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Timing of soft tissue management around dental implants: A suggested

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 Timing of soft tissue management
around dental implants: a suggested
protocol
Mahdi Kadkhodazadeh, DDS ¢ Reza Amid, DDS ¢ Mehdi Ekhlasmand Kermani, DDS ¢ Mahdieh Mirakhori, DDS
Sepanta Hosseinpour, DDS, MPH

Survival of dental implants depends on several factors;

soft tissue (ST) management around dental implants
is one of the foremost. Several studies have suggested
techniques for ST management around dental implants,
but none of them has discussed a suitable timetable
D ental implants are used for the replacement of lost
teeth.1,2 The final goal of tooth replacement with dental
implants is to achieve hard tissue (HT) stability, healthy
periodontal tissue, and optimal soft tissue (ST) esthetics. The
characteristics of the peri-implant ST are important in achieving
for this process. This study aimed to review published a successful implant restoration.3 The success of implant and
articles related to the timing of ST management around prosthodontic treatments depends mainly on patient selection,
dental implants and suggest a customized treat- preservation of the hard and soft tissues, proper surgical tech-
ment protocol. A search of the PubMed database was nique, and loading protocols.4 In addition to appropriate func-
conducted; the search was limited to English-language tion, esthetics are highly important in dental implant treatments.5
articles published from January 1995 to July 2015 with Esthetics in implant treatment depends on 4 factors: proper
available full texts. Only in vivo studies and clinical implant position; adequate bone on the buccal surface; shape and
trials in relation to the terms soft tissue management, form of the final crown; and peri-implant ST status.6-8
management timing, keratinized mucosa, free gingival The esthetic results of an implant-supported prosthesis
graft, connective tissue graft, soft tissue, augmentation, depend on the shape and texture of the soft tissues.9 Soft tissue
and dental implant were included. A total of 492 articles recession is among the most common problems encountered
were reviewed, and eventually 42 articles were thor- in anterior implants.10 According to Evans & Chen, gingival
oughly evaluated. Those with treatment protocols in recession increases in patients with thin biotypes.11 However, in
terms of the timing of ST grafting were selected and a study involving patients with thick, flat biotypes, the height of
classified. ST management around dental implants may the papilla next to the implant remained unchanged.12
be done prior to the surgical phase, after the surgical The gingival biotype is a diagnostic key for the esthetic suc-
phase, before loading, or even after loading. A thick cess of implants.13 According to Abrahamsson et al, thick gingi-
gingival biotype is more suitable for implant placement, val tissue (more than 2.5 mm) can significantly prevent crestal
providing more favorable esthetic results. A treatment bone loss around implants.14 Puisys & Linkevicius reported that
plan should be based on individual patient needs as well bone loss was lower around bone-level implants placed in sites
as the knowledge and experience of the clinician. The with thick gingival biotypes.15 In 1996, Berglundh & Lindhe
width and thickness of keratinized tissues, the need for stated that thin gingival tissue may lead to marginal bone loss
bone management, and local risk factors that influence during the formation of biologic width around implants.16
esthetic results determine the appropriate time for Moreover, due to the importance of bone volume in implant
ST augmentation procedures. therapy—especially the thickness of buccal bone—different
methods are used for diagnosis and treatment with dental
Received: September 27, 2015 implants.17-21 Cone beam computed tomography (CBCT) is an
Revised: February 5, 2016 alternative to a computed tomography scan and is beneficial for
Accepted: March 7, 2016 a wide range of craniomaxillofacial applications. In spite of its
limitation in soft tissue visualization, CBCT’s volumetric imag-
Key words: connective tissue, dental implant, ing generates high-resolution data with geometric accuracy and
free gingival graft, keratinized mucosa, regeneration, spatial resolution at a low effective radiation dose.22-26
soft tissue Placement of an immediate implant in a thick gingival biotype
can yield predictable results, and a thick biotype is more suit-
Published with permission of the Academy of General Dentistry.
© Copyright 2017 by the Academy of General Dentistry. able for implant placement, providing more favorable esthetic
All rights reserved. For printed and electronic reprints of this article results.27 Decreased gingival thickness can lead to periodontal
for distribution, please contact rhondab@fosvterprinting.com. attachment loss and marginal bone loss.28 Based on the results
reported by Sammartino et al and Belser et al, the presence of
thin peri-implant ST increases the risk of gingival recession and
subsequent exposure of the metal margin of the implant prosthe-
Exercise No. 403, p. 57 sis.29,30 Vandana & Savitha, in a 2005 study in humans, and Kyllar
Subject code: Implants (690) & Witter, in a 2008 study in dogs, demonstrated that gingival
thickness varies by sex and age as well as dental arch form.31,32

50 GENERAL DENTISTRY May/June 2017

 It appears that, in some cases, assessment of the ST at the It has been reported that the degree of mucosal collapse
implant site is as important as the HT status; therefore, clini- depends on the biotype of the peri-implant mucosa.8,38 Thus,
cians must pay special attention to this tissue. Some researchers converting thin and medium gingival biotypes to thick biotypes
believe that if an implant is going to be covered with a thin by reinforcing the KT can stabilize ST dimensions around
gingival biotype, it must be positioned more coronally relative dental implants.39
to the bone crest.14 In some cases, even the implant crest design Many of the selected studies investigated the relationship of
may change the ST status. the presence of KT around implants to plaque accumulation
Soft tissue management around dental implants may be and plaque control. Some studies have stated that no correlation
accomplished prior to the surgical phase, after the surgical exists between plaque control and the success of dental implants
phase, before loading, or even after loading.33 Previous studies and presence of peri-implant KT.40-44 However, in 2006, Chung
have discussed some techniques of ST management around et al found that plaque accumulation and gingival inflamma-
dental implants, but none of them has evaluated the most suit- tion were higher around dental implants with KT of less than
able timing for this process. This study aimed to review the 2 mm.45 The majority of studies evaluated in the current review
available literature to suggest a timing protocol for ST manage- used an apically positioned flap (APF) technique for ST manage-
ment around dental implants. ment around dental implants. The APF technique has several
advantages: It does not require a second surgical site, results in
Materials and methods minimal postoperative bone loss, controls postoperative gingival
This study reviewed existing human and animal studies to margin status, and has higher patient acceptance.46 Use of this
answer the following questions: technique can increase gingival width and vestibular depth, thus
•• When is the optimal time for ST augmentation (STA) in facilitating oral hygiene control by the patient. This is especially
placement of dental implants? important because plaque accumulation around dental implants
•• Does STA increase gingival thickness or width? can cause inflammation of the surrounding tissues and may
The PubMed database was electronically searched for relevant lead to peri-implantitis.47 Moreover, regeneration of periodontal
articles published from January 1995 to July 2015. The search and alveolar structures lost as a consequence of infection is
was limited to English-language articles with available full texts. extremely difficult, if not impossible.48
Key words used were keratinized mucosa, free gingival graft, Many of the selected studies investigated the relationship of
connective tissue graft, soft tissue, augmentation, soft tissue man- the presence of KT around implants to crestal bone loss. Block &
agement, management timing, and dental implant. A total of 492 Kent demonstrated that the presence of KT was significantly cor-
articles were retrieved. Articles deemed to be irrelevant based on related to the gingival health; crestal bone loss of 2 mm or more
titles and abstracts were eliminated, and the full texts of poten- was seen in areas with lost KT.49 Bouri et al and Kim et al reported
tially appropriate articles were obtained for final evaluation. that increased KT width around dental implants resulted in less
ST loss and greater HT stability.50,51 Cardaropoli et al prospec-
Results tively measured ST and HT dimensions around 11 single-implant
A total of 42 articles were evaluated. Articles with the same restorations 1 year after loading.52 The authors concluded that
treatment protocol (in terms of the timing of ST grafting) were buccal and lingual bone loss reached 1.3 mm within this time
selected. In the selected articles, ST management around dental period; the amount of ST height loss was 0.6 mm.52 Studies
implants was done prior to the surgical phase, after the surgical have indicated that most of these changes occur within the first
phase, before loading, or even after loading. In these articles, a 4 weeks of the implant uncovering process.53,54 In some cases, ST
thick biotype was deemed more suitable for implant placement, grafts can be used to cover serious bone defects or for esthetic
providing more favorable esthetic results. reconstruction over improperly positioned implants.55
Many of the selected studies investigated the relationship of Such correlations led to the introduction of several aug-
the presence of keratinized tissue (KT) around implants with mentation techniques to reinforce thin soft tissue, increase
gingival recession. In 2008, Zigdon & Machtei reported that the thickness and width of gingiva, and increase the vestibular
gingival width was negatively correlated with gingival recession depth at dental implant sites. Moreover, recognition of the exact
and positively correlated with pocket formation.34 In a 2013 anatomy of a future implant site is essential for achieving good
review study on 11 articles, Lin et al stated that the presence of esthetics and sound biomechanical support. Two-dimensional
keratinized mucosa was associated with less attachment loss radiographic evaluations cannot disclose the exact situation of
and gingival marginal recession.35 These results were clinically buccal or labial cortical plates. A cross-sectional view is required
significant because marginal recession and attachment loss can via 3-dimensional imaging. A CBCT provides this information
be endpoints of a treatment outcome. However, Bengazi et al with less radiation than previously available methods.56-58 Arora
reported that ST loss around implants can merely be the result et al and Joshi & Gupta demonstrated that CBCT imaging of the
of tissue regeneration for the stabilization of biologic width by anterior maxilla is highly recommended prior to implant place-
the peri-implant mucosa.36 The difference in results may be due ment to improve the functional and esthetic outcomes.59,60
to the effect of confounding factors, such as differing follow-up Free gingival grafts (FGGs) and connective tissue grafts
times, implant position, quality of ST and HT, and oral hygiene (CTGs) have been reported as effective techniques with pre-
standards among the studies.35 Warrer et al revealed that gingival dictable results for augmentation of KT width and vestibular
recession and attachment loss occurred more frequently around depth.61,62 However, these techniques are associated with com-
implants without KT than around those with adequate KT.37 plications, such as donor site morbidity (pain and discomfort),

www.agd.org/generaldentistry 51
Timing of soft tissue management around dental implants: a suggested protocol

Chart. Suggested protocol for the appropriate timing of soft tissue management around dental implants.

Medical and dental examinations

Prosthetic treatment plan

Keratinized tissue evaluation

Adequate keratinized tissue Inadequate keratinized tissue

Sufficient bone Insufficient bone Sufficient bone Insufficient bone

Imp Mild-moderate Severe bone STA Imp STA

bone defect defect +
Imp STA Imp

BA BA STA BA BA STA Imp BA BA BA

+ + + +
Imp Imp BA STA Imp Imp BA STA Imp STA
+ + +
Imp Imp STA BA STA Imp STA Imp
Abbreviations: BA, bone augmentation;
Imp, implantation; STA, soft tissue augmentation.

increased surgical time, a longer healing period, and increased graft; increased gingival thickness and height were observed in
patient cost. To prevent these complications, use of an acellular both groups.66 Basegmaz et al performed 64 implant treatments
dermal matrix, collagen matrix, APF, and coronally advanced in sites with primary KT dimensions of less than 1.5 mm and
flap (CAF) has been investigated in several studies. Studies signs of mucositis.67 After 12 months, the FGG technique was
comparing the efficacy of these techniques for increasing significantly more successful than vestibuloplasty alone. Tissue
gingival width and thickness and improving peri-implant ST width in the FGG group reached 2.36 mm, a significantly greater
esthetics are scarce. In a retrospective 3-year study, Speroni et al improvement compared to the 1.15 mm increase in the vestibu-
demonstrated that a 1.75-mm increase in thickness of mucosa loplasty group. The authors theorized that the reason for the dif-
is expected 12 months following the placement of an FGG or a ference was the lower rate of relapse found in the FGG group.67
subepithelial CTG.63 A greater increase in ST thickness is more If necessary, plastic surgery around dental implants should be
likely in primarily thin mucosa than thick mucosa (2.14 versus performed prior to implantation, during the first or second stage
0.64 mm). Also, the likelihood of increase in mucosal thickness is of implant surgery, or after prosthetic loading.68-74
higher in the mandible (2.17 mm) than in the maxilla (0.81 mm). The appropriate preoperative timing for increasing gingival
In a 2010 study by Lee et al, 3 techniques (APF, APF plus col- width is a matter of controversy. It has been reported that this
lagen matrix, and APF plus FGG) were evaluated in 9 patients, procedure may be performed during second-stage surgery or at
and the KT widths of patients in the 3 groups were compared.64 the time of prosthetic loading. In a 2015 study by Baltacıoğlu et
The results revealed that the increase in gingival width after al, different treatment groups with preimplantation and post-
augmentation of KT was the greatest in the group receiving APF implantation ST surgeries were evaluated (before, during, and
plus FGG; the next greatest increase resulted from APF plus after the second-stage implant surgery).75 In their 2011 study
collagen matrix, and APF alone provided the smallest increase. on 2 groups with different augmentation times (either simulta-
The results of a study by Schwarz et al found no significant neous with implant insertion or at the second-stage surgery),
differences in the gingival thickness increases resulting from Stimmelmayr et al revealed that the amount of shrinkage of the
the following 3 methods: CAF, CAF plus collagen matrix, and FGG was greater in the group receiving augmentation simulta-
CAF plus CTG.65 Moreover, in their 2015 study, Bengazi et al neously with implant placement; this difference was not statisti-
found no significant differences in HT or ST dimensions after cally significant, however.76 In the majority of studies evaluated
removing the masticatory mucosa in dogs and subsequently in the current review, ST management around dental implants
placing implants along with either a CTG or a gingival mucosal was performed at the time of implant surgery. This timing has

52 GENERAL DENTISTRY May/June 2017

A B C

Fig 1. A. Preoperative palatal view of the anterior maxilla. The keratinized tissue is adequate and bone is
insufficient (mild to moderate bone defect). B. Intraoperative situation after implant placement. Note the
membrane and bone substitute placement for guided bone regeneration. C. Buccal view 6 months postoperatively.

A B C

Fig 2. A. Preoperative buccal view of a posterior mandibular site. The keratinized tissue is inadequate and bone
is sufficient based on 3-dimensional evaluations. B. Intraoperative buccal view after implant placement. A free
gingival graft has been placed for soft tissue augmentation. C. Buccal view 6 months postoperatively.

A B patient dissatisfaction.77 Several studies have emphasized the

presence of KT around implants.78,79 However, the timing of the
ST augmentation process is also important. As stated previously,
this study aimed to assess the timing of ST management around
dental implants, as reported in relevant studies, in order to come
up with a protocol for this process.
The Chart shows the protocol suggested by the authors for the
appropriate timing of ST management around dental implants
in patients with adequate and inadequate KT and bone based
on the time of implant placement. Due to the significance of
the height and thickness of ST and the resultant effects on HT
regeneration, the authors suggest that the ST status be evaluated
Fig 3. A. Buccal view of fresh socket implantation via acellular dermal first in terms of height and thickness. Clearly, this assessment
matrix for simultaneous soft tissue augmentation. B. Occlusal view depends on several factors, including the clinician’s experi-
6 months postoperatively. ence, the method of measurement of ST parameters (thickness,
height, and vestibular depth), the need for HT regeneration,
the implant placement site, and the implant position relative to
several advantages: it requires fewer surgeries; enables simul- the adjacent teeth. An ST assessment in implant candidates will
taneous HT and ST healing; results in a shorter healing time; reveal 1 of 2 situations: adequate or inadequate KT.
produces less pain and discomfort; causes less stress; lowers the
costs; and provides greater patient satisfaction. Adequate thickness and height of KT
1. If the bone is of adequate quality and quantity in all
Protocol for soft tissue management 3 dimensions, an implant may be placed.
Soft tissue management around dental implants has been greatly 2. If the bone is inadequate:
emphasized in recent years. Gingival thickness, width, and con- a. If the bone defect is mild to moderate, implant place-
tour are of great esthetic importance in the anterior region. Thin ment and bone augmentation (BA) are done simultane-
and narrow gingivae lead to gingival recession, bone loss, plaque ously (Fig 1).
accumulation, gingival inflammation, impaired oral hygiene, b. If the bone defect is severe, BA is performed first. Then,
difficult impression-taking for prosthetic fabrication, visibility when optimal bone quality has been achieved in all 3
of the gray shadow of implants, compromised esthetics, and dimensions, an implant is inserted.

www.agd.org/generaldentistry 53
Timing of soft tissue management around dental implants: a suggested protocol

A B C

Fig 4. A. Preoperative palatal view of the posterior maxilla. The keratinized tissue is inadequate and bone is
insufficient. B. Intraoperative palatal view of the apically positioned flap technique for soft tissue augmentation
at the second-stage implant surgery. C. Buccal view 6 months postoperatively.

A B C

D E

Fig 5. A. Preoperative buccal view of the posterior mandible. The keratinized tissue is inadequate and bone is insuffient. B. Implant
placement. C. Bone augmentation performed simultaneously with implant placement. D. Free gingival graft for soft tissue grafting
procedure. E. Buccal view 6 months postoperatively.

Inadequate thickness or height of KT a. STA is performed first. This is followed by BA in a sepa-

1. If the bone is of adequate quality and quantity in all 3 rate procedure. After adequate ST and HT are ensured,
dimensions, the clinician chooses from the following treat- an implant is placed.
ment sequences based on personal preference and profes- b. BA is performed first. This is followed by STA in a sepa-
sional experience: rate procedure. After adequate ST and HT are ensured,
a. STA is performed first. After the thickness and height of an implant is placed.
ST are found to be adequate, an implant is placed. c. BA is performed first. After HT has been found to be
b. An implant is placed first. STA is performed either adequate, the implant is inserted. STA is performed
simultaneously with the second-stage implant surgery after implantation surgery (Fig 4).
or after restorative treatment. d. STA is performed first. After ST is deemed adequate,
c. Implant placement and STA can be performed simulta- implant placement and BA are performed at the same
neously (Fig 2 and 3). time.
2. If the bone is inadequate, the clinician chooses from the e. The implant is placed simultaneously with BA. After
following treatment sequences based on personal prefer- the bone augmentation and implant site have healed
ence and professional experience: adequately, STA is performed (Fig 5).

54 GENERAL DENTISTRY May/June 2017

 f. BA and STA are performed simultaneously. After HT 8. Kan JY, Rungcharassaeng K, Umezu K, Kois JC. Dimensions of peri-implant mucosa: an eval-
and ST are adequate, the implant is placed. uation of maxillary anterior single implants in humans. J Periodontol. 2003;74(4):557-562.
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h. BA, STA, and implant placement are performed 11. Evans CD, Chen ST. Esthetic outcomes of immediate implant placements. Clin Oral Implants
Res. 2008;19(1):73-80.
simultaneously. 12. Romeo E, Lops D, Rossi A, Storelli S, Rozza R, Chiapasco M. Surgical and prosthetic manage-
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in conjunction with BA. 7(3):212-219.
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around bone-level implants. A prospective controlled clinical trial. Clin Oral Implants Res.
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clinicians to select the technique and appropriate timing of maxilla and the mandible with cone-beam computed tomography. Am J Orthod Dentofacial
soft tissue management around dental implants. Some of the Orthop. 2010;137(2):218-222.
timing sequences presented in the protocol have yet to be used 20. Agbaje JO, Jacobs R, Maes F, Michiels K, van Steenberghe D. Volumetric analysis of extraction
sockets using cone beam computed tomography: a pilot study on ex vivo jaw bone. J Clin
in studies; therefore, they can be used as a guide for researchers Periodontol. 2007;34(11):985-990.
and to facilitate the comparison of results in this field. 21. Veyre-Goulet S, Fortin T, Thierry A. Accuracy of linear measurement provided by cone beam
The important points to be taken from this article are the computed tomography to assess bone quantity in the posterior maxilla: a human cadaver
study. Clin Implant Dent Relat Res. 2008;10(4):226-230.
importance of assessing the patient’s needs and determining the 22. Liang X, Lambrichts I, Sun Y, et al. A comparative evaluation of cone beam computed tomog-
gingival width and thickness and vestibular depth with accurate raphy (CBCT) and multi-slice CT (MSCT), II: on 3D model accuracy. Eur J Radiol. 2010;75(2):
methods prior to implant surgery. Keeping these considerations 270-274.
in mind will help the clinician to stabilize esthetic results, ensure 23. Hua Y, Nackaerts O, Duyck J, Maes F, Jacobs R. Bone quality assessment based on cone beam
computed tomography imaging. Clin Oral Implant Res. 2009;20(8):767-771.
periodontal health, and achieve patient satisfaction. 24. Draenert FG, Coppenrath E, Herzog P, Müller S, Mueller-Lisse UG. Beam hardening artefacts
occur in dental implant scans with the NewTom cone beam CT but not with the dental 4-row
Author information multidetector CT. Dentomaxillofac Radiol. 2007;36(4):198-203.
25. Aranyarachkul P, Caruso J, Gantes B, et al. Bone density assessments of dental implant sites,
Drs Kadkhodazadeh and Amid are associate professors, Dr
2: quantitative cone-beam computerized tomography. Int J Oral Maxillofac Implants. 2005;
Kermani is an assistant professor, and Dr Mirakhori is a dentist, 20(3):416-424.
Department of Periodontics, Dental Research Center, Research 26. Arai Y, Tammisalo E, Iwai K, Hashimoto K, Shinoda K. Development of a compact computed
Institute of Dental Sciences, Shahid Beheshti University of tomographic apparatus for dental use. Dentomaxillofac Radiol. 1999;28(4):245-248.
27. Nagaraj KR, Savadi RC, Savadi AR, et al. Gingival biotype—prosthodontic perspective.
Medical Sciences, School of Dentistry, Tehran, Iran, where J Indian Prosthodont Soc. 2010;10(1):27-30.
Dr Hosseinpour is a research fellow, School of Advanced 28. Januário AL, Barriviera M, Duarte WR. Soft tissue cone-beam computed tomography: a novel
Technologies in Medicine. method for the measurement of gingival tissue and the dimensions of the dentogingival unit.
J Esthet Restor Dent. 2008;20(6):366-373.
29. Sammartino G, Marenzi G, di Lauro AE, Paolantoni G. Aesthetics in oral implantology: biolog-
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