Soft Tissue

Considerations
in Implant Site
Development
Nicolaas C. Geurs, DDS, MS, Philip J. Vassilopoulos, DDS,
Michael S. Reddy, DMD, DMSc*

KEYWORDS
 Soft-tissue  Regeneration  Prosthesis  Implant therapy

THE CHARACTERISTICS OF SOFT TISSUE the soft-tissue interface, aspects of soft-tissue

SURROUNDING IMPLANTS health, and esthetics during treatment planning
and therapy.
Healthy soft tissue surrounding a dental implant is
essential for successful implant restoration. This THE SOFT-TISSUE INTERFACE
success includes the establishment of health,
function, and esthetics. The functional implant Bone grafting as part of the site development will
restoration must have a component that traverses be less successful without healthy soft tissue over-
the oral mucosa. As with a natural tooth, there is lying the osseous graft. The implant–soft-tissue-
a need to provide a connection or seal around bone interface is similar to that of natural teeth.
the neck of the implant or an abutment. The devel- The function of the epithelium surrounding dental
opment process of the tooth includes the forma- implants is similar to gingival epithelium. It
tion of a biologic connection between the living includes an oral epithelium, a sulcular epithelium,
tissues. For a dental implant, this connection has and a junctional epithelium with underlying
to be created during the healing process after connective tissue. From the gingival margin into
placement of the implant; the difference being the sulcus the epithelium changes to sulcular
that the oral mucosa will have to interface with epithelium and ends in a junctional or barrier
a foreign body. The resulting attachment, although epithelium.1–3 This junctional barrier protects the
similar in function, has biologic differences that bone supporting the tooth. When the mucosal
must be comprehended to design surgical tech- wound is created to place the implant or attach
niques and biomaterials that will surround the the abutment, the surrounding epithelium will
dental implant with biologically functional and migrate over the fibrin clot or granulation tissue.
esthetic soft tissue. The success of dental Once the epithelium reaches the implant surface,
implants is dependent on the establishment of migration will occur in an apical direction. Despite
a soft-tissue barrier that is able to shelter the being in contact with the implant surface during
underlying osseous structures and the osseointe- apical proliferation, the epithelium will undergo
gration surrounding the implant body. The major morphologic and functional changes and
esthetics of a dental implant prosthesis depend the junctional epithelium will be formed. The
on the health and stability of the peri-implant attachment is facilitated by the basal lamina and
oralmaxsurgery.theclinics.com

mucosa. Understanding of soft-tissue healing the formation of hemidesmosomes.4,5 The epithe-

and maintenance around dental implants is para- lial downgrowth is believed to be limited by the
mount for implant success. This article discusses presence of underlying granulation tissue.

Department of Periodontology, University of Alabama at Birmingham, 1530 Third Avenue South, SDB 412,
Birmingham, AL 35294-0007, USA
* Corresponding author.
E-mail address: [email protected]

Oral Maxillofacial Surg Clin N Am 22 (2010) 387–405

doi:10.1016/j.coms.2010.04.001
1042-3699/10/$ – see front matter. Published by Elsevier Inc.
388 Geurs et al

Adhesion of this connective tissue to the implant tissue zone.17 In a human histologic and scan-
will prevent the apical movement of the epithelium. ning electron microscope (SEM) evaluation of
As the maturity of the connective tissue increases soft tissue surrounding 2-piece implants with
around the implant it will limit the epithelial apical laser microgrooved channels, fibers were found
migration.6,7 Berglundh and colleagues1 hypothe- in close contact with the microgrooves and
sized that contact with the titanium oxide layer were oriented perpendicular to the implant
would prevent epithelial downgrowth. The implant surface, showing more similarities to natural
surface characteristics can also influence apical dentition.8 The fibroblast-rich layer adjacent to
migration of epithelium.8 The epithelial attachment the titanium surface has an important role in
can be observed after 1 to 2 weeks of healing, and the maintenance of a proper seal between the
a mature barrier epithelium occurs after 6 to 8 oral environment and the peri-implant tissue.18
weeks of healing.3 The ability of biomaterials to The quality of the mucosal barrier depends on
promote epithelial wound healing and to establish the material of the surface. In an animal experi-
a junctional epithelium is an important aspect of ment, mucosal healing with a zone of connective
the success of dental implant bone site prepara- tissue attachment was observed around titanium
tion. The protection of the connective tissue and and ceramic abutments but not around gold
osseous tissue surrounding the implant by alloys.19
providing this barrier is crucial for the maintenance Collagen type V, which has a higher collagenase
of peri-implant structures and the stability of the stability, was localized in higher amounts in the
implant system. Poor gingival health and chronic lamina propria of the peri-implant gingival tissues,
inflammation will compromise this process. as compared to natural teeth. This anatomic differ-
The apical portion of the junctional epithelium is ence may be responsible for the defense of peri-
separated from the alveolar crest by a zone of implant keratinized gingival connective tissues to
connective tissue.9 This is where the similarities bacterial penetration.20
between the natural tooth and the implant soft
tissues end. During healing, the adhesion of the
fibrin clot results in the formation of granulation THE VASCULAR SUPPLY OF THE
tissue. Collagen fibers of the mucosa are orga- PERI-IMPLANT MUCOSA
nized after 4 to 6 weeks of healing.3 The connec-
tive tissue is void of fibroblast and vascular The main vascular supply for the gingiva is derived
structures and rich in fibers. It resembles scar from the supraperiosteal blood vessels and the
tissue and is an important part of the seal that anastomosis with the vessels from the periodontal
forms around the implant surface to exclude the ligament and alveolar bone. The vascular supply of
oral environment.2,10–12 the peri-implant mucosa is almost solely supplied
The dentogingival fibers around a natural tooth by the supraperiosteal blood vessels. An osseoin-
insert into cementum and bone and are firmly tegrated implant does not have a periodontal liga-
attached. These fibers serve as a barrier of epithe- ment, and therefore the blood supply is markedly
lial downgrowth and are important for the seal different from the situation around a tooth. During
function of the gingiva.11 The dental implant the osseogenesis phase, bone surrounding the
surface does not contain a layer of cementum, implant undergoes osseoconduction, de novo
therefore the fibers do not insert into the titanium bone, and remodeling resulting in osseointegra-
surface of the implant. Collagen fibers surrounding tion. The bone surrounding an implant has
the dental implant surface form a cuff. The increased density and is void of vessels.21,22
connective tissue adhesion at the implant has When a thin layer of bone is present surrounding
less mechanical resistance than that of natural an implant, infraosseous vessels diminish or
teeth.12,13 disappear. Remodeling following extraction could
Surface characteristics of the implant influence result in diminished dimensions of the remaining
the orientation of the fibers, which are mostly bone.23 When implants are placed in close prox-
parallel to the implant surface when the implant imity to a natural tooth or to another implant, the
surface is smooth.1,6,14 Surface roughness dimensions of the osseous tissue bone are
provides for different stimulation, allowing reduced and the vascular supply compromised.
connective tissue to be embedded into the The lack of anastamosis reduces the blood supply
surface. When implants are loaded, the orienta- to the peri-implant connective tissue.2,10–12 Under-
tion of these fibers is more traverse.15,16 The standing the differences in the vascular supply and
orientation of the collagen fibers is more perpen- the importance of angiogenesis and the vascular
dicular to the surface in implants with a rough- supply to wound healing are important for the
ened surface interface in the soft connective design of surgical techniques.
 Soft-Tissue Regeneration and Development 389

KERATINIZED ATTACHED MUCOSA whereas the connective tissue attachment varied

the least.35 The biologic width represents the
The stability of the peri-implant mucosa is important zone responsible for the establishment of the den-
for the overall stability of the dental implant and the togingival junction and the seal around the tooth.
maintenance of bone health around an implant. Violation of the biologic width will result in a disrup-
Whether the stability is secured by non-keratinized tion of the seal function, which becomes evident
mucosa or keratinized attached mucosa is a point when the margin of a restoration is placed within
of discussion. Some investigators report no differ- the zone of the soft-tissue attachment and
ence in the maintenance of peri-implant bone disrupts the dentogingival junction.36
levels,24–26 whereas others report an increased The earlier outline of an epithelial attachment and
risk for peri-implant bone loss when the implant is a connective tissue attachment to the implant
surrounded by alveolar mucosa.27,28 Insufficient surface showed the similarities between the
keratinized mucosa in the vicinity of implants does attachment around a tooth and an implant. The
not necessarily mediate adverse effects on hygiene establishment of this zone of biologic width around
management.24 an implant has been found around nonsubmerged
The lack of consensus regarding peri-implant and 2-piece submerged implants.2,10,37–39 Around
soft-tissue health is related to multifactorial issues. a nonsubmerged implant, the biologic width estab-
Oral hygiene, host immunologic responses, implant lishes itself in the months following implant place-
design, location in the mouth, local anatomy, func- ment.3 Once established, the dimensions of
tion, and surgical techniques make it difficult to biologic width are stable38 and are not influenced
design studies that will give conclusive answers. if implants are loaded early.40 The dimensions are
The advantages of keratinized attached mucosa approximately 2 mm for the epithelial attachment
surrounding the implant are less controversial. and 1 mm for the connective tissue attachment.
Most clinicians prefer to surround the implant This will guide the surgeon’s decision for pre-
with an adequate zone of keratinized mucosa. implant bone grafting.
The advantages include the overall health of the One-piece nonsubmerged implant systems
tissues, greater patient satisfaction, and fewer offer several advantages, including the need for
complications.28 only 1 surgery, a mature soft-tissue implant inter-
The stability of the mucosa will provide better face, and avoidance of a microgap.41 For 2-piece
support for the underlying connective tissue, and implant systems, a zone of attachment is formed
the junctional epithelium will provide the seal after placement of an abutment. In an animal
around the implant. As a result of the increased model, soft-tissue height around a 2-piece implant
stability of the tissues, prosthetic techniques are was reduced at abutment attachment to less than
more precise. Challenges to the soft tissue during 2 mm.42 Compared with a control with no reduc-
the prosthodontic phase are better absorbed by tion, the soft-tissue levels were lower; however,
keratinized tissue.10,25,26 the zone of biologic width was the same after 6
When considering the final esthetics, a wide months. The implants with thinned soft tissue
band of keratinized mucosa is a prerequisite.29,30 showed bone resorption around the neck of the
A thick biotype offers the ability to hide the implant accounting for the re-establishment of
shine-through of the underlying structures.26,31 a zone of attachment or biologic width around an
implant. Peri-implant bone remodeling could be
influenced by the establishment of the biologic
THE BIOLOGIC WIDTH width.10 The bone resorption around the implant
neck does not start until the implant is uncovered
The dimensions of the physiologic dentogingival and exposed to the oral cavity. The bacterial
junction around natural teeth is referred to as the contamination of the gap between the implant
biologic width. It encompasses the width of the and the superstructure is one of the factors influ-
epithelial and connective attachments when eval- encing crestal bone loss.13,43–48
uated with histology. In a classic report using The loss is in height, but there is also a horizontal
cadaver specimens, the average width of the component that has greater consequences when
epithelial attachment was 1.07 mm, connective implants are placed adjacent to one another. The
tissue attachment 0.97 mm with an average bio- zone of bone loss in a horizontal direction could
logic width of 2.04 mm around the natural tooth.32 overlap and result in loss of interimplant bone
These measurements are averages, and individual height, and with it the interimplant papillary height.
differences exist, based on the location in the This problem is an issue when implants are placed
mouth and aspect of the tooth.33,34 The greatest closer than 3 mm apart.44 The dimensions of the
variation was found in the epithelial attachment, biologic width are stable in a well-healed 2-piece
390 Geurs et al

implant without additional challenges.37 The Some implants have a roughness that extends to
dimensions of the biologic width around an implant the collar of the implant. This roughness provides
are implant-system specific. In an animal model, better support of the implant but could also
implants of different configurations were placed in enhance biofilm formation.52 Surface tension on
varying locations in relation to the crest of the the implant surface can also enhance the forma-
bone. The biologic width dimension for 1-piece tion and attachment of a biofilm.53 Some implant
implants, with the rough/smooth border located designs use a beveled collar or even a horizontal
at the bone crest level, were smaller compared part of the implant platform for the soft-tissue
with 2-piece implants with a microgap located at attachment. The dimensions of the attachment
or below the crest of the bone. Biologic width are similar, but the height of soft tissue coronal
dimensions are more similar to natural teeth around to the crest of bone can be reduced.54 This
1-piece nonsubmerged implants compared with concept has been shown to reduce the amount
2-piece nonsubmerged or 2-piece submerged of crestal bone loss.55,56 Implant surfaces that
implants. The location of the microgap has an influ- facilitate the attachment of the soft tissues can
ence on bone maintenance and soft-tissue attach- also result in more stability of the soft-tissue
ment. When the microgap is placed below the zone around an implant.8
crest, remodeling of the bone results in bone loss Schwarz and colleagues17 evaluated histologic
apical to the crest. The connective tissue attach- sections of a healed implant with high hydrophilicity
ment is on the implant surface and bone is never and a microtopography. They concluded that soft-
found coronal to the microgap. Bone was not found tissue integration is enhanced on surfaces with
on a machined surface but always on the rough- increased surface tension.
ened surface. The size of the microgap did not influ- Implants with microgrooved laser etched collars
ence the amount of bone loss. The micromobility of resulted in less crestal bone loss compared with
the abutment connection also resulted in greater control implants without the microgrooves. The
amounts of bone remodeling.39,45 When the micro- use of tissue-engineered collars with microgroov-
gap is placed below the crest, greater amounts of ing seems to promote bone and soft-tissue attach-
inflammation were present surrounding the neck ment along the collar and facilitate development of
of the implant, resulting in greater bone loss.46,47 a biologic width, and seems not to lead to an
With submerged implants, early spontaneous increase in biofilm on the implant surfaces.57,58
exposure results in crestal bone loss.48 Small
exposures not exposing the full cover screw are OSSEOUS SUPPORT FOR SOFT TISSUES
associated with greater amounts of bone loss.49
When spontaneous exposure occurs, it is recom- Thus far, this article has emphasized soft-tissue
mended to expose the implant completely.50 attachment to the implant surface and stabilizing
The issue of bone healing and maintenance of the implant by protecting the bone. However,
around the cervical portion is an area of debate. the reverse relationship is also true. The lack of
Many factors are discussed as having an influence proper bone volume surrounding a dental implant
on bone stability. During the surgical procedure, will result in the loss of peri-implant bone and the
trauma may occur and result in loss of the crestal loss of soft-tissue height or recession around
bone during healing. It is important to follow a dental implant. This outcome is important in
proper surgical protocols to minimize trauma or planning for an implant. It is important to under-
overheating. The flap design may also be influen- stand the importance of site development
tial on the amount of initial bone loss. In an animal because of the support that hard tissue gives to
experiment, less bone loss was found using a flap- soft tissue. Bone support is important for the pres-
less approach after 3 months of healing.51 The ence of a papilla around an implant restoration.
implant surface characteristics are also important.
Bone loss around implants when the junction THE PAPILLA AROUND IMPLANT
between a smooth and roughened surface was RESTORATIONS
placed apical to the crest of bone occurred to
the level of the roughened surface.39,45 The interdental papilla is an important aspect of
Most of the literature regarding biologic width the esthetic appearance of a smile. The lack of the
around dental implants concerns implants with dental papilla results in a dark triangle that will
a machined portion of the implant that has been make the esthetics less desirable. The presence
the designated area of soft-tissue attachment. of the papilla between natural teeth is dependent
This situation was established at the time of on the presence of 2 adjacent teeth, a contact
implant placement or at the time of the second- point, and supporting bone. If the crest of the
stage surgery followed by bone remodeling. bone is within 5 mm of the contact point, the full
 Soft-Tissue Regeneration and Development 391

presence of a papilla is predictable. If the distance dentures and fixed partial-denture reconstruction
increases, the likelihood of the papilla being cases. These findings differed from the previous
present decreases.59 A similar relationship has ones; in this study 24% of sites lacked keratinized
been reported around dental implants. The impor- mucosa, 13% of sites had less than 2 mm of ker-
tant measurement is the level of the bone on the atinized mucosa, and 61% of sites exhibited
proximal surface of the adjacent tooth. On restora- mobility of soft-tissue margins around the
tions with papillae, the average distance to the implants. The author concluded that there was
crest of bone is slightly reduced compared with no effect on the mobility of the marginal peri-
that of natural teeth.60–66 The attachment on the implant soft tissue and the absence of keratinized
adjacent tooth provides for the support of the mucosa had no impact. Hence, the health of peri-
papilla.61 The situation between dental implants implant tissues, as determined by bleeding on
is different. The interimplant is supported by 2 probing, shows that a lack of keratinized mucosa
implant surfaces. As discussed earlier, the soft does not clearly indicate inevitable recession.
tissue lacks the insertion of fibers. There is poten- Clinically, implant insertion within the keratinized
tial for overlapping crestal resorption if the mucosa is preferred. The level of oral hygiene and
implants are placed too close together. Implants inflammation rather than keratinized mucosa is the
placed closer than 3 mm to each other exhibit predominant determinant of soft-tissue health
greater amounts of bone loss.44 The height of the around an implant.
interimplant papilla is limited and, in general, no
greater than 3 mm from the underlying bone.62,63
The Partially Edentulous Patient
In the esthetic areas, the results may be improved
by avoiding 2 dental implants adjacent to each In implant dentistry, esthetics are a significant
other or choosing implants of a smaller diameter consideration for the dentate population. The
to ensure a minimum of 3 mm between the gingival scaffold frames the shape of the implant
implants.63 In areas of limited space, small-diam- restoration and is important for simulation of the
eter implants could be considered. The smaller natural dentition.69
diameter leaves a greater space for soft tissues The treatment planning of edentulous spaces in
and provides a created osseous base for the the esthetic zone presents surgical and restorative
support of soft tissues around an implant.64 challenges. Soft-tissue examination before
implant procedures is of great importance in deter-
mining the predictability of a treatment approach.
IMPLANT PLANNING FOR OPTIMAL
Kopp and Belser70 proposed a series of objective
SOFT-TISSUE OUTCOMES
criteria relating to dental esthetics. The evaluation
The Edentulous Patient
of a tooth-bound edentulous site should include
In fully edentulous patients, soft-tissue evaluation periodontal examination and probing, ridge
should include a soft-tissue–specific clinical exami- mapping, bone sounding, and gingival biotype.
nation to assess the condition of soft tissue and to When a tooth needs to be extracted and is to be
investigate the presence of keratinized mucosa.65 replaced by a dental implant, the implant site soft-
The conflicting evidence on the necessity of ker- tissue evaluation begins with the clinical examina-
atinized and attached mucosa surrounding dental tion of periodontal status of the specific tooth and
implants for optimal outcomes must be addressed the adjacent teeth. Periodontal probing will deter-
before proceeding with soft-tissue evaluation. In mine the periodontal attachment levels of these
an animal study, the lack of keratinized peri- teeth and will identify any existing pathology.
implant mucosa and accumulated plaque resulted Probing should be complemented by periapical
in soft-tissue recession.66 In a human study, 58 radiographs that reveal the interproximal bone
patients received 307 implants for a full-arch, fixed levels of the adjacent teeth.
mandibular prosthesis.67 A lack of peri-implant The attachment levels of the adjacent teeth are
keratinized mucosa was associated with buccal the predetermining factor for the level of interprox-
soft-tissue recession as well as lingual plaque imal bone and soft-tissue height. For an edentu-
accumulation and bleeding. There was no correla- lous site, the assessment may require ridge
tion of the buccal plaque accumulation and mapping.71 Mapping entails a series of soft-tissue
bleeding with the subjects who had peri-implant thickness buccal and lingual measurements of the
keratinized mucosa. area. The clinician can then transfer these
In another human study, Wennström and measurements onto a cast by taking an impres-
colleagues68 evaluated the influence of the width sion of this area, pouring a diagnostic cast,
of keratinized mucosa on the maintenance of sectioning the cast through the proposed implant
peri-implant soft-tissue health in complete site, and transferring the soft-tissue thickness
392 Geurs et al

around the alveolar crest. Information related to fenestrations and dehiscence. Moreover, a thin
the soft-tissue profile, the underlying bone biotype is susceptible to soft-tissue recession
morphology, and bone dimensions is readily avail- after surgical procedures. Conversely, a thick
able in the cast and could be of use for the clinician gingival biotype has a low-scalloped thick soft
when determining the need for bone grafting or tissue, square teeth, and small gingival embrasure
even additional soft-tissue grafting of the implant spaces, and long contact surfaces positioned at
site. Although cone beam computed tomography the middle third of the teeth. This biotype is more
may provide more accurate and detailed informa- resistant to recession after surgical manipulation
tion about implant sites, bone mapping of a single- of soft tissue.72–75
tooth edentulous area is a quick and inexpensive Immediate implant placement in a thin-tissue
method of assessing bone and soft-tissue volume. biotype is associated with high risk of experiencing
Bone sounding is a technique-sensitive proce- soft-tissue recession, as opposed to patients with
dure that detects the height of bone at the cervical a thick-tissue biotype.
region of a hopeless tooth. The accuracy and
successful outcome in using this technique is
based on a clinician’s experience and accurate DIAGNOSIS AND CLASSIFICATION
measurements of anatomic variations such as
A series of classification systems has been devel-
tooth crown morphology and thickness of the alve-
oped to address soft- and hard-tissue deformities
olar crest. Bone sounding is best used to examine
of edentulous ridges before implant surgery.
soft tissue around a tooth that will be extracted
These classifications provide the clinician with
and immediately replaced by an implant.
specific guidelines to proceed in assembling an
The soft-tissue examination should include the
appropriate treatment plan. The classification of
assessment of the gingival biotype of the implant
sites may be helpful in forecasting the outcome
site and adjacent teeth. This type of evaluation is
of bone and soft-tissue grafting procedures to
particularly useful in immediate implant situations.
achieve successful function and esthetics.
Thin and thick biotypes are characteristically
Seibert76 proposed the following classification
different (Fig. 1). A thin gingival biotype is charac-
for edentulous ridge soft-tissue defects:
terized by high-scalloped thin soft tissue, slender
teeth, and long interproximal gingival embrasure 1. Class I: soft-tissue deformity of the edentulous
spaces with small contact points located at the ridge in a buccolingual dimension
incisal third of the teeth. There is a strong correla- 2. Class II: soft-tissue deformity of the edentulous
tion of thin biotype with the presence of bone ridge in an apicocoronal dimension

Fig. 1. (A) Thin scalloped periodontal biotype. (B) Thick flat periodontal biotype.
 Soft-Tissue Regeneration and Development 393

3. Class III: soft-tissue deformity of the edentulous  The 3-mm space is needed on the pros-
ridge in both dimensions. thetic abutment for formation of biologic
width
Palacci and Nowzari77 developed a classification  An ideal emergence profile of implant resto-
system combining soft- and hard-tissue defects. rations needs room for a smooth transition
Greater challenges for reconstruction of the under- from the circular implant platform to the
lying hard tissue supporting the soft tissue exist for triangular or square abutment and crown
defects that have a vertical component.  There is room available for placement of
Jemt61 conducted a retrospective study in 21 restorative margins below marginal soft
patients with 25 single-implant crowns. He evalu- tissue
ated the papillary height of soft tissue between  The possibility of peri-implant marginal soft-
single-implant crowns and teeth and created an tissue recession is more likely as the patient
index for assessment of soft-tissue contours ages
around implants. 2. Buccolingually, the implant is placed so that
The Jemt index comprises 5 different scores: the outer aspect of its platform is 1 mm
1. Index score 0: absence of papilla palatal from the anticipated facial margins of
2. Index score 1: less than half of the papilla the restoration. Some clinicians use a 2-mm
present placement rule from the facial cortical plate
3. Index score 2: more than half of the papilla in anticipation of the 1.4-mm lateral bone
present but not reaching the contact point loss as a guideline.79 Kan and Rungcharas-
between the implant crown and the adjacent saeng80 recommended that the buccolingual
tooth placement be 1 mm palatal in relation to
4. Index score 3: the papilla fills the entire embra- facial emergence profiles of the adjacent
sure space teeth, and not less than 1 mm because of
5. Index score 4: the papilla is enlarged and over- the risk of losing the facial bone and soft
fills the interproximal space. tissue
3. The implant platform is located on the same
Esthetic compromises occur when the papilla axis with the gingival zenith and 3 mm lower
does not completely fill the interproximal space than the free soft-tissue margin. Magne and
under the contact point, resulting in the display Belser81 suggested that the gingival zenith is
of a black triangle. This condition is consistent distal to the long axis of maxillary anterior teeth.
with Jemt index 0 to 2 and is difficult to correct. Although Rufenacht82 noted that the gingival
zenith of lateral incisors is in the same line as
their long axis, and that only central and lateral
incisors have the gingival zenith on the distal
Implant Placement third of the tooth (Fig. 3).
Optimal implant position should consider the three-
dimensional placement of implants that respects IMPLANT SPACING
established biologic and prosthetic principles
related to implant restoration. The relationship Spacing requirements between tooth and implant,
between the bone and the implant determines the as well as spacing between implants, were devel-
dental implant soft-tissue contours, including inter- oped to preserve the bone and overlying soft-
proximal papilla. The relationship defines the tissue support of the implant and crown.
esthetic appearance of the final implant prosthesis. The minimum recommended distance between
A successful outcome is maintained for a period of a tooth and an implant is 1.5 mm, based on a study
time because it preserves the original soft-tissue by Esposito and colleagues.83 The study indicated
morphology and features. a strong correlation between bone loss of adjacent
Specific placement guidelines have been devel- teeth and horizontal distance of the implant fixture
oped to accomplish soft-tissue stability around to the tooth. The greatest amount of bone loss was
dental implants. These guidelines are applicable noted at the lateral incisor position. Although all
when bone is sufficient and of good quality: the implant fixtures were 4.1 mm in diameter, and
bone loss increased as the distance was decreased,
1. The apicocoronal placement of the dental only 17% of bone loss variation was attributed to this
implant platform should be positioned 3 mm reduced distance. It seems that other intra- and
below the facial marginal tissue (Fig. 2).78 The interindividual parameters played a role.
3-mm rule was created for the following The minimum recommended interimplant
reasons: distance is 3 mm in a 2-stage implant protocol.
394 Geurs et al

Fig. 2. Fig. 2. (A) Gingival height around #9 prior to extraction. (B) #9 extracted and an implant and bone graft
placed; tip of probe placed on top of platform of implant. (C) Sub-epithelial connective tissue graft harvested
from the palate. (D) CT graft placed in a pouch on the palatal and facial aspect. (E) CT graft covers the implant
and graft. (F) Soft tissue healing at 2 weeks. (G) Soft tissue healing after 2 months.

Tarnow and colleagues44 conducted a retrospec- implants within a distance of less than 3 mm.
tive radiographic study in 36 patients who had 2 When implants were within 3 mm of each other,
adjacent implants placed. The author found that they developed 1.04 mm of interproximal bone
lateral bone loss at the implant-abutment interface loss compared with 0.45 mm of bone loss for the
was 1.34 to 1.4 mm. This finding had an effect on implants placed with more than 3 mm distance
the height of bone and papilla support between between them.
 Soft-Tissue Regeneration and Development 395

Fig. 3. The location of the gingival zenith. + Indicates the location of the gingival zenith located distal to the
long axis of the maxillary incisors.

Based on the potential for interproximal bone loss results,85–93 dental implant therapy can be compli-
on adjacent implants, Grunder and colleagues79 cated by numerous developmental, traumatic, or
proposed buccal augmentation of the site in situa- anatomic factors such as a thin gingival biotype
tions with less than 3 mm of bone interproximally. in association with a high smile line, leading to
They proposed that the bone thickness should be esthetic shortcomings in the anterior maxilla.
augmented to at least 2 mm, and ideally 4 mm, to Therefore, various soft-tissue augmentation tech-
maintain the soft-tissue height facially and inter- niques have been advocated to provide better
proximally. The investigators suggested that the esthetic outcomes.86,87 These studies have
additional bone can support and maintain the proposed procedures used to treat dehiscence
interproximal papilla. defects, achieve primary soft-tissue closure over
The three-dimensional implant placement guide- single implants immediately placed into maxillary
lines and spacing requirements may lead to the use extraction sockets (with or without guided bone
of small-diameter implants in the esthetic zone that regeneration), and improve soft-tissue healing.
allow bone preservation between implants as well
as between implant and tooth. The narrow diameter SURGICAL TECHNIQUES FOR
implants may provide more bone support in all AUGMENTATION
dimensions for development of the soft-tissue Pedicle Grafts
form that simulates the natural dentition.64
Pedicle full- or split-thickness palatal flaps for
SURGICAL AUGMENTATION OF SOFT TISSUE primary coverage of implants placed after extrac-
AROUND DENTAL IMPLANTS tion and treatment of maxillary peri-implant
defects have been described in numerous reports
Peri-implant soft-tissue management can be re- in the literature.
garded as a category of mucogingival procedures Nemcovsky and colleagues88 described
analogous to reconstructive procedures around a rotated split palatal flap (RSPF) technique for
teeth including root coverage, papilla reconstruc- soft-tissue primary coverage over extraction sites
tion, ridge augmentation, and ridge preservation. with immediate implant placement. This technique
These soft-tissue augmentation procedures can was used only if palatal mucosal thickness ex-
be accomplished at the time of extraction before ceeded 4 mm. The surgical procedure consisted
implant placement, at implant placement, at the of a full-thickness mucoperiosteal palatal flap
time the implant is uncovered, or even after that was raised, extending at least 1 tooth mesially
the completed restoration has been placed.84 and distally from the tooth to be extracted. A
Although the ability to permanently replace minimal buccal flap, including only interdental
single or multiple missing teeth with osseointe- papillae and marginal gingiva, exposing the bone
grated dental implants has been thoroughly re- crest, was also reflected. The tooth was carefully
ported in the literature, with consistent long-term extracted and the implant was placed slightly
396 Geurs et al

palatal and off center. The palatal flap was split a subepithelial connective tissue flap was
into deep and superficial layers. A second incision, removed, the palatal wound at the donor site could
involving only the deeper flap, further discon- be totally closed and sutured.
nected these 2 flaps. The deeper flap was thus Goldstein and colleagues87 described the
transformed into a pediculated flap, becoming palatal advanced flap technique for single-
mobile and easily rotated. The RSPF was tucked implant and multiple-implant cases, with the
and sutured under the minimally reflected buccal same efficiency and with highly predictable
flap, covering the implant site. The superficial layer results. First, the mesiodistal, and especially
of the palatal flap was then repositioned and the labiopalatal, aspects of the gap were
sutured. Consequently, complete primary soft- measured. Then, the outline of an L-shaped
tissue closure over the implant site was achieved. flap with parallel incisions was marked. The
This technique is sometimes used to change the flap was planned so that the long leg of the L
gingival thickness in an edentulous space (Fig. 4). was toward the distal and the short leg was
One year later, Nemcovsky and colleagues89 perpendicular to the extraction site. The
proposed the use of full-thickness rotated distance between the parallel incisions had to
palatal flap (RPF) only when palatal gingival be equal to the mesiodistal size of the extraction
thickness measures 5 mm or less at the time site. A triangular area was marked coronal to
of immediate implant placement after extraction the incisions, in the inner part of the L-shaped
of maxillary anterior and premolar teeth. In this flap. The base of the triangle was on the short
case, a sharp, deep, internal-beveled incision leg of the L, and its apex was pointed distally
delineating a pediculated full-thickness palatal along the long leg. This arrangement was the
flap was made. The extension was planned to key part of this technique, and careful planning
enable full coverage of the alveolus and overlap- was required so that the base of the triangle
ping of the buccal crestal bone, usually extend- was equal in size to the labiopalatal dimension
ing 1 or 2 proximal teeth on both sides. The of the gap area. The dimensions of the triangle
pediculated flap was then carefully elevated area determined the amount of coronal
from the underlying bone, starting from the advancement of the flap. At this stage, the trian-
side away from the tooth. An oblique proximal gular area was de-epithelialized, and the
incision and periosteal fenestration facilitated L-shaped area was dissected, performing
rotation of the pediculated flap, which was wider a split-thickness dissection. The flap was
than 5 mm. Buccal margins of the RPF were de- advanced in a coronal position and sutured
epithelialized. The pediculated flap was then with 6-0 or 5-0 sutures. Thus, complete and pre-
rotated with the use of atraumatic surgical cise coverage of the implant area was achieved
pliers, tucked, and sutured under the reflected without any tension. A denuded area was left on
minimal buccal flap. Further sutures secured the apical side of the flap.
the RPF in the palatal tissues. The donor palatal
site, which was left exposed, healed by
Free Gingival Grafts
secondary intention.
Conversely, the palatal subepithelial connective Free gingival grafts have been used to correct
tissue flap method to cover maxillary defects was or limit the potential for soft-tissue complications
promoted by Khoury and Happe.90 According to around endosseous implant permucosal abut-
this technique, a palatal paramarginal incision ments. The rationale for free gingival grafting is
was made from the molar region to the defect to largely to prevent peri-implantitis and its associ-
be covered. The length of the incision depended ated bone loss by increasing the amount of ker-
on the size of the defect. Dissection of the muco- atinized mucosa adjacent to the implant
periosteal flap and the underlying preparation of abutment.91 This approach is believed to have
a subepithelial connective tissue flap to a depth 2 potential benefits. First, keratinized tissue is
of 5 to 8 mm were then performed. A sharp incision believed to form a more stable seal on a smooth
of the subepithelial tissue was made parallel to the titanium or zirconium abutment, limiting the
first incision in the same manner to harvest potential for biofilm migration down to the
a connective tissue graft, but leaving it attached implant interface. Second, keratinized tissue is
in the anterior region. The subepithelial connective generally firmer and less subject to abrasion
tissue flap was elevated and rotated to cover the from tooth brushing and other oral hygiene
defect or reconstruct soft tissue. Because the practices, allowing the patient to be more
donor site is situated in a well-vascularized area vigorous with oral hygiene. The firmer kerati-
(palatal artery), heavy bleeding can occur and nized tissue may therefore protect the implants
may require cauterization. Because only and improve their prognosis by decreasing
 Soft-Tissue Regeneration and Development 397

Fig. 4. (A) An edentulous space with loss in vertical dimension. (B) Occlusal view indicating the loss in bucco-
lingual dimensions. This is a Siebert class III ridge deformity. (C) The ridge was expanded and the implant placed.
(D) A rotated split palatal graft was prepared and rolled over the implant site. (E) Suturing of the site. (F) Healing
after 6 months. (G) The occlusal view of the healing after 6 months. (H) The gingival zenith at time of abutment
placement.

potential discomfort and inflammation that could mandible before implant placement in an effort to
occur from vigorous oral hygiene at a mucosal improve the long-term prognosis.92 To a lesser
implant interface. extent, free gingival grafts have been used in
In fully edentulous implant reconstructions, ves- immediate implant placement. A graft is obtained
tibuloplasty and free gingival tissue grafting tech- with a biopsy punch from the palate, and then it
niques have been used to obtain attached is used to cover the exposed surface of the implant
keratinized tissue in the anterior edentulous without repositioning the mucoperiosteal flap.
398 Geurs et al

Free Connective Grafts apical migration on the implant surface potentially

leads to an esthetic compromise (Fig. 5). Imme-
The use of subepithelial connective tissue grafts
diate implant placement and provisionalization
around dental implants was a natural extension
has been considered a preservative procedure
from their use to cover exposed root surfaces
when replacing failing teeth, especially in the
with greater predictability and superior clinical
esthetic zone. Nevertheless, an average facial
gingival color match compared with free gingival
gingival tissue recession of 1 mm is still common
grafts.93 Connective tissue grafts have been
after 1 year of function. Facial gingival recession
used as a soft-tissue barrier to close over an
of thin periodontal biotype seems to be more
immediate postextraction implant as a soft-tissue
pronounced than that of thick biotype. For that
extension over a barrier membrane or in place of
reason, gingival grafting as a method of changing
the barrier membrane (see Fig. 2).94,95
the gingival phenotype of natural teeth and
Immediate implant placement and subepithelial
implants with subepithelial connective tissue graft
connective tissue grafts for single-tooth restora-
has been advocated. The resulting tissues seem to
tion versus immediate implant alone were studied
be more resistant to recession.98
for preservation of keratinized mucosa amount
and bone tissue, optimal peri-implant marginal
Soft-tissue Allografts
sealing, and esthetic outcomes.95 The 9-year
cumulative survival rate was 100% for test and Initial reports examined the clinical efficacy of
control groups. Comparative statistical analysis acellular dermal matrix allograft to achieve
of soft- and hard-tissue peri-implant parameters increased peri-implant keratinized mucosa
showed a more favorable outcome for the connec- around99–108 implants. These proof-of-concept
tive tissue graft group. The connective tissue studies used a sheet form of acellular dermal
group showed good results in terms of esthetic matrix allograft to increase the attached kerati-
parameters, which estimated the keratinized nized mucosa. Park99 found a statistical difference
mucosa width, the alignment of crown emergence in pocket depth and modified plaque index at 6
profile, and the patient’s satisfaction. months compared with the baseline measure-
Covani and colleagues96 extracted teeth and ments. The width of peri-implant keratinized
placed implants after periodontal treatment on mucosa increased from a mean of 0.8  0.6 mm
teeth deemed to have a poor prognosis. The teeth to 2.2  0.6 mm at 6 months. Based on these find-
were extracted and implants were placed without ings, there is potential that an acellular dermal
reflection of a mucoperiosteal flap. Immediately matrix allograft could be applied as a grafting
after implantation, a connective tissue graft was material to increase the width of peri-implant kera-
placed over the implants to treat the gingival tinized mucosa. Along with an increase in attached
recession. The investigators considered the tissue, there are some benefits for oral hygiene.
surgical approach used in this study to be a viable Further long-term randomized controlled trials
treatment option in cases with nonsalvageable are necessary to establish the use of acellular
teeth showing gingival recession and the absence dermal allografts compared with free gingival
of attached gingiva. grafts or subepithelial connective tissue grafts for
In a prospective case series to evaluate the heal- long-term benefits to patients.
ing outcome of soft-tissue dehiscence coverage at Geurs and colleagues100 investigated the appli-
implant sites, 10 patients with 1 mucosal recession cation of micronized acellular dermal graft for the
defect at an implant site and a contralateral unre- reconstruction of papillae around teeth. The
stored clinical crown without recession were re- micronized allograft technique showed promise
cruited.97 The soft-tissue recessions were for the repair of interproximal areas of tissue loss.
surgically covered using a coronally advanced flap Buccal augmentation with acellular dermal
in combination with a free connective tissue graft. grafting has been used to thicken the peri-implant
The implant sites revealed a 66% coverage of the mucosa to mask the shine-through of a gray cast
dehiscence and clinically significant improvement from an implant abutment or collar in which the
following coronal mucosal displacement in combi- host tissue biotype is thin (Fig. 6). This technique
nation with connective tissue grafting; however, in preliminary reports has been effective in
complete implant soft-tissue dehiscence coverage improving the esthetics along with the increase in
could not be achieved in all sites. tissue thickness. In addition, facial acellular dermal
Even in cases without recession pre-extraction, grafts have been used in combination with partic-
once the gingival fibers inserting into the tooth are ulate bone grafts to augment tissue on the facial
severed there is a tendency for gingival collapse surface of implants.101 Although there is limited
and apical migration of the gingival margin. This evidence of regeneration of bone around these
 Soft-Tissue Regeneration and Development 399

Fig. 5. (A) The patient presents with external resorption on the maxillary left central incisor (tooth #9), with the
gingival margin located slightly more incisal than the adjacent central incisor (tooth #8). (B) The resorption was
located on the palatal surface of the tooth and, after extraction with a periotome technique, the facial plate of
bone was intact. (C) An occlusal view indicating limited or no loss of adjacent soft-tissue support. (D) Insertion of
a provisional restoration made at the same clinical crown height of the natural tooth indicating the immediate
loss of soft-tissue support without the gingival fiber support provided by the extracted tooth. (E) Final implant-
supported crown with a compromised esthetic result due to the loss of soft vertical margin height after
extraction.

augmentation sites, there seems to be a predict- indication for the soft-tissue allograft in these
able improvement in the esthetics in anterior applications is containment of the graft to allow
areas. Acellular dermal grafting has also been for organization of the blood clot, the dermal allo-
used as a form of barrier membrane for guided graft may also serve to augment the thickness of
tissue regeneration. Although the primary the mucosa in the area of the implant.102,103
400 Geurs et al

when multiple techniques and materials are

combined into a single wound-healing procedure,
there is clinical evidence of the potential effective-
ness of this technique in delayed- and immediate-
implant cases.

LIMITING ESTHETIC PROBLEMS AROUND

IMPLANTS
Buccal Augmentation
One of the most difficult esthetic soft-tissue situa-
tions is the extraction of a single tooth or multiple
anterior teeth and replacement with implants. The
loss of the facial plate complicates the situation
and further compromises the esthetics. Severing
interdental fibers attached to the tooth almost
universally leads to some loss of soft-tissue height
and subsequent recession of the tissue. In a retro-
spective study, the soft-tissue and esthetic
outcomes at single-tooth immediate implants
placed without flap elevation in maxillary central
and lateral incisor sites was evaluated. Chen and
colleagues104 recorded the mucosal level of 85
consecutive patients. In this study, the change in
mucosal level was expressed as a percentage of
the length of the reference central incisor. Significant
recession of the mesial papilla ( 6.2%  6.8%),
distal papilla ( 7.4%  7.5%), and facial mucosa
( 4.6%  6.6%) between surgical placement and
1 year was observed. Recession was significantly
greater for implants placed facially within the extrac-
tion socket compared with those placed lingually.
Sites with gingival margins initially coronal achieved
mucosal levels close to the line of symmetry with the
contralateral tooth. Sites initially level or apical failed
to reach the line of symmetry and remained
Fig. 6. (A) Patient with a gray cast or shine-through receded. For sites with initially level gingival
due to the collar of the implant under relatively thin margins, recession greater than 10% occurred at 6
mucosa. (B) Tunneling of an acellular dermal graft of 25 thin-biotype sites compared with 2 of 19
over the implant collar through a single vertical inci- thick-biotype sites.
sion in the vestibule to limit interruption of blood This study shows that immediate implant place-
supply to the region. (C) The initial healing illustrating
ment, even without elevation of surgical flaps,
masking of the implant collar color by thickening the
over mucosa.
was associated with recession of the marginal
mucosa. This finding underscores the need to
consider the placement of the implant away from
the facial surface and the assessment of the
Combination Hard- and Soft-tissue Grafting biotype during implant treatment planning. In addi-
The combination of bone grafting and soft-tissue tion, if esthetics are a major treatment consider-
augmentation has been used for site preparation. ation, augmentation of the soft tissue incisal to
The technique used may incorporate a particulate the adjacent teeth may limit the potential for reces-
bone graft, growth factors, and barrier membrane sion during restoration.
along with a pedicle or free connective tissue graft
Papilla Grafting
to simultaneously augment the hard and soft
tissue. In patients with the loss of the facial plate Implant papilla loss is often the result of limitations
and requiring extraction of anterior teeth, imposed by the quantity of the supporting bone,
combined approaches may be advantageous. periodontal bone loss on adjacent teeth, and
Although there is an increasing level of complexity bone volume and direct effect on the soft-tissue
 Soft-Tissue Regeneration and Development 401

biotype in the region. Because of these limitations, in re-establishing papillae at implant sites, the
there are frequent situations in which implants are papillary soft-tissue grafting is much less compli-
placed in areas of minimal interproximal soft tissue cated to achieve when attempted before the resto-
that can result in dark triangles between crowns ration of the implant with a crown.
and crown margins that become supragingival.
Both of these can lead to a poor esthetic outcome
Provisional Restorations
that is often disappointing for the patient and the
practitioner. Several procedures have been The selection of the type of provisional restoration
described to improve the interproximal papillae can significantly influence esthetics during the
contour around implants. Grunder105 described period of implant integration and soft-tissue
the inlay graft technique to create papillae between healing.108 A restoration that preserves or helps to
teeth. Azzi and colleagues106 outlined a technique regenerate interdental papillae will enhance the
of tunneling/pouching and the use of submerged final esthetic result of the soft tissue (Fig. 7).
connective tissue grafts. This technique allows for The importance of establishing proper contours in
the thickening of the existing gingiva but is also the provisional restoration should be part of the
potentially useful for reconstructing interdental treatment plan for any esthetic implant case. A
papillae around implant-supported restorations. provisional restoration was used immediately after
Reddy107 described a tunneling connective tissue extraction to preserve the interdental papillae.
grafting technique with access through a vertical Whenever possible, a fixed restoration should be
incision in the vestibule that allowed for vertical considered as a good alternative to removable
augmentation of the papillae with minimal interrup- provisional restorations. The contour of the soft
tion to the blood supply in the region. Although tissue is largely dictated by the crown contact
these techniques collectively have been successful points and emergence profile during healing.

Fig. 7. (A) Atraumatic extraction of a fractured tooth. (B) Immediate implant placement with a surgical guide. (C)
Provisional restoration to establish soft-tissue contour and esthetics without functional loading. (D) Initial heal-
ing response of the soft tissue after 1 week. (E) Healing response to provisional soft-tissue support after 1 month.
(F) Two months after immediate implant placement and establishment of gingival contours relative to anterior
teeth.
402 Geurs et al

All of these aspects of soft-tissue healing, zirconia dental implant necks: an animal study. Int
implant design, and maintenance of soft tissue J Oral Maxillofac Implants 2009;24(1):52–8.
around dental implants need to be considered 15. Traini T, Degidi M, Caputi S, et al. Collagen fiber
before implant placement. In treatment planning, orientation in human peri-implant bone around
the proper sequence of site development of the immediately loaded and unloaded titanium dental
hard and soft tissue needs to be made with the implants. J Periodontol 2005;76(1):83–9.
biology of the final restoration in mind. 16. Traini T, Pecora G, Iezzi G, et al. Preferred collagen
fiber orientation human peri-implant bone after
REFERENCES a short- and long-term loading period: a case
report. J Oral Implantol 2006;32(4):177–81.
1. Berglundh T, Lindhe J, Ericsson I, et al. The soft 17. Schwarz F, Ferrari D, Herten M, et al. Effects of
tissue barrier at implants and teeth. Clin Oral surface hydrophilicity and microtopography on
Implants Res 1991;2(2):81–90. early stages of soft and hard tissue integration at
2. Buser D, Weber H, Donath K, et al. Soft tissue reac- non-submerged titanium implants: an immunohis-
tions to non-submerged unloaded titanium implants tochemical study in dogs. J Periodontol 2007;
in beagle dogs. J Periodontol 1992;63(3):225–35. 78(11):2171–84.
3. Berglundh T, Abrahamsson I, Welander M, et al. 18. Moon I, Berglundh T, Abrahamsson I, et al. The
Morphogenesis of the peri-implant mucosa: an barrier between the keratinized mucosa and the
experimental study in dogs. Clin Oral Implants dental implant. An experimental study in the dog.
Res 2007;18(1):1–8. J Clin Periodontol 1999;26(10):658–63.
4. Gould T, Westbury L, Brunette D. Ultrastructural 19. Abrahamsson I, Berglundh T, Glantz P, et al. The
study of the attachment of human gingiva to tita- mucosal attachment at different abutments. An
nium in vivo. J Prosthet Dent 1984;52(3):418–20. experimental study in dogs. J Clin Periodontol
5. Steflik D, Corpe R, Young T, et al. The biologic tissue 1998;25(9):721–7.
responses to uncoated and coated implanted 20. Romanos G, Schröter-Kermani C, Weingart D, et al.
biomaterials. Adv Dent Res 1999;13:27–33. Health human periodontal versus peri-implant
6. Listgarten M. Soft and hard tissue response to en- gingival tissues: an immunohistochemical differen-
dosseous dental implants. Anat Rec 1996;245(2): tiation of the extracellular matrix. Int J Oral Maxillo-
410–25. fac Implants 2009;10(6):750–8.
7. Chehroudi B, Gould T, Brunette D. The role of 21. Davies J. Mechanisms of endosseous integration.
connective tissue in inhibiting epithelial down- Int J Prosthodont 1998;11(5):391–401.
growth on titanium-coated percutaneous implants. 22. Davies J. Understanding peri-implant endosseous
J Biomed Mater Res 1992;26(4):493–515. healing. J Dent Educ 2003;67(8):932–49.
8. Nevins M, Nevins M, Camelo M, et al. Human histo- 23. Araújo M, Lindhe J. Dimensional ridge alter-
logic evidence of a connective tissue attachment to ations following tooth extraction. An experi-
a dental implant. Int J Periodontics Restorative mental study in the dog. J Clin Periodontol
Dent 2008;28(2):111–21. 2005;32(2):212–8.
9. Abrahamsson I, Zitzmann N, Berglundh T, et al. 24. Kim B, Kim Y, Yun P, et al. Evaluation of peri-implant
The mucosal attachment to titanium implants tissue response according to the presence of kera-
with different surface characteristics: an experi- tinized mucosa. Oral Surg Oral Med Oral Pathol
mental study in dogs. J Clin Periodontol 2002; Oral Radiol Endod 2009;107(3):e24–8.
29(5):448–55. 25. Abrahamsson I, Berglundh T, Lindhe J. The
10. Berglundh T, Lindhe J. Dimension of the periim- mucosal barrier following abutment dis/reconnec-
plant mucosa. Biological width revisited. J Clin Pe- tion. An experimental study in dogs. J Clin Perio-
riodontol 1996;23(10):971–3. dontol 1997;24(8):568–72.
11. Stern I. Current concepts of the dentogingival 26. Linkevicius T, Apse P, Grybauskas S, et al. The
junction: the epithelial and connective tissue influence of soft tissue thickness on crestal bone
attachments to the tooth. J Periodontol 1981; changes around implants: a 1-year prospective
52(9):465–76. controlled clinical trial. Int J Oral Maxillofac
12. Ericsson I, Lindhe J. Probing depth at implants and Implants 2009;24(4):712–9.
teeth. An experimental study in the dog. J Clin Pe- 27. Cairo F, Pagliaro U, Nieri M. Soft tissue manage-
riodontol 1993;20(9):623–7. ment at implant sites. J Clin Periodontol 2008;
13. Broggini N, McManus L, Hermann J, et al. Peri- 35(Suppl 8):163–7.
implant inflammation defined by the implant-abut- 28. Bouri AJ, Bissada N, Al-Zahrani M, et al. Width of
ment interface. J Dent Res 2006;85(5):473–8. keratinized gingiva and the health status of the
14. Teté S, Mastrangelo F, Bianchi A, et al. Collagen supporting tissues around dental implants. Int
fiber orientation around machined titanium and J Oral Maxillofac Implants 2008;23(2):323–6.
 Soft-Tissue Regeneration and Development 403

29. Klinge B, Flemmig T. Tissue augmentation and 44. Tarnow D, Cho S, Wallace S. The effect of inter-
esthetics (Working Group 3). Clin Oral Implants implant distance on the height of inter-implant
Res 2009;20(Suppl 4):166–70. bone crest. J Periodontol 2000;71(4):546–9.
30. Kois J. Predictable single-tooth peri-implant esthetics: 45. Hermann J, Schoolfield J, Schenk R, et al. Influ-
five diagnostic keys. Compend Contin Educ Dent ence of the size of the microgap on crestal bone
2004;25(11):895–6 898, 900 passim [quiz: 906–7]. changes around titanium implants. A histometric
31. Jung R, Holderegger C, Sailer I, et al. The effect of evaluation of unloaded non-submerged implants
all-ceramic and porcelain-fused-to-metal restora- in the canine mandible. J Periodontol 2001;
tions on marginal peri-implant soft tissue color: 72(10):1372–83.
a randomized controlled clinical trial. Int J Peri- 46. Piattelli A, Vrespa G, Petrone G, et al. Role of the
odontics Restorative Dent 2008;28(4):357–65. microgap between implant and abutment: a retro-
32. Gargiulo AW, Wentz FM, Orban B. Dimensions and spective histologic evaluation in monkeys. J Perio-
relations of the dentogingival junction in humans. dontol 2003;74(3):346–52.
J Periodontol 1961;32:261–7. 47. Todescan F, Pustiglioni F, Imbronito A, et al.
33. Perez J, Smukler H, Nunn M. Clinical evaluation of Influence of the microgap in the peri-implant
the supraosseous gingivae before and after crown hard and soft tissues: a histomorphometric study
lengthening. J Periodontol 2007;78(6):1023–30. in dogs. Int J Oral Maxillofac Implants 2002;
34. Barboza E, MonteAlto R, Ferreira V, et al. Supra- 17(4):467–72.
crestal gingival tissue measurements in healthy 48. Van Assche N, Collaert B, Coucke W, et al. Corre-
human periodontium. Int J Periodontics Restorative lation between early perforation of cover screws
Dent 2008;28(1):55–61. and marginal bone loss: a retrospective study.
35. Vacek J, Gher M, Assad D, et al. The dimensions of J Clin Periodontol 2008;35(1):76–9.
the human dentogingival junction. Int J Periodon- 49. Tal H. Spontaneous early exposure of submerged
tics Restorative Dent 1994;14(2):154–65. implants: I. Classification and clinical observations.
36. Maynard JJ, Wilson R. Physiologic dimensions of J Periodontol 1999;70(2):213–9.
the periodontium significant to the restorative 50. Tal H, Artzi Z, Moses O, et al. Spontaneous early
dentist. J Periodontol 1979;50(4):170–4. exposure of submerged endosseous implants re-
37. Abrahamsson I, Berglundh T, Moon I, et al. Peri- sulting in crestal bone loss: a clinical evaluation
implant tissues at submerged and non- between stage I and stage II surgery. Int J Oral
submerged titanium implants. J Clin Periodontol Maxillofac Implants 2001;16(4):514–21.
1999;26(9):600–7. 51. Jeong S, Choi B, Li J, et al. The effect of thick
38. Hermann J, Buser D, Schenk R, et al. Biologic mucosa on peri-implant tissues: an experimental
width around titanium implants. A physiologically study in dogs. J Periodontol 2008;79(11):
formed and stable dimension over time. Clin Oral 2151–5.
Implants Res 2000;11(1):1–11. 52. Cosyn J, Sabzevar M, De Wilde P, et al. Two-piece
39. Hermann J, Buser D, Schenk R, et al. Biologic implants with turned versus microtextured collars.
width around one- and two-piece titanium implants. J Periodontol 2007;78(9):1657–63.
Clin Oral Implants Res 2001;12(6):559–71. 53. Subramani K, Jung R, Molenberg A, et al. Biofilm
40. Bakaeen L, Quinlan P, Schoolfield J, et al. The bio- on dental implants: a review of the literature. Int J
logic width around titanium implants: histometric Oral Maxillofac Implants 2009;24(4):616–26.
analysis of the implantogingival junction around 54. Trammell K, Geurs N, O’Neal SJ, et al. A prospec-
immediately and early loaded implants. Int J Peri- tive, randomized, controlled comparison of plat-
odontics Restorative Dent 2009;29(3):297–305. form-switched and matched-abutment implants in
41. Buser D, Mericske-Stern R, Bernard J, et al. Long- short-span partial denture situations. Int J Peri-
term evaluation of non-submerged ITI implants. odontics Restorative Dent 2009;29:599–605.
Part 1: 8-year life table analysis of a prospective 55. López-Marı́ L, Calvo-Guirado J, Martı́n-
multi-center study with 2359 implants. Clin Oral Castellote B, et al. Implant platform switching
Implants Res 1997;8(3):161–72. concept: an updated review. Med Oral Patol Oral
42. Hermann J, Cochran D, Nummikoski P, et al. Cir Bucal 2009;14(9):e450–4.
Crestal bone changes around titanium implants. 56. Hürzeler M, Fickl S, Zuhr O, et al. Peri-implant bone
A radiographic evaluation of unloaded nonsub- level around implants with platform-switched abut-
merged and submerged implants in the canine ments: preliminary data from a prospective study.
mandible. J Periodontol 1997;68(11):1117–30. J Oral Maxillofac Surg 2007;65(7 Suppl 1):33–9.
43. Quirynen M, van Steenberghe D. Bacterial coloni- 57. Weiner S, Simon J, Ehrenberg D, et al. The effects
zation of the internal part of two-stage implants. of laser microtextured collars upon crestal bone
An in vivo study. Clin Oral Implants Res 1993; levels of dental implants. Implant Dent 2008;
4(3):158–61. 17(2):217–28.
404 Geurs et al

58. Pecora G, Ceccarelli R, Bonelli M, et al. Clinical 72. Olsson M, Lindhe J. Periodontal characteristics in
evaluation of laser microtexturing for soft tissue individuals with varying form of the upper central
and bone attachment to dental implants. Implant incisors. J Clin Periodontol 1991;18(1):78–82.
Dent 2009;18(1):57–66. 73. Weisgold A. Contours of the full crown restoration.
59. Tarnow D, Magner A, Fletcher P. The effect of the Alpha Omegan 1977;70(3):77–89.
distance from the contact point to the crest of bone 74. Olsson M, Lindhe J, Marinello C. On the relation-
on the presence or absence of the interproximal ship between crown form and clinical features of
dental papilla. J Periodontol 1992;63(12):995–6. the gingiva in adolescents. J Clin Periodontol
60. Choquet V, Hermans M, Adriaenssens P, et al. Clin- 1993;20(8):570–7.
ical and radiographic evaluation of the papilla level 75. Becker W, Ochsenbein C, Tibbetts L, et al. Alveolar
adjacent to single-tooth dental implants. A retro- bone anatomic profiles as measured from dry
spective study in the maxillary anterior region. skulls. Clinical ramifications. J Clin Periodontol
J Periodontol 2001;72(10):1364–71. 1997;24(10):727–31.
61. Jemt T. Regeneration of gingival papillae after 76. Seibert JS. Reconstruction of deformed, partially
single-implant treatment. Int J Periodontics Restor- edentulous ridges, using full thickness onlay grafts.
ative Dent 1997;17(4):326–33. I. Technique and wound healing. Compend Contin
62. Kourkouta S, Dedi K, Paquette D, et al. Interprox- Educ Dent 1983;4:437–53.
imal tissue dimensions in relation to adjacent 77. Palacci P, Nowzari H. Soft tissue enhancement
implants in the anterior maxilla: clinical observa- around dental implants. Periodontol 2000 2008;
tions and patient aesthetic evaluation. Clin Oral 47:113–32.
Implants Res 2009;20(12):1375–85. 78. Priest G. The esthetic challenge of adjacent
63. Tarnow D, Elian N, Fletcher P, et al. Vertical implants. J Oral Maxillofac Surg 2007;65(7
distance from the crest of bone to the height of Suppl 1):2–12.
the interproximal papilla between adjacent 79. Grunder U, Gracis S, Capelli M. Influence of the
implants. J Periodontol 2003;74(12):1785–8. 3-D bone-to-implant relationship on esthetics. Int
64. Reddy M, O’Neal S, Haigh S, et al. Initial clinical J Periodontics Restorative Dent 2005;25(2):113–9.
efficacy of 3-mm implants immediately placed 80. Kan J, Rungcharassaeng K. Interimplant papilla
into function in conditions of limited spacing. Int J preservation in the esthetic zone: a report of six
Oral Maxillofac Implants 2008;23(2):281–8. consecutive cases. Int J Periodontics Restorative
65. Weber HP, Buser D, Belser UC. Examination of the Dent 2003;23(3):249–59.
candidate for implant therapy. In: Lang NP, Lindhe J, 81. Magne P, Belser U. Bonded porcelain restorations
editors.Clinicalperiodontologyandimplantdentistry, in the anterior dentition. A biomimetic approach.
vol. 1. 5th edition. Ames (IA): Blackwell Publishing; Carol Stream (IL): Quintessence; 2002.
2009. p. 587–97. 82. Rufenacht CR. Principles of esthetic integration.
66. Warrer K, Buser D, Lang N, et al. Plaque-induced Chicago (IL): Quintessence Publishing; 2000.
peri-implantitis in the presence or absence of kera- 83. Esposito M, Ekestubbe A, Gröndahl K. Radiolog-
tinized mucosa. An experimental study in monkeys. ical evaluation of marginal bone loss at tooth
Clin Oral Implants Res 1995;6(3):131–8. surfaces facing single Brånemark implants. Clin
67. Schrott A, Jimenez M, Hwang J, et al. Five-year eval- Oral Implants Res 1993;4(3):151–7.
uation of the influence of keratinized mucosa on peri- 84. Gasparini D. Double-fold connective tissue pedicle
implant soft-tissue health and stability around graft: a novel approach for ridge augmentation. Int
implants supporting full-arch mandibular fixed pros- J Periodontics Restorative Dent 2004;24(3):280–7.
theses. Clin Oral Implants Res 2009;20(10):1170–7. 85. Adell R, Eriksson B, Lekholm U, et al. Long-term
68. Wennström J, Bengazi F, Lekholm U. The influ- follow-up study of osseointegrated implants in the
ence of the masticatory mucosa on the peri- treatment of totally edentulous jaws. Int J Oral Max-
implant soft tissue condition. Clin Oral Implants illofac Implants 1990;5(4):347–59.
Res 1994;5(1):1–8. 86. Becker W, Becker B. Guided tissue regeneration
69. Cooper L. Objective criteria: guiding and evalu- for implants placed into extraction sockets and
ating dental implant esthetics. J Esthet Restor for implant dehiscences: surgical techniques and
Dent 2008;20(3):195–205. case report. Int J Periodontics Restorative Dent
70. Kopp FR, Belser U. Esthetic checklist for the fixed 1990;10(5):376–91.
prosthesis. In: Sharer P, Kopp FR, Rinn LA, editors. 87. Goldstein M, Boyan B, Schwartz Z. The palatal
Esthetic guidelines for restorative dentistry. Chicago advanced flap: a pedicle flap for primary coverage
(IL): Quintessence Publishing Co; 1982. p. 187–92. of immediately placed implants. Clin Oral Implants
71. Wilson D. Ridge mapping for determination of alve- Res 2002;13(6):644–50.
olar ridge width. Int J Oral Maxillofac Implants 88. Nemcovsky C, Artzi Z, Moses O. Rotated split
1989;4(1):41–3. palatal flap for soft tissue primary coverage
 Soft-Tissue Regeneration and Development 405

over extraction sites with immediate implant 98. Kan J, Rungcharassaeng K, Lozada J. Bilaminar
placement. Description of the surgical procedure subepithelial connective tissue grafts for imme-
and clinical results. J Periodontol 1999;70 diate implant placement and provisionalization in
(8):926–34. the esthetic zone. J Calif Dent Assoc 2005;
89. Nemcovsky C, Artzi Z, Moses O. Rotated palatal 33(11):865–71.
flap in immediate implant procedures. Clinical eval- 99. Park J. Increasing the width of keratinized mucosa
uation of 26 consecutive cases. Clin Oral Implants around endosseous implant using acellular dermal
Res 2000;11(1):83–90. matrix allograft. Implant Dent 2006;15(3):275–81.
90. Khoury F, Happe A. The palatal subepithelial 100. Geurs N, Romanos A, Vassilopoulos P, et al. Effi-
connective tissue flap method for soft tissue cacy of micronized acellular dermal graft for use
management to cover maxillary defects: a clinical in interproximal papillae regeneration. Int J Peri-
report. Int J Oral Maxillofac Implants 2000;15(3): odontics Restorative Dent, in press.
415–8. 101. Park S, Wang H. Management of localized buccal
91. Simons A, Darany D, Giordano J. The use of free dehiscence defect with allografts and acellular
gingival grafts in the treatment of peri-implant soft dermal matrix. Int J Periodontics Restorative Dent
tissue complications: clinical report. Implant Dent 2006;26(6):589–95.
1993;2(1):27–30. 102. El Helow K, El Askary AS. Regenerative barriers in
92. Hoelscher D, Simons A. The rationale for soft-tissue immediate implant placement: a literature review.
grafting and vestibuloplasty in association with Implant Dent 2008;17(3):360–71.
endosseous implants: a literature review. J Oral Im- 103. Park S, Lee K, Oh T, et al. Effect of absorbable
plantol 1994;20(4):282–91. membranes on sandwich bone augmentation.
93. Langer B, Calagna L. The subepithelial connective Clin Oral Implants Res 2008;19(1):32–41.
tissue graft. J Prosthet Dent 1980;44(4):363–7. 104. Chen S, Darby I, Reynolds E, et al. Immediate
94. Edel A. The use of a connective tissue graft for implant placement postextraction without flap
closure over an immediate implant covered with elevation. J Periodontol 2009;80(1):163–72.
occlusive membrane. Clin Oral Implants Res 105. Grunder U. The inlay-graft technique to create
1995;6(1):60–5. papillae between implants. J Esthet Dent 1997;
95. Bianchi A, Sanfilippo F. Single-tooth replacement 9(4):165–8.
by immediate implant and connective tissue graft: 106. Azzi R, Etienne D, Takei H, et al. Surgical thick-
a 1-9-year clinical evaluation. Clin Oral Implants ening of the existing gingiva and reconstruction
Res 2004;15(3):269–77. of interdental papillae around implant-supported
96. Covani U, Marconcini S, Galassini G, et al. Connec- restorations. Int J Periodontics Restorative Dent
tive tissue graft used as a biologic barrier to cover 2002;22(1):71–7.
an immediate implant. J Periodontol 2007;78(8): 107. Reddy M. Achieving gingival esthetics. J Am Dent
1644–9. Assoc 2003;134(3):295–304 [quiz: 337–8].
97. Burkhardt R, Joss A, Lang N. Soft tissue dehis- 108. Sachdeva K, Kula K, Hains F. Provisional restora-
cence coverage around endosseous implants: tion to preserve interdental papillae in the esthetic
a prospective cohort study. Clin Oral Implants zone: a case report. J Indiana Dent Assoc 2009;
Res 2008;19(5):451–7. 88(1):31–5.