Periodontology 2000, Vol. 0, 2018, 1–17 © 2018 John Wiley & Sons A/S.
Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Printed in Singapore. All rights reserved
Soft-tissue dehiscence coverage
at peri-implant sites
CLAUDIO MAZZOTTI, MARTINA STEFANINI, PIETRO FELICE,
VALENTINA BENTIVOGLI, ILHAM MOUNSSIF & GIOVANNI ZUCCHELLI
Implant therapy is a successful and predictable
option to replace missing teeth, as documented in
the literature (2, 4, 49, 51, 71, 72). However, for
patients, the success of implant therapy is judged not
only by the long-term function of the implant but also
by the early esthetic outcome of the implant and its
stability over time. Similarly to teeth, stability of soft
tissue around implants is a significant factor in
achieving a satisfactory esthetic outcome. In the liter-
ature, several terms are used to define the apical shift
of the peri-implant mucosal margin; these include
soft-tissue dehiscence, mucosal recession, midfacial
recession, soft-tissue recession, mucosal dehiscence,
soft-tissue deficiency and soft-tissue defect. A major
concern, from this point of view, is the appearance of
soft-tissue dehiscence in the buccal aspect, a com-
mon finding following implant restorations (3, 10, 21,
23, 24, 32, 36, 41, 48, 52, 68, 83).
Gingival recession around teeth is defined as the
apical shift of the gingival margin below the cemento–
enamel junction (5). As dental implants have no such
standard reference level for the ‘normal’ position of
the mid-buccal mucosa, there is a lack of agreement
among clinicians about its definition. Consequently,
there is currently no agreed classification of mucosal
recessions around implants. To assess soft-tissue
dehiscence, some authors use the mucosal margin at
the time of the final restoration or exposure of the
metallic implant/abutment grey surface as a reference
point. These choices may not be appropriate because
they do not take into account the gingival margin of
the homologous adjacent or contralateral natural
tooth (if present), which may result in a exaggeratedly
long, implant-supported prosthetic crown with dishar-
mony of the marginal soft-tissue scallop with respect
to the adjacent teeth. For this reason, other authors,
including those writing this article, take the gingival
PERIODONTOLOGY 2000
margin of the adjacent/contralateral natural teeth into
consideration, as suggested by a recent consensus for
future research (66). Peri-implant soft-tissue dehis-
cence can be defined as an apical shift of the soft-tis-
sue margin of the implant-supported crown with
respect to the homologous natural tooth, with or with-
out exposure of the metallic part of the implant
(Fig. 1). Unlike teeth, where the classification system
of gingival recessions itself leads to a prognostic evalu-
ation of the treatment (18, 64), the prognosis of the
soft-tissue dehiscence treatment is difficult to assess.
Compared with gingival recession around teeth, very
little is known about the diagnosis and treatment of
soft-tissue dehiscences around implants.
Patient satisfaction is the main goal of implant
rehabilitation, and esthetics seems to be the main con-
cern for patients. Consequently, when dental implant
dehiscence occurs in an esthetic area, it is an impor-
tant and challenging clinical situation to resolve. Like
complete root coverage for treatment of gingival
recession, complete dehiscence coverage (i.e. reposi-
tioning the soft-tissue margin of the implant-sup-
ported crown to the same level of the homologous
natural tooth) should be the main goal of the treat-
ment (Fig. 2). The esthetic success of dental implant
therapy is related not only to soft tissues but also to
the coronal restoration. In the literature, there are
indices that evaluate esthetic outcomes, all of which
consider the position and the quality of the buccal
marginal gingiva as key esthetic factors that need to
be evaluated. The implant crown esthetic index by
Meijer et al. (63) rates nine items that focus on soft
tissues and the coronal restoration, including the
position, contour, color and surface of the labial peri-
implant mucosa. The pink esthetic score by Furhau-
ser et al. (39) includes seven criteria exclusively to
assess peri-implant soft tissues: mesial papilla; distal
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Mazzotti et al.

A B

Fig. 1. Peri-implant soft-tissue dehiscence: apical shift of the soft-tissue margin of the implant-supported crown with
respect to the homologous natural tooth. With (A) and without (B) exposure of the metal part of the implant.

papilla; midfacial level; midfacial contour; alveolar
process deficiency; soft-tissue color; and soft-tissue
texture. On the contrary, the white esthetic score by
Belser et al. (9) evaluates the esthetic outcome of
implant restoration by analyzing only the coronal
restoration in terms of tooth form, tooth volume, tooth
color (with hue and value), tooth texture and translu-
cency. Both the pink esthetic score and the white
esthetic score are assessed in comparison with a refer-
ence tooth, which is the homologous contralateral
incisors or cuspid for anterior tooth replacement or
the neighboring premolar for bicuspid replacement.
Some, physiological soft-tissue remodeling usually
occurs following implant placement and abutment
connection, and a change in the level of the soft-
tissue margin and papillae height have been reported
in studies with different placement protocols (24).
Bengazi et al. (10), in a 2-year longitudinal, prospec-
tive study, observed an average apical displacement
of the midfacial mucosa of 0.5 mm, with greater
recession in women than in men, in the mandible
than in the maxilla, at lingual than at buccal sites
and with increased initial probing depth. Small &
Tarnow (83), in a longitudinal study, reported that
peri-implant dehiscence occurs within 3 months
after the placement of an implant, with a mean
recession of 1.05 mm after 1 year. They showed that
there were no differences between maxillary and

A B

C D

Fig. 2. Complete coverage of the dehiscence: repositioning
of the soft-tissue margin of the implant-supported crown at
the same level of the homologous natural tooth. (A) Deep
buccal soft-tissue dehiscence with exposure of the implant
surface. (B) Complete coverage of the dehiscence after the
restorative–surgical–restorative approach (restorative ther-
apy was performed by Dr Alessandro Marchetti). (C) Deep
buccal soft-tissue dehiscence without exposure of the metal
part of the implant. (D) Complete coverage of the dehiscence
after the restorative–surgical–restorative approach.

2

mandibular tissues, type of abutments and provision-
alized restorations, suggesting a trend in soft-tissue
healing around implants, as demonstrated in experi-
mental studies (1, 12). Oates et al. (68) followed 106
implants in 39 patients over a 2-year period to investi-
gate mucosal stability at the buccal midfacial aspect.
In 61% of these implants, apical displacement of the
facial mucosa of ≥ 1 mm was observed after 2 years.
In evaluating patients showing a loss in tissue height
around one or more implants, the mean loss in tissue
height was 1.6 mm after 2 years. Cardaropoli et al.
(21) found similar results with a mean apical migra-
tion of the gingivae of 0.6 mm, 1 year after prosthetic
restoration. In a review, Chen & Buser (24) reported
an average midfacial recession value of 0.75 mm for
immediate implant placement, with similar results
found in early and late implant placements. Although
a small degree of mucosal recession will occur after
implant placement, comparison of treatment options
shows that there seems to be a higher frequency
of recession of > 1 mm for immediate implant place-
ment compared with early implant placement (24).
The recession of midfacial mucosa, even when com-
bined with graft of bone or bone substitute, is a
common complication associated with immediate,
postextractive implant placements (24). In a system-
atic review concerning immediate single implants,
Cosyn et al. (30) reported that gingival dehiscence
was a common event to expect. They found only four
prospective studies reporting the frequency of
advanced midfacial recession (> 1 mm), with a risk of
less than 10% when an intact facial bone wall and
thick gingival biotype were present and flapless sur-
gery with immediate placement of a prosthetic crown
were carried out. Similar results were found by
Khzam et al. (55) in a recent systematic review in
which advanced mucosal recession was seen in
approximately 11% of low-risk cases. The aim of the
present review is to analyze factors affecting the posi-
tion and stability of the peri-implant soft-tissue
margin and to describe the surgical and combined
prosthetic-surgical approaches to treat unesthetic
peri-implant soft-tissue dehiscence.
Factors affecting stability of the
peri-implant soft-tissue margin
The reasons why buccal soft-tissue dehiscence occurs
on implant restorations are still controversial. They
include anatomic/predisposing factors (such as a
buccally positioned implant platform, osseous dehis-
cence or fenestration, a thin gingival biotype,
Buccal soft-tissue dehiscence treatments
inadequate keratinized attached mucosa, high fre-
num or muscle pull) along with pathological/precipi-
tating factors [such as recurring inflammation, over-
contoured prostheses and self-inflicted injury (such
as toothbrushing or flossing trauma)] (38).
The principal factor seems to be incorrect place-
ment of the implant in the three-dimensional posi-
tion, which influences both the hard- and soft-tissue
remodeling processes during healing and after abut-
ment connection in two-stage implant systems (21,
22, 35). Similar soft-tissue remodeling is reported in
single-stage implant systems (68). Both animal and
human studies show that postextraction remodeling
results in vestibular bone resorption, even in cases of
immediate implant placement (7, 14). The orofacial
position of the implant shoulder is strongly associated
with mucosal recession, especially following immedi-
ate implant placement (25, 26, 31, 36, 96). In a retro-
spective study of the esthetic outcomes, Evans &
Chen (36) found that implants with a buccal shoulder
position showed three times more recession than
implants with a lingual shoulder position. Cosyn et al.
(31), in a retrospective cohort study, reported that the
buccal shoulder position increased the likelihood of
mid-buccal recession (odds ratio = 17.2). The more
buccal the position of the implant, the more the mid-
buccal margin recedes apically (96). Likewise, a more
proclined implant position and an increased depth of
the implant platform significantly increase the risk of
buccal recession defects (67).
Similarly to teeth, a thin tissue biotype was identi-
fied as a risk factor for mucosal recession (26, 28, 36,
53, 54, 67, 78). In a review, Chen & Buser (24) reported
that immediate implant placement in sites with a
thin biotype had a higher frequency of recession
of > 1 mm compared with sites with a thick biotype.
According to Nisapakultorn et al. (67), soft-tissue bio-
type was the most significant factor in determining
the buccal marginal mucosal level. They showed that
having a thin peri-implant biotype increased the risk
of mucosal recession (odds ratio = 18.8). In this
cross-sectional study, the mean soft-tissue recession
at thin biotype sites was also significantly greater than
that at thick sites (1.4 mm vs. 0.4 mm). Therefore,
sites with a thin tissue biotype should be regarded as
being at greater risk of mucosal recession compared
with sites with a thick biotype. Similar results were
found in a 2- to 8-year follow-up study of immediate
implant placement and provisionalization (53). Sites
with a thick gingival biotype exhibited significantly
less buccal gingival level change than sites with a thin
gingival biotype, both 1 year after implant placement
( 0.25 mm vs. 0.75 mm, respectively) and at the
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Mazzotti et al.
most recent follow-up examination ( 0.56 mm vs.
1.50 mm, respectively). These results suggest that
buccal gingival tissue recession is a dynamic process
and may continue beyond 12 months postimplant
surgery. The main concern with these articles is that
the threshold of thickness, in mm, is not provided to
classify the soft-tissue biotype into ‘thin’ or ‘thick’
regarding the risk of developing soft-tissue dehis-
cence around the implant. Furthermore, if one con-
siders that, in a natural tooth, the buccal soft tissue is
attached to the root surface with a connective tissue
attachment, there is no such corresponding attach-
ment to the suprabony component of an implant
(abutment and/or subgingival portion of a screw-
retained crown). Hence, it does not automatically
mean that a soft-tissue biotype which is thick enough
to prevent gingival recession around a tooth is also
thick enough to prevent mucosal dehiscence around
an implant. One could speculate that the connective
tissue thickness in the transmucosal area should be at
least thicker than the inflammatory infiltrate induced
by subgingival plaque or toothbrushing trauma. As
the inflammatory infiltrate occupies an area of
approximately 1–2 mm (87), a minimum soft-tissue
thickness of 2 mm is advised to prevent soft-tissue
dehiscence at the implant-supported crown. In vitro
and in vivo studies (50, 86) reported that a minimum
buccal soft-tissue thickness of 2 mm was necessary to
mask the metallic transparency at the buccal aspect
of the implant site.
It has been suggested that, in addition to biotype,
the keratinization of soft tissues may affect their sta-
bility (77, 80, 89). In a retrospective clinical trial, Zig-
don & Machtei (89) examined 63 functioning dental
implants and found more recession in mucosa that
was less keratinized. They concluded that these find-
ings were of special importance in the esthetic zone,
where thin, narrow bands of keratinized tissue may
lead to greater mucosal recession. Similar results were
found by Schrott et al. (80), when analyzing data from
a 5-year prospective multicenter trial. In patients
exercising good oral hygiene and receiving regular
maintenance therapy, implants with a reduced width
(< 2 mm) of peri-implant keratinized mucosa were
more prone to buccal soft-tissue recession over a
period of 5 years. Recently, Roccuzzo et al. (77), in
a 10-year prospective comparative study, showed
that implants not surrounded by keratinized tissue
were more prone to plaque accumulation and muco-
sal recession than implants surrounded by kerati-
nized tissues. A systematic review and meta-analyses
(59), investigating the effect of keratinized mucosa
on implant health, concluded that the absence of
4
an adequate band of keratinized mucosa around
endosseous implants was associated with greater
mucosal recession, as well as plaque accumulation,
tissue inflammation and loss of attachment. In con-
trast, Bengazi et al. (10) evaluated the position of
peri-implant soft-tissue margins after insertion of
fixed prostheses and found that a lack of keratinized
mucosa and greater mobility of the peri-implant soft
tissues at the time of bridge installation were poor
predictors of soft-tissue recession occurring during
the 2 years of follow-up. Despite some discrepancy,
most of the recent literature seems to indicate the
presence of buccal keratinized tissue as a key factor to
improve plaque control and minimize mucosal reces-
sion at implant sites, even though the critical width of
keratinized tissue value has not yet been clarified.
A key determinant for an esthetic implant restora-
tion is the available bone in three dimensions. Ade-
quate bone seems to be essential to enable correct
placement of the implant and to maintain soft-tissue
margin and papillae positions. Based on the evidence
available, a minimum thickness of buccal bone wall
of 2 mm is necessary after implant placement in a
healed site to ensure adequate soft-tissue support
and to avoid the complete resorption of the buccal
bone wall following restoration (16, 42, 47, 73, 85).
Spray et al. (85) studied the relationship between
vertical bone loss and thickness of facial bone on
two-stage implants placed in healed sites and
detected greater bone loss when the vestibular bone
was less than 1.4 mm thick. In contrast, sites with no
change in facial bone response had a mean thick-
ness of vestibular bone of 1.8 mm at implant place-
ment. They concluded that as the bone thickness
approached 1.8–2 mm, bone loss decreased signifi-
cantly and even some evidence of bone gain was
seen. Thus, to avoid vestibular bone loss and associ-
ated recession, one must leave a minimum thickness
of 1.8 mm of external bone. Recently, Barone et al.
(8), in a 1-year randomized clinical trial, reported that
implants inserted with a high insertion torque (be-
tween 50 and 100 N
cm) into healed sites showed
more buccal soft-tissue recession and facial bone
remodeling than implants inserted with regular tor-
que (< 50 N
cm); moreover, sites with a thick buccal
bone wall (≥ 1 mm) seemed to be less prone to buc-
cal mucosal recession than sites with a thin buccal
bone wall (< 1 mm). The maintenance of the buccal
bony wall seems more essential in cases of immediate
implant placement and loading. Kan et al. (54)
reported that damage to the buccal bone at the time
of immediate implant placement represented a signif-
icant risk factor for mucosal recession. Nisapakultorn

et al. (67) evaluated the association between peri-
implant soft-tissue recession and buccal bone level
and thickness. They showed that the buccal mucosal
level around single-tooth implants was significantly
affected by the buccal alveolar crest level and that
the mean buccal crest thickness decreased as the
buccal marginal mucosal level increased, although
this association was not statistically significant. Like-
wise, Miyamoto & Obama (65), through a dental
cone beam computed tomography analyses of post-
operative labial bone thickness in maxillary anterior
implants, showed a significant, negative correlation
between buccal bone thickness and mucosal reces-
sion. Recession was minimal in sites where the labial
bone thickness at the cervical area of the implant was
approximately 1.2 mm or more at the postoperative
measurement (at least 6 months after implant place-
ment). The author suggested that if approximately
0.7 mm of bone resorption occurs, on average, which
is related to removal of the periosteum during the
surgery, the criterion of 2 mm of buccal bone wall ap-
pears to be satisfied. The authors also reported a sig-
nificant, positive correlation between vertical bone
loss and mucosal recession. Benic et al. (11), in
another cone beam computed tomography study,
concluded that sites without radiographically detect-
able buccal bone in the 7-year control presented with
a mucosal level 1 mm more apical than the mucosal
level in implants with intact buccal bone. These stud-
ies show that buccal bone thickness (at least 2 mm)
and height affect the peri-implant soft-tissue dehis-
cence (11, 65, 67), suggesting the importance of the
volume of bone crest in maintaining peri-implant
soft-tissue margins.
Considering implant placement and its relationship
with the bone, Nisapakultorn et al. (67) showed that
the level of the first bone–implant contact and the
interproximal bone crest were associated with the
buccal soft-tissue level. In this study, increased dis-
tance from the contact point to the bone crest and
from the contact point to the first bone–implant con-
tact significantly increased the risk of buccal marginal
mucosal recession (odds ratios = 3.4 and 2.4,
respectively).
In addition to correct implant positioning, the
diameter of the implant platform seems to play a role
in determining the extent of mucosal recession (78,
84). Small et al. (84) compared soft-tissue levels in
wide- and standard-diameter implants in a 3- to 5-year
prospective study. Wide-diameter implants showed
greater mean recession and greater number of sites
with recession at the time of prosthesis installation
compared with standard-diameter implants. Soft-tissue
Buccal soft-tissue dehiscence treatments
recessions at wide-diameter implants increased at the
5-year follow-up. Ross et al. (78), in a retrospective
study, analyzed the soft-tissue margin changes of 47
maxillary anterior single implants over 5 years. The
results showed a statistically significant difference
between mucosal recession and the different implant
diameter at the lateral incisor position (4.3 mm vs.
3.5 mm). The amount of recession was directly corre-
lated to the implant diameter. In this study, when
a narrow-diameter implant was used for an immedi-
ate implant placement and provisionalization app-
roach, less mucosal recession was seen in comparison
with a wider implant (0.080 mm vs. 0.812 mm). These
studies suggest that the implant diameter can influ-
ence the amount of mucosal recession: the greater
the diameter, the larger the risk for soft-tissue dehis-
cence.
Recently, Raes et al. (75), in a prospective cohort
study, evaluated the impact of smoking on soft-tissue
changes around single implants placed in the anterior
maxilla. Eighty-five implants with immediate provi-
sionalization were placed in healed sites (39 non-
smokers, 46 smokers), followed by placement of a
definitive restoration 8–12 weeks later (baseline). The
soft-tissue margin was evaluated during the 2 years of
follow-up. Mid-buccal soft-tissue level demonstrated
statistically significant regrowth in nonsmokers
(0.53 mm), whereas it remained stable in smokers.
The authors concluded that smokers showed more
mid-buccal recession following single implant treat-
ment compared with nonsmokers.
There are controversial results in the literature
regarding immediate implant placement, immediate
provisionalization, the use of implants with conical
connection and platform switching to limit mid-buc-
cal recession (19, 70). Immediate provisionalization of
an immediate single-tooth implant has been pro-
posed to optimize the esthetic outcome. De Rouck
et al. (33), in a 1-year randomized clinical study of 49
patients, showed that the amount of mid-buccal
recession was 2.5- to 3-times higher in the delayed-
restoration group compared with the immediate-
restoration group, showing a mean difference of
0.75 mm at study termination and favoring immedi-
ate restoration (mid-buccal recession was 1.16 mm in
the delayed-restoration group and 0.41 mm in the
immediate-restoration group). However, two other
randomized controlled clinical trials (34, 43) found no
statistically significant difference in mucosal reces-
sion, 1 year after the final restoration, between imme-
diate and conventional loading implants placed into
sites with healed soft tissues. Similarly, one study
showed significantly less mucosal recession when a
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Mazzotti et al.
flapless surgical approach was used (74) but other
studies failed to support this finding (13, 54).
In conclusion, incorrect implant placement, thin
buccal soft tissue and bone and reduced buccal bone
height are the factors more strongly associated with
mucosal recession at implant sites.
Surgical techniques
A recent literature search revealed that a variety of
surgical and restorative techniques have been pro-
posed to treat unesthetic implant soft-tissue dehis-
cences. Most reports in this search were case reports
(17, 20, 27, 29, 37, 40, 44, 45, 56, 58, 61, 62, 69, 81, 82,
91), four were prospective studies (15, 76, 79, 92), one
had a long-term follow-up (90), one was a retrospec-
tive study (57) and only one was a randomized con-
trolled trial (6). So far, there is limited evidence
available on which treatment approach is the most
effective and predictable. The surgical techniques
reported in the literature and analyzed in this review
can be categorized into eight groups:
 coronally advanced flap, with or without (envelope
coronally advanced flap) vertical releasing inci-
sions with connective tissue graft: one randomized
controlled clinical trial (6); four prospective studies
(15, 76, 90, 92); and five case reports (17, 37, 81, 82,
91).
 envelope flap/pouch/tunnel techniques with con-
nective tissue graft or collagen matrix: five case
reports (20, 29, 44, 45, 58) and one prospective
study (79).
 submerged techniques with or without connective
tissue graft: two case reports (27, 56).
 coronally advanced flap with acellular dermal
matrix: one randomized controlled clinical trial (6)
and one case report (61).
 pedunculated connective tissue graft: one case
report (62).
 free gingival graft: one case report (37).
 guided bone regeneration: one retrospective study
(57).
 multiple surgical approaches in different surgical
steps: three case reports (20, 40, 69).
Coronally advanced flap with connective
tissue graft
The most commonly described techniques in the lit-
erature are those that combine a coronally advanced
flap with or without vertical releasing incisions and a
connective tissue graft harvested using different
6
methods. Anderson et al. (6), in a randomized con-
trolled trial, compared the outcomes of connective
tissue graft and acellular dermal matrix in correcting
esthetic discrepancies associated with definitively
restored implant crowns. Thirteen patients present-
ing with single-crown dental implants with recession
and/or soft-tissue concavity randomly received either
subepithelial connective tissue graft (control group,
seven patients) or acellular dermal matrix (test group,
six patients), both under coronally positioned flaps
with vertical releasing incisions. The results showed
improvement of recession from baseline to 6 months
(40% for the control group and 28% for the test
group), and both groups showed a gain of tissue
thickness (63% for the control group and 105% for the
test group) and demonstrated reduced concavity
(82% for the control group and 92% for the test
group). Clinicians evaluated a significantly esthetic
improvement over time for both groups, unlike
patients, who did not report a change in their esthet-
ics. The authors concluded that this trial established
the feasibility of soft-tissue grafting with connective
tissue graft and acellular dermal matrix under coro-
nally advanced flap for the correction of implant-
associated soft- and hard-tissue defects in the
esthetic zone.
The first prospective cohort study was published in
2008 by Burkhardt et al. (15). Ten patients, each with
a single mucosal soft-tissue dehiscence at an implant
site, were treated with a coronally advanced flap with
connective tissue graft (Figs 3–6) harvested from
the palate (46, 60), and the healing was evaluated up
to 6 months postoperatively. The mean soft-tissue
dehiscence coverage was 75% at 1 month, 70% at
3 months and 66% at 6 months postoperatively.
The authors concluded that a clinically significant
improvement in soft-tissue dehiscence was obtained
using a combination of coronally advanced flap and
connective tissue graft, but complete dehiscence cov-
erage at implant sites was not possible. In contrast,
Zucchelli et al. (92), in a prospective pilot study,
treated 20 patients with buccal soft-tissue dehis-
cence around single implants in the esthetic zone
using a novel prosthetic–surgical–prosthetic approach
(Figs 7–12). In all sites, prosthetic crowns were
removed at least 1 month before surgery, and short
provisional crowns, not in contact with marginal soft
tissue, were placed following abutment reduction.
This allowed undisturbed interproximal soft-tissue
growth and maturation. Exposed implant surfaces
were mechanically treated using diamond burs and
polished with rubber cups before being covered using
coronally advanced flaps with connective tissue grafts

Fig. 3. Soft-tissue dehiscence at the
implant site with exposure of the
metallic grey surface of the implant.
(A) Buccal view. (B) Lateral view.
Fig. 4. Surgical procedure: coronally
advanced flap with connective tissue
graft. (A) The coronally advanced
flap was elevated and the connective
tissue graft was sutured at the base
of the de-epithelialized papillae to
cover the implant surface. (B) Lat-
eral view showing good adaptation
of the connective tissue graft on the
implant surface to compensate for
the soft-tissue defect.
Fig. 5. The flap was advanced and sutured coronally.
deriving from the disepithelization of a free gingival
graft harvested from the palate (93). After surgery,
soft-tissue maturation was left undisturbed for sev-
eral months and the definitive restorations were
made 8 months after surgery. One-year follow-up
showed a mean coverage of 96.3%, with complete
coverage, at the level of the gingival margin of the
homologous tooth, achieved in 75% of treated sites.
Buccal soft-tissue dehiscence treatments
B
The results reported an increase of 1.54  0.21 mm
in buccal soft-tissue thickness at 1 year, which was
significantly correlated with connective tissue graft
thickness at the time of the surgery. Analysis of
esthetic outcomes showed a significant improvement
between the baseline and 1-year visual analogue scale
scores. The results of this study demonstrate that the
proposed technique was effective in coverage of buc-
cal soft-tissue dehiscence and was esthetically suc-
cessful (Fig. 12). The long term (5-year) data have
recently been accepted for publication (90) and con-
firm the stability of the esthetic (Fig. 13) and com-
plete dehiscence coverage (80%) results reported in
the 1-year study. Furthermore, no clinical sign of
mucositis was found, and a statistically significant
increase in buccal soft-tissue thickness and kera-
tinized tissue height between 1 and 5 years were
demonstrated. These successful long-term results
were mainly ascribed to the emphasis placed on the
control of the toothbrushing technique and the very
strict regimen of postsurgical control visits with
renewing of oral hygiene education and motivation.
Roccuzzo et al. (76) published a prospective study
with the aim to evaluate the outcome of soft-tissue
dehiscence coverage techniques at single, nonsub-
merged implant sites with shallow, isolated, buccal
mucosal recession. Sixteen patients were treated with
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Mazzotti et al.
Fig. 6. Two-year follow-up. (A) Frontal view. (B) Lateral view.
Fig. 7. Soft-tissue dehiscence around the implant-sup-
ported crown: misalignment of the soft-tissue margin is
apparent but there is no exposure of the metal part
of the implant. This case was treated with the
prosthetic–surgical–prosthetic approach.
envelope coronally advanced flaps plus connective
tissue grafts harvested from the tuberosity area
(Figs 14–17). One-year follow-up demonstrated clini-
cal and esthetic improvements. The mean coverage
was 89.6% (mean recession decreased significantly
from 2.0  0.7 to 0.3  0.3 mm) and complete
implant soft-tissue coverage was achieved in 56.3%
(nine of 16) of cases. The esthetic outcome, evaluated
using a visual analogue scale, showed significant
improvement. The authors suggested that by using
A B
Fig. 8. (A) Presurgical prosthetic phase to increase the quality and quantity of interproximal soft tissue. (B) Preoperative
radiograph.
8
the proposed surgical technique, buccal soft-tissue
dehiscences around single implants can be success-
fully treated.
The five remaining studies (17, 37, 81, 82, 91), using
coronally advanced flaps with connective tissue grafts
to treat soft-tissue dehiscence around implants, were
case reports and included seven sites treated. Three
of these studies (81, 82, 91) reported substitution of
the implant crown with a temporary prosthesis before
surgery and a new restoration after soft-tissue heal-
ing. Almost all the cases described a qualitative
assessment of the implant coverage.
Envelope flap/pouch/tunnel technique
with connective tissue graft or collagen
matrix
Five of the studies analyzed in this review described
use of a connective tissue graft in conjunction with
an envelope, tunnel or pouch technique used for
coverage of soft-tissue dehiscence. Lee et al. (58)
reported one case in which a modified vestibular-
incision subperiostal tunnel approach, originally
described by Zadeh (88) for root coverage, was used
with a connective tissue graft harvested from the
palate to treat a buccal mucosal recession on the
implant site. The soft-tissue defect was treated with

A B
C D
Fig. 9. Surgical procedure: coronally advanced flap with con-
nective tissue graft. (A) The connective tissue graft is positioned
at the level of the gingival margin of the homologous tooth. (B)
Occlusal view shows the precise adaptation of the connective
A B
Fig. 10. Four months postsurgery: the end of the postsurgical soft-tissue maturation phase. (A) Frontal view. (B) Lateral
view. (C) Occlusal view.
a connective tissue graft placed underneath the buccal
peri-implant tissue using a frenulum access incision
and supraperiosteal tunneling flap moved coronally.
The authors concluded that this approach resulted in
an increase in tissue height and width, which sug-
gested its potential use around implants. Caplanis
et al. (20), took into account soft-tissue complications
and reported a case of mucosal recession successfully
treated with an envelope flap plus a connective tissue
graft. Cosyn et al. (29), in a prospective study of 22
immediately placed implants, reported two cases
with 1.5 and 2 mm mid-buccal recession 3 months
after first-stage surgery; additional treatment, with
Buccal soft-tissue dehiscence treatments
tissue graft to the abutment surface and the interproximal
papillae. (C) Coronal advancement of the flap. (D) Primary
intention closure at the interproximal space between the surgi-
cal and anatomical de-epithelialized papillae.
subepithelial connective tissue graft harvested from
the palate inserted under an envelope flap, left 0.5 mm
residual recession at 6 and 12 months in both cases.
Happe et al. (44) reported a 1-year follow-up of a
soft-tissue defect and color mismatch at one single
implant-supported crown, treated with a minimally
invasive tunneling approach and a connective tissue
graft. A vertical access incision was created approxi-
mately 3 mm apical to the soft-tissue margin at the
distal line angle of the implant crown. The labial soft
tissue was undermined split thickness, resulting in a
pouch that extended to the soft-tissue margin coro-
nally and over the mucogingival junction apically.
9
Mazzotti et al.

A B

Fig. 11. (A, B) Soft-tissue conditioning phase with a screw-retained temporary crown. (C) End of conditioning phase.

A B

Fig. 12. Final restoration (restorative therapy was performed by Dr Astrid Razem). (A) Buccal view. (B) Lateral view.

The connective tissue graft was inserted into the

A B
Fig. 13. Long-term outcome. (A) The buccal view confirms
the stability of the complete dehiscence coverage result.
(B) The lateral view shows the increase in soft-tissue thick-
ness compared with the 1-year outcome.
pouch and the access incision was sutured. With the
use of a spectrophotometer, clinical and esthetic
improvements were measured objectively. At the 1-
year follow-up, no visual mismatch could be seen and
partial coverage of the soft-tissue dehiscence was
observed (reduced from 1.5 to 0.6 mm). Hidaka &
Ueno (45) presented a case in which the soft-tissue
dehiscence resulted in 3 mm of abutment exposure.
The mucosal recession was corrected with a two-step
surgical technique using connective tissue graft
placed over the implant underneath a partial-thick-
ness pouch constructed around the dehiscence. In a

A B

Fig. 14. (A) Shallow buccal soft-tissue dehiscence at the nonsubmerged implant-supported crown. (B) Periapical radio-
graph. Courtesy of Dr M. Roccuzzo (Turin).

10
 Buccal soft-tissue dehiscence treatments

A B

Fig. 15. Surgical procedure. (A) Split-thickness flap with no vertical releasing incisions (envelope coronally advanced flap).
(B) Connective tissue graft harvested from the tuberosity area and trimmed to give it a U-shape.

A B

Fig. 16. (A) Adaptation of the graft to the recipient site and around the smooth collar of the implant. (B) Flap sutured to
cover the graft.

was elevated, a subepithelial connective tissue graft

Fig. 17. One-year follow-up with coverage of the soft-tis-
sue dehiscence and physiological probing depth.
recent multicenter pilot study (79), a surgical pouch
procedure plus porcine collagen matrix was primarily
addressed to increase keratinized and soft-tissue
thickness, and the coverage of soft-tissue dehiscence
was evaluated as a secondary end point. No dehis-
cence coverage was achieved at 6 months.
Submerged technique, with or without
connective tissue graft
Lai et al. (56), in 2010, first described the resubmer-
gence technique to manage soft-tissue dehiscences at
implant sites. They reported a case of a dental implant
that developed mucosal recession after being used for
anchorage during orthodontic treatment. Following
crown and abutment removal, a partial-thickness flap
was placed above the implant and the labial flap was
coronally positioned to cover it. The implant was
uncovered after 2 months and the definitive prosthe-
sis was delivered later. The resubmergence treatment
with connective tissue graft successfully resolved soft-
tissue recession. Three years later, Chu & Tarnow (27)
published a clinical case to explain their remediation
treatment for mid-buccal implant recession defects.
As an exposed implant abutment is devoid of blood
supply and may be contaminated with endotoxins
that would constrain the predictability of healing
with a coronally positioned connective tissue flap,
the authors recommended removing the prosthetic
crown (‘implant decoronation’) and placing a healing
cover screw, which allows soft-tissue growth around
the implant. Three months post-decoronation, during
implant uncovering, they suggest soft-tissue augmen-
tation with connective tissue graft if necessary and,
after soft-tissue healing, they advise restoring the
implant with an abutment–crown complex (flat or
undercontoured) to prevent soft-tissue recession. The
outcome was described as successful by the Authors.
Coronally advanced flap with acellular
dermal matrix
In a case report, Mareque-Bueno (61) showed the pos-
sibility of using an acellular dermal matrix in associa-
tion with a novel technique of a coronally advanced
flap to treat soft-tissue dehiscence associated with a

11
Mazzotti et al.
single dental implant. Triangular shape incisions were
performed mesially and distally to the implant. The
coronal part of the incision was designed as a butt
joint and the apical part was beveled. The flap was
elevated split thickness so that it could be moved
coronally over the acellular dermal matrix after de-
epithelization of the triangular area between the inci-
sions. A mucosal recession, measuring 3 mm, on the
upper right lateral incisor implant was partially cov-
ered and the tissues appeared thicker at the 6-month
follow-up. According to the author, this case report
shows the possibility of achieving partial soft-tissue
dehiscence coverage providing that enough kera-
tinized tissue is present preoperatively. Only recently,
Anderson et al. (6) published a randomized controlled
clinical pilot trial comparing coronally advanced flap +
connective tissue graft vs. coronally advanced flap +
acellular dermal matrix. The results of this study were
previously reported.
Pedunculated connective tissue graft
Mathews (62) described a clinical case of unesthetic
implant restorations with soft-tissue dehiscence in the
anterior maxilla that were resolved using the peduncu-
lated connective tissue graft technique. Congenitally
missing lateral incisors were replaced with two apically
and buccally malpositioned implants 2 years previ-
ously. The prosthetic crowns were removed and inter-
nal cover screws were placed. Two months later, 2 mm
healing abutments were placed and pedunculated con-
nective tissue grafts were performed on both implants,
suturing them approximately 3 mm apically to the
implant platforms into labial split-thickness pouches.
Each pedunculated connective tissue graft was dis-
sected near the first molar and its width was dictated
by the site to be augmented and the depth of the pala-
tal vault. Four months after surgery, the healing abut-
ments were uncovered by means punches and two
provisional crowns (with ovate pontic forms), bonded
to adjacent teeth, were placed. Three months later,
screw-retained provisional crowns were placed for
3 months, then replaced with definitive ceramic
restorations. The author suggested that pedunculated
connective tissue grafts are an excellent technique for
vertical and labial augmentation of soft tissues to
improve peri-implant esthetics.
Free gingival graft
Only one study described the coverage of soft-tissue
dehiscence around a single implant with a free gingi-
val graft (37). The author suggested the use of this
12
technique for small peri-implant mucosal recession
defects in esthetically unimportant areas where there
is a lack of attached keratinized mucosa. The case
showed a small soft-tissue dehiscence involving a sin-
gle implant in the lower incisor area. After prepara-
tion of the recipient bed and decontamination of
the implant/abutment surface using an airborne
particle-abrasion instrument, a free gingival graft
was stabilized to cover the implant dehiscence. One
year after surgery, the soft-tissue dehiscence was
corrected.
Guided bone regeneration
Le et al. (57) first described, in a retrospective clini-
cal case series, the treatment of soft-tissue dehis-
cence at buccal aspects of implants using guided
bone regeneration. The authors analyzed the records
of 14 patients with soft-tissue dehiscences around
implant-supported crowns (maxillary central or lat-
eral incisors) that had been treated with guided bone
regeneration procedures. After crown removal and
placement of a healing abutment, a bone allograft
with a resorbable xenogeneic membrane was placed,
in conjunction with a roughened titanium tenting
screw and a coronally advanced flap. After 4 months
of nonsubmerged healing, a screw-retained provi-
sional prosthesis was made, with the definitive
restoration being delivered 4–5 months later. One
year after treatment, the results showed a mean
increase of crestal bone thickness (evaluated 2 mm
from the crest) and mid-implant buccal bone thick-
ness of 1.84  0.89 mm and 2.07  0.81 mm, res-
pectively. At the same time, the authors noted a
significant increase in mean soft-tissue thickness
(1.28  0.53 mm), keratinized tissue width (1.29 
0.81 mm) and gingival height (1.23  0.53 mm). The
authors suggested that gingival recession, keratinized
tissue height and soft-tissue thickness can be posi-
tively influenced by augmentation of hard tissue and
concluded that the use of allograft and xenogeneic
membrane effectively increased alveolar hard- and
soft-tissue dimensions in the esthetic zone of the
anterior maxilla.
Multiple surgical approaches in different
surgical steps
Other studies reported correcting soft-tissue dehis-
cences via various surgical procedures performed at
different times. In a recent paper, Paniz & Mazzocco
(69) described a multidisciplinary approach toward
treating an anterior sextant with various esthetic

concerns, including a left lateral incisor dental
implant with 3 mm of recession (when compared
with the contralateral) and altered passive eruption of
teeth from the right canine to the right central incisor.
This approach included two soft-tissue surgeries with
connective tissue graft; the first periodontal plastic
surgery was performed 10 days after removal of
the implant restoration (implant decoronation) and
peri-implant soft-tissue maturation, with a coronally
advanced flap and connective tissue graft completely
covering the head of the implant. The second con-
nective tissue graft was positioned in a small pouch
buccally during the placement of an undercontoured
provisional restoration. Two months later, a peri-
odontal crown-lengthening procedure was performed
from the right canine to the right central incisor in
order to correct the gingival marginal asymmetry
resulting from altered passive eruption. The defini-
tive prosthetic phase of treatment was carried out
6 months later. For the authors, this approach repre-
sents a valid treatment modality to re-create a more
natural and coronally positioned gingival scallop-
ing contour. In 2014, Caplanis et al. (20) reported a
case of an implant with 2 mm of exposed titanium
abutment. Three separate surgical techniques were
performed to achieve coverage of the mucosal reces-
sion: a coronally advanced flap plus connective tissue
graft; followed by an envelope coronally advanced
flap with connective tissue graft; and finally a semilu-
nar advanced pedicle flap. The final restoration was
provided after resolution of the soft-tissue defect. In
the same year, Gluckman & Du Toit (40) described a
case in which two implants (in the central incisor
position) with soft-tissue dehiscences were treated
using two different approaches. First of all, a vesti-
bular incision subperiosteal tunnel approach tech-
nique was carried out, according to the authors, for
minor augmentation of the soft tissue buccal to the
implants. Then, a split-thickness flap (without involv-
ing the papillae) with two vertical releasing incisions
was performed to cover a free connective tissue graft
with the coronal epithelial border left exposed. The
authors showed a 6-year result, reporting that the
implants remain fully covered by bulked healthy soft
tissue, but it was possible to note the clefting at the
healed incision margins.
Discussion
Coverage of peri-implant soft-tissue dehiscence is a
relatively new topic in the literature and most of the
studies are case reports or case series. The only
Buccal soft-tissue dehiscence treatments
randomized controlled clinical trial on this topic (6)
has a limited number of patients with shallow soft-tis-
sue dehiscence and a very short follow-up (6 months).
Nevertheless, coverage of soft-tissue dehiscence is
important as the treatment is often driven by the
patient’s esthetic demand. Furthermore, the alterna-
tive to the treatment of soft-tissue dehiscence around
implants is fixture removal, an option that is not well
accepted by patients. The first, true criticism is the
lack of a clear definition of soft-tissue dehiscence
around implants. This is mainly because of the lack of
a reference point, such as the cemento–enamel junc-
tion in the natural dentition, on implants. Some
authors consider mucosal recession to be the apical
shift of the soft-tissue margin with reference to the
homologous adjacent or contralateral tooth, while
others consider exposure of the abutment/implant
grey surface as mucosal recession. From a patient’s
point of view, lengthening of the implant-supported
crown compared with the homologous tooth is the
primary esthetic concern. Therefore, it would be
appropriate to take into account the gingival margin
of the homologous adjacent or contralateral tooth as
a reference point when detecting peri-implant soft-tis-
sue dehiscence. It follows that the primary outcome
of the treatment should be complete coverage of
the soft-tissue dehiscence (i.e. the repositioning of the
soft-tissue margin to the same level as that of the
homologous tooth).
The management of such cases, in the literature,
might be divided into two categories: (i) surgical; and
(ii) combined surgical-prosthetic. In the latter, we
can recognize two different procedures: the first
consisting of the pre and postsurgical prosthetic
phase; and the second providing submergence of the
implant. Obviously, from the patient’s point of view,
the solely surgical option, compared with the surgi-
cal-prosthetic approach, would be preferable, espe-
cially for economic reasons. Nevertheless, it is worth
remembering that complete coverage of soft-tissue
dehiscence is the main outcome from the patient’s
perspective. The two prospective studies (15, 76) in
which only surgical procedures were used, showed
contrasting results regarding complete soft-tissue
dehiscence coverage. Burkhardt et al. (15) reported
unpredictable complete soft-tissue dehiscence cover-
age, while Roccuzzo et al. (76) showed better results
but with one implant system only. The best com-
plete soft-tissue dehiscence coverage outcomes were
achieved with the prosthetic–surgical–prosthetic app-
roach described by Zucchelli et al. in 2013 (92): 75%
of complete soft-tissue dehiscence coverage was
reported. This approach (91, 92) (Figs 7–12) differs
13
Mazzotti et al.
from the others in that it involves many different
steps: a presurgical prosthetic treatment phase, con-
sisting of abutment reduction and application of
a short temporary crown, must be completed to
allow interproximal soft-tissue growth and maturation
(Fig. 8); care must be taken in the surgical procedure to
position the connective tissue graft at the same level
of the soft-tissue margin of the homologous tooth
(Fig. 9A); several months after surgery, once soft-tissue
growth is complete (Fig. 10), a prosthetic treatment
with a new temporary screw-retained restoration must
be performed for soft-tissue conditioning (Fig. 11). The
successful esthetic and complete dehiscence coverage
results were well maintained for 5 years (90) with no
sign of mucositis or peri-implantitis (Fig. 13).
The importance of the interproximal soft tissue has
been extensively evaluated for root-coverage proce-
dures (94, 95). In the same way it can be speculated
that the quality/quantity (height, width and thick-
ness) of the mesial and distal papillae to the implant-
supported crown could represent the key factor for
the choice between the surgical-only approach or the
prosthetic–surgical–prosthetic approach. In the favor-
able, but rare, event of wide and thick papillae, the
coronally advanced flap with connective tissue graft
could be used, keeping the implant-supported crown
in position. In other, less-favorable situations with
a limited amount of interproximal soft tissue, the
prosthetic–surgical–prosthetic approach should be
mandatory. Further studies with longer-term follow-
up are advocated to confirm this hypothesis.
Recently, a regenerative approach has been sug-
gested to treat soft-tissue dehiscence around implants.
The suitability of such an approach needs further
evaluation before being considered a true alternative
to the soft-tissue augmentation surgical procedures
described.
Conclusion
Within the limits of this review, some conclusions can
be drawn:
 incorrect implant placement, thin buccal soft tis-
sue and bone, and reduced buccal bone height
are the factors most strongly associated with peri-
implant soft-tissue dehiscence.
 soft-tissue dehiscence should be defined as an
apical shift of peri-implant soft-tissue margin with
respect to the gingival margin of the homologous
adjacent or contralateral tooth.
 complete soft-tissue dehiscence coverage is the
primary outcome of the therapy.
14
 the recommended soft-tissue augmentation surgi-
cal technique is the coronally advanced flap with
connective tissue graft.
 the quality/quantity of the interproximal soft tis-
sue might represent a critical factor for choosing
the appropriate treatment approach.
 the prosthetic–surgical–prosthetic approach should
be used when the papillae neighboring the implant-
supported crown are not in an ideal condition.
 further studies, especially randomized controlled
trials, with a longer follow-up, are needed to prove
the effectiveness of the therapeutic procedures
reported in this review.
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