RANDOMISED CONTROLLED CLINICAL TRIAL

Nurit Bittner, Ulrike Schulze-Späte, Cleber Silva, John D. Da Silva, David M. Kim, Dennis Tarnow,
Mindy S. Gil, Shigemi Ishikawa-Nagai

Changes of the alveolar ridge dimension and

gingival recession associated with implant position
and tissue phenotype with immediate implant
placement: A randomised controlled clinical trial

KEY WORDS
alveolar ridge dimension, immediate implants, peri-implant mucosa, soft tissue aesthetics

ABSTRACT
Purpose: This prospective, randomised, controlled clinical trial evaluated the relationship between
alveolar ridge dimensional change and recession with the implant position (horizontal and verti-
cal) and tissue phenotype in immediately placed and provisionalised implants without the use of
bone grafting.
Materials and methods: Patients (n = 40) with a hopeless maxillary anterior tooth received an
immediate implant and immediate provisional or customised healing abutment after flapless
extraction. Implants were finally restored 3 months after placement and followed up for 6 months
after delivery of the restoration. The alveolar ridge dimensional change and recession were meas-
ured using cone beam computed tomography (CBCT) scans and digitalised dental casts. Alveolar
contour changes were correlated to implant position and tissue phenotype.
Results: The tissue phenotype showed no significant correlation to the alveolar ridge dimensional
change. At 6 months, the average alveolar ridge dimensional change was approximately 0.7 mm
in the buccolingual dimension independent of tissue phenotype. A statistically significant differ-
ence was observed on the recession values comparing tissue phenotypes, with more recession
observed in the thin phenotype (1.96 mm) than in the thick phenotype (1.18 mm). A significant
correlation was observed between horizontal implant position and buccolingual alveolar ridge
change. A positive correlation was observed between the horizontal implant position and the
dimensional change measured in the casts at the level of the free gingival margin. A statistically
significant negative correlation was observed between the horizontal implant position and the
resorption measured by the CBCT scans.
Conclusions: Patients with thin tissue phenotype had a more marked recession. The horizontal
implant position showed a relationship to the alveolar ridge dimensional changes observed. The
greater the buccal gap distance between the implant and the buccal plate, the lesser the radio-
graphic changes observed in the alveolar bone, however, the greater the changes observed in the
buccal aspect of the casts at the level of the free gingival margin.

Conflict of interest statement: This study was funded by Keystone Dental. Dr Tarnow is a
consultant for Keystone Dental and Dr Bittner has lectured for Keystone Dental. The remain-
ing authors have no financial interest in the companies whose materials were included in this
article.

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Bittner et al Alveolar ridge dimensional change associated with implant position and tissue phenotype
Introduction
An aesthetic area can be defined as any area
restored that is visible in the patient’s full smile1.
The success of single-implant therapy in the an-
terior zone is not only determined by high survival
rates, but even more by the long-term quality of
survival, dictated by a mixture of several factors2.
The determining factor in the natural appearance
of any implant restoration is the soft tissue con-
figuration of the implant site3.
Dimensional changes to the peri-implant fa-
cial bone following immediate placement and
provisionalisation of a maxillary anterior single im-
plant are usually expected4. Placement of a den-
tal implant5-8 or bone graft9 do not prevent the
remodelling of the buccal plate in both delayed
and immediate placements. The missing volume in
the horizontal direction at the buccal aspect of the
alveolar ridge may cause a shadow in the respec-
tive region, which can be aesthetically displeas-
ing10. There is a wide variation on the reported
buccolingual resorption observed with an immedi-
ate implant placement; the majority of the dimen-
sional loss (two-thirds) has been reported to occur
during the first 3 months of healing8. It has been
suggested that the volumetric tissue changes after
immediate placement in the aesthetic area can be
minimised, if a provisional crown is immediately
connected and a bone graft is inserted simulta-
neously11-13. Vertical loss of buccal peri-implant
tissue volume may still lead to recession and a
crown length differing from the contralateral or
adjacent tooth, or to a visible abutment or implant
shoulder14,15. At the 1-year follow-up assessment
after immediately placed implants a recession of
0.55 mm was observed16. A systematic literature
review showed that up to 26% of the immediately
placed implants presented a recession of the mid-
facial mucosa of > 1 mm17.
A horizontal resorption and recession can also
be influenced by the implant position, tissue phe-
notype and buccal plate thickness. A thick tissue
phenotype (51.9%) is more frequently observed
in the population than a thin tissue phenotype
(42.3%)18. A thick soft tissue phenotype is a desir-
able characteristic, because it is more resistant to
470
mechanical and surgical insults, less susceptible to
mucosal recession, and has more tissue volume
for prosthetic manipulation19. Sites with thin tis-
sue phenotype have been shown to have a higher
frequency of recession, particularly if the implants
are positioned buccally20.
The thickness of the buccal plate has also been
shown to contribute to a risk of soft tissue recession
after immediate implant therapy21. Significantly
greater amounts of facial bone loss were observed
between implant placement and abutment connec-
tion surgery, for implants placed on healed ridges
that had a facial bone thickness of less than 1.8 mm
after osteotomy preparation22. A minimal buccal
bone width of 2 mm is recommended to maintain
a stable buccal bony wall; however, only a limited
number of sites in the anterior maxilla display such
a clinical situation. In the majority of extraction sites
in the anterior maxilla, the buccal wall has been
reported to be < 1.0 mm thick23 and additionally,
close to 50% of sites have been shown to have a
bone wall thickness of ≤ 0.5 mm. Such a thin bone
wall may undergo marked dimensional changes24.
The position of the immediately placed implant
within the extraction socket is also an important
factor in determining treatment outcomes20,25.
Implants with a buccal shoulder position have
shown three times more recession than implants
with a lingual shoulder position20. The size of the
horizontal buccal gap was shown to significantly
influence the hard tissue alteration that occurred
during a 4-month period of healing26.
The material presented here is from a pro-
spective randomised controlled clinical study that
evaluated the optical effects of the pink-neck im-
plant/abutment system as a primary objective. The
results showed that when a pink abutment was
used, there was a significant colour change of the
peri-implant mucosa in the red aspect of colour
compared with the conventional grey implant/
abutment system27. The secondary objective of
this study evaluated the optical effects of the
anodised pink-neck implant and abutment versus
the conventional grey implant/abutment system
in relation to the adjacent gingiva28. The results
demonstrate that the colour difference between
the peri-implant mucosa and natural gingiva can
Int J Oral Implantol 2019;12(4):469–480
 Bittner et al Alveolar ridge dimensional change associated with implant position and tissue phenotype
be minimised when a pink abutment and pink-
neck implant are used in patients who received an
immediate implant without any additional aug-
mentation procedures. The present article shows
the evaluation of the tertiary objectives, which
include the dimensional soft tissue changes of the
alveolar ridge (buccolingual dimensional change
and recession) after immediate implant placement,
during a 6-month follow-up period after final res-
toration and a 9-month period after immediate
implant placement, in relation to soft tissue phe-
notype and implant position.
Materials and methods
Patient selection and population
The Institutional Review Boards of the Harvard
Medical School/Harvard School of Dental Medi-
cine and Columbia University approved this mul-
ticentre, randomised, controlled clinical study. The
centres where this study was performed were
the Harvard School of Dental Medicine and the
Columbia University College of Dental Medicine.
Patients 18 years of age or older who met the
study inclusion criteria, were recruited through the
Harvard Dental Centre Faculty and Teaching Prac-
tices and the Columbia University College of Den-
tal Medicine Triage, Periodontics, Prosthodontics
and Implant Dentistry Clinics.
A total of 52 patients were screened, from which
40 patients met all the inclusion criteria and none the
exclusion criteria, and thus, all were included in the
study (20 patients in each study centre). The inclu-
sion criteria included presence of a hopeless max-
illary anterior tooth (including second premolars)
without periodontal disease, with probing depths of
3.0 mm or less on the mid-buccal gingiva of the test
site, as well as presence of a healthy contralateral
or adjacent tooth. Patients were excluded if they
had a medical systemic condition that prevented
surgical intervention or implant placement proced-
ures. Female patients who were pregnant, lactating
or planning to become pregnant during the study
period, were also excluded, as well as patients with
presence of acute infection on the study site, history
Int J Oral Implantol 2019;12(4):469–480
of smoking within the last 6 months, presence of
occlusion that could affect the immediate loading
result and presence of iatrogenic pigmentations of
the gingiva on the study site.
Patients were randomly divided into two
groups with each group receiving a different type
of immediate implant: a conventional grey im-
plant (PrimaConnex, Keystone Dental, Burlington,
MA, USA) or an implant with an anodised pink-
neck implant (Genesis implants, Keystone Dental).
However, for the purpose of the tertiary objectives
presented in this article, all study subjects were
either evaluated as one group, regardless of the
randomisation and the implant placed, or stratified
according to tissue phenotype.
Surgical procedure
All patients had extraction of the hopeless tooth
using a flapless approach after premedication with
either 2 g of amoxicillin or 600 mg of clindamy-
cin, 1 hour prior to surgery. Once an intact buccal
plate was confirmed, implants were immediately
placed, following the manufacturer’s instructions,
according to each of the randomisation groups.
No bone graft material was used to fill up the
space between the implants and the sockets. The
implants were positioned with their platform 3 to
4 mm apical to the cementoenamel junction (CEJ)
of adjacent teeth and placed in a lingualised pos-
ition. The final torque at placement was estab-
lished by titrating the insertion torque values in
increments of 5 Ncm with a minimum final torque
of 10 Ncm at placement.
If the buccal plate was affected, grafting pro-
cedures were performed and the implant was
planned for a later time on a stage-two surgery.
These patients were not included in the study.
Subjects were given postsurgical instructions
and medications including antibiotics (500 mg of
amoxicillin or 300 mg of clindamycin) and analge-
sics (600 to 800 mg of ibuprofen).
Prosthetic procedure
After implant placement, the restorations were
placed based on the insertion torque. If the final
471
Bittner et al Alveolar ridge dimensional change associated with implant position and tissue phenotype
Fig 1 Horizontal implant position measurement. Periodontal
probe used to measure the distance from the buccal aspect
of the implant to the buccal plate.
implant torque was < 25 Ncm, a customised heal-
ing abutment was made with auto-polymerised
polymethyl methacrylate (Super T, American Con-
solidated, West Conshohocken, PA, USA) to pre-
vent any occlusal forces to the implant, while main-
taining the subgingival contours. If the implant
insertion torque was ≥ 25 Ncm, a full-contoured
screw-retained provisional restoration was made
with auto-polymerised polymethyl methacrylate
(Super T), which was maintained out of occlusion.
Three months after implant placement, a final
implant level impression was made using dispos-
able plastic trays (Disposable Trays, GC America,
Alsip, IL, USA) and polyether impression material
(Impregum, 3M ESPE, St Paul, MN, USA). The sub-
gingival contours were copied to the impression
coping using auto-polymerised polymethyl meth-
acrylate (Super T).
Patients received a titanium computer-aided
design/computer-assisted manufacture (CAD/CAM
customised abutment as a final restoration, which
was anodised to appear pink or conventional grey
depending on the randomisation group (Genesis or
PrimaConnex implants, respectively), and a zirconia
cement-retained crown (Katana Noritake, Kuraray,
Tokyo, Japan), cemented with provisional cement
(TempBond NE, Kerr Dental, Brea, CA, USA).
Follow-up appointment
After receiving the final implant restoration, the
patients were assessed at two different follow-up
472
appointments: at 3 and 6 months. This means that
patients were followed up for 9 months after the
implant placement and 6 months after the final res-
toration was inserted.
Measurements
• Tissue phenotype: was considered thin if when
probing the midbuccal gingiva, the probe was
visible through the soft tissue, and thick if the
probe was not visible (15 UNC colour-coded
probe, Hu-Friedy, Chicago, IL, USA).
• Horizontal implant position: the distance from
the buccal aspect of the implant to the inter-
nal side of the buccal socket wall was meas-
ured using a periodontal probe (15 UNC colour-
coded probe, Hu-Friedy) (Fig 1).
• Vertical implant position: the vertical distance
of the implant to the free gingival margin,
measured using a probe (15 UNC colour-coded
probes, Hu-Friedy).
• Radiographic measurements: two cone beam
computed tomography (CBCT) scans of the
maxillary arch were taken on each patient using
the i-CAT Next Generation tool (Imaging Sci-
ences International, Hatfield, PA, USA) with
an image resolution of 0.3 mm. The first was
taken prior to implant placement, the second
was taken 6 months after delivery of the final
crown. The software InVivo 5 (Anatomage San
Jose, CA, USA) was used to orient the scans and
analyse the sagittal sections to ensure accuracy
on measurements (Fig 2).
Radiographic measurements were obtained by sub-
tracting the measurements of the preoperative scan
with the postoperative scans, and these included:
1. Buccolingual dimensional differences between
the two CBCT scans at the level of the crest of
the alveolar ridge. Using the digital software, the
measurements were done at corresponding areas
of the ridge, by measuring the distance from an
arbitrary distinct anatomical point to the crest of
the bone ridge on the preoperative scan and rep-
licating this distance on the postoperative scan.
The distance measured was from the most buccal
to the most lingual aspect of the alveolar ridge.
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 Bittner et al Alveolar ridge dimensional change associated with implant position and tissue phenotype

19.46 mm
19.45 mm 90.0 deg. 90.0 deg.
3.00 mm 3.00 mm

a b

a b

Fig 2a-b Scan measurements: (a) Preoperative (tooth to buccal plate, 1.14 mm; buccolingual [B-L] width at 3.0 mm, 8.34
mm; B-L width at crest, 8.57 mm); (b) Postoperative (implant to buccal plate, 0.44 mm; B-L width at 3.0 mm, 5.98 mm; B-L
width at crest, 5.69 mm). The vertical line in yellow bisecting the tooth serves as a reference. The orange horizontal line was
used to determine the distance of the measurements at the crest of the ridge on the preoperative scan. The same distance
between the arbitrary anatomical point selected (marked with a green circle) to the crest of the ridge was used on both scans
to ensure standardisation of the measurement. Note that measurements were performed at the same height with a difference
of 0.01 mm (19.45 mm of distance for the preoperative scan and 19.46 mm for the postoperative scan. The blue line marks
the measurement conducted 3 mm below the crest of the ridge. At this height the thickness of the buccal plate was also
measured on both scans.

2. Buccolingual dimensional differences were
measured between the two CBCT scans
3.0 mm below the crest of the alveolar ridge
as indicated above. Using the digital software,
the measurements were done at corresponding
areas of the ridge from the most buccal to the
most lingual aspect.
3. Differences in thickness of the buccal plate on
both CBCT scans were noted, by measuring
from the buccal aspect of the root, or the im-
plant, to the most buccal aspect of the buc-
cal plate at a predetermined height of 3.0 mm
below the crest of the alveolar ridge.
All radiographic measurements were recorded as
positive since the values of the preoperative scans,
which were subtracted with the postoperative
scans, were larger on all patients.
Cast analysis
The digital software Compare (Planmeca, Helsinki,
Findland) was used to digitally analyse the casts
made at baseline and at the 6-month follow-up
visit. The casts were obtained by alginate impres-
sions (Jeltrate Fast Set, Dentsply, York, PA, USA)
and poured in a type III gypsum (Microstone, Whip
Mix, Louisville, KY, USA). All casts were scanned and
superimposed digitally. The recession was meas-
ured first with a vertical line, then the differences in
the buccal contours between the baseline cast and
the 6-month follow-up visit cast were measured
at the sagittal view, starting from the edge of the
free gingival margin of the postoperative cast in
increments of 1 mm (Fig 3). These measurements
corresponded only to the dimensional change
observed in the buccal aspect on the casts, not the
full buccolingual dimensions that were recorded
radiographically. Because the dimensional change
was determined by the distance between the two
buccal contours (marked with red lines in Fig 3),
the values obtained were recorded as positive for
the dimensional change and the recession, even
though they denoted a loss of tissue dimension
between the preoperative dimensions and the
6-month follow-up dimensions.

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Bittner et al Alveolar ridge dimensional change associated with implant position and tissue phenotype
2.4556 mm
1.0783 mm
1.9335 mm
1.0512 mm
1.5148 mm
1.0302 mm
1.2324 mm
1.0089 mm
0.93743 mm
0.90336 mm
Fig 3 Digital cast measurements superimposing the pre-
operative and postoperative scans with the aid of a digital
software (Romexis, Planmeca). The red arrow marks the
buccal aspect of the study site on the preoperative cast. The
green arrow marks the buccal aspect of the study site in the
postoperative cast. The measurements were performed from
the buccal aspect of the preoperative cast to the postopera-
tive cast in 1.0-mm increments apically. The reduction in
alveolar contour from the preoperative cast to the postopera-
tive cast can be observed.
Statistical analysis
Summary statistics (mean, standard deviation
and range) were calculated for the buccolingual
alveolar dimensional change, recession, implant
position and buccal plate thickness. Two-sample
t test with unequal variance was used to compare
the measurement of the casts and the CBCT scans
with the tissue phenotype. An evaluation of the
correlation between all variables was conducted
with the Pearson’s correlation test for each pair of
variables. Values were considered statistically sig-
nificant at P ≤ 0.05.
474
Results
The patient population included 20 males and
20 females, aged from 24 to 72 years old, with
a mean age of 46.9 (± 3.2) years. The treatment
sites included 13 central incisors, 11 lateral incisors,
4 canines, and 12 premolars. The torque insertion
for the implants ranged from 5 Ncm to 50 Ncm.
Eighteen patients presented an insertion torque
for the implants of 25 Ncm or more and received
a provisional crown at the time of surgery. The
other 22 patients had implants placed at a torque
value of < 25 Ncm, and thus, received a custom-
ised healing abutment at the time of surgery.
When the tissue phenotype was evaluated,
31 patients were classified with thick phenotype
and 9 patients with thin phenotype.
Table 1 shows the summary of the measure-
ments obtained by comparing the CBCT scans
performed before implant placement and the
6-month visit after the restoration insertion, clas-
sified by tissue phenotype. The measurements
include buccolingual alveolar change at the crest
of the ridge, 3.0 mm below the crest of the ridge
and the buccal plate thickness difference. The
two-sample t test with unequal variance showed
no statistically significant difference between the
resorption observed radiographically on patients
with thick and thin phenotype, and for the buccal
plate thickness. The average buccolingual differ-
ence observed at the level of the crest of the al-
veolar bone was 0.54 mm for the thin phenotype
and 1.06 mm for the thick phenotype (P = 0.29).
The average buccolingual difference observed in
the alveolar bone (3.0 mm below the bone crest)
was 0.47 mm and 0.66 mm for the thin and thick
phenotypes, respectively (Figs 4 and 5). For the
buccal plate thickness difference, the average dif-
ference observed was 0.14 mm for the thin pheno-
type patients and 0.26 mm for the thick phenotype
patients (P = 0.35). From all of the radiographic
measurements, the measurement of the buccal
plate could not be performed in three patients (two
with the thin phenotype and one with the thick
phenotype), since these patients presented with
primary teeth with short roots; the root was not
present at 3 mm below the crest of the ridge.
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 Bittner et al Alveolar ridge dimensional change associated with implant position and tissue phenotype

Table 1 Cone beam computed tomography (CBCT) scan measurements (results classified by tissue phenotypes)

Variable Measurement Thin phenotype Thick phenotype P value

B-L difference at the crest Mean (mm) 0.54 1.06 0.29
n 7 28
Standard deviation (mm) 1.11 0.86
B-L difference 3.0 mm from Mean (mm) 0.47 0.66 0.10
the crest n 7 28
Standard deviation (mm) 1.52 0.75
Buccal plate thickness Mean (mm) 0.14 0.26 0.35
difference n 5 27
Standard deviation (mm) 0.80 0.96

B-L, buccolingual; statistical analysis comparing values of the two different tissue phenotypes, performed with two-sample t test
with unequal variance; variables assessed include the buccolingual dimension difference from the preoperative and postoperative
CBCT scans at the crest of the bone and 3.0 mm below the bone crest, as well as the difference of the buccal plate thickness.

a b

c d

Fig 4a-d A patient classified with thin phenotype. The study site of the maxillary right central incisor: (a) Preoperative
frontal view; (b) Postoperative frontal view; (c) Preoperative occlusal view; (d) Postoperative occlusal view (at the 6-month
follow-up).

The measurements performed by digitally
comparing the dimensions on casts obtained
before implant placement and at the 6-month
visit after the restorations were inserted, are
depicted in Table 2. The alveolar dimensional
change was measured at different vertical levels
from the free gingival margin, starting from the
edge of the gingiva (0 mm) of the postoperative
cast to 5.0 mm, apically. Using the two-sample
t test with unequal variance it was determined
that there was no statistically significant differ-
ence of the buccal resorption between patients
with thin or thick phenotype, when the initial
cast and the 6-month follow-up cast were com-
pared digitally. At 6 months the average buccal
dimensional change was approximately 0.73 mm
for patients with thin phenotype and 0.67 mm
for patients with thick phenotype.

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Bittner et al Alveolar ridge dimensional change associated with implant position and tissue phenotype

a b

c d

Fig 5a-d A patient classified with a thick phenotype. The study site of the maxillary right lateral incisor: (a) Preoperative frontal
view; (b) Postoperative frontal view; (c) Preoperative occlusal view; (d) Postoperative occlusal view (at the 6-month follow-up).

Table 2 Buccal alveolar dimensional changes observed in The results based on the correlation of the hori-
the casts (results classified by tissue phenotype)
zontal and vertical implant position and casts and
Thin Mean (SD), Thick Mean (SD), P CBCT scan measurements, are shown in Table 3.
n mm n mm value To assess the correlation between values, the Pear-
0 mm 4 0.59 (0.86) 25 0.99 (0.54) 0.43 son’s correlation test was used. The vertical implant
1 mm 4 0.74 (1.08) 25 0.74 (0.43) 1.00 position showed no significant correlation to the
2 mm 4 0.89 (1.01) 25 0.67 (0.42) 0.70 alveolar dimensional change or recession observed
3 mm 4 0.87 (1.04) 25 0.61 (0.52) 0.66 in the casts, or to the resorption observed on the
4 mm 4 0.74 (0.91) 25 0.57 (0.65) 0.74 CBCT scans. However, the horizontal implant pos-
5 mm 4 0.52 (0.64) 23 0.45 (0.58) 0.86 ition showed a statistically significant correlation
Recession 4 1.96 (0.40) 25 1.18 (0.85) 0.02* to some of the alveolar ridge changes. A statistic-
Statistical analysis comparing values of the two different tissue
ally significant positive correlation was observed
phenotypes, performed with two-sample t test with unequal between the horizontal implant position and the
variance (*statistically significant, P ≤ 0.05); measurements
obtained using the Planmeca Romexis digital software by
dimensional change measured in the casts at the
comparing the buccal dimensions of the preoperative and post- crest of the gingiva of the 6-month follow-up cast
operative casts on a sagittal view. SD, standard deviation.
(0 mm) and 1 mm below the gingiva (r = 0.54,
P = 0.003 and r = 0.45, P = 0.01, respectively).
Regarding the recession observed by digitally This indicates that the bigger the horizontal gap
comparing the preoperative and the 6-month fol- between the implant and the buccal plate at im-
low-up cast, the two-sample t test with unequal plant placement, the more marked the dimensional
variance showed statistically significant difference change observed in the casts at the level of the free
on the different tissue phenotypes (P = 0.02), with gingival margin.
more recession observed in patients with thin phe- A statistically significant negative correlation
notype (1.96 mm) than in patients with thick phe- was observed between the horizontal implant
notype (1.18 mm). position and the changes on the alveolar ridge

476 Int J Oral Implantol 2019;12(4):469–480

 Bittner et al Alveolar ridge dimensional change associated with implant position and tissue phenotype

Table 3 Pearson’s correlation between implant position and measurements observed in the casts and the cone beam com-
puted tomography (CBCT) scans

Horizontal implant Vertical implant

position position
B changes measured at 0 mm on casts Pearson correlation 0.54 –0.28
P value 0.003* 0.14
B changes measured at 1 mm on casts Pearson correlation 0.45 –0.01
P value 0.01* 0.95
B changes measured at 2 mm on casts Pearson correlation 0.36 0.07
P value 0.06 0.73
B changes measured at 3 mm on casts Pearson correlation 0.24 0.09
P value 0.22 0.66
B changes measured at 4 mm on casts Pearson correlation 0.19 0.08
P value 0.32 0.69
Recession measured on casts Pearson correlation –0.15 –0.24
P value 0.43 0.20
B-L measurement on CBCT scan at crest Pearson correlation –0.20 0.06
P value 0.26 0.73
B-L measurement on CBCT scan 3 mm below crest Pearson correlation –0.51 –0.11
P value 0.002* 0.53
Buccal plate thickness Pearson correlation 0.37 0.29
P value 0.04* 0.11

B, buccal; B-L, buccolingual; Pearson’s correlation between implant position and measurements observed in the casts and the cone
beam computed tomography (CBCT) scans; Variables include buccal dimensional changes (B), recession, buccolingual changes
(B-L) measured with the CBCT scans and buccal plate thickness; *P ≤ 0.05 statistically significant result.

dimensions measured on the cone beam scans Discussion

3.0 mm below the crest of the bone (r = –0.51,
P = 0.002). This indicates that the bigger the hori-
zontal gap between the implant and the buccal
plate at implant placement, the less the resorption
observed in the scans. For this analysis, no cor-
relation was conducted with the tissue phenotype
due to the limited number of subjects with thin
phenotype.
There was also a statistically significant cor-
relation between the horizontal implant position
measured at the time of implant placement and
the buccal plate thickness difference measured in
the CBCT scans (r = 0.37; P = 0.04). This indicates
that the higher the buccal gap distance, the more
the buccal plate thickness differs between the pre-
operative scan and the postoperative scans.
This study demonstrates that certain variables,
such as tissue phenotype and horizontal implant
position in the socket, can be crucial to obtain
improved aesthetic results with the immediately
placed implants.
The results of this study are in agreement with
those reported in the literature in regard to alveolar
ridge dimensional change in immediate implant
placement. The results show an overall average
loss of the buccolingual dimensions of 0.7 mm,
6 months after implant restoration. The follow-up
time is adequate, since the majority of the alveolar
ridge dimensional changes were observed during
the first 3 months of healing8. Some studies have
shown improved results with the use of bone graft-
ing, depicting an average loss of 0.32 mm29.
The amount of recession observed showed a
statistically significant difference depending on

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Bittner et al Alveolar ridge dimensional change associated with implant position and tissue phenotype
tissue phenotype, with patients with thin phe-
notype showing significant more recession, and
this finding is supported by other studies20. The
recession observed in this study was 1.96 mm
for patients with thin phenotype and 1.18 mm
for patients with thick phenotype. These values
are similar to the values reported by Evans and
Chen20; these authors reported that sites with
the thin tissue phenotype had a mean recession
of 1.8 ± 0.82 mm (range from 1 to 3 mm) and
the sites with thick phenotype presented a mean
recession of 1.3 ± 0.52 mm (range from 1 to
2 mm).
The implant position proved to be a very im-
portant variable when evaluating the alveolar
ridge dimensional change, with a positive cor-
relation between implant position and buccal
dimensional change observed in the casts, which
indicates that the greater the buccal gap dis-
tance the greater the dimensional change. On
the other hand, a negative correlation was noted
when evaluating the alveolar ridge dimensional
changes observed radiographically in the CBCT
scans, indicating that the greater the buccal gap
distance the lesser the resorption observed. The
greater the buccal gap distance between the im-
plant and the buccal plate, the lesser the radio-
graphic changes observed in the alveolar bone;
however, the greater the buccal alveolar dimen-
sional changes observed in the buccal aspect, at
the level of the free gingival margin. Even though
these results can be confusing, an important
aspect to note is that not only the alveolar ridge
dimensions measurements were performed with
two completely different techniques, but also the
area measured on each one was a different area.
The alveolar ridge dimensional changes were
measured on the casts from a predetermined line
dissecting the tooth to the buccal aspect of the
soft tissue, measuring only the buccal aspect.
Results were shown to be significant on the 0
and 1 mm values, which measure the thickness
of the free gingival margin. On the CBCT scans,
the measurements were performed from the buc-
cal to the lingual alveolar dimensions; however,
these measurements were performed at the bone
crest and at 3 mm below the bone crest, which is
478
potentially 4 to 6 mm more apical than the cast
measurements. These results suggest that as the
buccal gap distance increases from the implant
to the buccal plate, the overall thickness of the
free gingiva decreases; however, the dimension
of the alveolar bone buccolingually may show
less reduction.
Ferrus et al26 reported a relationship between
the size of the horizontal buccal gap and the
amount of hard tissue alteration that occurred dur-
ing a 4-month period of healing following imme-
diate implant placement; they concluded that the
larger the horizontal gap, the greater the amount
of newly formed bone. This could explain why the
alveolar ridge dimensions showed improvement
radiographically with the greater horizontal gap
distance of the implant position. Nevertheless,
this dimension may not necessarily be associated
with the buccal aspect of the alveolus.
It has been previously suggested that volu-
metric tissue changes after immediate extraction
placement in the aesthetic area can be minimised
if a provisional crown is immediately connected
and a bone graft is inserted simultaneously11. The
results of the present study could have been dif-
ferent if a bone graft material had been used.
One limitation of this study is the small num-
ber of patients with thin phenotype. While the
total percentage of patients with thin phenotype
in this study is consistent with the ones reported
in the literature30, it may have been too small
to determine a strong relationship between vari-
ables. This limitation prevented evaluating the
correlation between the three variables of tissue
phenotype, implant position and the alveolar
dimensional changes. Future studies with larger
sample groups may be able to evaluate the spe-
cific variables.
Another limitation of this study was that no
graft material was added between the implant
and the buccal bone plate. This was due to the
protocol design and could be considered as a limi-
tation, since previous studies have reported that
placing a bone graft at the time of immediate im-
plant placement can reduce the amount of alveolar
and soft tissue collapse11-13.
Int J Oral Implantol 2019;12(4):469–480
 Bittner et al Alveolar ridge dimensional change associated with implant position and tissue phenotype
Conclusions
The soft tissue phenotype and the horizontal
implant position showed an important relation-
ship to the recession and buccolingual resorption
observed, respectively, on immediately placed
implant cases with immediate provisionalisation
without the use of any soft tissue or bone grafting.
Acknowledgements
The authors acknowledge Audra Boehm for her
collaboration during the dental student research
fellowship. The authors thank Dr Stephen Chu
for his help in developing the protocol. Also, the
authors appreciate the help of the Department of
Biostatistics at the Columbia University, as well as
the Irving Institute for the clinical and translational
research.
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Nurit Bittner, DDS, MSc David M. Kim, DDS, DMSc

Director, Postgraduate Prosthodontics,
Division of Prosthodontics, Section of Oral
and Diagnostic Rehabilitation Sciences,
Columbia University College of Dental
Medicine, New York, USA.
Ulrike Schulze-Späte, DDS, PhD
Director, Section of Geriodontics, Depart-
ment of Conservative Dentistry and Peri-
odontology, Center of Dental Medicine
Nurit Bittner University Hospital Jena, Friedrich Schiller
University, Jena, Germany; Assistant
Professor of Dental Medicine, Division of
Periodontics, Columbia University, College
of Dental Medicine, New York, USA.
Cleber Silva, DDS
Assistant Professor of Dental Medicine,
Course Director of Oral Radiology, Divi-
sion of Oral and Maxillofacial Radiology,
Columbia University, College of Dental
Medicine, New York, USA.
John D. Da Silva, DMD, MPH, ScM
Associate Professor and Vice Dean,
Restorative Dentistry and Biomaterials
Sciences, Harvard University School of
Dental Medicine, Boston, MA, USA.
Associate Professor, Postdoctoral Peri-
odontology Program Director, Division of
Periodontology, Harvard University School
of Dental Medicine, Boston, MA, USA.
Dennis Tarnow, DDS
Clinical Professor of Dental Medicine,
Director of Implant Dentistry, Division of
Periodontics, Section of Oral, Diagnostic
and Rehabilitation Sciences, Columbia
University, College of Dental Medicine,
New York, USA.
Mindy S. Gil, DMD, DMSc
Department Oral Medicine, Infection,
and Immunity, Division of Periodontol-
ogy, Harvard University School of Dental
Medicine, Boston, MA, USA.
Shigemi Ishikawa-Nagai, PhD, DDS,
MSD
Associate Professor, Postdoctoral Peri-
odontology Programme Director, Division
of Periodontology, University School of
Dental Medicine, Boston, MA, USA.

Correspondence to:
Professor Nurit Bittner, Director, Postgraduate Prosthodontics, Division of Prosthodontics, Section of Oral and
Diagnostic Rehabilitation Sciences, Columbia University College of Dental Medicine, 630 W 168th Street. PH 7W
Room 119, New York, NY 10032, USA. E-mail: nb2203@cumc.columbia.edu

480 Int J Oral Implantol 2019;12(4):469–480