Int. J. Oral Maxillofac. Surg.

2013; 42: 660–665

http://dx.doi.org/10.1016/j.ijom.2013.01.008, available online at http://www.sciencedirect.com

Clinical Paper
Dental Implants

A palatal roll envelope Y. Man1,2, Y. Wang2, Y. Qu1,

P. Wang2, P. Gong1,2
1
State Key Laboratory of Oral Diseases,

technique for peri-implant West China Hospital of Stomatology, Sichuan

University, Chengdu, PR China; 2Implant
Center, West China Hospital of Stomatology,
Sichuan University, Chengdu, PR China

mucosa reconstruction:
a prospective case series study
Y. Man, Y. Wang, Y. Qu, P. Wang, P. Gong: A palatal roll envelope technique for
peri-implant mucosa reconstruction: a prospective case series study. Int. J. Oral
Maxillofac. Surg. 2013; 42: 660–665. # 2013 International Association of Oral and
Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. The aim of this study was to evaluate peri-implant soft tissue changes after
performing a palatal roll envelope technique. Twelve patients, presenting a labial
flat or concave profile before second-stage surgery, underwent soft tissue
augmentation using the palatal roll envelope technique with papilla reservation
design. The convex profile on the facial aspect, Jemt papilla index, facial mucosal
level, marginal bone level, proximal bone levels of the adjacent teeth, and surgical/
prosthetic complications were evaluated before surgery as the baseline, and then
reevaluated at 1 week, 3 months, and 6 months after surgery. Data were analyzed
using the Friedman test and Wilcoxon signed-rank test. Results indicated that the
convex profile and the average papilla index score were improved, while the facial
mucosal level was adjusted to a level similar to that of the contralateral tooth at Key words: palatal roll envelope technique;
peri-implant mucosa; soft tissue augmentation;
3 months and then remained stable for the follow-up visit. With the limitations
convex profile; facial mucosal level; jemt papilla
identified in this report, the palatal roll envelope technique can be considered an index.
alternative method to augment the soft tissue during second-stage surgery. This
technique obviates the need for another surgical site and papillae area, and also Accepted for publication 14 January 2013
reduces the risks of graft shrinkage and scarring on the labial site. Available online 18 February 2013

Dental implants have been used success-
fully to replace missing teeth.1,2 With
rapid developments in this area, empha-
sis has shifted from implant osseointe-
gration towards predictable aesthetic
success.2,3 In order to achieve pleasing
aesthetic results, the soft tissue contour
around implant-supported restorations
should be identical or similar to the
contralateral tooth or in harmony with
the adjacent natural teeth or artificial
restorations. An inadequate vertical
dimension of the buccal peri-implant tis-
sue might otherwise lead to an unusually
longer crown, and missing volume in the
horizontal direction at the buccal aspect
could cause a flat or concave profile in
the respective region, resulting in food
retention and bacterial trap. Therefore,
soft tissue management and peri-implant
aesthetics have become a focus of
implant dentistry.4,5
The pink aesthetic score (PES)6 is an
objective aesthetic criterion comprising
five parameters. The five parameters can
generally be categorized into two main
parts: papilla parts (mesial and distal
papillary scores) and facial parts (the cur-
vature of the facial soft tissue, the level of
the facial peri-implant mucosa, and the
convex profile on the facial aspect).
Besides bone augmentation, various flap
designs7,8 and free connective tissue

0901-5027/050660 + 06 $36.00/0 # 2013 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

grafts5,9 have commonly been used to
enhance the papilla and facial parts. How-
ever, it has been reported10 that papillae
adjacent to single-implant restorations
regenerate to some extent after 1–3 years
of prosthetic placement without any clin-
ical manipulation of the soft tissue, and
can be in complete harmony with the
adjacent natural teeth. The most likely
reason for this phenomenon is that a papil-
la’s presentation after an implant-sup-
ported restoration is mainly determined
by the distance between the crestal bone
and the base of the contact area.11 In the
case of a single implant, this means that
peri-implant papilla levels are dictated by
the proximal bone levels of the adjacent
teeth.12,13 Hence, soft tissue management
in the papilla area, or some other
method,14 could restore the papilla faster,
but the final volume is similar after a
period of prosthetic restoration. On the
other hand, a limited flap design, without
involving papillae, does protect crestal
bone levels compared to a widely mobi-
lized flap design15 that includes papillae.
A large flap could result in a decrease in
interproximal crestal bone height.16 As a
result, a limited flap might protect the
papilla more effectively than a raised
papilla with a soft tissue graft underneath.
Connective tissue grafts have often
required a second surgical site, such as
the palatal vault or maxillary tuberosity.
This can aggravate the discomfort for
patients. In one study, more than half of
patients preferred the aesthetic result but
would not undergo the same soft tissue
augmentation procedure again.17 More-
over, compared to pedicle grafts free con-
nective tissue grafts have a higher risk of
shrinkage.5
The purpose of this study was to evaluate
the efficacy of a palatal roll envelope tech-
nique. The technique was performed at
implant exposure, and the intention was
to reconstruct the convex configuration,
facial mucosal level, and peri-implant
papillae around maxillary implant-sup-
ported restorations with no need for a sec-
ond surgical site. This technique could also
reduce the risks of graft shrinkage and
scarring on the labial site. It is a minimally
invasive surgery that could be used alone or
as a backup for the unpredictable shrinkage
of former augmentation procedures.
Materials and methods
Patients included in the study had to reveal
the absence of a convex profile before
the second surgery (Fig. 1a and b) and
no tobacco abuse (maximum 15 cigar-
ettes/day). Twelve patients (seven women
Palatal roll envelope technique for periimplant mucosa reconstruction 661
Fig. 1. (a) Frontal view of the labial concave profile on the maxillary right lateral incisor.
(b) Occlusal view of the concave feature on the labial site of the maxillary right lateral incisor.
The dotted green line indicates the concave feature. The incision design: the green line indicates
the superficial mucosal incision while the yellow line indicates the deeper connective tissue
incision. (c) Frontal view of the surgical site immediately after the palatal roll envelope
technique. The convex profile was reconstructed while the marginal mucosa was in the coronal
position compared to the contralateral tooth. (d) Occlusal view immediately after palatal roll
envelope technique. The convex profile is obvious, while the palatal superficial flap is secured
back to the original position.
and five men), who underwent surgery teeth and were not included in the partial-
between December 2009 and July 2010, thickness flap. Both extremities of the
were included in this study; their incision extended palatally to a point
age ranged from 19 to 45 years (mean approximately 5–10 mm from the crestal
age 30  8.7 years). Each patient had incision. A partial-thickness (superficial
one implant placed at the position of half) flap was raised, using a scalpel. Then,
maxillary central incisor or lateral incisor. within the margin of the superficial flap, the
Ten Osstem GS II implants (OSSTEM incision of the deeper half was extended
Co., Ltd., Busan, Korea) and two Ankylos down to the bone with a pedicle at the
implants (FRIADENT GmbH, Mannheim, alveolar ridge (Fig. 1b). The deeper half
Germany) were used. Implants were was raised with a thin periosteal elevator
allowed to heal for 3 months. The palatal and formed a subepithelial pediculated con-
roll envelope technique was performed at nective tissue flap. Both vertical incisions
second-stage surgery. Immediately after were allowed to extend a little bit towards
removing the suture, implant-supported the labial but within the junction line
interim restorations were fabricated and between the alveolar ridge and buccal plate.
secured to the dental implants. Peri-implant These extensions facilitated rolling of pedi-
soft tissue underwent remodelling and cle palatal connective tissue. The facial
matured around these interim restorations mucosa was undermined and the deeper
for 3 months, and then soft tissue stability palatal connective tissue could be rolled
was investigated for another 3 months as a and positioned in the labial envelope.
follow-up before final restoration. The implant cover screw was then retrieved
and a healing abutment was inserted
(Fig. 1c and d). Interrupted sutures (6–0)
Surgical procedure
fixed the palatal superficial flap to the
A local anaesthetic was administered proximal tissue.
before treatment. An initial partial-thick-
ness crestal incision was made 1–2 mm
Prosthetic restoration
towards the palatal site, and 1–2 mm from
the teeth adjacent to the edentulous space. Restorative procedures were initiated
Papillae remained adhered to the proximal immediately after removing the suture.
662 Man et al.

up the entire interproximal space,

2 = papilla fills more than half of the
height of the interproximal space,
1 = papilla fills less than half of the height
of the interproximal space, 0 = no papilla)
was evaluated at T1, T2, and T3.

FML change
The location of the FML in relation to the
location of the contralateral tooth or
restoration was recorded at T1, T2, and
T3. A positive value was given when the
FML was in a coronal position when
compared to the contralateral tooth or
restoration.

MBL and PBL changes

The MBL and PBL were measured using
sequential peri-apical radiographs (Fig. 2d
and e). A peri-apical radiograph was taken
with paralleling technique. In the case of
an angular difference between T0 (or T1)
and T3, the measured distance was stan-
dardized by implant length. The marginal
bone levels on the mesial and distal
aspects of the implants at interval T0
(or T1) to T3 were measured and averaged
to the nearest 0.1 mm.

Complications
Complications were also recorded, includ-
Fig. 2. (a) Three months after surgery, the peri-implant soft tissue has remodelled and matured ing peri-implant radiolucency, mobility,
around the interim crown. (b) Frontal view: final restoration. (c) Occlusal view: final restoration.
(d) Peri-apical radiograph immediately after interim crown placement (T1). The black arrows
soft tissue complications, prosthetic com-
indicate the marginal bone level, while the white arrows indicate the proximal bone level. (e) plications, and patient discomfort.
Peri-apical radiograph after final restoration (T3). The black arrows indicate the marginal bone
level, while the white arrows indicate the proximal bone level. Statistical analysis
A provisional screw-retained abutment (T0) and at 1 week (T1), 3 months (T2), Descriptive statistics were used to explain
lined with composite resin was used as and 6 months (T3) after surgery. Data the MBL and PBL changes. The Friedman
an interim crown. The interim crown was were evaluated at the designated time- test, using mean ranks, was applied to
shaped according to the contralateral tooth points: the convex profile on the facial evaluate CPF, PIS, and FML changes.
and manually screwed in. The occlusion aspect (CPF; at T0, T1, T2, and T3), facial The level of significance was set at
was adjusted until there were no contacts mucosal level (FML; at T1, T2, and T3), a = 0.05. If there was an overall statisti-
in centric occlusion and in protrusive/lat- Jemt papilla index score (PIS10; at T1, T2, cally significant difference among the
eral movements. Patients were instructed and T3), marginal bone level (MBL) and mean ranks of CPF, PIS, and FML at
on how to properly brush their teeth. The proximal bone levels of the adjacent teeth the different evaluation points, separate
interim crown was adjusted 1–3 times to (PBL) (changes between T0 (or T1) and Wilcoxon signed-rank tests were run on
mimic the natural emergence profile of the T3), and related surgical and prosthetic the different combinations of related times
contralateral tooth. After 3 months with complications. to examine where the differences actually
the interim crown in place, a mature status occurred. The statistical analysis was per-
of the peri-implant mucosa was achieved formed using SPSS v. 11.5 program.
CPF change
for each patient (Fig. 2a). The interim
crown was kept in place for another 3 CPF6 was evaluated at T0, T1, T2, and T3
Results
months. The final restoration was manu- (3 = the over-contour of a CPF, 2 = the
factured and seated 6 months after surgery presence of a CPF, 1 = the partial presence Healing was uneventful. No patient was
(Fig. 2b and c). of a CPF, and 0 = the absence of a CPF). lost during the 6-month follow-up, and
every patient received a clinical evalua-
tion at each follow-up. Every patient felt
Clinical evaluation PIS change
slight postoperative discomfort. Two
Clinical examinations were performed at The Jemt papilla index score (PIS10; patients presented partial necrosis of the
the following time-points: pre-surgery 4 = hyperplastic papilla, 3 = papilla fills palatal mucosa at suture removal. The

Fig. 3. (a) Pre- and postoperative evaluations of the convex profile on the facial aspect;
*P < 0.05, a significant difference. (b) Papillae changes around the single implant-supported
interim restoration. *P < 0.05, a significant difference. (c) Facial mucosal level changes after
single implant-supported interim restoration. *P < 0.05, a significant difference.
necrotic area healed 2–3 weeks later with-
out any treatment. During the observation
period, all implants were stable, and none
had lost osseointegration. One of the
patients presented interim crown debond-
ing at 1 month after the initial interim
restoration and was treated with a new
interim crown.
The CPF ranged from 0–1 (0.58  0.51)
at T0, to 2–3 (2.58  0.51) at T1, 1–2
(1.91  0.29) at T2, and 1–2
(1.83  0.39) at T3. The Friedman test
showed statistically significant differences
among the four groups (x2 (2) = 32.818;
df = 3; P < 0.001). Wilcoxon signed-rank
tests showed statistically significant differ-
ences between T0 and T1 (Z = 3.166,
P = 0.002), T1 and T2 (Z = 2.828,
P = 0.005), T0 and T2 (Z = 3.176,
P = 0.001), T0 and T3 (Z = 3.217,
P = 0.001), and T1 and T3 (Z = 3.000,
P = 0.003), but no statistically significant
difference between T2 and T3 (Z = 1.000,
P = 0.317) (Fig. 3a).
The mean of the mesial and distal
papilla measurements within the same
implant was considered a unit at each
evaluation time. Postoperative PIS ranged
from 0 to 2 (0.88  0.74) at T1, to 1 to 3
(2.54  0.75) at T2 and 2–3 (2.79  0.40)
at T3. The Friedman test showed statisti-
cally significant differences among the
three time-points (x2 (2) = 22.40; df = 2;
P < 0.001). Wilcoxon signed-rank tests
showed statistically significant differences
between T1 and T2 (Z = 3.088,
P = 0.002) and T1 and T3 (Z = 3.129,
Palatal roll envelope technique for periimplant mucosa reconstruction
P = 0.002), and no statistically significant
difference between T2 and T3
(Z = 1.857, P = 0.063) (Fig. 3b).
FML ranged from 2.2 to 0.5
( 1.22  0.49) at T1, to 0.6 to 0.1 at
T2 ( 0.19  0.18) and 0.5 to 0.2
(0.10  0.18) at T3. The Friedman test
showed statistically significant differences
among the three time-points (x2
(2) = 15.765; df = 2; P < 0.001). Wil-
coxon signed-rank tests showed statisti-
cally significant differences between T1
and T2 (Z = 2.668, P = 0.008) and T1
and T3 (Z = 3.062, P = 0.002), and no
statistically significant difference between
T2 and T3 (Z = 1.543, P = 0.123)
(Fig. 3c).
A measured value of zero for MBL and
PBL was given to T0. A negative value,
bone resorption, was given when the MBL
and PBL was apical to T0. The mean MBL
change from T0 (or T1) to T3 was
0.88  0.34, ranging from 0.32 to
1.31 mm, while the mean PBL change
from T0 (or T1) to T3 was 0.15  0.26,
ranging from 0.42 to 0.11 mm.
Discussion
Among the 12 cases in our study, eight
underwent the procedure with guided bone
regeneration, three underwent free con-
nective tissue grafting, and one lacked
primary stability (less than 10 N cm) at
the time of implant placement. All the
implants were submerged in the case of
graft infection or losing osseointegration.
663
Each augmentation procedure underwent
shrinkage5,18,19 to some extent during the
3-month healing period. As a result, soft
tissue augmentation at second-stage sur-
gery was considered an option for these
patients.
Soft tissue augmentation around natural
teeth has been proven to be effective.20
However, based on the morphological
situations of the hard and soft tissue sup-
port around implants, shrinkage of the soft
tissues could be more severe than that of
the periodontal tissue.21
A pedicle soft tissue flap22 could be a
good option for peri-implant mucosa
grafts. It has been used to accomplish soft
tissue coverage for immediate implant or
grafted socket23,24 and simultaneous hard
and soft tissue augmentation.25 The tech-
nique used in this research has several
advantages: the graft part still gets vascu-
larization through the pedicle, it is easier
to stabilize, and the donor site remains
covered after harvesting subepithelial
connective tissue. This technique pro-
duced an increase in labial thickness at
100% of the sites. The convex feature,
which is considered to be the biggest
challenge,6 was significantly improved
and clinically appreciable in this study.
Three months after the surgical proce-
dure, our findings showed that the con-
nective tissue graft was incorporated into
the surrounding soft tissue, and a healthy
peri-implant mucosa was present. In the
following months, volume changes were
insignificant, denoting a stable condition.
This is in accordance with other
research,26,27 which has shown that most
recession happens in the first 3–6 months
after prosthetic restoration.
In the present report, an increase in the
papillary height was noted in each case.
Nineteen papillae (of 24 in total) in the
current report filled the initial black trian-
gle in the first 3 months, which indicates
intact bone height at adjacent teeth is
crucial for the morphology and nutrition
of papillae.12,13
The mean marginal bone loss was higher
than that found in other research.9,28 There
could be several reasons for this. First, the
papillae are preserved by a limited flap;
nevertheless, part of the peri-implant peri-
osteum is still detached from the bone. This
can affect the nutrition of the bone close to
the implant and might result in an unpre-
dictable degree of resorption. Second,
the restorations could also affect the bone
response. It has been reported that bone may
recede more from composite resin than a
titanium surface.29 The interim crown mate-
rial used in the study could have increased
this risk of crestal bone loss. Finally, a
664 Man et al.
platform-switched implant could have a
more favourable bone response when the
offset between the implant margin and abut-
ment is more than or equal to 0.4 mm.30 In
this report, the offset in six cases was less
than 0.4 mm. However, this phenomenon
still needs further investigation.
A substantial FML apical displacement
was noted in every case between T1 and
T2. One of the main reasons for this
phenomenon is physiological remodelling
of the soft tissue. Based on our clinical
manipulation and knowledge, there are
two more factors affecting this ‘reces-
sion’. First, the palatal incision design
transfers a part of the keratized mucosa
on the crestal ridge to the labial site, which
contributes to a more coronal position of
FML at T1. Second, all the interim
crowns, adjusted by adding composite
resin on the labial site 1–3 times during
the first 3 months, were intended to push
the FML apically to the same level as the
contralateral tooth and restoration.
Gentle handling of the partial-thickness
flap is required for the whole procedure. A
thicker tissue at the palatal site is desirable
to facilitate splitting and maintaining
the integrity of both parts. Measuring
the thickness of the palatal tissue with a
probe is necessary before the incision.
Several limitations need to be taken into
consideration when evaluating the results
of the present report. First, this study was a
case series without a control group. Sec-
ond, local plaque and gingival indices
were not evaluated.
Based on the preliminary results of this
report, the aesthetic outcomes indicate that
the palatal roll envelope technique is use-
ful for labial soft tissue and interproximal
papilla reconstruction adjacent to an ante-
rior maxillary single-implant restoration.
This technique only needs a minimal trau-
matic preparation that can be easily
accepted by patients.
Funding
Sichuan Provincial Science and Technol-
ogy Pillar Program (no. 2011GZ0130, no.
2010SZ0099) and ITI small grant (no.
2009660). The funds have no involvement
in the study design, or in the collection,
analysis and interpretation of data.
Competing interests
None declared.
Ethical approval
The research was approved by the Human
Ethics Committee of the West China
School of Stomatology (Protocol
2009034).
Acknowledgements. All authors acknowl-
edge the valuable technical work of Jian-
shen Guo and appreciate Dr Kirk Mosley
for critical review of the manuscript.
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