect corresponds to a dimin-
ished alveolar ridge thickness on the buccal
side . Whatever technique was implemented for
buccolingual bone augmentation to solve the
apical defect wou ld not have been able to in-
crease the soft tissue vo lume at the leve l of the
transmucosal path. However, the authors' hy-
pothesis was that if the soft tissue augmenta-
tion was extended apically, it cou ld compensate
for the bone deficiency from a morphologic and
esthetic point of view, therefore rendering buc-
cal bone regeneration unnecessary. Obviously,
this theory cou ld only be tested if there was
enough bone height and thickness for the in-
sertion of an implant with the ideal dimensions
for the rep lacement of the missing premolar.
Further analysis by means of a CT scan is man-
datory in these cases in order to make a precise
diagnosis and, in case of adequate bone cond i-
tions, for the development of a computer-guid-
ed treatment plan for implant placement. As of-
ten happens, despite the amount of horizontal
deficit, bone dimensions were appropriate for
guided implant placement.
345
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
The goals of the surgery were to perform guid-
ed implant placement with a surgical stent,
ach ieve the needed primary stability for im-
mediate provisionalization , and increase soft
tissue thickness with the addition of a long
connective tissue graft at the level of both the
future transmucosal path and the more apical
area of buccal bone deficiency. In the authors'
opinion, the choice of computer-assisted im-
plant placement is a must in these kinds of
cases with reduced buccolingual ridge dimen-
sions, in which there is no allowance for the
slightest mistake during implant placement.
Furthermore, guided implant placement allows
the fabrication of a very precise provisional res-
toration that the practitioner can easily rebase
during the surgery, which is crucial for pro-
viding stable support to the connective tissue
graft and the coronally advanced flap.
The surg ical technique foresees the creation of
an envelope-type buccal flap, similar to the one
used in mucogingival surgery for treatment of
multiple gingival recessions . Th e oblique para-
marginal incisions are placed in the interproxi-
mal spaces of the adjacent teeth and should be
convergent toward the edentulous site; there,
a slightly scalloped incision is performed buc-
cally. The surg ical papillae and the facial soft
tissues at the edentu lous site are elevated
split-thickness until reaching the bone, at wh ich
point the flap is elevated full-thickness for 2 to
3 mm. Apically, the set of deep and superficial
split-thickness incisions relieve tension from the
flap and allow its coronal advancement. Coronal
advancement of the buccal soft tissues shou ld
be such as to allow passive positioning of the
flap on the occlusal aspect of the edentulous
site whi le reaching the palatal aspect.
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

The site-specific removal of crestal soft tissues corresponding to the site of future implant placement
is done using th e metal sleeve of the surgical stent as a guide. A microblade is inserted, and the inci-
sion is performed following the sleeve's outline. In this way the mesial and distal soft tissues, sites for
the future papillae, are not traumatized by the burs during the drilling procedure.

347
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
When establishing implant position during
treatment planning, it is important to use the
gingival margins of the adjacent teeth as ref-
erence points, as opposed to the position of
the buccal bone crest. Implant placement is
guided in such a way that the implant's rough
surface is located 3.5 mm apical to the gingi-
val margin of the adjacent reference tooth (red
dotted line) , considering that the presurgical
position of the latter wil l be improved by the
coronal advancement of the flap. The use of a
transmucosal implant is not mandatory, but it
is recommended in order to displace the im-
plant-abutment connection as coronal to the
bone crest as possible; th is wi ll help reduce
peri-implant marg inal bone resorption . Despite
a reduced buccolingual bone thickness, guid-
ed placement allowed minimization of the bone
dehiscence buccal to the implant.
The th ickness of the implant's buccal bone
plate is less than 1 mm, which is less than half
of the th ickness recommended (2 mm) to be
present at the buccal aspect of implants (white
dotted line) to avoid formation of buccal bone
dehiscences. Therefore, formation of an even
bigger bone dehiscence than the one present
at the moment of the surgery is to be expected
during the process of bone remode ling that
takes place after implant placement.
The authors' decision to perform solely soft
tissue augmentation procedures was based
on:
1. the possibility of min imizing peri-implant
bone resorption through the augmentation
of the peri-implant soft tissue th ickness;
2. lack of evidence supporting the efficacy
of bone regeneration techniques for solv-
ing small buccal bone dehiscence defects
«3mm);
3. the need to augment soft tissue thickness
at the level of the peri-implant transmuco-
sal path to avoid unesthetic defects result-
ing from the formation of soft tissue de-
hiscences and/or dark discoloration of the
buccal soft tissues due to visibility of the
underlying metall ic implant-prosthetic com-
ponents and to give the implant-supported
crown an adequate emergence profile for
hygiene and esthetics. The placement of a
connective tissue graft is needed to obtain
an increase in soft tissue thickness. In the
current clinical case, the graft should have
increased length and thickness to compen-
sate for the osseous defect.
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

349
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
One of the advantages of computer-guided im-
plant placement is the fabrication of a precisely
fitting provisional restoration that can be easi-
ly and quickly rebased during surgery. Having a
screw-retained provisional is imperative in order
to provide a stable surface for the adaptation of
the connective tissue graft and the coronally ad-
vanced flap. The papillae mesial and distal to the
implant platform are de-epithelialized on their oc-
clusal aspect in a palatal direction; other papillae
involved in the flap are de-epithelialized accord-
ingly. This will provide coronal vascular beds for
the surgical papillae of the coronally advanced
flap.
The presence of an edentulous site with reduced
mesiodistal dimensions, unlike the case shown,
would resu lt in peri-implant papillae of inadequate
dimensions that would not allow both suturing the
connective tissue graft to their base and, at the
same time, providing a suitable vascular bed for
the papillae of the surgical flap. In this case, it is
advised to suture the connective tissue graft to
the internal aspect of the flap in a submarginal
position with internal horizontal mattress sutures.
After it has been sutured, the graft should be
placed 1 mm apical to the gingival margin of the
buccal flap. To ensure this position, it is necessary
to measure 2 mm from the most apical portion
of the marginal scallop and transfer this measure-
ment horizontally to the base of the surgical papil-
lae, at which point the internal horizontal mattress
suture is performed (7-0 PGA, 8-mm needle).
The suturing sequence is the following: from the
E
buccal side, the needle perforates the base of the
surgical papilla (illustration 1) and the graft (1 mm
from its coronal border; illustration 2); from the in-
ternal aspect, the needle goes back, perforating
the graft (illustration 3) and the flap (illustration 4),
and exits horizontally to the starting point on the
buccal side where the suture is closed with a
surgical knot (illustration 5). Perforating the flap 2
mm from its coronal margin and the graft 1 mm
from its coronal border ensures graft positioning
at the base of the surgical papillae as well as its
placement 1 mm apical to the flap's scalloped
margin. In this way, the whole internal surface of
the surgical papillae (pink area in the graphic on
the photo) is free for first intention closure with the
anatomical, palatally de-epithelialized papillae.
The graft's mesiodistal dimension should be 6
mm greater than the diameter of the implant plat-
form ; apicocoronally it should start at the level
of the gingival margin of the reference tooth and
cover 3 to 4 mm of buccal bone apical to the
dehiscence. The graft's thickness, around 1 mm,
is not expected to compensate the buccolingual
defect by itself; flap thickness and the subgingival
portion of the immediate provisional also contrib-
ute to the defect's compensation.
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

Fl ap closure starts with sling sutures anchored to the cingula of the teeth adjacent to the implant site.

One of the two peri-implant surgical papillae
should also be sutured to its correspond ing ana-
tomical de-epithelialized papilla before placement
of the provisional crown. The remaining peri-im-
plant papilla is sutured after the screw-retained
provisional has been placed in order to provide op-
timal adaptation of the keratinized tissue of the flap
onto the buccal surface of the provisional. This ad-
aptation is completed w ith a sling suture anchored
to the cingulum of the provisional restoration.

Soft tissues are left to heal undisturbed for 6
months. During the first 2 weeks, the patient per-
form s only chemical plaque control with a chlor-
hexidine-based mouth rinse. After suture remov-
al, mechanical cleaning is reinstated w ith use of
an ultra-soft toothbrush for 1 month and a soft
toothbrush for the follow ing 2 months wh il e still
using the chlorhexidine rinse. Three months af-
ter the surgery, it is evident how the buccolingual
defect has been completely compensated with
the adopted surgical technique. It is important to
highlight how the desired increase in soft tissue
volume has been completely accomp li shed not
only at the level of the gingival margin of the ad-
jacent teeth (white dotted line), where the deficit
corresponded entirely to the soft tissues, but also
at a more apical level, the area corresponding to
the buccal bone defect. From a dimensional and
morphologic point of view, the result was ade-
quate even in the absence of bone augmentation .

35 1
MUCOG INGIVAL APPROAC H FOR DELAYED IMPLANT PLACEMENT
Soft tissue maturati on is co nsidered complete af-
ter 6 months. The comparison between the base-
line and the 6-month postoperative image shows
both the buccolin gual soft tissue increase, which
allowed resolution of th e prior defect, and the api-
coco ronal increase, which allowed im provement
Th e soft tissues, particularly those at the level of
the peri-implant papillae, showed subsequent
coronal growth at the end of the conditioning
phase. This was possible th anks to th e adjust-
ments made on th e provisional, such as changes
in the emergence profi le and the gradual shift of
of th e position of the buccal soft ti ssue margin
at the level of the implant-supported crown and
adjacent papillae. At th is stage, the conditioning
phase is started, with the primary goal of promot-
ing furth er coronal growth of the papillae th anks to
th e compressive effect of the provisional crown.
the contact point in a coronal sense (squeezing
effect). Increasing soft tissue thickness at the
level of the papillae, as a result of extending the
connective ti ssue graft toward the base of th e
flap's surgical papillae, is th e determining factor
for their coronal growth .
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

Th e superimposition of the images at baselin e

and after soft ti ssue cond itioning highlights the
coronal growth of the peri-implant tissues.
Additionally, comparison between the occlusal
and profile views of the initial situation and af-
ter the co nditioning phase shows the degree of
correction achieved at the defect site with th e
increase in soft tissue volume. This increase in
volume translates into increased thickness of the
con nective tissue component of the peri-implant
mucosa, which is cru cial for the prevention of
buccal soft ti ssue dehiscences and to mask the
presence of the underlying metallic components. starts at the level of the mucosal marg in , con-
It is important to bear this in mind , given that the tinues throughout the peri-implant transmucosal
presence of a thin buccal plate cou ld lead to path , and extends apically to what once co rre-
bone dehiscence formation at the implant's fa- sponded to the tooth's buccal bone plate. If the
cial aspect. Augmenting the soft tissue thickness goal of the current surgical technique was that
buccolingually is equally important in order to of correcting the ridge defect by increasing only
create an adeq uate emergence profile, regard- the soft tissues, without resorting to bone aug-
ing maintenance and hygiene, for the prosthetic mentation, it is safe to say that, at least from a
crown. The profile view shows how the increase morphologic and esthetic point of view, the goal
in the buccal soft tissues (white dotted line) was accomplished.

353
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

One year after delivery of the final restoration, there is a good esthetic result that satisfies the patient's
demands and expectations. On the follow-up periapical radiograph, the implant shows no signs of
bone loss, and there is radiopacity of the bone crest.

Comparison of the images at baseline and from
the 1-year recall after placement of the definitive
restoration illustrate how the apicocoronal soft
tissue augmentation enabled the rehabilitation of
the edentulous site with a mucosal margin that is
symmetric to those of the adjacent teeth and good
papi lla fill of the interproximal spaces, especially
considering the initial situation. The buccolingual
increase allowed the creation of a restoration with
adequate emergence profiles that allow implant
maintenance. By looking at the baseline image,
we can confirm that the final results wou ld not
have been possible without performing soft tissue
augmentation techniques.
 MUCOGINGIVAL APPROAC H FOR DELAYED IMPLANT PLACEMENT

Three years after delivery of the final restoration, the result is still maintained and is estheti cally pleas-
ing for the patient. Careful observation allows appreciation of furth er growth of the peri-implant papil-
lae. The periapical radiograph shows stability of the supporting bone levels and radiopacity of the
bone crest.

Comparison by superimposition of the baselin e result is to be attributed to both th e applied sur-

and 3-year images illu strates how the placement
of a crown with clinical dimensions similar to
th ose of the adjacent premolar wou ld not have
been possible without soft tissue augmentation.
Peri-implant papillae growth becomes ever more
evident considering the initial situation . This
gical technique and to the immediate provision-
alization. In the authors' opinion, in the absence
of even one of the elements of the procedure-
coronally advanced flap, connective tissue graft,
and immediate provisionalization-achievement
of th is resu lt would have hardly been possible.

355
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

The occlusal and profile views confirm the sta-
bility of the outcome. The buccolingual augmen-
tation allowed the crown to have a complete ly
natural emergence profile while enabling proper
hygiene maintenance by the patient. Frequent
recalls (four times a year), patient motivation,
absence of periodontitis, and no smoking habits
are fundamental requirements for the implemen-
tation of techniques such as the one shown in
this clinical case. The aforementioned require-
ments are also key for the success and long-
term maintenance of the therapy.

... ........
..
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

Once more, superimposition of the images

allows appreciation of the fully formed papil-
lae, quite an accomplishment consideri ng
the flat initial outline of th e edentulous site.
Growth of the peri-implant papillae is in no
way associated with changes in the height
of the interproximal bone peaks of the teeth
delimiting the edentulous site, but it is a re-
sult of the buccolingual increase in soft tissue
thickness (black dotted lines). These tissues,
cond itioned both by th e provisional and the
definitive restoration, are given the cond itions
needed to continue growing coronally thanks
to th e creeping phenomenon.

Clinical and radiographic controls show stabili-

ty of the outcome over ti me. The horizontal and
verti cal increase in the soft tissues allowed the
placement of an implant-supported crown with
adequate dimensions and proper emergence
profiles that contributed to correct hygiene
maintenance. The result completely satisfies
the patient's esthetic demands. The periapical
radiograph confirms stability of the peri-implant
supporting bone levels.

357
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
Comparison between the baseline and the 5-year
follow-up highlights the complete resolution of
the buccolingual defect, even without the imple-
mentation of bone reconstruction techniques.
Th e superimposition of the images illustrates
how the soft tissue augmentation allowed a re-
duction in the crown's apicocoronal dimensions
as well as the complete fill of th e interproximal
spaces by th e peri-implant papillae. The latter
This reveals new opportuniti es for the sole appli-
cation of mucogingival surgery in certain cases
where it cou ld esthetically and functionally com-
pensate for buccal bone deficiencies.
was possible thanks to the cond itioning of the
thickened soft tissues with the provisional crown
at earlier stages and later w ith the definitive res-
toration, promoting coronal growth of the papil-
lae (ie, creeping).
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

359
MUCOGINGIVAL A PPROACH FOR DELAYED IMPLANT PLACEMENT
The surg ical technique described for augmenting
soft tissues in conjunction with implant place-
ment and immediate provisionalization can be
performed only in edentulous sites that are suf-
ficiently wide mesiodistally. As a general rule,
the mesiodistal dimension of the edentulous site
must exceed the implant diameter by at least 4
mm (2 mm each for the mesial and distal papil -
lae). This allows enough room mesial and distal
to the immediate provisional for wide and deep
anatomical papillae that can be de-epithelialized
palatally, providing adequate vascu larity for the
surg ical papillae of the coronally advanced flap.
When the dimensions of the edentulous site are
smaller, the surgical technique requ ires some
vari ations from what was previously described .
As a matter of fact, after placing the provisional,
reduced mesiodistal dimensions of the edentu-
lous site would not allow papillae wide enough
so that both the connective ti ssue graft and the
surgical papillae of the coronally advanced flap
could be sutured to them.
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
If the interproximal soft tissues are inadequate,
this cou ld lead to early shrinkage of the buc-
cal flap with consequent graft exposure, risk of
failure of the soft tissue augmentation surgery,
and/or unesthetic results due to the difference
in color and surface texture between the grafted
area and the adjacent soft tissues. Th is clinical
case describes the bilateral treatment of healed
edentulous sites (6 months after tooth extraction)
with reduced mesiodistal dimensions and me-
dium-sized buccoli ngual defects . On the right
side, the edentulous ridge is at exactly the same
apicocoronal level as the gingival margin of the
adjacent tooth (second premolar); the papilla
mesial to the second premolar is considerably
flat, and the papilla distal to the canine is almost
nonexistent. It is the authors' opinion that im-
plant placement without simultaneous buccolin-
gual and apicocoronal soft tissue augmentation
wou ld resu lt in further papillae contraction and
a clinical crown that is longer than the adjacent
tooth and has an inadequate emergence profile.
An apicocoronal and buccolingual augmentation
of the soft tissues is indicated to provide the re-
storative dentist an excess of soft tissues that
can be cond itioned in order to place the muco-
sal margin of the implant-supported crown at
t he same level as that of the adjacent tooth and
also to create papillae mesial and distal to the
implant restoration with similar height and shape
as those of the adjacent teeth . The surgical tech-
nique requires the placement of a connective
tissue graft in a paramarginal position, sutured
onto the internal aspect of a coronally advanced
envelope flap, simultaneous to implant place-
ment with immediate provisionalization.
361
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

Flap design and elevati on are executed as previously described for the wider edentulous sites.
 MUCOG IN GIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

Instead of performing the soft ti ssue excision as

previously described, the crestal soft tissues are
elevated full thickness to expose th e underlying
bone for correct impl ant placement. Limited pal-
atal flap elevation produces a vertical rotation of
th e supracrestal soft ti ssues (verticalization tech-
nique), whose margin is coronally displaced with
respect to its original position. Coronal advance -
ment of the buccal flap and ve rti calization of th e
supracrestal soft tissues allows an approximation
of the respective marginal tissues in a significantly
more coronal position in relation to the bone crest.

363
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
After guided implant bed preparation and im-
plant placement, the connective tissue graft,
which cannot be sutured to the base of the
papillae, is sutured in a paramarginal position
on the internal aspect of the flap. After sutur-
ing, the graft should be placed 1 mm apical
to the scalloped margin of the buccal flap. To
ach ieve this, it is necessary to measure 2 mm
from the most scalloped part of the flap margin
and translate this measurement horizontally to
the base of the surgical papillae, performing an
internal horizontal mattress suture at this level
(PGA 7-0, 8-mm needle). The needle perforates
the base of the surgical papilla from the outer
aspect of the flap (illustration A) and reaches
the graft (1 mm from the coronal edge; illus-
tration B) . The needle returns horizontally, per-
forating the graft (illustration C) and the flap (il-
lustration 0) from the internal aspect and then
exits horizontal to the starting point, where a
surgical knot is made (illustration E). Given
that the needle perforates the graft at a 1-mm
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLA NT PLACEMENT

distance from its coronal edge and th e flap at
a 2-mm distance from the most apical point of
its scalloped margin, when suturing is finished ,
the connective tissue wi ll be positioned 1 mm
apical to the scalloped margin and the surgical
papi llae. Without interference from the under-
lying graft, the whole of the surgical papillae's
internal surface (translucent pink area) remains
free for first intention closure with th e vertical-
ized supracrestal soft tissues.

In continuation, the intraoral relining of the provisional is done. The provisional is kept out of occlusion,
and space is left interproximally to allow primary closure between the surgical papillae of the buccal
flap and the verticalized supracrestal soft tissues.

365
MUCOGI NGIVAL APPROACH FOR DELAYED IMPLANT PLAC EMENT

Flap closu re consists of a series of sling su-
tures, suspended around the palatal cingula of
the provisional and the adjacent teeth . Simple
interrupted sutures help improve the pri ma-
ry closure of the surg ical papillae with the su-
pracrestal soft tissues mesial and distal to the
provisional crown. Precise adaptation of the
flap's keratin ized tissue to the convex surface
of the provisional crown's buccal surface is fun-
damental. This, together with the presence of
the underlying graft, prevents contraction of the
buccal flap.
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

During th e first 6 months of healing, the soft tis-
sues must be left to mature undisturbed, with-
out interference of the provisional restoration,
which is progressively reduced accompanying
the coronal growth of th e soft tissues. After
the maturation phase follows the condition-
ing phase, in which the marginal soft tissues
are displaced apically until they reach the level
of the adjacent tooth's gingival margin; at th e
interproximal level, the profile of the provisional
crown is modified to progressive ly displace the
contact points coronally to favor papillae growth
(squeezing effect). Once tissue cond itioning is
finished, th e mucosal margin will be at th e same
level as the ging ival margin of the adjacent tooth
and the mesial and distal papillae w ill have the
same height as the anatomical papillae of th e
adjacent teeth .

Durin g the maturation and cond itioning phases, it is necessary that the patient "massages" the treated
area by performing atraumatic hygiene techniques (brushing with a roll technique) and that interproxi-
mal spaces are kept clean with the use of dental floss (thin spongy floss).
367
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
The final restoration can be placed when the
conditioning phase is completed . The superim-
position of the soft tissue images at baseline and
before definitive restoration placement shows
how the buccal mucosal margin is slightly more
coronal with respect to the initial level of the
edentulous ridge. Much more significant is the
interproximal papillae growth, especially the me-
sial one, which was almost nonexistent before
surgery.
 MUCOG IN GIVAL APPROACH FOR DELAYED IM PLANT PLACEMENT

Three years after th e surgery, the implant ap-
pears well osseointegrated and shows good
radiopacity of the interproximal bone crest ra-
diog raphically. The use of a transmucosal im-
plant, which displaces the implant-abutment
connection coronally from the bone crest,
prevents or limits crestal bone resorption . The
apicocoronal aug mentati on of th e soft tissues
allowed optimization of the esthetic result with
the growth and formation of the papi llae.

The images of the clinical profiles show the amount of soft tissue thickness gained with the coronally
advanced flap in association with a connective tissue graft. This, along with adequate prosth etic plan-
ning , makes it possible to obtain a correct emergence profile.

369
MUCOGINGIVAL APPROAC H FOR DELAYED IMPLANT PLACEMENT

To demonstrate the reproducibility of the previ-

ously described surgical procedure, it has been
repeated on the contralateral side of the same
patient. On this side as well , the soft tissues of
the edentulous ridge (white dotted line) are at the
same level of the gingival margin of the adjacent
tooth, and interproximal papillae are completely
absent.
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

Three months af-

ter the su rgery, th e
buccolingual soft
tissue increase and
formati on of the in-
terproxi mal papillae
are already evident,
and the mucosal gin-
gival margin is still at
the same level as th e
gingival marg in of the
adjacent premolar.

37 1
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

Soft tissues are allowed to ma-

ture undisturbed for 6 months.
This is followed by the condition-
ing phase with th e provisional
crown. Proper and atraumatic
hygiene maintenance, through
the use of toothbrushes with pro-
gressive ly stronger bristles and
interdental spongy floss, is fun-
damental to allow maturation of
the soft tissues and adaptation of
th e latter to the provisional crown
in the best way possible, exploit-
ing their growth potential.

The profile and occlusal images

show correction of the horizontal
defect with soft tissues that are
thickened mainly in the most cor-
onal aspect (peri-implant trans-
mucosal path). It is precisely at
this level that the increase in soft
ti ssue thickness is fundamental
for the final estheti c result, for th e
creation of a prosthetic crown
with a correct emergence profile
that is maintainable by the pa-
tient, and to prevent development
of PSTD and visibility of the un-
derlying implant and prosthetic
components.
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

At the i-year follow-up after

placement of the definitive res-
toration, it is evident how the
apicocoronal soft tissue aug-
mentation allowed the reshap-
ing of the papillae mesial and
distal to the implant-supported
crown whi le keeping the mu-
cosal margin at the same level
as the gingival margin of the
adjacent tooth. The buccolin-
gual soft tissue augmentation
allowed treatment of the hori-
zontal defect and the creation of
an adequate emergence profile
that is easily maintainable by the
patient in terms of hygiene. The
3-year follow-up shows even
further papil lae growth. The ra-
diograph confirms good implant
osseointegration, radiopacity of
the bone crest, and stability of
the interproximal bone levels.

373
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
It is worth pointing out that soft tissue growth
contin ues over time following surgical techniques
that involve the placement of a connective tissue
graft, obtained from the de-epithelialization of
a free gingival graft, covered by a coronally ad-
vanced flap . For this reason, it is advised not to
close the interproximal spaces when placing the
definitive restoration but, instead, to place the
contact points in the esthetically ideal position.
These small empty spaces are rarely a reason
for esthetic concern on behalf of the patient and
allow further papillae growth due to the quality
of the final restoration's material, wh ich is more
smooth and biocompatible in comparison with
the provisional. This leads to an improvement of
the esthetic result over time.
Comparison between baseline and 3-year fol-
low-up images, especially when superimposed,
highlights the growth of the interproximal papillae
in spite of their virtual absence initially. This is due
to the vertical soft tissue augmentation done in
conjunction with im plant placement. On the oth-
er hand, the adequate emergence profile of the
prosthetic crown is a result of th e buccolingual
soft tissue augmentation that allowed treatment
of the preexisting horizontal defect.
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

The 10-year follow- up shows stability

of the esthetic outcome for both of the
treated sites. The peri-implant papil-
lae are present, and the emergence
profiles of the prosthetic crowns are
adequate. Th ese long-term resu lts
are the product of the active collab-
oration of the patient regarding both
self-perform ed hyg iene practices as
well as strict compliance with the reg-
ular maintenance appointments every
3 months.
375
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

Comparison between the baseline situation and the 10-year follow-up shows how the vertical soft
tissue augmentation allowed creation of a natural-looking scalloped margin and peri-implant papillae
around the implant-supported crown. The horizontal soft tissue augmentation, on the other hand , al-
lowed the placement of a prosthetic crown with proper emergence profiles, wh ich also promotes oral
hygiene maintenance.
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

The same result has been achieved on the contralateral side. Even here, despite starting with an
almost flat outline at the edentulous site, adequate soft tissue contours were created around the
prosthetic crown resembling those present around the natural dentition.

377
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

379
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

As an alternative to the procedure just described , in the presence of

narrow edentulous sites (lateral incisors and premolars in the maxil-
la) associated with moderate horizontal defects, it is possible to first
treat the buccolingual defect with soft tissue ridge augmentation
techniques and then , once healed, place the implant "flapl ess" w ith
immediate provisionalization. Of course, all of this is only possible if
the three-dimensional studies confirm an adequate quantity of bone
for the placement of an implant w ith the ideal length and diameter
to replace the missing tooth. The disadvantage is that thi s becomes
a two-stage procedure (stage-one soft tissue surgery for ridge aug-
mentation of the edentulous site and stage-two implant placement),
but it is more appropriate for the treatment of larger buccolingual
defects and w hen the papillae at th e edentu lous site do not need
improvement (they have the same height as the papi llae on adjacent
teeth). Additionally, this technique is less risky and can therefore be
more suitable for a less skilled clinician with respect to the coronall y
advanced flap with a connective ti ssue graft simultaneous to im-
plant placement and verticalization of the supracrestal soft tissues,
as indicated for narrow edentulous spaces (case done in collabora-
tion with Dr Giovanni Polizzi and Dr Walter 8entivoglio).
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

The buccal view makes it pos-

sible to appreciate the ade-
quate level of the papillae de-
limiting the edentulous site,
as well as the absence of an
apicocoronal defect. On the
other hand, the occlusal view
shows a moderate to severe
horizontal defect, especially in
the most coronal aspect (white
dotted line), where the supra-
crestal soft tissues need to be
reconstructed.

Surgical soft tissue ridge augmentation in this case and vertical dimension of the crestal soft tissues.
aims at increas ing the crestal soft ti ssues only in Th e surgery in this case also requires a coro nally
the buccolingual dimension and therefore wi ll re- advanced envelope flap that will cover a connec-
quire only a buccal approach , keeping the integrity tive tissue graft placed on th e edentulous site.

381
MUCOGINGIVAL APPROAC H FOR DELAYED IM PLANT PLAC EMENT

The interdental incisions at the level of th e papillae are submarginal and obliquely oriented toward the
edentulous site, where the horizontal incision is made along the most coronal outline of th e crestal soft
tissues.

Th e flap is reflected with a variable thickness:
split thickness at the level of the surgical papil-
lae, full thickness at the level of the buccal bone
crest, and again split thi ckness apically to allow
coronal mobilization of the flap.
This last step is needed because, even if it
will be repositioned at the same level, th e flap
w ill have to cover a graft w hose thi ckness w ill
vary according to the extent of th e horizontal
defect.
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
.,
'l: , ." ,',• • :'\
When the size of the horizontal defect is moderate
to severe, a thick graft is needed. This graft can
be harvested from the tuberosity, or if that is not
available, a double-length (twice the mesiodistal
dimension of the edentulous site) epithelium-con-
nective tissue graft can be harvested from the pal-
ate. After being de-epithelialized, the connective
tissue graft can be folded in half so as to double its
thickness, and two internal mattress sutures are
placed to keep th is configuration. By doing th is,
an excessively deep graft harvest can be avoided
since such a graft wou ld have to include adipose
and glandular tissue, causing the patient higher
postoperative morbidity (see chapter 3). The con-
nective tissue graft is fixed to the supracrestal soft
tissues coronally, through horizontal internal mat-
tress sutures, and to the periosteum apically, with
simple interrupted sutures. When perform ing the
horizontal internal mattress sutures, the needle
first perforates the graft (double) from the outer
aspect and the supracrestal soft tissues from their
inner aspect and exits palatally (illustration A and
white arrow in photo); here it returns horizontal-
ly, perforating the supracrestal soft tissues from
the outer aspect and the graft from the internal
aspect and exits horizontally with respect to the
starting point (illustration B and black arrow in
photo); finally, a surgical knot is performed on top
of th e graft (illustration C). It is important that the
final graft position , once sutured, is slightly sub-
marginal (around 1 mm) relative to the level of the
crestal horizontal incision so that primary closure
of the coronally advanced flap can be achieved
w ithout interference of the graft.
383
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

The coronally advanced flap is closed with sling sutures suspended around the palatal cingulum of
the teeth included in the procedure and anchored to the papillae adjacent to the edentulous site; the
horizontal crestal incision is closed with simple interru pted sutures. Whenever a removable prosthesis
is used for replacement of the missing tooth, it is important that it is reduced at the end of the surgery
in order to avoid impinging on the treated area.

The patient performs chemical plaque control for 2 weeks, after which the sutures are removed.
During this period , the patient must avoid chewing on the treated site and wear the removable pros-
thesis only for esthetic/social reasons.
 MUCOGINGIVAL APPROAC H FOR DELAYED IMPLANT PLACEMENT

Clinical images 1 month after the surgery show first intention wound healing and complete resolution
of the horizontal defect. The height of th e papillae delimiting the edentulous site has been perfectly
preserved.

The occlusal view shows the realignment of th e buccal soft tissue profile achieved through the site-spe-
cific placement of the connective tissue graft.

During the first months of soft tissue maturation it is necessary to perform monthly recall appointments
to assess hyg iene maintenance by the patient and to ensure that the volume increase is not impaired
by the provisional prosth esis.
385
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

The soft tissues are left undisturbed for 6 variations occur between monthly recalls, it
months. Even if further volume increase occurs is possible to proceed with implant therapy.
over tim e, the biggest variations occur during Photographic documentation helps in assessing
the first 6 months. When no evident clinical volume changes.
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
The comparison between the clinical images
at baseline and 6 months after the soft tissue
ridge augmentation surgery shows perfect
preservation of the height of th e papillae delim -
iting th e edentulous site and optimal blending
of the treated area with the adjacent tissues .
This is possible because there was no expo-
sure of the connective tissue graft.
Once the soft tissues have matured it is pos-
sible to proceed to guided implant placement.
The radiographic three-dimensional assess-
ment showed adequate bone height for implant
placement. However, small buccal dehiscences
or fenestrations cannot be ruled out due to the
thi ckness of the bone ridge. If ridge thickness
allows proper (ie, prosthetically guided) implant
placement, the authors do not consider the
formation of small buccal bone dehiscences
or fenestrations to be an absol ute indication for
bone augmentation because the buccal soft
ti ssues have been augmented in the area of the
future transmucosal path. Whenever t he soft
tissues already have an ideal shape, flapless
implant placement is advised.
387
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

It is the authors' opinion that guided implant surgery is necessary in cases with reduced bone th ick-
ness and in wh ich a flapless approach is planned .
MUCOGINGIVAL APPROAC H FOR DELAYED IMPLANT PLACEMENT

If primary stability is achieved

and occl usal co nditi ons are
favorable, immediate implant
provisionalizati on is indicated.
Soft tissues are conditioned
for 3 to 4 months through the
use of the provisional until the
ideal morphology is obtained,
using the natural contralateral
tooth as reference. At the end
of the conditioning phase,
the final restoration can be
placed .

Ad hesive restorations placed

on th e adjacent natural teeth
frequently allow improvement
of th e overall estheti c result
through an adequate manage-
ment of th e shapes and spac-
es, with the objective of creat-
ing harm ony of the prosthetic
crown with th e adjacent teeth .
Th e esthetic result can be ap-
preciated in the patient's smile.
389
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

At the 1-year recall after final

restoration placement, clin ical
and rad iographic examination
makes it possible to appreci-
ate the health of the peri-im-
plant tissues and how well the
surgically treated area blends
in with the other tissues.

Clinical and radiographic images 3 years after final restoration placement show stability of the out-
comes, both in terms of esthetics and implant osseointegration .
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
Even with a two-stage surgical approach, the
final esthetic resu lt is extremely pleasing to the
patient. The maintenance of papillae height al-
lowed the creation of highly scalloped morphol-
ogy of the marginal soft tissues, characteristic of
the patient's phenotype. The buccolingual soft
ti ssue augmentation made it possible to fab-
ri cate a prosthetic crown with adequate emer-
gence profiles that are easily cleanable by the
patient. The superim position of the clin ical and
radiographic images makes it possible to appre-
ciate the peri-implant transmucosal path and the
relationship between the interproximal hard and
soft tissues, which remain stable 3 years after
definitive restoration placement. The area of po -
tential bone dehiscence/fenestration buccal to
the implant is not clinically visible given that the
adhered soft tissues don't allow deep probing
and their thickness does not allow visibility of the
underlying metallic structure.
391
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

Comparison between the baseline occlusal
image and the one at 3 years shows even fur-
ther vo lume increase of the buccal soft tissues .
Once again , this can be attributed to the ten-
dency of the connective tissue, com ing from the
de-epithelialization of a free gingival graft and
covered by the coronally advanced flap, to in-
crease in thickness over time. Even if hardly ever
noti ced by the patient, this represents the major
inconvenience of this surgical technique.

Long -term results seem stable both clin ically and rad iographically. Th e patient is extremely happy with
th e achieved esthetic result even years after the treatment was done.
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

After 10 years, patient satisfaction and the stability of the resu lt confirm the suitability of the chosen
treatment.

393
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLAC EMENT

395
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

Pre-implant soft tissue augmentation of the of flap dehiscence. Nevertheless, this technique
edentulous site is particularly indicated in cas- requires an add itional surgical procedure (case
es of horizontal soft tissue defects (moderate to done in collaboration with Or Giovanni Polizzi
severe deficiency) in edentulous spaces of re- and Or Marco Barana).
duced mesiodistal diameter adjacent to teeth
that are receiving restorations. In these situa-
tions, it is actually possible to replace the miss-
ing tooth w ith a provisional anchored to the ad-
jacent teeth . This kind of two -stage approach ,
in contrast with soft tissue augmentation si-
multaneous to implant placement, is advisable
for less experienced clinicians . This procedure
all ows primary closure of the surgical wound
without interference from the implant-support-
ed provisional crown, therefore reducing the risk
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
The surgical technique requires a buccal enve-
lope flap, which is reflected at a variable thick-
ness and advanced coronally. Interdental inci-
sions at the level of the papillae on the adjacent
teeth are submarg inal with an inclination toward
the edentulous area. In the latter, the horizontal
incision is done following the most coronal part
of the crestal soft tissue outline. The connective
tissue is sutured at the coronal aspect to the
supracrestal soft tissues with internal horizontal
mattress sutures, and apically it is fixed to the
periosteum. The flap is coronally advanced, cov-
ering the connective tissue graft, and sutured
with simple interrupted sutures on the edentu-
lous site and with sling sutures anchored around
the palatal cingu lum at the adjacent teeth.
397
MUCOGINGIVAL APPROAC H FOR DELAYED IMPLANT PLACEMENT

Once soft tissues have matured, after 6 months the flapless technique is that the previously aug-
without interference from the provisional, it is mented crestal soft tissues can remain unal-
possible to start planning for guided implant tered and surgical trauma is reduced, therefore
placement. In the presence of adequate bone also minimizing patient postoperative morbidity.
(both in height and thick-
ness) for the placement
of an implant with ide-
al length and diameter
to replace the missing
tooth, it is advisable to
proceed with flapl ess
implant placement with
immed iate provisional-
ization. The advantage of
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

During the next 3 to 4 months, the

provisional is modified in order to
condition the soft tissues until
the morphology of the marginal
soft tissues resembles that of the
adjacent tooth and has a correct
emergence profile. After finish-
ing soft tissue conditioning, final
restoration can be placed , which
will further improve the overall es-
thetic of the rehabilitation.

399
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
One year after placement of the definitive res-
toration, the soft tissues at the treated area are
stable and well integrated. The absence of ex-
posure of the gingival graft allows the mainte-
nance of excellent esthetics at the peri-implant
soft tissues, which are indistinguishable from
the adjacent areas. The increase in soft-tissue
thickness along with proper prosthetic planning
has allowed the creation of an adequate emer-
gence profile, important for hygiene mainte-
nance by the patient and to avoid bothersome
food retention.
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

Absence of bleeding on probing and

radiographic proof of stability of the
interproximal bone crest over time are
signs of healthy peri-implant tissues.

401
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

Comparison between the cl inical presurgical
situation and the 2-year follow-up shows the
esthetic and functional improvement achieved
with the two-stage technique (pre -im plant
soft tissue ridge augmentation and consec-
utive implant placement with immed iate pro-
vis ionalization). From the baseline image it
is evident how restoring the edentu lous site
exclusively with an implant-supported pros-
thesis or w ith a canti lever supported on the
adjacent teeth w ithout augmentation of the
soft tissues wou ld not have allowed creation
of esthetically pleasing conditions that cou ld
also be easily cleaned by the patient.

The soft tissue augmentation technique, despite being on ly buccolingual, has allowed the implant clinical
crown to be shortenedw with respect to the dimensions of the provisional and also made it possible to
give the prosthetic crown an esthetically adequate emergence profile that the patient is able to keep clean.
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

403
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT
The kind of surgical approach for implant reha-
bilitation of a completely healed postextraction
site (6 months after tooth extraction) is chosen
based on a series of cli nical features (such
as the mesiodistal dimension of th e edentu-
lous site and the type and extension of the
postextraction defect), but it also depends on
the clinician's level of experience and on the
procedure-related risks. As a general rule , the
one-stage surg ical technique, wh ich entail s si-
multaneous soft tissue augmentation and im-
plant placement with immediate provisionaliza-
tion, constitutes a more comp lex, higher-risk
procedu re; consequently, it demands a higher
level of expertise from the clinician in compari-
son with a two-stage procedure, in which soft
tissues are first augmented and then, once
once they are healed, the implant is placed
in a flapless fashion. Another procedure that
is recommended for less experienced practi-
tioners divides treatment in two phases: during
the first phase, soft tissue augmentation is
done simultaneously to implant placement with
submerged healing; during the second phase,
implant uncovering and provisionalization are
performed .
It is the authors' opinion that this procedure
entails fewer risks in comparison to the oth-
er two-stage procedure previously described
because it does not entail flap less implant
placement, a technique that requires a more
experienced clinician or guided implant place-
ment systems. The proposed technique is also
indicated in th e case of failure to ach ieve th e
needed primary stabi lity for immediate implant
provisionalizati on . The fo llowing clinical case
refers to this last situation (case done in collab-
oration with Or Valentina 8entivogli).
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

After extraction site healing (6 months) follow-

ing tooth removal for dental reasons, a small
horizontal defect is present along with gingival
recession on the adjacent natural tooth (ca-
nine). The recession is classified as Miller Class
III due to the small amount of attachment loss
distally. Presence of a narrow edentulous site
suggests the use of a coronally advanced en-
velope flap with verticalization of the supracr-
estal soft tissues .

The buccal flap is extended from the lateral in-
cisor to th e second premolar; an interproximal
paramarginal incision is made, starting from th e
gingival margin of the lateral incisor and end -
ing at a distance from the tip of the papilla that
corresponds to the coronal advancement of the
marginal tissues needed to cover the recession.
The flap is reflected at a variable thickness: split
t hickness at the level of the surgical papillae and
at the edentulous site until reach ing the buccal
bone crest, full thickness in ord er to expose 2 to
3 mm of buccal bone, and split thi ckness apical-
ly to free the flap from periosteal insertion (deep
split-thickness incision) and from muscle inser-
tions on the internal surface of the fl ap (superfi-
cial split-thickness incision).

405
MUCOG INGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

The supracrestal soft tissues are elevated full dimensions of the peri-implant transmucosal
thickness and verticalized unti l the cresta l path have been augmented. In th is case, a
bone is visible for correct implant placement. bone-level implant was chosen because of the
Verticalization of the supracrestal soft tissues need for an adequate emergence profile in the
in conjunction w ith coronal advancement of the presence of reduced interocclusal space.
flap, supported by the underlying connective
tissue, serves to increase the apicocoronal-in
addition to the buccolingual-dimension of the
soft tissues. The periapical radiograph taken in-
traoperatively al lows the assessment of correct
apicocoronal and mesiodistal im plant position-
ing. As previously described , the first-choice
implant for this type of surgical approach is the
transmucosal implant; this is due to the fact that
tissue-level impl ants make it possible to coro-
nally displace the implant-abutment connection,
reducing crestal resorption and making hygiene
maintenance easier for the patient in an area
in wh ich th e apicocoronal and buccolingual

After de-epithelialization of the anatomical papilla
between the lateral incisor and canine, the con-
nective ti ssue (harvested from the palate and
de-epithelialized extraorally) was sutured to the
internal aspect of the flap 1 mm apical to the
marginal tissue border. In this case, simultaneous
treatment of the horizontal defect at the eden-
tulous site and of the recession on the canine
called for placement of a connective tissue graft
of greater dimensions (covering from the distal
surface of the lateral incisor to the mesial aspect
of the second premolar).
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

Since adequate primary stability for immediate provisionalization was not obtained, it was decided to
suture the flap for first intention wo und healing (submerged healing).

At th e time of suture removal it is possible to observe how, in spite of the lack of support that would have
been provided by the immediate provisional, the horizo ntal defect is no longer present, and a slight api-
coco ronal increase of the crestal soft tissues was obtained along with recession coverage of the canine.

During the first months of healing, th e grafted soft tissues mature undisturbed . The first month after
suture removal, the patient performs plaque control w ith the roll brushing technique with an ultra-soft
toothbrush and afterward w ith a soft toothb rush.
407
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

At least 4 months must

pass before proceeding
with implant uncovering .
This time serves for mat-
uration and integration of
the grafted tissue onto the
recipient site and also for
osseointegration.

Comparison between the occlusal presurgi-
cal and 4-month follow-up images demon-
strates the buccolingual increase of the soft
tissues ach ieved w ith the described technique.
After waiting 4 months after implant placement
and soft tissue volume augmentation, it is
possible to perform minimal surgical access
to position the healing abutment and take an
impression for the fabrication of a provisional
crown.
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

Around 1 month after implant uncovering , the

screw-retai ned provisional is placed in order
to start the soft tissue condition ing phase. The
purpose of this phase is to obtain a margin-
al soft tissue morphology that resembles and
is at the same level as that of the adjacent
premolar.
Soft tissues adapt to the provisional and form
the transmucosal path .
Th e occlusal image during soft tissue con-
ditioning makes it possible to appreciate the
thickness of the buccal tissues obtained with
the technique of the coronally advanced flap
and submarg inal connective tissue graft. This
allows an optimal esth etic result , masking the
underlying im plant-prosthetic components
and favoring the blending in of the restoration
w ithin the treated area.

Another goal of the prosthetic cond itioning is
to obtain the maximum growth possible of the
papillae mesial and d istal to the provisional crown
(squeezing effect). Thi s can be obtained by pro-
gressively modifying the crown's interproximal
profiles and progressively moving the contact
points coronally. Modifications of the provisional
must be minimal and repeated as needed to ob-
tain the most papillae growth. When, after mod-
ifying the provisional , there is no further papillae
growth (they no longer fi ll up the previously open
interproximal spaces) in-between recall appoint-
ments, it is time to proceed with the final resto-
ration phase.
409
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

One year after final restoration, the achieved es- adherent to the subjacent structures, is the key
thetic result satisfies patient expectations thanks factor (even more important than height of kera-
to a prosthesis that is in harmony with the adja- tinized tissues) for preventing gingival recession
cent teeth and to the peri-implant soft tissues, and PSTD and allowing proper hygiene mainte-
which are similar in shape, color, and surface nance by the patient.
characteristics to the gingiva on adjacent teeth . Simultaneously, the described surgical tech-
Tension-induced ischemia due to the use of the nique has allowed partial coverage of the Miller
lip retractor while taking the photo highlights a Class III gingival recession present on the ca-
wh itish area that corresponds to the increased nine, positioning its margin slightly apical with
thickness and to the dense connective tissue respect to that of the lateral incisor and first pre-
beneath the alveolar mucosa buccal to the ca- molar, as required by the soft tissue esthetic pa-
nine and the implant-supported crown. This rameters. The i -year radiographic image shows
whitish aspect disappears when the retractor is physiologic remodeling of the bone crest and
removed. The surgical techniques that involve good implant osseointegration.
the use of a connective tissue graft completely
covered by a coronally advanced flap have the
advantage of not creating differences in color or
texture, as happens with techniques that leave
the connective tissue partially exposed. The in-
crease in the height of keratinized gingiva is the
result of the realignment of the mucogingival
junction and, therefore, happens over time in
correspondence to the height of the keratinized
tissue on the adjacent teeth and not because
of the re-epithelialization of the connective tis-
sue harvested from the palate. The presence of
dense connective tissue, sufficiently thick and
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

The increase in thickness of the

soft tissues buccal to the im-
plant-supported crown reduc-
es the risk of PSTD, masks the
underlying implant-prosthetic
components, and facilitates hy-
giene maintenance around the
prosthetic restoration. An ad-
equate prosthetic emergence
profile promotes self-cleaning
during mastication, favors at-
raumatic toothbrushing (roll
brushing technique) and avoids
unpleasant food impaction on
the buccal-aspect typical in
cases with concave emergence
profiles in association with a
horizontal soft tissue deficien-
cy. The simultaneous increase
in thickness of the gingiva
buccal to the canine prevents
recurrence/worsen ing of the
recession and allows the pa-
ti ent to brush the treated area
effectively.

411
MUCOGINGIVAL APPROAC H FOR DELAYED IMPLANT PLACEMENT
Comparison between the presurgical image and
th e 1-year recall after final restoration demon-
strates the good results that were obtained in
spite of not reaching the primary stability need-
ed for immediate provisionalization at th e time of
th e surgery. This is an incentive for less experi-
enced clin icians, who can reduce th e risks and
th e complexity related to soft tissue surgery per-
formed in co njuncti on with implant placement
and immediate provisionalization by choosing to
do a two-stage approach. As illustrated in this
chapter, th e staged approach can be done in dif-
ferent modalities:
1. first th e volume augmentation at th e eden-
tulous site and then implant placement;
2. or first soft tissue augmentation with simul-
taneous implant placement and subsequent
implant loading . In the authors' opinion,
setting aside the need for more surgeries,
w ith the staged approach predictab le and
long-lasting results can be obtained.
That which remains essential is the need to im-
plement soft tissue augmentation procedures in
the case of delayed implant placement in the es-
th etic zone.
MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

413
 MUCOGINGIVAL APPROACH FOR DELAYED IMPLANT PLACEMENT

SUGGESTED READINGS
Marzadori M, Stefanini M, Mazzotti C, Ganz S, Zucchelli G, Tavelli L, McGu ire MK, Rasperin i
Sharma P, Zucchelli G. Soft-tissue augmentation G, Feinberg SE, Wang H- L, Giannobile Wv.
procedures in edentu lous esthetic areas. Autogenous soft tissue grafting for periodontal
Periodontol 2000. 2018;06;77(1):1 11 -122. and peri- implant plastic surgical reconstruction. J
Periodontol. 2020;91 :9-16.
Monaco C, Arena A, Corsaletti L, Santomauro
V, Venezia P, Cavalcanti R, Oi Fiore A, Zucchelli
G. 2D/3D accuracies of implant position after
guided surgery using different surgical protocols: A
retrospective study. J Prosthodont Res. 2020 Feb
13. pii: S1883-1958(19)30271-3.

Morton D, Chen ST, Martin WC, Levine RA, Buser

O. Consensus statements and recommended
clinical procedures regard ing optimizing esthetic
outcomes in implant dentistry. Int J Oral Maxillofac
Implants. 2014;29 Suppl:216-20.

Stefanini M, Fel ice P, Mazzotti C, Marzadori M,

Gherlone EF, Zucchelli G. Transmucosal Implant
Placement with Submarginal Connective Tissue
Graft in Area of Shallow Buccal Bone Dehiscence:
A Three-Year Follow- Up Case Series. Int J
Periodontics Restorative Dent. 2016;36:621-30.

SU H, Gonzales-Martin 0, Weisgold A, Lee E.

Considerations of implant abutment and crown
contour: critical contour and subcritical contour. Int
J Periodontics Restorative Dent. 2010;30:335-43.

Testori T, Tasch ieri S, Scutella F, Del Fabbro

M. Immediate Versus Delayed Loading
of Postextraction Implants: A Long-Term
Retrospective Cohort Study. Implant Dent.
2017;26:853-859.

Testori T, Weinstein T, Scutella F, Wang H-L,

Zucchell i G. Implant placement in the esthetic area:
criteria for positioning sing le and multiple implants.
Periodontol 2000. 2018;77:176-196.

Zucchelli G, Mazzotti C, Bentivog li V, Mounssif I,

Marzadori M, Monaco C. The con nective tissue
platform techn ique for soft tissue augmentation. Int
J Periodontics Restorative Dent. 2012;32:665-75.

415
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Mucogingival
Approach
for the Immediate
Postextraction
Implant
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

One of the most fascinating and complex
challenges in dentistry is the immediate re-
placement of an extracted tooth in the maxil -
lary anterior area, a treatment that minimizes
the psychologic and esthetic burden on the
patient. This explains why, in recent years,
great emphasis has been placed on implant
therapy for the replacement of anterior teeth
with postextraction implants and immediate
provisionalization .
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT
It is the authors' opinion that thi s therapy should
only be considered in the case of tooth ex-
traction for dental reasons. Tooth extraction for
periodontal reasons implies the presence of
periodontal disease, w hich must be treated pri-
or to implant placement. Even in the rare case
of a localized form of periodontitis that affects
only one tooth (sporadic loss of attachment), if
the extent of bone loss excludes the possibility
of performing regenerative periodontal therapy,
th ere is even more reason not to place a postex-
traction implant with immediate provisionaliza-
tion . In the case of extraction for dental reasons,
it is still necessary to perform a careful clinical
and rad iographic evaluation before choosing
the postextraction, immediately provisionalized
implant approach. The authors believe that
postextraction implants are the first-choice
treatment for patients that require extraction of
a tooth in the esthetic area on ly when clinical
conditions are suitable for immediate provision-
alization of the implant. In fact, the esthetic ad -
vantages are mainly related to the ability of the
provisional crown to support the soft tissues,
preventing their collapse and shrinkage. The
case described refers to a central incisor that
had to be extracted because of a mesiopalatal
crown fracture that ended at leve l of th e inter-
proximal bone crest. Therapeutic alternatives,
such as orthodontic extrusion of the root and
its subsequent esthetic-functional rehabi litation,
were not accepted by th e patient.
419
MUCOG INGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT
,...__~_ ____. . . ". -=-=-=-___ I
In th e case of immed iate postextraction implants,
even more frequently th an in the case of delayed
implant pl acement, there is rarely enough buccal
• Improved vasc ularity.
• Less buccal bone resorpti on?
• Less invasive .
Among the advantages reported in th e literatu re,
there are still some doubts regard ing reduced
bone loss in association with the flapl ess tech-
nique. The authors beli eve that buccal bone loss
is more related to ridge remodeling due to th e
loss of the tooth than to the surgical trauma of
buccal flap elevation.
Courtesy of' 'John Wiley and Sons. Clin Oral Implants Res. 2016 Dec;27(12):1511-15 14.
gingival thickness (~ 2 mm) at th e most co ronal
portion to mask the im plant-prosthetic compo -
nents and reduce the ri sk for development of
peri -implant soft tissue dehiscence (PSTD). In
the authors' opinion, buccal soft tissue augmen-
tation techniques must always be perform ed si-
multaneously with postextraction, immediately
1 mm provisionalized im plants. The ideal position for
the co nnective tissue graft is 1 mm more coronal
than the gingival margin of the contralateral ho-
mologous tooth . This is done to co mpensate for
future primary and/or secondary graft shrinkage,
but especially to obtain an excessive increase in
height and thickn ess of the buccal soft ti ssues,
w hich can th en be conditioned by the restorative
dentist to achieve optim al esthetics .
Once more, the surgical technique requires a
coronally advanced enve lope flap for the cover-
age of the co nnective ti ssue graft. It is the au-
thors' opinion that a buccal flap design presents
numerous advantages in comparison to th e fl ap -
less technique:
• Easier extraction (l ess t rauma to soft
ti ssues) .
• Better visibility.
• Easier to differentiate between areas in
need of bone reconstruction or soft tissue
augmentation.
• Less risk of incorrect implant position ing
(altered passive eruption of adjacent teeth).
• Coronal advancement of the flap makes it
possible to:
1. Ac hieve co mplete coverage of a correctly
positioned connective tissue graft.
2. Treat adjacent gingival recess ions.
3. Compensate for flap shrinkage.
4. Compensate for/correct preexisting
unfavorable gingival margin position.
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

Easier tooth extraction (less trauma to soft tissues)

An open-flap extraction is more simple and results in less trauma to the buccal soft ti ssues (which are
protected by gauze) and on the interdental papillae. During flapless extractions, the use of periotomes
and elevators often induce significant trauma on the papillae and the buccal keratin ized tissues.

Better visibility and easier to differentiate between areas in need of bone

reconstruction or soft tissue augmentation
The gap between th e buccal bone plate and the implant surface is an area that requires bone grafting
because the implant is positioned more palatal with respect to the original root position. When there is
a wide gap (>1 mm), placing a biomaterial (preferably combined with autogenous bone) in thi s space
will favor bone form ati on and reduce the risk of premature loss of the buccal bone even when it is
extremely thin (exclusively bundle bone).

In an apicoco ronal sense, the grafted area
should end at th e level of the implant's rough
surface (black arrow). Th e buccal bone (white
arrow) does not always completely cover the
implant 's osseointegratable portion because
of the presence of varying degrees of buccal
bone dehiscence. A very large bone deh is-
cence is a contraindication for postextraction
implant placement. On the other hand, a small
buccal dehiscence (::;;3 mm) can be treated with
biomaterials/autogenous bone and a resorbable
co llagen membrane, whose main objective is to
give stability to the bone graft in the absence of
th e buccal plate. Excessive amou nts of bioma-
terial/autogenous bone, which cou ld impinge
on the supracrestal im plant portion (blue arrow),
should be removed, leaving the bone graft on ly
at a level where buccal bone reconstruction is
predictable (yellow arrow) before placement of
the connective tissue graft.

421
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT
The area corresponding to the soft ti ssues
(peri -implant transmucosal path) starts coronal-
Iy to the implant 's rough surface (green arrow).
These tissues should be thi ckened to allow for
an adequate emergence profile of the implant
supported crown, to mask th e underlying im-
plant-prosthetic components, and to prevent de-
velopment of buccal PSTD. Coronally, th e area
exclusively reserved for the soft tissues ends at
the level of th e gingival margin of the adjacent
tooth. For this reason, the connective tissue graft
should be placed starting coronally at this lev-
el (even better, 1 mm more coronal) and should
end apically, restin g on top of the marginal bone,
th erefore covering the endosseous portion of the
im plant and preventing development of PSTD or
risk of tissue discoloration due to the proximi-
ty of the underlying metallic structures . It is the
authors' opinion that in the presence of a small
buccal bone dehiscence (~3 mm), placement
of biomaterial/autogenous bone, a resorbable
membrane, and a connective tissue graft be-
comes more difficult and harder to control when
employing a flapless techn ique. In the case of
buccal flap elevation, the connective tissue graft
should be positioned 1 mm coronal to the soft
tissue margin of the contralateral tooth and cov-
er 2 to 3 mm of bone apical to the buccal bone
dehiscence. In this situation, the graft can serve
both th e role of a collagen membrane, ie, give
stability to the biomaterial/autogenous bone
graft, and also the role of a graft, ie, increase soft
tissue thi ckness at the level of the peri-implant
transmucosal portion (red arrow). This proce-
dure is fairly simple to do thanks to the good vis-
ibility and easy access.
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

It is the authors' opin ion that the presence mentioned above. Such tall connective tissue
of deeper buccal bone dehiscences (::;;5 mm) grafts, which extend from the gingival margin
does not constitute a contraindication for the level of the adjacent tooth up to 2 mm apical to
placement of a postextraction implant with im- the bone dehiscence buccally, should also be
mediate provisionalization if a buccal access sutured apically with simple interrupted perios-
flap is performed. However, it is important that teal anchorage sutures (7-0 polyg lycolic acid
excessive biomaterial/ autogenous bone graft [PGAj, 8-mm needle).
that cou ld , even with an
open flap , cover the su-
pracrestal implant portion
(blue line) is removed be-
fore placing the connec-
tive tissue graft, leaving
the bone graft only at a
level at which reconstruc-
tion of the buccal bone
is possible (black arrow).
Excessive biomaterial at
the supracrestal level does
not become integrated,
but is encapsulated in scar
tissue, and at the most
coronal portion free bio-
material particles can favor
bacterial contamination of
the implant site due to the
roughness of their surface
(see chapter 2). The pres-
ence of a deeper buccal
bone deh iscence requires
the placement of a taller
connective tissue graft, so
that it can serve both as a
membrane (yel/ow arrow)
and as a soft tissue graft
in the area of the transmu-
cosal path (red arrow), as
423
MUCOGINGIVAL APPROAC H FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

Coronal advancement of the flap because the initial unfavorabl e position of th e

allows compensation for preexisting
unfavorable gingival margin position
A more apical position of the gingival mar-
gin on the tooth to be extracted is no lon-
ger a contraindicati on for the postextraction
implant w ith immediate provisionalization
marginal soft tissues can be compensated
by the coronal advancement of the access
flap , along w ith the presence of the under-
lying connective tissue graft, w hich make it
possible to obtain a vertical increase of th e
soft ti ssues.
 MUCOGINGIVAL APPROAC H FOR THE IMMEDIATE POSTEXTRACTION IMPLANT
Less risk of incorrect implant
positioning (altered passive eruption
on the adjacent teeth)
One of the most serious mistakes can happen
when implant placement is performed in a pa-
tient with undiagnosed altered passive eruption
on the teeth adjacent to the implant site. This
mistake happens more commonly with flapless
implant placement. In fact, if th e implant plat-
form is positioned using the ideal gingival mar-
gin of the future prosthetic crown as a reference,
whenever this margin is placed more coronal to
the cementoenamel juncti on (CEJ) of th e neigh-
boring teeth , in case of recession, a pseudo-de-
hiscence of the peri-implant soft tissues can oc-
cur because of the altered passive eruption (see
chapter 2). In thi s clinical scenario, the implant 's
buccal mucosal margin can be in the right posi-
t ion, wh ile the gingival margins of the adjacent
teeth are excessively displaced in a coronal po-
sition due to the altered passive eruption . If the
implant 's platform is positioned too coronal in re -
lation to th e CEJ and bone crest of the adjacent
teeth, the implant should be extracted.
425
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

Th e surgical techniqu e for postex-

traction implants with simultaneous
buccal soft tissue augmentation re-
quires the execution of an enve lope
flap that can cover th e connective
tissue graft that will be positioned
1 mm coronal to the gingival mar-
gin of the homologous tooth. The
buccal envelope-type flap, with
oblique interdental submarginal in-
cisions oriented toward the tooth to
be extracted, is elevated at a vari-
able thickness: split thickness at
the level of the surgical papillae, full
thickness buccally by inserting the
periosteum elevator at the sulcus
until 2 to 3 mm of buccal bone are
exposed , and again split th ickness
to allow coronal advancement of
the flap. The tooth should be ex-
tracted only after flap elevation , in
an atraumatic fash ion, protecting
the soft tissues and preserving the
interd ental papillae, the buccal ke-
ratinized tissues, and the buccal
bone wall. This is very important
because loss of the buccal bone
wall (>5-mm dehiscence) wou ld re-
sult in the need to perform bone re-
generation procedures before im-
plant placement, which in that case
would then have to be delayed.

The bucco lingual position of the implant shoulder should be palatal to the imaginary line that con-
nects the buccal profile of the adjace nt teeth (white line), without placing it excessively palatal and
trying to keep the implant axis in correspon dence to the palatal aspect of the incisal edge. This is
to avoid creating prosthetic emergence profiles that are too horizontal , which are hard to maintain in
term s of hygiene (see chapter 6).
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

In an apicocoronal direction, the endosseous

implant portion is positioned 3 to 3.5 mm apical
to an imaginary horizontal line (black line) at the
same level as the gingival margin of the natural
homologous tooth (red dotted line), wh ich always
represents the reference point for implant posi-
tioning. In the case of transmucosal implants,
the beginning of the endosseuos implant sur-
face should be taken into consideration, not the
implant shoulder as is done with bone-level im-
plants. Mesiodistally, the implant should maintain
a minimum distance of 1.5 mm from the adjacent
natural tooth . It is the authors' opinion th at, in the
case of immediate postextracti on implants, the
use of guided implant placement tech niques is
particularly indicated to minimize the risk of mis-
takes during implant positioning, which are far
more frequent in comparison to delayed implant guarantee stability of the soft tissue margin , and
placement. contribute to creating a correct and hygienical-
At the end of treatment, the buccal mucosal ly maintainable emergence profile for the pros-
margin of the implant crown should be at th e thetic crown. The use of transmucosal implants
same level and have the same scallop as the (in wh ich the height of the polished neck can
gingival margin of the homologous natural tooth be chosen in relation to the peri-implant trans-
(red dotted lines). Therefore, there will always mucosal portion) is useful for displacing the im-
be a peri-implant transmucosal portion com - plant-abutment connection away from the bone
posed exclusively of soft tissues, whose buccal crest. This reduces bone resorption and facili-
thickness should be enough to mask the im- tates hygiene maintenance by both the patient
plant-prosthetic components of the restoration, and the hygienist.
427
courtesy of: • John Wiley and Sons. Clin Orallmplants Res. 2016 Oec;27(12): 1511-1514.
MUCOGINGIVAL APPROACH FOR TH E IMMEDIATE POSTEXTRACTION IMPLANT
Th e space between the im plant surface and th e
buccal bone wall , an area in which bone recon-
struction is predictable, is fi lled with biomaterial!
autogenous bone when its buccopalatal dimen-
sion is :::2 mm . The implant 's mesial and distal
interproximal soft tissues (papillae) are of crucial
importance for the peri-implant plastic surgery
because they make up the vascular bed and
also serve as anchorage for the surgical papil -
lae of the coronally advanced flap overlying the
connective tissue graft. One of the most import-
ant differences between the clin ical scenario of
the postextracti on implant and delayed implant
placement (6 months after tooth extraction; see
chapter 6) is related to th e mesiod istal and bu cco-
lingual dimension of the interproximal soft tissues.
When the site is allowed to heal completely after
tooth extraction, the anatomical papillae (which
remain even after th e circular gingivectomy per-
formed for crestal access) are wide mesiodistally,
thick buccolingually, and made up mostly of dense
and mature co nnective tissue. In addition, papil-
lae on delayed implants have a wide isthmus that
can be de-epithelialized toward the occlusal plane
in a palatal direction, significantly increasing the
vascu lar bed for the surgical papillae of th e cor-
onally advanced flap. On the other hand , in cases
of immediate implant placement, papillae have a
smaller dimension, are narrower, barely thick, and
most of the time are partially mobile. For th ese rea-
sons, it is particularly important not to traumatize
them during tooth extraction. Anatom ical papillae
of reduced dimensions, like those found in postex-
traction sites, hardly allow suturi ng of the connec-
tive tissue graft to their base because not enough
vascular bed ti ssue would be left for the anchorage
of the surgical papillae of the coronally advanced
flap. That is why in cases of post-extraction im-
plant placement th e co nnective ti ssue graft must
be sutured to the internal surface of the flap.
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT
Th e apicocoronal dimension of the connective
tissue graft is chosen by taking into consider-
ation two reference points: the gingival margin
of the contralateral tooth and th e buccal bone
crest. Th e graft should be sutured 1 mm cor-
onal to an imaginary horizontal line (black line)
traced from the gingival margin of the contralat-
eral tooth (red dotted line), and it must extend
2 to 3 mm apical to the bone crest. The exces-
sive coronal placement of the graft is done to
compensate for future tissue contraction and to
have, once the tissues have
healed , soft tissue that is
coronally positioned in re-
lation to the gingival margin
of the co ntralateral tooth
and that can be prostheti-
cally cond itioned in order to
obtain a mucosal margin of
the implant crown that is at
the same height and has the
same morphology of the gin-
gival margin of the homolo-
gous tooth. Considering that
the implant 's osseointegrat-
able surface matches the
position of the buccal bone
crest, and is th erefore at a
distance of 3.5 mm from the
gingival margin of the con-
tralateral tooth, it follows that
the height of the connective
tissue graft should be 6.5
mm. The graft is sutured to
the flap 's internal surface in
a paramarg inal position with
internal horizontal mattress sutures, keep ing the
anatomical de-epithelialized papillae (white ar-
rows) free from any interference and allowing first
intention wound healing with the surgical papil-
lae of the coronally advanced flap (black arrows).
Suturing the graft to the flap's internal surface
doesn't preclude the graft from acting as a mem-
brane for stabilization of biomaterial/autogenous
bone when the bone graft is not completely pro-
tected by the alveolar bone due to the presence
of bone dehiscence.
429
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

After being sutured to the flap's internal aspect,

the graft should be in a paramarginal position 1
mm apical to the scalloped margin of the buccal
fl ap. To achieve this positi oning, it is necessary to
measure 2 mm apical from the most apical por-
tion of th e gingival margin scallop and displace
this measurement horizontally toward the base
of the surgical papillae, the level at which a hor-
izontal internal mattress suture (7-0 PGA, 8-mm
needle) should be performed. From the external
aspect, the needle penetrates first the surgical
papilla (illustration A) and then the graft (illustra-
tion B; placed 1 mm from the coro nal margin),
then it goes back and reenters horizontally, per- of 2 mm from the most apical part of the mar-
forating first the graft (illustration C) and then ginal tissues, when the suture is finished the
the flap (illustration 0) from their internal aspect, connective tissue graft will be positioned 1 mm
and exits horizontally with respect to the starting apical to the scalloped margin and at the base
point; the suture is closed with a surgical knot of the surgical papillae. The whole of the surgical
(illustration e; black arrows in photos). Since the papilla, void of any underlying graft, remains free
needle perforates the graft at a distance of 1 mm to be closed by first intention with the de-epithe-
from its coronal border and th e flap at a distance lialized ti ssues of the anatomical papilla.

and adjacent teeth. Simple interrupted sutures

After screwing in the provisional (or, as in the
case illustrated, an abutment onto which the
provisional will be rebased), the flap is sutured
coronally with sling sutures that are suspend-
ed arou nd th e cingula of the provisional crown
(7-0) comp lete the first intention wound closure
of the surgical papillae and th e corresponding
anatomical papillae mesial and distal to the
provisional crown . Th e flap's keratinized tissue
must have a thorough and precise adaptation
to the prosthetic provisional crown, with no
blood seeping from the margin at the end of the
surgery. This wil l provide stability to the surgi-
cal wound and prevent contraction of the flap's
marginal tissues.
 MUCOGING IVAL APPROACH FOR THE IMM EDIATE POSTEXTRACTION IMPLANT

The main role of the pros-

thetic provisional crown is to
provide a stable support that
is firm , polished, and convex
so that it can prevent risk
of collapse and contraction
of the flap's marginal soft
tissues. The paramarginal
position of the graft makes
it possible for the flap's mar-
ginal tissues to adapt firmly
and precisely to the pros-
thetic crown without any
interference with the graft
itself. The presence of both
the keratinized tissue on the
coronally advanced flap and
the paramarginal connective
tissue graft contri bute sig-
nificantly to the stability of
the marginal tissues that are
adapted to the provisional
crown.

431
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IM PLANT
Sutures are removed 14 days after the surgery, at
which time th e increase in height and thickness
of the implant's buccal soft tissues can already
be appreciated. The mucosal margin is coronal
to the gingival margin of the homologous tooth,
and the graft is completely covered by the flap.
During the first 3 postsurgical weeks, the pa-
tient does not perform mechanical oral hygiene,
but instead performs chem ical plaque control
by keeping a ch lorhexidine-based mouthwash
(0.12%) on the surgical site for 1 minute with a
frequency of three times a day.
Three weeks after the surgery, the patient starts
to brush with an ultra-soft toothbrush and reduc-
es local application of the chlorhexidine rinse to
twice a day. The toothbrushing technique should
be a coronally directed roll technique, keeping
the bristles in contact with the tissues wh ile per-
forming an apicocoronal movement from the soft
tissues toward the tooth's crown. After 4 weeks
of using the ultra-soft toothbrush, the patient
changes to a soft toothbrush and uses ch lorhex-
idine rinse only once a day.
Th e soft-bristled toothbrush, applying the roll
technique, is used for 2 months. Around 3.5
months after the surgery, the patient stops using
the ch lorhexidine mouthwash and begins using
a medium-bristled toothbrush (always with th e
ro ll technique) and reinstates use of the spongy
interdental floss.
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

Soft tissue maturation should remain undisturbed
for around 6 months. During this period, it is es-
sential that the provisional crown does not inter-
fere negatively w ith growth and maturation of the
soft tissues. Therefore, it should be smooth , well
fini shed , and progressively reduced buccally and
at the interproximal level of th e emergence profile
in order to leave some space for maturation of the
connective tissue. Th e occlusal images show an
increase in the volume of the buccal soft tissues,
w hich is greater apically (black arrow) th an at the
level of the transmucosal portion. This can be at-
trib uted to the 2-mm apical extension , at the time
of the surgery, of the con nective tissue graft on
top of the buccal bone, which still has to complete
the postsurgical remodeling process. In time, buc-
cal bone resorpti on in a palatal direction w ill lead
to a reduction in the vo lume of the apical tissues,
w here excessive augmentation would be useless
and is often not we ll accepted by the patient.

Six months after the surgery, remodeling of the hard tissues and maturation of the soft ti ssues can be con-
sidered nearly complete, and therefore it is possible to proceed with the soft tissue conditioning phase.

433
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT
During these first 6 months, the grafted soft tis-
sue matures, increasing its own vo lume, as op-
posed to th e osseous tissue, wh ich undergoes
a resorption process following tooth extraction.
Resorption of th e hard tissues in a buccolingual
4 MONTHS
6 MONTHS
6 MONTHS
6 MONTHS
direction is clinically noticeable at the apical area
as a reduction in tissue prominence (black ar-
rows), a phenomenon that cannot be appreciated
at the most coronal portion (transmucosal path),
where only soft tissues are present (white arrows).
6 MONTHS
 MUCOG IN GIVAL APPROAC H FOR THE IMMEDIATE POSTEXTR ACTI ON IMPLANT

Six months after the surgery, soft ti ssue condition -
ing starts with the use of a screw-retained provi-
sional. During thi s phase, the goal is to obtain a
soft tissue morphology that resembles, as much
as possible, that of the homologous tooth . In thi s
regard , an excess of mucosal tissues (ie, peri -im-
pl ant soft tissue margin is coronal to th e gingival
margin of the homologous tooth) will all ow for bet-
ter prostheti c conditioning. Another objective of
the co nditioning phase is to achieve th e maximum
growth of the papill ae mesial and distal to the pro -
visional implant crown th rough the "squeezing"
effect. This is obtained by the prog ressive mod-
ification of the provisional's interproximal profiles
to gradually shift the contact point coronally.
Adjustments on the provisional should entail small
changes, repeated several tim es, if necessary, in
order to obtain more papillae growth .

Comparison of the occlusal imag es at 6 and 9 months after th e surgery shows a further slight reduc-
ti on of th e soft ti ssue volume apically (black arrows) but not coro nally. This is presumably due to the
rem odeling process that, even if clinically less noti ceable, co ntinues long after the first 6 months.

6 MONTHS 9 MONTHS

435
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

The final restoration can be placed once an ad-

equate morphology of the peri-implant muco-
sal margin is obtained (both in height and scal-
lop) and there is no further papillae growth after
the last modification to the provisional (papil-
lae are no longer able to fill the vertex of the
interproximal triangular space). Special care
should be taken in this last phase not to alter
the result obtained with the provisional crown.
Collaboration with proficient dental technicians
is essential for obtaining excellent esthetic
results.
Comparison between the occlusal image at 2
and 12 months after surgery shows how the view. On the other hand , soft tissue volume of
reduction in apical tissue volume (black line) the supracrestal soft tissues remains stable or
is absolutely significant from a clinical point of might even increase over time.

As a general rule, the authors prefer screw-re-
tained restorations to avoid problems related to
cementation (cement residues have been iden-
tified as predisposing factors for development
of peri-implantitis). Nevertheless, it is still pos-
sible to achieve optimal results with cement-
ed restorations , both in terms of esthetics and
maintenance. In the case shown, the choice of
a cemented restoration was made due to the
absence in those days of angulated abutments
that wou ld allow correction of a voluntary buccal
implant placement (esthetically guided) with re-
spect to the center of the palatal cingu lum (pros-
thetically guided) (see chapter 6).
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT
In case of a cemented restoration , it is import-
ant for the prosthetic abutment to faithfully re-
produce the shape of the provisional at the level
of the peri -implant transmucosal portion , sup-
porting the soft tissue margin and the interden-
tal papillae so as to maintain the morphology.
Another cruc ial factor is that the location of the
final crown margin should be only slightly apical
to the soft tissue margin (0.5 to 1 mm) to al -
low for masking of the crown margin but at the
same time make cement removal and patient
home maintenance easier.
The risk of cement residues remaining subgin-
givally must be taken into consideration and
minimized by using retraction cords at the mo-
ment of cementation.
From a clinical point of view, the aim is to satis-
fy the patient's esthetic and functional requ ire-
ments. The treated area should be virtually un-
distinguishable from the rest of the dentition,
both regarding the prosthetic crown and the soft
tissues.
Radiographic examination should depict good
implant osseointegration and radiopacity of the
bone crest, wh ich, in addition to the absence of
clinical signs of inflammation, confirms health of
the peri-implant tissues.
437
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

Augmentation of soft tissue thi ck-

ness reduces the risk of PSTD,
camouflages the underlying im-
plant-prosthetic components, and
aids in hyg iene maintenance of the
restoration. Furthermore, an ad-
equate emergence profile favors
self-clean ing during mastication,
facilitates atraumati c toothbrushing
(roll technique), and prevents both-
ersome food entrapment on the
buccal surface, typical in cases with
concave emergence profiles in wh ich
a horizontal defect is present on the
buccal tissues. One year after deliv-
ery of the final restoration , the out-
come appears stable. Comparison
between the clinical images at base-
line and 1 year after placement of
the definitive restoration confirm
success of the performed treatment.
MUCOGINGIVAL APPROAC H FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

1 MONTH

5 MONTHS

6 MONTHS

9 MONTHS

1 YEAR

439
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

Two years after final restoration placement, the clinical outcome remains stable and fulfills the patient 's
esthetic demands. The soft tissues are morphologically and dimensionally stable.
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

441
MUCOG INGIVAL APPROACH FOR TH E IMM EDIATE POSTEXTRACTION IMPLANT

Clinically, the comparison betwee n the baseline situation and the outcome after 7 years makes it pos-
sible to appreciate the long-term stability of the procedure.

In the authors' opinion, the increase in buccal soft tissue thickness at the level of the peri-im plant trans-
mucosal portion is a prerequisite for the esthetic and functional success of an immediately restored
implant placed immediately after tooth extraction.
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

Maintenance of the clinical outcome is supported radiographically by tissue stability over time.
Comparison between the intraoral fi lms taken during various follow-ups is essential to keep track of
bone level changes interproximally. An increased radiopacity of the interproximal bone crest should be
considered indicative of peri-implant tissue health.

1 YEAR 3 YEARS 7 YEARS

~---- ----~

443
MUCOGINGIVAL APPROACH FOR THE IM MEDIATE POSTEXTRACTION IMPLANT
This clinical case shows a patient that is ex-
tremely satisfi ed with the obtained estheti c result.
The challenge, but also the greatest advantage,
of tooth replacement due to dental reasons with
an immediately provisionalized postextraction
im plant is to make the treated area blend in com-
pletely with the adjacent sites, regarding both the
soft tissues and dental structures. To achieve
thi s goal, correct (preferably co mputer-guided)
implant placement, immed iate provisionalizati on ,
and buccal soft tissue height/thickness augmen -
tation are essential. All of this is done in order
to compensate for the bone remodeling that will
take place around the postextraction alveolus,
parti cularly on the buccal bone plate.
The latter occurs mainly during the first 6 months
and can be appreciated as a progressive reduc-
tion in tissue volume on the area apical to the
peri-implant transmucosal portion where, on the
co ntrary, soft tissue thickness must remain sta-
ble (or eventually increase over time) to mask the
implant-prosth etic components and prevent the
development of PSTD on the buccal aspect of
the implant-supported crown.
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

Clinical follow-up at 10 years shows the long -term stability of the outcome. The patient is highly sat-
isfied, both from an esthetic and functional point of view. Th e increase in buccal soft tissue thickness
led to further creeping of the marginal gingiva at the implant site, which now appears to be in a slightly
more coronal position than th at of the adjacent central incisor. This, however, has not been perceived
by the patient.

445
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

Comparison between the baseli ne situati on and
the 10-year fo llow-up emphasizes the quality of
the resu lt. Soft tissue augmentation performed
at the time of implant placement made it pos-
sible to obtain an optimal esthetic outcome and
provide adequate emergence profiles for the
implant-supported crown, wh ich facilitates hy-
giene maintenance. Patient co llaboration with
self-performed hygiene and comm itment to the
maintenance recall program are essential for
long-term success. The periapical radiograph
shows stability of the peri -implant bone.
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

447
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

One of the most common indications for tooth ex-

traction due to dental reasons are root fractures
that do not al low functional recovery of the affect-
ed tooth . These occur most frequently in end-
odontically treated teeth that, after years of func-
tional stress, undergo loss of structural integrity.
Clinically, diagnosis is made by encountering a
deep, localized probing depth that coincides with
the site of the vertical fracture. Radiographically,
the fracture can rarely be identified (unless tooth
fragments have been displaced), but presence
of an intrabony lesion is a common finding as a
result of contamination of the fracture line and
corresponding development of an inflammatory
response on the adjacent tissues. Occasionally,
clinical and radiographic signs might be absent,
but the patient reports pain or discomfort on
mastication .
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT
When the gingival margin of
the tooth to be extracted is at
the same level as that of the
homologous tooth, a surgical
technique must be used that,
in addition to postextraction
implant placement, all ows for
a horizontal and vertical soft
tissue augmentation in order to
compensate for the physiologic
remodeling of the buccal bone
that follows tooth extraction and to provide the
restorative dentist excess coronal soft tissues
that can be conditioned during the provisional
phase to emulate the height and scall op of the
gingival margin on the homologous tooth.
Failure to augment the soft tissues vertical-
ly wou ld most likely lead to an implant crown
that is longer than the homologous tooth. It is
the authors' opinion that a postextraction im-
plant shou ld only be performed with a flapless
Persistence of painful symptoms during masti-
cation, even after the attempted reconstruction
of the fractured abutment and placement of a
provisional restoration , led to the decision to ex-
tract the root remnant. The patient 's high esthetic
demands, good condition of the soft and hard
tissues (good height and thickness of the kerati-
nized tissues and reduced buccal bone sounding
measurements), as well as the limited root length
supported the choice of postextraction implant
placement with immediate provisionalization.
technique when the gingival margin of the tooth
to be extracted is coronal to that of the contra-
lateral tooth . This condition is rather rare, un-
less orthodontic extrusion of a root with buccal
connective tissue attachment is done in order
to coronally displace the gingival margin of the
tooth to be extracted. In the authors' experience,
the patient seldom accepts several months of
orthodontic therapy if tooth preservation is not
the final goal.
This helps reduce the number of surgical appoint-
ments and prosthetic steps, wh ile optimizing the
esthetic resu lt. Teeth adjacent to the future ex-
traction site have gingival recession and appear
longer in relation to the correspond ing contralat-
eral teeth. Another advantage of performing the
surgical technique that foresees the use of an
envelope type of coronally advanced flap is the
possibility of treating the recessions on adjacent
teeth at the same time, therefore improving the
overall harmony of the buccal soft tissues.
449
MUCOGINGIVAL APPROACH FOR THE IMM EDIATE POSTEXTRACTION IMPLANT

Th e envelope buccal flap was elevated at a vari-

able thickness that would allow its coronal ad-
vancement as well as expose the underlying
bone crest in order to make the root extraction
easier. Special care shou ld be taken to preserve
the integrity of the anatomical papillae mesial and
distal to the root, since they are essential for the
surgery's successfu l outcome.

Aesthetically-guided implant placement (the implant axis coincides with the palatal surface of the
incisal margin) is done with a surg ical stent that guides the burs during the preparation of the implant
site. Regarding the apico-coronal position, the rough portion of the transmucosal implant is placed
at a distance of 3-3 .5 mm from the ideal position of the gingival margin of the implant crown, which
should be placed at the same level as that of the corresponding reference tooth (lateral incisor) by
the end of the treatment.
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

The gap between th e buccal bone plate and the implant surface is fill ed w ith a biomaterial/autogenous
bone mix to provide stability to the clot and red uce the loss of buccal bone, especially w hen the latter
is particularly thin .

Excessive biomaterial present at the level of the
transmucosal implant collar (black arrow) should
be removed. The most coronal aspect of the bio-
material/autogenous bone mix remains exposed
in correspondence to the area of the small buc-
cal bone dehiscence. Th e bone particles are sta-
bilized by the membrane effect created by the
connective tissue that was sutured to the fl ap's
internal surface. The apicocoronal dimension of
the graft should cover 2 mm of native bone apical
to the dehiscence. The suture of the graft onto the
fl ap in a paramarginal position leaves the surgical
papi llae free (white arrows), making it possible to
suture them on top of the anatomical de-epithe-
li alized pap illae (simple interrupted sutures, 7-0).
A tall healing abutm ent is placed while th e pro-
visional crown, rebased intraoperatively, is refin-
ished and polished.

Once the provisional is screwed onto the im-
plant, a sling suture (6-0 PGA, 11-mm needle)
anchored to the palatal aspect of the restoration
is done to achieve tight adaptation of the buccal
keratinized tissues onto the provisional crown.
The absence of blood seeping from the margins
is a sign of surgical wound stabi lity, w hich w ill
minimize contraction of the coronally advanced
fl ap. Not leaving extra space between the provi-
sional crown and the adjacent teeth (white arrow)
is a common mistake that interferes w ith undis-
turbed, fi rst intention wound healing between the
surgical papilla and the underl ying anatomical
papi lla.
451
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

Sutures are removed 14 days after the surgery. Since the provisional's mesial interproximal space
was closed by th e resto ration, the early healing of the papilla was affected .

However, adequate management of th e buccal flap made it possible to preserve complete coverage
of the connective tissue graft. Early shrinkage of the buccal flap could lead to failure of the surgery in
the worst-case scenari o; in the best-case scenario, it cou ld lead to graft exposure. The latter would
resu lt in a lesser increase in thi ckness and height of the buccal soft ti ssues, not to mention th e unes-
thetic appearance resu lting from the white, keloid-l ike aspect typical of a healed free gingival graft.
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

It is crucial to identify as soon as possible if the provisional is interfering with the healing process,
especially at the level of the papillae. If the interproximal spaces are opened (black arrow) before the
soft ti ssue growth and maturati on phase starts, the ti ssues wi ll be able to heal as planned.

The combined thickness of the graft and its coveri ng flap leads to an increase in th e buccal soft
ti ssue vo lume, w hich continues growing throughout the healing period. Thi s increased thi ckn ess en-
tail s coronal soft ti ssue growth (creeping phen omenon) that resu lts in the mucosal margin of the im-
plant-supported crown being at a more co ronal level with respect to the correspond ing contralateral
tooth . Thi s is essential for the success of soft tissue conditioni ng at the end of the maturati on phase.

453
MUCOGINGIVAL APPROACH FOR THE IMM EDIATE POSTEXTRACTION IM PLANT

A comparison between the occlusal presurgical
view and follow-up images after a few months
showcases the increase in thickness of the
soft tissues bu ccal to th e implant, achieved
th anks to th e add ition of th e co nnective ti ssue
graft. Regardl ess of the increased volume, the
peri-im plant soft ti ssues display a co lor and
surface textu re indistinguishable from that of the
surrounding soft tissues. Thi s is possible thanks
to the slightly paramarg inal position of the graft
and th e tight adaptation of th e flap's keratinized
ti ssues onto th e surface of the provisional- both
key elements to avoid early dehiscence of th e
coronally advanced flap.

During the first months after the su rgery, th e provisional should not co mpress the soft tissues, th ere-
by allowi ng them to mature freely without any obstru ction. Th e increase in soft tissue vo lume more
th an compensates for the remodeling of the buccal bone plate resulting from the root extraction.

Th e maturation process of the soft ti ssues is al-
lowed to run its course for 6 months. The buc -
co lingual increase in the soft tissues is a direct
resu lt of the increased thickness of the connec -
tive tissues along th e most coronal 3.5 mm of
th e peri-impl ant transmu cosal path . Ti ssues
that are less th an 2 mm thick are not able to
comp letely mask th e underlying implant-pros-
thetic stru ctures and do not protect agai nst the
risk of soft tissue dehiscence.
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

The vertical soft tissue increase made it possible
for the mucosal margin of the im plant-supported
crown to be in a more coronal position than the
gingival margin of the reference tooth. Thi s al-
lows the restorative dentist to conditi on the soft
tissues until the level and scallop of the margin
coincide with those of th e natural contralateral
tooth. Soft tissue cond itioning in an apical di-
rection , in addition to modifications of th e pro-
visional crown 's interproximal profiles that pro-
gressively displace the contact point in a more
coronal position, favors vertical growth of the
papillae mesial and distal to the provisional res-
torati on (squeezing effect).

Conditioning of the surgically augmented soft tissues starts after 6 months of healing . Thi s can be
done with the same provisional that was rebased intraoperatively and modified during the maturation
ph ase or, even better, with a new screw-retained provisional.

455
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

Once th e position and the contour of the peri-implant soft ti ssues resemb le
those of the gingival margin at the reference tooth, and the papillae mesial and
distal to the im plant crown don't show further growth after the last modifications
to the contact points, it is possible to proceed w ith the final prosthetic phase.
Th e increased co nnective tissue thickness at the leve l of the tran smucosal path
w ill suffice to mask any kind of prosth eti c material, optimizing the esthetics of
the rehabi litation.

Esthetics are influenced not only by the morphology and quality of th e soft tissues, but also by the
characteristics of the prosthetic crown , which should blend in well with the adjacent natu ral teeth 's
shape, co lor, surface characteristics, and translucency.
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

The coverage of the gingival recessions on the teeth adjacent to the implant-supported crown, achieved
thanks to the coronal advancement of the buccal flap, contributes to the improvement of the overall
esthetic outcome.

The appropriate emergence profi le created between the pros-

thetic crown and the buccal soft tissues facilitates hygiene prac-
tices for the patient, who can implement atraumatic brushing
techniques that are effective in removal of dental plaque without
the risk of deve loping buccal soft tissue dehiscences. The peri-
apical radiograph shows good implant osseointegration .
457
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

Five years after the treatment, the result remains stable from both a clinical and radiographic point of
view. Comparison between the presurgical image and the 5-year foll ow-up after placement of the final
restoration reveals a good esthetic and functional outcome.
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

459
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

The determination of which areas are import- are almost always needed in the anterior areas
ant to esthetics is completely up to the patient. where ridge thickness is reduced , but they can
Some patients have esthetic complaints regard - frequently be avoided in lateroposterior areas
ing previous treatments performed in the latero- when standard periapical radiographs and bone
posterior areas. That was the case of a young sounding confirm adequate levels interproximally,
patient who, following a surg ical crown lengthen- buccally, and palatally.
ing procedure done to treat a second maxillary
premolar that suffered a distal crown fracture,
complained about the creation of black triangles
between the second premolar and the adjacent
teeth and also about the increased height of the
clinical crowns. The situation created great dis-
comfort for the patient from an esthetic point of
view and also because of food impaction in the
area. Although the chief complaint was related
to esthetics, probing depths distal to the pre-
molar revealed the presence of a deep localized
defect at the premolar's distopalatal line angle.
Buccal and palatal probing depths were indica-
tive of good preservation of the bone level. In the
authors' opinion, three-dimensional radiographic
evaluation along with guided implant placement
 MUCOGINGIVAL APPROACH FOR THE IM MEDIATE POSTEXTRACTION IMPLANT

An envelope flap spanning from the can ine to the distal aspect of th e molar (the center of rotation being
the implant) was elevated with a variab le thickness and freed from muscle insertions to obtain its coro-
nal advancement. After atraumatic tooth extracti on, the site was prepared for implant placement, trying
to obtain the primary stability needed for immed iate provisionalization.

Th e residual gap between the buccal bone plate and the implant was filled w ith biomaterial and
autogenous bone, and the connective tissue graft was sutured to the internal surface of the flap in a
paramarginal position.

After de-epithelializing the anatomical pap il-
lae, th e flap is sutured coronally w ith sling su-
tures suspended around the palatal surface
of each of th e teeth invo lved in the surg ical
area. Simple interrupted sutures are used to
achieve first intention wo und closure between
the surgical papi llae and the underlying an-
atom ical papillae mesial and d istal to the tall
healing abutment; the latter is used to provide
stabi lity to the buccal flap w hile performing
chairs ide re lining , refinishing, and poli shing of
the provisional.

461
MU COG IN GIVAL APPROAC H FOR THE IMMEDI AT E POSTEXTRACTI ON IM PLANT

Besides allowing immed iate replacement of the kept completely out of occlusion to avoid early
extracted tooth (fundamental for a patient with loading of the implant.
high esthetic demands),
th e provisional should pro-
vide a convex and smooth
surface onto w hich th e
keratinized tissues of the
coronally advanced flap
can adapt firmly in a pre -
cise way. In fact , a fl at or
co ncave surface would
not block blood flow from
the flap margins at the end
of the surgery, resulting in
an unstable wound and 1 MONTH
predisposing it to early
flap shrinkage. The provi-
sional crown should leave
enough space interproxi-
mally to all ow undisturbed
healing of the papillae. For
thi s reason, co ntrary to
the buccal surface, the in-
terp roximal profiles should
be flat and slightly con-
3 MONTHS
cave. This is particularly
important since th e goal is
not only to preserve pre-
surgical papilla height, but
also to improve it. In th e
lateroposteri or areas it is
necessary to pay special
attention to th e occlusion:
th e provisional should not
have any contact with the
antagonist, and it must be
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

After 6 months of undisturbed maturation of the soft tissues that were augmented horizontally and vertical-
ly (notice the mucosal margin at the provisional, which is more coronal than the gingival margin of the adja-
cent premolar), it is possible to bring the provisional crown into occlusion and start soft tissue conditioning .

After approximately 3 months, having obtained a satisfying shape and position of the buccal peri-im-
plant mucosal margin and of the papillae mesial and distal to the implant crown, the final restoration
was placed.
463
MUCOGINGIVAL APPROAC H FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

The clin ical outcome 1 year after placement of the definitive restoration is esthetically pleasing thanks
to th e buccal soft tissue augmentation, which has made it possible to reduce the clinical crown height
of th e implant restoration .

More importantly, comparing the baseline situation and the 1-year follow-up after delivery of the final
prosthesis shows such an improvement of the papillae mesial and distal to th e implant crown that they
almost completely fill the embrasure space and are even more coronal than th eir preoperative position.

The presence of suboptimal papil -

lae (both in quality and/or height),
once consi dered a contraindication
for the execution of immediate im-
plant placement in a pati ent w ith
high esthetic demands, has become
an indication for immed iate im plant
placement w ith immediate provi-
sionalization , as long as a coronal ly
advanced flap with a connective tis-
sue graft in a paramarg inal position
is done sim ultaneously. Peri-implant
soft tissue augmentation, both buc-
co li ngually and apicocoronally, is the
prerequisite for obtaining a surplus of
tissues that can th en be conditioned
to achieve maximum growth of the
peri-implant pap illae.
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

The periapical radiograph shows good implant
osseointegration and absence of any signs of
marginal bone loss. Th e comparison between
the profile image before the tooth extraction and
the profile image at 1 year after final prosthesis
delivery emphasizes the significant increase in
buccal soft tissue thickness, partly responsible
for the restoration's great esthetics and for the
absence of tissue discoloration from the underly-
ing implant-prosthetic structures.

465
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

The 5-year follow-up after the definitive restoration
shows stability of the clinical and radiographic re-
sults. The soft tissues appear thicker in compar-
ison to the 1-year recall, a frequent finding when
the coronally advanced flap has been implement-
ed with an adjunct de-epithelialized connective
tissue graft. There was also further improvement
at the peri-implant papillae. The periapical radio-
graph shows stability of the peri-implant bone
and radiopacity of the bone crest; along with the
absence of signs of mucositis, this indicates a
healthy status of the peri-implant tissues.
MUCOG IN GIVAL APPROAC H FOR THE IMMEDIATE POSTEXTR ACTI ON IMPLANT

467
MU COG IN GIVAL A PPROACH FOR THE IM M ED IATE POST EXTRACTION IM PLANT
One of th e greatest challenges for a clinician
is th e restoration of a central incisor in a young
pati ent with high esthetic demands - even more
so if the pati ent presents a thin and scalloped
phenotype, with teeth that are triangular in shape
and long, slender papill ae. The situati on gets
more co mplicated when the gingival margin of
th e tooth to be extracted is more apical than the
gingival margin of its adjacent counterpart and
the distal papilla is extremely thin (bucco lingually)
and not supported by an intact bone peak at the
lateral incisor (due to a slight loss of bone and
attachment on its mesial aspect). In these situa-
ti ons, immed iate implant placement with imme-
diate provisionalization is generally considered to
be contraindicated . However, the authors believe
this is true only in the case of flapless implant
placement.
In this case, the periapical radiograph revealed
an endodontically treated tooth that had suffered
severe external resorption, most likely resulting in
root fracture during tooth extraction. A co mplex
extracti on is also an important indicati on for the
elevation of a buccal flap. Th e risk for soft tis-
sue trauma, especially of the already weak distal
papilla, is extremely high if a "cl osed" tooth ex-
traction is attempted . In the authors' opinion, it's
not a risk worth taking when the pati ent has high
estheti c demands.
 MUCOGINGIVAL APPROACH FOR TH E IMMEDIATE POSTEXTRACTION IM PLANT

The occlusal and profile views highlight the re-

duced thickness of the soft ti ssues buccal to
the tooth to be extracted, and even more so at
the leve l of the distal papilla, where the epithelial
invag ination (black arrow) is suggestive of a sig-
nificant loss of connective tissue thickness. The
ti ssues are so thin that the pigmented root of the
endodontically treated tooth has led to dark tissue
discoloration.
In cases like the one just described, the margin
for error is almost zero. As previously stated , im-
plant malposition and a thin phenotype are the
factors most commonly associated with peri-im-
plant soft tissue dehiscences (see chapter 1). The
phenotype problem can be solved by perform- with implant placement, while the risk of implant
ing soft tissue augmentation techniques along malposition needs to be reduced to a minimum
by using comput-
er-guided systems
that allow fully guid-
ed implant place-
ment. The use of
dedicated software
all ows virtual plan-
ning of dental implant
placement, analyzing
its three-dimensional
housing and relation-
ship with adjacent
teeth and anatomical
structures.

469
MUCOGING IVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT
In addition, comp uter-supported implant plan-
ning allows maximum usage of the bone apical
and lateral to the root to be extracted , gu ides
implant bed preparation as we ll as implant
placement, and minimizes th e su rgical trauma
and therefore th e associated bone loss. All of
these aspects increase the chances of reach-
ing a primary stability su itable for immediate
implant provisionalization, a key element for
the attainment of the best estheti c result.
Incorrect buccopalatal implant inclinati on and
too buccal/apical placement of the im plant
platform have been li sted among the factors
related to implant position th at have a great-
er impact on the development of PSTD (see
chapter 1). Computer-guided soft ware pro-
grams can be used to assess the distance
between the osseointegratable implant surface
and the ideal mucosal margin of the prostheti c
crown (wh ich should be at the same level as
the gingival margin of the contralateral tooth) in
ord er to plan the apicocoronal position of th e
implant platform.
Th e cross-sectional view is useful to evaluate
the correct buccolingual inclination of the im-
plant and th e emergence angle of the future
restoration in order to create screw-retained
prosthetic stru ctu res (if possible) w ith profiles
that are easy to maintain from a hygienic point
of view. In fact, a very wide emergence ang le
wou ld lead to horizontal probing at the level of
the transmucosal path , w hich wou ld make hy-
giene maintenance difficult, if not impossible,
for both the pati ent and the hyg ien ist.
 MUCOG INGIVAL APPROAC H FOR TH E IMMEDIATE POSTEXTRACTI ON IMPLANT

Once the implant position has been planned wou ld most li ke ly not be able to w ithstand graft
three-d imensionally, it is possible to manufac- suturing alone. The absence of an adequate
ture a su rgical stent that allows fully guided vasc ular bed could lead to early shrinkage of
im plant site preparati on and placement of the t he co ronally advanced flap and to th e expo-
impl ant. At thi s point, th e cl inician can be free su re of th e grafted connective tissue, resu lting
to co nce ntrate on the assessment and man - in estheti c problems and reduced soft tissue
agement of the soft ti ssues without having to augmentation. Th ese considerati ons prompt
wo rry about im plant positioning . t he cli nician to opt for suturing the graft onto
Give n that th e increase in soft tissue th ick- the intern al aspect of the fl ap in a paramarg inal
ness must take place at the same level as th e position in order to keep the anatomical papil-
gingival margin of th e contralateral tooth , th e lae free to receive the surg ical papillae of th e
co nnective ti ssue graft should be positioned co ronally advanced flap.
1 mm coronal to that margin. Thi s
w ill help co mpensate for potential
ti ssue shrin kage while obtaining an
excessive increase in height and
thi ckness of th e marginal soft ti s-
sues so that they can be adeq uately
co nditioned during the postsurg ical
prosth eti c phase.
However, if th e graft we re to be su -
tured in th e described position to
th e base of th e anatomical de-ep -
ithelialized papill ae, t here wou ld be
little surface left to serve as a vas-
cular bed for th e surg ical papillae of
the coronally advanced fl ap. Thi s is
especially true fo r th e distal papil-
la, w hich is so small and thin that it

1mmlL ___ _ "; c"'-_ _ ___ _ .,_ -

471
MUCOGINGIVAL APPROACH FOR THE IM MEDIATE POSTEXTRACTION IMPLANT
The surg ical technique consists of the execu-
tion of a coronally advanced envelope flap with
a frontal approach, wh ich requires oblique sub-
marginal interproximal incisions directed toward
the flap's center of rotation (in this case the
tooth to be extracted); the latter start from the
gingival margin of the adjacent tooth and end
at a distance from the vertex of the papilla that
should equal the desired amount of coronal ad-
vancement of the marginal tissues. The flap is
elevated in a split-full -spl it fashion: a split-thi ck-
ness incision is done at the papillae by keeping
th e blade parallel to the tooth's long axis, being
careful not to thin them down excessive ly; then ,
the buccal flap is elevated fu ll thickness with
a periosteal elevator until 2 to 3 mm of buccal
bone is exposed; apically, flap elevati on is con-
tinued first with a deep split-thi ckness incision,
keeping th e blade parallel to the osseous plane
and detaching the muscle insertions from the
periosteum , and afterward s with a superficial
split-thickness incision, placing the blade par-
allel to the external mucosal surface and con-
trolling its movement through the transparency
of the thin ti ssue while detaching the superficial
muscle insertions from the inner aspect of th e
flap. Thi s last incision is th e one responsible for
flap mobility.
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

Once the buccal flap has been elevated, atraumatic extraction of the tooth becomes easier, even if
root fracture is sti ll a possibility. Full visib ility and access helps to avoid both trauma to the anatomical
papi llae and damage to the buccal bone plate.

The implant site is prepared in a fully guided manner, using drills of a progressively larger diameter,
so that at the moment of guided implant placement the fixture can reach the pre-establi shed position
with enough primary stability to allow immediate provisionalization (35 Ncm).

473
MUCOG INGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

Just as planned with the three-dimensional
computer-guided plan ning, the transmucosal
implant 's osseointegratabl e su rface is roug hly 3
mm apical to the gingival margin of the adjacent
reference tooth . Th e implant platform is posi-
tioned slightly palatal with respect to the buccal
profile of the neighboring teeth, in the so-called
comfort zone, and the implant axis co incides
with the palatal surface of the occlusal mar-
gin (esthetically guided implant placement).
Whenever soft ti ssue augmentation is done
simultaneously to implant placement, the use
of transmucosal implants is particu larly indicat-
ed in order to distance the implant-abutment
connection from the bone crest and red uce its
resorption.
 MUCOGI NGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

After achieving the primary stability needed for perfo rates first th e graft (illustra tion and photo
immediate provisionalization, it is possible to C) and then the base of the surgical papilla of
screw in the provisional abutment and reline the the buccal flap (illustration and photo OJ, exit-
resin crown . Another advantage of gu ided im- ing at a horizontal distance of 1 mm from the
plant planning is the possibility of having a pro- starting point. The surgical knot (black arrow)
visional crown that is quite precise in relation to is closed on the buccal aspect (illustration and
the implant platform , reducing the time needed photo E). After performing the mesial and distal
for its relining. During thi s phase, it is important sutures, the graft should be positioned 1 mm
to be particularly careful with the resin materi - apical to the mucosal margin of th e flap without
al so that it does not contaminate the im plant 's impinging on the internal con nective tissue sur-
rough surface. The provisional obtained from face of th e surgical papillae, allowing first inten-
the computer-gu ided planning has such a pre- tion wo und healing due to their intimate co ntact
cise fit already at th e initial intraoperative relining with the respective anatomical de-epithelialized
that it might only require minimal touch-ups at papillae after flap suture.
the interproximal level to avoid interfering with
healing and maturation of the papillae. While the
restorative dentist finishes and polishes the pro-
visional, the co nnective tissue graft- harvest-
ed from the palate as a free gingival graft and
de-epithelialized with a surgical blade extraoral-
, Iy- can be sutured to the internal aspect of the
flap. The graft is placed inside the buccal fl ap
and sutured 1 mm apical to the mucosal margin
with two horizontal internal mattress sutures.
Th e suture is initiated from the external surface
of the flap by inserting the needle at the base
of th e surgical papilla (illustration and photo A)
and perforating the graft (1 mm from its· coro-
nal border; illustration and photo B); the needle
then goes back from the internal aspect and

475
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

After de-epithelializiation of the anatomical sutures suspended around th e cing ulum of the
papillae involved in the surgical area, the flap teeth adjacent to the edentulous site. At th is
is sutured coronally. Flap closure starts from point, the graft is only vis ible if the buccal mu-
the periphery and is ach ieved w ith t wo sling cosal marg in is sli ghtly displaced.

After completing the peripheral sutures, the ce ntral portion of the fl ap almost reaches the desired
coronal position. It is important to suture the soft tissues buccal to the edentulous site last in order
to reduce the tension in the area to a minimum.
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT
The graphic in the photo shows how th e param-
arginal position (1 mm apical to the highest point
of the marginal scallop) of the connective tissue
graft (white rectangular area) sutured to the inter-
nal aspect of the fl ap makes it possible to keep
Closure of the surgical papilla over the anatomi-
cal papilla is done with simple interrupted sutures
(7-0 thread, 8-mm needle). As a general rule, it
is advisable to suture the weakest papilla (in this
case the distal one) before placing the provision-
al restoration. This simplifies suturing and makes
After comp lete closure of the papillae, a final
sling suture suspended around the cingulum
of the implant-supported crown is done to ob-
tain a tight adaptation of the fl ap's keratinized
ti ssue onto the convex, smooth surface of th e
provisional-a prerequisite for the stabi lity of the
the surgical papillae free (yellow areas); in this way
they can adapt onto the anatom ical de-epitheliali-
zed papillae (red areas) without th e interference of
the connective tissue graft, th us guaranteeing first
intention wound healing in the interproximal areas.
it possible to obtain an ideal adaptation of the
surgical papilla on top of the smaller anatomical
papilla. After screwing in the provisional, it is pos-
sible to suture the second surgical papilla onto
the larger anatomical papilla (in this case the me-
sial one) with a simple interrupted suture.
surg ical wound and to minimize the risk of flap
sh rinkage. At the end of the surgery, the peri-im-
plant mucosal margin and the gingival margin
of the correspond ing natural tooth are perfectly
aligned, and it becomes evident th at the baseline
unfavorable situation has already been resolved .
477
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

A side-by-side view of the right maxillary half (before surgery) and the left one (after surgery) allows
the reader to appreciate how the con nective tissue graft (white rectangular area), coronally advanced
along with the buccal flap, is positioned nearly 1 mm coronal to the presurgical level of the gingival
margin of the adjacent natural tooth , as had been planned before the surgery.

At the end of the surgery, a telltale sign of optimal surgical wou nd stability is the absence of blood
seeping between the flap's keratin ized tissue margin and the anatomical/prosthetic crowns, even
when the lip is moved and pulled on by the surgeon.

The fin al esthetic outcome will be determin ed by the relationship between the soft tissues and the
prostheti c crown regarding parameters such as color, shape, surface texture, transparency and
blending with th e surrounding natural dentition.
 MUCOGINGIVAL APPROAC H FOR THE IMM EDIATE POSTEXTRACTION IMPLANT

At suture removal, 14 days after th e surgery, it tissues needed for the subseq uent prosthet-
is already evident how the mucosal margin buc- ic cond itioning phase. It is important to notice
cal to th e implant crown is slightly more coronal how, after only 2 weeks, the buccolingual defi-
than the gingival marg in of the corresponding ciency at the level of the distal papilla has been
tooth . Therefore, it can be stated that the wound completely resolved thanks to the presence of
stability achieved at the end of the surgery and the underlying connective tissue graft. The pro-
the presence of the underlying graft have effec- visional crown should not interfere with the early
tive ly prevented contraction of the flap's mu- heali ng process or with the ensu ing maturation
cosal margin . Furthermore, co nsidering th at of th e papillae.
the coro nal advancement of the envelope flap
has caused shortening of the clinical crowns
of the adjacent teeth , it becomes clear that the
peri- implant mucosal margin has been coronally
displaced from its baseline position by at least 2
mm . In time, the gingival margin of the adjacent
tooth will shrink and reposition itself at its pre -
surg ical level (about 1 mm coro nal to the CEJ).
Al l the while, the peri-implant mucosal tissues
wi ll tend to increase in height and thickness
as they mature, creating the "surplus" of soft
479
MUCOGINGIVAL APPROAC H FOR THE IM MEDIATE POSTEXTRACTION IMPLANT

In the months following, misalignment of the mucosal margin of the implant-supported c row n
(which migrates coronally) and the gingival margin of the adjacent tooth (which shrinks apically)
becomes progressively more evident. At th e same time, an increase in th e th ickness of the tissues
buccal to the prosthetic crown takes place.

Six month s after the surgery,

the maturation process can
be considered completed,
and it is possible to start
with the conditioning phase.
The use of computer-guided
plannin g allows th e clinician
to have a provisional that is
very precise already at the
moment of intraoperative
relining, requiring minimal
touch-ups by the restorative
dentist mostly at the inter-
proximal area to avoid in-
terference with healing and
maturation of the papillae.
Thi s makes it possible to
sometimes use the same
provisional during the soft
tissue conditioning phase.
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

The peri-implant soft tissues are conditioned
with the provisional until a shape and posi-
ti on of the mucosal scallop that resembles the
gingival margin of the adjacent corresponding
tooth is obtained. At the end of the condition-
ing phase, it is possible to place the definitive,
screw-retained restoration. Th e occlusal view of
the treated area, and its comparison with the
presurgical situation, shows the significant in-
crease in thickness obtained with the described
technique, particularly in the most coronal
millimeters that make up the buccal transmu-
cosal path. Precisely at this leve l, the increase in
soft tissue thickness is of extreme importance
in order to mask the underlying implant-pros-
thetic components and reduce the risk of PSTD
formation. It is important to notice that with this
technique the increase in the height of the trans-
mucosal path takes place only on the buccal
aspect-where it is essential for the final esthet-
ic outcome, but also easy to maintain from a
hygiene perspective by the patient.

Increasing the transmucosal path on the palatal aspect would have no esthetic implications and
would render the area inaccessible to the patient's hygiene maneuvers. In this case, the implant plat-
form is barely subgingival on the palatal side, which makes it easy to reach with oral hygiene devices
(both by the patient and hygienist).
481
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTI ON IMPLANT

The cl inical outcome 1 year after delivery of the final res-

toration has completely fulfilled the patient's esthetic and
functional demands. The periapical radiograph 1 year af-
ter placement of the final restoration shows good implant
osseointegration and the presence of a clearly visible
radiopaq ue bone crest, evidence of healthy periodontal
tissues. The comparison with the periapical radiograph
before tooth extraction shows how interproximal bone re-
sorption was minimum or almost nonexistent. Thi s is pro-
moted by the implant's transmucosal collar, which distanc-
es the implant-abutment connection from the bone crest.

The final esthetic resu lt is determined by the color, shape, surface texture, transparency, and blending
of th e soft tissues-implant crown complex with the adjacent natural dentition.
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

The scallop of the peri-implant mucosal margin
highly resembles that of the gingival margin of th e
natural corresponding tooth , creating symmetry
and harmony with the surrounding soft tissues-
critical elements for the esthetic assessment
of the outcome. Th e final result is even more
commendab le when taking into consideration
the unfavorable baseline situation. After all, the
presence of an apically positioned gingival mar-
gin on the tooth to be extracted, together with a
thin-scalloped phenotype and the buccolingual
and apicocoronal deficiency at the level of the
distal papilla were all factors that contraindicated
postextraction implant placement with imme-
diate provisionalization. The emergence profile
that was obtained appears adequate, since it
protects the soft tissue margin from mechanical
trauma when chewing and facilitates patient oral
hyg iene maneuvers.
The occlusal views highlight the increased thick-
ness of the soft tissues buccal to the prosthetic
crown. It is interesting to notice how this increase
in th ickness starts at the mucosal margin of the
implant crown and continues apically for 4 to
5mm . Soft tissue vo lume augmentation precisely
at this level is of crucial importance for the final
esthetic outcome, preventing soft tissue discol-
oration due to the underlying implant-prosthetic
structures and preventing future development of
PSTD.

The comparison of the occlusal view images taken at the end of

the postsurgical soft-tissue maturation phase and at 1 year after
the final prosthesis delivery confirm the stability of the marginal
soft tissues and a reduction in the volume of the apical soft tis-
sues (black line). The reduction in the apical prominence can be
attributed to the remodeling of the buccal bone, which undergoes
horizontal resorption as a consequence of tooth extraction.

483
MUCOGIN GIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

The increase in buccal soft tissue thickness, evident in the profile and occlusal views, confers a
good emergence profile to the prosthetic crown, as it seems to emerge naturally from the buccal soft
tissues, and guarantees the stabi lity of the resu lt over time by reducing the risk of buccal mucosa
dehiscence.

The continued increase in soft tissue thick-

ness, even after several years , is a frequent
finding when using the coronal ly advanced
flap with an underlying connective tissue graft
com ing from the de-epith elial ization of a free
gingival graft. In some patients, this increase
becomes so significant that it leads to coro-
nal migration of the buccal mucosal margin
(due to the creeping phenomenon) with con-
sequent shortening of the cl inical crown at the
implant site.
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

485
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT
Most of the time, the patient remains unaware
of this, and it is on ly by comparing the photo-
graphic documentation taken over time that the
clinician can observe the additional increase in
height and vo lume of the soft tissues buccal to
the implant crown. Very rarely, highly motivated
and esthetically demanding patients can notice
this situation and complain to the clinician about
the excessive increase in soft tissue thickness
and shorten ing of the implant crown. In many
cases, the main complaint by these patients is
not so much the reduced clinical crown height,
but the increased thickness of the apical soft
tissues (white arrows). This area corresponds to
the most apical part of the graft that was placed
on top of the buccal bone crest.
It is interesting that this undesired increase in
soft tissue vo lume should happen so apically
in relation to the mucosal margin of the implant
crown, possibly where the buccal bone wall is
located. Execution of buccolingual bone aug-
mentation techniques wou ld create a soft-tis-
sue volume increase at about 3.5 to 5 mm from
the mucosal margin, which is the level at which
the bone buccal to an implant should ideally be
placed.
At this point, it is worth posing several ques-
tions: Why is bone augmentation performed
with the sole purpose of increasing the volume
of the buccal soft tissues for esthetic reasons, if
that same outcome is considered an undesired
comp lication after using surg ical techniques for
soft tissue augmentation? Can an increase in
soft tissue vo lume taking place in such an apical
position with respect to the mucosal margin of
the implant crown be esthetic?
 MUCOGINGIVAL APPROACH FOR THE IMM EDIATE POSTEXTRACTION IMPLANT

The periapical radiographs captured over time document the stabil ity of the marginal bone. The use
of transm ucosal implants paired with the increase in soft tissue thickness has prevented interproxi-
mal bone resorption .

The continued increase in thickness of the soft
tissues buccal to th e implant becomes evident
by looking at the occlusal images taken over
the years . This could be considered th e only
negative aspect of th e described surgical tech-
nique and is hard to predict or control because
the expression of thi s phenomenon varies from
one patient to another and also accord ing to
the type of palate and area of graft harvest.
However, it is worth remembering that the
biggest doubt regard ing surgical techniques
for peri-implant soft ti ssue augmentation was
whether there was a risk of losing the stability
of the outcome over tim e; continued increase in
tissue thi ckness, on th e oth er hand, guarantees
long-term stability.

487
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT
The prob lem of tissue creeping associated with
th e reduced clinical crown height at the implant
site can be resolved by modifying the emer-
gence angle of the definitive crown so that it
can give support to the thickened soft tissues
on the marginal level; this is done by creating an
overcontour that displaces the tissues apically
and bl ocks the coronal growth of the mucosal
margin . Even if this could present difficulty for
th e pati ent 's oral hygiene maneuvers, given that
it creates a prevailingly horizontal prob ing area, if
thi s is limited to a few millimeters it can be con-
sidered a viable compro mise in an area of such
esthetic impact for a highly demanding patient.
After modifying the definitive crown, the peri-im-
plant mucosal margin and the gingival margin on
the contralateral central inc isor seem, once again ,
perfectly aligned .
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

The emergence profiles are

adequate, and the health of
the peri-implant tissues is
maintained thanks to the pa-
tient's good oral hygiene. The
increased thickness of the
marginal soft tissues masks
the underlying implant-pros-
thetic components and pre-
vents the risk of PSTD. The
control at 7 years shows sta-
bility of the esthetic result and
a high ly satisfied patient.

489
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

491
M UCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT
The presence of soft tissue recession buccal to
th e tooth to be extracted no longer represents,
by itself, an absolute contraindication for imme-
diate postextraction implant placement. The sur-
gical technique of th e coronally advanced flap
combined with a connective tissue graft makes
it possible to treat the gingival recession simul-
taneously with postextracti on implant pl acement
with immediate provisionalization. In such cases,
a flap less technique would result in a longer im-
pl ant crown or it would require leaving the co n-
nective tissue graft partially exposed in an at-
tempt to cover the soft tissue dehiscence. The
survival of an exposed connective tissue graft
placed to cover the implant-prosthetic structures
is not very predictable; even in the unlikely sce-
nario that the graft survived in its entirety, its color
and surface characteristi cs wo uld hardly bl end in
with the adjacent soft tissues.
Furtherm ore, the question remains as to how
thick the graft should be so that once healed,
even if left partially exposed , it can maintain a
thickness of at least 2 mm in order to prevent
PSTD and mask the metallic aspect of the un-
derlying implant-prosthetic structu res. The apical
root fracture of the tooth in question represents
an additional factor supporting the elevation of
a buccal flap, ie, to sim plify the extraction while
minimizing trauma at the level of the soft tissues
and the buccal bone plate.
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IM PLANT

Computer-gu ided implant planning makes
it possible to optim ize implant position and
choose the type of implant to be used . In some
cases, the distance between the bone crest and
the ideal soft-ti ssue profile advises against the
use of transmucosal implants (which are usual-
ly the first choice), sin ce it wo uld result in a very
horizontal emergence angle of the prosthetic
crown and render self-performed oral hygiene
difficult for the patient. Guided implant place-
ment is particu larly recommended in cases with
reduced buccolingual bone dimensions, where
the error margin for im plant placement is ex-
tremely small, and it is essential to obtain a pri-
mary stabi lity that allows immed iate provisional-
ization. By performing digital implant planning,
the clinician can obtain
a surgical stent, w hich
guides all the phases of
implant site preparation

~~
.'

...... ~ '. "

. . .' A
I and placement, as well
a provisional with an ex-
ill ~
tremely precise fit with
. #'
".' "" respect to the implant
platform, wh ich reduces
the time needed for in-
traoperative re lining and
finishing. Oftenti mes,
w ith this provisional be-
ing so precise, it can also
be used for the soft tis-
sue cond itioning phase,
thus avoid ing the need
for a second provision-
al. This represents an
econom ic advantage for
th e patient and can par-
tially compensate for the
added cost of th e surgi-
cal stent used for guided
implant placement.
In the authors' opinion,
one of the main advan -
tages of computer-g uid-
ed implant placement is
the opportunity for the
clinician to concentrate
on adequate soft tissue
management without
having to be preoccu-
pied w ith correct implant
placement.

493
MUCOGINGIVAL APPROAC H FOR THE IMMEDIATE POSTEXTRACTION IM PLANT

The soft tissue surgery consists of an envelope-t ype buccal flap-with paramarginal, oblique interden-
tal incisions that are directed toward the center of rotation of the flap (the tooth to be extracted)-ele-
vated with a variable thickness (split-full-split).

Surgical access to the root and to the underlying bone facilitates tooth extraction and helps minimize
the trauma to the surrounding soft tissues.

Good visibility allows atraumatic extraction of the tooth and root fragment, preserving the integrity of the
anatomical papillae and the buccal bone plate.

It is very important to make sure that the surgical stent is stable and properly positioned before starting
implant site preparation.
 MUCOGINGIVAL APPROACH FOR THE IMM EDIATE POSTEXTRACTION IM PLANT
After guiding the implant into the planned position
and obtaining a primary stability compatible with
immediate provisionalization (at least 35 Ncm),
the provisional is relined intraoperatively. On th e
provisional crown, the implementation of wings
that adapt onto the palatal surfaces of the ad-
jacent teeth allows correct positi oning of the
implant crown as previously established during
digital implant planning. It is very important that
the interproximal surfaces of the provisional are
reduced in order to avoid com pression of the
anatomical de-epithelialized papillae, which are
Th e connective tissue graft is sutured onto the
flap's internal surface with two internal horizon-
tal mattress sutures placed at the base of the
surgical papilla. The fl ap, free from the deep
and superficial muscle insertions, can be cor-
onally advanced and is fi xed with sling sutures
necessary for the anchorage of the surgical
papillae of the coronally advanced flap. The buc-
cal surface of the provisional must provide a hard
and smooth convex surface for optimal adapta-
tion of the flap's keratinized tissues.
suspended around the cingula of the adjacent
teeth, fol lowed by simple interrupted sutures
at the level of the papillae mesial and distal to
the provisional crown; one last sling suture is
placed around the implant-supported provi-
sional crown.
495
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

Six months after the surgery, the period in which

the soft tissues were left to mature undisturbed,
the peri-implant mucosal margin is placed at
the same height as the gingival margin of the
corresponding contralateral tooth. The com-
parison between the presurgical image and the
6-month postoperative image clearly highlights
the increase in soft tissue height with complete
coverage of the recessions once present on the
extracted tooth and the adjacent can ine. The
profile view shows the soft tissue thickness
augmentation achieved with the described
technique.
 MUCOGINGIVAL APPROAC H FOR THE IMM ED IATE POSTEXTRACTION IM PLANT

and w ill provide the

definiti ve restoration
with a very natural
emergence from the
soft tissues, favoring
blending of the pros-
thesis and patient
self-performed oral
hygiene maintenance.
Th e periapical rad io-
graph shows good im-
plant osseoi ntegration.
A slight remodeling of
th e crestal bone, typ-
ical of bone-l evel im -
plants, is evident and
can most likely be at-
tributed to the form a-
tion of the peri-imp lant
supracrestal complex .
One year after place-
ment of the final res -
toration, it is possible
to appreciate how the
The same provisional is progressive ly modi- technique of the coronally advanced flap plus
fied during the conditioning phase, at the end connective tissue graft, simultaneous with im-
of which (approximately 3 months) adequate plant placement, allowed such an increase in
thi ckness of the soft ti ssues in th e transmuco - soft tissue heig ht and thickness that it was
sal path can be seen. Th is will aid in masking possible to ach ieve a good estheti c outcome
th e underlying implant-prostheti c components in spite of th e unfavorable baseli ne situation.

497
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

The periapical radiograph taken 1 year after final restoration delivery shows stab ility of the peri-implant
bone level. The area of crestal bone remodeling seems unchanged from the previous radiographic
checkup.

The occlusal and profile views highlight the increased thickness of the buccal soft tissues, ensuring
stability of the outcome over time.
 MUCOGINGIVAL APPROAC H FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

Small modifications in the translucency of the the surgically augmented soft tissues around
definitive crown, made after the 1-yearfollow-up, the definitive crow n continues even after some
have allowed further improvement of the final years. The periapical radiograph shows stability
esthetic outcome. Once again , conditioning of of the peri-implant bone level.

499
MUCOGINGIVAL APPROAC H FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

The 7-year clinical and radiographic control shows stability of the esthetic outcome and of the peri-im-
plant bone level over tim e.

The occlusal and profile images confirm the stability of the surgically augmented soft tissues.
MUCOG INGIVAL APPROACH FOR THE IMMEDIATE POSTEXTR ACTION IMPLANT

501
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

Anterior single-tooth replacement with implants entai ls ele-

vated esthetic risks in patients with a high smile line. Any
potential misalignment or asymmetry in the gingival mar-
gin position or metallic hues showing through the gingiva
cou ld be quickly detected by the patient since they wou ld
be visib le when smiling. In this cl inical scenario, the risk of
not completely fulfilling patient expectations is very high. In
the authors' opinion, postextraction implant placement with
immediate provisionalization is the first-choice treatment to
maximize predictability of the esthetic result and reduce the
number of procedures and overall treatment time. Still, this
approach requires a surgical intervention that allows soft
tissue augmentation along with implant placement (clinical
case performed in collaboration with Or Giovanni Polizzi and
Or Tommaso Cantoni) .

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 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

Despite the site- and patient-related difficulties (high smile line), the case presents some particularly fa-
vorable conditions for implant placement with immediate provisionalization: at the tooth to be extracted,
the gingival margin is at the same level as that of the corresponding contralateral tooth, and the papillae
mesial and distal to it are wide, tall , and thick.

Even when taking into consideration the ideal position for the con-
nective tissue graft (1 mm coronal to the gingival margin of the
adjacent central incisor), the remaining anatomical papillae to be
de-epithelialized are wide and tall enough to ensure adequate vas-
cular support for the surgical papillae of the coronally advanced
flap . This fairly rare situation allows the graft to be sutured at the
base of the papillae, as opposed to the internal aspect of the flap,
when performing the surgical technique of a coronally advanced
flap plus a connective tissue graft.
503
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MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT
*
The previously described advantages of comput-
er-guided implant planning can be summarized
as follows:
1. reduced risk of implant malposition ;
2. greater probability of achieving the primary sta-
bility needed for immediate provisionalization;
3. availability of a surg ical stent that guides im-
plant site preparation and implant placement;
The soft tissue surgery consists of a coronally
advanced envelope flap with the frontal approach
technique. The anatomical papill ae are wide,
tall, and thick enough to be de-epithelialized
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4. a very precise and easy to reline prefabricated
provisional is provided to the clinician, which
reduces the duration of the surg ical procedure;
5. greater peace of mind for the clinician , who
can concentrate on the proper surg ical man-
agement of the soft tissues .
occlusally in a palatal direction, similarly to the
papillae that result from performing a tissue punch
in a comp letely healed edentulous site in the case
of delayed implant placement (see chapter 6).
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

The convex surface of the

provisional starts at around 2
mm coronal to the CEJ (1 mm
coronal to the presurgical po-
sition of the gingival margin ,
red dotted line) of the corre-
sponding natural tooth, rep-
licating the buccal profile of
that tooth's crown. Apically,
toward the implant platform,
the buccal surface of the
provisional should be slightly
concave to aid in the adapta-
tion and suturing of the graft.
The provisional crown must
be reduced at the interprox-
imal level to avoid compres-
sion-or interference with the
healing-of the papillae. The
apicocoronal dimension of the
connective tissue graft should
be enough to cover 2 to 3 mm
of buccal bone. Fixation of the
graft is done with simple in-
terrupted sutures (7-0 thread ,
8-mm needle) at the base of
the anatomical de-epitheliali-
zed papillae.
The good adaptation of the
connective tissue graft onto
the provisional crown and
*
underlying bony plate creates
a flat surface upon which the buccal flap can embracing the convex surface of the provisional
easily slide to be sutured in a coronal position , without any tension.

505
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MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

Closure of th e coronally advanced flap is achieved
with a series of sling sutures suspended around
th e cingula of each tooth involved in the su rgery.
The sling suture correspond ing to the implant
site is performed last and is the one that ensures
primary closu re between the surgical and ana-
tomical papillae while providing precise and tight
adaptation of the keratinized tissues of the flap
onto th e convex surface of th e provisional crown.
At th e end of th e surgery it is very important to
achieve stability of th e surg ical wound; th is is as-
sessed by pulling on the lip and making sure that
there is no blood seeping between the soft tissue
margin and the profile of the underlying crowns.

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 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

For the first 3 postoperative weeks, the patient
should abstain from mechanical hygiene ma-
neuvers and is instructed to carry out chem-
ical plaque control with the use of a ch lorhexi-
dine-based mouthwash (0.12%), rinsing three
times a day for 1 minute each time. Afterwards,
the patient can begin brushing the treated area
with an ultra-soft toothbrush wh ile performing
rinses only twice a day. During the first months of
healing , it is crucial that self-performed oral hy-
giene is atraumatic so that tissues can adapt and
mature around the provisional.
If there are any areas of compression that ob-
struct soft tissue growth and maturation, the
provisional crown should be trimmed in these
places. For this reason , the patient should have
monthly recall appointments for the duration of
the postsurgical soft tissue maturation phase.

Over the course of the first months, the grafted to the one on the natural adjacent tooth. The in-
tissue undergoes a maturation process that re- crease in thickness of the buccal soft tissues at
sults in increased height and thickness of the soft the level of the transmucosal path will be crucial
tissues buccal to the implant crown. An excess for the creation of an adequate emergence pro-
of tissue in the apicocoronal direction will allow file of the prosthetic crown, to mask the metallic
the prosthodontist to condition the soft tissues in hue of the implant-prosthetic components, and
order to achieve a soft tissue morphology similar to prevent the formation of PSTD.
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MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT
The occlusal view at 6 months shows the thick-
ness of the buccal supracrestal soft tissues. The
mucosal margin of the implant crown is more
coronal than the gingival margin of the corre-
sponding natural tooth . Soft tissue conditioning
At the end of the conditioning phase, the mu-
cosal margin at the implant crown should be
at the same level and have the same shape
as the gingival margin of the contralateral inci-
sor, and the papillae should resemble as much
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can be started 6 months after the surgery with
the goal of creating a mucosal margin at the im-
plant crown that resembles the gingival margin
of the natural reference tooth in both height and
scallop.
as possible those of the adjacent teeth. Once
these goals have been accomplished, it is pos-
sible to proceed with the final restoration , tak-
ing care to maintain the resu lt achieved with the
provisional .
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

One year after final restoration placement, the esthetic result com pletely satisfies the patient's de-
mands. The 1-year radiographic image shows good implant osseointegration and absence of inter-
proximal bone loss.
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M UCOGI NGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IM PLANT

The comparison between the images at base-
line and 1 year after final restoration placement
highlights the results ach ieved .
Augmentati on of the implant 's buccal soft ti s-
sues masks the underlying im plant-prosth etic
components and , along with an adequately
shaped prosthesis, it reduces the risk of futu re
PSTD development while creating an emer-
gence profil e that allows th e patient to maintain
good oral hygiene.

The 2-year follow-up images confi rm the stability of the esthetic result and show a satisfied patient. Soft
tissue thickness, visible in the occlusal image, appears stable with respect to the 1-year control.

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 MUCOG IN GIVAL APPROACH FO R THE IMMEDIATE POSTEXTR ACTI ON IMPLANT

5 11
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MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

The 5-year follow-up after final restoration
placement shows the stability of the outcome
over time. The patient is still satisfied with the
treatment and the maintenance of the outcome
even after several years.
The radiographic control highlights the stabil-
ity and radiopacity of the peri-implant bone,
which, together with absence of bleeding or
increased probing depths, is a sign of healthy
peri-implant tissues.

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 MUCOGINGIVAL APPROACH FO R THE IMMEDIATE POSTEXTRACTION IMPLANT

513
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MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT
At the beginning of this chapter, some of the ad-
vantages of opening a buccal flap versus per-
forming a flapless technique were discussed.
One of the most important amongst them is
the possibility of covering, through the coronal
advancement of the flap, the connective tissue
graft (white transparent area in photo) placed 1
mm more coronal than the gingival margin of the
reference tooth. This allows an increase in soft
tissue thickness that begins from the mucosal
margin of the implant-supported crown, reduc-
ing the risk of graft exposure-and its esthetic
consequences-to a minimum. On the other
hand, one of the cases that can be treated with-
out the need to elevate a buccal flap is when, at
baseline, the position of the gingival margin of
the tooth to be extracted is at least 2mm more
coronal than the gingival margin of the contra-
lateral correspond ing tooth. This clinical scenar-
io is hard to come by, unless it has been cre-
ated intentionally through orthodontic extrusion
of the affected tooth. Slow dental extrusion will
lead to coronal displacement of the buccal soft
tissues attached to the suprabony root surface
by means of the supracrestal fibers (case per-
formed in collaboration with Or Mauro Fadda).
 MUCOGINGIVAL APPROACH FOR THE IMM EDIATE POSTEXTRACTION IMPLANT
Regarding postextraction implant placement,
slow extrusion of the root provides other very im-
portant advantages:
1. increased quantity of alveolar bone (both in
height and thickness), wh ich makes pros-
theti cally guided implant placement easier
and increases th e possibility of obtaining
the primary stability needed for immediate
provisionalization;
2. coronal displacement of the buccal bone
crest when there was a bone dehiscence,
w hich improves the odds for the placement
of a postextraction implant and reduces the
need for the execution of surgical procedures
for buccal bone reconstruction;
3. increased height of th e buccal keratinized tis-
sue band (when the mucogingival junction is
fou nd apical to th e buccal bone crest);
4. easier extraction of th e root remnant, reduc-
ing soft and hard tissue trauma that cou ld
hinder/preclude postextraction implant place-
ment with immediate provisionalization .
The following clin ical case describes a patient
with a fractured ce ntral incisor that underwent
endodontic retreatment 3 years earlier, following
the removal of a root canal post. As a result of an
accidental trauma, the tooth developed increased
mobility and an abscess with localized drainage
on the palatal aspect. For th is particu lar case, th e
choice of performing orthodontic extrusion was
made for three main reasons:
1. presence of palatal bone loss;
2. loss of periodontal support on the affected
tooth 's distal aspect;
3. absence of the buccal bony wall due to facial
displacement of th e tooth in question .
These three factors, especially if occurrin g con-
comitantly, represent contraindications to imme-
diate postextraction implant placement.
515
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT
At the end of orth odontic extrusion, which lasts
about 5 to 6 months, the reduced .size of the
residual root fragment and its increased mobil-
ity render its extraction very simple and barely
traumati c. Special periosteal micro-elevators are
used under the papillae mesial and distal to the
extraction site, placing th e instrument in contact
with the bone and taking care to not lacerate
the isthmu s. Whenever orthodontic extrusion
has been done, it is important to take into ac-
count that the buccal bone crest migrates cor-
onally along with the root; for this reason , the
buccal soft tissues will be firmly adhered to the
underlying bone. In order to preserve th e entire
soft tissue thickness in this area, full-thickness
elevation should be performed by inserting the
micro-elevator between th e soft tissues and th e
buccal bone (white arrow). Once the alveolar mu-
cosa has been reached, partial -thickness eleva-
tion can be started with a microblade (first with a
deep and then a superfi cial split-thickness inci-
sion) in order to obtain coronal advancement of
the buccal soft tissues. It shou ld be emphasized
that the superficial incision cannot be performed
like in the envelope flap technique because it is
difficult to keep the blade parallel to the external
surface of the alveolar mucosa without the risk
of perforation. Therefore, coronal repositioning
of the buccal soft tissues will be limited and
much less passive in comparison to what can
be achieved with the coronally advanced flap
surgical technique.
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

517
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT
Th e buccal bone, sti ll attached to the root by the
periodontal ligament, migrates coronally during
the extrusion of the root. As a consequence, at
the end of the orthodontic extrusion the buccal
bone crest is in a more coronal position than the
CEJ of the adjacent reference tooth (white line).
If the mucogingival line was placed apical to the
buccal bone crest before the extrusion , then it
wi ll not migrate coronally, and the result will be
an increased height of the buccal keratinized tis-
sues thanks to the coronal displacement of the
gingival margin during orthodontic extrusion .
The question worth asking is if slow dental ex-
trusion can, in addition to increasing the buccal
band of keratinized tissues, allow an increase in
buccal soft tissue thickness at the level of the
future transmucosal path-the latter being a
necessary cond ition to prevent soft tissue de-
hiscence buccal to the implant crown. In other
words, can orthodontic extrusion be enough to
avoid the need for placement of a connective
tissue graft at the time of postextraction implant
placement w ith immediate provisionalization?
In the authors' opinion, the buccal soft tissues
wi ll not be significantly thickened after ortho-
dontic therapy, even if clinically they will ap-
pear en larged due to the coronal position of
the underlying buccal bone crest. Nevertheless,
this coronally displaced bone is particularly thin
and almost entirely composed of bundle bone,
which means that it wi ll undergo a physiologic
remodeling process once the tooth is gone. If
the buccal soft tissues are not thick enough on
their own (at least 2 mm) to ensure the stabili-
ty of the implant crown 's mucosal margin, then
they should still be augmented with the addition
of a connective tissue graft at the time of im-
plant placement. Th e connective tissue graft,
obtained from the extraoral deepithelialization
of a free gingival graft, is placed between the
bone and the buccal soft tissues and carefu lly
extended with the help of temporary mesial and
distal sutures that are anchored to the graft and
exit through the sulcus of the adjacent teeth. To
avoid apical displacement of the graft, the latter
is sutured to the internal aspect of the flap with
two internal mattress sutures (black arrows) as
described for the coronally advanced flap tech-
nique. It is the authors' opinion that not elevating
the papillae makes it harder to ensure that the
graft is in the right final position, and it also limits
the possibility of extending the graft toward the
base of the mesial and distal papillae without
risking its exposure.
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT
Guided implant placement allows its esthetical-
ly and prosthetically adequate positioning and
makes it possible to have a very precise pre-
fabricated provisional that can be quickly and
easily relined intraoperatively. It is important
to emphasize that the gap between the buc-
cal bone wall and the implant's transmucosal
portion (white arrow) should not be filled with
bone replacement materials. The reason is that
this area-even if seemingly infraosseous at the
moment of implant placement due to the coro-
nal displacement of the buccal bone crest-will
In the case of traditional prosthetically guid-
ed placement of postextraction implants, there
is always a gap between the implant's buccal
surface and the internal wall of the alveolus (A)
that is normally filled with bone or bone substi-
tutes. After orthodontic extrusion (8) the implant
is placed without leaving any gap between the
implant and the buccal bony wall, which is pos-
sible thanks to the fact that the diameter of the
residual root is significantly reduced and the api-
cal portion has been filled by new bone. After
prosthetically guided implant placement (C) , the
gap between the implant's transmucosal por-
tion and the coronally displaced buccal bone
be the future transmucosal path. During bone
remodeling, the slowly resorbing material would
prevent an increase in soft tissue thickness ,
and the lingering particles could be a poten-
tial cause of infection , since they can be easily
colonized by bacteria from the oral cavity. If the
extrusion is performed correctly and complete-
ly (leaving only the most apical millimeters of
the root), the endosseous implant portion will
be completely covered in native bone without
any gaps and therefore without the need for
bone grafting.
crest should not be filled with bone substitutes
because this area will undergo bone remodel-
ing ; to compensate for the latter, a connective
tissue graft and immediate implant-supported
provisional should be placed (0). Both the graft
and the provisional (E) will provide support to the
buccal soft tissues even after the buccal bone
has been resorbed physiologically. In time and
after proper conditioning, the increase in soft
tissue thickness derived from the integration of
the flap and connective tissue graft (F) will allow
re-creation of the buccal soft tissue profile in the
same position as it was before orthodontic tooth
extrusion (compare A and F).
519
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

Successful mobilization of the tunneled papillae
and buccal soft tissues requires a specific suturing
technique that allows their coronal advancement
and precise adaptation to the provisional crown.
As a matter of fact, without the suture, both the
buccal soft tissues and the papillae would shrink
apically, leaving a space between them and the
provisional crown that would prevent adequate
clot stabilization . The suturing technique, as pro-
posed by Hurzeler and Zuhr, foresees the anchor-
age of each papilla around interproximal splints
made with flowable composite resin , placed at
the level of the incisal contact points between the
provisional crown and the adjacent teeth.
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

The clinical images at suture removal show op-
timal healing and perfect stability of the soft
tissues, which maintain the same position they
had at the end of the surgery after suture place-
ment. It should be noted that with the flapless
technique it is also necessary to wait for tissue
maturation so that the papillae can adopt a more
natural appearance and blend in with the sites
not involved in the surgery.

521
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

Undisturbed soft tissue maturation lasts 4 to 6 months.

Six months after the surgery, soft tissue conditioning starts by modifying the shape of the provisional
crown and also by placing small composite restorations on the adjacent teeth to improve overall space
distribution.
 MUCOGINGIVAL APPROACH FOR TH E IMMEDIATE POSTEXTRACTION IMPLANT
Th e buccal peri-implant soft ti ssues appear
thi cke ned and well shaped at the end of the
conditioning phase, and their buccal profil e is
positioned at the leve l of the gingival ti ssues
buccal to th e adjace nt reference tooth. Side-
by-side co mpari son of the occlusal images
At the tim e of final restoration placement, ap-
proximately 9 months after implant surgery,
both th e prosthesis and the soft tissues at the
treated area blend in we ll w ith th e surrounding
dentition. Th ere are still some visible signs of
incomplete papillae maturation at th e implant
at th e start of th e orth odontic therapy and
after soft ti ssue maturation shows how the
increased thickness of the buccal soft tis-
sues was able to compensate for th e loss of
the root and the subseq uent resorpti on of the
buccal bone.
site. The volume and thickness of the soft
tissues allowed the creation of a very natural
emergen ce profile for the prosthetic crown, re-
sembling that of the adjacent reference tooth .
Th e periapical radiograph shows good implant
osseointegration and no sig ns of bone loss .
523
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

Comparison between the images at baseline and 1 year after the delivery of the final restoration high-
lights the good outcome, which completely satisfies the patient's esthetic demands. Correspondingly,
periapical radiographs reveal an improvement in the position of the lateral incisor's mesial bone peak
and good maintenance of the peri-implant bone level.

Th e occlusal and profile views show th e pleas-
ant emergen ce of the prosthetic crown from
the buccal soft tissues. Still, in comparison to
the reference tooth, there seems to be a slight
deficiency regarding the buccal soft tissue vol-
ume in the most coronal aspect. In the authors'
opinion, the flap less technique does not allow
control of the final position of the connective tis-
sue graft in the way that buccal flap techniques
do; this results in a slightly more apical position
of the graft with respect to the desired level of
maximum soft tissue augmentation.
MU COG INGIVAL APPROAC H FOR THE IMMEDIATE POSTEXTR ACTION IM PLANT

525
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IM PLANT
One of the major mistakes associated with
postextraction implant that can have important
esthetic implications is a very shallow apicocoro-
nal implant placement (see chapter 2). This hap-
pens frequently when the natural teeth adjacent
to the implant are affected with altered passive
eruption. Given that the apicocoronal implant po-
sition is directly dependent on the position of the
ging ival margin of the reference tooth , failure to
identify the presence of altered passive eruption
The patient presented with discomfort in th e
area apical to the maxillary right central incisor,
wh ich had been endodontically treated following
an episode of dental trauma at a younger age;
years afterward , an apicoectomy had also been
performed. Furthermore, the patient comp lained
of the unesthetic appearance of both the resto-
ration, whose co lor did not match that of the ad -
jacent natural teeth, and of the dark root, which
became visible due to a gingival recession that
had occurred during the previous year. These
esthetic problems, in addition to significant gin-
gival exposure and rather square-shaped teeth,
were particularly noticeable because of the pa-
tient 's high smile line.
on the latter cou ld lead to shallow apicocoronal
implant placement. This is more li kely to occur
when employing a flapless technique because it
is not possible to see intraoperatively the posi-
tion of the CEJ of the adjacent tooth in relation
to the position of its gingival margin. The fo llow-
ing clinical case demonstrates the treatment of
altered passive eruption and postextraction im-
plant placement with immediate provisionaliza-
tion in a single surgical procedure.
In order to establish the diagnosis of altered
passive eruption, a periapical radiograph shou ld
be taken with a gutta-percha tip fixed with th e
help of soft blue wax onto the enamel surface
of th e tooth , coinciding with th e gingival mar-
gin. In this way, by measuring the length of the
gutta-percha tip clinically and radiographically, it
is possible to extrapolate th e real length of the
anatomical crown. In the case described, the
anatomical crown was 4.5 mm longer than the
clinical crown; this meant that 4.5 mm of tooth
structure was covered by the gingiva and made
it possible to establish the diagnosis of altered
passive eruption . The patient was informed
about the presence of altered passive eruption
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT
on th e adjacent teeth and about the significant
esthetic improvement associated with the treat-
ment of this cond ition. However, he was told that
surgical crown lengthening should be done first
because apicocoronal implant positioning was
guided by the final level of the gingival margin on
the adjacent tooth.
The patient was very motivated to treat the gum -
my smile, but due to personal time constraints,
he asked to perform both the crown lengthen-
ing and implant placement simultaneously. In
the authors' opinion , three-dimensional plan-
ning and guided implant surgery are necessary
when implant positioning cannot be based on
the position of the gingival margin of either the
tooth to be extracted or of the adjacent natural
tooth. When planning implant placement, it is
necessary to predetermine the amount of crown
lengthening to be done on the adjacent teeth
and place the endosseous portion of the im-
plant 3.5 to 4 mm more apical than the predeter-
mined position of the mucosal margin of the im-
plant-supported crown. In this current case, the
gingival margin of the tooth to be extracted was
situated 2 mm apical to that of the adjacent cen-
tral incisor. Since the latter had to be lengthened
by 3.5 mm in order to treat the altered passive
eruption, the mucosal margin of the future im-
plant crown would be have to be located 1 mm
apical to its baseline position . For this reason ,
the end osseous implant portion was placed at a
distance of 4.8 mm from the presurgical position
of the gingival margin of the tooth to be extracted
(3.8 mm apical to the predetermined position for
the future implant crown's mucosal margin). The
main problem regarding simultaneous implant
placement and treatment of the altered passive
eruption is that at the implant site the flap should
be coronally advanced and adapted around the
immediate provisional crown , whi le at the level
of the adjacent teeth the flap should be reposi-
tioned apically to obtain , along with the osseous
surgery, the desired crown elongation . Since cor-
onal advancement of the flap is essential in order
to provide stability to the surgical wound and to
cover the connective tissue graft at the level of
the implant, it should be taken into account that
it won 't be possible to displace the flap apically
as much as needed for the treatment of altered
passive eruption at the level of the neighboring
central and lateral incisors. For this reason, the
clinician should anticipate that once healing has
occurred there will be a need for a gingivectomy
on the teeth adjacent to the implant to finalize
the treatment of the altered passive eruption.
The gingivectomy wi ll only work if bone surgery
(osteoplasty and osteotomy) has been previously
performed; also, a sufficiently wide band of ke-
ratinized tissues should be preserved during the
first surgery.
3.5 mm
527
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

Regarding fl ap design, specifically when per-
form ing the paramarginal incisions for the treat-
ment of altered passive eruption on the teeth
adjacent to the implant site, the cl inician should
take into account that an additional millimeter
of keratinized tissue wi ll be lost in the subse-
quent surgical phase when the gingivectomy is
performed. Therefore, the incisions on the two
neighboring teeth should be about 1 mm more
coronal than the normal paramarginal incisions
done solely for the treatment of altered passive
eruption. On the tooth to be extracted, intrasul-
cu lar full-thickness flap elevation is done with
a periosteal elevator to keep the entire height
and thickness of the keratinized tissue buccal
to the future implant crown. The absence of a
paramarginal incision in thi s area will also help
reduce the amount of coronal advancement of
the buccal ti ssues . Th e flap was extended from
one premolar to the other in order to treat the
altered passive eruption from canine to canine;
split-thickness incisions are performed at the
leve l of the papillae, while the buccal keratinized
tissues are elevated full thickness. The flap is
released from the deep and superficial muscle
insertions only at the level of the tooth to be
extracted and the two adjacent teeth to allow
coronal advancement in the future implant site.

Full-thickness flap elevation exposes the areas
of thickened buccal bone, wh ich is the main
cause of the altered passive erupti on. Th e buc-
cal bone crest was in a very coronal position at
the level of the left ce ntral incisor and both ca-
nines , impinging on the suprabony root portion
th at in physiologic circumstances should house
the supracrestal tissue attach ment. Elevation
of the buccal flap helps perform an atraumatic
extraction of the maxillary right central incisor,
keeping the integrity of the thin buccal bone
plate and the interdental papillae.

Regarding the hard tissues, treatment of al-

tered passive eruption consists of restoring a
physiologic bony architecture by performing
osteoplasty to reduce bone thickness and
site-specific ostectomy to place the buccal
bone crest of each tooth at a distance of 2 to
3 mm from the CEJ.
Some initial osteoplasty was performed with
a mini bone scraper to collect some autoge-
nous bone, and then osteoplasty was fin-
ished with a round diamond bur. A mixture
of autogenous bone and xenograft was used
to fill the gap between the implant and the
buccal bone wall.
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT
The ostectomy is performed with the tip of the sur-
gical blade to create a scallop in the bone crest that
runs parallel to the CEJ at a distance of 2.5 to 3 mm.
Root planing should not be done on the root surface
exposed by the ostectomy to avoid removing root
cementum still contain ing periodontal ligament fi-
bers, thus allowing the formation of the supracrestal
tissue attachment. As preestablished by the digital
planning, the endosseous surface of the implant is
placed 3.8 mm apical to the predetermined position
of the mucosal margin of the implant crown , which
The presence of very thin tissues (0.9 mm, as
measured intraoperatively with a soft tissue
gauge) buccal to the implant crown is an in-
dication for the addition of a connective tissue
graft. The goal of the graft, obtained from the
de-epithelialization of a free gingival graft har-
vested from the palate, is to increase soft tis-
sue thickness at the level of the peri-implant
transmucosal path on the buccal aspect. Th e
apicocoronal dimension of the connective tis-
sue graft should cover 1 mm coronal to the
predetermined level of the gingival margin of
th e adjacent reference tooth and sit a couple
of millimeters on top of the buccal bone crest.
should coincide with the position of the gingival
margin of the adjacent central incisor, placed 1
mm coronal to its CEJ after the treatment of the al-
tered passive eruption. Guided implant placement
allows proper three-dimensional implant place-
ment. In addition to the apicocoronal position, it is
essential that the buccolingual implant position al-
lows the placement of a screw-retained crown; an
adequate space should be left between the facial
bundle bone and the endosseous implant portion
for bone reconstruction.
The mesiodistal dimension should be enough
to cover the buccal surface of the de-epithelial-
ized papillae, and it should be close to 1 mm in
thickness. Extending the graft onto the base of
the papillae wi ll guarantee an increase in their
buccolingual vo lume, a necessary cond ition for
their coronal growth (ie, creeping of the peri-im-
plant papillae). The graft is sutured to the flap's
internal surface in a paramarginal position; this
w ill allow th e superimposition of the internal
surface of the coronally advanced flap's surgi-
cal papillae and the anatomical papillae (de-ep-
ithelialized in a palatal direction) w ithout the in-
terference of the graft.
529
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

One of the advantages of computer-guided implant planning is the ability to have, at the moment of the
surgery, a very precise, prefabricated provisional that can be relined in just a few minutes. However, the
provisional should be reduced at the interproximal level to avoid any interference with primary wound
closure between the surgical papillae and the anatomical de-epithelialized papillae.

Flap clos ure consists of simple interrupted su-
tures that stabilize the vertices of the surgical
papillae at th e base of the corresponding ana-
tom ical de-epithelialized papillae, allowing api-
cal repositioning of the flap at the level of the
teeth being treated for altered passive eruption.
Simple interrupted sutures are performed on the
peri -implant papillae along with a sling suture an-
chored to th e palatal cingu lum of the provisional
crown, allowing precise adaptation of th e flap's
keratin ized tissues onto th e buccal surface of the
provisional. As seen in the frontal clin ical image,
the flap appears slightly more coronal than the
ideal position required for the treatment of th e
altered passive eruption at the level of the two
teeth adjacent to the implant, but the wide band
of keratinized tissue and the adequate distance
from the bone crest wi ll allow the execution of a
gingivectomy in a subsequent phase to relocate
the gingival margin in the desired apical position.
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

After 2 weeks of undisturbed healing, the soft tissues remain in the same position in wh ich they were
sutured at the end of the surgery; this is proof of the good tissue stability achieved with the surgery.

After 2 months, the provisional is extended incisally to improve esthetics. The peri-implant soft tissues
appear healthy and thickened.

531
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

Nearly 3 months after the surgery, the gingivec-
tomy was performed on the teeth adjacent to
the implant crown. To avoid thinning the buccal
soft tissues , a full-thickness gingivectomy was
performed with the surgical blade almost per-
pendicular to the facial surface.
Since this type of incision could lead to coro-
nal regrowth of the soft tissues, the emergence
profiles of the teeth involved were overcon-
toured with cervical composite restorations to
block this phenomenon; control of the bleed-
ing was achieved with a gingival retraction cord
impregnated with an astringent-hemostatic
agent. Once the soft tissues subjected to the
gingivectomy had healed, the composite resto-
rations could be removed.

Simultaneously, soft tissue conditioning at the level of the implant crown is also started with the dual
purpose of apically repositioning the buccal mucosal margin-recreating the same scallop as that of
the gingival margin on the adjacent reference tooth-and promoting papillae growth.
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

Six months after the surgery, the mucosal margin
of the implant crown is positioned at the same
level as the gingival margin of the adjacent cen-
tral incisor, and there is good alignment of the
gingival margins of the teeth previously affected
by altered passive eruption The prosthetic crown
emerged in a very natural fashion from the buc-
cal soft tissues. At the level of the transmuco-
sal path , the soft tissues appear thickened and
healthy; peri-implant papillae are long and thick.

533
MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT
It has long been known that there is a relationship
between the width and height of the interdental
papillae. This notion is particu larly important at
the implant level: in order to obtain the maximum
growth and dimensional stability of the papillae,
it is necessary to increase their connective tissue
base (ie, their mesiodistal and buccolingual di-
mensions). The importance of extending the me-
siodistal dimension of the connective tissue graft
onto the base of the papillae in order to increase
their bucco-lingual thickness (white dotted line)
has been mentioned several times. The choice
of the anatomy of the transmucosal implant
portion can also play a key role in the growth
of peri-implant papi ll ae. If divergent, the metallic
structure wi ll come closer to the adjacent teeth,
and the mesiodistal dimension of the papillae
(black lines) will be reduced in comparison to a
convergent collar, wh ich distances itself from the
adjacent teeth and leaves more space for soft
tissue growth . In the authors' opinion, the trans-
mucosal implant portion in areas of high esthetic
value should ideally be convergent-especially in
cases of reduced mesiodistal space.
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT

Delivery of the final restoration is done approxi-
mately 1 year after th e surgery. Comparison be-
tween the baseline and final situation highlights
the overall esthetic improvement derived from
the co mbined treatm ent of the altered passive
eruption and postextraction implant placement
with immediate provisionalization and simultane-
ous soft tissue augmentation. The periapical ra-
diograph shows good implant osseointegration
and no signs of bone loss.

535
MUCOGINGIVAL APPROACH FOR THE IM MEDIATE POSTEXTRACTION IMPLANT
 MUCOGINGIVAL APPROACH FOR THE IMMEDIATE POSTEXTRACTION IMPLANT
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