oriGinal research

Clinical investigation of mucosal thickness stability after soft

tissue grafting around implants: A 3-year retrospective study

Stefano Speroni, Marco Cicciù, Paolo Maridati, Giovanni Battista Grossi, Carlo Maiorana

Department of Implantology,
Dental Clinic IRCSS, University
ABSTRACT
of Milan, Italy Purpose: To assess the long-term stability of gingival grafts placed around dental implants at the
time of second surgery uncovering and to further investigate the association between mucosal
thickness (MTh) by demographic variables and clinical investigation.
Materials and Methods: Fourteen patients with submerged dental implants covered by inadequate
keratinized mucosa were studied. The subjects underwent a periimplant plastic surgery (PPS) at
the second-stage dental implant surgery and free gingival autograft orsubepithelial connective
tissue graft were used according to the patients’ clinical situation. Clinical measurement of
MTh was assessed by bone sounding with a periodontal probe using customized acrylic stents
andthe values were recorded at baseline (day of graft) and at 0.5, 1.5, 4, 12, 24 and 36 months
after grafting.
Results: At 12 months postoperatively, the mean MTh was 2.89 mm, with a mean additional
increase of 1.75 mm when compared with baseline (P=0.0001). No statistically significant
differences in MTh were found between the 12- and the 36-month observations (P=0.09).
In addition, at 36 months, a thin mucosa was associated with a greater increase in the MTh
compared with a thick mucosa (2.14 and 0.64 mm, respectively, P=0.006). Similarly, the
mandibular sites were associated with a greater increase in the MTh in comparison with the
maxillary sites (2.17 and 0.81 mm, respectively; P=0.02).
Conclusions: Within the limitations of this investigation, the data suggest that PPS at the second-
stage dental implant surgery could results in additional increases in MTh, especially when it
is performed in areas where the mucosa is of a thin biotype.
Received : 30-12-09
Review completed : 12-02-10 Key words: Dental implants, implant exposure, keratinized mucosa, mucosal thickness,
Accepted : 14-08-10 soft tissue

Currently, it is widely accepted that keratinized mucosa of KM adjacent to implants bear the same significance as
(KM), although not essential to the existence of a tooth to natural teeth.[6-15] The structure and function of the
and its attachment apparatus, does enhance the long-term mucosa that surrounds the implants has been examined,[16]
survival of the tooth. On a review of the literature, it is and it was observed that the soft tissue response to plaque
evident that the presence of KM is especially important develops in a similar manner around natural teeth and
around restorations and prostheses or if the tooth is in a dental implants.[17,18] Longitudinal studies definitively
dentition susceptible to periodontal breakdown.[1-5] However, establish that while patient comfort may be enhanced in
there has been considerable discussion whether the extent selected patients with the presence of keratinized gingiva
the around implants, its presence is neither necessary for
Address for correspondence:
the establishment of osseointegration or for its long-term
Dr. Marco Cicciù maintenance.[19]
E-mail: acromarco@yahoo.it
However, with increasing duration of plaque accumulation,
Access this article online the periimplant mucosa seems to be less-effective in
Quick Response Code: Website: encapsulating the inflammatory lesion.[20] Dental implants
www.ijdr.in are often placed in patients with a history of poor oral
PubMed ID:
hygiene and edentulism, and can have structures and
*** surfaces that are different from those of natural teeth. Thus,
they are more susceptible to developing inflammation and
DOI:
10.4103/0970-9290.74208
bone loss from plaque accumulations or microbial invasion,
and the establishment of an adequate amount of gingiva
Indian J Dent Res, 21(4), 2010 474
Mucosal thickness stability around dental implants
firmly attached to the underlying periosteum and bone has
been cited as a goal in implant maintenance.[6]
Nevertheless, little is known about the influence of KM
dimension around implants on the hard and soft tissue health.
Recent studies showed that mucosal inflammation and plaque
accumulation were significantly higher around implants with
KM<2 mm,[21] that there was a negative correlation between
KM and mucosal recession[22] and that increased width of KM
is associated with lower mean alveolar bone loss.[23] More
recently, Zigdon and Machtei showed that a thick mucosa (≥1
mm) was associated with lesser mucosal recession compared
with a thin mucosa (≤1 mm).[23]
The general belief that mucosal thickness (MTh) and KM
width are of special importance in the esthetic zone, where
narrow and thin KM may lead to greater mucosal recession,
has resulted in the introduction of numerous surgical
procedures to increase the width of the gingiva around the
dental implants.[6,24-37]
The purpose of the present study is to assess the stability
of gingival grafts around dental implants and to further
investigate the association between MTh and clinical and
demographic variables.
MATERIALS AND METHODS
The subjects eligible for the study were identified from a
population of patients attending the Unit of Implantology
at the University of Milan School of Dentistry, Italy.
The following inclusion criteria were used: (a) lack of
attached KM at the end of the recommended submerged
healing period and(b) medically healthy adults. The
following exclusion criteria were considered: (a) severely
reduced vestibular fornix,(b) pregnancy and lactation,(c)
heavy smoking (>10 cigarettes/day),(d) poor oral hygiene
and (e) contraindications to periodontal surgery.
Informed written consent was obtained from all patients
before they were included in this study.
Data collection
Figure 1 illustrates the study design and timetable. The
same operator performed all the recordings and surgical
procedures for all patients. Clinical measurements were
recorded at the baseline examination (before graft surgery)
and at 0.5, 1.5, 4, 12, 24 and 36 months after graft surgery.
Preoperative assessment
Before the baseline measurement, a customized acrylic
stent was fabricated in order to obtain reliable and
reproducible measurements of MTh. Starting from alginate
impressions, a working cast was fabricated with a wax-up
of the proposed restoration and a soft tissue wax-up was
475
Speroni, et al.
Figure 1: The study design and timetable
then performed with pink wax to develop the ideal soft
tissue thickness. An alginate impression was taken to
create the working cast for fabrication of a master cast.
A custom acrylic stent was then fabricated on the master
cast to measure the MTh after grafting positioning and
to have controllable and reproducible conditions. The
stent had a circular metal sleeve, allowing for passage of
a North Carolina probe(UNC 6; Hu-Friedy, Chicago, IL,
USA) [Figure 2].
Transgingival probing measurement was assessed after the
application of local anesthesia in the buccal gingiva with
xylonar spray (Lignocaine 15.0g). Measurements were then
rounded up to the nearest millimeter.
Surgery
Before beginning the study, each patient received a full-
mouth scaling and polishing and oral hygiene instructions.
Preoperative clinic photographs were taken [Figure 3]. A
mouth rinse with 15ml of 0.2% chlorhexidine solution
(Dentosan®; Pfizer Consumer Healthcare, Rome, Italy) for
1 min was used before surgery and immediately after the
operation.
Because the sample included only patients with poor or
absent KM and vestibular fornix maintained, periimplant
plastic surgery (PPS) techniques have been used according
to the Maiorana and Speroni classification[37] [Table 1].
At the time of uncovering of implant and healing screws
placement, all patients underwent to the elevation of a
split-thickness flap.The preparation of the recipient bed was
prepared using a size 15c scalpel blade mounted in a Bard/
Parker scalpel handle. The bilaminar technique and free
epithelial–connective graft[38-41] were chosen for performing
surgery in order to offer the best esthetic results to the
patients [Figures 4–6]. The donor site was located on the
same lateral palate, except for one gingival graft that was
obtained from the tuberosity.
Postoperative assessment
Postoperative instructions were given to each patient. The
day after the surgery, the patients started home use of the
chlorhexidine solution twice a day for 2 weeks.
Indian J Dent Res, 21(4), 2010
Mucosal thickness stability around dental implants
At 1–2 weeks postsurgery, palatal sutures and sutures at
the grafted area were removed respectively. No major
postoperative problems developed [Figures 7 and 8].
To survey soft tissue grafts under the same biological
conditions of healing and maturation, all patients had
implant-retained restorations 2 months postoperatively.
Study variables, data management and analysis
We used Student’s t-tests for paired data to compare the
mean MTh measured postoperatively against either MTh
at baseline or at 36 months. Unpaired t-tests were used
to evaluate the mean keratinization at baseline and at 36
months in relation to gender, age and clinical covariates
(mucosal thickness, arch, receiving site, type of performed
graft and type of connection fixtureabutment). MTh
difference in relation to the same covariates was analyzed
with simple and multivariate linear regression models.
Statistical analyses were performed using Statistica version
6 and Stata version 10.
RESULTS
Fourteen patients (eightfemales and sixmales) aged 28–58
years (average, 42.2 years) were entered in the study. The
mean MTh at baseline was 1.14 mm. We recorded a mean
increase in MTh of 4.11 mm at 2 weeks after surgery,
followed by a progressive reabsorption, which was faster and
almost complete within 8 months (mean increase in MTh
at 12 months=1.75 mm; P=0.09 vs. MTh at 36 months).The
mean MTh at 36 months was 2.54 mm (P=0.0005 compared
to baseline), with a mean gain of 1.40 mm [Table 2 and
Figure 9].
At 36 months after grafting, patients with thin morphotype
had a 3.3-times increase of MTh (2.14 mm) in comparison
withthick morphotype (0.64 mm; P=0.006) [Table 3].
Patients who received a graft in the lower jaw had an
increase in MTh of 2.17 mm, over 2.5-times in comparison
withthose operated in the upper jaw (0.81 mm; P=0.02). In
multiple regression models, the morphotype remained as
the strongest predictor of increase in MTh at 36 months
Table 1: Classification of PPS (from “Advanced osseointegration,” Milan, Italy, RC Libri, 2004)
Keratinized mucosa Fornix Surgical intervention
Adequate Present Simple incision
Punch technique
T-shaped incision
Flap
Pedicled flap technique
Roll flap technique
Poor Present Bilaminar flap (connective graft)
Bilaminar flap (connective graft) + simple incision
(punch technique or T-shaped incision)
Absent Present Free gingival graft (epithelium–connective graft)
Absent Free gingival graft (epithelium–connective graft) +
vestibuloplasty
Indian J Dent Res, 21(4), 2010
Speroni, et al.
postoperatively (data not shown).
DISCUSSION
To date, there have been a limited number of studies
investigating the relationship between the presence or
absence of keratinized tissue and periimplant health in
the long-term maintenance of dental implants. Recently,
Chung et al. showed that mucosal inflammation and plaque
accumulation were significantly higher around implants
with KM <2 mm.[21] More recently, Bouri et al. reported that
increased width of KM around implants is associated with
lower mean alveolar bone loss and improved indices of soft
tissue health.[23] Likewise, Zigdon and Machtei investigated
the association between the dimensions of KM with clinical
and immunological parameters around dental implants.[24]
It was observed that a thick mucosa (≥1 mm) was associated
with lesser buccal mucosal recession compared with a thin
mucosa (<1 mm). These findings are of special importance
in the esthetic zone, where narrow and thin KM may lead
to greater mucosal recession. Therefore, the periodontal
biotype not only affects the natural dentition but also affects
the esthetic result in an implant-supported prosthesis as
well. In fact, the type of tissue around an implant is essential
for the ideal emergence profile and esthetic illusion of a
natural tooth[42] and for the long-term health of the implant
and its ability to withstand periimplantitis.[6,43]
A good amount of keratinized gingiva can be obtained around
the teeth by several different types of procedures,[1-3,6,7,44-48]
eitherbefore, simultaneously or after implant placement.[43,49-52]
In the recent literature, the procedure most indicated to
increase the width of attached gingiva seems to be the gingival
graft. It is a reliable procedure and graft shrinkage is around
35%. However, it may have some problems, such as the need
for a donor area with sufficient dimensions to remove a graft,
two surgical areas with a possibility of increasing pain after
surgery and a longer time of surgery.[53,54,55]
To the best of our knowledge, this is the first study to assess
Note
For esthetic areas
Microinvasive
For soft tissue thickness augmentation
For esthetic areas Two-stage procedure to
have a betterprosthetic emergence profile
To increase soft tissues thickness and height
476
Mucosal thickness stability around dental implants Speroni, et al.

Figure 2: The custom acrylic stent Figure 3: Clinical preoperative evaluation of the keratinized mucosa
at the stage of second surgery unrecovering screw

Figure 4: Elevation of split-thickness flap

Figure 5: A particular of the free gingival graft harvested from the palate

Figure 7: Two-weeks postoperative healing

Figure 6: Graft placed and sutured

Figure 9: Individual and mean trends in the keratinized mucosa after

Figure 8: Evaluation of the new thickness of the keratinized mucosa periimplant plastic surgery

477 Indian J Dent Res, 21(4), 2010

Mucosal thickness stability around dental implants Speroni, et al.

Table 2: MTh at baseline and postoperatively explanation for this phenomenon might be related to the
Months post- Min Max Mean Mean P value P value fact that gingival thin phenotype starts with an unfavourable
operatively (mm) difference *vs. *vs. 36 local situation in comparison witha thick one. Recently, Kan
vs. baseline baseline months
et al. showed that the dimensions of periimplant mucosa
0 0.0 4.0 1.14 - - 0.0005 in the thick biotype were significantly greater as compared
0.5 4.0 9.0 5.25 +4.11 <0.0001 0.0002 with the thin biotype.[52,55] Therefore, this is no surprise since
1.5 3.0 6.0 4.14 +3.00 <0.0001 0.0001 the thin mucosa benefits more with PPS.[53]
4 2.0 5.0 3.43 +2.29 <0.0001 0.0003
12 1.5 5.0 2.89 +1.75 0.0001 0.09 Finally, in the current study, it appears that patients who
24 2.0 4.0 2.68 +1.54 0.0007 0.10 received graft in the lower jaw had a greater increase of
36 1.5 4.0 2.54 +1.40 0.0005 - MTh in comparison withthose operated in the upper jaw.
*Student’s t-tests for paired data Likewise, this difference is probably attributable to the fact
that thin morphotype may be more common in mandibular
Table 3: MTh at baseline (0 months) and at 36 months
postoperatively, by selected demographics and clinical
areas. The choice of the technique used for each patient
variables was also related to the treated area and to the patients’
Variables n Mean at Mean Mean morphotype.The patients who underwent uncovering
baseline at 36 difference implants in the anterior or esthetic area were treated with
(mm) months (mm) a split-thickness flap and connective tissue (CT) placement
(mm) in order to maintain the color of the treated area unaltered.
Gender Male 6 1.50 2.83 1.33
Female 8 0.87 2.31 1.44
Unfortunately, no comparison data are available on this
P=0.37 P=0.57* P=0.87**
Age (years) <40 7 0.86 2.64 1.78 subject and, therefore, these preliminary results should be
40+ 7 1.43 2.43 1.00 treated with some caution. To further establish these results,
P=0.41 P=0.15 P=0.20 a larger sample size and longer follow-up will be required.
Area of the graft Posterior 9 0.89 2.39 1.50
placement Frontal 5 1.60 2.80 1.20
Anterior P=0.32 P=0.28 P=0.65 CONCLUSION
Biotype Thick 7 2.00 2.64 0.64
Thin 7 0.28 2.42 2.14 Within the limitations of this investigation, the investigation
P=0.004 P=0.57 P=0.006
Jaw Upper 8 1.75 2.56 0.81 data suggest that PPS at the secondstage results in
Lower 6 0.33 2.50 2.17 additional increases in MTh, especially in the presence of
P=0.03 P=0.87 P=0.02 a thick periimplant biotype as compared to a thin biotype.
Type of graft Connective 7 1.71 2.93 1.21 Moreover, stability of the peri-implant mucosal thickness
Epithelial– 7 0.57 2.14 1.57
connective P=0.08 P=0.02 P=0.57
was noted 8 months after the surgical soft tissue correction.
Connection of the Cam 3 2.67 3.17 0.50
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How to cite this article: Speroni S, Cicciù M, Maridati P, Grossi GB,
Maiorana C. Clinical investigation of mucosal thickness stability after soft
tissue grafting around implants: A 3-year retrospective study. Indian J Dent
Res 2010;21:474-9.
Source of Support: Nil, Conflict of Interest: None declared.
Indian J Dent Res, 21(4), 2010
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