PERIODONTOLOGY 2000 • VOLUME 77 • 2018

Esthetic Periodontics and Implantology

PRD_v77_i1_title.indd 3 2/28/2018 8:10:14 AM

 VOLUME 77 • 2018

Esthetic Periodontics and

Implantology
Editor
Giovanni Zucchelli

Contents

7 Esthetics in periodontics and implantology

Giovanni Zucchelli, Praveen Sharma & Ilham Mounssif

19 Esthetic evaluation and patient-centered outcomes in root-coverage

procedures
Ilham Mounssif, Martina Stefanini, Claudio Mazzotti,
Matteo Marzadori, Matteo Sangiorgi & Giovanni Zucchelli

54 Decision making in root-coverage procedures for the esthetic

outcome
Martina Stefanini, Matteo Marzadori, Sofia Aroca, Pietro Felice,
Matteo Sangiorgi & Giovanni Zucchelli

65 Esthetic treatment of altered passive eruption

Monica Mele, Pietro Felice, Praveen Sharma, Claudio Mazzotti,
Pietro Bellone & Giovanni Zucchelli

84 Crown lengthening and restorative procedures in the esthetic zone

Matteo Marzadori, Martina Stefanini, Matteo Sangiorgi,
Ilham Mounssif, Carlo Monaco & Giovanni Zucchelli

93 Simplified procedures to treat periodontal intraosseous defects in

esthetic areas
Leonardo Trombelli, Anna Simonelli, Luigi Minenna,
Renata Vecchiatini & Roberto Farina

111 Soft-tissue augmentation procedures in edentulous esthetic areas

Matteo Marzadori, Martina Stefanini, Claudio Mazzotti,
Sabrina Ganz, Praveen Sharma & Giovanni Zucchelli

PRD_v77_i1_toc.indd 3 16-Mar-18 1:07:24 PM

 123 Surgery without papilla incision: tunneling flap procedures in
plastic periodontal and implant surgery
Otto Zuhr, Stephan F. Rebele, Stefani L. Cheung &
Markus B. Hürzeler on behalf of the Research Group on Oral Soft
Tissue Biology and Wound Healing

150 Esthetic evaluation and patient-centered outcomes in single-tooth

implant rehabilitation in the esthetic area
Martina Stefanini, Pietro Felice, Claudio Mazzotti, Ilham Mounssif,
Matteo Marzadori & Giovanni Zucchelli

165 Alveolar ridge preservation in the esthetic zone

Ronald E. Jung, Alexis Ioannidis, Christoph H. F. Hämmerle &
Daniel S. Thoma

176 Implant placement in the esthetic area: criteria for positioning

single and multiple implants
Tiziano Testori, Tommaso Weinstein, Fabio Scutellà, Hom-Lay Wang
& Giovanni Zucchelli

197 Immediate implant placement and provisionalization of maxillary

anterior single implants
Joseph Yun Kwong Kan, Kitchai Rungcharassaeng, Matteo Deflorian,
Tommaso Weinstein, Hom-Lay Wang & Tiziano Testori

213 Horizontal bone-augmentation procedures in implant dentistry:

prosthetically guided regeneration
Matteo Chiapasco & Paolo Casentini

241 Vertical ridge augmentation in the esthetic zone

Isabella Rocchietta, Luca Ferrantino & Massimo Simion

256 Soft-tissue dehiscence coverage at peri-implant sites

Claudio Mazzotti, Martina Stefanini, Pietro Felice,
Valentina Bentivogli, Ilham Mounssif & Giovanni Zucchelli

PRD_v77_i1_toc.indd 4 16-Mar-18 1:07:24 PM

 Contributors
Sofia Aroca, DDS, PhD Sabrina Ganz, DDS, MSc
Visiting Professor Research Assistant
Department of Periodontology Department of Biomedical and Neuromotor Sciences
Bern University Bologna University
Bern, Switzerland Bologna, Italy

Pietro Bellone, DDS, MSc Christoph H. F. Hämmerle, Dr. med. dent.

Research Assistant Professor and Chairman
Department of Biomedical and Neuromotor Sciences Clinic of Fixed and Removable Prosthodontics and Dental
Bologna University Material Science
Bologna, Italy Center of Dental Medicine
University of Zurich
Zurich, Switzerland
Valentina Bentivogli, DDS, MSc
Research Assistant Markus B. Hürzeler, DDS, Dr. med. dent.
Department of Biomedical and Neuromotor Sciences Associate Professor
Bologna University Department of Operative Dentistry and Periodontology
Bologna, Italy University School of Dentistry
Albert-Ludwigs-University
Paolo Casentini, DDS Freiburg, Germany
Private practice
Milan, Italy Alexis Ioannidis, Dr. med. Dent.
Senior Teaching and Research Assistant
Stefani L. Cheung, DMD, MDS Clinic of Fixed and Removable Prosthodontics and Dental
Private practice Material Science
Hong Kong, China Center of Dental Medicine
University of Zurich
Implant Fellow Zurich, Switzerland
School of Dental Medicine
Department of Periodontics Ronald E. Jung, Dr. med. dent., PhD
University of Pennsylvania Head of Division of Implantology
Philadelphia, Pennsylvania, USA Clinic for Fixed and Removable Prosthodontics and Dental
Material Science
Matteo Chiapasco, MD Center of Dental Medicine
Professor and Head, Unit of Oral Surgery University of Zurich
Department of Biomedical, Surgical, and Dental Sciences Zurich, Switzerland
San Paolo Hospital
University of Milan Joseph Y. K. Kan, DDS, MS
Milan, Italy Professor
Department of Restorative Dentistry
School of Dentistry
Matteo Deflorian, DDS
Loma Linda University
Research Assistant
Section of Implant Dentistry and Oral Rehabilitation Loma Linda, California, USA
Department of Biomedical, Surgical and Dental Sciences, Matteo Marzadori, DDS, MSc
University of Milano Research Assistant
IRCCS, Galeazzi Institute Department of Biomedical and Neuromotor Sciences
Milan, Italy Bologna University
Bologna, Italy
Roberto Farina, DDS, PhD, MSc
Full-time Researcher Claudio Mazzotti, DDS, MSc
Research Centre for the Study of Periodontal and Peri-implant Research Assistant
Diseases Department of Biomedical and Neuromotor Sciences
University of Ferrara Bologna University
Ferrara, Italy Bologna, Italy
Chair of Oral Surgery
School of Dentistry Monica Mele, DDS, MSc
University of Ferrara Research Assistant
Ferrara, Italy Department of Biomedical and Neuromotor Sciences
Bologna University
Bologna, Italy
Pietro Felice, MD, DDS, PhD
Researcher Luigi Minenna, DDS, PhD, MSc
Department of Biomedical and Neuromotor Sciences Part-time Faculty
Bologna University School of Dentistry
Bologna, Italy University of Ferrara
Ferrara, Italy
Luca Ferrantino, MD, DDS, PhD
Adjunct Assistant Ilham Mounssif, DDS, MSc
Department of Periodontology Research Assistant
Maxillo-Facial and Odontostomatology Unit Department of Biomedical and Neuromotor Sciences
Fondazione Cà Granda IRCCS Ospedale Maggiore Policlinico Bologna University
Milan, Italy Bologna, Italy

PRD_v77_i1_contributors.indd 3 16-Mar-18 1:18:01 PM

 Stephan F. Rebele, DDS, Dr. med dent. Tiziano Testori, MD, DDS, FICD
Private practice Head, Section of Implant Dentistry and Oral Rehabilitation
Dinkelsbühl, Germany IRCCS, Galeazzi Institute,
University of Milan,
Visiting Scholar Milan, Italy
Department of Periodontics
School of Dental Medicine Adjunct Clinical Associate Professor
University of Pennsylvania Department of Periodontics and Oral Medicine
Philadelphia, Pennsylvania, USA School of Dentistry
University of Michigan
Isabella Rocchietta, DDS Ann Arbor, Michigan, USA
Private practice
London, UK Daniel S. Thoma, Dr. med. dent.
Head of Academic Unit
Research Consultant Clinic of Fixed and Removable Prosthodontics and Dental
Department of Biomaterials Material Science
Institute for Clinical Sciences Center of Dental Medicine
The Sahlgrenska Academy University of Zurich
University of Gothenburg Zurich, Switzerland
Gothenburg, Sweden
Honorary Senior Research Associate Leonardo Trombelli, DDS, PhD
Eastman Dental Institute Director
University College London Research Centre for the Study of Periodontal and Peri-implant
London, UK Diseases
Professor and Chair of Periodontology
Kitichai Rungcharassaeng, DDS, MS Dean
Professor School of Dentistry
Department of Orthodontics and Dentofacial Orthopedics University of Ferrara
School of Dentistry Ferrara, Italy
Loma Linda University
Loma Linda, California, USA Renata Vecchiatini, DDS, PhD
Chair of Restorative Dentistry and Endodontics
Matteo Sangiorgi, DDS, MSc School of Dentistry
PhD student University of Ferrara
Department of Biomedical and Neuromotor Sciences Ferrara, Italy
Bologna University
Bologna, Italy Hom-Lay Wang, DDS, MSD, PhD
Professor and Director of Graduate Periodontics
Fabio Scutellà, DDS, CAGS, MSD Department of Periodontics and Oral Medicine
Head of Oral Rehabilitation Department School of Dentistry
Humanitas Research Hospital University of Michigan
Dental Division Ann Arbor, Michigan, USA
Milan, Italy
Tommaso Weinstein, DDS, PhD
Praveen Sharma, BDS, MJDF, FHEA, NIHR Head of Diagnostic Department
Doctoral Research Fellow Humanitas Dental Center
Periodontal Research Group Humanitas Research Hospital
School of Dentistry Milan, Italy
University of Birmingham
Birmingham, UK Giovanni Zucchelli, DDS, PhD
Associate Professor
Massimo Simion, MD, DDS Department of Biomedical and Neuromotor Sciences
Professor Bologna University
Department of Periodontology Bologna, Italy
Maxillo-Facial and Odontostomatology Unit
Fondazione Cà Granda IRCCS Ospedale Maggiore Policlinico Otto Zuhr, DDS, Dr. med. dent.
University of Milano Research Associate
Milan, Italy Department of Periodontology
Center for Dental, Oral, and Maxillo-facial Medicine (Carolinum)
Anna Simonelli, DDS, PhD Johann Wolfgang Goethe-University
Research Fellow Frankfurt am Main, Germany
Research Centre for the Study of Periodontal and Peri-implant
Diseases
University of Ferrara
Ferrara, Italy

Martina Stefanini, DDS, MSc, PhD

Research Assistant
Department of Biomedical and Neuromotor Sciences
Bologna University
Bologna, Italy

PRD_v77_i1_contributors.indd 4 16-Mar-18 1:18:01 PM

Periodontology 2000, Vol. 77, 2018, 7–18
Printed in Singapore. All rights reserved
Esthetics in periodontics and
implantology
GIOVANNI ZUCCHELLI, PRAVEEN SHARMA & ILHAM MOUNSSIF
From ancient times, people have recognized the
importance of physical appearance and attractive-
ness. Greek art dealt with the concept of beauty by
carefully studying the ‘divine proportion’ associated
with esthetics and harmony in the fields of architec-
ture, sculpture, music, and the human body and face,
and the rules of golden proportions also help present-
day societies to define ideal beauty. In 1978, Levin
(84) applied the principles of golden proportions to
teeth and the anterior esthetic region. Mass media
and fashion magazines portray esthetics as being
associated with health and social success. Facial
attractiveness plays a particularly important role in
modern society as it can influence not only self-
esteem but also social opportunities, professional
performance and employment prospects (41, 56).
However, the novelist, Margaret Wolfe Hungerford,
wrote in 1878 that ‘beauty is in the mind of the
beholder’ and ‘each mind perceives a different
beauty’, pointing out the difficulty of defining the
concept of ‘beauty’.
The smile is an important focal point of people’s
attention and a key feature of the overall esthetic
appearance of a person. The eyes of a person, in a
face-to-face situation, initially observe the eyes and,
immediately afterwards, the mouth and the smile of
the other person (56, 99). Accordingly, facial esthetics
and a beautiful smile have become major reasons for
many patients to request orthodontic and other types
of dental treatment. The American Academy of Cos-
metic Dentistry, in 2013 and 2015, reported that 86–
89% of dental patients sought treatment to improve
physical attractiveness and self-esteem (4). The rea-
sons cited for dental treatment included fixing a pre-
viously failed cosmetic treatment, upcoming events
(such as a wedding), restorative or health-related
events (such as accident or injury) and desire to look
and feel younger (4).
© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
PERIODONTOLOGY 2000
The creation of excellent esthetics requires an anal-
ysis of patients in their entirety. The esthetics of the
smile has to be contextualized within the harmony
and esthetics of the entire face, and the smile’s visual
impact cannot be associated exclusively with the
beauty of one or more teeth. Analyzing and under-
standing the global facial esthetics may lead to modi-
fication of teeth, tissues or the smile itself by esthetic
dentistry, orthodontics, corrective surgery, etc. As sta-
ted by Morley & Eubank (103), the smile is part of
facial esthetics, macroesthetics, microesthetics and
gingival esthetics. Facial esthetics addresses how the
lips and the soft tissue frame the smile in different
positions of speech, smiling and laughter. Macroes-
thetics deals with the relationship between the teeth
and the surrounding tissue, including the facial char-
acteristics of the patient. Microesthetics considers the
anatomy, the color and the location of teeth in the
dental arch. Gingival esthetics includes the entire gin-
gival tissue surrounding the teeth. In sum, factors of
importance in smile esthetics are the midline of the
face, the smile line, the appearance of soft tissue,
black interdental spaces and the size, the shape, the
position and the color of teeth. Importantly, the vari-
ous components of an ‘ideal smile’ should be evalu-
ated not in isolation but in combination with each
other (103, 105).
Garber & Salama (49) proposed that the essentials of
a smile are the relationships between teeth, lip frame-
work and gingival scaffold. The dental factor includes
tooth color, position and shape or silhouette. The lip
framework entails the lip form and the frame of a
smile, termed the esthetic zone, and three levels of lip
lines were defined – high, medium or low – based on
the amount of tooth coverage by the upper lip. The
gingival scaffold addresses restoration and mainte-
nance of the health and integrity of the periodontal
tissues. However, from an esthetic perspective, the
7
Zucchelli et al.
smile determinants described above are not always
sufficient. An irregular gingival margin, despite being
healthy, may appear unesthetic, and restoration of the
harmony and continuity of the free gingival margin
may be important esthetically (49). Rotundo et al.
(121) presented a method to measure and evaluate the
esthetics of a smile using intrarater and inter-rater
agreement analysis. The method, termed the Smile
Esthetic Index, assessed 10 variables, including the
smile line, facial midline, tooth alignment, tooth defor-
mity, tooth dyschromia, gingival dyschromia, gingival
recession, gingival excess, gingival scars and diastema/
missing papillae (121). Based on smile frontal-view pic-
tures, examiners with different clinical experience
found the Smile Esthetic Index to constitute a useful
method to assess smile esthetics and to be helpful in
treatment planning of plastic surgery (121).
In the past few decades, as the esthetically pleasing
smile has become a key element of periodontal and
implant therapy, surgical techniques have been devel-
oped to improve esthetic outcome and functional
restoration. This volume of Periodontology 2000 pro-
vides clinical recommendations and technical aspects
of periodontal and implant surgical procedures
applied to the esthetic zone. Experienced researchers
and clinicians from different subdisciplines of peri-
odontology summarize the developments and the
most recent knowledge on the following: gingival
recession treatment with or without papilla elevation;
clinical crown lengthening in the natural dentition
and in a restorative context; periodontal regeneration
around natural teeth; and soft-tissue augmentation in
edentulous areas. Similarly, experts in different areas
of implant science address esthetic outcomes with sin-
gle and multiple implant rehabilitation, alveolar ridge
preservation, implant positioning and immediate
implant placement in the esthetic zone. Horizontal
and vertical bone augmentation and coverage of peri-
implant soft-tissue dehiscence are also discussed.
Periodontal plastic surgery
Mucogingival therapy is a general term for periodon-
tal treatment that corrects defects in morphology or in
the position and/or amount of soft tissue and under-
lying bone around teeth and implants (5). The con-
cept of mucogingival therapy has changed over time.
When Friedman, in 1957, introduced the term
‘mucogingival surgery’, it included all surgical proce-
dures designed to preserve or improve healthy soft tis-
sue (maintenance of attached gingiva, removal of
aberrant frena or muscle attachments and increase in
8
depth of the vestibulum), without consideration of
esthetics (44, 45, 51, 52, 78, 107, 122). Later on, the
concept of mucogingival developed into ‘periodontal
plastic surgery’ (93) and became accepted by the
international scientific community in 1996 to mean
surgical procedures performed to prevent or correct
anatomic, developmental, traumatic or disease-
induced defects of gingiva, alveolar mucosa or bone
(101, 102, 148). Surgery was performed for the purpose
of gingival augmentation, root coverage, correction of
esthetic defects around implants, crown lengthening,
gingival preservation at ectopic tooth eruption,
removal of aberrant frena, prevention of alveolar ridge
collapse and augmentation of the edentulous ridge.
Patient perception of the root-
coverage procedure: what is the
most suitable surgical technique?
Buccal gingival recession can cause esthetic concern
and root sensitivity, and occurs primarily in patients
with a high level of oral hygiene (5). Mounssif et al.
(106), in this volume of Periodontology 2000, describe
surgical techniques to achieve complete root cover-
age, reduction of gingival recession or increased kera-
tinized tissue, using photographs (16, 23, 31, 69, 70,
119, 146) or an outcome rating scale (36, 151, 155,
157) to evaluate color match, tissue texture, contour
and contiguity and keloid scar tissue. The treatment
decision depended almost exclusively on the knowl-
edge and clinical experience of the dentists, as well as
on financial considerations (109). Patients’ esthetic
perception and true treatment need are often under-
estimated in professional practice and are barely dis-
cussed in the periodontal literature (109). However, a
recent consensus of the European Federation of Peri-
odontology has emphasized the need for clinical trials
with patient-centered outcome (true end point) as
well as objective clinical outcome (surrogate end
point), especially because patient esthetic evaluation
can be at variance with the professional judgement
(72); patients tend to concentrate on color and con-
tour of gingiva rather than on the amount of root cov-
erage achieved. Stefanini et al. (134), in this volume
of Periodontology 2000, propose a decision-making
strategy for treatment of gingival recession that
includes selection of a surgical technique that can
achieve both complete root coverage and blending of
tissue color and texture of the treated area with that
of the adjacent soft tissues. Coronally advanced
flap + connective tissue graft for single tooth

recessions and the modified coronally advanced tun-
nel technique for multiple teeth recessions are the
recommended surgical methods. The treatment deci-
sion must also consider anatomic factors, such as the
presence of noncaries cervical lesion(s), interdental
clinical attachment loss, interdental soft-tissue loss,
buccal displacement of the root, degree of keratinized
tissue and gingival thickness, as well as patient
esthetic request and the need to minimize patient
morbidity. Patient morbidity can be assessed using
an easily administered visual analogue scale (114).
The main concern of patients regarding periodontal
plastic surgery seems to be the second surgical site
(palatal donor site). Surgical harvesting techniques
using primary wound closure, smaller and thinner
connective tissue grafts (156) or substitute materials
(allograft or xenograft) can help minimize postopera-
tive pain and discomfort. Shorter surgical interven-
tion time and use of analgesics seem also to reduce
postoperative complications.
Esthetic treatment of gummy smile
and altered passive eruption
The American Academy of Periodontology has identi-
fied altered passive eruption as a mucogingival defor-
mity around teeth (8). Altered eruption can cause
gummy smile, which implies a visible exposure of gin-
giva of > 2 mm from the inferior rim of the upper lip
(111). The correction of excessive gingival display can
be important for the esthetics of the smile and for
patient self-esteem (43, 71). Mele et al. (95) describe,
in this volume of Periodontology 2000, two main
types, each with two subgroups, of altered passive
eruption. Types 1 and 2 differ in keratinized tissue
height, and subgroups A and B differ in the distance
between the cemento–enamel junction and the alve-
olar bony crest. Type 1 displays keratinized tissue that
extends apically beyond the cemento–enamel junc-
tion; and type 2 displays less keratinized tissue with
the mucogingival junction located coronally to, or at,
the level of the cemento–enamel junction (38). Sub-
group A specifies the distance between the cemento–
enamel junction and the alveolar bone crest to be
great enough to allow for connective tissue attach-
ment on the root cementum; subgroup B has the
bony crest located at, or coronally to, the cemento–
enamel junction and provides no space for connec-
tive tissue attachment (38).
The etiopathogenesis and treatment of altered pas-
sive eruption warrant further studies. No data are
Esthetics in periodontics and implantology
available on changes in clinical crown length after
20 years of age, and thus it is unknown when altered
passive eruption has run its course. Altered passive
eruption can be diagnosed on periapical radiographs
using a long-cone parallel technique and a radiopa-
que reference point (e.g. the gutta-percha endodontic
point at the level of the soft-tissue margin), and the
diagnosis of altered passive eruption is usually made
when the distance between the tip of the gutta-
percha point and the cemento–enamel junction
exceeds 3 mm. Gummy smile is treated with gingivec-
tomy to expose the hidden tooth anatomy or by api-
cally repositioned full-thickness flap, with or without
osseous resective surgery (49). The need to reduce
bony thickness to change the relationship between
the bony crest and the cemento–enamel junction in
adjacent teeth favors apically positioned flap surgery
with bone recontouring. The postsurgical distance
between the cemento–enamel junction and the bone
crest should not exceed 1–2 mm (20, 35, 120, 150).
Surgical treatment of altered passive eruption can
markedly improve patient appearance and smile, but
research is lacking on the reasons why patients
request treatment for altered passive eruption and on
patients’ perception of the treatment outcome.
Crown lengthening for esthetic
reasons: surgical and restorative
concepts
Clinical crown lengthening is a common surgical
procedure in periodontal practice. A recent survey
by the American Academy of Periodontology found
that approximately 10% of all periodontal surgical pro-
cedures were performed to gain clinical crown
length. Several studies have addressed crown lengthen-
ing in the posterior area, but crown lengthening for
esthetic reasons in the anterior area has received rela-
tively little attention. Marzadori et al. (90) identified
only a few controlled clinical trials on esthetic crown
lengthening (10, 17, 47, 55, 112) and no systematic
review, which complicates clinical decision making.
Surgical and prosthetic procedures for esthetic crown
lengthening need to consider the vestibular and palatal
flap design, the amount of ostectomy and osteoplasty,
and flap suturing. The surgical procedures include
thinning of soft and hard tissues to minimize rebound of
soft tissue and placement of a provisional restoration
during healing to ensure the proper esthetic outcome.
Tooth preparation and provisional relining are usually
performed 3 weeks following surgery.
9
Zucchelli et al.
Simplified procedures for
treatment of intraosseous defects
in esthetic areas: why, when and
how
Treatment of deep intraosseous defects aims to
improve the prognosis of the affected teeth, prefer-
ably through regeneration of the lost periodontal tis-
sues. In esthetically sensitive areas, however, the
preservation (or improvement) of pre-existing esthet-
ics is just as important as the regenerative goals, and
combining these two therapeutic end points can be
challenging. Over the years, ‘simplified’ treatments of
intraosseous defects have appeared that promised
easily performed surgical techniques with less post-
surgical pain and discomfort, fewer adverse outcomes
and lower cost. ‘Simplified’ surgical procedures, such
as the single flap approach and its variants (37, 142,
154), involve elevation of a single flap on the buccal
or oral aspect, leaving the tissues on the lingual/pala-
tine side intact. The article by Trombelli et al. (143),
in this volume of Periodontology 2000, lends support
to nonsurgical treatment of infrabony pockets with
moderate depth, but not of deep infrabony defects.
The single flap approach, performed either as a
stand-alone treatment or in combination with regen-
erative devices, can achieve similar clinical attach-
ment gain or probing-depth reduction as traditional
papilla-preservation techniques. Simplified surgical
techniques seem also to result in minimal esthetic
impairment (i.e. post-treatment gingival recession)
and a more tolerable postoperative course compared
with conventional surgical (double-flap) techniques.
Despite these encouraging results, research data on
histologic, esthetic and long-term outcomes after
‘simplification’ surgery are still not available.
Esthetics of soft-tissue
augmentation in edentulous areas
The loss of teeth can create functional and esthetic
defects in the edentulous area, such as deformities of
hard and soft tissues in both apicocoronal and buc-
colingual directions, which may complicate pros-
thetic rehabilitation in esthetically sensitive areas.
Although prosthetic devices, such as apicocoronal
extended pontic or gingival-like porcelain, may be
acceptable from a functional standpoint, they often
look artifical and this is readily apparent on smiling.
Reconstructive plastic surgery aimed at restoring the
alveolar ridge to its former dimensions has therefore
10
become a treatment of great importance. Marzadori
et al. (89) describe, in this volume of Periodontology
2000, five surgical techniques for soft-tissue augmen-
tation: onlay grafts; inlay grafts; combination onlay–
inlay grafts; roll technique; and pouch procedures
with connective tissue grafts (1, 64, 80, 81, 97, 123,
126–128, 152). In highly demanding esthetic areas,
the pouch technique is preferred for soft-tissue aug-
mentation because of its potential for primary wound
healing and for maintaining color and surface charac-
teristics of the surrounding tissues. Onlay, inlay and
combination grafts are less suitable choices because
of poor esthetic outcome and high resorption rates of
the exposed graft. High-priority research is to develop
surgical techniques, such as the ‘connective tissue
platform technique’ (152), that can provide soft-tissue
correction and primary wound healing in a one-stage
approach, even with severe apicocoronal and buccol-
ingual defects. Development of connective tissue
substitutes to reduce morbidity from harvesting soft-
tissue grafts from a donor site is also an important
research topic. Current systems for morphologic and
metric assessment of tissue changes postsurgery lack
reproducibility, but three-dimensional detection
shows encouraging results (141). However, the high
cost of three-dimensional devices and exposure to
radiation (in the case of cone-beam computed
tomography) limit their use in clinical practice.
Esthetic surgery without papilla
incision in periodontics and
implantology
The mucogingival techniques for treatment of soft-
tissue defects are continually evolving. While early
studies have concentrated on quantitative measure-
ment of root coverage or changes in keratinized tissue
(117), recent research takes into account patient satis-
faction along with qualitative esthetic criteria of suc-
cess, such as tissue color, texture and contour (93).
The esthetic requirements and the need for blood-
supply preservation and wound stability have led to
the development of tunneling flap techniques in peri-
odontal and peri-implant plastic surgery. Zhur et al.
(161), in this volume of Periodontology 2000, discuss
how tunneling surgery with an incision-free flap ele-
vation, avoiding visible surface incisions, can produce
rapid and uneventful wound healing and high-quality
esthetic outcomes. The major obstacle seems to be
the treatment of single, deep, gingival recessions.
Although originally developed for treating gingival

recessions (3, 9, 113, 149), the versatility of the tunnel-
ing flap technique makes it useful also for minor (e.g.
surgical thickening of thin buccal gingiva or peri-
implant mucosa), moderate (e.g. alveolar ridge
preservation following tooth extraction with or with-
out immediate implants, as well as implant second-
stage surgery) and extensive (e.g. soft-tissue ridge
augmentation either with implants or for pontic site
development) soft-tissue reconstructions (11, 58, 158,
159). The tunneling technique has undergone several
changes over the years (3, 11, 113, 149, 157, 160) that
have resulted in improved flap design but also in a
more demanding and technique-sensitive procedure,
which even can require advanced surgical training
and specifically designed microsurgical instruments.
The tunneling flap procedure has shown excellent
short-term results for treatment of gingival recession-
type defects but long-term data are still missing and
its utility in other clinical applications is essentially
unknown.
Esthetics with single-tooth
replacement
The outcome of treatment with a single implant in
the esthetic area was traditionally assessed solely by
physical tissue measures, but esthetic assessment and
patient-reported outcomes have become an integral
part of the final evaluation of implant therapy (79).
The ideal esthetic outcome includes perfect integra-
tions of the treated area with the surrounding tissues
and of the prosthetic crown with the natural dentition
(94). Stefanini et al. (133), in this volume of Periodon-
tology 2000, evaluate indices to determine the esthetic
outcome. Early esthetic indices took into account
only aspects relating to the soft tissues but, later on,
more complex indices (which included both soft tis-
sues and prosthetic aspects) were developed. It is still
not clear which esthetic index performs best in
implant research (7, 14), but the pink/white esthetic
score is frequently used (13, 48). The dentist’s esthetic
assessment should ideally agree with the patient’s
evaluation, but studies have reported a discrepancy
and the reason for this is unclear (40).
Alveolar ridge preservation: does it
improve the final esthetic
outcome?
Tooth extraction can be expected to be followed
by alveolar bone loss, structural and compositional
Esthetics in periodontics and implantology
changes of the overlaying soft tissues and morpholog-
ical alterations of the alveolar ridge (124). These tissue
changes can complicate implant placement (19), and
tooth extraction in the esthetic zone can lead to chal-
lenging therapeutic decision-making. As described
by Jung et al., in this volume of Periodontology 2000
(61), treatment planning ideally starts before tooth
extraction and includes three therapeutic options:
(i) spontaneous tissue healing; (ii) immediate implant
placement; or (iii) preservation of the alveolar ridge
to counteract changes in soft and hard tissue. Alveolar
ridge preservation is associated with three time-points
of healing: (i) the soft tissues (soft-tissue preserva-
tion following 6–8 weeks of healing after tooth extrac-
tion); (ii) the hard and soft tissues (preservation of
hard and soft tissue following 4–6 months of healing
after tooth extraction); and (iii) the hard tissues (hard-
tissue preservation following > 6 months of healing
after tooth extraction) (30). Soft-tissue preservation
techniques aim to improve the quantity and quality of
soft tissues and are performed at the time of tooth
extraction with a flapless approach or with a minimal
coronal-flap advancement. Subepithelial connective
tissue graft, free gingival graft, soft-tissue substitute or
a resorbable membrane may be used to enhance
wound closure (12, 62, 132, 135–137). Hard-tissue
preservation techniques are typically used for anky-
losed teeth with a vertical soft-tissue deficiency, teeth
with soft-tissue recessions and teeth with lack of kera-
tinized tissue. The hard-tissue preservation technique
employs a variety of biomaterials (59, 74, 138, 147) but
because of the 6- to 8-week healing period, only mini-
mal new-bone formation can be expected within the
extraction socket at the time of complete soft-tissue
closure (86). Accordingly, the bone-substitute materi-
als serve mainly as a space-maintaining device for the
biomaterial or the soft-tissue graft. A combination of
soft- and hard-tissue preservation techniques is used
in patients in whom tooth extraction has caused both
soft- and hard-tissue deficits. More recent combina-
tion techniques for soft- and hard-tissue preservation
employ a minimally invasive, nonflapped approach
with a healing period of 4–6 months. These so-called
socket seal techniques, which combine biomaterials
placed at the bony level with autogenous soft-tissue
grafts or soft-tissue substitutes placed at the soft-tissue
level (62, 86, 87, 96), are indicated for treatment of
small buccal bony defects (in which < 50% of the buc-
cal bony plate is missing), with or without soft-
tissue defects, for sites having implant placement
4–6 months later or for pontic sites. A prolonged hea-
ling period before implant placement is recommended
for sites with severe loss of the buccal bone plate
11
Zucchelli et al.
(> 50%), and alveolar ridge preservation is performed
using a bone substitute covered with a membrane fol-
lowed by flap advancement to achieve complete or
partial wound closure, a bone substitute followed by
a coronal advancement or rotation of the flap to
obtain full wound closure or a bone-substitute mate-
rial without wound closure (39, 145). Research is war-
ranted to determine the long-term performance of
alveolar ridge preservation in sites with large alveolar
defects and missing buccal bony plates and for
implant treatment performed with and without
alveolar ridge preservation.
Placement of implants in the
esthetic area
The survival rate of the implant fixture was, for many
years, the sole measurement of therapeutic success,
but as implant treatment matured, patients started
demanding good esthetics as well. As discussed in
this volume of Periodontology 2000 by Testori et al.
(140), implant treatment in the esthetic area raises
questions regarding the timing of implant placement
and whether the best approach is immediate, early or
late placement following tooth extraction (53, 76).
Patients prefer immediate implant placement as it is
less traumatic and involves fewer surgical procedures,
and implants may be reliably placed even in infected
sites (139). However, immediate implant placement is
technique sensitive and requires experienced opera-
tors. In choosing the type of implant treatment, the
soft tissue and bony anatomy are obviously impor-
tant, but altered passive eruption and root morphol-
ogy of adjacent teeth, and even skeletal growth (110),
can also be important decision-making criteria. The
abutment design may also influence esthetic out-
come. Restorative abutments were traditionally made
with a wide horizontal preparation finish, but new
prosthetic concepts have led to the design of abut-
ments with a vertical (shoulder-less) finishing line
(125). Shoulder-less abutments provide more space
for soft-tissue growth and allow for the long axis of
the implant to aim at the incisal edge of the future
restoration, improving the opportunity to create a
restorative crown with a cervical contour that resem-
bles more closely a natural tooth. Novel diagnostic
methods to guide three-dimensional positioning of
implants and innovative abutment morphology may
soon give rise to new implant treatments that are sim-
ple, less invasive and produce highly esthetic out-
comes (125).
12
How do we improve the esthetic
outcome with immediate implant
placement and provisionalization?
One of the most desirable features of immediate
implant placement and provisionalization is the
preservation of existing osseous and gingival architec-
tures (50, 66–68, 108). As described by Kan et al. (65),
the esthetic success of immediate implant placement
and provisionalization is related to patient factors (re-
lationship between hard and soft tissues, the gingival
biotype and/or the sagittal root position in the alveo-
lar bone) and therapeutic factors (the three-dimen-
sional position and angulation of the implant, the
abutment contour and/or the provisional restoration)
(67, 73). The flapless procedure reduces discomfort
and is usually combined with guided implant surgery
templates but should be performed only by skilled
clinicians (85). Studies show the importance of fill-
ing the gap between the implant and the alveolus to
prevent bone resorption after tooth extraction (24),
and soft-tissue augmentation is suggested when the
patient presents a thin biotype (83). The success in
terms of esthetics of immediate implant placement
depends on the combination of all the different fac-
tors described above. Risks of mucosal recession are
widely described in the literature (104) and this type
of surgery should be performed adhering to a strict
clinical protocol and only by clinicians with proper
expertise. The future of this technique is strongly
linked to the accuracy and precision of the diagnostic
devices and their capability to guide and simplify
implant surgery.
Esthetic treatment of bony ridge
defects
In recent years, the focus in implantology has moved
from osseointegration (2), which of course is still fun-
damental to achieve proper implant integration,
to esthetic and functional aspects of implant treat-
ment (15). The prosthetic portion of implant-supported
rehabilitation then becomes the central point in
implant placement and in guiding successive thera-
peutic steps (28, 34). According to Chiapasco & Casen-
tini (32), a prosthetic-driven approach to implantology
provides clear definition of the size and the shape of
ridge defects and helps select the best reconstructive
technique. Different classes of ridge defects and their
most appropriate treatment can be defined in a three-
dimensional radiograph. In classes I and II, which have

the the lowest degree of ridge defects, implant place-
ment is usually combined with soft- and hard-tissue
augmentation but can otherwise proceed immediately
(19, 60, 98). Classes III and IV show a higher degree of
ridge atrophy, which requires bone grafting and
delayed implant placement (33, 131, 144). Research is
needed to determine which type of treatment of ridge
defects provides the best long-term successful out-
come.
Esthetic outcome with vertical
ridge augmentation
Implant placement in the esthetic zone often needs
complex treatment planning. Vertical alveolar ridge
deficiencies are probably the most demanding cases
because ridge reconstruction is often necessary
before implant placement and prosthetic rehabilita-
tion. Rocchietta et al. (115), in this volume of Peri-
odontology 2000, review several techniques used to
obtain vertical alveolar bone gain but guided bone
regeneration remains the most common and best-
documented reconstructive method. Guided bone
regeneration allows a three-dimensional reconstruc-
tion, which is crucial for correct implant placement
and final esthetics, and it has fewer drawbacks than
other techniques. However, although widely used in
clinical practice, the vertical guided bone regenera-
tion technique is highly operator-dependent with a
steep learning curve (116). Emphasis must also be
given to a proper analysis of the hard- and soft-tissue
alterations following tooth loss, and to patient expec-
tations and desire. Several indices exist for classifica-
tion of the esthetic outcomes of implant-supported
restorations, and interest in patient perception of
implant treatment is steadily increasing (92). Unfortu-
nately, treatment of severe bone atrophy has not
attracted similar research interest.
Soft-tissue dehiscence around
implant: how do we solve this
esthetic problem?
Implant treatment after tooth loss, irrespective of
whether this is delayed, early or immediate implant
placement and loading (29, 42), can create various
biologic or biomechanic complications (54, 63), but
the greatest problem esthetically may be the buccal
dehiscence, which can result in an oversized pros-
thetic crown and/or implant/abutment exposure.
Esthetics in periodontics and implantology
Several anatomic/predisposing and pathologic/pre-
cipitating factors can cause apical shift of tissue
around implants (46). Unlike recession in the natural
dentition, no definition and no classification exist for
soft-tissue dehiscence around implants, probably
because of the lack of a reference point, such as the
cemento–enamel junction (21, 100). Mazzotti et al.
(91) describe, in this volume of Periodontology 2000,
various treatments of buccal soft-tissue dehiscence
with implants, which can be grouped in mucogingival
surgery with or without prosthetic support and
guided bone regeneration. Treatment of soft-tissue
dehiscence with implants has been assessed in case
report series (77, 88, 129, 130, 153), and in longitudi-
nal (18, 118, 153) and retrospective (82) studies, but
only in one randomized controlled trial (6). The over-
all conclusion is that mucogingival treatment of soft-
tissue dehiscence with implants produces less tis-
sue coverage compared with treatment of gingival
recession with natural teeth. Nevertheless, proper
prosthetic management, before and after mucogingi-
val surgery, seems to improve soft-tissue coverage,
approximating that reported for teeth (22, 25). Evalu-
ation of treatment efficacy of soft-tissue dehiscence
around implants should employ objective measures
in order for readers to confirm and compare study
data (104).
Concluding remarks
The main goals of plastic surgery treatment around
teeth and implants are rehabilitation of function and
satisfying patients’ esthetic demands. Numerous stud-
ies have reported on plastic surgery techniques and
surgical outcomes (surrogate end points), and esthetic
results have been evaluated by dentists in some trials,
but very few studies have taken into account patient
needs and requests (true end points) (57). The esthetic
judgment of clinicians may not always be consistent
with patient satisfaction, as patients tend to rate the
cosmetic results more favorably than the clinicians
(14, 26, 27, 72, 75). The few studies available on patient
satisfaction concern treatment of gingival recession or
single implant placement. No adequate and validated
assessment questionnaires exist to quantitate patient
satisfaction in respect to esthetics, psychological diffi-
culty and morbidity following plastic surgery around
teeth and implants. Assessment of such outcome cri-
teria by dentists and patients might provide better
insight into important aspects of periodontal and
implant treatments and might also improve the den-
tist–patient relationship.
13
Zucchelli et al.
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Periodontology 2000, Vol. 77, 2018, 19–53
Printed in Singapore. All rights reserved
Esthetic evaluation and
patient-centered outcomes in
root-coverage procedures
ILHAM MOUNSSIF, MARTINA STEFANINI, CLAUDIO MAZZOTTI,
MATTEO MARZADORI, MATTEO SANGIORGI & GIOVANNI ZUCCHELLI
Treatment of buccal gingival recession is frequently
needed for esthetic concerns, root sensitivity, root
caries and cervical abrasion in patients applying
incorrect toothbrushing (4). Randomized controlled
trials, systematic reviews and meta-analyses have
evaluated the efficacy of surgical techniques for treat-
ment of gingival recessions. Various objective and
reproducible parameters (complete root coverage,
root coverage, recession reduction, keratinized tissue
increase) have been used to evaluate different surgi-
cal techniques, but frequently ignored are patient
concerns and hence the true indications for treat-
ment. True end points are outcomes that directly
measure how a patient feels, functions or survives
(43) and, as such, are tangible to the patient. Esthetics
and root sensitivity are examples of issues of concern
for patients. True end points may also include subjec-
tive oral health-related quality of life measurements
(70, 71, 93) or simple self-reported symptoms. Surro-
gate end points are outcomes intangible to patients
but are used by researchers as a substitute for true
end points (43). Complete root coverage or increase
in keratinized tissue are examples of intangible
changes that patients cannot identify or realize. The
surrogate end points are often objective measures
that can be obtained by the clinician (rather than
relying on self-report by patients) or by laboratory
assays (54).
Until a decade ago, studies assessed treatment out-
comes of gingival recession defects by relying on sur-
rogate end points. However, there has lately been an
emphasis on patient-centered outcomes for the eval-
uation of root-coverage procedures. Patient-reported
outcomes are defined as any report of the status of a
patient’s health condition that comes directly from
© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
PERIODONTOLOGY 2000
the patient, without interpretation of the patient’s
response by a clinician or anyone else (111). Creating
valid patient-reported outcome instruments and met-
rics requires more than simply removing clinicians
and staff from the interpretation of patient opin-
ions. The US Food and Drug Administration and the
European Medicines Agency have provided position
papers and guidelines for the development, imple-
mentation and interpretation of patient-reported out-
comes in clinical trials. In essence, patient-reported
outcomes instruments should: (i) be free from error
(be reliable); (ii) measure what they are intended to
measure (be valid); (iii) be sensitive to changes in the
patient’s condition (be able to detect treatment dif-
ferences); and (iv) be interpretable (be clinically
meaningful) (49). Patient-reported outcomes are sub-
jective and involve the measurement of patient
opinions and experiential responses in relation to dif-
ficult-to-quantify end points, such as anxiety, pain
and satisfaction. It is important to record, in real
time, the patient experiences that occur sporadically
(for example, sudden pain when chewing). Patient-
reported outcomes should ideally be administered
and recorded using a computerized methodology, or
questions should be posed by staff members who are
not involved in the clinical trial or clinical care of the
patient because patients may be reluctant to provide
honest, unguarded answers to such caregivers (88).
Recent systematic reviews by the European Federa-
tion of Periodontology group evaluated studies in
which the primary and secondary outcomes were
professional measurements of the soft-tissue dimen-
sions following surgery as compared with baseline
(23, 47). To our knowledge, only one study (66) has
tried to compare true and surrogate end points. In
19
Mounssif et al.
this study, 58 buccal, Miller Class I–III recession
defects were treated using a variety of surgical tech-
niques, including subepithelial connective tissue graft
with a coronally advanced flap, subepithelial connec-
tive tissue graft without coronally advanced flap and
a free gingival graft. The percentage of root coverage
and the root-coverage esthetic score system were
used as objective measurements and a patient-cen-
tered questionnaire with a five-point ordinal scale
was used for subjective evaluation. When esthetic
assessment was analyzed according to the degree
of root coverage, the percentage of root coverage
was found to be proportional to the root-coverage
esthetic score and the professional rating but not with
patient satisfaction. From the patients’ perspective,
degree of root-coverage alone might not be sufficient
to determine satisfaction. On the other hand, when
the root-coverage esthetic score or professional rating
was examined as an independent variable, it satisfied
all of the other measurements. However, in the
patient-based analysis, the professional rating did not
increase with patient satisfaction, suggesting that the
esthetic judgment of the periodontists may not
always be in line with patient satisfaction. Patient sat-
isfaction was correlated more with the root-coverage
esthetic score, which includes soft-tissue integration
variables, indicating that patients are affected by the
percentage of root coverage as well as by the integra-
tion of soft tissue with adjacent tissue. Finally,
patients in the trial appeared to rate the cosmetic
results more favorably than the professionals. The
authors concluded that, within the confines of the
study, clinicians seem to consider the percentage of
root coverage to be a dominant contributor toward a
successful outcome, and the inconsistency in satisfac-
tion between professionals and patients may be a
result, in part, of the different perceptions regarding
the importance of percentage of root coverage.
Figure 1 shows an example of root-coverage out-
come with an excellent evaluation score made by the
patient. The expert periodontist scored the result as
A B
Fig. 1. Good and excellent evaluations by the professional
and the patient, respectively. (A) Deep multiple gingival
recessions affecting the maxillary incisors and canines at
baseline. (B) One year after surgical treatment. The expert
20
good because of incomplete root coverage and a dif-
ference in the soft-tissue color. An example of a root-
coverage procedure with a good satisfaction score
from the patient’s perception is presented in Fig. 2.
The expert periodontist assessed the result as moder-
ate because of the difference in color between the
treated area and the adjacent soft tissue. Never-
theless, there are several clinical situations in which
a good professional evaluation corresponds to a
poor patient evaluation, above all with an exces-
sive increase of gingival thickness. As illustrated in
Fig. 3, despite a root-coverage esthetic score of 8 (26)
(Fig. 4), the patient was not satisfied with the clini-
cal outcome and requested a reduction of gingival
thickness.
The most recent consensus of the European Feder-
ation of Periodontology (109) pointed out the need to
include patient perception and request in future
research to align better professional (surrogate) end
points with patient-centered outcomes (true end
points). The present narrative review focuses on pro-
fessional assessments for various clinical outcomes of
root-coverage procedures in terms of esthetics. The
paper also considers patient-centered outcome mea-
sures (esthetic evaluation, morbidity and hypersensi-
tivity) in the treatment of gingival recessions.
Professional esthetic evaluation
Recent systematic reviews show that gingival reces-
sions can be successfully treated using various surgi-
cal techniques (23, 29). Coronally advanced flap in
combination with a connective tissue graft achieved
the best clinical outcomes in terms of complete root
coverage and recession reduction. The success of
surgery was based on the quantitative measure of
reduction of the initial recession defect. However,
if the esthetic appearance of the recession defect
is the main concern of patients, periodontal sur-
geons should evaluate the clinical outcomes of root-
periodontist evaluated the result as ‘good’ because incom-
plete root coverage was obtained at the level of the central
incisors and there was a difference in the soft-tissue color;
the patient evaluated the result as ‘excellent’.
 Patient-centered outcomes

A B

Fig. 2. Moderate and good evaluations by the professional and the patient, respectively. (A) Frontal view of gingival reces-
sions affecting the maxillary lateral incisors. (B) The patient evaluated the result as ‘good’; the expert periodontist evalu-
ated the result as ‘moderate’ because of the difference in color of the soft tissue.

A B

Fig. 3. Root-coverage esthetic score value of 8 and poor expert periodontist using the root-coverage esthetic
evaluation by the professional and the patient, respec- score. However, the patient was not satisfied at all with
tively. (A) Deep gingival recession affecting the right the result because of the excessive increase in gingival
maxillary canine. (B) A score of 8 was assessed by the thickness.

have evaluated detailed esthetic outcome, and this

Fig. 4. Root-coverage esthetic score. The final root-coverage
esthetic score was 8 (gingival margin, complete root cover-
age = 6; marginal tissue contour, scalloped gingival
margin = 1; soft-tissue contour, presence of scar forma-
tion = 0; mucogingival junction disalignment = 0; gingival
color, normal color = 1).
coverage surgical procedures based on the patients’
perception of subjective outcomes, such as esthetic
outcomes, as well as on objective criteria.
In the first clinical trials that compared different
surgical techniques for treatment of gingival reces-
sion, esthetic evaluation either was not reported (15,
60, 97, 106, 110, 120) or was reported using empirical
sentences, such as ‘patients were satisfied with the
esthetic results’ (17) or ‘excellent and good esthetic
results’ (13). To our knowledge, only a few studies
was performed using photographic assessment or
a categorical scale. Table 1 lists the study design,
methods of assessment and the major findings of
important papers on professional esthetic evaluation.
The first comparative trial by Bouchard et al. (16)
used a three-point photographic scale and impres-
sion assessment (poor, moderate and good) by two
blinded independent observers. Rosetti et al. (99)
introduced an esthetic objective scoring system, tak-
ing into consideration the root coverage as well as the
gingival anatomy, contour and color after surgery.
The scoring system was as follows: (i) good if esthetics
after treatment were better than before; (ii) regular if
esthetics did not improve after treatment; and (iii)
poor if esthetics after treatment were worse than
before. Clinical photographs taken at baseline and
after 18 months were provided to five independent,
calibrated and expert examiners who used scorings of
good, regular or poor. The esthetic analysis demon-
strated improvement using both subepithelial con-
nective tissue graft and guided tissue regeneration
with a collagen membrane; no significant difference
between the methods was demonstrated. None of the
defects was evaluated as poor, and regular and good
rating scores, respectively, were given to 20% and
80% of subepithelial connective tissue graft-treated

21
22
Mounssif et al.

Table 1. Professional esthetic evaluation

Study Study design Length Test group Control group Assessment method Major findings
of study

Bouchard Comparative 6 months Coronally advanced Coronally advanced flap + Photographic and impression Good results in 66% of the cases and
et al. 1994 study flap + connective connective tissue graft (15 evaluations were made by moderate results in 33%. The trend
(16) tissue graft Miller Class I–II gingival two independent and is toward better results in the
(epithelial collar recessions) blinded examiners. The control group than in the test
exposed; 15 Miller evaluation was scored as group
Class I–II gingival good, moderate or poor
recessions)
Rosetti et al. Split-mouth 18 months Coronally advanced Coronally advanced flap + Photographic evaluation by 20% of the subepithelial connective
2000 (99) comparative flap + guided tissue subepithelial connective five calibrated, independent tissue graft and 18.3% of the
study regeneration + tissue graft (12 Miller Class I and expert examiners. The guided tissue regeneration sites
demineralized –II gingival recessions) evaluation was scored as were scored as regular. 80% and
freeze-dried bone good, regular or poor 81.7% of the subepithelial
allograft (12 Miller connective tissue graft and guided
Class I–II gingival tissue regeneration-treated sites,
recessions) respectively, were scored as good
Aichelmann- Comparative 6 months Coronally advanced Coronally advanced flap+ Direct evaluation by an Better results for the acellular
Reidy et al. study flap + acellular connective tissue (12 Miller independent blinded dermal matrix group in terms of
2001 (2) dermal matrix (12 Class I–II gingival examiner. Color, contour, color match and contiguity.
Miller Class I–II recessions) contiguity and keloid Essentially similar scores between
gingival recessions) presence were evaluated on the two treatments for consistency
a four-point scale and lack of keloid formation
 Table 1. (Continued)

Study Study design Length Test group Control group Assessment method Major findings
of study

Wang et al. Comparative 6 months Coronally advanced Coronally advanced flap + Independent examiner was The examiner rated 15 out of 16 sites
2001 (113) split-mouth flap + collagen (16 Miller Class I–II gingival asked to evaluate as treated with collagen membrane
study membrane for recessions) excellent, good, adequate or for guided tissue regeneration as
guided tissue unsatisfactory the following having excellent color match
regeneration (16 parameters: color, contour, compared with only 11 sites
Miller Class I–II contiguity and keloid treated with subepithelial
gingival recessions) presence connective tissue graft. Good
contour was noted in 15 sites
treated with collagen membrane
for guided tissue regeneration vs.
13 sites treated with subepithelial
connective tissue graft. Tissues
showed firm consistency in all sites
treated with either technique.
Sixteen sites treated with collagen
membrane for guided tissue
regeneration were rated as having
an acceptable blend compared
with 14 sites treated with
subepithelial connective tissue
graft. Keloid formation was noted
in only one site treated with
subepithelial connective tissue
graft
Cheung & Split-mouth 8 months Platelet concentrate Subepithelial connective Clinical slides were evaluated All the examiners agreed that the
Griffin 2004 randomized graft + coronally tissue graft + coronally by three expert masked platelet concentrate graft group
(31) study advanced flap (25 advanced flap (29 Miller examiners: color match, yielded a better texture and
Miller Class I–II Class I–II gingival tissue texture and contour of contour.
gingival recessions) recessions) the surgical area were No statistically significant difference
compared with the adjacent could be detected in color match
tissue. The scoring scale between the two groups
ranged from 1 (most
favorable) to 4 (least
favorable)
Patient-centered outcomes

23
24
Mounssif et al.

Table 1. (Continued)

Study Study design Length Test group Control group Assessment method Major findings
of study

Zucchelli et al. Comparative 1 year Coronally advanced Coronally advanced flap for The esthetic evaluation was No statistically significant difference
2009 (123) controlled flap for multiple multiple recessions performed by an expert between groups was found
randomized recessions (with (envelope type; 45 gingival periodontist. Color match regarding the color match. Better
clinical trial vertical incisions; Miller Class I–II gingival and contour were scored on statistically significant results for
47 gingival Miller recessions) a visual analog scale; contour, contiguity and keloid
Class I–II gingival contiguity was rated as yes parameters in the coronally
recessions) or no; keloid was scored as advanced flap envelope type
absent or present procedure were reported
Kerner et al. Retrospective 24 years 495 gingival recessions treated by pedicle soft-tissue Photographic assessment was Photographic assessment of
2009 (64) study grafts, nonsubmerged grafts, submerged grafts or performed by a panel of quantifiable outcome variables is a
envelope techniques seven observers (five useful method. The assessment
professionals and two should be performed on the direct
nonprofessionals). evaluation of the difference
Two different methods of between preoperative and
assessment were postoperative views and not on the
successively used: ‘before– evaluation of each photograph a
after panel scoring system’ posteriori compared with the
(five-point ordinal scores. A five-point ordinal scale is
improvement scale: poor, a valuable and recommended tool
fair, good, very good and for subjective assessment of root
excellent) and ‘random coverage therapy
panel scoring system’ (four-
point ordinal scale: poor,
fair, good and excellent)
 Table 1. (Continued)

Study Study design Length Test group Control group Assessment method Major findings
of study

Kerner et al. Retrospective 24 years 281 gingival recessions treated by 162 root-coverage Three observers (two Good-to-excellent overall esthetic
2009 (65) study surgeries (pedicle soft-tissue grafts, nonsubmerged periodontists and one results were found by the
grafts, submerged grafts and envelope techniques) control) used a before–after professionals and control in > 70%
were included panel scoring system to of the surgical procedures.
evaluate the esthetics. A five- Degree of root coverage was not a
point ordinal scale (poor, significant predictive factor,
fair, good, very good and whereas soft-tissue appearance
excellent) was used to variables and the follow-up were
evaluate the overall esthetic significantly associated with
improvement and seven cosmetic assessment.
variables were considered in Nonsubmerged grafts are not
the assessment (root recommended in cases of esthetic
coverage, color match, demand
texture match, volume
match, lack of scars,
keratinized tissue, gingival
contour)
Patient-centered outcomes

25
26
Table 1. (Continued)

Study Study design Length Test group Control group Assessment method
Mounssif et al.

Major findings
of study

Zucchelli et al. Randomized 1 year Laterally moved Coronally advanced flap + The esthetic evaluation was No statistically significant difference
2012 (121) controlled coronally advanced connective tissue graft (25 performed by an expert between the techniques in terms of
study flap (25 Miller I and Miller I and II gingival periodontist. Color match color match. However, a
II gingival recessions at first molar and contour were scored on statistically significantly higher
recessions at first teeth) a visual analog scale; visual analog scale root-coverage
molar teeth) contiguity was rated as yes score for the coronally advanced
or no; keloid was scored as flap+ connective tissue graft group
absent or present with respect to the laterally moved
coronally advanced flap group was
found
Cairo et al. Prospective 6 months Thirty-one patients with Miller Class I and II An expert examiner evaluated The root-coverage esthetic score
2009 (26) study recession defects treated with root-coverage gingival margin, marginal system may be a useful tool for
procedures were evaluated (coronally advanced tissue contour, soft-tissue assessing the esthetic outcome
flap, coronally advanced flap+ connective tissue texture, mucogingival following root-coverage
graft, free gingival graft, double papilla flap) junction alignment, and procedures
gingival color. The ideal
esthetic score was 10
Cairo et al. Multicenter 6 months The inter-rater agreement of root-coverage esthetic Eleven periodontists were The root-coverage esthetic score
2010 (22) study score among expert periodontists selected in selected in different clinical seems to be a reliable method for
different clinical centers was assessed centers to evaluate gingival assessing the esthetic outcomes of
margin, marginal tissue root-coverage procedures
contour, soft-tissue texture,
mucogingival junction
alignment and gingival color.
The ideal esthetic score was
10
 Table 1. (Continued)

Study Study design Length Test group Control group Assessment method Major findings
of study

Zucchelli et al. Randomized 1 year Coronally advanced Coronally advanced flap + The esthetic evaluation was Statistically significant greater color
2014 (126) controlled flap + connective connective tissue graft (‘big performed by an expert match scores were demonstrated
study tissue graft (‘small graft’; 30 gingival Miller blinded independent in the test (‘small graft’) group.
graft’; 30 gingival Class I–II gingival periodontist. Color match Statistically greater keloid
Miller Class I–II recessions) and contour were scored on formation was found in the control
gingival recessions) a visual analog scale; group
contiguity was rated as yes
or no; keloid was scored as
absent or present
Zucchelli et al. Randomized 1 and Coronally advanced Coronally advanced flap for The esthetic evaluation was Colour match was statistically
2014 (127) controlled 5 years flap+ connective multiple gingival recessions performed by an expert significantly better at 1- and 5-year
study tissue graft for (25 patients) blinded independent follow-up visits in the coronally
multiple gingival periodontist. Color match advanced flap-treated patients.
recessions (25 and contour were scored on Contour was statistically significant
patients) a visual analog scale; better at the 5-year follow-up for
contiguity was rated as yes the coronally advanced flap +
or no; keloid was scored as connective tissue graft group.
absent or present Statistically greater keloid
formation was found in the test
group both at 1 and at 5 years
Cairo et al. Systematic Not A total of 16 randomized controlled trials were The gingival margin, marginal Periodontal plastic surgery
2016 (24) review and applicable selected in the systematic review; three tissue contour, soft-tissue techniques applying grafts
Bayesian randomized controlled trials presenting texture, mucogingival underneath coronally advanced
network professional esthetic evaluation with the root- junction alignment and flap with or without the addition of
meta- coverage esthetic score gingival color. The ideal enamel matrix derivative are
analysis esthetic score was 10 associated with improved esthetics
assessed using the root-coverage
esthetic score
CAF, coronally advanced flap; CTG, connective tissue graft; SCTG, subepithelial connective tissue graft; GTR, guided tissue regeneration; DFDBA, demineralized freeze-dried bone allograft; AD, acellular allogeneic dermal connective
tissue matrix; CT, connective tissue; GTRC, collagen membrane for guide tissue regeneration; PCG, platelet concentrate graft; VAS, visual analog scale; PSTG, pedicle soft tissue graft; NSG, non-submerged graft; SG, submerged grafts;
ET, envelope techniques; LMCAF, laterally moved coronally advanced flap; RES, root coverage esthetic score; RCT, randomized controlled trial; NA, not applicable; DPF, double papilla flap.
Patient-centered outcomes

27
Mounssif et al.
recessions and to 18.3% and 81.7% of guided tissue
regeneration-treated recessions. Aichelmann-Reidy
et al. (2) used a four-point scale to score color
match, contour, consistency, continuity or blending,
and degree of keloid formation at 3 and 6 months
post-treatment. Wang et al. (113) scored esthetic out-
comes by photographs at 6 months follow-up visit
and evaluated color match, contour, consistency,
continuity or blending, and degree of keloid forma-
tion. Cheung & Griffin (31) scored color match, tissue
texture and contour of the surgical area on a 4-point
grading scale at 8 months post-treatment and found
that platelet concentrate grafts yielded better texture
and contour than subepithelial connective tissue
grafts in treatment of Miller Class I and Class II reces-
sions. Zucchelli et al. (123) studied root coverage and
esthetic outcome of two types of coronally advanced
flap surgery – an envelope-type flap (test group) and
a flap with vertical-releasing incisions (control group)
– for treatment of multiple gingival recessions, using
as variables color match (blending), contour (correct
outline of the gingival margin in adjacent teeth), con-
tinguity (evaluated based on the invisible confluence
between the treated area and the adjacent soft tis-
sues) and the degree of keloid formation at 1 year
post-treatment. The surgically treated area was indis-
tinguishable from the adjacent soft tissues in all sub-
jects treated with the envelope type of coronally
advanced flap (test group) compared with seven of 15
patients treated using the coronally advanced flap
with vertical-releasing incisions (control group), and
keloid formation did not occur in any of the patients
in the test group compared with six of the 16 patients
in the control group (123). The results validate the
negative esthetic effect of vertical-releasing incisions
caused by the formation of white-scar keloids which
can compromise the continuity of the surgically
treated area (123). Zucchelli et al. (121, 126–128) used
the same professional assessment method in other
comparative studies and found it to be very use-
ful to evaluate esthetic outcomes of root-coverage
procedures.
Kerner et al. (64) emphasized the lack of consen-
sus regarding the best method to assess cosmetic
results, which should rely on simple quantitative
measures and is a prerequisite for comparing out-
comes between studies. A study of esthetic out-
come of root-coverage techniques which compared
a before–after panel or random panel scorings by
professional and nonprofessional, trained and
untrained observers, showed that trained professionals
and preoperative vs. postoperative views achieved
the highest intrarater reliability (63). Interestingly,
28
substantial preoperative intrarater agreement (k = 0.67)
but a negative corresponding postoperative value (k
= –0.53) was found for a nurse, suggesting inability
to score the result of the surgical procedure cor-
rectly (63). The study also showed that neither the
percentage of root coverage nor the percentage of
gingival augmentation correlated with subjective
scores (63), implying that the observers did not
consider the amount of root coverage to be the
most critical variable in judging the overall esthetic
outcome. Another study by Kerner et al. (65) evalu-
ated the esthetic outcomes of four root-coverage
techniques according to overall esthetic appear-
ance, degree of root coverage, color match, texture
match, volume match, lack of hypertrophic scars,
existing keratinized tissues and gingival contour. A
before–after scoring panel system was used (64).
The study showed that photographic assessment by
a dental professional using the before–after scoring
panel system is a good method for overall esthetic
evaluation, and that intra-observer reliability
between two periodontists was almost perfect and a
substantial degree of agreement was found between
them (65). The intra- and interobserver agreement of
a nurse was moderate to fair. The overall esthetic
results were good to excellent and seemed to confirm
that nonsubmerged grafts are less esthetic than other
root-coverage procedures (65).
Cairo et al. (26) introduced, in 2009, a root-cover-
age esthetic score system that evaluates five clinical
variables (gingival margin, marginal tissue contour,
soft-tissue texture, mucogingival junction alignment
and gingival color) at 6 months following periodontal
plastic surgery (pedicle flaps, soft-tissue grafts or
combinations). Each variable received a numerical
score, and the aggregate score for maximal esthetics
was 10; zero points were assigned if the final position
of the gingival margin was at, or apical to, the previ-
ous recession depth (failure of root-coverage proce-
dure), irrespective of color, the presence of a scar,
marginal tissue contour or mucogingival alignment,
or with a partial or total loss of interproximal papilla
(black triangle). An example of a root-coverage
esthetic score is shown in Fig. 4. A multicenter study
with experienced periodontists showed that the root-
coverage esthetic score had an almost perfect agree-
ment intraclass correlation coefficient of 0.92 (22).
Based on the classification of Landis & Koch (68), the
root-coverage esthetic score may be considered to be
a good instrument for using to evaluate the esthetic
outcomes of root-coverage procedures. Recently,
Cairo et al. (24) published a systematic review of ran-
domized controlled trials to explore if root-coverage

procedures, when assessed using the root-coverage
esthetic score system, were effective in improving
esthetics. Bayesian network meta-analysis was used
to create a network of interventions including both
direct and indirect comparisons among different
trials and to summarize the quantitative outcome
data. Three combinations of the coronally advanced
flap techniques (coronally advanced flap + connective
tissue graft; coronally advanced flap + connective
tissue graft + enamel matrix derivative; and coro-
nally advanced flap + acellular dermal matrix with
autologous fibroblasts) yielded higher root-coverage
esthetic scores than coronally advanced flap alone,
although the differences were not statistically sig-
nificant. The best outcomes were obtained with
coronally advanced flap + acellular dermal matrix
with autologous fibroblasts and with coronally
advanced flap + connective tissue graft, thus confirm-
ing that grafts improve the effectiveness of coronally
advanced flap alone (23, 25). An evaluation of excel-
lence by both the professional and the patient is
presented in Fig. 5.
Patient esthetic evaluation
The main indication for root-coverage procedures is
the esthetic demand of the patient (115). However,
few studies have evaluated the patients’ satisfaction
following therapy, and in those that have, patient
opinion was mainly collected without a standardized
approach. Nieri et al. (85) investigated patient per-
ception of gingival recessions and their requests for
treatment in a cross-sectional study. The authors
showed that only 11 of 120 patients requested treat-
ment for a total of 57 recession defects. Considering
the results of this study, and the fact that complete
root coverage is not fully predictable following sur-
gical procedures, the authors recommend careful
evaluation of the need for treatment of buccal reces-
sion defects if these are asymptomatic and unper-
ceived. Chambrone & Tatakis (30), in a systematic
A B
Fig. 5. Excellent evaluations by both the professional and the patient. (A) Frontal view of multiple gingival recessions in
the maxillary incisors and canines at baseline. (B) One year after the mucogingival surgery. The result achieved was evalu-
ated as ‘excellent’ by the expert periodontist and the patient.
Patient-centered outcomes
review and meta-analysis, found limited, but consis-
tent, evidence that untreated buccal gingival reces-
sion defects, in subjects with good oral hygiene, were
highly likely to progress (78% of defects) over a period
of more than 5 years.
Table 2 describes the methods of assessment and
the clinical relevance of studies on patient esthetic
evaluation. Bouchard et al. (17) reported that 30
patients who were concerned with the appearance of
their gingival recession defects were satisfied with
the esthetic treatment outcome. Rosetti et al. (99)
employed subepithelial connective tissue graft and
guided tissue regeneration with a collagen mem-
brane (demineralized freeze-dried bone allograft)
for the treatment of gingival recession defects, and
found that all patients were pleased with the esthetic
results of both procedures at 18 months postsurgery.
Romagna-Genon (97) compared, in a split-mouth
study, coronally advanced flap plus collagen barrier
membrane with coronally advanced flap plus connec-
tive tissue graft, and reported that only one of 20
patients was not satisfied with either treatment. Wang
et al. (113) recorded patient satisfaction with esthet-
ics (color match, overall satisfaction, amount of root
coverage) in a comparative study (guided tissue
regeneration with a collagen membrane vs. subep-
ithelial connective tissue graft) for root-coverage pro-
cedures, and found a greater degree of satisfaction
with treatment using guided tissue regeneration.
Aichelmann-Reidy et al. (2) compared an acellular
allogenic dermal connective tissue graft with an auto-
genous connective tissue graft for treatment of gingi-
val recession defects, and obtained a better patient
score for acellular allogenic dermal graft for appear-
ance (color match, overall satisfaction) and similar
scores for both tissue grafts for amount of root cover-
age. Zucchelli et al. (119) evaluated esthetic patient
outcomes in a split-mouth study in which gingival
recession defects, referred for esthetic concerns, were
treated with a bilaminar surgical technique, and the
size, thickness and positioning of the connective tis-
sue graft comprised the difference between test and
29
 Table 2. Patient esthetic evaluation

30
Study Study design Length of Test group Control group Assessment method Major findings
study

Bouchard Controlled 6 months Modified subepithelial Modified subepithelial NA All patients were satisfied with the esthetic results
Mounssif et al.

et al. 1997 clinical study graft plus citric acid graft plus tetracycline
(17) conditioning (15 Miller HCl
Class I-II gingival Conditioning (15
recessions) Miller Class I-II
gingival recessions)
Rosetti et al. Split-mouth 18 months CAF + GTR + DFDBA CAF + SCTG Patients were asked if All patients were pleased with the esthetic results
(2000) (99) comparative (12 Miller Class I-II (12 Miller Class I-II they were satisfied and obtained by both procedures at 6 and 18 months
study gingival recessions) gingival recessions) pleased with the result post-surgery
of the treatment by a
yes or no response.
Comments or subjective
responses were not
evaluated
Romagna- Comparative 6 months CAF + GTR CAF + CTG NA 19 out of 20 patients were satisfied with the clinical
Genon randomized (bioresorbable bilayer (20 Miller Class I or II results, whatever the technique. Only one patient
(2001) (97) controlled collagen mem- brane) gingival recessions) was disappointed
trial (20 Miller Class I or II
gingival recessions)
Aichelmann- Comparative 6 months CAF + AD CAF + CT Patients were asked to Better scores for AD for appearance (13 patients
Reidy et al. study (12 Miller Class I-II (12 Miller Class I-II score the esthetic result versus 8 patients rated the result as excellent)
(2001) (2) gingival recessions) gingival recessions) as excellent, good, fair were reported
and poor
Wang et al. Comparative 6 months CAF + GTRC CAF + SCTG Patients were asked to Patient satisfaction with esthetics (color match,
(2001) (113) split-mouth (16 Miller Class I-II (16 Miller Class I-II score the color match overall satisfaction, and amount of root coverage)
study gingival recessions) gingival recessions) and the overall esthetic was the same for both treatments. However,
(as excellent, good, fair patients expressed greater satisfaction overall
and no response) with GTRC
Zucchelli et al. Split-mouth 1 year CAF + CTG CAF + CTG Patients were asked to Patients were more satisfied with the appearance
(2003) (119) randomized (16 Miller Class I-II (16 Miller Class I-II express their esthetic of the test-treated areas with respect to the
clinical study gingival recessions) gingival recessions) opinion by selecting control sites
(CTG thin and with (CTG thick and with one of the following
reduced height) “conventional” height) choices: bad, sufficient,
good, optimum
aesthetics
 Table 2. (Continued)

Study Study design Length of Test group Control group Assessment method Major findings
study

Bittencourt Split mouth 6 months SCPF CAF + SCTG Patients expressed their The esthetic condition after both treatments was
et al. (2006) randomized (17 Miller Class I (17 Miller Class I opinion of each treated considered satisfactory by the patients
(10) study gingival recessions) gingival recessions) tooth by selecting one
of the following choices
on a questionnaire
given by an
independent
researcher: bad,
sufficient, good, or
excellent
Mahajan et al. Randomized 6 months CPF CPF + ADM Patient satisfaction (root There was no difference be- tween the two groups
(2007) (76) controlled (14 Miller Class I-II (14 Miller Class I-II coverage, color of gums, when overall patient satisfaction scores were
trial gingival recessions) gingival recessions) shape and contour of compared
gums) was assessed
using a three- point
rating scale: fully
satisfied = 3;
satisfied = 2; and
unsatisfied = 1
Bittencourt Split mouth 30 months SCPF CAF + SCTG Patients expressed their Patients in SCPF and SCTG groups were generally
et al. (2009) randomized (17 Miller Class I (17 Miller Class I opinion of each treated satisfied with both procedures
(11) study gingival recessions) gingival recessions) tooth by selecting one
of the following choices
on a questionnaire
given by an
independent
researcher: bad,
sufficient, good, or
excellent
Zucchelli et al. Comparative 1 year CAF for multiple CAF for multiple Patients were asked to No statistically significant difference between
2009 (123) controlled recessions (with vertical recessions (envelope select among 100 scores groups was demonstrated in terms of overall
randomized incisions) type) (0 indicating very bad, satisfaction, color match, and root coverage VAS
clinical trial (47 gingival Miller Class (45 gingival Miller 50 average and 100 value
I-II gingival recessions) Class I-II gingival indicating excellent)
recessions) (VAS) in terms of overall
satisfaction, color
match and amount of
root coverage
Patient-centered outcomes

31
32
Table 2. (Continued)
Mounssif et al.

Study Study design Length of Test group Control group Assessment method Major findings
study

McGuire & Split-mouth 1 year CAF + CM CAF + CTG Patient were asked to Overall subject-reported esthetic satisfaction with
Scheyer randomized (25 Miller Class I-II (25 Miller Class I-II score their esthetic both test and control treatments was equivalent
(2010) (78) controlled gingival recessions) gingival recessions) satisfaction
clinical trial (“unsatisfied” to “very
satisfied”) on a five-
point scale
McGuire et al. Split-mouth 10 years CAF + EMD CAF + CTG Patients were asked if Both procedures appeared to yield equally
(2012) (81) randomized (9 Miller Class I-II (9 Miller Class I-II they are equally satisfying esthetic results to the majority of the
controlled gingival recessions) gingival recessions) satisfied with the patients.
clinical trial esthetic results of the
two sites treated or they
are more satisfied with
one treated site over the
other
Roman et al. Prospective 1 year 33 patients with single or multiple gingival Patients were asked to All patients judged the esthetic appearance as
(2012) (98) case series recessions were treated using a CAF + CTG evaluate their esthetic improved. 87.9% of the patients reported
study changes on a Vas important improvements in esthetics
questionnaire
Zucchelli et al. Randomized 1 year CAF + CTG CAF + CTG Patients were asked to Better aesthetics outcomes were observed in the
(2014) (122) controlled (25 Miller Class I and II (25 Miller Class I and select among 100 scores test group
study gingival recessions at II gingival recessions (0 indicating very bad,
first molar teeth) LST at first molar teeth) 50 average and 100
indicating excellent)
(VAS) in terms of overall
satisfaction, color
match and amount of
root coverage
 Table 2. (Continued)

Study Study design Length of Test group Control group Assessment method Major findings
study

Zucchelli et al. Randomized 1 year CAF + CTG CAF + CTG Patients were asked to Patient root coverage esthetic assessment was high
(2014) (126) controlled (“small graft”) (30 (“big graft”) (30 select among 100 scores in both groups with no statistically significant
study gingival Miller Class I-II gingival Miller Class I- (0 indicating very bad, differences between them. Statistically significant
gingival recessions) II gingival recessions) 50 average and 100 better colour match scores were demonstrated
indicating excellent) for the test-treated patients
(VAS) in terms of overall
satisfaction, color
match and amount of
root coverage
Zucchelli et al. Randomized 1 and CAF + CTG for multiple CAF for multiple Patients were asked to Patient esthetic assessment was high in both
(2014) (127) controlled 5 years gingival recessions (25 gingival recessions (25 select among 100 scores groups with no statistically significant differences
study patients) patients) (0 indicating very bad, between them as well as the 5-year evaluation
50 average and 100
indicating excellent)
(VAS) in terms of overall
satisfaction, color
match and amount of
root coverage
McGuire & Split-mouth 5 years CAF + CM CAF + CTG Patient were asked to Patients were almost completely and equally
Scheyer randomized (17 Miller Class I-II (17 Miller Class I-II score their esthetic satisfied with both therapies
(2016) (79) controlled gingival recessions) gingival recessions) satisfaction
clinical trial (“unsatisfied” to “very
satisfied”) on a five-
point scale
Cairo et al. Systematic NA A total of 16 RCTs were selected in the SR; 3 Patients were asked to Periodontal plastic surgery is associated with high
(2016) (24) review and studies showed final self-perception using the score their overall patient satisfaction rated by VAS values indicating
Bayesian Visual Analogue Scale (VAS) esthetic satisfaction on that CAF + CTG with or without the adding of
network a Visual analog scale EMD is associated with highest aesthetic
meta- satisfaction after healing
analysis
CAF, coronally advanced flap; CTG, connective tissue graft; SCTG, subepithelial connective tissue graft; GTR, guided tissue regeneration; DFDBA, demineralized freeze-dried bone allograft; SCPF, semilunar coronally positioned flap;
AD, acellular allogeneic dermal connective tissue matrix; CPF, coronally positioned flap; ADM, acellular dermal matrix; LST, labial submucosal tissue; CM, collagen matrix; VAS, visual analog scale; EMD, enamel matrix derivative.
Patient-centered outcomes

33
Mounssif et al.
control sites. Twelve of 15 patients were more satis-
fied with the appearance of the test-treated areas
(smaller, thinner graft positioned apical to the
cemento–enamel junction) than of the control sites;
nine patients indicated excessive thickness of the
control-treated areas as one of the reasons for the
worst result, and in four patients the excessive thick-
ness was the only negative factor; eight patients
pointed to poor color blending and only one patient
indicated excessive tooth length (together with exces-
sive thickness of the graft and poor color blending)
for the worse esthetic outcomes in the control sites
(119). Bittencourt et al. (10, 12), in a split-mouth ran-
domized comparative study, found (at 6 months
post-treatment) that nine of 17 patients treated with
a semilunar coronally positioned flap reported an
excellent esthetic outcome (seven indicated a good
result and one reported a sufficient result), while 12
patients receiving a subepithelial connective tissue
graft reported an excellent result and the remaining
five patients a good result. Patients expressed no pref-
erence for either treatment at 6 months post-treat-
ment (10). At the end of the experimental period
(30 months) (12), 14 of 17 patients in the semilunar
coronally positioned flap group reported an excellent
or good esthetic outcome and three patients reported
a poor result, whereas all subjects in the subepithelial
connective tissue graft group reported an excellent or
a good result. In contrast to the 6-month results,
more patients stated that the subepithelial connective
tissue graft group was the better treatment with
regard to overall esthetics. All patients in the semilu-
nar coronally positioned flap group showed scar tis-
sue at 30 months post-treatment but only seven
patients complained about it (12). Mahajan et al.
(76), in a randomized controlled trial comparing an
acellular dermal matrix graft with a coronally posi-
tioned flap alone, found that patients rated the acel-
lular matrix graft and the coronally positioned flap
equally, but some patients were unhappy about the
soft-tissue bulge after the graft placement and two
patients rated the coronally positioned flap unsatis-
factory in terms of root coverage. Zucchelli et al.
(123), in a randomized clinical trial evaluating coro-
nally advanced flap with or without vertical incisions
for the treatment of multiple recessions, showed
patient satisfaction to be very high for both treatment
groups in terms of overall satisfaction, color match
and root coverage, and no poor esthetic scores were
recorded in either patient group. The same research
group found patient esthetic evaluation to be an
important component of root-coverage procedures
also in other randomized controlled studies (121, 122,
34
126, 127). McGuire & Scheyer (78) found that more
than 90% of subjects express improvement in esthet-
ics at 6 months after treatment of recession defects
with either a coronally advanced flap with a xeno-
geneic collagen matrix or a coronally advanced flap
with a connective tissue graft. At the 5-year follow-up,
satisfaction remained high for both treatments, with
more than 90% of patients still being satisfied or very
satisfied with the outcome (79). In a 10-year study
comparing subepithelial connective tissue graft with
enamel matrix derivative in combination with a coro-
nally positioned flap, McGuire et al. (81) found that
both procedures appeared to yield equally satisfying
esthetic results in the majority of the patients. Roman
et al. (98), in a clinical trial of single and multiple gin-
gival recessions treated with coronally advanced flap
plus connective tissue graft, found that 88% of
patients reported important improvements in esthet-
ics and no patients were dissatisfied with the esthetic
outcome at any of the 3-, 6- or 12-month examination
time points, suggesting that the grafted tissue was
integrated well enough at 3 months to confer a good
esthetic appearance. Cairo et al. (24), in the Bayesian
network meta-analysis review of randomized con-
trolled trials on root-coverage procedures, found that
the surgical procedures with the highest probability
of yielding the best esthetic outcomes, as judged by
patients, were the coronally advanced flap used with
connective tissue graft and coronally advanced flap
used with connective tissue graft as well as enamel
matrix derivative. This finding suggests that tech-
niques using connective tissue graft, which are also
more effective in terms of root coverage (20, 21, 23,
25), provide higher patient satisfaction. However,
despite achieving complete root coverage, Fig. 6
shows a poor esthetic satisfaction outcome, as judged
by both the professional and the patient, because of
differences in soft-tissue color and texture.
Morbidity
Surgical procedures for the treatment of gingival
recession defects are commonly carried out by clini-
cians and are well accepted by patients, and such sur-
gical procedures are associated with patient morbidity
(defined as a condition of being diseased) (4) because
of a risk of postoperative complications, including
infection and pain. These are a matter of concern for
the practitioner and the patient (74) and some studies
have assessed the incidence of such postoperative
complications after periodontal surgery. Curtis et al.
(36) assessed pain and the complications of bleeding,

A B
Fig. 6. Poor evaluations by both the professional and the
patient despite complete root coverage. (A) Frontal view of
the preoperative clinical situation. (B) A poor evaluation
by both professional and patient was reported; the
infection, swelling and adverse tissue changes (flap
necrosis or graft rejection) after periodontal surgery,
31.2% of which were scheduled as mucogingival sur-
gery (free gingival graft and pedicle graft). Postopera-
tive pain was measured using a simple verbal rating
scale (similar to the Bond scale) (14), and the number
and type of analgesics taken were recorded to obtain
an objective measurement of pain. The authors empir-
ically correlated the subjective and objective data to
create a nominal pain variable (0 = none, 1 = mini-
mal, 2 = moderate, 3 = severe) that was used in the
statistical analysis. The criteria thus established were
used to determine whether the postoperative compli-
cations that were present included both patient-
reported and operator-visualized findings. Compli-
cations were graded as nonexistent, minimal, moder-
ate or severe. Moderate and severe complications
required operator visualization. The authors reported
that approximately 50% of the patients reported mini-
mal or no postoperative pain, 4.6% reported severe
pain and 20.1% took five or more doses of an analgesic.
Mucogingival surgery was reported as being 3.5 times
more painful than bone surgery and six times more
painful than soft-tissue surgery. Increased duration of
the surgical procedure was significantly associated
with increased postoperative pain. Additionally,
mucogingival procedures frequently leave areas of
connective tissue exposed, necessitating wound cov-
erage by epithelial migration from the margins, lead-
ing to donor-site morbidity. It is notable that 94.5% of
the patients had no (46.1%) or minimal (48.4%) post-
operative complications of bleeding, infection, swel-
ling or adverse tissue changes.
Coronally advanced flap alone, for the treatment
of a single gingival recession defect, was a safe and
predictable procedure, and the adjunctive use of
connective tissue graft or enamel matrix derivative
under the coronally advanced flap enhanced the
probability of obtaining complete root coverage (23,
25). The main concerns, from a patient point of
Patient-centered outcomes
difference in soft-tissue color and texture resulted in a neg-
ative judgement of the outcome of surgery, even though
complete root coverage was achieved.
view, regarding periodontal plastic surgery seem to
be related to the second surgical site (donor site).
The free gingival graft, for many years, represented
the principal surgical technique for increasing the
width of attached gingiva. The literature on free
gingival grafts is contradictory and reports percent-
ages of root coverage ranging from 11% to 100%
(125). Increased postoperative morbidity may result
from the substantial wound created when harvest-
ing a thick graft from the palate and clinicians may
hesitate in attempting root coverage using a free
gingival graft because of the unforgiving nature of
this procedure, along with potentially undesirable
postoperative sequelae (82). In the first studies
that evaluated the free gingival graft procedure, no
questionnaire or standardized assessment methods
were applied to determine the postoperative course
experienced by patient; only empirical sentences
were reported (58, 83). Thereafter, novel surgi-
cal techniques that provided higher predictability
regarding esthetic outcomes, and which minimized
patient morbidity, replaced free gingival grafts in
periodontal surgery with subepithelial connective
tissue grafts; the latter were preferred by patients
because a less invasive palatal wound was created
and an improved esthetic result was obtained, com-
pared with epithelialized grafts (115). Different con-
nective tissue graft-harvesting procedures, with the
purpose of achieving healing of the palatal wound
by primary intention, have been described in the lit-
erature. In 1974, Edel (40) advocated the trapdoor
technique, a method for harvesting subepithelial
connective tissue grafts that allowed the residual
palatal epithelium to be retained, thereby reducing
patient discomfort. A single horizontal incision, par-
allel to the gingival margin, and two vertical-releas-
ing incisions were used to achieve sufficient visual
access. Later, Langer & Langer (69) introduced a
similar method that employed a second, parallel
horizontal incision to obtain a graft with an
35
Mounssif et al.
epithelial margin. Raetzke (94) resected a wedge of
connective tissue with an epithelial collar through
two semilunar converging incisions, whilst Harris
(51) advocated the use of a double-bladed scalpel
for harvesting a 1.5-mm-thick graft with an epithe-
lial margin. These flaps need an adequate thickness
of the palatal fibromucosa to avoid desquamation
of the undermined superficial flap as a result of
compromised vascularization.
In a free gingival graft, the surgical wound heals by
secondary intention within 2–4 weeks (41) and has
been consistently associated with greater discomfort
for the patient as a result of postoperative pain and/or
bleeding (37, 41, 58). However, this technique is easy
to perform and can be utilized even in the presence of
a thin palatal fibromucosa. Most of the aforemen-
tioned techniques involve the loss of parts of the pala-
tal epithelium, thereby precluding primary wound
closure and facilitating secondary wound healing.
Based on this knowledge, Hü rzeler & Weng (55) and
Lorenzana & Allen (75) presented a single-incision
technique that was designed to allow primary wound
healing, thereby decreasing patient discomfort.
Table 3 summarizes methods of assessment and
the major findings of studies on morbidity after root-
coverage procedures. Empirical results were reported
by Romagna-Genon (97) in a prospective randomized
clinical study comparing subepithelial connective
tissue graft and guided tissue regeneration for the
treatment of single gingival recession. The authors
reported that all patients were affected by postopera-
tive consequences from the palatal donor site for the
connective tissue graft. They complained of significant
pain and care they had to take when eating; no infor-
mation about the patient’s postoperative assessment
was given. McGuire & Nunn (77) evaluated the healing
pattern in a randomized controlled split-mouth study
[subepithelial connective tissue graft vs. enamel
matrix derivative (Emdogain)]; they categorized the
healing as ‘worse than expected’, ‘as expected’ or as
‘much better than expected’ on a visual analog scale.
At 1 week the healing observed with the enamel
matrix derivative was superior to that observed with
the connective tissue graft; this result was not surpris-
ing as the need for a second surgical site to harvest the
connective tissue would more than likely lead to more
discomfort than that associated with the enamel
matrix derivative-treated sites. Cheung & Griffin (31)
(Table 3), in a randomized clinical trial performed to
assess the clinical efficacy of platelet concentrate
grafts in the treatment of Miller Class I or Class II buc-
cal gingival defects and to compare their soft-tissue
healing with those of subepithelial connective tissue
36
grafts, asked patients to rate their postsurgical dis-
comfort level, on each side of the arch, at 1 week and
at 1 month of follow-up, according to their subjective
feelings. To do this, a form containing a visual analog
scale (of 0–10, with 0 indicating negligible discomfort
and 10 indicating unbearable pain) was provided. The
platelet concentrate graft procedure resulted in less
postoperative discomfort. Harris et al. (52) (Table 3)
evaluated the incidence and severity of the complica-
tions that occur after connective tissue grafts are used.
Five-hundred consecutively treated patients, for
whom connective tissue grafts were used for root cov-
erage or gingival augmentation, were included in this
study. Complications did occur, but the rates and
intensities seemed clinically acceptable. The authors
empirically correlated the subjective and objective
data to create a nominal variable: 0 = none; 1 = mini-
mal; 2 = moderate; 3 = severe [as in the study by Cur-
tis et al. (36)]. There was no pain reported in 81.4% of
the patients, no bleeding in 97.0%, no infection in
99.2% and no swelling in 94.6%. None of the factors
evaluated in this study were associated with a statisti-
cally significant increase in the rate or intensity of
complications. There is minimal evidence in the litera-
ture of differences in patient outcomes and morbidity
being evaluated following use of the connective tissue
graft and free gingival graft for root-coverage proce-
dures. A few prospective comparative studies (37, 48,
116) reported poorer patient outcomes, specifically a
greater incidence of postoperative pain, for free gingi-
val grafts compared with connective tissue graft pro-
cedures. Del Pizzo et al. (37) (Table 3) used a 4-point
discrimination scale (coronal, apical, mesial, distal)
around the donor area, before the surgical procedure
and afterwards at the follow-up visits. The immedi-
ate bleeding parameter – delayed bleeding – and the
complete wound epithelialization parameter were
assessed. Re-epithelialization was scored clinically as
none, partial or complete. Objective sensory loss was
recorded using a rubbing movement and pin pressure
nociception. Patients were asked to give a rating of
their loss of sensibility based on a 3-point verbal
descriptor scale (none, mild or moderate, or severe).
Discomfort was assessed as the level of pain experi-
enced from the palatal wound by the patients during
the postoperative weeks. Regarding the sensory
parameter, the same 3-point verbal descriptor scale
(none, mild or moderate, or severe) was used to record
discomfort levels reported by the participants. Follow-
ing the same scale, variation of feeding habits was
monitored as a change in patient’s diet on the basis of
its content and quality (liquid, soft or hard) and tem-
perature of the food (cold, tepid or warm). The authors
 Table 3. Morbidity after root-coverage procedures

Authors, year Type of study Test group Control group Time of Method of assessment Major findings
(ref. no.) assessment

Romagna- Comparative Coronally advanced Coronally advanced 3 and Not applicable All patients were affected by the
Genon 2001 randomized flap+ guided tissue flap+ connective 6 months postoperative consequences from the
(97) controlled trial regeneration tissue graft (20 Miller palatal donor site for the connective
bioresorbable bilayer Class I or Class II tissue graft. They complained of
collagen membrane; gingival recessions) significant pain and care they had to
20 Miller Class I or take when eating. The site treated with
Class II gingival the membrane was more frequently
recessions) symptom-free
Del Pizzo Case series Three different surgical procedures for 1, 2, 3 and Patients were asked to score Discomfort rate recorded for both single-
et al. 2002 harvesting a connective tissue graft were 4 weeks for ‘discomfort’ and ‘sensibility incision and trapdoor groups was
(37) evaluated: single incision; free gingival graft; discomfort, loss’ on a three-point verbal significantly lower than for the free
and trapdoor feeding descriptor scale: ‘none’; ‘mild or gingival graft group. Discomfort was
habits and moderate’; or ‘severe’. Variation statistically significantly higher during
sensibility; 5, of feeding habits was monitored the first postoperative week in the free
6, 7 and as a change in patient’s diet on gingival graft group than in the other
8 weeks for the basis of its content and two groups. No differences were
sensibility quality (‘liquid’, ‘soft’ or ‘hard’) recorded between the trapdoor and
and temperature of the food single-incision groups.
(‘cold’, ‘tepid’ or ‘warm’) Variation of feeding habits was more
marked (but not statistically
significant) for the free gingival graft
group with respect to the two other
groups. Complete sensibility was
recovered in all patients 8 weeks after
surgery
McGuire & Split-mouth, Coronally advanced Coronally advanced 1 week Patient perception of pain, The enamel matrix derivative group was
Nunn 2003 randomized flap+ enamel matrix flap+ connective discomfort, bleeding and superior to the connective tissue graft
(77) controlled trial derivative (17 Miller tissue graft (17 Miller sensitivity was evaluated by a group regarding postoperative
Class I or Class II Class I or Class II questionnaire discomfort
gingival recessions) gingival recessions)
Cheung & Split-mouth, Coronally advanced Coronally advanced 1 and 4 weeks Discomfort was evaluated on a No statistically significant difference
Griffin 2004 randomized flap+ platelet flap+ connective visual analog scale between the two groups was found
(31) controlled trial concentrate graft (15 tissue graft (15 Miller questionnaire during the first postoperative week.
Miller Class I or Class Class I or Class II The platelet concentrate graft
II gingival recessions) gingival recessions) procedure resulted in less
postoperative discomfort at 4 weeks’
follow-up
Patient-centered outcomes

37
 Table 3. (Continued)

38
Authors, year Type of study Test group Control group Time of Method of assessment Major findings
(ref. no.) assessment

Harris et al. Case series 500 consecutive patients treated with connective Not applicable The authors empirically No pain reported in 81.4% of patients,
Mounssif et al.

2005 (52) tissue grafts for root coverage or gingival correlated the subjective and no bleeding in 97.0% of patients, no
augmentation objective data to create a infection in 99.2% of patients and no
nominal variable: 0, none; 1, swelling in 94.6% of patients
minimal; 2, moderate; 3, severe
Griffin et al. Prospective 75 free soft-tissue grafts and 256 subepithelial 1 week Every patient was given a Free soft-tissue grafts will most probably
2006 (48) case series connective tissue grafts were performed by a questionnaire to rate increase the probability of postsurgical
single operator postoperative pain, swelling pain and bleeding
and bleeding for the previous
week and overall discomfort on
day 7 on a visual analog scale of
‘0–10’
Wessel & Observational 12 connective tissue grafts and 11 free gingival 3 days and Patients were asked to fill out a Free gingival grafts were associated with
Tatakis 2008 parallel-group grafts were performed; in five free soft-tissue 3 weeks questionnaire (visual analog a greater incidence of donor-site pain
(116) study and 84 bilaminar graft procedures, an acellular scale) regarding postoperative compared with connective tissue grafts
dermal matrix was used instead of autogenous pain, swelling and bleeding during the early postoperative period
tissue
Zucchelli et al. Comparative Coronally advanced Coronally advanced 1 week Visual analog scale A statistically significantly better
2009 (123) controlled flap for multiple flap for multiple questionnaire: postoperative postoperative course was reported by
randomized recessions (with recessions (envelope course was evaluated 1 week the test (envelope coronally advanced
clinical trial vertical incisions; 47 type; 45 gingival; following surgery based on a flap) compared with the control
gingival Miller Class I– Miller Class I–II visual analog scale. Patients (coronally advanced flap with vertical-
II gingival recessions) gingival recessions) were asked to select among 100 releasing incisions) patients
scores (of 0 indicating a very
bad, 50 an average and 100 an
excellent postoperative course).
Patients also had to specify if
and which adverse events
(including pain, swelling,
bleeding and hypersensitivity)
occurred during the
postoperative course
 Table 3. (Continued)

Authors, year Type of study Test group Control group Time of Method of assessment Major findings
(ref. no.) assessment

Cortellini Multicenter, Coronally advanced Coronally advanced 1 week Visual analog scale Visual analog scale values were very low
et al. 2009 randomized flap+ connective flap (43 gingival Miller questionnaire: immediately in both groups and the differences were
(34) controlled trial tissue graft (42 gingival Class I–II gingival after surgery (hardship of the not statistically significant
Miller Class I–II recessions) procedure and intrasurgical
gingival recessions) pain perception) and at the
time of suture removal
(postoperative pain, discomfort,
use of anti-inflammatory
tablets, interference with daily
life, interference with job,
interference with relationships
and tooth hypersensitivity)
Zucchelli et al. Randomized Coronally advanced Coronally advanced 1 week Visual analog scale Painkiller consumption increased with
2010 (124) controlled trial flap+ de-epithelialized flap+ connective questionnaire: discomfort, increasing height of the withdrawal and
gingival graft; 25 tissue graft (25 gingival bleeding, stress and inability to by reducing the thickness of the soft
gingival Miller Class I– Miller Class I–II chew. Postoperative pain was tissue still covering the palatal bone
II gingival recessions) gingival recessions). indirectly evaluated on the
The trapdoor basis of the mean consumption
technique was used as (in mg) of analgesics
the harvesting (ibuprofen)
technique
Mcguire & Split-mouth, Coronally advanced Coronally advanced 1 week, Visual analog scale Subjects’ assessments of pain and
Scheyer 2010 randomized, flap+ collagen matrix flap+ connective 1 month and questionnaire: pain or discomfort were equivalent. Collagen
(78) controlled (25 Miller Class I–II tissue graft (25 Miller 6 months discomfort assessments (‘no matrix+ coronally advanced flap
clinical trial gingival recessions) Class I–II gingival pain’ to ‘extreme pain’) on 10- presents a viable alternative to
recessions) cm visual analog scales. At the connective tissue graft+ coronally
same time intervals, subjects advanced flap, without the morbidity of
also indicated whether test, soft-tissue graft harvest
control or donor sites
presenting the greatest sites of
discomfort were equivalent
Hansmeir & Prospective Sixteen patients received connective tissue graft 1 week Oral Health Impact Profile Pain was more pronounced at the donor
Eickholz longitudinal harvested and grafted using the envelope questionnaire; visual analog site than at the recipient site regarding
2010 (50) study technique scale for the intensity prevalence, intensity and duration.
Baseline Oral Health Impact Profile was
decreased by 3 months after surgery
Patient-centered outcomes

39
 Table 3. (Continued)

40
Authors, year Type of study Test group Control group Time of Method of assessment Major findings
(ref. no.) assessment

Jepsen et al. Split-mouth, Coronally advanced Coronally advanced 1 and 2 weeks A questionnaire as well as a The patient assessments of pain or
Mounssif et al.

2013 (61) multicenter, flap+ collagen matrix flap (45 Miller Class I– visual analog scale was given to discomfort were equivalent for test and
randomized (45 Miller Class I–II II gingival recessions) the patients to assess pain and control groups
controlled trial gingival recessions) discomfort during the initial
healing phase
Aroca et al. Split-mouth Modified coronal Modified coronal 2 weeks Visual analog scale questionnaire Duration of surgery and patient
2013 (5) randomized advanced tunnel advanced tunnel+ for discomfort, duration and morbidity were statistically significantly
controlled trial +collagen matrix (78 connective tissue graft difficulty lower in the collagen matrix group
Miller Class I–II (78 Miller Class I–II compared with the connective tissue
gingival recessions) gingival recessions) graft group
Zucchelli et al. Randomized Coronally advanced Coronally advanced 1 week Postoperative pain was indirectly Lower analgesic consumption and better
2014 (126) controlled flap+connective tissue flap+ connective evaluated on the basis of the postoperative course evaluations were
study graft (‘small graft’; 30 tissue graft (‘big graft’; mean consumption (in mg) of found for the ‘small graft’ group
Miller Class I–II 30 Miller Class I–II analgesics (ibuprofen).
gingival recessions) gingival recessions) A visual analog scale
questionnaire was used to
record postoperative
discomfort, bleeding and
inability to chew
Zucchelli et al. Randomized Coronally advanced Coronally advanced 1 week Visual analog scale questionnaire The postoperative course-related visual
2014 (127) controlled flap+ connective flap for multiple for discomfort, bleeding, stress analog scale scores were high for both
study tissue graft for gingival recessions (25 and inability to chew procedures, indicating limited
multiple gingival patients) postoperative pain/discomfort for both
recessions (25 patient groups. However, a statistically
patients) significantly better postoperative
course was reported by the coronally
advanced flap group
Zucchelli et al. Randomized Coronally advanced Coronally advanced 1 week Postoperative pain was indirectly Very limited postoperative morbidity
2014 (122) controlled flap+ connective flap+ connective evaluated on the basis of the was reported by both patient groups.
study tissue graft (25 Miller tissue graft (25 Miller mean consumption (in mg) of There was no statistically significant
Class I and II gingival Class I and II gingival analgesics (ibuprofen). A visual difference in terms of discomfort and
recessions at first recessions at first analog scale questionnaire was bleeding according to the visual analog
molar teeth) labial molar teeth) used to evaluate postoperative scale value
submucosal tissue discomfort, bleeding and
inability to chew
 Patient-centered outcomes

reported that statistically significant differences were

SI, single incision; FGG, free gingival graft; TD, trap door technique; PCG, platelet concentrate graft; SCTG, subepithelial connective tissue graft; FSTG, free soft tissue graft; ADM, acellular dermal matrix; VAS, visual analog scale;
Postoperative pain was indirectly Surgical chair time required to develop a

connective tissue graft group reported

found between the single-incision and free gingival

Visual analog scale questionnaire Graft thickness was directly correlated

coronally advanced flap+ connective

Increased palatal mucosal thickness,

significantly longer than that in the

with the amount of pain perceived.
graft techniques in terms of complete wound epithe-

before and after graft harvesting,

tissue graft group. The coronally

lialization, which occurred faster in the single-incision

tunnel has been shown to be

advanced flap+ subepithelial

group. The discomfort rate recorded for both single-
incision and trapdoor groups was significantly lower

less pain or discomfort

decreased pain levels
than for the free gingival graft group, with no marked
differences between single-incision and trapdoor pro-
cedures. The latter was confirmed by patient inter-
Major findings

views. The results of this preliminary study have little

statistical significance because of the limited number
of patients but they represent an important basis for a
comparative clinical study. Griffin et al. (48) (Table 3)
conducted a prospective study to compare the fre-
mean consumption (in mg) of
evaluated on the basis of the

quency of occurrence of pain, swelling and bleeding

questionnaire was used to

discomfort, bleeding and after free soft-tissue grafting or subepithelial connec-

analgesics (ibuprofen).

evaluate postoperative

tive tissue grafting procedures, to evaluate any effect

Method of assessment

A visual analog scale

that the application of an acellular dermal matrix as

for perceived pain

inability to chew

the donor-tissue alternative to a free soft-tissue graft

or a subepithelial connective tissue graft might have
on the frequency and/or severity of these complica-
tions and to identify possible predictors for these com-
plications. At the 1-week follow-up appointment,
every patient was given a questionnaire to rate post-
and 28 days
1, 3, 7, 14, 21

operative pain, swelling and bleeding for the previous

assessment

DGG, de-epithelialized gingival graft; SCTG, subepithelial connective tissue graft; TT, tunnel technique; NA, not available.

week, and overall discomfort on day 7. The levels of

Time of

3 days

complications were classified as none to minimal if

the score was 0–3, moderate for a score of 4–6 and sev-
connective tissue graft connective tissue graft

gingival Miller Class I– gingival Miller Class I–

ere for a score of 7–10. Griffin et al. (48) reported that

90 patients scheduled for different periodontal

pain and swelling were the most significant complica-

Coronally advanced
flap+ subepithelial
and peri-implant plastic surgeries requiring

single or multiple
(25 patients with

tions, with 27–40% of subjects reporting moderate or

Control group

II recessions)

severe pain and 19–60% reporting moderate-to-severe

swelling. In general, bilaminar procedures were asso-
palatal mucosal graft harvesting

ciated with a lower incidence of moderate or severe

pain compared with free soft-tissue grafting (27% vs.
38.7%, respectively) but with a higher incidence of
moderate or severe swelling (31.6% vs. 21.3%, respec-
Tunnel technique+

single or multiple

tively). Only a small percentage of subjects (< 6%)

(25 patients with

experienced moderate or severe bleeding and only in

II recessions)
controlled trial subepithelial

the groups in which autogenous tissue was used.

Test group

Moderate or severe discomfort after 1 week was

reported only after subepithelial connective tissue
graft procedures and by relatively few subjects (7.6%).
The authors concluded that long surgical procedures
Observational
Authors, year Type of study

Gobbato et al. Randomized

and smoking habits correlate closely with postopera-

case series

tive complications. Among the different periodontal

Table 3. (Continued)

plastic surgeries, the free soft-tissue grafting proce-

dure will probably increase the probability of postsur-
gical pain and bleeding, whereas the use of an
Burkhartdt &
Lang 2015

acellular dermal matrix as an alternative graft material

2016 (46)
(ref. no.)

eliminates the second surgical site and may reduce

(18)

the likelihood for postsurgical swelling and bleeding.

The same procedures (connective tissue graft vs. free

41
Mounssif et al.
gingival graft) were investigated by Wessel & Tatakis
(116) (Table 3) in an observational parallel-group
study. Postoperative questionnaires were given to the
patients to evaluate pain using visual analog scale
scores from 1 to 10, with 1 indicating minimal pain
and 10 indicating severe pain. The 3-day question-
naire assessed pain in the first 3 postoperative days,
and the 3-week questionnaire assessed pain from 3-
days postoperatively to 3 weeks postoperatively. Sub-
jects were also asked to indicate the location of pain:
donor site; recipient site; or elsewhere in the mouth.
The results indicated that free gingival grafts were
associated with a greater incidence of donor-site pain
compared with connective tissue grafts during the
early postoperative period. There were significant dif-
ferences between early (3-day) and late (3-week) pain
levels for free gingival grafts. The results also indicated
that longer term (3-week) pain levels after soft-tissue
grafting were associated with higher levels of analgesic
usage. Among subjects treated with connective tissue
graft, 33% reported pain in the donor site, 25%
reported pain in the recipient site and none reported
pain elsewhere. Among the subjects treated with free
gingival grafts, 36% reported pain in the donor site,
18% reported pain in the recipient site and 9%
reported pain elsewhere. Intragroup comparisons for
the free gingival graft group showed that the visual
analog scale pain score was reduced significantly at
3 weeks compared with 3 days, whereas the differ-
ence did not reach significance for the connective tis-
sue graft group. The authors suggested that, from a
patient comfort perspective, connective tissue graft
might be the procedure of choice when both free gin-
gival graft and connective tissue graft can meet the
patient’s surgical needs. The results of that study also
suggested that there is an opportunity to improve the
postoperative protocols of commonly used soft-tissue
grafting procedures; such improvements may include
more effective analgesic protocols and donor wound-
protection schemes. In a recent systematic review,
Cairo et al. (25) showed that postoperative pain and
complications following therapy were difficult to
investigate as a result of data heterogeneity. Coronally
advanced flap plus barrier membrane was frequently
associated with membrane exposure (3, 60, 72, 106)
even if others did not report exposure (97). Coronally
advanced flap+ connective tissue graft was associated
with more pain at the donor site, even if this side
effects was not confirmed by others (60, 100). Possible
reasons may be related to different approaches in
the harvesting technique or suturing modalities
in different studies. Coronally advanced flap plus
enamel matrix derivative seemed to have limited
42
postoperative discomfort (25). In a randomized con-
trolled clinical study, Zucchelli et al. (124) (Table 3)
compared postoperative morbidity and root-coverage
outcomes in patients undergoing trapdoor connective
tissue (control group) and epithelialized (test group)
graft-harvesting techniques for the treatment of gingi-
val recession defects with bilaminar procedures. Post-
operative pain was indirectly evaluated on the basis of
the mean consumption (in mg) of analgesics (ibupro-
fen). Patients’ postoperative discomfort, bleeding,
stress and inability to chew were evaluated using a
questionnaire given to patients 1 week following sur-
gery. The questionnaire included evaluation of the
intensity of the given event on a visual analog scale of
100 mm. Discomfort was defined as the level of sore-
ness/pain experienced by the patients during the first
postoperative week as a result of the palatal wound.
Bleeding was considered to be the prolonged hemor-
rhaging during the postsurgical week as reported by
the patients. Stress was evaluated based on the level of
apprehension and fear experienced by the patients of
jeopardizing the palatal wound. Inability to chew was
described as the level of variation of the patient’s eat-
ing habits as a result of the presence of the palatal
wound. Healing was uneventful for all test patients. In
seven (28%) control patients, dehiscence/necrosis of
the primary palatal flap occurred during the first heal-
ing period (7 days). The difference in painkiller con-
sumption between control and test groups was not
statistically significant. A separate analysis demon-
strated statistically higher consumption of analgesics
in the seven patients experiencing primary flap dehis-
cence/necrosis than in test patients with secondary
intention palatal healing and in control patients with
primary intention palatal wound healing. In contrast,
the difference in analgesic consumption between the
test patients and the control patients experiencing pri-
mary intention wound healing was not statistically sig-
nificant. Painkiller consumption increased with
increasing height of the withdrawal and by reducing
the thickness of the soft tissue still covering the palatal
bone. Very limited postoperative morbidity was
reported in either patient group and no statistically
significant difference was demonstrated between the
control and the test patients in terms of postoperative
discomfort and bleeding-related visual analog scale
values. Statistically significant better results, in terms
of postoperative inability to chew and stress-related
visual analog scale values, were demonstrated in the
control patients than in the test patients. A parallel-
group, multicenter, double-blind, randomized-con-
trolled clinical trial was conducted to compare the
clinical outcomes and patient morbidity of coronally

advanced flap, alone, or in combination with a con-
nective tissue graft, in single Miller Class I and II gingi-
val recessions (34) (Table 3). Patient perception of
intraoperative and postoperative morbidity were eval-
uated using a questionnaire given to patients immedi-
ately after surgery (recording hardship of the
procedure and intrasurgical pain perception) and at
the time of suture removal (recording postoperative
pain, discomfort, use of anti-inflammatory tablets,
interference with daily life, interference with job,
interference with relationships and tooth hypersensi-
tivity). Questionnaires included dichotomous ques-
tions, and the intensity of the given event was
evaluated on a visual analog scale. Patient perception
of the intraoperative morbidity of the two procedures
was mild and there was no statistically significant dif-
ference between the coronally advanced flap alone, or
in combination with a connective tissue graft. How-
ever, the latter resulted in higher average visual analog
scale values and there was a significant effect accord-
ing to center. Hansmeier & Eickholz (50) (Table 3)
adopted oral health-related quality of life question-
naires to address patient-centered outcomes. The Oral
Health Impact Profile questionnaire is one of several
instruments developed to measure oral health-related
quality of life and is widely used in clinical research.
The 49-item version is the most comprehensive ques-
tionnaire to assess oral health-related quality of life
and is able to measure patients’ problems and symp-
toms. The results showed that more patients reported
postsurgical pain at the donor site (50%) than at the
recipient site (38%). Furthermore, those who reported
postoperative pain described it as more intense and
longer lasting at the donor site than at the recipient
site. It seems that harvesting of the connective tissue
graft causes more morbidity than grafting itself. The
results of that study showed that root coverage with
connective tissue graft used according to the envelope
technique improved the oral health impact profile,
although the improvement was not statistically signifi-
cant. Zucchelli et al. (126) (Table 3) evaluated, in a
double-blind, randomized, controlled clinical trial
with a parallel design, whether patient morbidity was
improved by diminishing graft thickness and height,
comparing connective tissue grafts of different thick-
ness and height used in conjunction with the coro-
nally advanced flap for the treatment of single gingival
recession. Postoperative pain was indirectly evaluated
on the basis of the mean consumption (in mg) of anal-
gesics (ibuprofen) (124). Patient postoperative dis-
comfort, bleeding and inability to chew (124) were
evaluated using a questionnaire given to patients
1 week following surgery. The questionnaire included
Patient-centered outcomes
an evaluation of the intensity of the given event using
a visual analog scale. Lower analgesic consumption,
better postoperative course evaluations, better patient
color-match scores and better periodontist esthetic
assessments were reported in the small graft group.
No statistically significant differences were demon-
strated between the two groups in terms of recession
reduction, complete root coverage and increase in
keratinized tissue height; greater gingival thickness
increase was obtained in the control-treated sites.
Recently, Burkhardt et al. (18) (Table 3) investigated
the factors influencing patients’ perception of pain
and morbidity at the palatal donor site after mucosal
graft harvesting. The authors found that pain was
most pronounced on the first postoperative day and
decreased with time. Graft thickness was directly cor-
related with the amount of pain perceived, while
increased palatal mucosal thickness before and after
graft harvesting was associated with decreased pain
levels. The denuded wound surface area, however, did
not influence the perceived pain level. The data
obtained confirm the results of previous studies (124,
126), in which less patient morbidity was reported in
coronally advanced flaps and connective tissue grafts
of reduced thickness and height compared with the
large graft group (126), and free gingival grafts with a
thinner dimension and the extra-oral removal of
epithelium are often preferred over thick grafts har-
vested using a trapdoor technique (124). In a recent
study, Gobbato et al. (46) (Table 3) pointed out that in
most instances, the focus of pain assessment revolves
around the tissue donor site, which is normally the
palatal region proximal to the maxillary premolars,
and minimal attention is paid to the perception of
pain from the recipient area or the overall oral cavity.
More trivial postoperative symptoms, such as pain,
discomfort, swelling and mild bleeding, are experi-
enced routinely by patients undergoing mucogingival
surgery (48, 52). In general, such manifestations are
short lived and occur over the early postoperative per-
iod (3 days) (116). The authors compared the patient
morbidity and root-coverage outcomes of a subep-
ithelial connective tissue graft used in combination
with a coronally advanced flap or tunnel technique.
Postoperative pain was indirectly evaluated on the
basis of the mean consumption (in mg) of analgesics
(ibuprofen). All patients were asked to complete a
questionnaire designed to evaluate pain experience,
such as postoperative discomfort, bleeding and inabil-
ity to chew, at early (3 days) stages following the surgi-
cal procedure. The survey utilized a visual analog scale
scored from 1 to 10, with 1 indicating minimal pain
and 10 indicating severe pain. If a patient indicated
43
Mounssif et al.
that no pain was present, a score of 0 was given. Differ-
ent parameters were investigated regarding postoper-
ative bleeding, quantity and type of analgesic
medication taken, and the patient undergoing a simi-
lar procedure in the future, if recommended by their
dentist. Discomfort was defined as the level of sore-
ness/pain in the grafted area that was experienced by
the patients during the first 3 days. Bleeding was con-
sidered to be prolonged hemorrhaging during the first
3 days postsurgery, as reported by the patient. Inabil-
ity to chew was described as the level of variation of
the patient’s eating and drinking habits because of the
presence of the wound. The results showed that
patients treated with subepithelial connective tissue
graft plus coronally advanced flap reported less pain
or discomfort in all four sections of the questionnaire:
pain experienced within the mouth as a whole; pain
experienced throughout the day; pain experienced at
night; and edema experienced after the surgery.
The surgical chair time required to develop a tunnel
was shown to be significantly longer than that in
the subepithelial connective tissue graft plus coro-
nally advanced flap group. On average, the surgeon
required 33.6 min for the subepithelial connective tis-
sue graft plus tunnel technique and 23.6 min for the
subepithelial connective tissue graft plus coronally
advanced flap. A positive linear relationship was
observed between surgical time and use of analgesic
medication. In other words, the longer the surgery, the
higher the dosage of painkillers consumed. This may
be explained in that the preparation of an adequate
tunnel requires extreme care and attention, in particu-
lar in patients with thin gingival soft tissue. In addi-
tion, in order to prepare adequately a tunnel, the
surgical area has to be extended at least one tooth
mesial and one tooth distal to the defect area. This
could explain why the group treated with subepithelial
connective tissue graft plus coronally advanced flap
reported less pain or discomfort in all four aspects of
the questionnaire. The pain perception and oral func-
tion gradually improved during the first week, but
social and recreational activities and daily routines
were affected, especially during the first three postop-
erative days.
To our knowledge, patient morbidity after root cov-
erage is highly associated with the harvest of soft tis-
sue from the palate, and the palate provides limited
donor tissue, allowing only a few teeth to be treated at
one time. Within the dental community, there is a
strong desire to identify an alternative graft material
that could be used as a substitute for connective tissue
graft (129). A suitable substitute would reduce morbid-
ity and the number of surgical sites required and
44
increase the number of teeth that could be treated in
one surgical visit. In principle, three basic soft-tissue
substitute materials of different origin can be distin-
guished – allogeneic (of human origin), xenogeneic
(from another species, e.g. of porcine or bovine origin)
and alloplastic (of artificial origin) (129) – and only a
few of these have shown scientifically documented
success. Acellular dermal substitutes were the first
soft-tissue substitute materials to be introduced to the
dental market. The best-researched type is the acellu-
lar dermal matrix, an allogeneic substitute that con-
sists of a freeze-dried connective tissue matrix,
without epithelium and cellular components, which is
obtained from tissue banks by a standardized, con-
trolled manufacturing process. A systematic review by
Cairo et al. (25) revealed considerable heterogeneity
in clinical outcome measures after 6–12 months and
concluded that adding acellular dermal matrix to
coronally advanced pedicle flaps did not improve the
clinical results compared with the use of coronally
advanced flaps alone and was inferior to the combina-
tion of coronally advanced flap and subepithelial con-
nective tissue graft (25), even though no postoperative
pain and complications were reported in comparisons
between coronally advanced flaps used with an acellu-
lar dermal matrix vs. coronally advanced flaps alone
(35, 117) and coronally advanced flaps used with an
acellular dermal matrix vs. coronally advanced flaps
used with connective tissue graft (62). Moreover, care
needs to be taken if grafts of larger dimensions are
required because folded or layered acellular dermal
matrices might impede vascularization and lead to
extensive shrinkage (8, 114). Ethical concerns stem-
ming from allograft being derived from human cadav-
ers and the purported risk of disease transmission are
remarkable counterpoints of the material frequently
expressed by patients (129). A newly developed xeno-
geneic collagen matrix has been shown to promote
regeneration of keratinized gingiva around teeth and
implants in association with tissue-augmentation pro-
cedures (102) and to improve early mucosal wound
healing (108). McGuire & Scheyer (78) studied the
safety and efficacy of this collagen matrix when used
with a coronally advanced flap in the treatment of
recession defects in 25 patients with bilateral Miller
Class I and Class II recession defects in a monocenter,
randomized, single-blind, split-mouth trial. Although
values of root coverage for coronally advanced flaps
used with connective tissue graft (99.3%) were higher
than for coronally advanced flaps used with collagen
matrix (88.5%), the latter procedure was found to be
less invasive and time consuming because of an
unlimited off-the-shelf supply of grafting material,

and it was concluded that it presents a viable alterna-
tive to the connective tissue graft procedure. A multi-
center single-blinded, randomized, controlled, split-
mouth trial (61) evaluated the clinical outcomes of the
use of a xenogeneic collagen matrix in combination
with the coronally advanced flap in the treatment of
localized recession defects. The use of collagen matrix
resulted in significantly more gain in gingival thick-
ness and width of keratinized tissue. The patients of
this study were instructed to record daily the intensity
of pain and the dose of medication in a patient ques-
tionnaire. The patient assessments of pain or discom-
fort were equivalent for test and control groups. No
differences could be observed in visual analog pain
scores at 7 and 14 days postsurgery. Aroca et al. (5)
(Table 3), in a prospective, randomized, controlled,
split-mouth clinical study, clinically evaluated the
treatment of Miller Class I and Class II multiple gingi-
val recessions using modified coronal advanced tun-
nel with either collagen matrix or connective tissue
graft. Both procedures were evaluated by the patient
(on a visual analog scale) for discomfort, duration and
difficulty. Postoperative complaints, duration of sur-
gery and patient morbidity were lower for the collagen
matrix group compared with the control group. The
authors showed that the use of collagen matrix may
represent an alternative to use of connective tissue
graft by reducing surgical time and patient morbidity,
but yielded lower complete root coverage than con-
nective tissue graft, in the treatment of Miller Class I
and Class II multiple adjacent gingival recession
defects, when used in conjunction with a modified
coronal advanced tunnel procedure. In a recent meta-
analysis, Atieh et al. (6) evaluated 645 studies, of
which six trials were included with 487 mucogingival
defects in 170 participants. The xenogeneic collagen
matrix had a significantly higher mean root coverage,
recession reduction and gain in keratinized tissue
compared with the coronally advanced flap alone. No
significant differences in patient’s esthetic satisfaction
were found between xenogeneic collagen and connec-
tive tissue graft, except for postoperative morbidity in
favor of xenogeneic collagen. Operating time was sig-
nificantly reduced with the use of xenogeneic collagen
compared with connective tissue graft but not with
coronally advanced flap alone. There is no evidence to
demonstrate the effectiveness of xenogeneic collagen
in achieving greater root coverage, recession reduc-
tion and gain in keratinized tissue compared with con-
nective tissue graft plus coronally advanced flap.
Superior short-term results in treating root coverage
compared with coronally advanced flap alone are pos-
sible. The authors showed that there is limited
Patient-centered outcomes
evidence that collagen matrix may improve esthetic
satisfaction, reduce postoperative morbidity and
shorten the operating time. Further long-term ran-
domized controlled trials are required to endorse the
supposed advantages of collagen matrix (6). The visual
analog scale is the most widely used approach to
assess patient morbidity after periodontal plastic
treatment; more recently, the use of CONSORT guide-
lines in reporting randomized clinical trials also
improved the information on patient-related out-
comes by using a visual analog scale (23) which is easy
to administer and is reproducible. There is evidence
showing that a visual analog scale has superior metri-
cal characteristics than discrete scales and thus a
wider range of statistical methods can be applied to
the measurements obtained using a visual analog
scale (96). McGuire et al. (80), in a recent commen-
tary, suggested that independent recorders administer
patient-reported outcomes questionnaires, before
and immediately after surgery, to investigate anxiety,
pain/discomfort and treatment preference. The
authors were able to understand the nature of the
patients’ experience of test and control therapies
only by asking multiple, specific questions about the
severity of pain experienced at different sites in the
mouth. This revealed that any pain advantage
offered by a nonharvest therapy is because of the
absence of tissue harvest and not a result of reduced
pain at the treatment site. Additionally, pain and
satisfaction changed dramatically over time, suggest-
ing that single measures of either construct may
miss important treatment differences at other time
points.
Hypersensitivity
Dentine hypersensitivity may be defined as pain aris-
ing from exposed dentine, typically in response to
chemical, thermal or osmotic stimuli and that cannot
be explained as arising from any other form of dental
defect or pathology (1). The main symptoms are sharp,
well-localized pain of short duration (91). Dentine
hypersensitivity is a common problem found in many
adults with prevalence figures ranging from 4% to 74%
(27, 42, 44, 57, 59, 73, 84, 87, 95). This wide variation in
prevalence may result from a number of factors,
including different methods used to diagnose the con-
dition and variation in the consumption of erosive
foods and drinks (39).
Cervical dentin hypersensitivity is one of the most
painful, and least predictably treated, chronic condi-
tions in dentistry (67). The treatment and prevention of
45
Mounssif et al.
cervical dentin hypersensitivity uses tubular occlusion
and/or the blockage of nerve activity (92, 107), and laser
therapy (45, 103), oxalates (7, 112) and dentinal tubule-
occluding agents (53, 104) were also investigated to
evaluate their effectiveness. Surgical root coverage is
another form of treatment for cervical dentin hypersen-
sitivity. In fact, alleviation of root sensitivity in areas with
localized or generalized soft-tissue recessions is one of
the major therapeutic goals in mucogingival surgery
(115). Surgical treatment occludes the exposed dentinal
tubules and offers the benefit of esthetic improvement
in the sensitive areas associated with gingival recessions
(23, 25, 28, 56).
Very few studies have evaluated root sensitivity fol-
lowing root-coverage procedures and no meta-ana-
lyses have been carried out as the data were few and
heterogeneous (23, 25). Recently, a systematic review
(39) surveyed the literature on the efficacy of surgical
root-coverage techniques at reducing cervical dentin
hypersensitivity in cases of gingival recession. They
evaluated nine randomized clinical trials that met the
inclusion criteria. In the studies analyzed, cervical
dentin hypersensitivity was assessed using patient
opinions in six and evaporative stimuli in two. One
randomized controlled study did not mention the
method used to assess dentin sensitivity (90). Cervical
dentin hypersensitivity was measured as present or
absent in six studies (9, 11, 34, 89, 100, 101) and on a
qualitative scale in the other randomized clinical tri-
als (10, 12, 77). The data extracted from the studies
evaluated in this review revealed heterogeneity in
relation to the type of intervention, follow-up period,
clinical parameters assessed, type of gingival reces-
sion, evaluation of cervical dentin hypersensitivity
and study design. Thus, it was not possible to estab-
lish a quantitative synthesis of the data, thereby
rendering meta-analysis impossible. A decrease in
cervical dentin hypersensitivity was observed after
periodontal surgery for root coverage, but the results
of this systematic review should be viewed with cau-
tion because most of the studies reviewed had a high
risk of bias and cervical dentin hypersensitivity was
assessed as a secondary outcome. Hence, there is not
enough evidence to conclude that surgical root-cov-
erage procedures predictably reduce cervical dentin
hypersensitivity. Adequately powered randomized
clinical trials with robust measurements of dentin
hypersensitivity are needed to allow periodontists to
indicate root coverage as a safe, lasting treatment for
cervical dentin hypersensitivity (39). The same group
conducted a case series (38) on 25 consecutive gingi-
val recession defects treated for cervical dentin hyper-
sensitivity. Dentin hypersensitivity was diagnosed by
46
cold stimulation spray and air blast from a triple syr-
inge (118). Cold was applied to the tooth using a cot-
ton swab for 5 s and the air blast was applied to the
exposed buccal cervical area at a distance of 1 cm for
5 s. Adjacent teeth were protected using utility wax. A
numeric rating scale was used to record the cervical
dentin hypersensitivity related to the stimuli, with a
pain score from 0 (no pain) to 10 (extreme pain). The
Oral Health Impact Profile-14 questionnaire was
used to assess oral health-related quality of life (86).
The Oral Health Impact Profile-14 evaluates seven
dimensions (functional limitations, physical pain,
psychological discomfort, physical disability, psycho-
logical disability, social disability, handicap) on a
scale ranging from 0 to 28 points, with higher scores
indicating more impact of oral conditions on quality
of life. The same instrument was used at baseline and
3 months after treatment and was completed by the
patient before the evaluation of clinical measures and
cervical dentin hypersensitivity. The participants
responded on a 5-point Likert scale. One operator
performed all surgeries using a coronally advanced
flap and connective tissue graft. The authors showed
a statistically significant reduction in cervical dentin
hypersensitivity evaluated by thermal and evapora-
tive stimuli. The difference found in cervical dentin
hypersensitivity before and after the surgery may
be explained by the increase of keratinized gingiva,
which was able to occlude the dentinal tubules.
However, some patients still complained of cervical
dentin hypersensitivity after the surgery, despite pain
levels being lower in comparison with baseline.
According to Clauser et al. (32), only complete defect
coverage ensures total recovery from cervical dentin
hypersensitivity. The statistically significant decrease
in cervical dentin hypersensitivity after defect cover-
age corroborates the findings of previous studies
(100, 101); however, those studies used no stimuli to
assess cervical dentin hypersensitivity – only patients’
reports were used, and cervical dentin hypersensitiv-
ity was measured as absent or present. Other ran-
domized clinical trials also found a reduction in
cervical dentin hypersensitivity after surgery (10, 34,
89) but cervical dentin hypersensitivity was reported
as absolute frequency and no statistical analyses were
performed regarding cervical dentin hypersensitivity
and defect coverage.
Conclusions
According to the literature, two main indications exist
for the treatment of gingival recession: esthetics and

hypersensitivity. The ultimate goal of treatment is to
achieve a satisfactory esthetic outcome in the eyes of
the patient and to resolve any hypersensitivity present
with minimal patient morbidity. Despite one of the
major goals of root-coverage surgery being the resolu-
tion of root sensitivity in areas with soft-tissue reces-
sions (115), very few data on this issue are available
in the literature. Numerous studies have reported
dentin hypersensitivity as an indication for the treat-
ment of gingival recessions; however, very few stud-
ies have carried out an appropriate assessment. In
fact, often the presence or absence of hypersensitiv-
ity, as well as its possible resolution after surgical
treatment, are reported with empirical sentences. A
standardized and reproducible method for the evalua-
tion of dentin sensitivity, which allows for compar-
ison between pre- and postoperative sensitivity, is
advocated.
Root-coverage surgical procedures are associated
with varying degrees of patient morbidity. Patients
report a greater degree of morbidity from the donor
site, where one is used, compared with the recipient
site during periodontal plastic surgery. Of the differ-
ent connective tissue graft-harvesting procedures
described in the literature, the trapdoor (40), single-
or double-incision technique (55, 75) and a thin free
gingival graft de-epithelialized extraorally (124, 126)
seem to be associated with a better postoperative
course. The wound depth at the donor site (graft
thickness) is positively correlated with the patient’s
perception of pain (18, 126). To date, the clinical deci-
sion of whether to harvest subepithelial connective
tissue grafts from the anterior or the posterior palate
is not based on scientific evidence but rather on the
amount of tissue available at the different donor sites,
the indication for transplantation and, in particular,
the personal preference of the treating surgeon (129).
As the palate provides limited donor tissue, allowing
only a few teeth to be treated at a time, efforts have
been made to identify an alternative graft material
that could be used as a substitute for connective tis-
sue graft. The use of allografts or xenogenic grafts
compared with connective tissue graft in the treat-
ment of gingival recessions were consistently associ-
ated with a better postoperative course (6, 78). The
method most commonly adopted to assess patient
morbidity is the visual analog scale, which seems
easy to administer and reproducible. It has been
suggested that this should be administered before and
after treatment by an independent assessor. Future
research should focus on standardized methods for
the evaluation of patient morbidity. These methods
should include postoperative discomfort (pain, bleeding,
Patient-centered outcomes
inability to chew) and the impact of the surgical pro-
cedure on patients’ life habits as well as anxiety and
treatment preference (80). The evaluation of esthetic
appearance by professionals after root-coverage pro-
cedures have been investigated in a few clinical trials.
The methods used are highly variable but all use pho-
tographic assessment (16, 26, 31, 64, 65, 99, 113) and
a scale (34, 122, 123, 126, 127). Color match, tissue
texture, contour, contiguity and keloid formation
were the parameters most commonly investigated by
expert periodontists. Root-coverage esthetic score
(22) seems to be a reliable method for professionals
to assess the esthetic outcomes of root-coverage pro-
cedures. Despite the numerous studies presents in
the literature on the treatment of gingival recessions,
only limited papers reported data about esthetic eval-
uation from a patient’s view. A visual analog scale or
a 5-point scale was the tool most commonly used to
determine patients’ satisfaction with the esthetic out-
come. The perception of recession defects by the
patients and the real need for treatment are often
underestimated in professional practice and are, as
yet, not discussed in the periodontal literature (85).
At present, no information on patient perceptions
and spontaneous patient requests for surgical or non-
surgical treatment are available in the literature.
Commonly, after the diagnostic phase, the treatment
used is decided exclusively by the periodontist and is
based on his/her own knowledge, clinical experience
and financial benefit (33, 125). Recently, it has been
shown (30) that untreated gingival recession defects
tend to progress over time. These findings may increase
the indications for treatment of gingival recession
defects. Therefore, the presence of gingival recessions,
per se, may become an indication for their treatment.
Untreated gingival recessions in teeth with no esthetic
relevance but localized in areas with unfavorable ana-
tomic conditions (i.e. mandibular incisors and molars)
(121, 122) should be treated by mucogingival surgery in
order to prevent further progression and worsening of
prognosis. In the mandibular incisors, the lack of early
diagnosis may render orthodontic repositioning of the
tooth/root with gingival recession mandatory before
the surgical treatment (128) (Figs 7–10).
The recent systematic reviews (23, 29) and consen-
sus (105, 109) point out the lack of patient esthetic
evaluation in the scientific studies and the authors of
the present review stress the need to focus research
on personal/individual requests. The patient per-
ception outcomes should be the center of the investi-
gation, and a standardized approach (taking into
account subjective evaluations) would be desirable.
The esthetic judgment of the periodontists (66) may
47
Mounssif et al.
not always be consistent with patient satisfaction and
it remains to be evaluated if what is more important
for the professional is really more critical for the
patient. For example, complete coverage provides a
greater contribution to root-coverage esthetic score
(26) but it has not been demonstrated that this is
really what the patient looks for in the final outcome.
Often, patients are more concerned by the difference
in color or, less frequently, by differences in tissue
thickness than incomplete root coverage. However,
overall, patients appear to rate the cosmetic results
more favorably than the professionals (66). The rea-
son for the discrepancy between the subjects’ and
professionals’ perceptions of esthetic outcome is
not well understood. Certainly, the subjectivity of
esthetic perception is crucial and it is different not
only between patient and clinician but also between
patients. The preoperative clinical situation probably
influences patients’ evaluation of the final outcome.
For example, when the preoperative situation is
highly compromised, patients’ expectations are real-
istic and accordingly patients might be more satisfied
than a professional evaluator, even when the esthetic
outcome, according to an objective index, is rated
acceptable or even poor. Furthermore, esthetic evalu-
ation made using photographs does not represent a
reliable method because in most of the photographs
used for esthetic assessment a lip retractor has been
A B
Fig. 7. Baseline clinical situation. (A) Deep gingival reces-
sion in the lower incisor. Tooth malposition, the depth of
root exposure, the absence of keratinized tissue and the
presence of a buccal probing pocket depth of 3 mm
A B
Fig. 8. Postorthodontic clinical situation. (A) Orthodon-
tic repositioning of the tooth/root allowed for reduction
of the root exposure in depth and width, new formation
of keratinized tissue and reduction of buccal probing
48
used, which removes the lip from the image and
influences the color and adds tension or muscles
and frenulum pull. Coupled with this, the reflection
of the flash light and different projection sometimes
make the outcome appear worse and sometimes bet-
ter than the true situation. Certainly, short videos
before and after therapy, during which the patient’s
speech, smile and usual gingival tissue show is appar-
ent, may represent a situation more similar to the
reality and may be used by the expert professional
periodontist for the esthetic evaluation of the out-
come of root-coverage surgical procedure. Finally,
comparison of photographs taken of the baseline,
presurgical clinical situation with photographs show-
ing the final result before undertaking the profes-
sional esthetic evaluation is a matter of debate. On
the one hand, it is true that the patient is influenced
in his/her evaluation of the final result by the mem-
ory of the pretreatment situation. On the other hand,
for an esthetic evaluation to be fair and objective, the
evaluation of the final result should be carried out
blinded to the preoperative situation. It is the opinion
of the authors that preoperative photographs (or,
better still, movies) should be used only to evaluate
certain outcomes of a surgical procedure, such as
the amount of root coverage, while post-treatment
photographs/movies should be utilized on their own,
by different, blinded operators (professional and
complicate surgical treatment. (B) The occlusal view shows
the disalignment, with buccal displacement of the tooth/
root with gingival recession. Orthodontic tooth/root repo-
sitioning is advocated before surgical treatment.
depth to (1 mm). (B) The occlusal view shows the
realignment of the tooth/root with gingival recession
and the newly formed keratinized tissue apical to the
root exposures.

A B
Fig. 9. Surgical technique. (A) A trapezoidal buccal flap
was elevated and the root exposure was planned. (B) A
connective tissue graft, deriving from the extra-oral disep-
ithelization of a free gingival graft, was sutured (7-0 PGA)
A B
Fig. 10. One-year clinical outcomes. (A) The buccal aspect
shows complete root coverage and good camouflaging of
the treated area with respect to the adjacent soft tissue.
The patient was extremely satisfied with the esthetic out-
come although she had not expressed any esthetic request
nonprofessional) to perform a more truthful esthetic
evaluation.
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53
Periodontology 2000, Vol. 77, 2018, 54–64
Printed in Singapore. All rights reserved
Decision making in root-
coverage procedures for the
esthetic outcome
M A R T I N A S T E F A N I N I *, M A T T E O M A R Z A D O R I *, S O F I A A R O C A , P I E T R O F E L I C E ,
MATTEO SANGIORGI & GIOVANNI ZUCCHELLI
Root-coverage periodontal plastic surgery procedures
have long been used for the treatment of gingival
recession. Esthetics, dental hypersensitivity and the
prevention of caries and non-carious cervical lesions
are considered the main indications reported in the
literature (16). In the 1960s and 1970s, mucogingival
surgery was focused on treating the so-called
mucogingival defects, in other words the lack of both
thickness and height of keratinized tissue. At that
time, Lang & Loe (27) demonstrated a relationship
between the inflammatory state of marginal tissue
and the amount of keratinized tissue, asserting the
need for a critical amount of keratinized tissue to
maintain a good state of health (16). With this ratio-
nale, the elective surgical technique was the free gin-
gival graft (21, 28, 31, 33, 36). Later on, studies
performed on animal and human subjects demon-
strated that the critical aspect in maintaining a peri-
odontally healthy condition is plaque control, despite
the width of keratinized tissue (18). The indications
for free gingival graft shifted from the augmentation
of keratinized tissue to root coverage. Along with free
gingival grafts, other pedicle flaps, essentially the lat-
erally positioned flap described by Grupe & Warren
(22), the coronally advanced flap, which was first
introduced by Norberg (32) and later modified by
Bernimoulin et al. (8) and Allen & Miller (2), and the
coronally advanced flap associated with a connective
tissue graft (35), were developed to reach this
objective.
As the esthetic expectations and perceptions of
patients have become increasingly more demanding
*These authors contributed equally.
54
© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
PERIODONTOLOGY 2000
in the last decades, the ultimate goal of mucogingi-
val surgery is not only root coverage but also an
esthetic outcome, which results in the complete
blending of tissue color and texture of the treated
area with the adjacent soft tissues (19). For these
reasons and in order to emphasize the esthetic pur-
pose of these procedures, the American Academy
of Periodondology (3) recently substituted the old
term ‘mucogingival surgery’ with ‘periodontal plastic
surgery’.
Along with the development of root-coverage surgi-
cal techniques, criteria have been developed to
improve evaluation of the esthetic outcomes. This
evaluation can be subjective or objective. The objec-
tive evaluation is intended as a professional judgment
based exclusively on clinical parameters and can be
assessed using different methods (12, 24, 50). The
subjective evaluation is intended as a judgment by
the patient based on his/her personal perception and
collected through questionnaires or visual analog
scores (17, 44).
Until a few years ago, clinicians and researchers
used complete root coverage (the gingival margin
located at the cementoenamel junction), healthy sul-
cus depth (≤ 2 mm), the presence of clinically
attached gingiva and no bleeding on probing of the
treated sites as primary outcomes of successful treat-
ment for gingival recession (30). The recent consen-
sus (37) underlined the lack of clinical trials that took
into account the real needs and requests of the
patient, often the main indication for root-coverage
procedures. Moreover, few studies evaluated patients’
esthetic satisfaction following therapy, mainly collect-
ing their opinion in a non-standardized way (14).
With procedures aiming to improve patient esthetics,

patient-centered parameters should be the primary
outcome variables.
The purpose of this paper is to suggest a decision-
making process for selecting the appropriate surgical
technique to achieve ideal esthetic outcomes, based
on clinical and anatomic factors.
Objectives of periodontal plastic
surgery
In literature, the predictability of root coverage in a
mucogingival surgical procedure is measured in
terms of the percentage of root coverage (i.e. the
percentage of root previously exposed which is cov-
ered with soft tissues after the healing period) and
the percentage of complete root coverage (namely
the percentage of the treated defect in which the
soft-tissue margin has been repositioned at the level
of, or coronal to, the cementoenamel junction). Very
often, the most coronal millimeters of the exposed
root are the only visible part of the recession when
the patient smiles; therefore, its persistence after
therapy may be considered an esthetic failure (51).
For this reason, in a patient with high esthetic
demand, obtaining complete root coverage is the
primary objective. However, complete root coverage
should not be considered as the sole factor for defin-
ing the outcome of gingival recession treatment (25).
Another important aspect of the esthetic evaluation
that should be considered is the appearance of tissue
after surgery, in terms of color and camouflaging,
between the treated area and the adjacent soft tis-
sues. The final objective of an esthetic treatment
should be to achieve complete root coverage with
perfect blending in terms of color and texture. The
above-mentioned considerations are incorporated
with the introduction of the root-coverage esthetic
score (15). Five variables (the level of the gingival
margin, the marginal contour, the soft-tissue surface,
the position of the mucogingival junction and the
gingival color) are evaluated. A large, multicenter
study among expert periodontists showed that the
root-coverage esthetic score is a reliable method
with which to assess final esthetics after periodontal
plastic surgery, with a total inter-rater agreement of
0.92 indicating almost perfect agreement (12). Fur-
thermore, to our knowledge, only one study (26) has
tried to compare professional and patient esthetic
satisfaction after root-coverage procedures. The
results of this study showed that esthetic judgment
of the periodontists may not always be consistent
with patient satisfaction. Patients were influenced
Esthetic outcome in root coverage
more by the soft-tissue integration variables than by
the percentage of root coverage; and patients
appeared to rate the cosmetic results more favorably
than did the professionals.
Surgical techniques
The most suitable surgical techniques to obtain
good esthetic outcomes are the coronally advanced
flap and subepithelial connective tissue graft proce-
dures (16). The adjunctive use of amelogenins with
the coronally advanced flap could improve root
coverage and gain of clinical attachment level out-
comes when compared with the coronally advanced
flap alone. Amelogenins are mainly indicated for
the treatment of deep and wide gingival recessions
(16). The use of amelogenins or connective tissue
graft substitutes has not been included in this deci-
sion-making process because of the currently lim-
ited evidence that they provide a further esthetic
advantage when compared with the surgical tech-
niques alone.
Coronally advanced flap procedures
Coronally advanced flap techniques can be applied
for the treatment of single or multiple recession
defects. In such techniques the residual gingival tis-
sue, apical to the recession, is coronally advanced
to accomplish root coverage. The coronally
advanced flap is a very safe and reliable approach
in periodontal plastic surgery and allows excellent
blending between the surgical area and the adjacent
tissues.
Coronally advanced flap for single recession defects
The flap is designed as follows: two horizontal
beveled incisions (3 mm in length) are made that
are mesial and distal to the recession defect and
located at a distance from the tip of the anatomical
papillae which is equal to the depth of the recession
plus 1 mm; and two vertical beveled oblique
incisions are made, starting at the end of the two
horizontal incisions and extending to the alveolar
mucosa (19). The resulting trapezoidal-shaped flap
is elevated using a split–full–split approach in the
coronal–apical direction: the surgical papillae are
elevated split thickness (keeping the blade almost
parallel to the bone) and the soft tissue apical to
the root exposure is elevated full thickness by
inserting a small periosteal elevator into the probe-
able sulcus and proceeding in the apical direction
55
Stefanini et al.
to expose 3 mm of bone apical to the bone dehis-
cence. The vertical incisions are elevated split thick-
ness, keeping the blade parallel to the bone plane,
thus leaving the periosteum to protect the underly-
ing bone in the lateral areas of the flap. Apical to
the bone exposure flap, elevation continues split
thickness and ends when it is possible to move the
flap passively in the coronal direction. In order to
permit the coronal advancement of the flap, all
muscle insertions present in the thickness of the
flap must be eliminated. This is carried out by keep-
ing the blade parallel to the external mucosal sur-
face. Coronal mobilization of the flap is considered
as ‘adequate’ when the marginal portion of the flap
is able to reach without tension a level coronal to
the cementoenamel junction of the tooth with the
recession defect. The facial soft tissue of the ana-
tomic papillae coronal to the horizontal incisions
is de-epithelized to create connective tissue beds
to which the surgical papillae of the coronally
advanced flap are sutured. The suture of the flap
starts with two interrupted periosteal sutures per-
formed at the most apical extension of the vertical
releasing incisions; then, it proceeds coronally with
other interrupted sutures, each of them directed
from the flap to the adjacent buccal soft tissue, in
the apical–coronal direction. A sling suture permits
stabilization of the surgical papillae over the inter-
dental connective tissue bed and allows precise and
tight adaptation of the flap margin over the under-
lying convexity of the crown.
Coronally advanced flap for multiple recession
defects
The flap design consists of a horizontal incision
extended to include one tooth or more on each side
of the recessions to be treated to facilitate the coronal
repositioning of the flap tissue over the exposed root
surfaces. The horizontal incision consists of a variable
number of interdental submarginal incisions, which
form, together with the intrasulcular incisions at the
mesial/distal margins of the recession defects, the
surgical papillae of the envelope flap (40). The flap is
raised using a split–full–split approach, in the same
manner as already described for the coronally
advanced flap for single recession defects. When
suturing, a variable (in relation to the number of teeth
included in the flap design) number of sling sutures
are used to obtain a precise adaptation of the buccal
flap on the convexity of the underlying crown sur-
faces and to permit the stabilization of every surgical
papilla over the corresponding de-epithelized ana-
tomic papilla.
56
When is the coronally advanced flap the first choice
in surgical management of recession defects?
The coronally advanced flap is the most suitable sur-
gical technique in patients with high esthetic expecta-
tion as it provides the best esthetic results. It is
indicated when the keratinized tissue height apical to
the root exposure(s) is > 2mm (46). However, some
anatomic factors limit its clinical applicability and
efficacy, such as:
 the absence or only a minimal amount (≤ 1 mm)
of keratinized tissue apical to the recession defect.
 the presence of interdental clinical attachment
loss.
 the presence of a gingival cleft extending into the
alveolar mucosa.
 high frenulum pull at the soft-tissue margin.
 deep root structure loss.
 buccally dislocated root.
 very shallow vestibulum depth.
Subepithelial connective tissue graft
procedures
Coronally advanced flap + connective tissue graft
The coronally advanced flap + connective tissue graft
consists of a pedicle flap covering a subepithelial con-
nective graft. Since the mid-1990s, clinicians have
introduced several modifications to the original bil-
aminar procedure described by Raetzke (35). These
modifications relate both to the type of graft and to
the design of the covering flap. The presence of the
connective tissue graft acts as a stabilizer for the coro-
nally advanced flap, resulting in increased root-cover-
age predictability. Furthermore, because of the
increase in soft-tissue thickness, the adjunct of con-
nective tissue graft allows better long-term mainte-
nance of the root coverage result compared with the
coronally advanced flap alone (34, 48). However, large
grafts can impair the vascular exchange between the
covering flap and the underlying receiving bed,
thereby increasing the risk of flap dehiscence and
unesthetic graft exposure. Recently (39, 47), it was
suggested that the reduced apicocoronal dimension
and thickness of the connective tissue graft could
facilitate graft coverage by the flap, improve esthetic
outcomes and reduce patient morbidity with no
change in root-coverage predictability.
Modified coronally advanced tunnel technique
For the modified coronally advanced tunnel tech-
nique, first of all intrasulcular incisions are placed
and mucoperiosteal flaps are raised using sharp
 Esthetic outcome in root coverage

tunnel elevators (Stoma, Tuttlingen, Germany) (4–6). limiting conditions. Such procedures represent the
The flap is extended beyond the mucogingival junc- first choice when an increase in soft-tissue thickness,
tion and under each papilla to allow passive, tension- as well as complete root coverage, is indicated. They
free mobilization in the coronal direction. The remain- are also the first choice in the presence of interproxi-
ing collagen bundles on the inner surface of the flap mal clinical attachment level loss.
are carefully cut using Gracey curettes until passive
coronal displacement of the flap and papillae are
obtained. A connective tissue graft, harvested immedi-
Decision-making process
ately after the tunnel preparation, is inserted under
The decision-making process starts from the clinical
the tunnelled flap starting from the deepest recession.
observation of the defects and it is structured in pro-
Then, the graft is pulled laterally toward each end of
gressive nodes that will guide the clinician to select
the tunnel using mattress sutures. Finally, the flap is
the most suitable surgical technique (Fig. 1).
positioned coronally to the cementoenamel junction
using suspended sutures placed above the contact
point, previously splinted with composite stops. NODE 1: non-carious cervical lesion
Connective tissue graft wall technique Non-carious cervical lesions are frequently associated
with gingival recessions, especially those induced by
A modification of the coronally advanced flap +
toothbrushing trauma (41). Non-carious cervical
connective tissue graft technique has been pro-
lesions are defined as the loss of hard tissue localized
posed by Zucchelli et al. (43) in gingival recession
in the cervical third of the tooth that may result in
defects associated with interdental clinical attach-
loss of the cementoenamel junction, which repre-
ment and soft-tissue loss. The surgical technique
sents the anatomic reference point for evaluating root
consists of the same coronally advanced flap design
coverage. The major concern related to loss of the
for the treatment of multiple recession defects, in
landmark of the cementoenamel junction is the diffi-
this instance associated with a simplified papilla
culty in determining the maximum level of root cov-
preservation technique (17), which is applied to
erage. One method used to determine maximum root
area affected by clinical attachment level and bone
coverage, based on calculation of the ideal height of
loss. The buccal flap is raised using a split–full–split
the anatomic interdental papilla (45, 51), was demon-
approach and the entire supracrestal soft tissue is
strated to be reliable in predicting the position of the
pushed in the palatal/lingual direction until the tip
soft-tissue margin after root-coverage surgery.
of the interdental papilla is shifted in the most
According to this method it is possible to restore,
coronal position and it is possible to gain access to
using a composite restoration made at the maximum
the bony defect. The palatal/lingual flap is not ele-
level of root coverage, the ideal length and convexity
vated. The remaining facial portion of the adjacent
of the clinical crown, thus providing a stable and
papillae is de-epithelialized and the granulation tis-
smooth substrate for the surgically advanced flap
sue filling the intrabony defect (if present) is
(41). An example of non-carious cervical lesions trea-
removed. A connective tissue graft is then sutured
ted with a composite restoration at the maximum
at the base of the anatomic papillae of the two
level of root coverage is shown in Fig. 2.
teeth neighboring the bony defect. After flap mobi-
lization, sling sutures are used to anchor the surgi-
cal papillae to the corresponding anatomic
NODE 2: interdental clinical attachment
papillae. Complete soft-tissue closure at the inter-
level loss
dental space is achieved using a horizontal mat-
tress suture at the base of the simplified papilla Interdental clinical attachment level loss is a major
and a vertical mattress or single interrupted suture prognostic factor associated with predictability of
in a more coronal position. root coverage by periodontal surgery (11, 13, 29).
There is little data available in the literature, but
When are subepithelial connective tissue graft
recent studies demonstrate that complete root cover-
procedures the first choice in surgical management
age can be achieved even in the presence of interden-
of recession defects?
tal clinical attachment level loss. In 2010, Aroca et al.
Subepithelial connective tissue graft procedures are (4) conducted a randomized clinical trial, with a 12-
indicated when coronally advanced flap alone cannot month follow-up, on 20 patients undergoing a modi-
be performed for the above-mentioned anatomic fied coronally advanced tunnel technique, with or

57
Stefanini et al.
Fig. 1. The decision-making process structured in progres-
sive nodes. CAF, coronally advanced flap; CAF+CTG, coro-
nally advanced flap + connective tissue graft; CTGW,
connective tissue graft wall; GT, gingival thickness; KT,
A B C
without the adjunctive use of amelogenins, in the
treatment of Miller Class III multiple recession
defects; complete root coverage was obtained in 38%
of cases. More recently, a randomized clinical trial
(10) conducted on 29 patients showing isolated reces-
sion type 2 gingival recession defects reported at 6
months, complete root coverage, in 57% of cases,
after treatment with a coronally advanced flap + con-
nective tissue graft and complete root coverage, in
29% of cases, after treatment with a coronally
advanced flap only. Additionally, when interdental
58
keratinized tissue; ICal, interdental clinical attachment
level; MCAT, modified coronally advanced tunnel; MRC,
maximum root coverage level; NCCL, non-carious cervical
lesion.
Fig. 2. NODE 1. Non-carious cervical
lesion. (A) Gingival recessions with
non-carious cervical lesions at the
buccal aspect of the canine and first
premolar (arrows). (B) Composite
restorations at the maximum root
coverage level (arrows). (C) Healing
1 year after root coverage surgery.
clinical attachment level loss was ≤ 3 mm, complete
root coverage was obtained in 80% of cases following
treatment with a coronally advanced flap + connec-
tive tissue graft. The long-term results of this study,
over 3 years, confirmed the stability of the clinical
outcomes achieved (11).
NODE 2bis: interdental soft-tissue loss
In the presence of interdental clinical attachment
level loss, the presence of interdental soft-tissue

A B
E F G H
Fig. 3. NODE 2. Interdental clinical attachment level loss.
The coronally advanced flap + connective tissue graft
technique is selected as surgical treatment. (A) Recession
defect associated with interdental clinical attachment level
loss. (B) Lateral view. (C) Radiograph showing bone loss
with suprabony and infrabony components. (D) The trape-
zoidal coronally advanced flap is elevated using a split–
full–split approach. Note the bony defects with no loss of
loss must be taken into consideration. While appli-
cation of the coronally advanced flap + connective
tissue graft was not able to demonstrate (10) an
improvement in the distance between the contact
point and papilla tip parameter at 6 months, the
modified coronally advanced tunnel technique
showed (4) an improvement, of 59%, in the dis-
tance between the contact point and papilla tip at
1 year. Furthermore, in a case report presented
by Zucchelli et al. (43) the connective tissue graft
wall technique showed root coverage along with
improvement in interproximal soft- and hard-tis-
sue levels.
For these reasons, in the presence of interdental
clinical attachment level loss with no interdental soft-
tissue loss, the coronally advanced flap + connective
tissue graft is indicated (Fig. 3). However, when inter-
dental clinical attachment level loss is also associated
with interdental soft-tissue loss, the connective tissue
graft wall technique or the modified coronally
advanced tunnel technique should be the first
surgical choice. The connective tissue graft wall tech-
nique is better suited for the treatment of single
recession defects (Fig. 4), while the modified coro-
nally advanced tunnel technique is better suited for
Esthetic outcome in root coverage
C D
I
the interdental soft tissue. (E) The connective tissue graft
is sutured at the level of the cementoenamel junction. (F)
The coronally advanced flap covers, in excess, the connec-
tive tissue graft. (G) One-year clinical outcome showing
root coverage. Composite restorations are carried out to
reduce the diastema. (H) Lateral view showing root cover-
age and increase in gingival thickness. (I) Radiographic
healing.
the treatment of multiple gingival recession defects
(Fig. 5).
NODE 3: buccal malposition of the root(s)
Buccal malposition of teeth may be the result of exces-
sive tooth/teeth proclination beyond the cortical bone
as a consequence of specific anatomic conditions, or
created (or worsened) by orthodontic movement. In
these cases, the occurrence of gingival recession is
often associated with poor mucogingival characteris-
tics (e.g. the apical third of the root may become
transparently visible through the extremely thin alveo-
lar mucosa, the keratinized tissue apical and lateral to
the root surface may be lost completely and the soft
tissue apical to the root exposure may become probe-
able). As a result of these poor mucogingival condi-
tions and root malpositioning, root-coverage surgical
techniques become very challenging and complete
root coverage is unpredictable (1, 42). The orthodontic
repositioning of root(s) within the limits of the alveolar
bone may alter the prognosis of root-coverage proce-
dures as the surgical procedure becomes easier to per-
form as a result of the improved quality and quantity
of the keratinized tissue apical and lateral to the
59
Stefanini et al.
A B C D
E F
Fig. 4. NODE 2bis. Loss of interdental clinical attachment
level with loss of interdental soft tissue. A connective tissue
graft wall technique is selected as surgical treatment for a
single type recession defect. (A,B) Clinical and radio-
graphic images showing a single recession defect associ-
ated with interdental soft-tissue loss and bone loss with
suprabony and infrabony components. (C) The bony
defects after flap elevation. (D) Suture of the connective
tissue graft at the base of the anatomic papillae of the two
A B
C D
exposed root (1, 42, 49). In fact, it is seen that when a
buccally displaced root is moved lingually, under opti-
mal plaque control, the gingival dimensions on the
labial aspect increase both in the buccal–lingual and
coronal–apical dimensions (20, 38). Once the buccal
malposition has been corrected, the root coverage sur-
gical technique is selected according to the baseline
amount of keratinized tissue apical to the exposed
root (see NODE 4).
However, sometimes orthodontic repositioning of
the buccally displaced root cannot be performed for
anatomic reasons, such as limited dimension of buc-
cal–lingual bone, in which there is a risk of inducing
lingual bone dehiscence or because the patient does
60
H
G
teeth neighboring the bony defect. The connective tissue
graft acts as a soft-tissue wall on the suprabony and
infrabony components of the bony defect. (E) The coro-
nally advanced flap covers, in excess, the connective tissue
graft. Primary healing of soft tissue is achieved interden-
tally above the bony defect. (F) One-year clinical outcome
showing complete root coverage. (G) Radiographic heal-
ing. (H) Clinical aspect after composite restorations and
closure of the residual interdental spaces.
Fig. 5. NODE 2bis. Loss of interden-
tal clinical attachment level with loss
of interdental soft tissue. A modified
coronally advanced tunnel tech-
nique is selected as surgical treat-
ment for multiple gingival recession
defects. (A) Baseline clinical situa-
tion in a patient affected by multiple
gingival recession in the lower jaw
associated with clinical attachment
level loss with loss of interdental soft
tissue. (B) Connective tissue graft
placed under the tunnelized flap. (C)
Coronally advanced tunnelized flap,
suspended with the connective tis-
sue graft completely submerged. (D)
One-year clinical outcome showing
complete root coverage.
not wish to undergo orthodontic treatment. In these
unfavorable cases, the first technique of choice is the
coronally advanced flap + connective tissue graft,
which should be performed with removal of the sub-
mucosal labial tissue (42) in order to render the root-
coverage procedure more predictable. Nevertheless,
in these cases, unesthetic graft exposure is highly
likely. For these reasons, whenever possible in
the presence of gingival recession associated with
buccal displacement of the root(s), it is recom-
mended to perform an orthodontic treatment before
root-coverage surgery in order to improve complete
root-coverage predictability and the final esthetic
result.

A C
E F
B H
Fig. 6. NODE 3. Buccal malposition. Orthodontic reposi-
tioning and coronally advanced flap + connective tissue
graft surgical treatment. (A) Recession defects associated
with a buccal malposition. (B) Occlusal aspect showing buc-
cal displacement of the exposed roots. (C) Post-orthodontic
clinical situation: the recession defects are smaller and a
remarkable increase in quantity and quality of keratinized
tissues is noticeable apical and lateral to the root exposures.
A coronally advanced flap + connective tissue graft tech-
nique is selected for the surgical treatment. (D) Root
An example of gingival recession defects associated
with buccal displacement of the roots treated with
orthodontic root repositioning followed by coronally
advanced flap + connective tissue graft, is shown in
Fig. 6.
NODE 4: keratinized tissue apical to the
exposed root
In the absence (or after restorative treatment) of non-
carious cervical lesions, interdental clinical attach-
ment and soft-tissue loss, and in the absence (or after
orthodontic treatment) of buccal displacement of the
exposed root, selection of the root-coverage surgical
procedure is mainly influenced by the baseline
amount of keratinized tissue apical to the exposed
root.
Very little data are available on the critical amount
of remaining keratinized tissue, apical to the root
exposure, necessary to provide stability of the coro-
nally repositioned gingival margin in order to with-
stand the postsurgical inflammation and to facilitate
patient plaque control. Clinical experience of the
authors and a long-term case-series study (in press)
in which 267 gingival recessions have been treated,
suggest the use of the following criteria:
 Keratinized tissue height ≤ 1 mm. In this situa-
tion, the coronally advanced flap + connective
tissue graft (Fig. 7) or the modified coronally
Esthetic outcome in root coverage
D G
exposures after flap elevation. (E) Suture of the connective
tissue graft at the cementoenamel junction. Note that the
height of the connective tissue graft (4 mm) does not reach
the buccal bone crest. The thickness of the connective tis-
sue graft is less than 1 mm. (F) The coronally advanced flap
covers in excess the connective tissue graft. (G) One-year
clinical outcome showing complete root coverage. (H)
Occlusal aspect showing the increase in soft-tissue thick-
ness. The teeth previously affected by gingival recessions
are well aligned with respect to the neighboring teeth.
advanced tunnel (Fig. 8) are the techniques of
choice. The rationale is to improve the stability
and prevent shrinkage of the marginal tissue
coronally advanced with the additional use of a
dense and collagen-rich connective tissue graft.
The lack, or minimal amount, of baseline kera-
tinized tissue height makes exposure of unes-
thetic graft quite probable with both techniques.
While the coronally advanced flap + connective
tissue graft can be used for both single and
multiple gingival recessions, the modified coro-
nally advanced tunnel technique is indicated
more for the treatment of multiple gingival
recessions.
 Keratinized tissue height > 2 mm. In this situation
the coronally advanced flap is the technique of
choice. In fact, 3 mm of keratinized tissue can be
considered adequate to be tightly and well
adapted to the convexity of the crown; this will
favor formation of blood clot and stabilization
between the root surface and the coronally dis-
placed soft tissue. Both of these factors are critical
in preventing marginl soft-tissue shrinkage. Fur-
thermore, 3 mm of keratinized tissue can be con-
sidered as adequate for effective patient plaque
control and toothbrushing.
In the presence of keratinized tissue of 1 to ≤ 2 mm
in height, gingival thickness has to be taken into
consideration.
61
Stefanini et al.
A B
C
E F
Fig. 7. NODE 4. Baseline amount of keratinized tissue api-
cal to the root exposure. Coronally advanced flap for mul-
tiple gingival recession + site-specific connective tissue
graft. (A) Frontal view of the same case shown in Fig. 1.
Gingival recession affects teeth of the first quadrant. Non-
carious cervical lesions are present at the buccal aspect of
the canine and first premolar and molar. (B) After execu-
tion of composite restorations at the maximum root cover-
age level of the canine, first premolar and molar. (C)
Coronally advanced flap for multiple gingival recession
A B
Fig. 8. NODE 4. Baseline amount of keratinized tissue api-
cal to the root exposure. The modified coronally advanced
tunnel technique is selected as surgical treatment for mul-
tiple gingival recession defects. (A) Frontal view showing
the baseline clinical situation in a patient affected by
NODE 4bis: gingival thickness
 Gingival thickness < 1 mm. In this situation, coro-
nally advanced flap + connective tissue graft is
the technique of choice. Based on Huang et al.
(23) and Baldi et al. (7), the chance of achieving
complete root coverage is positively related to gin-
gival thickness. More recently (9), a randomized
clinical trial conducted on 32 patients concluded
that, at sites with gingival thickness ≤ 0.8 mm,
coronally advanced flap + connective tissue graft
resulted in better outcomes in terms of complete
root coverage and recession reduction with
62
D
defects is selected as the root coverage surgical procedure.
The site-specific adjunct of connective tissue graft is
related to the baseline amount of keratinized tissue. (D)
Small (4 mm in height) and thin (< 1 mm in thickness)
connective tissue grafts, applied at the maximum root cov-
erage level, do not reach the buccal bone crest. (E) The
coronally advanced flap covers in excess the connective
tissue grafts. (F) One-year healing showing root coverage
and increase in keratinized tissue height. For the increase
in gingival thickness see Fig. 1C.
C
multiple gingival recession in the upper jaw. (B) Tunnel-
ized coronally advanced flap stabilized with suspended
sutures around the contact point. (C) Root coverage and
increase in keratinized tissue height are shown after
2 years of healing.
respect to coronally advanced flap alone. In this
clinical situation (keratinized tissue of 1 to
≤ 2 mm in height and gingival thickness of
< 1 mm) the keratinized tissue height apical to the
exposed root, even if not adequate to perform the
coronally advanced flap alone, provides enough
stability to the gingival margin coronally displaced
and thus reduces the risk of exposure of unes-
thetic graft. The adjunct use of connective tissue
graft increases soft-tissue thickness and makes the
long-term root-coverage outcome more pre-
dictable.

 Gingival thickness ≥ 1 mm. In this situation the
coronally advanced flap is the technique of choice
because there is no need to increase gingival
thickness further by adding a connective tissue
graft to the coronally advanced flap.
Conclusions
There is still a lack of studies evaluating the esthetic
outcomes, beyond complete root coverage, of peri-
odontal plastic procedures, despite esthetic concerns
representing the main indication for the treatment
of gingival recession. There is also a lack of studies
comparing the esthetic outcome achieved using dif-
ferent surgical procedures. A decision-making pro-
cess with esthetic outcome as the main goal of
therapy has been suggested in the present study.
Three main surgical procedures have been included:
the coronally advanced flap; the coronally advanced
flap + connective tissue graft; and the modified
coronally advanced tunnel technique. The selection
of the most suitable surgical technique should be
performed in a step-by-step manner through the fol-
lowing nodes: presence of non-carious cervical
lesions; presence of interdental clinical attachment
level loss, with or without loss of interdental soft tis-
sue; and presence of buccal displacement of the root
(s). In the absence (or after treatment) of the clinical
conditions described in these nodes the selection of
the surgical procedure is influenced primarily by the
baseline amount of keratinized tissue apical to the
exposed root and secondarily by gingival thickness.
The selection of the surgical technique, based on the
patient’s esthetic concern and a reproducible patient
esthetic outcome assessment (taking into account
complete root coverage and soft-tissue variables),
should be introduced. This selection should also take
into account the need to minimize patient morbid-
ity.
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Periodontology 2000, Vol. 77, 2018, 65–83
Printed in Singapore. All rights reserved
Esthetic treatment of altered
passive eruption
MONICA MELE, PIETRO FELICE, PRAVEEN SHARMA, CLAUDIO MAZZOTTI,
PIETRO BELLONE & GIOVANNI ZUCCHELLI
Gingival excess has been recognized by the American
Academy of Periodontology as a mucogingival defor-
mity around teeth (6). Several conditions may result
in the excessive display of gingiva, including pseu-
dopockets caused by gingivitis, drug-induced gingival
enlargement and altered passive eruption of teeth.
These clinical presentations may lead patients to seek
treatment to address esthetic and/or functional con-
cerns. Excessive gingival display may also result from
altered passive eruption of the maxillary dentition, a
high lip line, a hypermobile upper lip or vertical max-
illary excess (49), and the management of excess gin-
gival display is dictated by its etiology. The aim of this
article is to present a narrative review of the etiology,
classification and management of altered passive
eruption.
Tooth eruption: active and passive
eruption phases
Tooth eruption comprises two phases: an active erup-
tion phase in which the tooth emerges into the oral
cavity; and a passive eruption phase that is character-
ized by apical migration of the soft tissue covering the
crown of the tooth (Fig. 1).
Active eruption phase
According to Steedle & Proffit (55) the active eruption
phase can be subdivided into six distinct phases:
three prefunctional phases (follicular growth, pre-
emergence and post-emergence eruptive outbreak)
and three post-functional phases (juvenile occlusal
equilibrium, pubertal eruptive outbreak and adult
occlusal equilibrium). Some studies have shown that
in its final stages, tooth eruption is regulated not only
© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
PERIODONTOLOGY 2000
by occlusal contact but also by the periodontal
ligament and supracrestal fiber complex (30, 53).
Anthropometric studies have shown that continuous
tooth eruption can compensate for incisal tooth wear,
in severe cases by up to 60%, without affecting the
lower face height. This is seen more readily in
younger patients, who are more likely to exhibit con-
tinued eruption of teeth without occlusal contact,
compared with older patients.
Passive eruption phase
Passive eruption, a term coined by Gottlieb & Orban
in 1933 (28), is a gradual process by which the epithe-
lial attachment of the gingival tissues migrates api-
cally from the coronal enamel to a stable position just
coronal to the cemento–enamel junction with a
fibrous connective tissue attachment forming at the
base of the gingival sulcus (25). This phase can be sub-
divided into four phases depending on the location of
the dentogingival junction relative to the cemento–
enamel junction (25). The dentogingival junction may
be located on enamel alone, on enamel and cemen-
tum or on cementum alone, or both the dentogingival
junction and the gingival margin may be apical to the
cemento–enamel junction. The first phase of passive
eruption is considered to be physiological, while the
remaining three phases are a consequence of patho-
logical periodontal destruction. If passive eruption
does not progress, the gingival margin retains a more
coronal position covering more tooth enamel.
Altered passive eruption
Goldman & Cohen (27) defined altered or retarded
passive eruption as a situation in which ‘the
65
Mele et al.
A B
Fig. 1. Mandibular anterior sextant in a 13-year-old male
patient. (A) Note the active and passive phases of tooth
eruption. The mandibular central incisors have completed
both phases while the other teeth have not. As a result,
their gingival margin is still coronal to the cemento–
gingival margin in the adult is located incisal to
the cervical convexity of the crown and removed
from the cemento–enamel junction of the tooth’.
In the literature, this condition is also referred to
as ‘delayed passive eruption’ (59) and results from
failure of the passive eruption phase to conclude.
In investigating a cohort of over 1,000 adult
patients, with a mean age of 24 years, the preva-
lence of altered passive eruption was reported to
be approximately 12% (59). Coslet et al. (16) classi-
fied altered passive eruption into two types based
on the location of the mucogingival junction in
relation to the alveolar bone crest, and further
classified these into two subgroups based on the
position of the alveolar bone crest in relation to
the cemento–enamel junction. The different types
and subgroups of altered passive eruption are
shown in Fig. 2.
Fig. 2. Schematic drawing summarizing the types and
subgroups of altered passive eruption (courtesy of Guido
Gori). (A) Type 1 subgroup A: the mucogingival junction is
located apically with respect to the cemento–enamel junc-
tion and the buccal bone crest. The distance between the
cemento–enamel junction and the bone crest is physiologi-
cal for connective tissue fiber attachment. (B) Type 2 sub-
group A: the mucogingival junction is located at the level
of, or coronal to, the cemento–enamel junction. The dis-
tance between the cemento–enamel junction and the bone
crest is physiological for connective tissue fiber
66
enamel junction. (B) A lateral view of these teeth shows
the amount of apical gingival migration required before
the buccal soft tissue of the mandibular right lateral inci-
sor reaches maturation.
Relationship between the mucogingival
junction and the alveolar bone crest
Type 1 altered passive eruption is defined by the
gingival margin being incisal or occlusal to the
cemento–enamel junction where there is a noticeably
wider band of attached gingiva from the gingival mar-
gin to the mucogingival junction than the generally
accepted mean width of 3.0–4.2 mm in the maxilla
and 2.5–2.6 mm in the mandible (2, 12). The
mucogingival junction is usually apical to the alveolar
crest in these cases.
Type 2 altered passive eruption is defined by the
presence of a band of attached gingiva from the gingi-
val margin to the mucogingival junction which
appears to fall within the normal mean width as spec-
ified above (2, 12). However, in this type of altered
passive eruption, all the attached gingiva is located
attachment. (C) Type 1 subgroup B: the mucogingival
junction is located apically with respect to the cemento–
enamel junction and buccal bone crest. The bone crest is
located at the level of, or coronal to, the cemento–enamel
junction and there is no physiological space for connective
tissue fiber attachment. (D) Type 2 subgroup B: the
mucogingival junction is located at the level of, or coronal
to, the cemento–enamel junction. The bone crest is located
at the level of, or coronal to, the cemento–enamel junction
and there is no physiological space for connective tissue
fiber attachment. MGJ, mucogingival junction.

on the anatomic crown with the mucogingival junc-
tion located at the level of the cemento–enamel junc-
tion.
Relationship between the alveolar bone
crest and the cemento–enamel junction
In altered passive eruption subgroup A, the alveolar
crest is the normal distance (1–2 mm apical) from the
cemento–enamel junction, thus allowing the gingival
fiber apparatus to be inserted as normal onto cemen-
tum.
In altered passive eruption subgroup B, the alveolar
crest is at the level of or coronal to the cemento–
enamel junction, thereby impinging on the space for
connective tissue fiber attachment. This relationship
is frequently observed during the active eruption
phase of the transitional dentition.
As it is difficult to pinpoint when the physiological
movement of passive eruption ends, controversy
exists regarding the age at which a diagnosis of
altered passive eruption can be made. According to
Coslet et al. (16), by the age of 18–20 years, the
majority of individuals have a mature dentogingival
relationship with a distance between the cemento–
enamel junction and the gingival margin of 0.5–
2 mm (2). Several studies have investigated the
changing position of the gingival margin in different
age groups by measuring the clinical crown height.
In a cross-sectional study conducted in a Caucasian
population of 6- to 16-year-old subjects, the position
of the gingival margin, and therefore the clinical
crown height, was recorded using orthodontic study
models (60, 61). There was a significant difference in
the clinical crown height, between the age groups,
for all teeth except for the second lower molars. The
same authors subsequently conducted a longitudinal
study on subjects 18 years of age (62). The clinical
crown height of the incisor and canine teeth was
measured using standardized photographic tech-
niques, in 30 dental students, over a 3-year period.
There was a progressive increase in mean clinical
height during this period, similar to that observed in
the previous cross-sectional study, suggesting that
continual passive eruption of the teeth occurs until
the age of 20 years.
Morrow et al. (42) investigated the relationship
between age, gender and clinical crown height in a
longitudinal study in which 456 sets of study models
were examined. Each set of models corresponded to
a subject at three different ages: 11–12, 14–15 and
18–19 years. The clinical crown height of the right
maxillary central incisor, right maxillary canine, left
Esthetic treatment of altered passive eruption
maxillary lateral incisor and left mandibular central
incisor was measured from the gingival margin to
the incisal edge using digital calipers. Analysis of the
data obtained showed a significant relationship
between age and crown height for all four teeth
studied. A significant relationship was found with
gender whereby the upper right central incisor,
upper canines teeth, and upper left lateral incisor
were longer in men than in women. Such a relation-
ship was not found with the lower left central inci-
sor. The data in this study indicate that passive
eruption continues at least until age 18–19 years for
both male and female subjects. As it was not possible
to determine whether or not the gingival levels are
stable at this age, the authors made a comparison of
the clinical crown heights reported in their study
with those reported by Gillen et al. (26). It appeared
that in the female patient population, passive erup-
tion was essentially complete by the age of 18–
19 years. Evian et al. (22) compared anterior and
posterior teeth and found that for the former, gingi-
val stability was achieved by 20 years of age, while
for the latter, gingival maturation could continue
into the third decade. Robbins, in 1999 (49), sug-
gested that it may not be prudent to diagnose altered
passive eruption until growth is complete but did
not specify at which age this should be.
Etiopathogenesis of altered passive
eruption
According to some authors, the position of the alveo-
lar bone crest adjacent to the cemento–enamel junc-
tion could impede gingival migration during the
passive eruption phase (25), thereby providing a dis-
tinguishing feature between altered passive eruption
and altered active eruption. The hypothesis has been
proposed that two mechanisms play a part in altered
passive eruption, giving rise to two different morpho-
logical patterns at the level of the dentogingival
junction.
Type 1 altered passive eruption may be caused by
failure of the passive eruption phase, giving rise to
excessive overlap of gingiva and the anatomical
crown of the tooth, but the distance from the bone
crest to the cemento–enamel junction is normal. On
the other hand, type 2 altered passive eruption may
be caused by failure of the active eruption phase and,
as a result, the tooth does not emerge sufficiently
from the alveolar bone, thereby leaving the cemento–
enamel junction positioned in proximity to the alveo-
lar bone crest. This situation, in turn, may prevent
67
Mele et al.

the apical migration of gingiva during the passive
eruption phase.
Few studies have postulated possible causes of
altered passive eruption and several factors have
been proposed. These include occlusal interference
by soft tissues during the eruptive phase, the pres-
ence of thick and fibrotic gums that tend to migrate
more slowly during the passive phase, genetic
causes, the presence of thick bone that might pre-
vent the apical migration of soft tissue, orthodontic
trauma and endocrine conditions (4). Zucchelli (66)
indicated that the presence of thick buccal bone
was a common observation in surgically managed
cases of altered passive eruption, regardless of the
subgroup (A or B; Figs 3 and 4) and that surgical
reduction of this thick bone was essential in the
management of such cases (Fig. 5). The increased
bone thickness might be a consequence of the lack
of gingival retraction. Rossi et al. (51) investigated
the genetic component of altered passive eruption
in a study which aimed to understand whether or
not patients with altered passive eruption have sib-
lings or parents presenting with similar dental char-
acteristics. Immediate family members of 20
patients (10 male and 10 female) with altered pas-
sive eruption were evaluated and the results showed
that family members of patients with altered passive
eruption had a higher-than-average incidence of
altered passive eruption. In this small study, more
than 50% of patients had one family member show-
ing signs of altered passive eruption, and for 15% of
patients, all family members showed signs of altered
passive eruption. The type of passive eruption
within family members was not reported. Orthodon-
tic trauma may also be a causative factor in altered
passive eruption (Fig. 6). A cross-sectional study by
Nart et al. (43) determined the prevalence of altered
passive eruption following orthodontic treatment
using maxillary and mandibular fixed appliances,
and a comparison was made with the prevalence of
altered passive eruption in patients who had never
received orthodontic treatment. The prevalence of
altered passive eruption in patients who had
received orthodontic treatment was higher than in
those who had not received orthodontic treatment,
although the results were not statistically significant
(43). This is in agreement with the clinical impres-
sion of some authors who reported that orthodontic
treatment often gives rise to a gummy smile (31, 33).
Nart et al. (43) also showed a statistically significant
association between altered passive eruption and
gingival biotype, categorized into thin-scalloped,

A B

Fig. 3. Increased thickness of the buccal bone in a patient with altered passive eruption and with physiological distance
between the cemento–enamel junction and the bone crest (subgroup A). (A) Lateral view. (B) Occlusal view.

A B

Fig. 4. Increased thickness of the buccal bone in patients with altered passive eruption. (A) Frontal view: some teeth (cani-
nes) have normal, physiological distance between the cemento–enamel junction and the bone crest, while in others (lateral
and central incisors) the bone crest reaches or covers the cemento–enamel junction (subgroup B). (B) Lateral view.

68

A B
Fig. 5. Increased buccal bone thickness of the patient in
Figs 13 and 21 with altered passive eruption and a gummy
smile. (A) Lateral view showing the increase in thickness of
the buccal bone. (B) Reduction of bone thickness (osteo-
plasty) to treat altered passive eruption.
Fig. 6. Altered passive eruption and gummy smile after
orthodontic therapy in an 18-year-old female patient.
thick-flat or thick-scalloped (19), while age, sex and
the duration of orthodontic treatment were not
associated with altered passive eruption. Many
authors have investigated the causes and mecha-
nisms that may lead to tooth eruption failure (46).
Piattelli et al. (46) used the term ‘primary failure of
eruption’ for those cases with no apparent mechani-
cal cause of failure of tooth eruption, such as root
ankylosis, the presence of supernumerary teeth,
odontogenic tumors, cyst, soft tissues interposed
between teeth and deformities of the crown or root
of the teeth. The authors suggested altered metabo-
lism or blood flow in the periodontal ligament as
the etiological mechanism for this primary failure of
eruption. Certain endocrine alterations, such as
hypopituitarism and hypogonadism, are also related
to a delay in tooth eruption. In a study by Barberi
et al. (7), the authors reported that children who
had a deficiency of growth hormone also presented
a delay in dental and bone age. As early as 1968,
Esthetic treatment of altered passive eruption
Goldman & Cohen (27) reported that the association
between hypothyroidism and the presence of altered
passive eruption was not infrequent. We now have a
clearer understanding of the possible role of hor-
mones, such as growth hormone, insulin-like growth
factors I and II (10), thyroid hormones and epider-
mal growth factor (65), in the eruption process.
Altered passive eruption and
periodontal health
Studies have related altered passive eruption to peri-
odontal health, including altered passive eruption
being a potential risk factor for development of peri-
odontal disease. Coslet et al. (16) indicated that in
altered passive eruption type 2A, the gingiva is unsup-
ported by connective tissue fibers, is frequently of a
thin tissue type and appears to be susceptible to peri-
odontal breakdown. In altered passive eruption type
1B and type 2B, the absence of collage bundles of the
gingival apparatus may predispose to gingival patho-
sis. Prichard (47) postulated that an incisally placed
gingival margin is more prone to trauma from oral
function and is more susceptible to periodontal
pathoses. Factors such as trauma, movement of food
and other debris may contribute to chronic inflam-
mation of a bulbous marginal gingiva.
In altered passive eruption, as the gingiva does not
recede to its normal position and remains on the con-
vex surface of the crown, it is at risk from repeated
trauma. In some cases, excess gingival tissue may also
interfere with adequate oral hygiene and the resultant
accumulation of plaque may give rise to marginal gin-
gival inflammation (Fig. 7) (4). Moreover, restorations
and orthodontic appliances (Fig. 8) placed in close
proximity to the gingival margin may cause an
inflammatory response resulting in gingivitis and
attachment loss in periodontally susceptible patients
Fig. 7. Altered passive eruption and periodontal health.
The excess of gingival tissue may interfere with oral
hygiene practices, and plaque accumulation may give rise
to marginal gingival inflammation.
69
Mele et al.
A
B
(22). Weinberg & Eskow (64) suggested that in the
presence of pseudopockets which develop as a result
of excessive keratinized mucosa (Fig. 9), increased
plaque accumulation and an inflammatory response
may not be esthetically pleasing to the patients. Vol-
chanky & Cleaton-Jones (59) reported a relationship
between the presence of altered passive eruption and
acute necrotizing ulcerative gingivitis, arguing that a
deep gingival sulcus creates the necessary anaerobic
conditions for the development of this infection
(Fig. 10). Although such pathoses may occur in rare
instances, the gingiva of the patient with altered pas-
sive eruption, like all patients, is generally healthy in
the absence of plaque deposits.
Altered passive eruption and
restorative requirements
Altered passive eruption can make restoration of
teeth challenging and the restorative treatment
plan should be formulated before gingival surgery.
Although it is preferable, where possible, to place
restorative margins supragingivally, for esthetic
reasons it may sometimes be necessary to place sub-
gingival restorative margins. If restorations with sub-
gingival margins are prepared in teeth with altered
passive eruption, the margin is likely to be placed on
70
Fig. 8. Altered passive eruption and
periodontal health. (A) Orthodontic
appliances and (B) restorations may
cause an aggravated inflammatory
response in patients with altered
passive eruption.
the enamel with unprepared enamel apical to the
finish line. At a later date, the restorative margin
may become visible if passive eruption continues,
presenting possible esthetic complications (20, 44, 63)
(Fig. 11).
It is also necessary to re-create an adequate bio-
logic width in order to maintain gingival health, to
allow sufficient space between the restorative margin
and the alveolar crest and to prevent an inflammatory
lesion from developing that may result in loss of
attachment (20, 44). A common restorative error,
made when patients with altered passive eruption are
treated, is the placement of margins at what would be
‘normal’ anatomic levels. Such marginal placement
may impinge on the biologic width because of the
increased alveolar bone height, resulting in compro-
mised esthetics as the biologic width re-establishes
itself (21). According to Evian et al. (22), in multi-
rooted teeth, excess soft tissue can interfere with the
interproximal placement of restorations. Eliminating
the excess tissue allows improved access and makes
plaque control easier for the patient. Anteriorly,
altered passive eruption can result in short-looking
teeth, and crown and bridgework can be used to
improve esthetics. However, incorrect placement of
crown margins can cause an inflammatory response,
worsening the appearance of the teeth in the long
term (22).
Fig. 9. Altered passive eruption and
periodontal health. Pseudopocket in
patient affected by altered passive
eruption.
Fig. 10. Altered passive eruption and
periodontal health. Altered passive
eruption associated with necrotizing
periodontal disease.
 Esthetic treatment of altered passive eruption

A C

B D

Fig. 11. Restorative challenges with altered passive erup-
tion. (A,B) Patient with altered passive eruption affecting
the maxillary left central incisor where the margin of the
restoration was probably subgingival at the time of place-
ment. With continuation of passive eruption, this margin
is now supragingival and presents an esthetic challenge.
(C,D) Surgical treatment of altered passive eruption allows
optimal delivery of restorative treatment and achievement
of a more esthetic outcome. Restorative treatment courtesy
of Dr Carlo Monaco.

Altered passive eruption and Peck et al. (45) describe three classes of smile line.
A ‘normal’ smile line is one in which the upper ante-
esthetics: gummy smile
rior teeth are completely visible and the lower border
of the upper lip reveals 1–2 mm of gingiva. A ‘low’
For dentists, improvement in esthetics is one of the
smile line is described as one in which the lower bor-
main reasons for the delivery of clinical treatment,
der of the upper lip covers 25% of the upper anterior
and esthetic concerns frequently pose a challenge to
teeth. A ‘high’ smile line, also known as a ‘gummy
the periodontist. Such concerns often relate to gingi-
smile’, is described as one having more than 2 mm of
val margin misalignment or excessive tooth length as
maxillary gingival display (Fig. 12). The prevalence of
a result of gingival recession or excessive gingival
excessive gingival display has been estimated at 10%
exposure when the patient smiles or speaks. The
of 20- to 30-year-old subjects, and it is more common
characteristics of an esthetic smile include:
 A straight dental midline. in women (14%) than in men (7%) (57). Excessive dis-
 A smile line that follows the convexity of the lower play of gingiva can have an adverse effect on the
patient’s perception of attractiveness, friendliness,
lip.
 Symmetric central incisors. trustworthiness, intelligence and self-confidence (39)
 Incisal embrasures that gradually deepen from (Fig. 13). There are different possible etiologic factors
for this clinical presentation, one of which is altered
central incisors to canines.
 Teeth that are straight or mesially inclined. passive eruption (24). If the origin of the excessive
 A width-to-length ratio of the central incisors of gingival display is a skeletal abnormality, then orthog-
nathic surgery and orthodontic treatment should be
75–80% (17).
considered. If there is a dental reason for the exces-
There are also other factors influencing the esthet-
sive gingival display, then correction of the gingival
ics of a smile, including incisor and gingival display
and osseous architecture is indicated.
(23, 58). In fact, maxillary anterior teeth, along with
Malkinson et al. (39) performed a study to demon-
the position of the gingival zenith and balance of the
strate how a major determinant of the esthetics of a
gingival levels, are considered to be the key elements
smile is the amount of gingival display, which can be
of a pleasant smile (38, 52).

A B

Fig. 12. High smile line or gummy smile (pre- and postsurgical correction). (A) Gummy smile as a result of altered passive
eruption. (B) Surgical treatment of altered passive eruption modifies the Peck classification of this smile from a high smile
line to a normal smile line.

71
Mele et al.
A B
excessive in cases of altered passive eruption. The
aims of this research were twofold: first, to investigate
differences in people’s perceptions of the aforemen-
tioned social parameters, when looking at simulated
before- and after-treatment photographs of gummy
smiles; and, second, to investigate differences in these
perceptions between senior dental students and
laypeople. The authors demonstrated that excessive
gingival display negatively affected how attractive a
person’s smile was judged to be, and lay people were
just as sensitive to these differences as senior dental
students (39). Furthermore, research shows that a
patient’s smile can influence his or her perceived
beauty (23, 32). Therefore, the correction of excessive
gingival display may be an important element, not
only in terms of smile esthetics but also in terms of
patients’ self-esteem. In a study by Ribeiro et al. (48),
patients reported high satisfaction with their esthetic
appearance both at 7 days and at 6 months after sur-
gical correction of a gummy smile. In a similar man-
ner, Cairo et al. (13) reported that patients rated the
final outcome of surgical intervention as satisfactory
at the 6-month time-point.
In addition to the presentation of a gummy smile,
altered passive eruption can compromise esthetics in
other ways, such as the short appearance of teeth, or
gingival or tooth-length asymmetry when contralat-
eral teeth have different positions of the gingival mar-
gin (Fig. 14). In fact, the beauty of the human body is
represented by the right–left symmetry and the har-
mony of tissues in terms of color and quality. Kokich
et al., in 1999 (34), evaluated the perception of lay
people and dental professionals (orthodontists and
general dentists), to symmetric alteration of anterior
dental esthetics. Smiling photographs were intention-
ally altered with one of eight common anterior
A B
72
Fig. 13. Altered passive eruption and
gummy smile. (A) Gummy smile as a
result of altered passive eruption. (B)
Patient’s attractiveness improves fol-
lowing periodontal surgery to
improve the dental and gingival
show.
esthetic discrepancies in varying degrees of deviation,
including variations in crown length, crown width,
incisor crown angulation, position of the midline,
open gingival embrasure, gingival margin, incisal
plane and gingiva-to-lip distance. The results of this
study showed that lay people, general dentists, and,
in particular, orthodontists detect specific dental
esthetic discrepancies at varying degrees of deviation.
Using a similar study deign, Kokich et al., in 2006
(35), found that asymmetric esthetic discrepancies
were more perceptible than symmetric ones. In gen-
eral, asymmetric alterations make teeth more
unattractive, not only to dental professionals but also
to the lay public. Symmetric alterations might appear
unattractive to dental professionals but the lay group
often did not recognize such alterations.
Diagnosis of altered passive
eruption
The lack of clear diagnostic criteria for altered passive
eruption has hampered studies in evaluating the
prevalence of altered passive eruption in the adult
population. Most of the literature references a study
by Volchansky & Cleaton-Jones from 1974 (59) that
reported a prevalence of altered passive eruption of
12.1%. Recently, Nart et al. (43) reported a higher
prevalence, of 35.8% (29.5% in the control group and
42.1% in the orthodontic therapy group), of altered
passive eruption. One possible explanation for this
could be the heterogeneity in diagnostic criteria used
to define altered passive eruption. Volchansky and
Cleaton-Jones (59) included only those teeth with a
gingival margin positioned 3 to 4 mm over the
cemento-enamel junction while in the last study (43)
Fig. 14. (A) Altered passive eruption,
gummy smile and gingival margin
asymmetry between the central inci-
sors. (B) In measuring the clinical
crown height of the central incisors,
7 mm for the maxillary right central
incisor, which has a clinical crown,
can described as ‘short’.

a diagnosis of altered passive eruption was estab-
lished if the distance from the gingival margin to the
cemento-enamel junction was ≥3mm. The literature
describes various procedures used to diagnose altered
passive eruption, including clinical observation, clini-
cal investigation of the cemento–enamel junction and
alveolar bone crest and radiographic analyses. These
will be explored individually in more detail below.
Clinical observation and investigations
The extra-oral examination includes an evaluation of
facial symmetry and height, lip or smile line, lip
length and mobility. First of all, the patient is
observed at rest and with a natural smile. If there is
an excessive display of gingiva during smiling, further
diagnostic measurements are required. During this
process, first of all the length and activity of the max-
illary lip at rest from the base of the nose to the wet
border of the maxillary lip is measured. This is usually
20–22 mm in female patients and 22–24 mm in male
patients. If the excessive gingival display is caused
solely by a shorter lip or lip hyperactivity, no treat-
ment is indicated (21).
Once the maxillary lip measurements are made, the
next step is to measure the clinical crowns to assess
their dimensions to determine if teeth have short clin-
ical crowns (Fig. 14). In the literature, several articles
report analysis of the dimensions of clinical crowns in
the permanent dentition. Sterrett et al. (56) gathered
this data using orthodontic study models from Cau-
casian patients. Digital calipers were used to measure
the widest mesiodistal length (perpendicular to the
long axis) and the longest apicocoronal length (paral-
lel to the long axis) of the test teeth on each cast. The
results of the study indicate that the mean width and
length of the clinical crowns is significantly greater in
male patients compared with female patients. The
mean mesiodistal tooth widths for male and female
patients were, respectively, 8.59 and 8.06 mm for the
central incisor, 6.59 and 6.13 mm for the lateral inci-
sor and 7.64 and 7.15 mm for the canine. The mean
apicocoronal tooth lengths for male and female
patients, respectively, were 10.19 and 9.39 mm for the
central incisor, 8.70 and 7.79 mm for the lateral inci-
sor and 10.06 and 8.89 mm for the canine. The mean
coronal tooth width/length ratios for male and female
patients were, respectively, 0.85 and 0.86 for the cen-
tral incisor, 0.76 and 0.79 for the lateral incisor and
0.77 and 0.81 for the canine (56). The study by Gillen
et al. (26) was designed and conducted in a similar
manner to determine the average dimensions of the
six maxillary anterior teeth in 18- to 35-year-old
Esthetic treatment of altered passive eruption
patients and to evaluate the relationships between
intertooth and intratooth dimensions. The results
were comparable with those of the previous study by
Sterrett et al. (56). Monaco et al. (41) indicated the
value of 11  2 mm for the clinical crown of the cen-
tral incisor. If the value was under 8 mm then it was
defined as short. In 1999, Robbins (49) defined ‘short’
clinical crown as one that was under 9 mm in length.
From data extrapolated from the literature, some
authors used the value of 10.5 mm for the length of
the central incisor (21, 47).
In a study by Alpiste-Illueca (5), 123 subjects with
upper anterior teeth presenting clinical evidence of
altered passive eruption were enrolled. Two subjec-
tive criteria were employed for the clinical diagnosis
of altered passive eruption: first, excessively flattened
gingival festooning; and, second, a disproportionate
papilla base width in relation to the height reached
by the tip. Altered passive eruption was diagnosed
when these criteria were met in the context of a
patient with a clinically evident short dental crowns,
considering probing depth, width of keratinized gin-
gival, mucogingival line, length of the clinical crown
and occlusal attrition of the teeth (54). Some authors
(21, 33) indicated that gingival sulcus probe depth is
important for the diagnosis of altered passive erup-
tion and claim that depths of over 3 mm without con-
comitant pathological signs are suggestive of altered
passive eruption. In the study by Alpiste-Illueca (5)
no such relationship was observed because no
patient had a probing depth in excess of 3 mm, the
most frequent value being 1.5 mm. In a study by Dolt
& Robbins, (21) the first step in the diagnostic process
of altered passive eruption is to detect the cemento–
enamel junction subgingivally using an explorer. If
the cemento–enamel junction is located in a normal
position in the gingival sulcus, the patient does not
have altered passive eruption. When the cemento–
enamel junction is not detectable in the sulcus, a
diagnosis of altered passive eruption may be made
and crestal ‘bone sounding’ is then performed. The
gingiva is anesthetized and the periodontal probing
depth is recorded. The probe is then pushed through
the base of the sulcus until the alveolar crest is
engaged and this measurement is recorded. As it is
common for the cemento–enamel junction to be
located approximately at the base of the sulcus, these
measurements can be used to determine the relation-
ship between the cemento–enamel junction and the
alveolar crest, as an aid to surgical treatment plan-
ning. Zucchelli (66) highlighted some challenges with
this approach as establishing the position of the
cemento–enamel junction through ‘sounding’ is not
73
Mele et al.
easy in patients with altered passive eruption, for two
reasons: first, the buccal gingiva is almost always
tightly attached, with a long junctional epithelium
along the enamel surface, making probing difficult;
and, second, teeth with altered passive eruption are
often associated with a buccal bone crest at, or coro-
nal to, the cemento–enamel junction, thereby pre-
venting detection of the cemento–enamel junction,
even in the presence of pseudopockets.
‘Bone sounding’, under anesthesia, is the tradi-
tional technique used to distinguish between altered
passive eruption subtypes A and B. If transgingival
probing reveals the cemento–enamel junction sub-
gingivally, a diagnosis of altered passive eruption sub-
type A can be made. If the alveolar bone crest is
palpated by the probe without the cemento–enamel
junction being detected, a diagnosis of altered passive
eruption subtype B can be made. According to Zuc-
chelli (66), ‘sounding’ is only effective in rare cases as
in the vast majority of cases only one interruption is
felt during subgingival probing and it is difficult to
distinguish the cemento–enamel junction from the
bone crest. Additionally, even if two subgingival
interruptions are detected it can be very difficult to
determine whether the distance between them is
physiologic (1–2 mm) or otherwise (66).
Radiographic analysis
A useful contribution in the diagnosis of altered
passive eruption comes from dental radiography.
Parallel profile radiography, as described by Alpiste-
Illeuca (3), was used to determine the dimensions of
the dentogingival unit components, so it was possi-
ble to measure discrepancies and the degree of
overlap characterizing altered passive eruption. This
radiograph was obtained using radio-opaque gutta-
percha inserted into the base of the sulcus and a
self-sticking lead plate positioned over the kera-
tinized gingival surface. In this way the author could
correlate the clinical and radiographic diagnoses. It
74
was concluded that a gingival overlap of over 19% of
the anatomical crown height is equivalent to the
clinical diagnosis of altered passive eruption. Levine
& McGuire (37) proposed that periapical radiography
should be used with the long-cone parallel tech-
nique to obtain information on the cemento–enamel
junction and bone crest. Many authors use radio-
graphic measures to obtain clinical measures for use
as a guide during surgical treatment (1, 13, 29, 40,
50, 51, 63, 64, 66). For example, Zucchelli (66) com-
pared the clinical and radiographic lengths of the
crown (Fig. 15) with the objective being to correct
the magnification created in the X-ray image in
order to calculate measurements precisely, particu-
larly the distance between the gingival margin and
the cemento–enamel junction and between the
cemento–enamel junction and the bone crest
(Fig. 16). When a significant difference (≥ 3 mm) is
found between clinical crown length (occlusal/incisal
edge to gingival margin) and the radiographic crown
length (occlusal/incisal edge to cemento–enamel
junction), a diagnosis of altered passive eruption is
confirmed. Furthermore, when two distinct lines,
one more coronal for the cemento–enamel junction
and one more apical for the bone crest, can be dis-
tinguished in the radiograph, the diagnosis of sub-
type A can be made and the measurement of the
distance between the cemento–enamel junction and
the bone crest can be recorded (Figs 16 and 17).
Nevertheless, the periapical radiographs do not
always readily distinguish between altered passive
eruption of subtypes A and B as, in some cases, it is
difficult to distinguish the buccal bone crest from
the cemento–enamel junction (66) or whether the
more apical line on the radiograph corresponds to
the buccal or the palatal bone crest (Fig. 18). Batista
et al. (8) suggested the use of cone beam computed
tomography to diagnose and characterize the hard-
and soft-tissue anatomic features of altered passive
eruption-affected teeth and to present a novel, com-
bined surgical approach to its correction based on
Fig. 15. Radiographic diagnosis of
altered passive eruption using a
long-cone periapical radiographic
technique. A gutta-percha cone is
placed buccally to the gingival mar-
gin, thereby highlighting the clinical
crown length. The use of a cotton
wool roll between the teeth and the
X-ray holder prevents displacement
of the gutta-percha cone.

A B
Fig. 16. Periapical radiograph with gutta-percha cone
identifying the gingival margin (GM). (A) The true length
of the gutta-percha cone is compared with its radiographic
length (dashed vertical white line) to correct for image
magnification. Once the cemento–enamel junction (CEJ) is
identified on the radiograph (solid horizontal red line), it is
possible to calculate the precise distance between the gin-
gival margin (GM) and the cemento–enamel junction
(dashed vertical red line) and the true length of the
anatomical crown (solid black vertical line). (B) High mag-
nification of the radiograph, together with the distance
between the gingival margin and the cemento–enamel
junction (GM-CEJ) makes it possible to calculate the dis-
tance between the cemento–enamel junction and the bone
crest (BC). This leads to a diagnosis of altered passive erup-
tion subgroup A.
the biometric information obtained using cone beam
computed tomography.
Treatment of altered passive
eruption
Treatments of altered passive eruption described in
the literature are mainly surgical; there are no data on
nonsurgical treatment of altered passive eruption.
A B
Esthetic treatment of altered passive eruption
Presurgical treatment phase
Most studies on the treatment of altered passive
eruption report that initial therapy consists of oral
hygiene instruction, scaling and ‘root’ planing (22). It
is clear that ‘root’ planing cannot be performed in
order to reduce the pseudopocket because the tissue
beneath the pseudopocket is enamel and not cemen-
tum or root dentine. On the other hand, the uninten-
tional curettage of the soft-tissue wall of the
pseudopocket might induce some marginal soft-tis-
sue shrinkage, which could be considered, by the
patient, as unesthetic ‘gingival recession’ as a result
of the elongated appearance of the tooth with a pseu-
dopocket when compared with the adjacent teeth.
Rossi et al. (50) observed that after initial therapy, the
gingival margin remained on the enamel coronal to
the cemento–enamel junction. Debridement reduced
inflammation, allowing accurate evaluation of the
extent of altered passive eruption, in the absence of
pseudopockets (50). The presurgical treatment phase
should precede any surgical treatment.
Surgical treatment phase
In periodontal health, the width of keratinized gin-
giva, the position of the gingival margins, the location
of the buccal alveolar crest, the location of the
mucogingival junction and the likelihood of concomi-
tant restorative therapy are all factors that collec-
tively determine the crown-lengthening treatment
approach. Garber & Salama (24) suggested that there
are only two treatment options for cases of altered
passive eruption: first, a simple gingivectomy to
expose the hidden anatomy in cases of altered passive
eruption type 1A; and, second, an apically reposi-
tioned full-thickness flap, with or without osseous
Fig. 17. (A) Periapical radiograph
with gutta-percha cone identifying
the gingival margin. Two different
lines (one more coronal for the
cemento–enamel junction and one
more apical for the bone crest) can
be distinguished in the radiograph;
the diagnosis of altered passive erup-
tion subtype A is confirmed. (B)
Intra-operative photograph confirm-
ing altered passive eruption subtype
A.
75
Mele et al.

A B

Fig. 18. (A) Periapical radiograph

with gutta-percha cone identifying
the gingival margin. It is difficult to
establish the buccal bone crest posi-
tion in relation to the cemento–
enamel junction, but as this line is
more than 3 mm apical to the refer-
ence cone, it is possible to make a
diagnosis of altered passive erup-
tion. (B) Intra-operative photograph
showing altered passive eruption
subtype B.

resective surgery, in other cases of altered passive A

eruption.

Type 1 subgroup A: gingivectomy/

gingivoplasty
When it is determined that the osseous level is appro-
priate, such that there is more than 1 mm separating
the buccal bone crest from the cemento–enamel B
junction, and that an adequate height of attached
gingiva will remain after surgery (type 1A), a simple
gingivectomy is indicated (64) (Figs 19 and 20). The
initial incision should be precise, symmetric and
reflect the normal gingival architecture, so that the
gingival zenith is slightly distal to the midline of the
tooth. To aid this precision, the initial incision is
lightly scored on the gingiva at the level of the C
cemento–enamel junction. Dolt & Robbins (21) claim
that it is difficult to make the initial scoring incision
accurately while sitting behind the patient and sug-
gested sitting in front of the patient and using an
acrylic resin or resin composite stent as a surgical
guide. Kurtzman & Silverstein (36) propose the use of
a black permanent marker guide line for the initial
incision, along with a surgical template. The dentist Fig. 19. Altered passive eruption type 1A treated with gin-
can then return to sitting behind the patient and givectomy. (A) Presurgical view. (B) Minimal gingival cor-
rections not involving bone removal. (C) Postsurgical view.
complete the beveled, full-thickness gingivectomy
incision. A second incision is made in the sulcus of
each tooth, which leaves a gingival collar that is contour, including scalpel, electrosurgery or carbon
excised with a periodontal curette. The tissue should dioxide laser (1, 9, 64). A bipolar electrosurgery pen
be removed cervically so as to not compromise the can be used under copious irrigation for the gin-
interdental papillae, which should be left undisturbed givectomy, then a gingivoplasty pen can be used to
except for minor blending into the gingivectomy inci- plane back the bulky tissue at the papilla and pro-
sion. vide a more natural contour. Finally, a coagulation
The literature suggests that a variety of instru- ball pen can be used in the bipolar unit on coagu-
ments can be used to expose the cemento–enamel lation mode to seal any bleeding over the gingivo-
junction and to obtain a more physiologic gingival plasty surface (36).

76

A B
Fig. 20. Esthetic improvement of the smile sometimes requires minor surgical soft-tissue changes. (A) Patient’s smile
before surgery (case shown in Fig. 19). (B) Patient’s smile 1 year after gingivectomy (case shown in Fig. 19).
Type 2 subgroup A: apically positioned
flap
In type 2A the width of the keratinized band of gin-
giva is relatively normal, and so a convectional gin-
givectomy might eliminate too much of the
keratinized gingiva, leaving the patient with nonideal
alveolar mucosa at the crown margin. The ideal man-
agement of patients with type 2A involves apical
repositioning of the band of keratinized gingiva to a
point at, or near, the cemento–enamel junction.
According to Zucchelli (66), apically positioned flap is
the treatment of choice in the vast majority of the
patients affected by altered passive eruption with an
increased thickness of the buccal bone, necessitating
osteoplasty.
Types 1 and 2 subgroup B: apically
positioned flap with osseous resective
surgery
When the diagnostic procedures reveal osseous levels
approximating the level of the cemento–enamel junc-
tion, ostectomy is indicated. This procedure is often
associated with an apically positioned flap, even if
some authors suggest a flapless esthetic crown-
lengthening procedure (48). The initial incision either
can be carried out as described for the gingivectomy
procedure, with or without a surgical template, or can
be made as a sulcular incision. The position of the
incision depends on a number of factors, including
the width of the buccal keratinized tissues, with
greater keratinized tissue width indicating a more
paramarginal incision; the cemento–enamel junc-
tion/buccal bone crest position, for which the more
apical the cemento–enamel junction/bone crest from
the gingival margin, the more submarginal is the inci-
sion; and dental esthetic proportion criteria, which
dictate that the gingival margins of the lateral incisors
should be coronal to the margins of the canines and
central incisors (Rufenacht gingival class 1) (52).
As a general rule, the incision should be made as
submarginal and as scalloped as possible. This allows
the incision to reproduce the scalloped outline of the
Esthetic treatment of altered passive eruption
cemento–enamel junction and allows wound healing
by primary intention at the level of the interdental
space. A variable-thickness flap is elevated, being split
thickness at the surgical papillae and full thickness at
the buccal aspect of the incision, with the aim of pro-
viding a uniform thickness of the surgical flap. The
incisions cut across the buccal surface of each papilla,
leaving the papilla totally intact interproximally
(Fig. 21). This flap design preserves papillae height
and provides fixed tissue for flap stabilization during
suturing. In fact, because no biologic requirement
exists for the removal of interproximal bone, the buc-
cal interdental papilla are not reflected with the flap.
Therefore, it is prudent to elevate a buccal flap, leav-
ing the interproximal papillae and the palatal tissue
intact so as to not compromise the blood supply to
those tissues, thereby decreasing the probability of
tissue shrinkage. A full-thickness flap is reflected
beyond the mucogingival junction, and the positions
of the cemento–enamel junction and bone crest are
verified visually. Osteoplasty is performed to reduce
bone thickness, while ostectomy is performed to
establish the correct distance between the cemento–
enamel junction and the bone crest. The buccal flap
reflection stops 3–5 mm apical of the buccal bone
crest and is governed by the extent of the osteoplasty
– for example, if the buccal bone is particularly thick,
more osteoplasty is indicated and the margins of the
full-thickness flap are more apical. The osteoplasty is
carried out using a high-speed rotary instrument,
such as a diamond or carbide round bur. According
to Zucchelli (66), most of the osteoplasty is performed
at the interradicular areas, where concave surfaces
are created (Figs 5, 21 and 22) for subsequent reposi-
tioning of the thinned surgical papillae in order to
minimize rebound of the interdental soft tissue.
Disagreement among authors exists in the amount
of octectomy that is needed in order to establish the
correct distance between the cemento–enamel junc-
tion and the buccal bone crest. Some authors suggest
1 mm (13, 66), while others suggest 2 mm (14, 18, 50),
2–2.5 mm (21, 49) or 3.0 mm (8, 11). Camargo et al.
(14) suggested measuring the dimension of the bio-
logical width on the teeth not affected by altered
77
Mele et al.
A B
C D
E F
Fig. 21. Surgical treatment of altered passive eruption
with apically positioned flap and osseous resective sur-
gery. (A) The clinical crowns of the maxillary canines
and lateral incisors are very short. Note the increased
volume of buccal bone. (B) Submarginal incisions are
cut across the buccal surface of each papilla, leaving the
papilla totally intact interproximally. The buccal flap is
elevated using a split full-thickness approach. (C) After
removal of the marginal issue and de-epithelization of
the anatomical papillae, the increased bone thickness is
evident. No physiological distance exists between the
cemento–enamel junction and the bone crest, for
passive eruption. In cases where altered passive erup-
tion affects all teeth, the authors suggest making an
empirical decision as to the extent of the ostectomy
to be performed, indicating that a 2 mm distance
between the cemento–enamel junction and the bone
crest is adequate in the majority of cases. Further-
more, the same authors advocate the additional
removal of bone in the thick biotype to reduce soft-
tissue regrowth and to ensure a stable long-term
result (14). Other authors do not indicate any specific
value, sometimes using terms such as ‘correct anat-
omy’ or ‘adequate ostectomy’ (22, 51, 64). Some
authors use the margin of the flap as a reference
instead of the cemento–enamel junction and osseous
resection can be carried out such that there is at least
3 mm between the osseous crest and the newly cre-
ated free gingival margin (1, 15, 37) (Table 1). In spite
of difference in the extent of the ostectomies, all
authors claim that the purpose of the ostectomy is to
allow space to accommodate the ‘biologic width’.
Chu & Karabin (18) discuss, in detail, scalloping bone,
with the parabolic form of the osseous crest over the
radicular surface mimicking the original osseous
78
connective tissue attachment (subgroup B). (D) Osteo-
plasty (to reduce bone thickness) and ostectomy (to re-
establish space for connective tissue attachment) were
performed. A view of the osteoplasty is shown in Fig. 5.
(E) The flap is positioned at, or 1 mm coronal to, the
cemento–enamel junction and secured with interrupted
sutures, anchoring the surgical papillae to the interdental
de-epithelized anatomical papillae. (F) After 6 months of
healing, clinical crown lengthening, harmonious kera-
tinized height over the teeth treated and correct esthetic
proportion criteria are observed. The smile of the patient
before and after treatment is shown in Fig. 13.
architecture that is thick-flat or thin-scalloped,
depending on the periodontal biotype present (18).
As the bony architecture should reflect the desired
soft-tissue architecture, Cairo et al. (13) and Zucchelli
(66) suggested shaping the osseous crest parallel to
the cemento–enamel junction (Figs 21 and 22).
Ostectomy may be carried out with hand instru-
ments, such as Oschenbein or Weidelstadt chisels.
The majority of authors advise against scaling or root
planing the denuded root surfaces after ostectomy.
This recommendation not to damage or remove the
root cementum relies on the fact that performing
scaling or root planing could produce additional,
unpredictable attachment and bone loss with poten-
tial impact on the esthetic outcome for patients. On
the other hand, in the procedure suggested by Ribeiro
et al. (48) and Cairo et al. (13), the exposed root sur-
faces are carefully planned using curettes.
Similarly, no agreement exists on the flap position-
ing at the end of the surgery, with some authors sug-
gesting suturing the flap at the cemento–enamel
junction (21, 48) and others suggesting that the sutur-
ing should be slightly coronal to the cemento–enamel
 Esthetic treatment of altered passive eruption

A B

C D

E F

Fig. 22. Surgical treatment of altered passive eruption
with apically positioned flap and osseous resective sur-
gery. (A) The clinical crowns of the teeth are short and
asymmetrical at the level of the lateral incisors. (B) Flap
elevation and de-epithelization of the anatomical papil-
lae. No physiological distance exists between the
cemento–enamel junction and the bone crest for attach-
ment of connective tissue in any of the teeth included in
the surgical area (subgroup B). (C) Osteoplasty (to reduce
bone thickness) and ostectomy (to re-establish the cor-
rect space for connective tissue attachment) were per-
formed. (D) The flap is positioned at, or 1 mm coronal
to, the cemento–enamel junction and is secured with
interrupted sutures anchoring the surgical papillae to the
interdental de-epithelialized anatomical papillae. (E) At
the time of suture removal (14 days) the soft-tissue mar-
gins are localized almost at the same level of the end of
the surgery. (F) One year after surgical treatment. The
length of the teeth did not change significantly with
respect to the time of suture removal. Note clinical
crown lengthening with respect to the baseline situation
and the harmonious keratinized tissue height over the
treated teeth. Both of these factors contribute to enhanc-
ing the esthetic outcome.

Table 1. Suggested distance post-ostectomy between the bone crest and cemento–enamel junction or gingival margin
to re-establish biological width

Authors Suggested distance between the bone crest and cemento–enamel

junction or gingival margin to re-establish biological width

Cairo et al. 2012 (13) Bone crest to cemento–enamel junction, 1 mm

Zucchelli 2012 (66) Bone crest to cemento–enamel junction, 1 mm

Camargo et al. 2007 (14) Bone crest to cemento–enamel junction, 2 mm

Rossi et al. 2008 (50) Bone crest to cemento–enamel junction, 2 mm

Dolt & Robbins 1997 (21) Bone crest to cemento–enamel junction, 2–2.5 mm

Robbins 1999 (49) Bone crest to cemento–enamel junction, 2–2.5 mm

Batista et al. 2012 (8) Bone crest to cemento–enamel junction, 3 mm

Ribeiro et al. 2014 (48) Bone crest to cemento–enamel junction, 3 mm

Levine & McGuire 1997 (37) Bone crest to gingival margin, ≥ 3 mm

Claman et al. 2003 (15) Bone crest to gingival margin, ≥ 3 mm

Abou-Aray & Souccar 2013 (1) Bone crest to gingival margin, ≥ 3 mm

79
Mele et al.
A B
C D
junction (13, 49). Zucchelli (66) suggested de-epithelia-
lization of the most coronal aspect of the interdental
papillae with microsurgical scissors and repositioning
the flap at, or 1 mm coronal to, the cemento–enamel
junction (Figs 21 and 22) with the aim of giving
the patient the final tooth length immediately after
surgery with no further significant postoperative
changes (Fig. 22). If clinical crown lengthening is indi-
cated on the palatal aspect, the surgical procedure
should be ideally performed on a separate occasion,
leaving the buccal and interproximal tissue undis-
turbed (Fig. 23).
Flapless procedure with osseous resective
surgery
Ribeiro et al. (48) suggested a minimally invasive flap-
less esthetic crown-lengthening procedure for the
treatment of altered passive eruption. The alveolar
bone is removed and recontoured using microchisels,
via incision, without flap elevation. In this split-mouth,
randomized controlled trial, esthetic crown lengthen-
ing, with or without flap elevation, was found to have
similar and stable clinical results up to 12 months. The
authors suggest using the flapless procedure because
it seems to be a feasible, predictable and time-saving
(31  12 min vs. 41  14 min) method for treatment
of gummy smile caused by altered passive eruption
compared with flap elevation (48). However, this tech-
nique is not applicable in cases of type 2B altered pas-
sive eruption.
Discussion and conclusions
Passive eruption is a complex process that lasts for at
least 20 years in the anterior sextant, in keeping with
changes related to the development of the rest of the
80
Fig. 23. Surgical treatment of altered
passive eruption in the palatal
aspect. (A) Baseline situation with
the soft tissue covering the palatal
cingulum. (B) Flap elevation, ostec-
tomy and osteoplasty. (C) Apically
positioned flap. (D) One-year out-
come with longer clinical crowns.
body. Many unanswered questions remain regarding
the diagnosis, etiopathogenesis, treatment indica-
tions and therapy of altered passive eruption. Most
studies investigating aspects of altered passive erup-
tion are preliminary studies characterized by small
sample sizes, and as there are no studies evaluating
changes in clinical crown length in subjects older
than 20 years of age, no conclusions regarding the
diagnosis, etiopathogenesis and surgical treatment
need for altered passive eruption can be made. The
clinical diagnosis of altered passive eruption also
remains uncertain because of the difficulty in distin-
guishing between the cemento–enamel junction and
the buccal bone crest during probing or ‘bone sound-
ing’. Long-cone periapical radiographs, even when
improved with radiopaque reference points, do not
always provide unequivocal information regarding
the positions of the cemento–enamel junction and
the buccal bone crest because of the similarity in their
radiopacities. Frequently, clinical observation, even if
not supported by data, reveals thick buccal bone in
patients affected by altered passive eruption. This
could explain the lack of gingival retraction, at least in
patients with a normal, physiologic relationship
between the cemento–enamel junction and bone
crest (subgroup A).
There are no data in the literature reporting how to
perform nonsurgical treatment and maintenance
therapy in patients affected by altered passive erup-
tion and pseudopockets. One limitation is because it
is impossible to perform the equivalent of ‘root plan-
ing’ on enamel in order to reduce the depth of the
pseudopockets. A second limitation derives from the
risk of inducing gingival shrinkage as the conse-
quence of trauma to the inner soft-tissue wall of the
pseudopockets during instrumentation, which can
create an unesthetic and unpredictable alignment of
the soft-tissue margins between adjacent teeth.

The difficulties in selecting an appropriate surgical
technique for the management of altered passive
eruption partly spring from difficulties in arriving at
an accurate diagnosis of altered passive eruption. In
particular, the difficulties in distinguishing between
subgroup A or subgroup B, along with the additional
challenge of the presence of different subgroups of
altered passive eruption among teeth in the same sur-
gical area, complicate surgical treatment planning. If
there is a lack of need for osteotomy or ostectomy, as
in the case of minor disharmonies of the soft-tissue
margin, then simple gingivectomy is the treatment of
choice. However, most cases of altered passive erup-
tion have a need for ostectomy or osteoplasty as a
result of excess bone volume, necessitating an api-
cally repositioned flap with bone recountouring as
part of their surgical management. The main dis-
agreement among the authors relates to the correct
distance between the bone crest and the cemento–
enamel junction (ranging from 1 to 3 mm) in patients
with altered passive eruption subgroup B. This dis-
tance is critical in determining the amount of ostec-
tomy to be performed during surgery. The confusion
is probably caused by the high variability in the width
of the human dentogingival junction. However,
because this distance should reflect the area occupied
by the connective tissue attachment only, it should
not be greater than 1–1.5 mm. This area should not
be instrumented (root planed) during surgery as this
could lead to further, unpredictable bone and attach-
ment loss.
Surgical treatment of altered passive eruption
results in an esthetic change in the patient’s appear-
ance and smile, and despite this there are a lack of
studies evaluating how often patients request treat-
ment of altered passive eruption for esthetic reasons,
as well as a lack of studies evaluating patients’ satis-
faction with the surgical treatment outcome. It is
clear that not all ‘concerns’ that the clinician per-
ceives will be noticed by most of the lay public and
hence they should not necessarily be corrected in the
name of esthetics.
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Periodontology 2000, Vol. 77, 2018, 84–92
Printed in Singapore. All rights reserved
Crown lengthening and
restorative procedures in the
esthetic zone
M A T T E O M A R Z A D O R I *, M A R T I N A S T E F A N I N I *, M A T T E O S A N G I O R G I ,
ILHAM MOUNSSIF, CARLO MONACO & GIOVANNI ZUCCHELLI
Crown lengthening is one of the most common surgi-
cal procedures in periodontal practice. A recent Ameri-
can Academy of Periodontology survey reported that
approximately 10% of all periodontal surgical proce-
dures are performed in order to achieve gain in crown
length (1). The main indications of crown-lengthening
surgical procedure include treatment of subgingival
caries, crown or root fractures, altered passive erup-
tion, cervical root resorption and short clinical abut-
ment. The rationale of crown lengthening is to re-
establish the biologic width (e.g. the natural distance
between the base of the gingival sulcus and the height
of the alveolar bone) in a more apical position to avoid
a violation that may result in bone resorption, gingival
recession, inflammation or hypertrophy.
The concept of biologic width stems from the clas-
sic histologic study by Gargiulo et al. (13), who mea-
sured the average dimension of the epithelial
junction (0.97 mm) and connective tissue attachment
(1.07 mm) in humans. These values were summed to
provide the biologic width, yielding an average
dimension of 2.04 mm. A recent systematic review
(22) found similar mean values of biologic width
(2.15–2.30 mm), although considerable intra- and
interindividual variances were reported (subject sam-
ple range: 0.20–6.73 mm). The integrity of the biologic
width is considered a necessary step, in restorative
and prosthetic rehabilitations, to obtain and maintain
healthy soft tissues. While crown-lengthening proce-
dures in posterior areas have been investigated in
detail, crown lengthening performed for esthetic
*Both authors contributed equally.
84
© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
PERIODONTOLOGY 2000
reasons in anterior areas is still a matter of debate. A
literature search on PubMed for ‘esthetic crown
lengthening’ returned a list of 250 articles. Among
these articles, there are no systematic reviews and
only a few controlled clinical trials (3, 5, 14, 16, 20).
Moreover, anterior crown lengthening is often
described as part of a multidisciplinary orthodontic
and restorative treatment plan. For these reasons,
although a number of surgical procedures are
described, an evidence-based technique is not avail-
able and many questions still remain unanswered.
The purpose of this paper is to focus on the descrip-
tion of the surgical and restorative phases in the
esthetic crown-lengthening procedure by answering
the following questions: what is the ideal surgical flap
design? how much supporting bone should be
removed? how should the position of the flap margin
relate to the alveolar bone at surgical closure? and
how should the healing phase be managed in relation
to the timing and the position of the provisional
restoration with respect to the gingival margin?
Soft- and hard-tissue management
Flap design (vestibular aspect)
The flap is designed by creating submarginal parabolic
incisions, starting from the angular lines of the adja-
cent teeth and crossing at the level of the interdental
papillae, thereby reproducing the natural scalloping of
a patient’s gingival margin. Correct placement of the
primary incision is based on the probing depth and on
the amount of keratinized tissue available (4, 7). In a
patient with an ‘adequate’ dimension of keratinized

tissue, the distance of the primary incision from the
gingival margin is proportional to the differences in
probing depth of the adjacent teeth (6). If the amount
of keratinized tissue is ‘inadequate’, the primary inci-
sion should be intrasulcular.
Flap elevation is a controversial issue. The litera-
ture describes full-thickness (3, 19), split-thickness (2)
and split-full-split-thickness approaches (4, 18, 25).
The rationale of the split-thickness elevation is to pre-
serve the periostium in order to minimize postsurgi-
cal bone resorption and to facilitate the apical
suturing of the flap. The full-thickness approach has
the advantages of being easier to perform and of
gaining direct access to the bone than the split-full-
split-thickness and full-thickness approaches. The
split-full-split-thickness approach merges the positive
aspects of both techniques: the papillae area is ele-
vated split-thickness in order to obtain a precise post-
surgical adaptation, while, apically, a full-thickness
elevation is made in order to gain access to the bone
and to preserve the periosteum, which would other-
wise be lost during osteoplasty, at the inner aspect of
the flap. Once an adequate amount of bone has been
exposed, a split-thickness dissection can be per-
formed to facilitate the apical anchorage of the flap in
the desired position (4, 7, 25).
Flap design (palatal aspect)
The palatal flap is raised using the thinned palatal
flap approach (9). As the palatal flap cannot be
moved apically, the position of the primary incision
must anticipate the future configuration of the crestal
bone and depends on the amount of crown lengthen-
ing required and on the palatal vault anatomy. In the
presence of a shallow palatal vault the distance of the
incision from the gingival margin is exclusively
related to the amount of crown lengthening required.
In the presence of a deep palatal vault, the soft-tissue
thickness has to be taken into consideration, with
thicker soft tissues necessitating a greater amount of
tissue removal with the secondary palatal flap and
more pronounced apical repositioning of the flap.
Hence, if the deep palatal vault has thick soft tissue,
the primary incision should be less para-marginal
than if the deep palatal vault has thin tissues. Other-
wise, there is a risk of incomplete coverage of the
palatal bone. In order to avoid excessive exposure of
palatal bone, great care must be taken not to make
the incision too far from the gingival margin, espe-
cially in the case of a shallow vault or a deep palatal
vault with thick soft tissue.
Crown lengthening and restoration in the esthetic zone
After vestibular and palatal flap reflection, the soft
tissue delimited with the primary incisions is
removed using manual and ultrasonic devices.
Ostectomy
Ostectomy consists of the removal of supporting
bone (bone connected to the root surface with peri-
odontal ligament), and the amount of bone resected
is determined by the extent of the crown lengthening
required. Many authors have proposed a range of val-
ues (3 mm to > 5 mm) for the amount of tooth struc-
ture to be exposed during crown-lengthening
procedures (12, 15–17, 21, 23). These ‘numbers’ are
derived from the histologic description of the den-
togingival complex by Gargiulo et al. (13). Although
considerable variations were reported, the dimension
of the supra-osseous soft tissue was, on average,
2.73 mm. Other authors (16, 18) proposed a method
to measure the individual biologic width dimension
using presurgical, transmucosal probing. In particu-
lar, Lanning et al. (16) reported a biologic width aver-
age of 2.26  0.13 mm, while Perez et al. (18)
measured a mean supra-osseous gingiva of 3.63 
0.64 (range: 2.67–5.00) mm. Although the mean val-
ues of biologic width found in these studies are simi-
lar, the significant range variability observed between
patients makes it reasonable to carry out presurgical
biologic width or supra-osseous gingiva measure-
ments in order to personalize the extent of bone
removal.
Osteoplasty
Osteoplasty consists of the removal of nonsupporting
bone and aims to thin the vestibular and lingual/
palatal aspects of alveolar bone and to eliminate any
osseous ledges or exostosis. It includes techniques of
vertical grooving and radicular blending aimed at
establishing physiologic osseous morphology and
root prominence (4, 6). The amount of bone required
to be removed has not been quantified in the litera-
ture, and whether osteoplasty is needed requires a
subjective clinical judgment. However, bone reduc-
tion could be considered as complete when the flap
can be precisely adapted over the underlying bone.
Instrumentation
Bone is removed by high-speed drilling under copi-
ous irrigation with sterile water. Aggressive, multita-
pered drills can be used initially, followed by the use
of diamond burs and handheld chisels to refine the
85
Marzadori et al.
bone surface. Care must be taken to remove all inter-
proximal bone remnants (i.e. widow’s peaks) and to
prevent inadvertent trauma to the teeth. Root planing
of the exposed root surface is carried out using ultra-
sonic and hand instruments to create a hard, smooth
and clean root surface.
Flap suturing and positioning
The flap is sutured with vertical mattress sutures
anchored to the periosteum with the rationale of
obtaining a tight adaption of the flap to the underly-
ing tissues at the desired apical position.
Esthetic considerations
The goal of esthetic surgery is to mimic, as much as
possible, the natural aspect of soft tissues and to give
a harmonious aspect to the surgical area. The presur-
gical and surgical variables to be considered to
achieve these objectives are:
 The position of the vestibular incision. As the
vestibular flap can be precisely adapted to the
bone crest and sutured at the desired position,
the vestibular incision should be mostly guided by
considering the final position of the mucogingival
line after flap suturing, with the purpose of
obtaining a uniform band of keratinized tissue
around the anterior teeth.
 Interdental soft tissues. The interdental soft tis-
sues should be left in place if no interproximal
crown lengthening is required. This is the case if a
patient is affected by buccal passive altered erup-
tion requiring restorative rehabilitation.
A B
Fig. 1. Ostectomy with esthetic proportion parameters. (A)
The right lateral incisor is the ‘guiding’ tooth being the
tooth in which the buccal bone crest has to be more api-
cally displaced because of the need to establish the ideal
distance between the bone crest and the composite
restorations. (B) The buccal and interdental bone crest of
all other teeth included in the flap design have been modi-
fied in order to accomplish the esthetic proportion criteria:
same level of the bone crest at homologous contralateral
elements, buccal bone crest of the lateral incisors more
86
o Ostectomy (Fig. 1). The tooth that will have the
buccal bone crest most apically displaced after
ostectomy (for a restorative, ferrule effect, or
esthetic or periodontal reasons) has to be
considered as the ‘guiding tooth’. Once the guid-
ing tooth is identified, the extent of the ostec-
tomy on the adjacent teeth should respect the
following esthetic proportion parameters: the
apicocoronal position of the bone crest should
be at the same level of homologous contralateral
elements; the position of the bone crest of the
central incisors should be at the same level or
more coronal to the bone crest of the canines;
and the position of the bone crest of the lateral
incisors should be more coronal to the bone
crest of the central incisors and canines.
 Osteoplasty. The osteoplasty must be performed
accurately in order to establish physiologic and
harmonious vestibular bone morphology. How
the bone thickness is managed has a direct influ-
ence on the appearance and rebound of soft tis-
sues and the tooth-emergence profiles.
Soft-tissue rebound
The regrowth of soft tissue after the crown-lengthen-
ing procedure has been investigated in detail. Bra €gger
et al. (5), performed a study on 25 patients to assess
changes in the soft-tissue level after a crown-length-
ening procedure with a 6-month follow-up. Immedi-
ately after suturing, the surgical procedure resulted in
apical displacement of the soft-tissue margin by an
average distance of 1.32 mm. At 6 months, stable
periodontal tissues with minimal changes in the
coronally displaced with respect to the central incisors,
buccal bone crest of the central incisors more coronally
displaced with respect to canine bone crests (white dot
lines). Also the interdental bone between lateral and
canine should be at the same level of the contralateral one
and more apical with respect to the interdental bone level
between lateral incisor and central incisor which should be
apical to the interdental bone height between central inci-
sors (black lines). This is critical for the final esthetic
appearance of the interdental papillae.

gingival margin levels were reported. These data were
partially confirmed by Lanning et al. (16), in a study
on 18 patients. These authors observed no significant
change in the position of the free gingival margin
between 3- and 6-month time points (7.64  0.32
and 7.90  0.30 mm, respectively). As no postsurgical
measures of the free gingival margin were provided, a
comparison between baseline (after flap suturing)
and 3- to 6-month time points is not possible. Con-
versely, Pontoriero & Carnevale (20), in a study on 30
patients, found significant alterations of the marginal
periodontal tissues from the immediate postsurgical
level (4.8  1.7 mm interproximally and
5.7  2.4 mm buccolingually) over a 12-month heal-
ing period (1.6  1.4 mm interproximally and
2.8  2.6 mm buccolingually), indicating significant
coronal displacement of the newly formed soft-tissue
margin. Moreover, a different pattern in the healing
response between different tissue biotypes was
observed, with the coronal regrowth at interproxi-
mal and buccal/lingual sites being significantly
more pronounced in patients with a thick tissue
biotype than in patients with a thin tissue biotype.
The tendency for a coronal shift of the soft-tissue
margin during healing was also confirmed by Perez
et al. (18), Arora et al. (3), and Deas et al. (10), on
studies with 6 months of follow-up. In particular,
Arora et al. (3) and Deas et al. (10) related the tissue
rebound to the postsurgical flap position, observing
greater growth when flaps were positioned closer to
the alveolar crest. These findings underline the
importance of a presurgical evaluation by the clini-
cian, and the extent of the ostectomy should be
considered according to the tissue biotype. Also, the
clinician should be aware that the position of the
flap directly influences the soft-tissue rebound and
accordingly should choose an appropriate suture
technique.
Provisional and definitive
prosthetic management
Management of the provisional prosthetic restoration
is a fundamental step in the esthetic rehabilitation
process that often troubles both the clinician and the
patient. Three procedures can be adopted based on
the time point when the teeth are prepared and on the
position of the margins of the prosthesis with respect
to the gingival margin: (i) intra-operative tooth prepa-
ration and relining of the provisional restoration; (ii)
early tooth preparation and relining of the provisional
Crown lengthening and restoration in the esthetic zone
restoration; and (iii) delayed tooth preparation and
relining of the provisional restoration.
Intra-operative tooth preparation and
provisional relining
In this approach, tooth preparation is carried out dur-
ing surgery, after ostectomy and osteoplasty, usually
with the use of diamond burs. Abutments are pre-
pared with knife-edge margins at the bone crest level.
The intra-operative preparation offers the following
advantages: elimination of undercuts; root proximity
correction; and smoothing and cleansing of root sur-
faces by removing calculus and necrotic cement rem-
nants. After preparation of abutments the provisional
restoration can be relined during surgery or immedi-
ately after suturing. Prosthetic margins should be
positioned at a distance of at least 1 mm from the gin-
gival level and constantly monitored in order not to
interfere with the healing of soft tissue. The frequency
with which the provisional restoration is modified is
related to the expected soft-tissue rebound (i.e. the
position of the flap at time of suturing and the gingival
biotype) (6). The final prosthesis can be delivered
when soft-tissue stability is observed.
Early tooth preparation and provisional
relining
In this approach tooth preparation occurs after 3
weeks from the surgery (25). During this period, the
presurgical provisional restoration is left in place. The
rationale for this approach is to manage the provi-
sional prosthetic steps after the initial healing has
taken place and following restoration of the connec-
tive tissue attachment (i.e. the re-establishment of
the biologic width and during the maturation phase
of the soft tissues). In the first 3 weeks after surgery,
approximately 1 mm of bone surrounding the teeth
involved in the surgery resorbs and leaves a portion
of healthy root cementum available for connective
tissue attachment to re-form, in a more apical posi-
tion (24). The area previously occupied by the con-
nective tissue attachment, where intra-operative root
planing was performed, is now a hard, smooth and
clean surface onto which the junctional epithelium
can adhere (8). Three weeks after surgery, the probing
depth is zero and the sulcus and the interdental
papillae are still absent. From a clinical point of view,
the tooth structure that, after the soft-tissue matura-
tion, will become subgingival is now still supragingi-
val, thus facilitating management of the provisional
prosthetic restoration. The abutment preparation is
87
Marzadori et al.
Fig. 2. Crown lengthening for esthetic reasons. (A) Patient complaints about the previous esthetic treatment. (B) Intraoral
radiographs showing no interdental bone loss.
A B
Fig. 3. (A) Pre-surgical phase. (B) Removal of the old restorations. (C) Abutment reconstruction.
A B
Fig. 4. (A) Gummy smile. (B) First provisional restorations.
now performed at, or close to, the gingival level with
a knife-edge margin and using the healed soft-tissue
margin as a guide. A new provisional restoration is
relined at the same level. The early tooth preparation
offers the following advantages (25): less aggressive
abutment preparation; the provisional prosthetic
phase does not interfere with the re-establishment of
the biologic width; no need for provisional relining at
the end of surgery; easy supragingival knife-edge
preparation using the healed soft-tissue margin as a
guide; easy supragingival relining of the provisional
restoration in a rested patient with no bleeding; con-
ditioning of the soft tissues during the maximal
88
C
regrowth period; and no need for retraction cords
during abutment preparation and relining of the pro-
visional restoration (necessary in the case of delayed
tooth preparation and provisional relining).
The provisional restorations are modified further
only in the interdental aspect, thus avoiding unes-
thetic exposure of tooth structure during the entire
healing phase. This also minimizes hypersensitivity.
The contact point is initially positioned at a distance
of 3 mm from the interdental soft tissues and is pro-
gressively shifted in a more coronal position, a mil-
limeter at a time, as the interdental space is filled by
the soft-tissue regrowth. Also, the convergence of the
 Crown lengthening and restoration in the esthetic zone

A B C

D E F

Fig. 5. The gummy smile, the absence of interdental
bone loss and the adequate interdental and palatal abut-
ment height suggest only buccal crown lengthening pro-
cedure to be performed. (A) Flap design: paramarginal
incisions. (B) Split-Full-Split thickness flap elevation. (C)
Removal of the marginal tissue and de-epithelization of
the papillae. (D) Osteoplasty and ostectomy performed
following the esthetic proportion criteria. (E) Apically
positioned flap and provisional replacement with no
need of relining. (F) Soft tissue healing after 2 weeks:
time for the impression for the new provisional
restoration.

A B C

Fig. 6. Three weeks after the surgery. (A) Feather-edge abutment preparation using the soft tissues as a guide. (B) 7 weeks
after the surgery, the papillae fill the interdental spaces. (C) The convergence of the provisional interproximal surfaces is
modified and the contact point shifted coronally to allow further growth of the papillae.

A B C

Fig. 7. Soft tissues maturation phase. (A) 3 months after the surgery the interdental spaces are filled. (B) 6 months after
surgery, soft tissues are mature and ready for the final impression. (C) Digital impression.

A B C

Fig. 8. (A) 1 year after cementation of the final restoration. (B) 3 years after cementation. (C) Radiographic control at
3 years.

89
Marzadori et al.

A B

Fig. 9. Crown lengthening for esthetic reasons. (A) Patient complaints about the previous esthetic treatment. (B) Intraoral
radiographs showing mild horizontal bone loss.

A B

Fig. 10. Pre-surgical phase. (A) Removal of the old restorations. (B) New temporary crown in position.

A B C

D E F

Fig. 11. (A) Bone recountouring (ostectomy and osteo-
plasty) was performed on the buccal and palatal aspects.
No intrasurgical abutments preparation was performed.
(B) The position of the buccal crest respects the aesthetic
proportion criteria independently of the previous length of
the temporary crowns. (C) Sutures of the apically posi-
tioned buccal flap. (D) Sutures of the apically positioned
thinned palatal flap. (E) Temporary crowns in position
with no need of rebasement. (F) 2 weeks after surgery at
the time of suture removal.

A B C

Fig. 12. Three weeks after surgery. Early restorative phase. (A) Before abutment preparation. (B) After feather edge abut-
ment preparation. (C) Rebasement of the temporary crowns.

90
 Crown lengthening and restoration in the esthetic zone

A B

Fig. 13. (A) Intermediate (4 months) maturation phase after modification of the temporary crowns. (B) 6 months after the
surgery at the time of final impression.

A B

Fig. 14. (A) 1 year after cementation of the final restoration. (B) 3 years after cementation. (C) Radiographic control at
3 years.

Fig. 15. Staging of the different crown lengthening prosthetic procedures.

provisional interproximal surfaces is gradually aug-
mented, to maximize the regrowth of the interdental
papillae. The frequency of the provisional modifica-
tions is related to the expected soft-tissue rebound.
The time for the final impression is specifically cho-
sen in each patient when, at the last control visit,
there is no further growth of the interdental papillae
with respect to the last contact point of the temporary
crowns (25). An example of esthetic crown lengthen-
ing limited to the buccal aspect and early restorative
phase is shown in Figs 2–8. An example of esthetic
crown lengthening and early restorative phase is
shown in Figs 9–14.
Delayed tooth preparation and
provisional relining
This approach is based on the concept of not interfer-
ing with healing of the soft tissues (11). After the
crown-lengthening procedure, the margins of the

91
Marzadori et al.
provisional restoration are maintained at the presurgi-
cal level until soft-tissue stability is achieved (9–12
months). At this point, the final abutment preparation
is performed and the final prosthesis is delivered.
Conclusions
Despite the fact that crown lengthening in esthetic
areas is a widely used clinical procedure, there is a lack
of evidence in the literature regarding the description
of both surgical and prosthetic procedures. However,
some indications can be summarized:
 The objective of resective surgery is to obtain an
increase in the clinical crown length. To achieve
this, hard and soft tissues must be thinned as
much as possible in order to minimize the amount
of supporting bone removal (ostectomy):
o The surgical papillae should be elevated in a
split-thickness manner.
o The palatal flap should be elevated using the
‘thinned palatal flap approach’.
o The nonsupportive bone should be thinned to
obtain a precise flap adaptation.
o The buccal ostectomy should be performed,
after choosing the guiding tooth, following the
esthetic proportion parameters.
 Regrowth of soft tissue after the crown-lengthen-
ing procedure is dependent on individual patient
factors and the timing of the placement of the
final restoration should be chosen accordingly.
 The provisional prosthetic restoration phase
should start 3 weeks after the surgery in order not
to interfere with the re-establishment of the bio-
logic width and to condition the soft tissues dur-
ing the period of maximal regrowth.
Figure 15 summarizes the staging of crown-lengthen-
ing prosthetic procedures.
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Periodontology 2000, Vol. 77, 2018, 93–110
Printed in Singapore. All rights reserved
Simplified procedures to treat
periodontal intraosseous defects
in esthetic areas
LEONARDO TROMBELLI, ANNA SIMONELLI, LUIGI MINENNA,
RENATA VECCHIATINI & ROBERTO FARINA
Intraosseous defects are defined by the apical loca-
tion of the base of the pocket with respect to the
residual alveolar crest (31). Clinically and radiograph-
ically, 18–51% of subjects present at least one
intraosseous defect (7, 22, 30, 33, 41, 42, 54, 60).
Intraosseous defects are at high risk of further
progression and may lead to tooth loss if left
untreated (32). The treatment of periodontitis, which
also encompasses intraosseous defects, is based on
removal of supra- and subgingival biofilm, achieved
by patient-performed oral hygiene associated with
professional nonsurgical periodontal debridement. As
intraosseous defects may be associated with persistent
deep pockets and bleeding following conventional
nonsurgical treatment, these lesions are frequently
considered as sites requiring surgical therapy (17).
Historically, the ‘classical’ surgical approaches used to
access and treat periodontal intraosseous defects were
based on flap designs characterized by either minimal
tissue resection (21, 35) or total preservation of inter-
dental tissues, such as the papilla-preservation tech-
nique (43) and its variants (2–4, 15, 26, 45). All these
flap designs are based on the elevation of a double
mucoperiosteal flap involving both buccal and oral
aspects (47).
The term ‘simplify’ means the act of making some-
thing less complex. Its etymology originates from the
Medieval Latin verb simplificare which, in turn,
derives from the terms simplex (simple) and facere
(make). We define a procedure as ‘simplified’ when
it provides more favorable conditions for either
the patient or the clinical operator. Although the
terms ‘simplification’ and ‘minimal invasiveness’ may
appear as synonyms when referring to periodontal
treatment, in our perspective ‘simplification’ implies
© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
PERIODONTOLOGY 2000
a substantially different concept. For the operator, a
simplified procedure should: (i) require limited surgi-
cal equipment; (ii) be characterized by a steep and
short learning curve; and (iii) limit the need for the
use of additional treatments/devices (through maxi-
mizing the inherent healing potential of the treated
lesion). For the patient, a simplified procedure should
have reduced impact on: (i) post-treatment daily
activities; (ii) post-treatment pain and discomfort
(also reducing the required compliance for post-treat-
ment regimens); and (iii) pre-existing esthetics. For
both patient and operator, a simplified procedure
should reduce: (i) chair-side time needed for treat-
ment administration and follow-up visits; and (ii)
treatment costs.
Nonsurgical therapy as a solo treatment always
represents a ‘simplified’ procedure, particularly when
compared with surgical approaches. Among the sur-
gical options available, ‘simplified’ surgical proce-
dures, as recently proposed, will be thoroughly
revised in this chapter of Periodontology 2000. These
procedures share a common technical aspect, namely
the elevation of a single flap on the buccal or oral
aspect, leaving the tissues on the opposite side intact
(see the ‘Technical aspects’ section for details). All the
simplified treatments (either nonsurgical or surgical)
described here were originally designed and proposed
as minimally invasive approaches for periodontal
treatment, mainly aimed at minimizing tissue trauma
and consequently intra- and postoperative morbidity
(16). In this respect, it will be shown that the minimal
invasiveness of such procedures may be partly a result
of the simplification of the treatment approaches. We
describe here the technical aspects and the effect on
clinical parameters and patient-centered outcomes of
93
Trombelli et al.
the simplified procedures for the treatment of
periodontal intraosseous defects, specifically when
located in the esthetic area. Particular emphasis is on
studies comparing simplified and classical procedures
as well as the application of simplified surgical proce-
dures in addition to regenerative devices.
Simplified procedures for the
treatment of periodontal
intraosseous defects: technical
aspects
Nonsurgical procedures
Table 1 summarizes the studies on nonsurgical ther-
apy for the treatment of intraosseous defects. All
studies incorporated a thorough subgingival instru-
mentation performed with manual instruments,
either alone (20, 36) or in combination with mechani-
cal instruments (19, 28, 29, 37). Recently, minimally
invasive nonsurgical periodontal therapy has been
introduced as a concept aimed at obtaining extensive
subgingival debridement with minimal tissue trauma
(37). Minimally invasive nonsurgical periodontal ther-
apy is based on the following principles: (i) thorough
debridement of the root surface to the bottom of
the periodontal pocket, avoiding root planing and
gingival curettage; (ii) use of a magnification system;
(iii) prevalent use of an ultrasonic device with speci-
fic thin tips, complemented by Gracey minicurettes;
and (iv) caution to preserve the integrity of soft
tissues.
Surgical procedures
In 2007, the first simplified surgical procedure was
proposed (48). This procedure, which was defined as
a single flap approach, is based on the elevation of a
flap on one aspect only (buccal or oral, depending on
the extension/morphology of the lesion), thus pre-
serving the integrity of the interdental soft tissue
(Fig. 1). The elevation of a single flap to access the
intraosseous defect may pose several clinical advan-
tages. First, it may facilitate flap repositioning and
suturing; the flap can be easily stabilized to the unde-
tached papilla, thus optimizing wound closure for
primary intention healing. Moreover, by leaving a
great volume of supracrestal soft tissues intact, accel-
erated re-establishment of the local vascular supply
may occur. Wound stabilization and preservation of
an intact interdental papilla may also contribute to
94
enhanced preservation of the pre-existing gingival
esthetics.
A prerequisite to apply the single flap approach
principles is that the morphology of the defect is
compatible with thorough root/defect debridement
when accessed by either the buccal or oral side only.
Whenever the bucco-oral extension of the defect pre-
vents successful removal of the oral biofilm from the
root surface as well as the complete degranulation of
the intraosseous component of the defect, conven-
tional double-flap approaches should be performed.
However, data derived from the distribution of
intraosseous defects according to the bone morphol-
ogy (44, 54), combined with observation from a
prospective trial (6), seem to suggest that a single-flap
(usually buccal) access to intraosseous defects may
be feasible in a relevant proportion of surgically trea-
ted defects.
The single flap approach is a simplified surgical
approach that is used to access periodontal intraoss-
eous defects (48, 49) (Fig. 1). The basic underlying
principle of the single flap approach consists of the
elevation of a limited mucoperiosteal flap to allow
access to the defect from either the buccal or oral
aspect only, depending on the main buccal/oral
extension of the lesion (as diagnosed by preoperative
bone sounding and periapical radiographs), preserv-
ing the integrity of the interproximal supracrestal gin-
gival tissues. A single flap approach mainly consists of
an envelope flap. Sulcular incisions are performed on
the buccal or oral side (for defects with a prevalent
extension on the buccal or oral side, respectively) fol-
lowing the gingival margin of the teeth included in
the surgical area. The mesiodistal extension of the
flap is kept as limited as possible while ensuring
proper access for defect debridement (as well as posi-
tioning/application of a regenerative device, if indi-
cated). Therefore, priority, in terms of flap extension,
is given to provide adequate surgical access, some-
times extending the incision to involve the papillae of
adjacent teeth in order to limit the use of vertical
releasing incisions. In the interproximal area (i.e. at
the level of the interdental papilla) overlying the
intraosseous defect, an oblique or horizontal butt-
joint incision is made following the profile of the
underlying bone crest. The distance between the tip
of the papilla and the apicocoronal level of the inter-
dental incision is based on the apicocoronal dimen-
sion of the supracrestal soft tissues. Preoperatively,
probing measurements are carefully performed to
assess the horizontal component of the bone loss and
therefore the apicocoronal dimension of the soft
tissues overlying the bone crest. The greater the
 Table 1. Clinical studies evaluating the effectiveness of non-surgical therapy in the treatment of intraosseous defects
Study Experimental Number of defects Radiographic depth of Baseline Treatment approach Localization of Follow-up Clinical outcomes Radiographic Patient-centered outcomes
design intraosseous probing intraosseous defects (months) outcomes
component depth (mean, Clinical Probing Gingival
mm) attachment level depth recession

Isidor Split-mouth, 13 ≥ 15% of root length 7.6 Root planing with Lateral incisors, canines, 12 Mean gain, 1.6 mm Reduced to Mean Mean gain in Not available
et al. 1985 prospective manual instruments premolars 4.2 mm increase, bone height: 0.9%
(20) clinical trial 1.8 mm (no alteration in
50% of defects;
change comprised
between 10%
and +10% in the
other 50% of defects)

Renvert Split-mouth, 25 Not available 6.7 Root planing with All tooth types 6 Mean gain, 0.8 mm Reduced to Mean Not available Not available
et al. 1985 prospective manual instruments 5.2 mm increase,
(36) clinical trial 0.8 mm

Hwang Case series 39 (sites) ≥ 3 mm 6.57 Scaling and root planing All tooth types 6 Not available Not available Not available Increase in Not available
et al. using mechanical and radiographic
2008 (19) manual instruments density in 83.3%
of the regions
analyzed

Nibali Retrospective 126 Mean, 3.8 mm 6.5 Scaling and root planing All tooth types Range, Mean gain, 1.42– Mean Mean Vertical defect Not available
et al. study using mechanical and 12–18 1.50 mm reduction, increase, 0.5 depth reduced
2011 (29) manual instruments 2.24– –0.7 mm to 3.08 mm
with/without systemic 2.29 mm (persistent
or local antibiotics radiographic
defect depth ≥ 2.0
mm in 71% of
defects)

Ribeiro Parallel-arm 13 patients with ≥ 1 ≥ 4 mm 6.35 Scaling and root planing Single-rooted teeth 6 Mean gain, Mean Mean Not available Low extent of discomfort, root
et al. 2011 randomized defect with minicurettes and 2.56 mm reduction, increase, hypersensitivity and edema
(37) controlled an ultrasonic device 3.13 mm 0.45 mm during the first post-therapy
trial with specific thin tips week
under an operating No hematoma, high fever or
microscope interference with daily activities
(minimally-invasive Mean number of analgesic
nonsurgical medications: 0.31
periodontal therapy) 92.30% of patients very satisfied at
6 months

14 patients with ≥ 1 ≥ 4 mm 7.07 Minimally invasive Single-rooted teeth 6 Mean gain, Mean Mean Not available Low extent of discomfort, root
defect surgical technique (4) 2.85 mm reduction, increase, hypersensitivity and edema
3.51 mm 0.48 mm during the first post-therapy week
No hematoma, high fever or
interference with daily activities
Mean number of analgesic
medications, 0.40
92.85% of patients very satisfied at
6 months

95
Simplified procedures for intraosseous defects
Trombelli et al.

distance from the tip of the papilla to the underlying

bone crest, the more apical (i.e. close to the base of

Patient-centered outcomes
the papilla) the incision in the interdental area. This
is undertaken to provide an adequate amount of
untouched supracrestal soft tissue connected to the

Not available
undetached papilla to ensure flap adaptation and
suturing as well as to warrant proper access to the
intraosseous defect for debridement and, when
needed, graft/membrane positioning. The defect is

increased from
Radiographic

intraosseous

Supraosseous
component,

component
Reduction of
approached by elevating a flap only on the buccal or

2.1 mm to
2.93 mm
outcomes

2.6 mm
oral side and leaving the opposite portion of the
interdental supracrestal soft tissues undetached. The
from 0.6 mm
to 0.8 mm

full-thickness elevation of the marginal portion of

Increased
recession
Gingival

the flap should be performed using a microsurgical

periosteal elevator. Partial-thickness dissection, if
reduction,
3.1 mm

needed, must be limited to the apical portion of the

Probing
depth

Mean gain, 2.8 mm Mean

flap to ensure flap replacement and suturing without

tension. Once root and defect debridement has been
Clinical outcomes

attachment level

completed, a horizontal internal mattress suture is

Clinical

placed coronal to the mucogingival junction between

the flap and the base of the undetached papilla in
order to provide the flap repositioning. Then, a verti-
cal or horizontal internal mattress suture (or an inter-
Follow-up
(months)

rupted suture) is placed between the most coronal

12

portion of the flap and the most coronal portion of

the intact papilla to ensure primary closure. Suture
intraosseous defects

removal is performed 14 days after surgery.

Localization of

All tooth types

More recently, other authors proposed variants of

the single flap approach in which only a single buccal
flap is raised to access the intraosseous defect (1, 5,
Treatment approach

periodontal therapy

63). In 2008, Checchi et al. (1) modified the original

7.8 (at deepest Minimally invasive

technique of the single flap approach by coronally

nonsurgical

advancing the flap, with the intention to minimize

(37)

the esthetic impairment related to the surgical proce-

depth (mean,

dure and optimize soft-tissue closure at the incision

Baseline
probing

margin. This technique was named the coronally

site)
mm)

positioned single flap approach. In order to coronally

≥ 3 mm mean, 6.7 mm
Radiographic depth of

advance and stabilize the flap, split-thickness prepa-

ration of the tissues in the apical portion of the flap
intraosseous
component

and de-epithelization of the interdental papillae were

recommended. The modified minimally invasive sur-
gical technique was proposed in 2009 (5). Substantial
Experimental Number of defects

overlap exists between the modified minimally inva-

sive surgical technique and the buccal single-flap
approach, including aspects related to the interdental
35

flap incision and flap management. However, in the

Retrospective
Table 1. (Continued)

modified minimally invasive surgical technique the

study
design

mesiodistal extension of the incision is kept at a mini-

mum (ideally, within the mid-buccal area of the
involved teeth) to allow reflection of a triangular buc-
cal flap. A microblade is used to cut through the inter-
et al. 2015

dental tissues, with an inclination suitable to

Nibali
Study

(28)

intercept the buccal side of the lingual bone crest, as

96

A B
D E
G H
J K
Fig. 1. Operative steps to perform a surgical access accord-
ing to the principles of the single flap approach. (A) Pre-
operative probing following non-surgical treatment of a
defect located at the mesio-buccal aspect of a maxillary lat-
eral incisor. (B) The defect has a minimal to null extension
on the palatal aspect, as detected by pre-operative probing.
(C) Pre-operative periapical radiograph. (D) An oblique or
horizontal, butt-joint incision is performed at the level of
the interdental papilla. The incision is extended intrasulcu-
larly at the adjacent teeth. (E) Buccal flap elevation with a
microsurgical periosteal elevator. The oral portion of the
interdental supra-crestal soft tissues is left undetached. (F)
Simplified procedures for intraosseous defects
C
F
I
L
In this case, the intraosseous component of the defect
(depth, 5 mm) is left filled with a blood clot only. (G) First
horizontal internal mattress suture at the base of the papilla.
(H) Second internal mattress suture at the most coronal
portion of the papilla. (I) Complete wound closure and
absence of fibrin line in the interproximal area (equivalent
to an early healing index of 1, as proposed by Wachtel et al.
(55)) are observed at suture removal (2-week post-surgery).
(J) Healing at 6 months after surgery. (K, L) Clinical and
radiographic aspect at 3 years following surgery (re-adapted
from Trombelli et al. (51)). This figure is reproduced with
permission from the American Academy of Periodontology.
97
Trombelli et al.
close as possible to its coronal edge, to isolate the
granulation tissue filling the intraosseous component
of the defect from the supracrestal papillary tissues.
Wound closure is obtained with a single, modified
internal mattress suture positioned at the defect-
associated interdental area. More recently, Zucchelli
et al. (63) combined the single flap approach with a
connective tissue graft in order to treat challenging
intraosseous defects associated with Miller’s Class IV
gingival recessions. To ensure sufficient graft cover-
age, the flap was coronally advanced and fixed to the
de-epithelialized interdental papillae. The entirety of
the interdental supracrestal soft tissue is pushed in a
palatal direction until the tip of the interdental papilla
is shifted in the most coronal position in order to
facilitate flap stabilization in the area overlying the
intraosseous defect. No attempt is made to elevate an
oral flap.
Simplified procedures for the
treatment of periodontal
intraosseous defects: effect on
clinical parameters and patient-
centered outcomes
Nonsurgical procedures
Clinical parameters
Data on the effectiveness of nonsurgical therapy in
the treatment of intraosseous defects are reported in
Table 1. In general, defects showing a probing depth
of < 7 mm and a radiographic depth of the angular
component of ≥ 2 mm were included. Although
improvements in clinical and radiographic parame-
ters were reported at 6–18 months of follow-up, sub-
stantial heterogeneity in treatment outcomes was
observed among studies. Some studies reported a
mean gain in clinical attachment level of 0.8–1.6 mm,
an increase in bone height of 0.9% and a mean resid-
ual probing depth of 4.2–5.2 mm (20, 36). In contrast,
when nonsurgical treatment was administered
according to minimally invasive nonsurgical peri-
odontal therapy, greater clinical improvements were
observed (28, 37). At 6 months, a clinical attachment
level gain of 2.56 mm and a probing depth reduction
of 3.13 were reported by Ribeiro et al. (37). Similarly,
an average reduction in the radiographic vertical
defect depth of 2.93 mm, accompanied by a clinical
attachment level gain of 2.8 mm and a probing depth
reduction of 3.12 mm, was observed by Nibali et al.
(28) at 12 months following treatment. The
98
magnitude of postoperative increase in gingival reces-
sion following nonsurgical treatment of intraosseous
defects also shows variations among studies
(Table 1). While some studies report a gingival reces-
sion increase of 0.8–1.8 mm (20, 36), a more limited
post-treatment recession has been observed in recent
trials. In particular, a mean gingival recession
increase of 0.2–0.45 mm was reported following mini-
mally invasive nonsurgical periodontal therapy (28,
37). In one arm of a randomized controlled trial (37),
the mean chair-time (as assessed from injection of
local anesthesia to completion of the professional
instrumentation of the tooth surfaces) for minimally
invasive nonsurgical periodontal therapy was
29.15  4.30 min.
Patient-centered outcomes
Data stemming from one arm of a randomized con-
trolled trial (37), in which nonsurgical treatment of
intraosseous defects was based on minimally invasive
nonsurgical periodontal therapy principles, indicated:
 Low levels of pain and discomfort following the
procedure. Also, the mean dose of analgesic medi-
cation consumed was low (fewer than one anal-
gesic tablet per patient).
 A negligible extent of discomfort, root hypersensi-
tivity and edema during the first week following
treatment. In addition, no patients reported inter-
ference with daily activities during the post-treat-
ment period.
 At 6 months, patient judgement on treatment out-
come ranged from ‘very satisfied’ (92.30%) to ‘sat-
isfied’ (7.7%).
Surgical procedures
Clinical parameters
Data from studies evaluating the effectiveness of sim-
plified surgical procedures in the treatment of
intraosseous defects are reported in Table 2. In gen-
eral, defects with a mean presurgery probing depth of
> 7 mm and an intraosseous component of the lesion
of ≥ 5 mm were included. When the principle of the
single flap approach or its variants was applied to
treat deep intraosseous defects, substantial clinical
and radiographic outcomes were reported at 6–
12 months following surgery (Table 2). The majority
of the studies showed a mean clinical attachment
level gain of at least 3.5 mm and a mean radiographic
bone fill ranging from 33.7% to 78%. Mean probing
depth reduction ranged from 3.82 to 5.3 mm. The
postoperative recession of the gingival margin was
generally within 1 mm (range: 0.1–1.5 mm) at
 Table 2. Clinical trials* evaluating the effectiveness of simplified surgical procedures in the treatment of intraosseous defects
Study Experimental design Number of defects Intraosseous Baseline probing Flap design and reconstructive technology Localization of Follow-up Clinical outcomes Radiographic Patient-centered
component (mm) depth (mean, mm) intraosseous (months) defect outcomes
defects Clinical Probing Gingival fill (%)
attachment depth recession
level gain reduction change†
(mm) (mm) (mm)

Trombelli et al. 2009 (49) Case series 10 Range, 5–14 9.0 Single flap approach + graft/guided tissue All tooth types Range, 6–14 4.8 5.2 0.4 Not available Not available
Mean, 8.1 regeneration (mean, 10.0)

Cortellini & Tonetti 2009 (5) Case series 15 Range, 4–9 7.7 Modified minimally invasive surgical Not available 12 4.5 4.6 0.07 Not available Week 1: no patients
Mean, 6 technique + enamel matrix derivative reported pain;
three patients
reported slight
discomfort

Trombelli et al. 2010 (51) Parallel-arm randomized 12 Mean, 6.1 8.5 Single flap approach alone All tooth types 6 4.4 5.3 0.8 Not available Not available
controlled trial
12 Mean, 8.0 9.1 Single flap approach + graft/guided tissue All tooth types 6 4.7 5.3 0.4 Not available Not available
regeneration

Cortellini & Tonetti 2011 (6) Parallel-arm randomized 15 Mean, 5.2 7.5 Modified minimally invasive surgical Not available 12 4.1 4.4 0.3 77 Week 1: no patients
controlled trial technique alone reported pain;
mean discomfort
(100-mm visual
analogue scale),
10.7
mean number of
analgesic
medications, 0.4

15 Mean, 5.3 7.8 Modified minimally invasive surgical Not available 12 4.1 4.4 0.3 71 Week 1: no patients
technique + enamel matrix derivative reported pain;
mean discomfort
(100-mm visual
analogue scale),
11.5
mean number of
analgesic
medications, 0.3

15 Mean, 5.2 7.3 Modified minimally invasive surgical Not available 12 3.7 4.0 0.3 78 Week 1: no patients
technique + graft/enamel matrix derivative reporting pain;
mean discomfort
(100-mm visual
analogue scale),
12.3
mean number of
analgesic
medications, 0.5

Trombelli et al. 2012 (52) ParAllel-arm randomized 14 Mean, 5.8 8.7 Single flap approach alone All tooth types 6 4.5 5.2 0.7 Not available Not available
controlled trial
14 Mean, 5.8 7.4 Double flap approach‡ alone All tooth types 6 3.4 3.9 0.5 Not available Not available

99
Simplified procedures for intraosseous defects
 Table 2. (Continued)

100
Study Experimental design Number of defects Intraosseous Baseline probing Flap design and reconstructive technology Localization of Follow-up Clinical outcomes Radiographic Patient-centered
component (mm) depth (mean, mm) intraosseous (months) defect outcomes
defects Clinical Probing Gingival fill (%)
attachment depth recession
level gain reduction change†
Trombelli et al.

(mm) (mm) (mm)

Farina et al. 2013 (10) Case series 43 ≥ 3 mm (on 8.9 Single flap approach alone All tooth types 6 3.4 4.7 1.3 Not available Not available
radiographs) Single flap approach + enamel matrix
derivative
Single flap approach + graft
Single flap approach + graft/enamel matrix
derivative
Single flap approach + graft/guided tissue
regeneration

Mishra et al. 2013 (25) Parallel-arm randomized 14 Mean, 5.08 (on 7.64 Modified minimally invasive surgical All tooth types 6 2.64 3.82 0.55 35.02 Not available
controlled trial radiographs) technique alone

14 Mean, 5.19 (on 7.73 Modified minimally invasive surgical All tooth types 6 3.00 4.18 0.82 36.20 Not available
radiographs) technique + platelet-derived growth factor
BB

Farina et al. 2014 (9) Pragmatic trial 12 Mean, 5.5 8.8 Single flap approach + enamel matrix All tooth types 6 3.8 4.9 1.2 Not available Not available
derivative

12 Mean, 6.1 8.6 Single flap approach + graft/enamel matrix All tooth types 6 3.4 5.0 1.5 Not available Not available
derivative

Farina et al. 2015 (8) Retrospective study 74 Range, 1–14 8.3 Single flap approach alone All tooth types 6 3.7 4.5 0.9 Not available Not available
Mean, 5.8 Single flap approach + enamel matrix
derivative
Single flap approach + graft/enamel matrix
derivative
Single flap approach + graft/platelet-derived
growth factor BB
Single flap approach + graft/guided tissue
regeneration

Schincaglia et al. 2015 (39) Parallel-arm randomized 15 Mean, 7.7 8.7 Single flap approach + graft/platelet-derived All tooth types 6 4.0 4.1 0.1 33.7§ Day +1: mean pain
controlled trial growth factor BB (100-mm visual
analogue scale),
4.8;
mean number of
analgesic
medications, 1.1

13 Mean, 5.8 7.7 Double flap approach‡ + graft/platelet- All tooth types 6 3.2 3.6 0.4 40.3§ Day +1: mean pain
derived growth factor BB (100-mm visual
analogue scale),
28.0;
mean number of
analgesic
medications, 3.2

*Case reports were excluded.

†
Positive value indicates an increase.
‡
According to papilla preservation techniques (2, 3).
§
Calculated ad hoc for this review (data not shown in the study).

6–12 months postoperatively (Table 2). Although
showing that these simplified approaches may mini-
mize the surgical trauma during the manipulation of
soft tissues (Fig. 2), a high heterogeneity in gingival
recession change was observed among and within
studies. Recently, a retrospective analysis was con-
ducted to evaluate the influence of patient-related
and site-specific factors, as well as the adopted regen-
erative strategy, on gingival recession change at
6 months following a single flap approach (8). The
results showed that the change in buccal recession
was significantly predicted by the depth of the buccal
osseous dehiscence and presurgery interproximal
probing depth (Fig. 3A). In particular, an increase in
buccal gingival recession may be expected when a
buccal osseous dehiscence of > 2 mm and a presur-
gery interproximal probing depth of > 5 mm are pre-
sent. In light of these findings, the authors reinforce
the need to combine the single flap approach with
specific additional procedures/technologies when-
ever a limited to null postsurgery shrinkage of the gin-
gival margin is of paramount importance (such as in
esthetic-sensitive areas). In this respect, different
authors have proposed coronal advancement of the
single flap approach (1) or the combination of a single
flap approach with an autologous soft-tissue graft (50,
63) (Fig. 4) or a tridimensional collagen matrix (38).
Although the combination of a single flap approach
with a connective tissue graft has been shown to lead
to defect resolution with concomitant substantial
root coverage (63), the efficacy of these procedures in
controlling the postoperative recession increase
needs to be evaluated further. The average chair-time
for a modified minimally invasive surgical technique,
as measured from the delivery of local anesthesia to
the completion of sutures, ranged from 52.9  5.6 to
58.9  6.2 min (5, 6).
Patient-centered outcomes
In a recent randomized clinical trial (39), significantly
lower pain levels were self-reported during the first
postoperative days by patients treated with a single
flap approach compared with patients undergoing a
double flap approach with papilla preservation tech-
niques (Fig. 5). The mean number of analgesics con-
sumed during the first 2 postoperative weeks was 2.73
in the single flap approach group and 8.69 in the dou-
ble flap approach group, with a significantly higher
dose of analgesics being used in the double flap
approach group than in the single flap approach
group (3.2 vs. 1.1, respectively) at day +1 (39). Data
from other clinical trials on modified minimally inva-
sive surgical techniques consistently showed low
Simplified procedures for intraosseous defects
postoperative pain levels and a limited consumption
of analgesics (5, 6). In the study by Cortellini &
Tonetti (5), only three patients reported very limited
discomfort in the first 2 days of the first postoperative
week, and none of the 15 treated patients reported
significant postoperative pain at week 1. In a more
recent study (6), none of the patients experienced
postoperative pain at week 1. Average visual analogue
scale scores (on a 100-mm scale) for postoperative
discomfort ranged from 10.7 to 12.3. The mean num-
ber of analgesics was < 1, with a maximum of three
analgesics being used during the postoperative period
(6). Neither infective complications nor adverse reac-
tions (edema or hematoma) were reported following
simplified surgical procedures (5, 6, 8–10, 25, 39, 49,
51, 52). These data support the safety of these proce-
dures in the treatment of intraosseous lesions.
May simplified surgical procedures
enhance postsurgery wound
stability?
The significance of primary closure and wound sta-
bility as a determinant of the regenerative outcome
has been universally recognized (34, 59). In particu-
lar, the first postoperative weeks seem to be critical
for the maintenance of wound stability (18, 56, 59).
Wound dehiscence may compromise wound stabil-
ity, which in turn would jeopardize the cascade of
biologic events leading to periodontal regeneration
(14, 23, 58, 61). Furthermore, when flap surgery is
used in association with regenerative devices, the
postoperative loss of primary closure may lead to
partial or complete exfoliation of the implanted
graft, contamination of the membrane or premature
clearance of the bioactive agent. In this context, the
surgical management of the supracrestal soft tis-
sues, including flap design and suturing technique,
is of paramount importance in controlling the
chances of wound failure during the early phases of
healing (57). Data from several studies on the early
postoperative healing achieved following a single
flap approach and modified minimally invasive sur-
gery, either alone or in combination with bioactive
agents, indicate that the use of these techniques
may result in high proportion of sites showing com-
plete flap closure during the first postoperative
weeks (5, 6, 10, 39, 51). In particular, a retrospective
analysis of defects treated with a single flap
approach (10) consistently showed that 84% of
defects showed complete closure of the incision
101
Trombelli et al.

A B C

D E F

G H I

J K L

M N

102

Fig. 2. Treatment of a narrow, mainly 3-wall intraoss-
eous defect with the single flap approach in combina-
tion with enamel matrix derivative. (A) Persistent
bleeding, 8-mm pocket at the mesio-buccal aspect of a
left maxillary central incisor as observed at 6 months
following non-surgical therapy. (B) Pre-surgery radio-
graph. (C) Sulcular incisions performed on the buccal
aspect. (D) Oblique, butt-joint incision at the level of the
interdental papilla. (E) Elevation of a buccal single flap.
(F) The defect is characterized by a narrow angle and a
6 mm – deep intraosseous component (as measured at
the completion of surgical debridement). (G) The defect
is mainly 3-walled. (H) Application of enamel matrix
wounds at 2 weeks, as assessed by an early healing
index score (55) of 1–3. In particular, 54% of the
treated defects showed optimal conditions (i.e. early
healing index score = 1) of wound closure (Fig. 2).
The results also suggest an impact of the different
early healing patterns on the 6-month clinical out-
comes of the procedure (10), with a trend toward
better clinical outcomes (greater clinical attachemnt
level gain, less buccal gingival recession increase)
when defects showed optimal wound closure com-
pared with incomplete wound closure. More
recently, a randomized clinical trial demonstrated
that a single flap approach may optimize the quality
of early wound healing of defects compared with a
B BC). (B) Six-month gingival recession
Simplified procedures for intraosseous defects
derivative to root surface and defect. (I) Primary inten-
tion wound closure. (J) Complete wound closure and
absence of fibrin line in the interproximal area (equiva-
lent to an early healing index of 1, as proposed by
Wachtel et al. (55)) is observed at 2 weeks following sur-
gery. (K, L) Clinical and radiographic aspect at 1 year
following surgery. A clinical attachment gain of 5 mm
and a residual probing depth of 2 mm have been
obtained. Also, a partial remineralization of the intraoss-
eous component of the defect is evident. (M, N) Clinical
and radiographic aspect at 5 years following surgery.
Probing depth is 3 mm and the residual angular compo-
nent of the defect is minimal to null.
double flap approach based on papilla preservation
techniques (39). Surgical access was combined with
recombinant human platelet-derived growth factor
BB and beta-tricalcium phosphate. At 2 weeks, 12
sites in the single flap approach group and six sites
in the double flap approach group showed com-
plete flap closure (i.e. early healing index = 1, 2 or
3). The frequency of sites showing optimal wound
healing (i.e. early healing index = 1) was eight in the
single flap approach group and three in the double
flap approach group. Improved clinical outcomes in
single flap approach group compared with a double
flap approach group were partly ascribed to
enhanced early wound healing (39).
Fig. 3. Prediction of 6-month buccal
gingival recession following single
flap approach. (A) Six-month gingi-
val recession increase at the buccal
aspect as predicted on the basis of
presurgery probing depth (PD) and
buccal osseous dehiscence (bCEJ–
increase at the interdental aspect as
predicted on the basis of presurgery
probing depth and treatment modal-
ity. (reprinted from Farina et al. (8)).
DBBM, deproteinized bovine bone
mineral; EMD, enamel matrix deriva-
tive; GTR, guided tissue regeneration;
HA, hydroxyapatite; iREC, interproxi-
mal recession, rhPDGF-BB, recombi-
nant platelet derived growth factor
BB. This figure is reproduced from
Farina et al. (8).
103
Trombelli et al.
A B
D E
G H
J K
Fig. 4. Single flap approach in combination with a connec-
tive tissue graft to prevent postoperative gingival recession.
(A, B) Nine-mm pocket positive to bleeding upon probing
at the disto-buccal aspect of a maxillary canine. (C) The
intraosseous defect is accessed with a buccal single flap
approach. The defect is mainly 2-walled and is associated
with the partial loss of the buccal cortical bone of the
affected tooth. (D) A connective tissue graft is harvested
from the tuber maxillae and fixed to mesial portion of the
buccal single flap with an internal mattress suture. (E) The
intraosseous component of the defect is treated with a
combination of enamel matrix derivative and a bovine-
104
C
F
I
derived xenograft according to the sandwich technique. (F,
G) The fixation of the graft to the single flap is completed
with an internal mattress suture. Wound closure in the
interdental area is achieved according to the original
suturing technique described for the single flap approach
(two internal mattress sutures) completed by an additional
interrupted suture. (H) Wound healing at 1 week following
surgery. (I) At 6 months following surgery, substantial
regenerative outcomes (clinical attachment gain, 5 mm;
probing depth reduction, 5 mm) have been obtained along
with the stability of the gingival margin. (J, K) Clinical and
radiographic aspect at 2 years following surgery.

Single or double flaps?
Adequate surgical access to provide proper root/de-
fect instrumentation of the intraosseous lesion is of
paramount importance in achieving the desired clini-
cal and histologic outcomes. In this respect, the
extent and morphology of the defect represents a key
aspect when selecting a flap design. On the other
hand, data from recent studies indicate that, should
the anatomic conditions permit it, a single flap
approach may lead to improved clinical outcomes
compared with the double flap approach. In this
respect, two- to three-walled intraosseous defects
were treated with surgical debridement using either a
single flap approach or a double flap approach (ac-
cording to papilla preservation techniques) (52). No
regenerative devices were used in addition to surgical
access. At 6 months, treatment resulted in 1 mm
greater clinical attachment level gain and probing
depth reduction compared with elevation of a flap at
both buccal and oral aspects. A trend toward a
greater clinical attachment gain for a single flap
approach compared with a conventional double flap
approach (papilla preservation techniques) was also
reported in association with the use of a bioactive
agent + graft (39).
Simplified surgical procedures: an
effective access flap protocol?
Data (Table 2) have shown that surgical access based
on the elevation of a single flap represents a valuable
treatment even when used per se (i.e. without the
additional use of reconstructive devices or bioactive
agents) (6, 25, 51, 52) (Fig. 1). The magnitude of clini-
cal attachment level gain observed for the simplified
procedures (ranging, on average, from 2.6 to 4.5 mm)
largely exceeds those reported for a double-flap
Simplified procedures for intraosseous defects
Fig. 5. Mean pain levels (as self-
reported with a 100-mm visual ana-
logue scale) following single flap
approach (SFA) or double flap
approach according to papilla
preservation techniques (DFA). **:
P < 0.01; *: P < 0.05. (reprinted from
Schincaglia et al. (39)). This figure
is reproduced with permission from
the American Academy of Periodon-
tology.
access, including the most conservative papilla
preservation techniques (11). Obviously, the assess-
ment of clinical improvement by probing recordings
prevents evaluation of the nature of the wound heal-
ing following the tissue-maturation phase. The poten-
tial of the simplified procedures per se to treat
intraosseous lesions may partly explain the findings
from three randomized controlled trials evaluating
the efficacy of different regenerative technologies (6,
25, 51). In essence, the results from these studies
failed to find any significant benefit from the use of a
resorbable membrane with bone substitutes (51),
enamel matrix derivative (with or without a xeno-
graft) (6) or recombinant human platelet-derived
growth factor BB (25) when combined with a simpli-
fied single-flap procedure. However, these findings
must be interpreted with caution in view of the base-
line defect characteristics and the appropriateness of
the regenerative device selected for study. In this
respect, in two studies (6, 25) defect selection resulted
in mainly two- to three-walled defects with a narrow
defect angle, which are characterized by an enhanced
healing response (46, 53). Although limiting the indi-
cation for a simplified procedure as a solo treatment,
these results indicate that surgical access based on a
single flap may be effective when performed in
defects more prone to spontaneous healing (Figs 1
and 2). In the study by Trombelli et al. (51), the com-
bination of a single flap approach with a resorbable
membrane and a hydroxyapatite-based graft resulted
in incomplete early wound closure (i.e. early healing
index = 4) in five of 12 defects, whereas the single flap
approach group showed complete wound closure in
all defects. Early wound failure may have partly com-
promised the additional clinical benefit exerted by
guided tissue regeneration compared with access flap
surgery (27), thus questioning whether the use of a
membrane represents a suitable regenerative choice
when combined to a single flap approach.
105
Trombelli et al.

A B C

D E F

G H I

J K L

106

Fig. 6. Treatment of a deep, non-containing intraosseous
defect with the single flap approach in combination with
enamel matrix derivative and a bovine-derived xenograft.
(A–C) Clinical and radiographic aspect (as observed at
6 months following initial therapy) of a maxillary central
incisor presenting a deep intraosseous defect at the mesio-
buccal aspect (probing depth, 11 mm). (D) Horizontal, butt-
joint incision at the level of the interdental papilla and
intrasulcular incisions at adjacent teeth. (E) After the eleva-
tion of a buccal single flap and the surgical debridement of
the lesion and root surface, a wide, mainly 2-wall defect
with a 9-mm intraosseous component is identified. (F) Fol-
lowing a first application of enamel matrix derivative, the
Which regenerative technology in
association with simplified surgical
procedures?
Several studies have demonstrated the effectiveness
of simplified surgical procedures when these are used
in association with various regenerative technologies
(Table 2). A series of studies investigated the combi-
nation of a single flap approach with membranes or
bioactive agents, with and without graft biomaterials
(8–10, 38–40, 48–51). A modified minimally invasive
surgical technique was combined with bioactive
agents alone (5, 25) or with enamel matrix derivative
and a bovine-derived xenograft (6). The additional
benefit of using a membrane–graft combination with
a single flap approach has been challenged (51), and
improved treatment outcomes following use of bioac-
tive agents (enamel matrix derivative, recombinant
human platelet-derived growth factor BB), with or
without bone substitutes, in association with the sin-
gle flap approach, were recently reported (8, 9).
Twenty-four deep periodontal intraosseous defects
were treated with a buccal single flap approach and
enamel matrix derivative, with or without depro-
teinized bovine bone mineral, according to the sur-
geon’s discretion. Both treatments were clinically
effective in terms of clinical attachment gain and
probing depth reduction. Interestingly, the adjunctive
use of deproteinized bovine bone mineral in wider,
predominantly one-wall, defects seemed to compen-
sate for the unfavorable effect of osseous characteris-
tics on treatment outcomes (9). The results published
in 2015 by Farina et al. (8) showed that the change in
gingival recession at the interproximal level was sig-
nificantly predicted by presurgery interproximal
probing depth and treatment modality. Defects trea-
ted with a single flap approach in combination with
enamel matrix derivative + deproteinized bovine
bone mineral were less prone to recession increase
Simplified procedures for intraosseous defects
intraosseous component of the lesion is filled with a bovine
derived xenograft mixed with the bioactive agent. (G) Appli-
cation of second layer of enamel matrix derivative. (H)
Wound closure is obtained with two internal mattress
sutures and additional interrupted sutures (due to the wide
mesio-distal dimension of the interdental papilla). (I) At
2 weeks following surgery, complete flap closure is main-
tained, and a fibrin clot is present in the interproximal area
(early healing index = 3; Wachtel et al. (55)). (J) Six-month
clinical attachment gain of 6 mm and residual probing
depth of 4 mm. A 1-mm increase in gingival recession can
be observed compared to pre-surgery. (K, L) Clinical and
radiographic aspect at 5 year following surgery.
compared with defects treated with a single flap
approach with enamel matrix derivative (Fig. 3B).
This finding was consistent with previous studies
showing that the combined use of enamel matrix
derivative and a graft may significantly temper the
postoperative recession compared with the use of
enamel matrix derivative alone in the treatment of
deep intraosseous defects (13, 24, 62). On the basis of
these findings, the combined use of enamel matrix
derivative with a xenograft seems to be indicated
when deep intraosseous defects of unfavorable mor-
phology are located at esthetic areas (Fig. 6).
Concluding remarks
Treatment of deep intraosseous defects in esthetic
areas implies clinical improvement of the lesion con-
sistent with long-term survival of the affected tooth,
preferably associated with true regeneration of the
lost attachment apparatus, as well as preservation (or
improvement) of the esthetic appearance of the
patient. It is hoped that such treatment end points
may be reached by procedures (‘simplified’) which,
on the one hand can be easily and successfully
applied by the majority of clinicians and, on the other
hand, are well tolerated by patients in terms of post-
surgical pain and discomfort, adverse events and
cost.
In the present review, we have described the tech-
nical aspects and analyzed the effect on clinical and
patient-centered outcomes of nonsurgical and sim-
plified surgical procedures. On the basis of the evi-
dence available, the following conclusions can be
drawn:
 Whenever indicated, treatment selection should
be oriented toward the adoption of a ‘simplified’
procedure. Data support the effectiveness of non-
surgical and simplified surgical treatments when
compared with conventional approaches.
107
Trombelli et al.
However, the appropriateness of such procedures
appears to be strictly related to patient and defect
selection as well as to treatment end points.
 Preliminary data from recent studies have shown
that nonsurgical treatment using a minimally
invasive technique may result in substantial clini-
cal attachment level gain and probing depth
reduction at 6–18 months following treatment,
with limited remodeling of the gingival profile.
Consistent with previous data (17), these studies
also indicate that such a technique may be appro-
priate in lesions with probing depth < 7 mm and a
limited intraosseous component. However, it
should be borne in mind that histologic studies in
humans have indicated that the healing process of
intraosseous lesions following nonsurgical treat-
ment is reparative rather than regenerative (12).
Moreover, the long-term effectiveness of this min-
imally invasive technique remains to be assessed.
 Should local conditions following nonsurgical ther-
apy not be compatible with a good prognosis of the
tooth presenting the defect (e.g. persistent bleeding
pocket), corrective surgical treatment is recom-
mended. After proper diagnosis of defect morphol-
ogy, severe intraosseous defects can be successfully
treated by surgical procedures based on the eleva-
tion of a single flap. Considerable clinical attach-
ment level gain and probing depth reduction
associated with no adverse events have been
reported in observational and experimental stud-
ies. A single flap approach was shown to be at least
as effective as traditional papilla-preservation tech-
niques, when evaluated either as a stand-alone
protocol or in combination with regenerative
devices. Successful outcomes may be, at least in
part, a result of enhanced wound stability during
the early wound-healing phase.
 Simplified surgical procedures are associated
with minimal esthetic impairment (i.e. post-
treatment recession). The magnitude of the
recession is similar to that observed following
the minimally invasive technique. However, a
certain amount of gingival shrinkage is to be
expected, even if the interdental papilla is left
untouched. As the postoperative recession
increase has been related to specific defect
characteristics, variants of the single flap
approach, which include additional procedures/
devices aimed at controlling the postsurgery
recession, have been proposed (1, 38, 50 63).
 Surgical access based on a single flap without any
regenerative device may result in improved clini-
cal conditions when this procedure is performed
108
in defects with a favorable prognosis (mainly two-
to three-walled defects with a narrow angle).
 A single flap approach and a modified minimally
invasive surgical technique have also been effec-
tively used in combination with different regener-
ative strategies, such as resorbable membranes or
bioactive agents, with or without graft biomateri-
als. Beside their potential for new attachment for-
mation, bioactive agents have shown the most
appropriate regenerative device when combined
to a single flap approach.
 When dealing with deep intraosseous defects of
unfavorable morphology, particularly at esthetic
areas, the combination of bioactive agent and
graft biomaterial may ensure substantial attach-
ment gain while limiting the postsurgery reces-
sion.
 Simplified surgical procedures result in a more
tolerable postoperative course when compared
with conventional approaches. The lower postop-
erative pain levels and dose of analgesics com-
pared with conventional double flap procedures
may be the result of reduced invasiveness and
shorter operative time.
Despite these encouraging results, some of the key
principles of ‘simplification’ still need to be investi-
gated for such procedures. In particular, limited to no
information is currently available with regard to gen-
eralizability, learning curve and cost–benefit ratio.
Moreover, the clinical improvements (radiographic
defect fill, clinical attachment gain) observed when
simplified surgical procedures were used per se needs
to be histologically characterized and evaluated long
term. Finally, the efficacy of single-flap approach vari-
ants, which were proposed to preserve/improve the
pre-existing esthetics of the patient, needs to be thor-
oughly evaluated.
Acknowledgments
The study was entirely supported by the Research
Centre for the Study of Periodontal and Peri-implant
Diseases, University of Ferrara, Ferrara, Italy.
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Periodontology 2000, Vol. 77, 2018, 111–122
Printed in Singapore. All rights reserved
Soft-tissue augmentation
procedures in edentulous
esthetic areas
MATTEO MARZADORI, MARTINA STEFANINI, CLAUDIO MAZZOTTI,
SABRINA GANZ, PRAVEEN SHARMA & GIOVANNI ZUCCHELLI
Loss of dentition results in functional and esthetic
issues that are strongly influenced by the anatomic
features of the edentulous area. A ridge that retains
the general shape of the alveolar process after socket
healing is defined as a ‘normal ridge’. However, it is
common to encounter ridges that deviate from this
‘normal’ in hard and soft tissues, both in the apico-
coronal and buccolingual dimensions. These defor-
mities can complicate prosthetic rehabilitation,
especially in situations where optimal esthetic out-
comes are desired. When pontic teeth are placed in
the ideal prosthetic relationship and shaped to mirror
the contralateral teeth in the dental arch, they rarely
touch the surface of the soft tissues or completely fill
the space of the defect. In these situations, the patient
may experience functional difficulties, such as prob-
lems with phonetics, food impaction and cleansabil-
ity of the prosthetic device, as well as esthetic issues
caused by alteration of the scalloped outline of the
dentition as well as the presence of an open interden-
tal space or spaces. Restorative solutions traditionally
applied to mitigate these functional challenges
include fixed partial denture pontics or implant-sup-
ported crowns made longer to contact the ridge, and
pink porcelain or acrylic resin on the pontic or
implant-supported element to mimic gingiva or
removable prostheses in an attempt to simulate the
anatomic contour of the edentulous alveolar ridge.
However, these solutions, although acceptable from a
functional standpoint, often do not appear natural
and can be easily recognized when the patient smiles.
For these reasons, reconstructive plastic surgery pro-
cedures aimed at restoring the alveolar ridge to its
former dimensions have gained clinical importance.
This review will focus on the description and the
expected outcomes of the different surgical
© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
PERIODONTOLOGY 2000
techniques for soft-tissue augmentation in edentu-
lous areas, as described in the literature.
Classification of ridge defects
Ideally, a classification of ridge defects should guide
the clinician as to the predictability and technical dif-
ficulty of surgically reconstructing the ridge. Three
classifications are available in the literature.
Seibert, in 1983 (28), suggested classifying ridge
defects based on the amount of volume loss, divided
into three classes:
 Class I: buccolingual loss of the ridge contour.
 Class II: apicocoronal loss of the ridge contour.
 Class III: combined loss of the ridge contour.
In 1985, Allen et al. (3) introduced a modification of
Siebert’s original classification, introducing an assess-
ment of the defect depth relative to the adjacent ridge:
 Type A (Class II in Siebert’s classification): apico-
coronal loss of ridge contour.
 Type B (Class I in Siebert’s classification): buccol-
ingual loss of ridge contour.
 Type C (Class III in Siebert’s classification): com-
bined loss of ridge contour in both apicocoronal
and buccolingual dimensions.
Each type is divided into three subgroups regarding
the depth of the defect relative to the adjacent ridge:
 Mild: < 3 mm.
 Moderate: 3–6 mm.
 Severe: > 6 mm.
In 1997, Studer et al. (34) described a new classifi-
cation in which localized alveolar ridge defects were
classified qualitatively (on the basis of their three-
dimensional form) and semiquantitatively (on the
basis of their severity and extent).
111
Marzadori et al.
Qualitative classification of the defect according to
Allen et al. (3) and Siebert (28) is as follows:
 Horizontal or buccal tissue loss with normal ridge
height corresponding to Class I (Seibert’s nomen-
clature) and Type B (Allen’s nomenclature).
 Vertical or apicocoronal tissue loss with normal
ridge height (Class II/Type A).
 Combined horizontal and vertical bone loss (Class
III/Type C).
Semiquantitative classification according to the
degree of severity in vertical and horizontal dimen-
sions in relation to adjacent papilla tips is as follows:
 Mild vertical/horizontal defect: < 3 mm.
 Moderate vertical/horizontal defect: 2–6 mm.
 Severe vertical/horizontal defect: > 6 mm.
Semiquantitative classification according to the
extent of the defect is as follows:
 One-tooth defect.
 Two-teeth defect.
 Three-teeth defect.
 Four-teeth defect.
As the choice of surgical intervention is largely
influenced by the qualitative anatomic characteristics
of the defect, such as the type (vertical, horizontal or
combined) of tissue loss, this article will refer to the
original Seibert’s classification (Classes I–III). The
extent of the defect influences the type (soft-tissue or
hard-tissue augmentation) of surgical intervention,
with soft-tissue augmentation being limited to areas
of single tooth replacement. Two-teeth defects can be
successfully treated with soft- and/or hard-tissue aug-
mentation procedures. Larger defects (three or more
missing teeth) should preferentially be treated with
bone-augmentation procedures as bony augmenta-
tion is more predictable in larger edentulous spaces
partly because of the greater availability of donor tis-
sue. In the latter clinical situations, soft-tissue plastic
surgery procedures can be used to improve the
esthetic outcome after hard-tissue augmentation sur-
gical procedures.
The surgical approach to correct a ridge defect is
also influenced by the type of prosthetic rehabilita-
tion planned, such as an implant- or tooth-supported
fixed restoration. If an implant rehabilitation is
planned, a hard-tissue reconstruction may be indi-
cated in order to provide the necessary bone volume
to allow proper positioning of the implant. However,
in these situations, a soft-tissue augmentation proce-
dure is often necessary to improve the quality and
quantity of mucogingival tissue and thus achieve an
ideal esthetic result. The soft-tissue surgery can be
performed either before or during implant placement
or at the time of the second stage of surgery. In
112
comparison, when the prosthetic rehabilitation is car-
ried out via a fixed partial denture, soft-tissue aug-
mentation procedures are often the treatment of
choice as, even in cases of severe alveolar ridge defor-
mities, it is easy and predictable to restore the lost
volume using soft tissues and achieve an excellent
esthetic result. This review will focus on the descrip-
tion and expected outcomes of different surgical
techniques for soft-tissue augmentation in edentu-
lous areas as described in the literature.
Classification of soft-tissue
augmentation
The literature describes five different surgical tech-
niques for soft-tissue augmentation. These are:
 Onlay grafts (28, 29).
 Roll technique (1, 25).
 Interpositional (inlay) grafts (4, 17, 28, 29).
 Combination onlay–inlay grafts (30).
 Pouch procedure and connective tissue grafts (8,
14–16).
Onlay graft procedures
The onlay graft technique was first described by Seib-
ert in 1983 (28, 29) to correct Seibert’s Class I, II or III
defects. A recipient bed is prepared with two parallel
split-thickness incisions in the lamina propria of the
edentulous area and the epithelium is removed in
order to expose the underlying connective tissue. A
free gingival graft is then harvested from the palate
and secured on the recipient vascular bed with inter-
rupted and compressive sutures, with the amount of
augmentation depending on the thickness of the
applied graft (Fig. 1). No data are available regarding
the shrinkage of the tissue grafted, but a varying
amount of volume is lost during the healing phase.
For this reason, it is frequently necessary to repeat
the surgical procedure at 2- to 3-month intervals in
order to reach the desired ridge height (13, 27–29).
Roll flap technique
This technique was introduced by Abrams in 1980 (1)
to correct small or moderate Seibert’s Class I defects.
The surgical procedure involves a connective tissue
pedicle flap that originates from the de-epithelializa-
tion of the palatal tissue close to the edentulous area.
Two parallel incisions are made from the occlusal
edentulous area toward the palate and connected
with a horizontal incision. A split-thickness palatal

A B
C D
Fig. 1. Onlay graft technique. (A) Pretreatment frontal
view. A gingiva-like resin in the pontic area was applied to
compensate for the buccolingual ridge defect in the upper
left central and lateral incisor region. (B) Postsurgical fron-
tal view. A free gingival onlay graft is sutured at the level of
flap is then elevated. In the defect area a pouch is
prepared with a split dissection of the supraperiosteal
connective tissue. The palatal flap is ‘rolled’ into the
pouch area and then sutured (Fig. 2). In 1992, Scharf
& Tarnow (25) introduced a different approach at the
palatal area. In this modified roll technique, a palatal
split-thickness flap is elevated without any de-epithe-
lialization. The connective tissue that ‘rolls’ in the
donor area is formed of the palatal underlying sub-
mucosa and the palatal periosteum. The rationale is
to avoid a secondary healing process of the donor
site. A further modification of the donor-site prepara-
tion was described in a case report by Sclar in 2003
(26). In this vascularized interposition periosteal-con-
nective tissue graft technique, a pedicle connective
tissue graft is prepared at the ipsilateral palatal area
of the defect, then mobilized and rotated into the
pouch prepared at the recipient site. In a more recent
randomized controlled clinical trial (2), the vascular-
ized interposition periosteal-connective tissue graft
technique was compared with a free subepithelial
connective tissue graft. After 6 months, a statistically
significant increase in median volume for sites
treated with the vascularized interposition periosteal-
connective tissue graft technique (1.18 mm; range:
0.16–1.75 mm) was found compared with sites trea-
ted with connective tissue graft only (0.63 mm; range:
0.28–1.22 mm).
Interpositional (inlay) graft procedures
Inlay graft procedures are used to correct Class I and
small or moderate Class II and Class III defects. In
1979, Meltzer (17) described a procedure in which a
Soft-tissue augmentation in esthetic areas
the ridge defect. (C) Nine months after surgery (without
prosthetic crowns). Note soft-tissue growth in the edentu-
lous area. (D) One year after surgery with a new porcelain
prosthetic device in situ (Courtesy of Massimo Pomo, Pri-
vate practice, Bologna).
pouch was prepared in the defect area and a free graft
derived from the palatal or maxillary tuberosity was
harvested. The graft obtained was partially de-epithe-
lialized and the exposed connective tissue was
inserted in the pouch area like a wedge (inlay graft).
Thus, the epithelialized part of the graft remained
outside the pouch and sutured at the level of the
epithelial surface of the surrounding tissues (14, 17,
19, 28, 29).
Combination onlay–inlay grafts
This technique was introduced by Seibert & Louis
(30) in 1996 for the treatment of Class III defects.
In this case report, the authors suggested a combi-
nation of onlay and inlay graft procedures to obtain
simultaneous tissue augmentation in the horizontal
and vertical dimensions. The donor site was prepared
with a full-thickness coronal dissection and a partial-
thickness apical dissection. The graft was thus com-
posed of two parts: the coronal part, which was
epithelialized; and the apical part, which was formed
of connective tissue only. On the defect area, the cre-
stal surface was de-epithelialized with a beveled inci-
sion and the apical surface was prepared with a
partial-thickness dissection with two vertical-releas-
ing incisions extended apically, without involving the
adjacent papillae, in order to create a pouch area.
The onlay section (epithelialized area) of the graft is
sutured on the crestal surface of the defect, while the
inlay section (connective tissue) is inserted and
secured in the vestibular pouch area. The objectives
were to use a single procedure to achieve simultane-
ously apicocoronal and buccolingual augmentation,
113
Marzadori et al.
A D
F
C
G area and sutured. (F, G) One year
to have a smaller open wound in the donor site and
less patient discomfort, and to guarantee better
revascularization of the onlay section aided by the
submerged connective tissue section of the graft.
Pouch procedures and connective tissue
grafts
Pouch procedures (Figs 3 and 4) were developed to
treat Class I ridge deformities. The surgical procedure
involves the use of a connective tissue graft, which
originates from the palatal area or from the maxillary
tuberosity, to increase the thickness of the buccal sur-
face (15, 16). In the defect area a pouch is prepared
with a split dissection of the supraperiosteal connec-
tive tissue and the connective tissue graft is sutured
to the periosteum. The flap is sutured in its original
position and covers the connective tissue graft com-
pletely. The main advantage of pouch techniques is
that they maintain the color and surface characteris-
tics of the existing tissues, while in onlay procedures
the exposed graft heals with a white scar which may
be an esthetic concern for the patient.
In a controlled clinical trial (33), 30 patients pre-
sented a single tooth deficiency of Seibert’s Class I in
the maxillary region. Twelve of these patients were
treated with a connective tissue graft pouch proce-
dure and 12 with a free gingival graft procedure. The
remaining six patients were not treated and acted as
a control group. Cast models from impressions
114
Fig. 2. Roll flap technique. (A, B)
Presurgical frontal and occlusal
views of a Seibert’s Class I defect. (C)
Connective tissue pedicle flap is ele-
vated. (D, E) Postsurgical frontal and
occlusal views of the palatal flap
‘rolled’ into the vestibular pouch
after surgery a porcelain Maryland
bridge is applied. Note the natural
emergence of the pontic tooth in the
edentulous area.
obtained before treatment and after observation peri-
ods of 1 and 3.5 months were analyzed for volumetric
changes using the Moire
method (35). The study
demonstrated median volume gains of 159  80 mm3
for the connective tissue graft procedures and
104  31 mm3 for the free gingival graft procedures.
The differences between the two treatment modali-
ties were statistically significant in favor of the con-
nective tissue graft group, while untreated defects
showed a slight increase in volume of 6.0  5.4 mm3,
which was statistically different from the two test
groups using autogenous tissue. In a 2001 case series,
Batista et al. (4) treated eight patients, presenting 18
defects, with a pouch procedure in which an acellular
dermal matrix was used instead of a connective tissue
graft. After 6 months, a median vertical increase of
0.61  0.77 mm and a median horizontal increase of
1.72  0.59 mm were achieved. However, shrinkage
in volume of 41.4% was observed in the same period.
In a more recent randomized controlled clinical trial,
Akcalı et al. (2) treated 17 patients presenting 17 Seib-
ert’s Class I defects divided into two groups. In group
1 (seven patients) a connective tissue graft pouch
procedure was performed, while in group 2 (10
patients) a modified vascularized interposition peri-
osteal-connective tissue graft procedure was applied.
At 6 months, a statistically significant increase in
median volume was found for sites treated with a vas-
cularized interposition periosteal-connective tissue
graft (1.18 mm; range: 0.16–1.75 mm) compared with

A D
E
B
C F
Fig. 3. Pouch procedure and fixed partial denture. (A, B)
Frontal and occlusal views of the edentulous area with a
provisional resin bridge. (C) Occlusal view of the defect
area showing a Seibert’s Class I defect. (D) Buccal flap ele-
vation. In the defect area a pouch is prepared with a split
dissection of the connective tissue. (E) A connective tissue
graft is positioned at the buccal surface in order to com-
pensate for the horizontal tissue loss and is sutured with
interrupted single sutures anchored to the periosteum. (F)
The flap is moved coronally to cover completely the
sites treated with a connective tissue graft (0.63 mm;
range: 0.28–1.22 mm). Moreover, 47% shrinkage in
the connective tissue graft group and 6% shrinkage
in the vascularized interposition periosteal-connec-
tive tissue graft group were observed. In 2016, Sanz-
Mart
ın et al. (23) reported the 5-year results of a ret-
rospective cohort study conducted over a population
of 24 patients. Twelve patients were treated using a
pouch technique and rehabilitated with a fixed den-
tal prosthesis (test group), while 12 patients did not
receive any intervention (control group). The dimen-
sional changes were registered on digitized casts
made from dental impressions taken at the prosthesis
delivery, and at 5 years a slight loss of median volume
was observed in both groups (5.31  1.1 mm3 in the
test group and 4.32  1.7 mm3 in the control
group), but no statistical difference was found
between the groups. However, no presurgical or
postsurgical data were collected until the prosthesis
delivery appointment; hence, the amount of aug-
mentation achieved by this procedure, and the
immediate postsurgical shrinkage, could not be
reported. These data were confirmed by a controlled
Soft-tissue augmentation in esthetic areas
G
H
I
connective tissue graft. The flap is sutured with sling
sutures anchored around the palatal cingula of the adja-
cent teeth included in the flap. (G) Single interrupted
sutures are used on the occlusal side to obtain primary
intention wound healing. (H) Nine months postsurgery,
soft-tissue augmentation has been completed. (I) One year
after the surgical procedure, definitive prosthetic crowns
are applied. Note the maintenance of color and surface
characteristics of the existing tissues.
clinical study (5) conducted in the same pool of
patients with a 10-year follow-up in which stability
of the augmentation procedure over time was
observed; no statistical difference was found
between the test group and the control group. Two
recent systematic reviews (36, 37) investigated the
subject of soft-tissue augmentation, among other
topics. While the number of studies included
increased over the years, no meta-analysis could be
performed because of the heterogeneity between
the studies. Another shortcoming was related to the
different methods employed in different studies to
measure soft-tissue augmentation. These included
the use of endodontic instruments or periodontal
probes with the aid of a standardized stent, three-
dimensional methods, such as the Moire
method, or
optical scans with dedicated software. However, the
authors concluded that the use of autogenous tissue
grafts (connective tissue grafts) results in increased
soft-tissue thickness at implant sites and in partially
edentulous sites and should therefore be considered
as the treatment of choice. They acknowledged that
some shrinkage of the augmented sites has to be
115
Marzadori et al.
A D
E H
B
F
C
Fig. 4. Pouch procedure and implant therapy. (A) Frontal
view of the treatment area with temporary crowns in place.
(B) Occlusal view of the edentulous area showing a Seib-
ert’s Class I defect. (C) A flap is elevated and a pouch is pre-
pared with a split dissection of the supraperiosteal
connective tissue. (D) A connective tissue graft is sutured
to the periosteum. (E, F) The flap is sutured in its original
position in order to obtain complete coverage of the graft
(occlusal and frontal views). (G) Occlusal view of the
taken into consideration and that further studies
were needed to investigate this topic.
While the pouch procedure is generally considered
the treatment of choice in Seibert’s Class I defect, in a
case report published in 2012, Zucchelli et al. (43)
described a modified pouch technique for soft-tissue
augmentation in Class III ridge defects (Fig. 5). The
surgical approach consisted of two parallel horizontal
incisions at the buccal and palatal edges of the eden-
tulous area. This allowed ‘in situ’ maintenance of a
soft-tissue platform, after buccal and palatal flap ele-
vation, which facilitated stabilization and suturing of
the connective tissue grafts used for soft-tissue aug-
mentation. The buccal incision continued with a
design similar to a coronally advanced flap, involving
the adjacent teeth, in order to obtain a passive and
primary closure of the flap. The occlusal surface of
the platform was then de-epithelialized to expose a
connective tissue platform acting as the recipient site
for the connective tissue grafts. Two different connec-
tive tissue grafts were used to compensate for the
horizontal and vertical components of the defect.
These grafts were derived from the de-epithelializa-
tion of free gingival grafts harvested from the palate,
in order to obtain a ‘high-quality tissue’ graft formed
116
G
I J
edentulous area 6 months after surgery. The horizontal
soft-tissue defect is almost completely corrected. (H) Six
months after surgery an implant was positioned, and
12 months after soft-tissue augmentation surgery an
implant-supported crown was applied. (I, J) Lateral views
of the edentulous area, before and 12 months after sur-
gery. Note the horizontal soft-tissue augmentation and the
natural emergence profile of the implant-supported
crown.
exclusively from connective tissue. The first graft was
then sutured to the buccal surface of the platform to
compensate for the horizontal loss of soft tissue,
while the second graft was sutured above the occlusal
surface of the platform to compensate for the vertical
loss of soft tissue. In the case of inadequate palatal
soft-tissue thickness or unavailability of the tuberos-
ity, the mesial–distal length of the free graft was
duplicated and folded in two after de-epithelializa-
tion. This allowed the surgeon to obtain a greater
thickness of connective tissue even in the presence of
thin palatal soft tissue. The buccal flap was then
moved coronally and sutured at the palatal incision,
obtaining primary closure of the flap and completely
covering the connective tissue grafts. As mentioned
above, in the literature, shrinkage of the augmented
site, varying from 6% to 47% in volume, is described
during the healing period. However, in this case
report the authors observed no reduction, but rather
a slow and constant maturation and increase in vol-
ume of the grafted area during the first 9 months
after the surgery. For this reason, the authors recom-
mended delaying the soft-tissue prosthetic condition-
ing for at least at 9 months after the surgery. Within
the limitations of a case report, it can be speculated

A D G J
B E H K
C F I L
Fig. 5. Connective tissue platform technique. (A) Frontal
view of the defect showing the disharmonic prosthetic con-
tour of the prosthetic device. (B, C) Frontal and occlusal
views of the edentulous area showing a Seibert’s Class III
ridge defect. (D, E) Buccal flap elevation. A split–full–split
thickness flap is performed with a design similar to a coro-
nally advanced flap for multiple gingival recessions. This
approach allows complete passivation of the vestibular
flap. (F) Occlusal view of the surgical area showing the con-
nective tissue platform and the palatal flap elevated split-
thickness. (G, H) Frontal and occlusal views of the de-
epithelialized connective tissue grafts anchored at the con-
nective tissue platform with interrupted single sutures. (I,
J) Postsuture occlusal and frontal views. The complete
that the primary and passive closure of the flap, with-
out any exposure of the graft, and the quality of the
connective tissue harvested from the palate may have
contributed to achieving this result.
Mucogingival soft-tissue
measurement methods
There is a specific need to quantify, reliably and
accurately, the morphologic and metric dimensions
of soft tissues in order to quantify gingival changes
before and after soft-tissue augmentation. According
to a recent review on this topic (21), soft-tissue
measurement methods can be divided into two-
dimensional and three-dimensional measurement
methods.
Two-dimensional measurements
This group can be further subdivided based on the
instruments involved in the measurements: peri-
odontal probe; oral photographs; and ultrasonic soft-
tissue determination (Table 1). The periodontal
probe represents an indispensable tool, in daily prac-
tice, to measure, metrically, clinical parameters such
as gingival recession, width of keratinized tissue, soft-
tissue margin level and papilla height. In a recent case
Soft-tissue augmentation in esthetic areas
M
N
O P
passivation of the vestibular flap allowed coronal advance-
ment and primary closure with the palatal flap. (K) Frontal
view 6 months after surgery. A provisional bridge is
applied and gradually modified during the healing of soft
tissue. Note the vertical soft-tissue augmentation in rela-
tion to the neighboring teeth and, in particular, to the posi-
tion of the soft-tissue margin of the healthy contralateral
incisor. (L) Augmentation of horizontal soft-tissue
6 months after surgery. (M, N) One year after surgery the
final prosthetic crowns are applied. (O, P) Presurgical and
final views of the edentulous area 1 year after treatment.
Note the natural emergence of the pontic tooth in the
edentulous area.
series, Stefanini et al. (32) proposed a reproducible
method to measure the vertical augmentation of soft
tissue before and after a transmucosal implant place-
ment with a simultaneous submarginal connective
tissue graft. This method involves manufacture of a
resin stent extended to the occlusal surfaces of teeth
adjacent to the edentulous ridge. A reference point
(slot) is impressed upon the stent at the mid-buccal
area of the implant site to facilitate reproducible posi-
tioning of the periodontal probe. The vertical soft-tis-
sue level was measured as the distance from the most
apical extension of the edentulous area to the refer-
ence point of the stent.
Oral photography is used extensively for evaluation
of soft tissue; however, most approaches are not stan-
dardized. In 2007, Ricci (20) introduced a method of
taking standardized photographs of study models by
positioning a digital camera in a fixed relationship to
the casts of preselected clinical situations. The pho-
tographs were then analyzed using dedicated soft-
ware and compared with each other for linear
measurements (20). Weinla €nder et al. (41) proposed a
standardized patient, camera and mirror positioning
method in which a photograph of the anterior maxil-
lary region was taken at 10-to 14-day intervals. The
acquired photographs were then transferred into
medical image-processing software to calculate the
gingivomorphometrical measurements.
117
Marzadori et al.

Table 1. Two-dimensional methods for measurement of soft tissue

Technique Accuracy Advantages Disadvantages

Periodontal Results accurate to 0.5 mm Noninvasive No three-dimensional information

probe Low variability between
Easy to apply
examiners
No discomfort to the patient
Oral Measurements accepted Noninvasive Limited three-dimensional information
photography at a 95% confidence interval
Standardized patient–camera– Slight discomfort with the
mirror positioning positioning of the mirrors
Ultrasonic Resolution of 0.1 mm Noninvasive Mild discomfort
devices
Painless Special tool needed (limited
practicability in the clinical setting)
Difficult to access the posterior regions

Table 2. Three-dimensional methods for measurement of soft tissue

Technique Accuracy Advantages Disadvantages

Soft-tissue cone-beam Measurement error (up to Painless Radiation exposure

computed tomography 1.11 mm or 7%) depending on
Three-dimensional Distinction of soft-tissue types is
accuracy of tomography
overview not possible

method
Moire Relative error of measurements Three-dimensional Discomfort of impression taking
is 2.2% or 50–600 mm3 measurements
Dental cast necessary
are possible

system cannot be used for
Moire
other purposes
Laser/computer-aided Median difference for replicas Noninvasive Discomfort of impression taking
design/computer-aided (0.01 mm3 or 0.8% for
Three-dimensional Computer-aided design/computer-aided
manufacturing devices computer-aided design/
measurements manufacturing devices or laser
computer-aided
are possible scanning needed
manufacturing method;
7.75 lm or 6561 lm3 for laser Dental cast necessary for laser scanning
scanning)

Soft-tissue thickness measurements, utilizing ultra- Three-dimensional measurements

sonic devices, have been performed by a number of
The three-dimensional determination of soft-tissue
researchers (6, 18, 24, 31, 39, 40). The system is based
volume has been investigated since 2002 using several
on the ultrasonic pulse-echo principle in which ultra-
different devices developed in this time (Table 2). In
sonic pulses are transmitted through the mucous
2008, Januario et al. (10) proposed the use of soft-tis-
membrane and reflected at the hard-tissue surface.
The thickness of soft tissues is determined by timing sue cone-beam computed tomography to improve
soft-tissue image quality and allow determination of
the echo received.
the dimensions and relationships of the structures of
Although these techniques have proven to be accu-
the dentogingival unit. The patients wore a plastic lip
rate, a major disadvantage is the inability to obtain
retractor and retracted their tongues toward the floor
information about the changes in volume of soft tis-
sues. Other issues could also affect the measure- of the mouth, thus allowing measurements to be
made of the distance from the gingival margin to the
ments, such as soft-tissue displacement during
facial bone crest and from the gingival margin to the
impression taking, dimensional changes of impres-
cementoenamel junction, and the width of the facial
sion or cast materials and inability to measure the
gingiva.
posterior areas because of difficulties in positioning
Studer et al. (33, 35) used the optical projection
mirrors or in accessing ultrasonic devices. Still, all
Moire
method to quantify three-dimensional volume
these techniques are noninvasive and could be rec-
changes of single-tooth pontic spaces after soft-tissue
ommended, especially in the anterior areas, if
augmentation. The ‘Moire
effect’ refers to the
changes in volume measurements are not needed.

118
 Soft-tissue augmentation in esthetic areas

A B

Fig. 6. Three-dimensional measurement of soft-tissue vol-
ume. The digital technology allows measurement of the
increase in gingival tissue after the soft-tissue augmenta-
tion procedure. (A) Image obtained with intra-oral scan-
ning before the connective tissue platform technique. (B).
Image obtained 6 months after surgery. (C)
Superimposition of the digital files shows the increase in
volume of the soft tissues after the surgical treatment. The
green color highlights the perfect matching of the files. The
blue color shows the difference, in millimeters, before and
after the soft-tissue augmentation.

Fig. 7. Soft-tissue augmentation techniques for the treatment of Seibert’s Class I, II and III defects.

interference of light seen by superimposing two Moire
system. The system consists of a Moire
driver,
nearly identical arrays of lines or dots. The study was a Moire
projector, a Moire
viewer, a video camera
conducted by computer analysis of a capture of den- and a personal computer with graphics software. The
tal casts covered with white-colored spray, using a validity of this model was better than 2.2% in volume

119
Marzadori et al.
changes, with variability of less than 2.8%. The dura-
tion of measurements for one series of casts was
approximately 3 h.
Many authors have worked on the principle of opti-
cal/active triangulation with a three-dimensional
laser scanner (9, 11, 12, 22, 38) or with computer-
aided design/computer-aided manufacturing devices
(7, 42). These systems were applied either to study
models or directly in the oral cavity and consisted of a
pre- and postcomputer analysis of different timed
acquisitions. A high accuracy was registered, varying
from 3 to 200 lm and from 0.05% to 1.5% in volume.
An example of three-dimensional presurgical/post-
surgical imaging processing is presented in Fig. 6.
Three-dimensional systems represent the future of
soft-tissue volume change measurements with
encouraging results being obtained from a number of
studies. Nevertheless, soft-tissue displacement and
dimensional changes of impression or cast materials,
when the analysis is carried out on study models, and
the difficulty in accessing posterior areas when the
sensors are directly used in the oral cavity, have to be
considered. In the case of cone-beam computed
tomography scans, the radiation dose is a major limi-
tation, especially in studies in which several, frequent,
follow-up appointments are required. Also, the cost
of these devices and the amount of time needed to
carry out the investigations need to be taken into
account.
Conclusions
Reconstructive plastic surgery procedures aimed at
restoration of the alveolar ridge to its former dimen-
sions are increasingly prescribed, particularly in the
anterior region where esthetic issues are concerned.
Nevertheless, there is a lack of clinical studies in the
literature investigating this concern and therefore evi-
dence-based conclusions cannot be drawn. More
information from a larger number of studies and from
randomized controlled clinical trials is needed. Fur-
thermore, because of the high esthetic impact it is
advised that patient-centered outcomes be incorpo-
rated in clinical trials.
The following conclusions can be drawn from the
data available in the literature (Fig. 7):
 Soft-tissue augmentation procedures are mainly
indicated for procedures used for replacement of
one or two missing teeth.
 Pouch procedures are the preferred choice for
soft-tissue augmentation, especially in areas of
high esthetic demand, because primary-intention
120
wound healing can be achieved, thus maintaining
the color and surface characteristics of the existing
tissues. Moreover, new surgical pouch-like
approaches (43) allow the treatment of Seibert’s
Class II or Class III defects.
 Roll techniques could be applied for shallow buc-
colingual soft-tissue augmentation, in order to
avoid palatal graft harvesting and to minimize
donor-site morbidity and improve recovery of
patients from surgery.
 Onlay, inlay and combination grafts are less fre-
quently used for soft-tissue augmentation because
of the poor esthetic results (especially concerning
texture and color variation from the grafted and
the adjacent areas) and the high resorption rate of
the exposed graft.
The treatment of Seibert’s Class III defects has
always been challenging and often led to multiple
surgical interventions to achieve sufficient soft-tissue
augmentation. The aim of future research ought to be
the development of surgical techniques that can
achieve soft-tissue correction using a one-stage
approach. Encouraging outcomes regarding this are
described in a recent case report (43). It is hoped that
the development of connective tissue substitutes will
lead to significant reduction of the morbidity associ-
ated with surgery, thus avoiding the necessity to har-
vest soft tissue from a donor site. A sufficient amount
of data on this topic are still lacking in the literature.
Three-dimensional measurement methods seem to
be the future of monitoring soft-tissue volume
changes, with encouraging results obtained from a
number of studies. Nevertheless, the cost of the
devices and the high dose of radiation (in case of
cone-beam computed tomography scans) limit their
use in clinical practice.
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Periodontology 2000, Vol. 77, 2018, 123–149
Printed in Singapore. All rights reserved
Surgery without papilla incision:
tunneling flap procedures in
plastic periodontal and implant
surgery
O T T O Z U H R , S T E P H A N F. R E B E L E , S T E F A N I L. C H E U N G & M A R K U S B. H UR
ON BEHALF OF THE RESEARCH GROUP ON ORAL SOFT TISSUE BIOLOGY AND
WOUND HEALING
Diverse clinical advancements, together with some
relevant technical innovations, have led to an
increase in popularity of tunneling flap procedures in
plastic periodontal and implant surgery in the recent
past. This trend is further promoted by the fact that
these techniques have lately been introduced to a
considerably expanded range of indications. While
originally described for the treatment of gingival
recession-type defects, tunneling flap procedures
may now be applied successfully in a variety of clini-
cal situations in which augmentation of the soft tis-
sues is indicated in the esthetic zone. Potential
clinical scenarios include surgical thickening of thin
buccal gingiva or peri-implant mucosa, alveolar ridge
preservation following tooth extraction with or with-
out immediate implants, implant second-stage sur-
gery and soft-tissue ridge augmentation, either with
implants or for pontic site development.
It may be assumed that flap elevation without
detachment of the papillary tissues and without
vertical-releasing incisions contributes to acceler-
ated blood supply and uneventful wound healing.
Moreover, it seems obvious that avoiding any kind
of visible incisions on the tissue surface (which was
also introduced as ‘incision-free’ flap elevation)
allows for an improved esthetic outcome because
of a minimized risk of postoperative scar-tissue for-
mation. For these reasons, tunneling flap proce-
dures have developed into a versatile clinical tool
that may currently be regarded as a genuine and
promising alternative in mucogingival therapy in
the esthetic zone.
© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
PERIODONTOLOGY 2000
€ ZELER
The aim of this article was to provide a compre-
hensive overview on tunneling flap procedures, to
introduce the successive development of the approach
along with underlying ideas on surgical wound healing
and to present contemporary clinical scenarios that
aim to provide clinically oriented and scientifically
supported guidance for clinicians in order to help
them to integrate tunneling flap procedures into their
clinical routine.
Principal considerations
The quantity and quality of surgical
outcomes
Mucogingival therapy, by definition, describes clinical
procedures that are designed to correct ‘defects in
morphology, position and/or amount of soft tissue
and underlying bone’ around teeth and dental
implants (3). As a matter of fact, any successful out-
come in plastic periodontal and implant surgery is
therefore inevitably dependent on a clinical result
that features, at the same time, both adequate quan-
tity (amount and position) as well as quality (appear-
ance or morphology) of the treated tissues. While
these words may seem rather self-evident, the quest
for quality still represents a somewhat new awareness
in plastic periodontal surgery. Using root- coverage
procedures as an example, with the first international
reports of such an intervention having been pub-
lished as early as in 1912 by Rosenthal (72), clinical
123
Zuhr et al.
protocols and scientific research focused for a long
time solely on quantitative results and most studies
therefore exclusively reported on surrogate outcomes,
such as the amount of root coverage or changes in
the amount of keratinized tissue (71). In the millen-
nium years, however, with the arrival of evidence-
based practices in plastic periodontal surgery, the
best possible coverage of the recession defect, and
thus the quantitative outcome, was no longer
regarded as the sole treatment goal of root-coverage
procedures. Instead, patient satisfaction (which may
be regarded as the true outcome), together with qual-
itative criteria of success, such as the chromatic and
textural integration of the covering tissues, the mar-
ginal tissue contour and scar tissue formation, have
become of increasing importance (55). Given that
root-coverage procedures are mainly undertaken for
esthetic reasons, aiming to improve the overall
esthetic appearance of patients’ smiles, these afore-
mentioned factors are presently acknowledged as sig-
nificant and indisputable parameters of success. As
such, the ultimate goal of root-coverage procedures
may be described as the complete coverage of the
recession defect associated with minimal probing
depths and nice esthetics (20, 25). As tools for objec-
tive esthetic assessment of root-coverage outcomes
have just been introduced in the past few years
(18, 21), most of the published literature lacks evalua-
tion of these additional parameters of success (50). It
is therefore not surprising that there is currently a
renewed and rather vibrant discussion in the scien-
tific community about which are the best and most
A B
Fig. 1. (A) The ultimate goal of root-coverage procedures
may be described as the complete coverage of the reces-
sion defect associated with minimal probing depths and
nice esthetics. In recent years, the introduction of
esthetic scoring tools drew the attention of researchers
as well as clinicians to consider additional (quality) out-
come parameters, thus going beyond an exclusive evalu-
ation of the amount of root coverage (quantity). The
use of such scoring tools in clinical research (such as
the root-coverage esthetic score (18, 21) for instance)
would identify the following two examples as failures.
(B) Clinical case following surgical root coverage with a
pedicle flap procedure in the upper anterior dentition.
124
contemporary surgical techniques to cover gingival
recession defects, now seeking for those techniques
which provide predictable treatment outcomes from
both perspectives – quantity as well as quality (50)
(Fig. 1A–C). In fact, the above-described development
regarding root-coverage procedures has extended to
the whole realm of plastic periodontal and implant
surgery during recent years: a similar trend can be
observed in implant-assisted rehabilitations, for
instance, where success for a long time was simply
equated to implant survival until, besides biological
and technical criteria of success, the introduction of
objective esthetic scores (9, 36, 57, 79, 82, 84) attracted
the awareness of both researchers and clinicians.
Irrespective of the specific technique that is chosen
in any clinical scenario, it is the achievement of a fast
and uneventful course of wound healing that is indis-
pensable to obtain quantitative as well as qualitative
success in reconstructive surgery (11, 14, 44). Primary
wound healing or healing by primary intention is
therefore a key success factor in plastic periodontal
and implant surgery, in which autologous grafts or
various substitute materials are frequently used to
achieve the reconstructive goal. The successful inte-
gration of these grafts is dependent on a variety of
clinical factors, in particular, the blood supply to the
treated tissues, the prevention of bacterial infection
and the stability of the wound. All these aspects are
decisive factors for successful integration of the
grafted tissues into the surrounding environment,
which consequently relies on the achievement of pri-
mary wound closure that is maintained during the
C
Despite complete root coverage, at least from the
upper-right canine to the left central incisor, the clinical
photograph identifies this outcome as a failure owing to
mucogingival junction misalignment, multiple scar tis-
sue formation, as well as interproximal soft-tissue vol-
ume loss. (C) Clinical case of an upper-right canine
following surgical root coverage using a de-epithelialized
free gingival graft placed underneath a pedicle flap.
Despite complete root coverage this outcome also must
be considered as a serious failure owing to altered
epithelial differentiation of the buccal gingiva, which
impairs the textural integration as well as the color of
the root covering soft tissues.

crucial phase of early wound healing (healing by pri-
mary intention). Impaired or complicated healing
(healing by secondary intention), on the other hand,
may lead to wound dehiscences, potentially resulting
in volumetric defects, fibrotic tissue areas or hyper-
trophic scar tissue formation, all of which negatively
affect the overall esthetic outcome. In view of the
importance of the healing pattern to the success of
any reconstructive surgery, it is therefore essential
from a clinician’s perspective to identify and control
the factors that are involved and influence the pro-
cess of wound healing in order to increase the pre-
dictability of the therapy in the best possible way.
Prognostic factors in plastic periodontal
and implant surgery
A prognostic factor is defined as a situation or condi-
tion, or as a characteristic of a patient, that can be
used to better estimate the patient’s eventual out-
come or response to a specific treatment. Prognostic
factors are not entirely responsible for the outcome,
but they do have a considerable influence on the
overall performance or predictability of the therapy.
Within the scope of reconstructive plastic periodontal
surgery, potential prognostic factors are best studied
for root-coverage procedures and may be divided into
three different categories (25, 87): patient-related fac-
tors; tooth- or site-related factors; and technique-
related factors. Tunneling flap procedures, as indi-
cated above, have, in recent years, developed into a
versatile tool for augmentation of the buccal soft tis-
sues in a rather broad range of clinical scenarios. As
these techniques originate from the field of gingival
recession treatment, however, it appears reasonable,
from a methodological point of view, to transfer some
of the insights gained through the research on prog-
nostic factors for root-coverage procedures to the
scope of indications where tunneling flap preparation
techniques are applied at present.
While patient-related prognostic factors (e.g.
systemic health, smoking habits, oral hygiene or
traumatic toothbrushing), as well as site-related
prognostic factors (e.g. defect location, defect forma-
tion or the clinical attachment level), are essentially
controlled by proper selection of the individual case,
or potentially also by cause-related therapy, it is the
technique-related factors that give the clinician
the opportunity to have an immediate impact on
the predictability and the overall outcome of the
surgical intervention. Soft-tissue handling, in this
context, is most crucial for success in plastic peri-
odontal and implant surgery as it directly affects the
Tunneling flap procedures
course of wound healing. The exact procedure, from
the outline of the incisions and the design of the
flap to the closure of the wound, should therefore
be carefully planned by the clinician before surgery,
who in doing so should ultimately focus on the
achievement of the best possible blood supply as
well as the highest possible stability of the wound
(Fig. 2).
Blood supply
Preservation of a sufficient vascular supply is essential
to ensure survival of the elevated flap and particularly
of the augmented tissues, which is indispensable for
success in reconstructive plastic periodontal surgery.
The quality of wound healing is directly affected by
the patency of the blood vessels inside the flap (58)
and depends on initial plasmatic diffusion followed
by fast anastomosis between capillaries of the flap
and the recipient site and/or between, for instance,
capillaries of a connective tissue graft and the flap/
recipient site (24, 42, 56, 60, 61). The design and the
outline of the flap are, for this reason, in particular
determined by the anatomy of the vascular network
of the tissue structures involved in the surgery.
The blood supply of the periodontal tissues is
derived from three independent sources: suprape-
riosteal vessels; intra-alveolar vessels; and vessels of
the periodontal ligament (54). Going further into
detail, it has been shown that the free and attached
gingiva is nourished mainly through supraperiosteal
vessels (33), which derive from larger vessels that run
parallel to the alveolar ridge in the vestibulum,
stretching smaller gingival branches toward the alve-
olar crest in a coronal direction (52). When investigat-
ing the periodontal structures of different laboratory
animals, some authors were also able to describe
anastomoses between vessels of the gingiva and the
periodontal ligament (51), but the results of subse-
quent functional experiments suggest that under nor-
mal conditions these vascular networks operate
rather independently from each other. As such, occlu-
sion of vessels in the periodontal ligament did not
impair the vascular supply of the gingival tissues (38),
and occlusion of arterioles supplying the gingiva also
did not appear to alter the blood flow in the peri-
odontal ligament (48). However, in the latter of these
two studies, it was demonstrated that the initial
revascularization of the marginal gingiva was estab-
lished through vessels coming from the periodontal
ligament. As other authors observed similar effects
also in later experiments (37, 49), it may be assumed
that the periodontal ligament appears to have a cer-
tain potential to provide for a compensatory vascular
125
Zuhr et al.
Smoking
Genetics
Systemic health
Patient-related
Plaque / infection
factors
Oral hygiene
habits Age
Graft volume
Incision design Blood
supply
Technique-related
factors
Flap thickness
Wound
stability
Preparation of the
wound bed
Fig. 2. In reconstructive plastic periodontal surgery, poten-
tial prognostic factors may be divided into three different
categories: patient-related factors; tooth/site-related factors;
supply to the gingiva when specific needs arise such
as, for instance, when a flap has been elevated (58).
This has been further confirmed in an angiographic
animal study by McLean et al. (56), in which the vas-
cular changes occurring after mucoperiosteal flap
surgery in dogs were evaluated. The authors elevated
and immediately readapted and sutured full-thick-
ness buccal and lingual flaps in the premolar to molar
region of the animals’ mandibular quadrants. It was
found that the sole act of raising a mucoperiosteal
flap initiated substantial vascular trauma. Recovery of
flap circulation, however, occurred much earlier in
the areas above the tooth prominences compared
with interdental aspects. This observation may again
be explained by the collateral vessels deriving from
the periodontal ligament, which contribute to the
marginal blood supply during the early stages of
wound healing.
Summarizing the findings of the above-cited studies
in a synoptic view also helps to get a better under-
standing of why certain reconstructive procedures
(e.g. soft-tissue recession treatment) generally show
126
Depth of
vestibule
Clinical
extent / anatomy
attachment level
of the defect
Site-related
factors
Soft tissue
Amount of thickness
keratinized tissue
Defect
localisation
Operator skills
Flap tension
Tissue trauma
and technique-related factors. The red arrows illustrate the
complexity of surgical variables related to oral mucosal heal-
ing.
poorer/inferior outcomes at implants when compared
with natural teeth (13). In a study on skin grafts it has
been demonstrated, for instance, that the revascular-
ization of the graft almost exclusively originates from
capillaries of the recipient bed (22). This angiogenic
capacity of the wound bed is expected to be compro-
mised much more around dental implants because of
the lack of a periodontal ligament structure.
Mo€ rmann & Ciancio (58) used the technique of flu-
orescein angiography in humans to evaluate alter-
ations of the gingival blood circulation following
experimental surgery with various modifications of
mucogingival flap designs. At the time, their observa-
tions led them to conclude that flaps receive their
major blood supply from the supraperiosteal network
arising from the flaps’ apical aspects. The authors
therefore suggested that ‘flaps should be broad
enough at their base to include major gingival vessels’
and also recommended that, in order to include more
blood vessels in the elevated tissues, flap preparations
should not be too thin. It seems logical that increased
flap width at its base will increase the blood supply

and hence support a greater flap length; however, a
deeper insight into oral wound healing tells us pre-
sently that the outline of a flap should not be planned
on pure geometric perception by solely aiming for a
favorable flap length-to-width ratio (16). As indicated
above, other aspects, such as the angiogenic capacity
of the wound bed, also deserve recognition. More-
over, it cannot be assumed that major nutrient ves-
sels enter the base of gingival flaps at regular
intervals. In addition, Jeffcoat et al. (43) were able to
demonstrate that the gingival vascular network in
Beagle dogs is characterized by arterial vessels
traversing somewhat obliquely in a general posterior-
to-anterior manner. From this perspective it can be
assumed that the vascularization of a pedicle flap can
be further improved if surface incisions and, in partic-
ular, vertical-releasing incisions, are minimized or –
even better – completely avoided (16, 52). Zucchelli &
De Sanctis (93), in this regard, proposed a surgical
technique, based on a modified version of a coronally
advanced flap without vertical releasing incisions, to
treat multiple adjacent gingival recession defects. The
authors reported excellent clinical outcomes in terms
of root coverage as well as nice esthetics of the root
covering soft tissues, which explains the increasing
popularity of this approach in recent years. The same
authors subsequently conducted a randomized con-
trolled clinical trial comparing coronally advanced
flap therapy, with and without vertical releasing inci-
sions, in the treatment of multiple recessions (94).
Both coronally advanced flap techniques were effec-
tive in reducing recession depth, but the modified
version without vertical releasing incisions demon-
strated an increased probability of achieving com-
plete root coverage as well as a better postoperative
course of healing. Moreover, the new flap design also
presented with more favorable esthetic outcomes, as
the conventional approach of a coronally advanced
flap is frequently associated with keloid formation
along the vertical releasing incisions (94).
The preference for thick flaps is in accordance
with the findings of a clinical study by Baldi et al.
(8) in which the influence of flap thickness on the
success of coronally advanced flap surgery for the
treatment of single Miller Class I or II recession-
type defects was evaluated. It was demonstrated,
using a modified gauge to measure flap thickness
during surgery, that thicker tissues were consis-
tently related to better clinical outcomes in terms
of recession reduction and complete root coverage.
The authors hypothesized that thicker flaps could
be associated with a more stable vascular network,
which is of fundamental importance for the
Tunneling flap procedures
survival of the flap and in particular of the mar-
ginal gingiva, the part of the flap that is farthest
away from the base of the pedicle. In a subsequent
review, Hwang & Wang (41) identified several more
studies correlating greater flap thickness with bet-
ter clinical outcomes after root-coverage surgery.
Despite the limitation of great heterogeneity of the
studies included, it was concluded that flap thick-
ness might be considered as a potential prognostic
factor in the treatment of gingival recession defects.
The thickness of the flap is directly influenced by
the type of flap elevation, within the meaning of a
full-thickness vs. a partial- or split-thickness prepara-
tion. As a full-thickness flap incorporates all bone-
covering soft tissue layers – epithelium, connective
tissue and periosteum – the thickness of the flap is
exclusively defined by the thickness of the pre-exist-
ing gingival (or peri-implant mucosal) dimensions.
The elevation of a full-thickness flap therefore gener-
ally allows for thicker flaps compared with a split-
thickness flap preparation; however, because of the
exposure of hard tissues, there is also more osteoclas-
tic activity and consequently more bone resorption to
be expected (30, 65, 75). The preparation of a split-
thickness flap, on the other hand, achieves ideal flap
mobility, which considerably reduces flap tension
and thus better maintains the circulation inside the
elevated tissues (58). Moreover, leaving the perios-
teum and thin layers of connective tissue on the bone
creates a recipient bed that may enhance the incor-
poration of a connective tissue graft as it would
receive, in addition to the blood supply from the
outer aspect (flap), increased nourishment from the
inner aspect (periosteum) (22, 77). From a clinical
point of view, the crucial aspect with the split-thick-
ness technique is to prepare a flap of sufficient thick-
ness in order not to impair the survival of the flap as a
result of insufficient vasculature of the elevated tis-
sues (24, 58). This is of particular relevance along the
margins of the flap, where a thin, beveled preparation
of the tissues should be avoided. As the incision
design has a considerable influence on the thickness
of flap margins, attention should be paid to the fol-
lowing details in the surgical procedure: initial inci-
sions should be made with the scalpel running
perpendicular to the tissue surface (97); and, with
regard to incisions along the gingival margin, intrasul-
cular incisions are preferred over marginal or para-
marginal incisions whenever possible (52).
The importance of blood supply, regardless of the
specific incision and flap design, has been further
stressed by Burkhardt & Lang (14), who compared
the performance of micro- vs. macrosurgical
127
Zuhr et al.
techniques in gingival recession treatment. The
authors evaluated the degree of vascularization fol-
lowing surgical root coverage with a double papilla
flap in combination with connective tissue graft in
patients with bilateral Miller Class I or II defects at
maxillary canines. In a split-mouth design, the defects
were randomly assigned to either a minimally inva-
sive microsurgical or conventional macrosurgical
approach of the same procedure. The angiographic
evaluations performed after the intervention revealed
earlier as well as better vascularization at microsurgi-
cally compared with macrosurgically treated sites.
The quality of the vascular supply apparently also
influenced the final outcome of the surgery, as the
sites treated in the microsurgical group presented
with significantly better root coverage when com-
pared with those in the macrosurgical group
(98.0  3.4% vs. 89.9  8.5% of average root coverage
after 12 months, P = 0.03). The authors assumed that
the use of finer and sharper instruments, together
with less traumatic suture materials, accounted for
the reduced tissue damage and thus superior out-
comes observed with the microsurgical approach
(14). Several other clinical studies were also able to
identify the additional benefits of the use of a micro-
surgical approach compared with surgery performed
under routine and macroscopic conditions, in root-
coverage procedures (11, 35) as well as in regenerative
periodontal surgery (26). Minimally invasive, careful
handling of the tissues, and the execution of sharp
cuts instead of laceration and contusion, promises
for substantially improved treatment outcomes from
better-maintained vasculature as a consequence of
less trauma, microthrombosis and vessel collapse.
Consequently, the use of microsurgical instruments,
together with magnifying aids and illumination, may
currently be regarded as the standard way to perform
periodontal plastic surgery (16).
Wound stability
Wound healing is primarily dependent on early for-
mation of a blood clot and the establishment of an
attachment of the clot which is capable of withstand-
ing mechanical forces acting on the interface between
the flap and opposing wound surfaces and which pre-
vents microbiologic contamination (89). The attach-
ment of the blood clot is substantially influenced by
the mechanical and biochemical properties of the dif-
ferent surfaces to which it adheres; it is more complex
to be established at the solid, nonshedding surfaces
of a root or dental implant when compared to wound
surfaces formed by the soft tissues or bone. Any dis-
turbance of clot adhesion, in particular to these solid,
128
avascular surfaces, may reduce the tensile strength of
the periodontal wound. In practice, if tear should
occur during early healing, this may leave the surgical
site more prone to epithelial downgrowth and/or
microbial infection. Consequently, healing following
periodontal (or implant) flap surgery is to be regarded
as conceptually more complex than wound healing in
most other sites of the oral cavity (16, 89).
Wikesjo€ et al. (88) studied early healing at the
dentin–connective tissue interface in an animal
experiment. The authors surgically created and sub-
sequently treated vertical, recession-type defects at
mandibular premolars in a dog model. Before wound
closure, the root surfaces were treated with either
heparin (an anticoagulant) or saline. Histometric
analysis after 4 weeks of healing revealed that con-
nective tissue repair at heparin-impregnated root sur-
faces averaged 50% of the formerly exposed root
surface compared with 95% at control sites. Heparin
treatment of the root surfaces interacted with the
extrinsic pathway of coagulation, thus impairing fib-
rin clot adhesion at these sites. The authors assumed
that tensile forces then caused a rupture between the
root surface and the inner aspect of the flap, which led
to rapid epithelial downgrowth and decreased connec-
tive tissue repair at these sites, while in wounds treated
with saline these same tensile forces were not suffi-
cient to violate the integrity of the root surface-adher-
ing blood clot. The results of this experiment
confirmed blot clot adhesion to be a prerequisite for
connective tissue repair of periodontal wounds (88).
Similarly, however, these results also emphasized the
overall significance of achieving a most stable soft-tis-
sue closure in periodontal surgery, which underlines
the importance of tension-free flap adaptation as well
as appropriate suturing techniques (16).
Angiographic studies in humans indicate that
favorable clinical outcomes in gingival recession
treatment are only to be expected if the flap is pas-
sively adapted and sutured without tension above the
formerly exposed root surface (58). Several anatomic
factors or conditions (e.g. the depth of the vestibule,
the presence of frenal pull or inserting muscle groups,
and the size and localization of the defect) may chal-
lenge passive advancement of the flap toward the
cemento–enamel junction. However, if soft-tissue
management (outline and design of the flap) does not
achieve full release of the flap, the sutures instead will
exert tension in order to hold the flap in the desired
position. This may cause severe vascular disturbances
in the elevated tissues, potentially leading to local
ischemia and subsequent necrosis, as observed by
Mo € rmann & Ciancio (58). Moreover, besides the

aspect of impaired vascularity, residual tension of the
flap may also increase the risk for flap retraction dur-
ing the early phase of wound healing.
The significance of this aspect was proven in a ran-
domized controlled clinical trial by Pini Prato et al.
(67), which evaluated the influence of residual flap
tension on the clinical outcomes of gingival recession
treatment. Patients presenting with bilateral Miller
Class I recession type defects were treated with a
coronally advanced flap procedure at contralateral
teeth in both sides of the jaw. Before suturing, the
residual tension of right and left flaps was measured
with the use of a dynamometer. While flaps at test
teeth were subsequently sutured under routine con-
ditions, further periosteal releasing and a second
measurement of residual flap tension were carried
out before suturing at control sites. In this way, an
average residual flap tension of 6.5 g at test sites was
reduced to only 0.4 g at control sites. Following
3 months of healing, mean root coverage of 78% at
test sites was documented; this value was 87% in the
control group. Statistical analysis revealed that higher
residual flap tension was associated with lower values
of recession reduction, which places further emphasis
on the importance and clinical benefit of a tension-
free flap closure (67).
In addition to various procedures applied for the
coverage of exposed surfaces of a root or dental
implant, the majority of most other techniques in
plastic periodontal and implant surgery also require
lengthening of the flap, in particular to achieve pri-
mary wound closure after augmentation. The most
common or routine way of flap lengthening consists
of one or two vertical releasing incisions, frequently
combined with a periosteal releasing cut performed
at the base of the buccal flap. As indicated above,
however, vertical releasing incisions can significantly
disturb the vascularity of the elevated tissues, which
becomes more pronounced with the increased num-
ber and length of incisions placed (52, 58). Moreover,
any vertical releasing incision inevitably implies the
risk of esthetic impairment as a result of scar tissue
formation or keloid appearance. Even though studies
of the inflammatory response in wounds indicate that
oral mucosa shows a privileged repair pattern with
faster healing and less remarkable scars when com-
pared with the outer skin (78), the occurrence of scars
should still be prevented as much as possible, in par-
ticular when surgical interventions are specifically
undertaken for the purpose of esthetic improvement.
With this in mind, it is once again important to focus
on the quality of wound closure, as experimental and
clinical studies have been able to demonstrate that
Tunneling flap procedures
wound margins sutured under higher residual ten-
sion are more prone to experience wound dehis-
cences and subsequent scar tissue formation (12, 15,
59). Moreover, the same studies also established that
the precision of wound closure influences scar tissue
formation: the occurrence of scars is less likely to be
expected if flap margins are accurately sutured, with
corresponding tissue layers intimately adapted, show-
ing neither overlapping nor displacement of the
wound edges. This ultimately underlines the impor-
tance of adopting a less traumatic approach using
magnification aids and microsurgical instruments
to achieve a precise and passively adapted wound
closure (16).
In order to overcome the aforementioned adverse
effects, new flap designs excluding vertical releasing
incisions, such as the modified coronally advanced
flap or tunneling techniques, have been developed
for root-coverage procedures (93, 96). These incision-
free approaches achieve flap advancement solely by
means of periosteal release, split-thickness prepara-
tion or some combination of these techniques. As the
periosteum mainly comprises irregularly oriented
dense collagen fibers, releasing of the periosteum
alone already allows for considerable coronal
advancement (63). In reconstructive surgery other
than root-coverage procedures, however, buccal flap
advancement alone may have a negative effect on the
functional as well as the esthetic outcome because of
the coronal displacement of the mucogingival junc-
tion, resulting in a reduced width of keratinized
mucosa, as well as esthetic irregularities and lack of
symmetry. In such cases, there may be a need also to
advance the flap margin from the lingual/palatal
aspect. The challenge of displacing palatal mastica-
tory mucosa, which does not allow for conventional
coronal advancement, has been addressed by Tinti &
Parma-Benfenati (80). The authors proposed a more
sophisticated technique of coronally advancing pala-
tal tissues involving split-thickness preparations in
different tissue depths that approach each other from
opposing directions. This results in slight, but some-
times significant, flap lengthening, allowing for dis-
placement toward the buccal aspect, which helps to
achieve passive wound closure with minimal distur-
bance to the mucogingival junction, even in cases of
extended augmentations in the anterior maxilla
(Fig. 3A–H).
In view of the considerations outlined above on
blood supply and wound stability, evidence clearly
suggests that interventions in plastic periodontal and
implant surgery significantly benefit from a less trau-
matic approach by the use of magnification aids and
129
Zuhr et al.
A B
D E
G H
Fig. 3. Preoperative facial (A) and occlusal (B) views of a
clinical case illustrating the theory of the coronally posi-
tioned palatal sliding flap (palatal island flap) (80). Sche-
matic drawings of the design of the flap, which basically
consists of two palatal vertical releasing incisions (C), which
are followed by split-thickness preparations in different tis-
sue depths that approach each other from opposing direc-
tions (D). (E) In this case, a xenogeneic soft-tissue graft is
used for alveolar ridge augmentation. Postoperative facial
(F) and occlusal (G) views demonstrating primary wound
corresponding microsurgical instruments. With
regard to closure of the wound, Burkhardt et al. (17)
were able to demonstrate that this essentially also
includes the use of finer, microsurgical suture materi-
als. Using a tensile-testing machine from the textile
industry, the authors evaluated, in a series of in vitro
experiments, the tearing characteristics of porcine
mucosal tissue samples for various suture sizes in
relation to the applied tension forces. Tensile pull
tests were performed with 3-0, 5-0, 6-0 and 7-0 suture
diameters. The results revealed that the thicker suture
material (3-0) resisted tensile forces that were (at an
average of 13.4 N) constantly leading to tissue break-
age, while the thinner sutures (7-0) always broke
before any damage to the tissues occurred (explicitly
at a mean force of just 3.6 N). This means, in practice,
that the selection of thinner, microsurgical suture
130
C
F
closure with minimal disturbance to the mucogingival junc-
tion. (H) Detailed occlusal view showing the slight, but
significant, lengthening of the palatal flap. In its original
description, Tinti & Parma-Benfenati (80) first introduced
this technique with an entirely different idea in the upper
posterior dentition; however, in combination with tunnel-
ing flap procedures, the use of this flap has proved highly
effective in releasing tension from the buccal and interprox-
imal tissues.
materials (6-0 or 7-0) does not just help to limit soft-
tissue damage, but actually allows the control of ten-
sile forces during wound closure. With this in mind, it
may be speculated that the use of thinner suture
materials could help to prevent wound dehiscences
and subsequent adverse side effects; as these materi-
als will exhibit thread breakage when wound margins
are sutured under residual flap tension, they improve
the predictability of achieving a true, passive flap
adaptation (16).
Successive development of the
tunneling approach
In recent years, with the rise of evidence-based prac-
tice in the profession and accompanied by an

increasing esthetic awareness among patients, the
field of periodontal surgery has been subject to enor-
mous scientific and clinical effort with a view to
improve existing treatment concepts. The ongoing
development of surgical procedures has thereby
evolved with the growing understanding of peri-
odontal wound-healing patterns – recent technical
advancements have therefore focused in particular
on improving the blood supply to the treated site as
well as on the stability of the postoperative wound.
This is true for periodontal regenerative procedures
(27) as well as for plastic periodontal surgery (16),
which is essentially evidenced by the continuous
development and further advancement of the design
of the flaps used in specific indications. A notable
part of this trend is the broad introduction of inci-
sion-free approaches and the increasing popularity of
tunneling flap procedures in gingival recession treat-
ment over the past decade (39).
Tunneling flap procedures originate from what was
first introduced as the ‘envelope’ technique by Raet-
zke in 1985 (69). Raetzke described this technique
with the aim to avoid any kind of releasing incisions
when covering localized areas of root exposure. The
main characteristic of his approach was the insertion
of an autologous connective tissue graft in an envel-
ope that was created in the buccal soft tissues around
the exposed root surface by means of an undermining
partial-thickness flap preparation. Favorable esthetic
outcomes, as well as the simplicity of the procedure,
were the main reasons why Raetzke’s technique soon
enjoyed quite a broad acceptance in clinical peri-
odontology. Although the envelope technique had
been originally proposed for single-tooth defects only,
Allen subsequently demonstrated the use of an envel-
ope technique at adjacent gingival recession defects
(1). Later, Zabalegui et al. (91) connected multiple
envelope preparations to form a continuous mucosal
tunnel in the buccal soft tissues, thereby creating the
tunnel technique. The same authors also introduced
a special kind of suture technique which facilitated
insertion of the connective tissue graft into the tunnel
underneath the tissue surface and allowed, to some
extent, stabilization of the graft in the desired posi-
tion. Soon afterwards, the group around Azzi (7) pre-
sented a further modification of Zabalegui’s flap
design, whereby they prepared a mucoperiosteal–
mucosal tunnel that also involved the tissues of the
interdental papillae. This extended tunneling flap
design allowed, for the first time, for considerable
coronal displacement of the entire gingivopapillary
complex, including the grafted tissues. The use of
horizontal mattress sutures anchored at the incisal
Tunneling flap procedures
edges of the treated teeth served to maintain the sur-
gically established position of the soft tissues. In
doing so, it was now possible for larger portions of
the connective tissue graft to become covered by the
flap, which reduced the risk of graft necrosis and thus
improved the overall predictability of the tunneling
approach.
The above-described modifications of the formerly
rather simple envelope technique undoubtedly
resulted in considerable improvement in the design
of the flap but this came at the expense of creating a
rather demanding and technique-sensitive proce-
dure. However, the promise for accelerated wound
healing and improved esthetic outcomes in incision-
free flap elevation encouraged Zuhr et al. (96) to
reassess the tunnel technique and to present some
further developments. While some of these modifi-
cations addressed flap design and aimed for sim-
plification of the technique, it was the successive
incorporation of a consistent microsurgical concept
that characterizes the contribution of the group
around Zuhr. The modified microsurgical tunnel
technique features split-thickness flap elevation to
prepare the entire soft-tissue tunnel in the buccal
aspects of the recessed area, which ensures ideal flap
mobility as well as the best possible blood supply to
the subsequently inserted connective tissue graft. The
supraperiosteal dissection is extended well beyond
the mucogingival junction, deep into the mucosal tis-
sues, in order to gain sufficient flap mobility from the
apical aspect. To ease flap elevation and minimize
trauma as well as the risk of perforation, Zuhr et al.
(96) introduced some new, specifically designed micro-
surgical instruments (tunneling knives; Fig. 4). Prepa-
ration of the buccal papillary regions, however, was
recommended for full-thickness flap elevation. Blunt
elevation of these fragile tissues provided the mobility
Fig. 4. Tunnelling knife (left) and bendable microsurgical
blade (right) (96).
131
Zuhr et al.
necessary for coronal flap advancement but, at the
same time, attempted to minimize surgical trauma and
the risk of tearing the papilla.
Subsequent modifications focused on closure of
the wound, where a new suturing technique was
introduced specifically to serve the goals of the proce-
dure (101). The use of double-crossed sutures further
stabilized and maintained the surgically established
coronal displacement of the entire gingivopapillary
complex (buccal flap, connective tissue graft and
mobilized papillae), but also provided a stable and
intimate contact of the graft and the covering flap
to the underlying nourishing tissues. Aiming for
improved wound stabilization, as well as the best-
possible blood supply and metabolic diffusion to the
surgical site, the suture probably makes an additional
contribution to accelerated wound healing and pre-
dictable graft survival.
Very recently, the authors of the present article
favored and promoted a further variation in the
design of the tunneling flap, as will be illustrated later
in this publication. In this regard, the authors suggest
to perform a full-thickness elevation of the soft tissues
at the level of the buccal bone crest, which ultimately
leads to a split–full–split-thickness preparation of the
flap. This modification is inspired by current trends
in the literature (25, 93) and seems to take better
account of some of the above-mentioned considera-
tions on wound healing in plastic periodontal surgery.
In more specific terms, this flap design is intended to
combine the advantage of greater flap thickness in
the coronal parts with the best possible flap mobiliza-
tion in the apical aspects.
Based on these developments over the last years,
Zuhr et al. then began to apply the tunneling flap
technique to an increasingly greater range of clinical
scenarios in which augmentation of the soft tissues
was indicated in the esthetic zone. Potential applica-
tions are manifold and range from minor (e.g. surgical
thickening of thin buccal gingiva or peri-implant
mucosa), through moderate (e.g. alveolar ridge pre-
servation following tooth extraction, with or without
immediate implants, as well as implant second-stage
surgery), to extensive (e.g. soft-tissue ridge augmenta-
tion either with implants or for pontic site develop-
ment) reconstructions of the soft-tissue volume (7, 40,
98, 99, 101). In this way, tunneling flap procedures
developed from a technique that was previously
almost exclusively used for root-coverage purposes
into a comprehensive treatment strategy for soft-tissue
augmentation in plastic periodontal and implant sur-
gery. The conceptual development of the approach
thereby traces the ever-increasing understanding of
132
factors involved in wound healing: atraumatic han-
dling of the tissues, respect for blood supply, as well as
high wound stability are all aspects of a consistent
microsurgical approach that aims for improved and
accelerated wound healing as well as predictable
quantity and quality in treatment outcomes.
The tunnel technique in treatment
of gingival recession
The published literature provides substantial evi-
dence that the combined approach with the addi-
tional use of a subepithelial connective tissue graft is
the most effective surgical procedure to cover gingival
recession-type defects, showing the best clinical out-
comes in terms of recession reduction as well as com-
plete root coverage (19, 20, 23, 25). The coronally
advanced flap represents, in this regard, the most
intensively studied and the most widely adopted
design for flap preparation (20, 25). This flap design
is, in its original version, based on two vertical releas-
ing incisions mesial and distal to the recessed area
(2, 53). Since the turn of the millenium, however, as a
result of the above-mentioned trends and develop-
ments in plastic periodontal and implant surgery,
newer designs of the coronally advanced flap, which
aim to avoid vertical releasing incisions, have gained
increasing popularity in research as well as in clinical
practice.
Graziani et al. (39), in a recent systematic review,
identified three reference techniques for the treat-
ment of multiple gingival recession-type defects: (i)
the standard procedure of a coronally advanced flap;
(ii) its modified version of a rotated envelope flap
without vertical releasing incisions, as described by
Zucchelli & De Sanctis (93); and (iii) techniques based
on a tunneling flap preparation (which are also
referred to, in this review, as modified coronally
advanced tunnel procedures). The authors concluded
that indirect evidence suggests that the coronally
advanced flap may benefit from these newer varia-
tions of the technique as well as from the additional
use of grafting (93). The conclusions of this review are
supported by an increasing number of comparative
studies or randomized controlled clinical trials that
prove the convincing clinical performance of both the
tunnel technique as well as the modified coronally
advanced flap in gingival recession treatment (5, 6,
81, 94, 100).
Aroca et al. (6), in a randomized controlled clinical
trial performed using a split-mouth design, compared
the clinical outcomes following treatment of multiple

adjacent Miller Class I and Class II recession-type
defects using a tunneling flap procedure in conjunc-
tion with either a connective tissue graft or a porcine
collagen matrix. The authors reported promising
findings in particular for the combination of the
tunnel technique with the autologous graft, which
performed significantly better compared with the
xenogeneic alternative: at 12 months, complete root
coverage was found at 85% of sites treated with the
connective tissue graft compared with 42% treated
with the collagen matrix. The corresponding values
for mean root coverage were 90% and 71%, respec-
tively. In an earlier study, the same group of authors
had already proved that the tunnel technique plus
connective tissue graft might represent a viable
approach also for the treatment of multiple Miller
Class III recession-type defects (5). Thus, in this speci-
fic indication, mean root coverage of 83% was
obtained after 1 year. At the same time, however, the
aspect of interproximal attachment loss seemed not
to allow for predictable outcomes in terms of com-
plete root coverage as this was only achieved in 38%
of the treated sites. Moreover, it was also shown that
the additional use of enamel matrix derivative did not
enhance the clinical outcome of the tunnel technique
with connective tissue graft alone.
In another comparative study, Tozum et al. (81)
tested two different connective tissue grafting tech-
niques in the treatment of Miller Class I and Class II
gingival recessions. When a tunneling flap prepara-
tion technique was compared with the traditional
approach of a coronally advanced flap, both com-
bined with a connective tissue graft, the documented
mean root coverage after 6 months amounted to
96.4% and 75.5%, respectively. The lack of adequate
allocation concealment weakens the meaningfulness
of this study, but the execution of vertical releasing
incisions using the traditional Langer & Langer tech-
nique may, at least to some extent, account for the
significant difference in the outcomes of both groups.
Exactly the same argument may also explain, in part,
the outcomes of a study recently published by Zuhr
et al. (100). In this investigation, the tunnel technique
was again compared with the traditional coronally
advanced flap design in the treatment of Miller Class
I and Class II gingival recessions. However, while the
tunnel technique was combined with a connective
tissue graft, enamel matrix derivative was used as an
additive to the coronally advanced flap, which added
another variable to the comparison of both proce-
dures in this study. The reported mean root coverage
after 12 months was 98.4% for the tunnel technique
Tunneling flap procedures
compared with 71.8% for the coronally advanced flap,
carried out in the traditional flap design with vertical
releasing incisions.
Referring again to the review by Graziani et al. (39),
which indicates that the coronally advanced flap
seems to benefit from newer variations of the tech-
nique that avoid vertical releasing incisions, the writ-
ten evidence is rather scarce when searching for a
direct comparison between the promising results of
the Zucchelli technique (94) and tunneling flap proce-
dures. However, the very first investigation was
recently carried out by Bherwani et al. (10), who com-
pared (in a randomized controlled clinical trial) Zuc-
chelli’s technique with the tunnel technique plus
connective tissue graft for the treatment of multiple
gingival recession-type defects. The authors included
20 patients and 75 Miller Class I and Class II gingival
recession defects, for scientific evaluation. After
6 months, the reported mean root coverage amounted
to 89.3% at sites treated with the modified coronally
advanced flap compared with 80.0% of root coverage
following treatment with the tunnel technique. This
difference did not reach statistical significance. How-
ever, it is important to mention that this study used a
connective tissue graft only in the tunnel procedure,
and not in the coronally advanced flap procedure,
which essentially limits the possibility for a true com-
parison between both flap designs. The same may be
said for slight differences in flap elevation: in this
study, the modified coronally advanced flap was pre-
pared in a split–full–split-thickness manner, whereas
the tunneling flap was exclusively elevated in split
thickness. Moreover, the authors neither provided any
patient-centered outcomes nor an esthetic evaluation
of the final outcomes, which additionally reduced the
meaningfulness of the investigation.
When comparing, from a methodological point of
view, the modified version of the coronally advanced
flap with the tunneling procedure, the clinical deci-
sion of which technique to choose essentially comes
down to the question of whether or not to incise and
detach the papillary tissues, as this aspect represents
the most fundamental difference in flap design
between these two techniques.
Advantages of not incising and detaching
the papillary tissues
The surgically created papilla is the weakest point in
the stabilization of a coronally advanced flap. Experi-
ence shows that once the papillae are cut, it is diffi-
cult to achieve healing by primary intention in these
133
Zuhr et al.

fragile tissues. Attempts to explain this clinical obser- Disadvantages of not incising and
vation tend to be speculative, but it may be assumed detaching the papillary tissues
to have a multifactorial cause; the following potential
In tunneling flap procedures, the use of specifically
reasons may be suggested for discussion in this
designed, microsurgical instruments is mandatory in
context.
order to allow fast, precise and (as far as possible)
The vascular supply to the papillary tissues can be
considered as the terminal end point of the gingival atraumatic preparation of the tissues. So-called tun-
neling knives feature, at their working tip, a cutting
microvasculature. Some experimental studies on the
edge that faces the periosteum as well as a rounded
structure and organization of the vessels in the peri-
edge that faces the gingiva/mucosa, which helps to
odontal tissues were able to demonstrate that the
minimize the risk of flap perforation (96). Moreover,
capillary loops, which run just beneath the oral
epithelium of the attached and free gingiva and which the introduction of bendable microsurgical blades
marks another significant advance toward improved
derive mainly from supraperiosteal vessels, do not
and facilitated flap elevation (Fig. 4). However,
continue into the interdental col area (33). This speci-
despite these technical innovations, the preparation
fic area is instead exclusively nourished from capillary
of a continuous mucosal tunnel in the buccal soft tis-
vessels ascending from the periodontal ligament and
sues may still be regarded as rather time-consuming
the crestal area of the interdental bone. This finding
and also comparatively technique sensitive. More-
might be, with caution, interpreted as a sign of a
over, clinical experience shows that tunneling flap
rather limited vascular supply to the papillary tissues.
procedures are correlated with higher patient mor-
Another possible cause refers to the clinical difficulty
bidity by means of postoperative swelling and hema-
to achieve complete de-epithelialization of the inter-
toma, as elevation of the flap needs more lateral
proximal aspect, which is necessary to create a favor-
able wound bed for the surgically created papilla of (mesial/distal) extension when compared with other
surgical techniques, such as the coronally advanced
the coronally advanced flap but which, at the same
flap, for instance.
time, should not sacrifice too much tissue volume.
The most relevant clinical limitation is, however,
Moreover, a further cause may simply be the limited
that tunneling flap procedures allow for only a rela-
amount of soft tissue in this area in general, which
tively limited amount of coronal flap advancement
substantially limits the possibilities for mechanical
(Fig. 5A–C). This excludes the tunneling approach
stabilization of the flap and suturing.
from the treatment of deep single gingival recession
During the crucial phase of early wound healing,
defects as the limited mobility of the flap may leave
the mechanical load, as well as the microbiologic
an unfavorably high amount of the graft uncovered,
challenge, is expected to be highest in the interproxi-
which would presumably result in subsequent necro-
mal area and the risk for secondary intention healing
in the papillary tissues is therefore rather high. This sis (100). Clinical experience suggests that single gin-
gival recession defects exceeding 3 mm in depth are
sign of overstressed wound-healing capacity may
unsuitable for a tunneling approach. On the other
cause formation of scar tissue, subsequently leading
hand, however, the modified version of the coronally
to impaired quality outcomes, even in cases where
advanced flap cannot be applied to this kind of defect
complete root coverage was achieved (Fig. 1B). Scar
tissue formed in the tip of the papilla may sometimes because this technique is specifically designed for
multiple adjacent gingival recession defects (93).
disappear all by itself over time; in some other cases,
Thus, in summary it is concluded that in the treat-
gingivoplasty with a diamond bur may be applied to
ment of deep single gingival recession-type defects
overcome the problem. Sometimes, however, the
use of a technique with vertical releasing incisions
occurrence of wound dehiscences and subsequent
cannot yet be avoided.
scar tissue formation in the papillary tissues implies
The aforementioned aspect of reduced flap mobil-
an esthetic failure of the procedure, which can be
ity implies one further limitation of tunneling flap
prevented reliably, if, from the very beginning, the
techniques, at least when applied in gingival reces-
papillae were not cut at all. The pretended benefit of
sion treatment: most clinical scenarios require some
tunneling flap procedures is therefore the unique idea
smaller parts of the connective tissue graft to be left
of an incision-free flap elevation (by avoiding any
kind of visible surface incisions) which promises for a uncovered in order to achieve a harmonious align-
ment of the gingival margin. This, however, limits the
fast and uneventful course of wound healing, pre-
use of dense and coarse connective tissue grafts as
dictably leading to unparalleled quality outcomes.

134

A B
Fig. 5. (A) Facial view of a single gingival recession-type
defect on a right lateral incisor, designated for surgical
root coverage with a tunneling flap procedure. The base-
line recession depth is approximately 3 mm, which
marks the boundary beyond which the tunnel technique
is not recommended for the treatment of single gingival
recession defects. (B) The postoperative view after
they can be harvested from the posterior palate or the
tuberosity area, for instance. This is because some
clinical observations indicate that autologous grafts
of this tissue quality seem to have a higher risk of
graft necrosis and subsequent shrinkage if not ideally
nourished from the wound bed (95); thus, better
results may be achieved by covering these grafts com-
pletely with the flap. It is for this same reason why no
soft-tissue substitutes are recommended in this indi-
cation (6). Experience therefore suggests preferential
selection of the rather loosely organized connective
tissue of grafts from the anterior palate when com-
bined with a tunneling flap procedure for gingival
recession treatment.
Clinical proceeding
The main indication of the tunnel technique is the
treatment of multiple gingival recession defects
(Fig. 6A–N for a step-by-step clinical documentation
of this process). The preparation of a continuous
mucosal tunnel over a longer span of the dentition
eliminates the problem of limited coronal flap
advancement, and retaining the possibility of leaving
some smaller parts of the connective tissue graft (at
deeper defects) uncovered helps to achieve harmo-
nious alignment of the keratinized tissues and the
gingival margin. Moreover, with particular regard to
multiple recession defects in the lower dentition, use
of the tunnel technique appears almost to be without
a good alternative as a result of the superior wound
stability offered by this technique (Fig. 7A–D).
Following adequate local anesthesia and preopera-
tive irrigation with chlorhexidine digluconate solu-
tion, it is recommended that the exposed root
surfaces are polished before surgery. Cleansing the
recessed roots is mandatory in order to achieve
a biocompatible surface for successful soft-tissue
Tunneling flap procedures
C
suturing reveals the extent to which the connective tis-
sue graft was left uncovered in the present case. Any
deeper baseline defect would probably have resulted in
an unfavorably high amount of connective tissue left
uncovered, substantially decreasing the chance of graft
survival. (C) Final outcome of the case, 5 months after
the surgery.
attachment (62). The use of a rubber cup, together
with low-abrasive pumice powder, for instance, has
proven effective in this regard (Fig. 6C) (68). The last
preparatory step before surgery is to splint the con-
tact points of the affected teeth temporarily with the
use of a flowable, light-curing resin. This measure is
necessary to create a coronal anchor for subsequent
wound closure with double-crossed sutures (101). As
a result of undercuts in the interproximal areas, no
additional etching or bonding is required; hence, only
flowable composite is applied and light cured to a dry
surface (Fig. 6D).
Flap preparation starts with intrasulcular incisions
around the necks of the affected teeth. The use of a
microsurgical blade with a rounded tip and sharp on
both sides (beaver tail) is strongly recommended as
this type of blade provides easy access to the buccal
bone crest while minimizing the risk of nicking the
gingival margin (Fig. 6E). The purpose of intrasulcular
incising is to include the full thickness of the marginal
soft tissues into the flap but, at the same time, to pre-
serve the supracrestal connective tissue attachment
on the exposed root surface. Reaching the buccal
bone crest with intrasulcular cuts, flap elevation is
then continued by full-thickness preparation for the
next 3–4 mm (Fig. 6G). Finally, a sharp horizontal dis-
section of the periosteum has to be performed, and
subsequent split-thickness preparation of the tissues
is extended well into the mucosa (Fig. 6I). In sum-
mary, the described procedure leads to a split–full–
split–thickness design of the flap. This flap design is
adopted from the technique described by Zucchelli &
De Sanctis (93) and attempts to combine the advan-
tage of greater flap thickness in the coronal parts with
the best possible flap mobilization in the apical
aspects. Adjacent papillary tissues are carefully
detached also using a split-thickness preparation
(Fig. 6F). It is not recommended to elevate the flap
135
Zuhr et al.
A B
D E
G H
J K
M N
Fig. 6. (A) Preoperative clinical presentation of a patient
designated for surgical root coverage in the upper anterior
dentition. Before surgery, the patient was restored with
long-term provisionals. (B) A more detailed view reveals
mild-to-moderate gingival recession-type defects with
some interproximal attachment loss. (C) Following local
anesthesia, the recessed roots are cleaned and polished
with a rubber cup and pumice powder. (D) A flowable,
light-curing resin is used to splint the contact points of the
affected teeth temporarily, which is necessary to provide a
coronal anchor for wound closure with double-crossed
sutures. (E) Using a microsurgical blade, flap preparation
starts with intrasulcular incisions around the necks of the
affected teeth. (F) Adjacent papillary tissues are carefully
detached also using a split-thickness preparation. (G)
136
C
F
I
L
Reaching the buccal bone crest, flap elevation is then con-
tinued by a full-thickness preparation for the next 3–
4 mm. Switching back to a bendable microsurgical blade,
the periosteum is dissected with a sharp horizontal cut (H)
and flap preparation is finalized by splitting the tissues
well beyond the mucogingival junction (I). (J) An autolo-
gous connective tissue graft harvested from the patient’s
palate is inserted into the tunnel. Accessory positioning
sutures help to place it in the desired position. (K) Double-
crossed sutures are placed in each interproximal space in
order to stabilize the entire buccal soft-tissue complex in
the surgically established position. (L) Immediate postop-
erative facial view. (M) One week postoperatively. (N) Clin-
ical presentation of the site after 6 months of healing with
the long-term provisionals still in place.

A B
C D
Fig. 7. (A) Preoperative view of a clinical case with severe
multiple gingival recession-type defects in both the upper
and lower dentition. Note that some of the lesions repre-
sent combined defects involving soft-tissue defects as well
as wedge-shaped hard-tissue defects. (B) Detailed view of
the lower anterior dentition. (C) Immediate postoperative
up into the tips of the papillae, as this poses a high
risk of papillary height loss after the surgery. Prepara-
tion of the papillae just in their apical aspects, on the
other hand, provides sufficient mobility for the
desired coronal advancement of the buccal tissues.
The use of magnifying aids/illumination and specifi-
cally designed instruments is mandatory. Full-thick-
ness preparation in the area of the buccal bone crest
is best carried out using a microsurgical papilla eleva-
tor; recently developed, bendable microsurgical
blades have proven worth for supraperiosteal dissec-
tion beyond the mucogingival junction. Special care
must be taken to ensure the preparation of a mucosal
tunnel that is continuous through the whole aspect of
the recessed area, which is indispensable to allow
smooth insertion of the connective tissue graft.
It is suggested to harvest an autogenous subepithe-
lial connective tissue graft from the lateral palate. The
thickness of the graft should not substantially exceed
1 mm. In a recent clinical study on healing dynamics
following surgical root coverage with connective tis-
sue grafting, Rebele et al. (70) demonstrated that
increased gingival thickness is associated with better
surgical outcomes in terms of recession reduction and
root coverage. Exceeding a certain tissue thickness,
however, was not found to be worthwhile with regard
to the surgical outcome and did not provide any fur-
ther benefit. This suggests the use of rather reasonably
sized, thinner, grafts which, in addition, also promises
for better patient perception as well as more favorable
Tunneling flap procedures
view of the lower anterior dentition following surgical root
coverage with the tunnel technique and connective tissue
graft. (D) Final outcome. Therapy in the upper jaw con-
sisted of a combined approach in terms of surgical root
coverage together with restorative measures (cervical com-
posite fillings).
esthetic outcomes (70, 92). Accessory positioning
sutures have proved to be an effective way to insert
the connective tissue graft into the tunnel and to place
it in the desired position (Fig. 6J). Double-crossed
sutures are applied to stabilize the entire buccal soft-
tissue complex (graft and covering flap) in the surgi-
cally established position (101). At deeper recession
defects, some smaller parts of the connective tissue
graft can be left uncovered in order to achieve a har-
monious alignment of the gingival margin; secondary
intention healing of the graft will also lead to a certain
broadening of the keratinized tissues in these areas
(47). The postsurgical position of the gingival margin
(or the exposed graft) should be about 1–2 mm above
the cemento–enamel junction (66). Patients are
instructed to avoid any mechanical trauma or tooth-
brushing in the surgical site for 2 weeks. Chlorhexi-
dine rinses are prescribed three times per day for
2 weeks and sutures are removed after 7 days.
Tunneling flap procedures in other
clinical scenarios: further
indications
Minor reconstructions of the soft tissues
A number of different clinical conditions may indicate
soft-tissue augmentation in terms of surgical thicken-
ing of thin buccal gingiva or thin buccal peri-implant
137
Zuhr et al.
mucosa. The common purpose of these interventions
is to increase the horizontal volume of the soft tis-
sues. This serves to reduce the translucency of the
affected gingiva or peri-implant mucosa and thus
helps to conceal discolored roots of endodontically
treated teeth or dark implant components. Moreover,
gingival augmentation is also used to stabilize the
soft-tissue architecture in order to protect against the
risk of gingival recession. In this way, gingival aug-
mentation may serve as a preventive measure before
orthodontic or restorative treatment. Tunneling flap
procedures may be applied in all of the following sce-
narios, thereby providing the previously mentioned
benefits of accelerated blood supply and uneventful
wound healing. The clinical proceeding is analogous
to the approach used in treatment of gingival reces-
sion, with the sole exception that no significant coro-
nal advancement is carried out with the elevated
tissues.
Gingival/mucosal augmentation to reduce
translucency
Jung et al. (45) evaluated, in vitro, color changes in
the soft tissues caused by restorative materials
placed below the surface of experimental sites with
different mucosal thickness. The spectrophotometric
experiments revealed that all of the tested materials
resulted in a certain color change, the intensity of
which decreased with increasing soft-tissue thick-
ness. Color changes induced by zirconia became
invisible for the human eye once the mucosal thick-
ness reached more than 2 mm; the corresponding
value for titanium was 3 mm. The findings of this
study come into clinical relevance around endodon-
tically treated teeth or at implants with thin soft tis-
sues at the buccal aspect, when discolored roots or
dark abutments show through the gingiva or
mucosa, respectively. The resulting greyness of the
soft tissues may compromise the esthetic outcome
of prosthetic treatment. In such cases, gingival or
mucosal augmentation can be applied to make the
marginal soft-tissues thicker and less transparent.
The purpose of an intervention like this is self-evi-
dently not to establish a marginal soft-tissue thick-
ness of considerably more than 2 mm, as this would
make the affected gingiva or mucosa appear hyper-
trophic and unesthetic (70, 92). However, clinical
experience shows that a combination of restorative
measures (internal bleaching of endodontically trea-
ted teeth or the fabrication of a new abutment in
contemporary ceramics), together with surgical aug-
mentation, is likely to produce favorable esthetic
outcomes in most cases.
138
Gingival augmentation to prevent gingival recession
following prosthetic treatment
Some situations of prosthetic treatment in the
esthetic zone require the subgingival placement of
restorative margins. Owing to the technologies and
materials offered by modern restorative dentistry, this
is particularly true for situations in which the color of
the tooth structures is significantly different from the
color of the restoration. The subgingival placement of
restorative margins, however, denotes a biologic
compromise. Following the mechanical trauma of
preparation (28), intrasulcular restorative margins
generally result in increased plaque accumulation
and an inflammatory response in the surrounding
soft tissues, which can ultimately lead to the loss of
periodontal attachment and the occurrence of gingi-
val recession (64). As a matter of fact, a large percent-
age of restorative margins originally placed in a
subgingival position shift to a supragingival location
over time (83), thus potentially impairing the esthetic
outcome of the treatment.
Current scientific evidence suggests that a narrow
zone of keratinized gingiva does not increase the risk
of gingival recession, but a low marginal soft-tissue
thickness does seem to do so (29, 86). As a conse-
quence, the occurrence of gingival recession has to be
expected over time if restorative margins are placed
in a subgingival position in particular at sites of thin
tissue biotypes. To avoid this type of esthetic failure,
as well as the associated loss of periodontal attach-
ment, prophylactic gingival augmentation can be
applied in order to stabilize the soft-tissue architec-
ture and prevent gingival recession in such cases.
Gingival augmentation to prevent gingival recession
following orthodontic treatment
Labial gingival recession secondary to orthodontic
treatment is a frequent finding (34, 85), merely
because orthodontic movement might cause bone
dehiscence or worsen dehiscence of bone at sites
where this is already present. Successive development
of gingival recession can be the result. The risk for gin-
gival recession is particularly high in patients with
thin tissue biotypes. Studies demonstrated that labial
orthodontic movement always leads to a certain
stretching and thinning of the buccal gingiva (76, 85).
This appearance seems to represent a locus minoris
resistentiae to external stresses such as microbial pla-
que or toothbrushing trauma, which can subse-
quently lead to the loss of periodontal attachment
and the occurrence of gingival recession. Clinical
experience therefore suggests that careful periodontal

A B
C D
Fig. 8. (A) Preoperative view of a lower anterior dentition
in a patient designated for orthodontic correction.
The treatment plan proposes surgical thickening of the
buccal gingiva before orthodontic treatment in order to
prevent further progression of the gingival recession
defects. (B) Clinical photograph showing the postoperative
assessment should be performed before orthodontic
treatment with labial tooth movements. As long as the
proposed movements are restricted to the confines of
the alveolar ridge, the risk of gingival recession will be
low, irrespective of the dimensions of the surrounding
soft tissues. However, if the orthodontic movement is
likely to result in buccal displacement of a tooth out-
side the bony housing of the alveolar ridge, the vol-
ume of the buccal gingiva will determine the risk of
gingival recession. In situations with thin tissue bio-
types, surgical augmentation of the soft tissues should
be considered before orthodontic treatment because
labial tooth movement will further decrease the thick-
ness of the soft tissues at these sites (Fig. 8A–D).
Minor-to-moderate reconstructions of
the soft tissues
Alveolar ridge preservation/socket preservation
Healing after tooth extraction is accompanied by sub-
stantial resorption of the alveolar ridge. Such changes
are of particular relevance in the esthetic zone
because they make the replacement of teeth and the
reconstruction of dento–facial harmony a challenging
task for the practicing clinician. In a clinical study,
Schropp et al. (74) evaluated human extraction sock-
ets in the posterior segments of maxillary and
mandibular dentitions. These authors demonstrated
that healing resulted in a reduction of approximately
Tunneling flap procedures
situation immediately after gingival augmentation with a
subepithelial connective tissue graft used in a tunneling
approach. (C) Situation 1 week after the grafting interven-
tion. (D) The follow-up at 5 months reveals a successful
increase in buccal soft-tissue thickness.
50% in buccolingual bone width after 1 year. More-
over, it was found that two-thirds of this bone loss
occurred on the buccal aspect. To explain these find-
ings, Araujo & Lindhe (4) histologically investigated
bone resorption following tooth removal in an experi-
mental animal study. They reported that the coronal
part of the buccal bone plate was often comprised
solely of bundle bone. Lining the inner surface of the
socket, bundle bone is the part of the alveolar process
into which the fibers of the periodontal ligament
insert. The authors observed complete resorption of
the bundle bone during the early stages of socket
healing and believed the loss of its (tooth-dependent)
function to be responsible for this finding. The
resorption of the bundle bone was considered to
account for substantial vertical as well as horizontal
reduction of the buccal bone crest, which subse-
quently leads to the collapse of the buccal soft tissues,
thereby causing remarkable alterations of the alveolar
ridge. Later, Fickl et al. (32) further substantiated this
explanatory approach in another experimental trial in
dogs, in which three-dimensional digital scans were
used to evaluate volumetric changes between pre-
and postextractive situations. The authors reported
significant tissue decline for both the horizontal and
the vertical dimensions, which was much more pro-
nounced on the buccal surface compared with the
lingual surface. It is expected that similar events
explain the healing of the human extraction socket,
139
Zuhr et al.
where the formation of this tissue defect in the
esthetic zone can cause cosmetic concerns. Therefore,
if no preventive measures are taken at the time of
tooth extraction, augmentation surgery will be needed
to correct resorption-related defects afterwards.
Various techniques, or combinations of different
techniques, for alveolar ridge preservation (frequently
also referred to as socket-preservation techniques)
have been described in the literature. The vast major-
ity of these techniques are focusing on bone-grafting
measures in terms of guided bone regeneration or
socket-filling procedures. However, many experts and
clinicians also endorse the concept of soft-tissue aug-
mentation in addition to bone grafting. The use of a
connective tissue graft on the buccal side of the
extraction socket stabilizes the marginal soft tissues
and intends to compensate for some of the tissue
decline that follows tooth extraction. Even though the
results of some animal experiments seem to question
the efficacy of soft-tissue grafting as a means of alveo-
lar ridge preservation (31), the findings from clinical
studies, as well as experience from clinical practice,
are rather promising (46, 73, 90). For this reason,
currently many concepts developed for single-stage
(immediate) tooth replacement in the esthetic zone
include the use of soft-tissue grafts in addition to
bone-grafting measures.
Tunneling flap procedures are especially well suited
for this purpose of soft-tissue augmentation in terms
of alveolar ridge preservation (98). In this regard, the
tunnel technique can be applied in the same way
both with immediate implants as well as with fixed
partial denture (pontic) restorations. Following tooth
extraction, the orifice of the extraction socket offers
facilitated access for preparation of the mucosal
tunnel in the buccal soft tissues; moreover, it simpli-
fies the preparation of the papillae adjacent to the
extracted tooth and thus also allows for a certain
degree of augmentation in these areas. The connec-
tive tissue graft, which is preferably placed before the
insertion of the provisional, not only augments the
buccal marginal soft tissues but, at the same time,
also seals the socket and thus promotes ideal healing
of the site (Fig. 9A–G).
Pontic site development
As stated above, tooth extraction is followed by sub-
stantial resorptive processes of the alveolar ridge,
which result in the need for surgical reconstruction
when teeth in the esthetic zone are to be replaced at
edentulous ridge areas in situations where the tooth
or the teeth to be replaced are missing or have
already been extracted. The same is true for
140
edentulous sites at congenitally missing teeth, as age-
nesis also causes deficiencies of the alveolar ridge.
From an esthetic point of view, the ultimate goal of
reconstruction is to achieve an outcome that blends
in so well that it appears to be virtually indistinguish-
able from the surrounding teeth and soft-tissue archi-
tecture.
The treatment alternatives available for defect
reconstruction depend on whether an implant or a
fixed partial denture is planned to replace the missing
tooth or teeth. While implants usually require hard-
tissue augmentation to allow complete osseointegra-
tion of the fixture, soft-tissue augmentation alone
may suffice to achieve successful outcomes with fixed
partial dentures. Fixed partial dentures, either in con-
ventional or in adhesive techniques, in conjunction
with surgical alveolar ridge augmentation (pontic site
development) can produce excellent esthetic out-
comes at comparatively low cost and effort.
In a clinical study, Studer et al. (77) used different
connective tissue grafting techniques to treat single-
tooth ridge defects. These authors were able to
demonstrate successful augmentation of the soft tis-
sues by evaluating volumetric tissue alterations using
an optical projection Moire  method. Admittedly,
during the first 3–4 months of healing, substantial
loss of the augmented volume occurred, which was
evident for both onlay (full-thickness) grafts as well
as inlay (interpositional connective tissue) grafts.
Although scientific studies on the long-term stability
of alveolar ridges augmented with autologous con-
nective tissue are still lacking, clinical experience
suggests that only minimal further volume changes
occur after a 4- to 6-month period. Therefore, the
great advantage of soft-tissue augmentation alone
appears to be a comparably shorter process of tissue
remodeling or, conversely, greater long-term stability
when compared with reconstructive surgery involv-
ing hard-tissue augmentation in addition.
A modification of tunneling flap procedures – the
modified pouch technique – has proven to be an ele-
gant treatment modality for pontic site development
(99). The technique allows for surgical reconstruction
of the alveolar ridge with definitive tissue sculpting
around the provisional pontic in a single intervention
(Fig. 10A–L). In doing so, the modified pouch tech-
nique combines the advantage of a tunneling flap
preparation with the benefit of a substantially simpli-
fied and shortened surgical procedure when com-
pared with conventional ways of alveolar ridge
augmentation, such as the inlay grafting technique,
for instance. However, clinical experience has shown
that the modified pouch does not provide sufficient

flap mobility for the augmentation of large horizontal
defects. Therefore, the treatment of more extensive
tissue defects requires a further modification of the
technique, which involves the additional preparation
of an island flap on the palatal side, as will be
explained below.
Implant second-stage surgery
Defect reconstruction in the case of implant-assisted
prosthetic rehabilitations in the esthetic zone
requires, most of the time, augmentation of the bone
in order to re-establish a hard-tissue architecture that
allows complete osseointegration of the implant. The
defect situation at the edentulous site is then reas-
sessed at implant second-stage/implant uncovering
surgery. If a deficit in the buccal tissue volume is no
longer present at that time, a minimally invasive
mucosal punch procedure can be used to expose the
implant. In the case of moderate tissue deficits, on
A B
D E
Fig. 9. (A) Preoperative facial view of an upper-right cen-
tral incisor affected by an untreatable endodontic pathol-
ogy. (B) As a result of the young age of the patient, the
treatment plan involves the placement of a resin-bonded
long-term provisional bridge, as well as hard- and soft-
tissue augmentation for alveolar ridge preservation. (C)
Occlusal view of the extraction socket. (D) Immediate post-
operative view. Before the insertion of the provisional
Tunneling flap procedures
the other hand, a modified roll flap technique can be
used in order to augment the buccal soft tissues at
second-stage implant surgery (40).
The modified roll flap technique represents a fur-
ther modification of tunneling flap procedures and
basically uses the soft tissues above the implant to
augment tissue deficits at the buccal aspect. The pro-
cedure starts with de-epithelialization in the area
above the implant. Following creation of a u-shaped
horizontal incision, a buccal pedicle flap is elevated,
exposing the implant. Subsequently, the buccal tis-
sues, as well as the remaining interproximal tissues,
are mobilized in terms of an undermining split–
full–split-thickness flap preparation. In doing so, flap
preparation is nearly comparable with the approach
used to treat gingival recession. In the last step, the
pedicle flap is rolled into the buccal pouch and the
soft tissues are stabilized with sutures, as required
(Fig. 11A–F).
C
F
bridge, a tunneling flap procedure was carried out for aug-
mentation of the buccal soft tissues with an autologous
connective tissue graft, and xenogeneic particulate bone
graft (deproteinized bovine bone mineral) was used to fill
the socket. (E) Clinical situation 1 week after the proce-
dure, before suture removal. Facial (F), as well as occlusal
(G) views of the site showing the provisional bridge still in
place 2 years after extraction of the tooth.
141
Zuhr et al.
A B
D E
G H
J K
Fig. 10. (A) Initial clinical presentation of a patient with
congenitally missing lateral maxillary incisors designated
for surgical alveolar ridge augmentation. Detailed facial
(B) and occlusal (C) views of the patient’s left edentulous
site. (D) Alveolar ridge augmentation will be carried out
using the modified pouch technique. The first step of the
procedure is to de-epithelialize an area, which corresponds
in position and size to the emergence profile of the pontic.
(E) The next step is to perform a tunnel preparation in
the soft tissues buccal to the defect region using a split-
thickness flap preparation. The preparation of the pouch
extends in a lateral direction to the adjacent teeth and in
an apical direction beyond the mucogingival junction in
order to ensure sufficient flap mobility. Flap preparation
In the presence of more extensive defects, the roll
flap technique may not provide sufficient volume to
compensate for the tissue deficit at the buccal aspect
and therefore further soft-tissue augmentation may
be necessary. In these cases, a conventional mucosal
142
C
F
I
L
also includes elevation of the interproximal tissues lateral
to the edentulous site. (F) Depending on the size of the
individual defect, a comparatively large connective tissue
graft may be needed. In these cases, it is recommended to
place a vertical releasing incision in the alveolar mucosa
apical and distant to the defect. (G) The graft can then be
easily drawn into the pouch with the aid of positioning
sutures. (H) The provisional fixed partial denture is
bonded with the pontic imbedded into the soft-tissue
opening. Double-crossed sutures are used for the fixation
of the buccal soft-tissue complex, including the connective
tissue graft. Facial (I) and occlusal (J) views of the site
5 months after the surgery, at the time when the restora-
tive treatment is finalized. (K, L) Final outcome of the case.
punch is excised and a free subepithelial connective
tissue graft is inserted into the buccal tunnel. How-
ever, analogous to the limitation described for pon-
tic site development, conventional preparation of
the buccal pouch does not provide sufficient flap

A B
D E
Fig. 11. (A) Clinical presentation of an edentulous site at
the upper-left central incisor position. Dental implant
placement with guided bone regeneration for reconstruc-
tion of a hard-tissue defect was carried out 5 months ear-
lier. As a result of moderate buccal tissue deficits, the
treatment plan designates a modified roll flap technique
for second-stage surgery. (B) Following de-epithelializa-
tion of an area of the alveolar ridge that corresponds to the
emergence profile of the missing tooth, a u-shaped
mobility to accommodate large, voluminous grafts.
The treatment of extensive tissue deficits therefore
requires further modification of the technique in
terms of the additional preparation of a palatal island
flap, as explained in the following section.
Moderate-to-extensive reconstructions of
the soft tissues
As stated above, additional technical strategies
become necessary when tunneling flap procedures
are used to treat large horizontal defects. This is
because conventional preparation of the buccal tun-
nel does not provide sufficient flap mobility to
accommodate large, voluminous grafts. In greater
detail, the insertion of such grafts exerts a consider-
able buccal-oriented pull on the covering flap. This
tension on the buccal flap ultimately becomes trans-
mitted to the interproximal tissues, which are pulled
down in an apical direction. Subsequent loss of inter-
proximal tissue height can be the result. To avoid this
adverse effect, additional release from the palatal
aspect becomes necessary.
The challenge of displacing palatal masticatory
mucosa, as mentioned earlier, has been addressed by
Tinti & Parma-Benfenati (80) who introduced a
Tunneling flap procedures
C
F
horizontal incision is performed to expose the underlying
implant cover screw. (C) A buccal pedicle flap is elevated
and the buccal, as well as the neighboring, interproximal
tissues are mobilized in terms of a tunneling flap prepara-
tion. (D) The pedicle flap is then rolled into the buccal
pouch. (E) In the last step, a long-term provisional is
inserted and double-crossed sutures are placed for wound
closure. (F) Final outcome of the case following comple-
tion of the restorative treatment.
coronally positioned palatal sliding flap (a palatal
island flap; Fig. 3A–I). The design of the flap basically
consists of two palatal vertical releasing incisions,
which are followed by split-thickness preparations in
different tissue depths that approach each other from
opposing directions. The first, more superficial, split
extends from the alveolar ridge toward the roof of the
palate, thereby creating a superficial partial-thickness
flap – this superficial partial-thickness flap merges,
via the interproximal tissues, with the tunneling flap
on the buccal side. The second split-thickness prepa-
ration stays close to the periosteum and extends for a
few millimetres from the depth of the palate into
coronal direction. This results in slight, but relevant,
lengthening of the superficial flap, allowing a certain
amount of buccal displacement.
The palatal island flap has proven very successful
when used in combination with tunneling flap pro-
cedures for the treatment of large horizontal defects
(99). The combined flap design releases considerable
tension from the interproximal tissues and helps
to achieve passive wound closure without causing
substantial disturbance (coronal displacement) to the
mucogingival junction. In this way, it is possible to
extend further the range of indications for soft-tissue
augmentation using tunneling flap procedures.
143
Zuhr et al.
Application of this technique allows for the treatment
of moderate-to-severe buccal-tissue deficits in virtually
any esthetic situation; for instance, pontic site devel-
opment, implant second-stage surgery, soft-tissue
recession treatment around implants (Fig. 12A–K), as
well as alveolar ridge augmentation in conjunction
with delayed, guided implant placement (Fig. 13A–H).
A B
D E
G H
J K
Fig. 12. (A) Preoperative facial view of an upper anterior
dentition with an implant-supported restoration in the
position of the right central incisor. Recession of the
buccal soft tissues at the implant site lead to a severely
compromised esthetic appearance. (B) The occlusal per-
spective also reveals a severe horizontal component of the
defect. The treatment plan proposes augmentation of the
soft tissues, together with fabrication of a new restoration
on the implant. (C) The surgical procedure starts with a
tunneling flap preparation on the buccal side. On the pala-
tal aspect, a palatal sliding flap (palatal island flap) is
144
Conclusions
The field of plastic periodontal and implant surgery
has undergone, and continues to undergo, tremen-
dous change and innovation. Increased awareness
and demands for soft-tissue esthetics have prompted
enormous scientific and clinical effort in order to
C
F
I
prepared (D), which merges via the interproximal tissues,
with the tunneling flap on the buccal side (E). The palatal
flap releases tension from the interproximal tissues (F)
when the subepithelial connective tissue graft is inserted
into the mucosal tunnel on the buccal side (G). Immediate
postoperative facial (H) and palatal (I) views. Double-
crossed sutures are placed with the long-term provisional
in place. Occlusal (J) and facial (K) views showing the con-
clusive stages of the treatment, when a new abutment and
a cemented crown serve as the final restoration on the
implant.

A B
D E
G H
Fig. 13. (A) Initial clinical presentation of a patient with
congenitally missing lateral maxillary incisors. Preopera-
tive diagnostic cone-beam computed tomography imaging
revealed sufficient bone volume to allow installation of
dental implants without augmentation of the hard tissues.
(B) The treatment plan therefore comprises guided, three-
dimensional navigated implant placement in conjunction
with alveolar ridge augmentation of the soft tissues to cor-
rect for the horizontal defects at both sites. Clinical
improve existing treatment strategies, seeking for sur-
gical concepts that provide predictable clinical out-
comes with respect to quantity as well as quality. This
trend of innovation is reflected in the increasing pop-
ularity of tunneling flap procedures in the past
decade.
The tunnel technique was originally described
for the treatment of gingival recession-type defects
and it is still predominantly perceived in this particu-
lar indication. Application of the technique demands
advanced surgical training, and the use of specifically
designed microsurgical instruments is strongly rec-
ommended. However, the design of the flap provides
some distinct clinical advantages: flap elevation with-
out detachment of the papillary tissues and without
vertical releasing incisions promises for accelerated
blood supply and uneventful wound healing. More-
over, avoiding any kind of visible incisions on the
Tunneling flap procedures
C
F
photographs illustrating the surgical proceedings in terms
of implant bed preparation (C) and flap elevation (D). At
both left and right sides, a tunneling flap preparation was
combined with a palatal sliding flap. Following installation
of the implants (E), autologous connective tissue grafts
were inserted into the buccal soft tissues at both aspects
(F). (G) Immediate postoperative view. (H) Facial view
showing the final outcome of the case after completion of
the prosthetic treatment.
tissue surface allows for improved esthetic outcomes
owing to a minimized risk of postoperative scar tissue
formation. A first set of clinical studies was able to
confirm the excellent clinical performance of tunnel-
ing flap procedures in the treatment of gingival reces-
sion-type defects, in particular in multiple defect
cases. Nonetheless, long-term data are still missing
and further controlled clinical trials are necessary to
substantiate the promising findings obtained in the
short term.
In the more recent past, tunneling flap procedures
experienced an important development toward a truly
multifunctional approach for soft-tissue augmenta-
tion in the esthetic zone. Anticipating the above-men-
tioned benefits of incision-free flap elevation, the
technique has been introduced to a considerably
expanded range of indications. Written evidence from
controlled clinical trials or comparative studies is
145
Zuhr et al.
lacking, but clinical experience has shown predictable
clinical outcomes and excellent esthetic results. Atrau-
matic management of the tissues, respect for blood
supply, as well as prevention of tension or pressure to
the wound area represent key characteristics of a con-
sistent microsurgical concept that allows for improved
and accelerated wound healing in virtually any clinical
situation in which soft-tissue augmentation is indi-
cated in the esthetic zone. In this way, tunneling flap
procedures developed from a technique that was orig-
inally intended merely for surgical root coverage into
a comprehensive surgical conception in plastic peri-
odontal and implant surgery.
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Periodontology 2000, Vol. 77, 2018, 150–164
Printed in Singapore. All rights reserved
Esthetic evaluation and
patient-centered outcomes in
single-tooth implant
rehabilitation in the esthetic area
MARTINA STEFANINI, PIETRO FELICE, CLAUDIO MAZZOTTI, ILHAM MOUNSSIF,
MATTEO MARZADORI & GIOVANNI ZUCCHELLI
Dental implant treatment is considered a safe and
suitable option for the replacement of single missing
teeth in the esthetic area. Survival rate of implant reha-
bilitation is well documented, while there is a lack of
consensus regarding the criteria that define ‘success’.
The most widely used criteria (2, 102, 107) take into
consideration only clinical aspects, such as implant
stability, absence of pain or inflammation, marginal
bone loss and absence of peri-implant radiolucency
(6). Recently, during the VIII European Workshop on
Periodontology (114), a new definition of implant suc-
cess criteria was proposed, according to which implant
success should be determined by using composite out-
come measures, including patient-reported outcome
measures, peri-implant tissue health and functional
and esthetic outcomes related to implant-supported
reconstruction.
Esthetic outcomes can be evaluated objectively and
subjectively. Subjective evaluation can be carried out
by using the patients’ perception of the esthetic out-
come that may be measured using specific question-
naires in which patients can express their satisfaction
or dissatisfaction (45). Objective evaluation can be
performed by a professional examiner and is based
on defined criteria aiming at an overall evaluation of
the harmonic appearance and the natural integration
of the artificial restoration with the patient dentition
(71). Both evaluations should be taken into consider-
ation in order to provide a complete overview of the
final esthetic outcome. This paper focuses on the cur-
rent use of objective methods for esthetic assessment,
as well as patient-centered/reported outcomes in sin-
gle-tooth implant rehabilitation in the esthetic area.
150
© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
PERIODONTOLOGY 2000
The relationship between patients’ subjective and
professionals’ objective esthetic evaluations is also
reviewed.
Objective assessment of esthetics
The literature describes many objective methods,
scores and indexes for the assessment of esthetic out-
comes. These methods are useful to evaluate improve-
ments in patient appearance after implant therapy.
They can also be used in the training and education
of students or technicians in order to provide stan-
dard, objective esthetic parameters (71). Finally, they
are vital as research instruments to allow comparison
of outcomes between studies (117).
The peri-implant esthetic result is influenced by
the esthetic appearance of the mucosa as well as
by the esthetics of the prosthetic reconstruction. Ide-
ally, the peri-implant soft tissues should be in har-
mony with the surrounding mucosa of the adjacent
teeth, and the implant crown should be well inte-
grated with the natural dentition (64, 81). Several
indexes have been proposed to assess peri-implant
esthetic outcome in an objective manner. Initial
indexes considered only mucosal esthetic characteris-
tics (e.g. interdental papilla height and mid-buccal
mucosal margin level) (36, 42, 59, 84, 100, 112). How-
ever, in addition to the mucosal appearance, the
supra-structure should also be evaluated taking into
account parameters related to the quality of the pros-
thetic restoration (e.g. marginal integrity, contour,
color and anatomic shape) (16, 25, 27, 49, 86, 108).

Recently, to provide an overall evaluation of the final
esthetic outcome, new indexes have been proposed
for assessment of both the mucosa and the recon-
struction (9, 13, 19, 33, 65, 76, 81, 97, 120). Table 1
shows the most recent and commonly applied
esthetic indexes for both the mucosa and the recon-
struction. An example of an implant-supported
reconstruction with an excellent esthetic result for
both soft tissues and the reconstruction is shown in
Fig. 1.
Parameters and methods for
assessment of esthetics
Esthetic indexes primarily include dimensional (met-
ric and volumetric) and optical characteristic fea-
tures. The majority of parameters are assessed by
comparison with the healthy, contralateral site in the
anterior region or adjacent sites in the posterior
region (11, 71).
Metric and volumetric assessment of soft
tissues
The parameter most frequently used for the esthetic
assessment of peri-implant mucosa is the vertical
levels of the buccal mucosal margin and of the inter-
proximal papillae (11). In order to assess any changes
of tissue dimension accurately over time, the use of a
stable and reproducible reference point is of highest
importance. The two principal ways of assessing
mucosal level are either direct clinical assessment
using a calibrated probe or indirect analysis of pho-
tographs/casts representing the clinical situation. For
the direct clinical assessment, in order to obtain
accurate and reproducible measurements, tooth-
supported stents are recommended to guide instru-
ments in the clinical evaluation (17, 29).
Increasingly, digital photographs are being used for
the assessment of changes in soft-tissue dimensions
over time (31, 60). However, as photographs are
prone to distortion because of differences in angula-
tions, methods of standardizing photographic mea-
surements are required. Such methods include the
use of a calibrated and reproducible exposure posi-
tion or dedicated software that allows standard
measurements to be made. To standardize images,
Weinlander et al. (121), in 2009, introduced a method,
termed ‘gingivomorphometry’, for esthetic evaluation
of the peri-implant mucogingival complex; this
method involves the collection of standardized oral
Esthetics in implant rehabilitation
photographs and computer-assisted measurements
of reproducible data. They concluded that gingivo-
morphometry can be considered an accurate and
reproducible method for the evaluation and mea-
surement of different dentogingival parameters. The
advantages of this noninvasive method include relia-
bility, objectiveness and standardization of the neces-
sary parameters, particularly for evaluation of the
dentogingival complex in the esthetic region of the
anterior maxilla.
The three-dimensional assessments for the buccal
soft-tissue volume can be performed either directly
using an intra-oral scanner or indirectly by scanning
study casts obtained from a conventional impres-
sion. Dedicated software is able to compare volu-
metric changes between two measurements made at
different time points. Three-dimensional systems rep-
resent the future of soft-tissue volume change mea-
surements, with encouraging results being obtained
from a number of studies; however, a recent narrative
review (10) stated that there is limited knowledge
on the reliability of three-dimensional imaging tech-
nology for the assessment of peri-implant soft-tissue
esthetics.
Color assessment
Peri-implant mucosa or prosthetic reconstruction
color evaluation can be performed either subjectively
by the unaided eye (9, 42) or objectively by using spec-
trophotometry (44, 89, 98). When compared with the
ability of the human eye to assess colors in a clinical
setting, spectrophotometry is more accurate and
reproducible (44, 63) but is also more time consuming
and technically complex. For this reason, spectropho-
tometery is rarely used in clinical studies. Indepen-
dently from the adopted method, Benic et al. (10)
suggested, in a recent narrative review, that ideally
three measurements should be included when assess-
ing color changes in a clinical setting: (i) color match
between the test and the control sites before the inter-
vention; (ii) color match between the test and the con-
trol sites after the intervention; and (iii) color change
at the test site before and after the intervention.
Assessment time points
As with other clinical parameters, there is a need to
standardize the time points of assessments. A major
concern is the evaluation of esthetics at the final
point of the implant-supported treatment rather than
at the first patient visit. Lang & Zitzmann (71) sug-
gested that the baseline documentation to assess the
151
152
Table 1. Parameters and scores of indexes for the esthetic evaluation of both the mucosa and the reconstruction

Pink and white esthetic score Implant Crown Aesthetic Peri-implant and Crown Complex Esthetic Index (65) Copenhagen Index
Stefanini et al.

(9) Index (81) Index (113) Score (33)

Parameters of the peri- Mesial papilla, distal papilla, Labial margin, papillae, Papillae, zenith, root Soft-tissue contour variations, Mucosal discoloration,
implant mucosa facial curvature, level of contour of the labial surface, convexity vertical deficiency, Color and papilla level mesially
(pink esthetic) facial mucosa, root convexity color and surface texture variations, and distally
and color appearance of mesial and
distal papillae
Parameters of the Tooth form, outline/volume, Mesiodistal dimension, Shape color, characterization Color and translucency, labial Crown morphology,
implant crown (white color (hue/value), surface position of the incisal edge, convexity in abutment/ crown color match,
esthetic) texture, translucency and labial convexity, color/ implant junction, implant/ symmetry/harmony
characterization translucency, surface crown incisal edge position,
crown width/length ratio,
surface roughness and ridges
Parameters of the None None None Mesial and distal None
predictive index interproximal bone height,
gingival tissue biotype,
implant apicocoronal
position, horizontal contour
deficiency
Subjective overall None None Crown, mucosa overall None None
criteria (crown and mucosa)

Reference tooth Contralateral tooth Contralateral and adjacent Contralateral tooth Adjacent and contralateral Adjacent teeth
tooth teeth
Scores per parameters 2 (No deviation) 0 (No deviation) 100 mm visual analogue scale Specific parameters were 4: unacceptable
1 (Small deviation) 1 (Small deviation) evaluated and graded as 3: suboptimal and
0 (Large deviation) 5 (Large deviation) adequate (rating 20%), below the delivery
compromised (rating 10%) standard
or deficient (rating 0%) 2: almost optimal
1: optimal
Overall score 0–20 0–45 0–600 0–100 6 (optimal)
24 (unacceptable)
Threshold of clinical ≥ 12 <5 ≥ 360 > 60% Not established
acceptability

A B
Fig. 1. Esthetic outcome assessment. (A) Baseline clinical
situation and (B) radiograph showing tooth #21 with a
hopeless prognosis because of a fracture. (C) Clinical situa-
tion and (D) radiograph showing the result 2 years
influence of the therapy under investigation ideally
needs to be obtained before any intervention is
made. Furthermore, follow-up evaluations are recom-
mended, in order to evaluate the stability of the
esthetic result.
Reproducibility and validity
To increase the reproducibility of repeated esthetic
measurements, it is recommended that the evalua-
tion be carried out by calibrated and blinded examin-
ers (31, 43, 91, 122). Nevertheless, only a few studies
report whether or how evaluators were calibrated.
Barwacz et al. (7) proposed a novel, tablet-based
method to calibrate assessors for the esthetic evalua-
tion in a multicenter clinical trial. The authors high-
lighted that providing a standard calibration tutorial
with simulated subject cases, with which to familiar-
ize esthetic index evaluators, was critical for acquiring
repeatable measures. Most of the proposed index sys-
tems have been examined for their reproducibility (9,
19, 42, 44, 45, 53, 59, 65, 81, 113), but the validity of
these has seldom been evaluated. Furthermore, a
variation of inter- and intraobserver agreement is
reported to be dependent on the specialization of the
investigator. The demographic background of the
examiners, such as their gender, age and practice
experience, may also play a role in their assessment
(45, 81, 113). It is interesting to note that only a few
studies recruited periodontists as esthetics examin-
ers (1, 21, 110, 117) and they were seen to provide
more favorable ratings than examiners from other
specialties, such as prosthodontists.
Current use of scores/indexes
In spite of the frequent use of various scores and
indexes for the esthetic evaluation of implant-sup-
ported reconstructions in the anterior region, there is
Esthetics in implant rehabilitation
C D
following implant-based reconstruction. The final appear-
ance showed excellent integration of the reconstruction
with the natural dentition and excellent peri-implant soft-
tissue blending. Courtesy: Dr. Cantoni.
no universally accepted or recommended system
available in the literature. A recent systematic review
(6) stated that the most frequently used index is the
papilla index of Jemt (59). This index is the first
attempt to evaluate esthetics scientifically and objec-
tively; however, only the interproximal soft-tissue
level and the soft-tissue contour are taken into con-
sideration. For this reason, the papilla index is often
combined with other indexes or integrated with fur-
ther measurements. One relatively recent method is
the pink and white esthetic score (9), which seems to
have gained popularity in clinical research publica-
tions (37). The pink and white esthetic score is an
index used to evaluate the appearance both of soft
tissue and of the prosthetic restoration. Den Hartog
et al. (30) evaluated the esthetic outcome of single-
tooth implants in the esthetic zone according to the
pink and white esthetic score and the implant crown
esthetic index and concluded that the most repro-
ducible index seemed to be the pink and white
esthetic score. Tettamanti et al. (113) compared three
different esthetic indexes for the evaluation of a single
implant-supported crown and assessed the validity
and the influence of the examiner’s dental specialty
(compared with the views of laypeople and the
patients themselves). They concluded that in compar-
ison with the implant crown esthetic index, the pink
and white esthetic score and peri-implant and crown
index were more reproducible and were not influ-
enced by different observers (113). They also con-
cluded that the pink and white esthetic score has
been rated the fastest and the easiest to use (113).
Subjective assessment of esthetics:
patient-reported outcome
measures
Patient-reported outcome measures are essentially
‘subjective’ reports of patients’ perceptions of their
153
Stefanini et al.
oral health status and its impact on their daily life
or quality of life (termed oral health-related quality
of life), reports of satisfaction with oral health status
and/or oral health care and other nonclinical
assessments (71, 79, 83). The concept of health care
that aims to integrate the patient’s needs with the
professional’s point of view has been introduced in
medicine in the last two decades and has only
recently been adopted by dentistry. Tooth loss,
according to the World Health Organization’s 2001
criteria, is a physical impairment because it consti-
tutes loss of important parts of the body and is
associated with a series of sequelae, not only physi-
cal (such as difficulty in chewing and speaking) but
also psychological, which affect the quality of life.
Investigations of the psychological impact following
dental implant therapy are, however, still scarce, in
particular regarding the treatment of partially eden-
tulous patients (61). It is now widely accepted that
clinical measures on their own, such as implant and
reconstruction survival and bone and soft-tissue
response, provide limited understanding of what
constitutes ‘oral health’ and thereby what consti-
tutes an ‘oral health outcome’ (71). Subjective and
objective esthetic outcomes of implant-supported
prostheses have to be considered together in order
to obtain a comprehensive evaluation of the out-
come from patients and clinicians.
Patient-reported outcome measures are proposed
to incorporate the patient’s perceptions and can pro-
vide important adjunctive information to clinical
parameters. The use of such measures in controlled
clinical trials is of paramount importance in provid-
ing a standardized evaluation of implant dentistry
(34, 71). Furthermore, they can be considered as use-
ful tools in informing patients because they can
explain treatment outcomes in lay terminology as
opposed to clinical parameters, which are often too
technical and complex to be understood by patients.
They can also be employed as tools in clinical audits,
offering a patient-centered focus on the quality of
care (71). Patient-reported outcome measures usually
take the form of a series of questions posed to the
patient, at various time points, regarding their per-
ception of their treatment. These questions can be
posed through face-to-face interviews or completion
of a written questionnaire. It is essential that patients
have a clear understanding of what parameters they
are being asked to assess and how to assess these
parameters without ambiguity and without any inter-
ference from the interviewer (71).
Patient-reported outcome measures can focus on a
number of aspects in order to target a variety of the
154
patient’s perceptions, such as: (i) patient satisfaction/
preference; and (ii) other patient-reported outcomes/
subjective oral health measures, such as recording
pain, comfort and attributes of the physical, social
and/or psychological impact of oral health status
(79). Patient-reported outcome measures should ful-
fill certain criteria, including psychometric properties
(i.e. validity and reliability), appropriateness, accept-
ability, feasibility, precision, responsiveness and in-
terpretability (79, 114). There is already a range of
standardized patient-reported outcome measures, the
psychometric properties of which have been evaluated
in dentistry (5) and, in addition, have been translated
and adapted for use in many different cultural settings
(with obvious linguistic differences) from which it is
possible to make comparisons between different pop-
ulations and nationalities (3).
The Oral Health Impact Profile (104) is one of the
most comprehensive subjective oral health status
measures. It has a sound theoretical framework based
on an oral health model of ‘disease/condition–impair-
ment–disability–handicap’ with seven domains, as
described by Locker et al. (77). It consists of 49 items
which measure both the frequency and the severity of
the impact of oral problems on physical, social and
psychological well-being. Since its development over
a decade ago, the Oral Health Impact Profile has been
used as an outcome measure in a number of epidemi-
ological studies, cohort studies and in clinical trials
(55). As it is not feasible, in some research settings, to
use the full battery of 49 questions in the original
instrument, a shorter form, the Oral Health Impact
Profile-14, was developed (4, 93, 94, 103). The Oral
Health Impact Profile-14 has been validated for sev-
eral types of oral health-related problems (92), such as
burning mouth, temporomandibular dysfunction,
oral mucosal pain, malocclusion (74), impacted wis-
dom teeth (41) and primary care (96), but has not
been specifically adapted for a single missing tooth in
the anterior area treated with implant therapy.
Despite a recent increased interest in the patient’s
perspective, the number of controlled studies collect-
ing patient-reported outcome data is still scarce.
Following scrutiny of recent papers including patient-
reported outcome pertaining to patients with a single
missing tooth-implant rehabilitation in the esthetic
area, it is proposed that some critical aspects should
be considered:
 In the majority of the studies evaluations were
usually made by the researchers in a nonstandard-
ized way (11, 18, 32, 35, 38–40, 46, 48, 56, 58, 68,
70, 75, 82, 85, 87, 88, 92, 95, 100, 101, 109, 110,
124). Moreover, patient’s opinions were scored

using different methods, including visual analog
scales, Likert scales, dichotomous or multiple
choice answers and other scales. The use of such
nonstandardized measures prevents comparison
between studies and does not allow the results to
be combined in a meta-analysis (71, 79). De Bruyn
et al. (28) suggested that one reason which can
explain the use of these ‘ad hoc’, rather than vali-
dated, methods could be the fact that they have
only been validated for fully edentulous patients
and not for rehabilitation with a single implant.
 The time points for assessments is another impor-
tant aspect to take into consideration. Ideally,
questionnaires should be administered before any
therapy and at the end of the treatment in order
to capture the benefit. In the majority of the stud-
ies, only the final evaluation (i.e. after crown deliv-
ery) has been performed. This makes it impossible
to tell if the patient’s expectations have been met
and if implant treatment has mainly addressed
patient needs (79).
 A validated, implant-specific, patient-reported
outcome measure focused on esthetic evaluation is
not available. Mehl et al. (80) performed a study to
evaluate whether the Oral Health Impact Profile-49
was able to measure the impact of dental appear-
ance. They concluded that the Oral Health Impact
Profile-49 is a generic instrument that is not able
to discriminate esthetics and needs to be com-
bined with an additional esthetic modulus. As,
to the best of our knowledge to date, a validated,
implant-specific, patient-reported outcome mea-
sure focused on esthetic evaluation is not available,
other patient-reported outcome measures devel-
oped in different specialties in dentistry could be
adapted and validated (71). For example, the Oral
Health Impact Profile-Esthetic (123), the Orofacial
Esthetic Scale (62, 72, 73) and the Psychosocial
Impact of Dental Esthetics questionnaire (20, 67)
are tools developed for other dental branches and
are focused on the patient’s perception of their
esthetic outcome. These instruments could be
used as a framework to develop an implant condi-
tion-specific patient-reported outcome measure
for the assessment of esthetic satisfaction (71).
Relationship between the patient’s
subjective and the professional’s
objective evaluations of esthetics
Treating patients with an esthetic complaint is chal-
lenging because perception of esthetics is subjective
Esthetics in implant rehabilitation
and is influenced by many factors, such as age, gen-
der and educational background, and furthermore is
also related to general aspects of psychological well-
being.
Ideally, subjective and objective evaluations should
be in accordance; however, different studies performed
in general dentistry have shown a discrepancy between
patients’ and dentists’ perceptions of oral esthetics.
Understanding this difference would be invaluable as it
would assist dentists in predicting patient-reported
impairment in dental esthetics and thereby allow for
the attainment of an optimal treatment result that
could enhance the patients’ oral health-related quality
of life and general self-esteem (26). This leads to the
question: how are professionals’ and patients’ esthetic
evaluations of single tooth implant-supported crown
related (37)? Only a handful of studies have investigated
this and, among these, even less have performed a cor-
relation between the two evaluations (1, 7, 9, 12–14, 18,
19, 21–24, 29, 30, 32, 35, 37–40, 43, 47, 50–54, 58, 66, 68,
82, 85, 87, 88, 90, 99, 105, 106, 110, 111, 113, 116, 118–
120).
Standardized instruments should be used to com-
pare patients’ and professionals’ esthetic evaluations.
While the professional’s objective evaluation can be
assessed using reliable indexes, a validated question-
naire for the patient’s esthetic evaluation is still not
available. For this reason, a comparison between the
two evaluations is difficult. However, we find that in
the great majority of the studies there is no correla-
tion between the two evaluations, and professional
assessment of esthetics seems considerably more crit-
ical than that performed by patients (19, 69). This
indicates that, regarding the esthetics of implant-sup-
ported reconstructions and their surrounding tissues,
patients have different views from professionals
regarding satisfaction with the final result (11). It is
still difficult to understand to what degree, and on
which specific aspects of oral esthetics, dentists and
patients seem to agree or disagree (26). Some authors
(37) suggest that factors other than the actual esthetic
outcome itself appear to influence patients’ satisfac-
tion with their final results. Among these factors, the
starting point for the patient is certainly related to
their final appreciation of the outcome. For example,
when the preoperative situation is compromised and
patient’s expectations are realistic, the patient might
be satisfied even when the esthetic outcome, accord-
ing to an objective index, is rated as acceptable or
poor (30). If the professional who rates the final result
is blind to the initial presentation, his/her objective
evaluation would not take into account the ‘relative’
esthetic improvement obtained with the therapy
155
Stefanini et al.

A B

Fig. 2. Preoperative situation in a patient with very compromised esthetic situation. (A) Baseline clinical situation of the
frontal area in a patient affected by aggressive periodontitis. (B) Radiograph showing severe bone loss all around the
central incisor and mesial to the lateral incisor.

A B

Fig. 3. Four months after tooth extraction. (A) Severe apico-coronal (vertical) soft-tissue loss. (B) Severe buccolingual (hor-
izontal) soft-tissue loss.

A B

C D

Fig. 4. The connective tissue platform surgical technique
used for augmentation of soft tissue. (A) The buccal flap,
consisting of a horizontal and two vertical incisions, was
elevated split thickness in order to be coronally advanced
and reach the palatal flap, which was raised split thickness
with a horizontal incision made at the edentulous area.
One connective tissue graft taken from the tuberosity was
used to compensate for the vertical soft-tissue loss. The
grafts were anchored with 7-0 polyglycolide sutures at the
connective tissue deriving from the de-epithelization of the
crestal soft tissue of the edentulous area (connective tissue
platform) located between the buccal and palatal incisions.
Two connective tissue grafts deriving from the de-epitheli-
zation of free gingival graft taken from the palate were used
to compensate for the horizontal soft-tissue loss. (B) Occlu-
sal aspect showing the palatal horizontal incision and the
connective tissue grafts used to compensate for the hori-
zontal and vertical soft-tissue loss. (C) Complete coverage
of the connective tissue grafts was achieved by the buccal
flap which was advanced coronally and palatally to reach
the palatal flap. (D) First-intention wound healing was
accomplished by suturing the buccal flap to the palatal
flap.

156

A B
Fig. 5. Eight months after the surgical procedure. (A) The soft tissue was allowed to heal undisturbed for 8 months. The
frontal aspect shows successful treatment of vertical soft-tissue loss. (B) The palatal aspect shows complete resolution of
the horizontal soft-tissue loss.
A B
Fig. 6. One year after tooth extraction. (A) Periapical radio-
graph showing bone fill of the edentulous area and
improvement of the bone level at the mesial aspect of the
A B
Fig. 7. Installation of an implant using the flapless proce-
dure. (A) Surgical treatment of the soft-tissue defects and
spontaneous resolution of the bone defect allowed
performed. It is interesting to underline that in the
majority of the studies a preoperative esthetic assess-
ment was not performed. Figures 2–8 show a clinical
example of a patient who is in need of an anterior
rehabilitation, presenting a highly compromised base-
line esthetic situation. Other authors (78) suggest that
patient expectations can be met more readily, result-
ing in increased overall satisfaction, when they under-
stand the risks, benefits and alternatives to treatment.
In other words, a well-informed patient is a patient
Esthetics in implant rehabilitation
lateral incisor. (B) Computer planning of implant installa-
tion: the cone beam shows sufficient bone thickness and
height for installation of prosthetically guided implants.
C
installation of the implant using the flapless procedure. (B)
Good primary stability allowed for immediate temporiza-
tion. (C) Periapical radiograph showing implant positioning.
who will be more readily satisfied (37). The smile line
is another aspect that is usually of paramount impor-
tance in the patient’s esthetic evaluation, although
this parameter is never reported. Some authors (8, 15)
suggest that a stronger correlation between the res-
ponses to our questions, regarding the esthetic out-
come of the treatment and the different indexes used,
might be expected in those participants with a high
smile line (120). Other authors suggest that the rea-
son why the subjective evaluation is significantly
157
Stefanini et al.

A B C

Fig. 8. Definitive implant-supported restoration 1 year
after implant installation. (A) Frontal aspect showing an
esthetic result evaluated by a blind examiner, according to
the pink and white esthetic score, as acceptable (total
score = 13) because of the dimension of the distal papilla,
the presence of scars and the differences in form, color
and translucency of the clinical crown. However, the
patient rated the final result as ‘excellent’. The discrepancy
between the two evaluations could be ascribed to the ini-
tial situation where the patient was aware of the preopera-
tive situation and was very satisfied with the result
obtained. (B) Occlusal aspect showing increased soft-tissue
thickness at the implant-supported crown. (C) Periapical
radiograph showing stability of the bone levels around
the implant. Restorative treatment courtesy of Dr Carlo
Monaco.

A B

Fig. 9. ‘Excellent’ level of esthetic satisfaction by both the professional and the patient. Frontal view (A) and radiograph (B)
2 years after single tooth replacement in the maxillary anterior area. The result achieved was evaluated as ‘excellent’ by
both the expert professional and the patient. Restorative treatment courtesy of Dr Carlo Monaco.

A B

Fig. 10. Good level of esthetic satisfaction by the profes-
sional and excellent level of esthetic satisfaction by the
patient. Frontal view (A) and radiograph (B) 1 year
after single tooth replacement in the maxillary anterior
area. The patient evaluated the result as ‘excellent’ for
both the mucosa and the reconstruction; the profes-
sional examiner evaluated the result as ‘good’ because
of the slight difference of the marginal soft-tissue level
of the lateral incisor with respect to the central and
the cuspid.

more favorable than the objective evaluation might
be related to different perspectives of observation.
The patients’ self-assessment is performed using
a mirror, whereas the pictures evaluated by den-
tists had been taken using retractors that held the
lips back, forcibly exposing the peri-implant soft tis-
sues (90).
An example of implant-supported therapy with
an excellent level of both professional and patient
esthetic satisfaction is reported in Fig. 9. An exam-
ple of implant-supported therapy with an excellent
level of patient esthetic satisfaction and a good level
of professional esthetic satisfaction is reported in
Fig. 10. An example of implant-supported therapy

158

A B
Fig. 11. Moderate level of esthetic satisfaction by the pro-
fessional and good level of esthetic satisfaction by the
patient. Frontal view (A) and radiograph (B) 1 year after
single tooth replacement in the maxillary anterior area.
The patient evaluated the result as ‘good’ for both the
mucosa and the reconstruction; the professional examiner
A B
Fig. 12. Poor level of esthetic satisfaction by both the pro-
fessional and the patient. Frontal view (A) and radiograph
(B) 1 year after single tooth replacement in the maxillary
anterior area. Both professional and patient evaluated the
with a good level of patient esthetic satisfaction and
a moderate level of professional esthetic satisfaction
is reported in Fig. 11. An example of implant-
supported therapy with a poor level of both profes-
sional and patient esthetic satisfaction is reported
in Fig. 12.
Conclusions
In spite of the growing interest in methods to assess
success in implant dentistry, it is not yet possible to
provide evidence-based conclusions. In the literature,
there is no consensus on the implant-supported
crown esthetic index suitable for universal use. The
use of a universally adopted esthetic index is highly
recommended to improve clinical research in implant
dentistry and to compare clinical studies. In this light,
in order to obtain a reproducible and comparable
objective esthetic evaluation it is advisable:
 to calibrate the assessors properly in order to
reduce the risk of bias (81).
Esthetics in implant rehabilitation
evaluated the result as ‘moderate’ because of the difference
in the marginal soft-tissue level between the two central
incisors and the transparency of the grey metallic color
through the mucosa apical to the implant-supported
crown.
result as ‘poor’ because of the differences in soft-tissue
color, texture and level with respect to the contralateral
incisor and the difference in the color and the shape of the
reconstruction.
 to recruit more examiners in each dental specialty
to reduce the effect of subjective individual bias
(117).
 to provide study casts or computer-assisted mea-
surement in addition to clinical photographs to
facilitate the assessment of crown outline, volume,
texture, root convexity, papilla and soft-tissue
texture (15, 121).
 to use spectrophotometry that could be helpful to
achieve higher reproducibility for the color assess-
ment.
 to use a stable reference point for assessing
repeated measurements.
 to assess esthetic results before and after therapy
(71).
The use of patient-reported outcome measures is
also becoming more frequent because researchers
appreciate the need to integrate the professional clin-
ical outcomes of therapies with the ‘true end point’
which captures patients’ perception (57, 115). In the
field of esthetics implant dentistry, there is the
need for standardized methods of patient-reported
159
Stefanini et al.
outcome in partially edentulous patients (28). This
represents a matter of concern for future research.
These questionnaires could be developed by adapting
previous validated patient-reported outcome mea-
sures in other dental branches (71) and should be as
comprehensive and as brief as possible so as to not
burden patients (77). They should be presented to the
patient at different stages of the therapy, starting
from baseline (i.e. before any treatment), in order to
compare pre- and post-therapy results properly.
Concerning the correlation between objective and
subjective assessment of esthetics, the professional
evaluation is not always consistent with patient-
reported satisfaction, with patients rating the cos-
metic outcomes more favorably than the profession-
als. In the future, the use of a universally accepted
and validated method for the professional’s esthetic
assessment, in conjunction with specific patient-
reported outcome measures for subjective esthetic
evaluation, should be able to provide a complete and
comparable overview of the success outcomes of the
implant therapy.
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Periodontology 2000, Vol. 77, 2018, 165–175
Printed in Singapore. All rights reserved
Alveolar ridge preservation in the
esthetic zone
R O N A L D E. J U N G , A L E X I S I O A N N I D I S , C H R I S T O P H H. F. H AM
D A N I E L S. T H O M A
Anatomy of the extraction socket in
the esthetic zone
Following tooth extraction, alveolar bone loss and
structural and compositional changes of the covering
soft tissues, as well as morphological alterations, can
be expected (30). The numerous alterations in the
alveolar process may lead to difficulties at the time of
implant placement when a prosthetically driven
implant position is desired (11).
In order to understand the changes following tooth
extraction in the esthetic zone, it is fundamental to
comprehend the anatomic and histologic characteris-
tics of tissues surrounding the tooth foreseen for
extraction. Being part of the periodontium, the alveo-
lar process surrounds the fully erupted tooth. Histo-
logically, the inner part of the socket wall contains
lamellar bone, the so-called bundle bone (2). The
thickness of this bundle bone is reported to be 0.2–
0.4 mm (29). Similarly to the root cementum and to
the periodontal ligament, its existence is strictly
tooth-dependent (2).
In a recent clinical study, the thickness of the buc-
cal bone plate in the maxillary anterior area was mea-
sured using cone beam computed tomography (18).
The thickness of the buccal bone plate was measured
at three different positions relative to the buccal bone
crest (18). It was found that the buccal bone plate, in
most locations in the anterior maxilla, is less than
1 mm in thickness. In addition, nearly 50% of the
sites investigated had a bone plate, which was (at
maximum) 0.5 mm thick. This, is turn, means that
the bundle bone and the buccal bone plate com-
monly have a similar thickness in the anterior maxil-
lary region. Therefore, one might assume that, after
tooth extraction in the esthetic area, the buccal bone
plate will be resorbed predominantly in the more
crestal region.
© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
PERIODONTOLOGY 2000
€ MERLE &
Therefore, in the esthetic zone, the clinician is con-
fronted with a challenging situation regarding the
decision-making process required to provide an opti-
mal treatment solution. Hence, in recent years, the
healing process of the extraction socket and the
related changes of respective hard and soft tissues fol-
lowing tooth removal has become a well-investigated
research field. Ideally, the therapeutic plan starts
before tooth extraction and offers three therapeutic
options: spontaneous healing of the extraction socket;
immediate implant placement; and techniques for
preserving the alveolar ridge at the site of tooth
removal. This narrative review focuses on alveolar
ridge preservation techniques in the esthetic zone.
Besides the evidential background of alveolar ridge
preservation procedures, this article provides a clini-
cal decision tree and corresponding cases demon-
strating the different treatment options.
Spontaneous healing following
tooth extraction
After tooth extraction, the alveolar ridge undergoes
evident reduction in both vertical and horizontal
directions (7, 8, 19). The processes taking place after
tooth removal were systematically reviewed in an
article that included 20 human studies and aimed to
assess the magnitude of dimensional changes of both
the hard and soft tissues of the alveolar ridge after
tooth extraction (35). Based on the evidence of the
review, the vertical dimensional reduction on the
buccal side amounted to 11–22% ( 1.24  0.11 mm)
after 6 months, whereas the horizontal dimensional
reduction on the buccal side was greater, amounting
to 29–63% ( 3.79  0.23 mm) after 6–7 months (35).
It was concluded that human re-entry studies demon-
strated rapid alteration within the first 3–6 months
165
Jung et al.
after tooth removal, followed by gradual reduction in
dimension thereafter. Subsequently, 0.5–1% reduc-
tion of the bone contour, per year, can be expected
(6). In summary, following single-tooth extraction, up
to 50% of the ridge width will be resorbed and bone
resorption will predominantly occur at the buccal
aspect (2).
Immediate implant placement
Immediate implant placement can be performed in a
variety of therapeutic procedures – either with or
without flap elevation and with or without additional
guided bone-regeneration procedures. The alter-
ations in hard tissue following immediate implant
placement without guided bone-regeneration proce-
dures were evaluated in a study including 18 patients
with a total of 21 teeth scheduled for extraction (10).
Following flap elevation and tooth removal, an
implant was placed without additional membranes or
bone-substitute materials (10). The follow-up exami-
nation at 4 months of healing demonstrated horizon-
tal resorption of the buccal bone dimension of
approximately 56% at the buccal aspect and 30% at
the lingual and palatal aspects (10). This is underlined
by further preclinical and clinical studies demonstrat-
ing that immediate implant placement in a fresh
extraction socket fails to prevent bone resorption
(3–5, 15, 26, 28).
The outcomes of immediate implants were also
assessed concomitant with guided bone-regenera-
tion procedures (12). The aim of that prospective
clinical study was to evaluate the clinical perfor-
mance of immediately placed implants. In total, 30
patients received immediate transmucosal implants
in the maxillary anterior region. The patients were
randomly assigned into three treatment groups: 10
patients received implants without additional
guided bone-regeneration procedures; 10 patients
received implants grafted with demineralized
bovine bone matrix alone; and 10 patients received
implants grafted with demineralized bovine bone
matrix and a collagen membrane. The horizontal
resorption at 4 years amounted to 48.3% in the
group without grafting material, whereas in the
other two groups significantly less horizontal
resorption was observed: 15.8% in the group with
demineralized bovine bone matrix; and 20% in the
group with demineralized bovine bone matrix and
a collagen membrane (12).
In summary, immediate implant placement with-
out additional guided bone-regeneration procedures
166
results in a reduction of the ridge dimension of about
half of the initial bone width in a horizontal dimen-
sion and therefore seems not to be beneficial when
compared with spontaneous healing (2, 10). However,
less horizontal bone resorption can be expected by
addition of a grafting material and by combining
immediate implant placement with a guided bone-
regeneration procedure.
Alveolar ridge preservation
procedures
Alveolar ridge preservation techniques have been
widely used in the past and are continuously evalu-
ated. These techniques are performed to counteract
changes in soft tissue and hard tissue that follow
tooth extraction. More recent research has focused
on a variety of materials and techniques and has dif-
ferent aims depending on the need for preservation
of soft tissue and/or hard tissue, as well as on the
optimization of the ridge profile. According to previ-
ous systematic reviews (14, 16, 24, 40), three options
for alveolar ridge preservation exist: the use of soft-
tissue grafts; the use of hard-tissue graft materials; or
the use of a combination of soft-tissue and hard-
tissue biomaterials. The main goals include: the elimi-
nation, or at least a limitation, of post extraction ridge
alterations; the promotion of healing of soft and hard
tissue within the former extraction socket; and facili-
tating the placement of dental implants in a prosthet-
ically ideal position without the need for further
augmentative procedures (16, 24). From a clinical
point of view, the decision to perform a certain alveo-
lar ridge preservation technique depends mainly on:
(i) the time-point chosen and the ability to place a
dental implant; (ii) the quality and quantity of soft tis-
sue in the region of the extraction socket; (iii) the
remaining height of the buccal bone plate; and (iv)
the expected implant survival and success rates. Ide-
ally, from a patient’s perspective, dental implants
should be placed immediately. However, this tech-
nique is associated with a number of limitations and
may not be suitable in all cases. This is mostly
because of existing deficiencies in terms of bone and
soft tissues. Three healing time-points are described
in the literature for alveolar ridge preservation; these
focus on the need for: (i) optimization of the soft tis-
sues (soft-tissue preservation with 6–8 weeks of heal-
ing after tooth extraction); (ii) optimization of the
hard and soft tissues (hard- and soft-tissue preserva-
tion with 4–6 months of healing after tooth
extraction); and (iii) optimization of hard tissues

(hard-tissue preservation with > 6 months of healing
after tooth extraction) (13).
Preservation of soft tissue
Alveolar ridge preservation procedures have been
described to enhance the quality and/or regenerate
the quantity of the soft tissues that demonstrate a defi-
ciency prior to, or after, tooth extraction. From a mate-
rial point of view, the options available include the use
of an autogenous subepithelial connective tissue graft
harvested from the tuberositas area or the palate, a
free gingival graft harvested from the palate, or a soft-
tissue substitute or a resorbable membrane that
enhances closure of the soft-tissue wound (9, 21, 31–
34). These procedures are performed predominantly
using a flapless approach or with a minimal coronal
flap advancement, in order to preserve or gain kera-
tinized tissue. Scientific evidence ranges from a variety
of preclinical studies to clinical studies applying differ-
ent biomaterials also at the level of the hard tissue (17,
22, 36, 41). As the healing period for such an interven-
tion is kept to 6–8 weeks, only minimal new-bone for-
mation can be expected within the socket, but
complete soft-tissue closure (23). The biomaterials
mainly serve as a space-maintaining device for the
biomaterial or the graft placed at the soft-tissue level.
As a result of heterogeneity of the studies using various
biomaterials and techniques, outcomes are difficult to
compare. To date, however, an autogenous soft-tissue
graft appears to be the most suitable method for opti-
mizing the ridge profile at the soft-tissue level during
short-term healing periods (37, 38). Alternative soft-tis-
sue substitutes, which appear to reduce postoperative
morbidity (39), have not been documented as exten-
sively for short healing periods and can currently not
replace the use of autogenous tissue (38).
Preservation of hard tissue and soft tissue
In some clinical cases, deficits in both hard and soft
tissue may be observed following tooth extraction. In
these cases, more recent techniques suggest a combi-
nation of soft- and hard-tissue preservation with a
longer-term healing period (4–6 months), applying a
minimally invasive, nonflapped approach. These so-
called socket seal techniques combine the use of bio-
materials that are placed at the bony level and of
autogenous soft-tissue grafts or of soft-tissue substi-
tutes at the level of the soft tissues (20, 23, 25, 27). In
one of the earlier studies, a xenogenic bone-substi-
tute material with 10% collagen was used, and a soft-
tissue seal was obtained with a free gingival punch
Alveolar ridge preservation in the esthetic zone
graft harvested from the palate (21). This study
demonstrated successful integration of the soft-tissue
graft; however, volumetric changes and implant-
related outcomes were not assessed. More recent
studies have evaluated the same combination and
compared different alveolar ridge preservation tech-
niques also using a soft-tissue substitute (collagen
matrix) (1, 20, 23). It was demonstrated that after a
healing period of 6 months, alveolar ridge preserva-
tion with a xenograft and sealing of the extraction
socket with an autogenous soft tissue graft or a colla-
gen matrix were effective (20, 23, 27) and even supe-
rior to the results observed in control groups
(spontaneous healing or a biomaterial without a seal)
(20). Horizontal and vertical changes were minimal
(20) and allowed placement of dental implants with
high survival rates at the 1-year follow-up (27). Histo-
logic outcome measures additionally revealed that
the placement of a graft material within the socket
retarded healing. Moreover, the presence of the bio-
material within the extraction socket appeared to be
a major contributing factor for the minimal dimen-
sional changes observed (1, 23). Furthermore, it was
demonstrated that soft-tissue substitutes could be
successfully used as a socket seal for alveolar ridge
preservation, allowing for simplification of the proce-
dure. The use of autogenous grafts may be avoided,
thereby reducing the postoperative morbidity of
patients (20, 27).
Preservation of hard tissue
In the case of severe loss (> 50%) of the buccal bone
plate, preservation of hard tissue with a prolonged heal-
ing time before implant placement has been suggested.
For that purpose, alveolar ridge preservation is per-
formed using a bone-substitute material covered with a
membrane followed by flap advancement to achieve
complete or partial wound closure (most commonly
used), a bone-substitute material with full wound clo-
sure achieved by coronal advancement or rotation of
the flap (the second most-common technique) or a
bone-substitute material without wound closure (weak-
est evidence) (14, 40). Various materials were used for
these procedures, but none of the material or tech-
niques demonstrated were more favorable than others
(24). Based on meta-analyses, statistically significantly
less reduction of bone height (vertical dimension) for
alveolar ridge preservation was observed compared
with control groups (weighted mean differ-
ence = 1.47 mm) and statistically significantly less
reduction of bone width (horizontal dimension) for
alveolar ridge preservation was observed compared
167
Jung et al.

with controls (weighted mean difference = 1.83 mm).
In addition, a significant, positive effect of flapped sur-
gery was observed (40). This clearly demonstrated supe-
riority of alveolar ridge preservation compared with
control groups regarding changes of the ridge profile
following tooth extraction. Apart from benefits in terms
of changes in soft and hard tissue, other outcomes,
such as the need for further bone augmentation, the
feasibility of implant placement and implant survival
and success rates, might further support the use of alve-
olar ridge preservation techniques. Based on a more
recent systematic review, meta-analyses demonstrated
a need for further bone augmentation at implant place-
ment, ranging between 0% and 15% for alveolar ridge
preservation and between 0% and 100% for sponta-
neous healing (24). This indicated a decrease in the
need for further bone augmentation with a relative risk
of 0.15 (95% confidence interval: 0.07–0.30) for alveolar
ridge preservation compared with controls. As in all the
studies included, implant placement was feasible, no
advantage of alveolar ridge preservation compared with
controls is evident. Whereas this may not be in favor of
alveolar ridge preservation procedures per se, one needs
to understand that implant placement, in most cases,
can be conducted independently of whether or not
alveolar ridge preservation or spontaneous healing is
performed. Given the fact that backwards planning and
not bone-driven implant placement appears to be the
state-of-the-art in implant therapy, it is crucial to report
where the implants were placed, which diameters were
used and which angulation was chosen. This informa-
tion can currently not be derived from the scientific evi-
dence and therefore might underestimate the effect of
alveolar ridge preservation in daily routine practice.
Similar data with no differences in terms of implant sur-
vival and success rates and marginal bone level changes
are reported for alveolar ridge preservation sites and
control sites (24). Overall, the data derived from the lit-
erature support the use of alveolar ridge preservation to
preserve the ridge volume, mainly at the hard tissue
level, but do not offer more clinical benefits in terms of
implant-related outcomes, and are associated with a
long healing period (> 6 months) and a flapped
procedure.
Clinical concept for alveolar ridge
preservation procedures
Clinical decision-making process
When it comes to the esthetic area, the clinical con-
cept in today’s dentistry has clearly changed in a way
that the treatment plan and the decision-making pro-
cess should take place before a tooth is extracted.
This allows the patient to benefit from the multiple
treatment options that are available at the time of
tooth extraction.
All treatment modalities have their individual
aims, clinical indications and limitations (Table 1).
The aim of this part of the review is to present a
decision tree (Fig. 1) followed by a therapeutic con-
cept illustrated by clinical cases (Figs. 2–5). Figure 1
shows the decision tree, which starts with the most
general question that needs to be asked before a
tooth is going to be extracted (Question 1): Is

Table 1. Individual aims, clinical indications and limitations of treatment modalities

Treatment option Aim Clinical indications Limitations

Soft-tissue Improve the quantity Ankylosed teeth with vertical Teeth with acute infections.
preservation and quality of soft-tissue deficiencies. Large bone defects
soft tissues at the Teeth with soft-tissue recessions Technique sensitive in terms of
time of tooth extraction. Teeth lacking keratinized tissue soft-tissue management in sites
with extensive soft-tissue defects
Hard- and Regenerate and preserve Small buccal bone defects The socket seal technique does not
soft-tissue the hard tissue and the (less than 50% of the buccal allow for 100% preservation of the
preservation soft tissue at the time of bone plate missing), with or ridge contour and therefore needs,
(socket seal tooth extraction without without soft-tissue defects. in highly esthetic areas, a further
technique) flap elevation. As a method for implant small contour augmentation.
placement 4–6 months thereafter
Pontics of conventional
reconstructions
Hard-tissue Regenerate and augment Large buccal bone defects (> 50% Invasive surgery at the time of tooth
preservation the alveolar bone at of the buccal bone plate missing), extraction without implant
(guided bone the time of tooth extraction. scheduled for late (> 6 months) placement.
regeneration) implant placement. Long healing time

168

implant placement possible or indicated within the
next 0–2 months after tooth extraction? If the
answer is ‘yes’ (Answer 1.1), and implant placement
is possible and indicated within the next 0–2
months, an alveolar ridge preservation procedure is
generally not indicated. However, an additional
question needs to be asked before tooth extraction
(Question 2.1): Do the soft tissues need to be opti-
mized prior to implant placement? If the answer is
‘no’ (Answer 2.1), the extraction socket is left for
spontaneous healing with subsequent implant
placement 6–8 weeks later [Type 2 implant place-
ment according to Chen et al. (13)] or an immedi-
ate implant placement [Type 1 implant placement
A2.1
no
Fig. 1. Clinical decision tree, leading to the different alveolar ridge-preservation procedures. A, Answer; Q, Question.
Alveolar ridge preservation in the esthetic zone
according to Chen et al. (13)] is indicated. The
decision on the timing for implant placement is
based on patient-related, clinical and radiographic
findings and is not part of the present review.
In cases with soft-tissue deficiencies and defects at
the time of tooth extraction, a soft-tissue preservation
technique (soft-tissue preservation) is indicated in
order to improve the soft tissues at this early time-
point (Answer 2.2). This generally includes the need
for bone graft materials and autogenous soft-tissue
grafts. If the answer is ‘no’ and implant placement is
not possible or is indicated at a later time-point
(> 2 months) an alveolar ridge preservation proce-
dure might be recommended according to today’s
A2.2 A2.3 A2.4
small big
yes
< 50% > 50%
169
Jung et al.
A B
E F
I J
M N
Fig. 2. (A) Ankylosed tooth #11 revealing a vertical soft-
and hard-tissue deficiency. (B) Atraumatic tooth extraction.
(C) Partial flap elevation using a tunnel technique. (D) Fill-
ing the extraction socket with a deproteinized bovine bone
mineral embedded in a 10% collagen matrix. Placement of
a connective tissue graft (E) underneath the elevated gin-
giva (F). (G) Postoperative situation after adjusting the tem-
porary removable prosthesis to avoid excessive pressure on
literature (Answer 1.2). In order to identify the most
appropriate technique, the subsequent question is
related to the amount of remaining buccal bone
(Question 2.2): Size of bone defects at the extraction
socket? If less than 50% of the buccal bone plate is
missing, a flapless ridge preservation procedure
(hard- and soft-tissue preservation = socket seal
technique) using a slowly resorbing graft material and
either an autogenous graft or a collagen matrix is
indicated (Answer 2.3). If more than 50% of the buc-
cal bone plate is missing, good documentation is
available for standard open-flap ridge preservation/
augmentation (hard-tissue preservation) using cur-
rent guided bone regeneration procedures (Answer
2.4). Hence, the more invasive and technique-sensi-
tive procedure is indicated for larger bone defects,
whereas flapless procedures are indicated for extrac-
tion sockets with smaller bone defects.
170
C D
G H
K L
O P
the augmented site. (H) Suture removal after 7 days. (I, J)
Situation after a healing period of 3.5 months. (K, L, M, N)
Implant placement with a simultaneous guided bone-
regeneration procedure. (O) Suture removal after 1 week of
healing. (P) Five-year follow-up of the all-ceramic implant-
retained crown in the region #11 and the veneer on tooth
#21, showing a harmonious esthetic outcome.
Clinical concept for soft-tissue
preservation with an autogenous
soft-tissue graft
The clinical concept starts in general with a correct
diagnosis and thorough analysis of the clinical and
radiographic situations. Depending on the difficulty
of the extraction, the tooth will be removed using
either a flapless or an open flap access. A flapless pro-
cedure should be selected whenever possible. In a
representative clinical case a 29-year-old woman pre-
sented with an ankylosed tooth #11 revealing a verti-
cal soft- and hard-tissue deficiency (Fig. 2). Owing to
external buccal root resorption the tooth needed to
be extracted, and the patient had requested an
improved esthetic situation. To compensate for the
soft-tissue defect an autogenous connective tissue
graft from the palate was selected. A soft-tissue

substitute or an autogenous punch graft does not
allow for augmentation of such an extended defect.
Following atraumatic tooth extraction, a partial flap
elevation using a tunnel technique without any fur-
ther incision was performed. The extension of the flap
elevation includes the buccal, the palatal and the
interproximal parts, and should allow for tension-free
insertion of the connective tissue graft. After eleva-
tion, the socket was filled with a deproteinized bovine
bone mineral embedded in a 10% collagen matrix.
Thereafter, the connective tissue graft was placed
underneath the elevated gingiva and stabilized by
vertical mattress sutures on the buccal and the palatal
parts. The orifice of the socket was reduced by cross
sutures. Subsequently, the temporary removable
prosthesis was adjusted to avoid excessive pressure
on the augmented site. The patient received antibi-
otics immediately before tooth extraction and for a
further 5 days postoperatively. Analgesics were pre-
scribed according to the patient’s need. The patient
was asked not to mechanically clean this area and to
rinse with a chlorhexidine solution (0.2%) for 7–10 days
until the day of suture removal.
After a healing period of at least 6–8 weeks, the next
therapeutic interventions can be started. In the pre-
sent situation the patient received an implant with a
simultaneous guided bone regeneration procedure
3.5 months later. As flapless ridge preservation can
only maintain the buccal contour to about 80–85% of
A B
E F
I J
Fig. 3. (A, B) Mesiodistally fractured tooth #24. Situation
after tooth extraction (C) and application of demineralized
bovine bone matrix with collagen (D). (E) Collagen matrix
of 8 mm diameter is sutured to the host gingival margin.
Alveolar ridge preservation in the esthetic zone
maximum (20) additional augmentation of the buccal
contour is needed in cases with a high esthetic
requirement. Therefore, in the present case, further
augmentation of the buccal contour, using deminer-
alized bovine bone matrix and a collagen membrane,
was performed. After a further healing period of
2 months, abutment connection was performed and
eventually an all-ceramic implant-retained crown on
tooth #11 was inserted. In order to close the diastema,
a ceramic veneer on tooth #21 and an additional par-
tial veneer on tooth #12 were inserted. The 5-year
follow-up shows a stable and harmonious esthetic
outcome.
Clinical concept for hard- and soft-tissue
preservation (socket seal technique)
using hard- and soft tissue substitutes
A 31-year-old pregnant women presented with a
mesiodistally fractured tooth #24, revealing a high lip
line. As she was pregnant, implant surgery could not
be scheduled and was not expected to be performed
until she had given birth. Hence, it was decided to
perform an alveolar ridge preservation procedure in
order to maintain at least 80–85% of the buccal con-
tour, facilitating implant placement when the patient
returned a few months later. As there was no need to
enhance the soft-tissue thickness, it was decided to
perform a socket seal technique using a slowly
C D
G H
K
(F) Six months after healing. Implant placement without
any further augmentation (G, H) and transmucosal healing
(I). (J, K) Clinical situation, after a further 6 weeks, with a
screw-retained all-ceramic crown.
171
Jung et al.
resorbing bone-substitute material (demineralized
bovine bone matrix plus collagen) covered by a colla-
gen matrix (Fig. 3). After gentle tooth extraction and
cleaning of the socket using hand instruments and
saline solution, the demineralized bovine bone matrix
with collagen was applied and the 8-mm-diameter
A B
C D
E F
G H
I J
K L
Fig. 4. (A) Central right incisor #11 with buccal fistulae and
increased pocket depth. (B) Cone beam computed tomog-
raphy reveals a large apical and pararadicular radiolu-
cency involving also the apex of tooth #12. (C) Filling of the
extraction socket, including the apical bone defect, with
demineralized bovine bone matrix with collagen. (D)
Sutured punch graft to the host soft-tissue margin of the
extraction socket. (E, F) Clinical situation, 7 months later,
showing a partially maintained soft contour. (G, H) Flap
elevation revealing well-regenerated bone in the entire
area except for some fibrous tissue distocoronally. (I, J)
172
collagen matrix was sutured to the host gingival mar-
gin. Six months later, implant placement was possible
without any further augmentation and the implant
was allowed to heal transmucosally. After a further
6 weeks, a screw-retained all-ceramic crown was
inserted, revealing a perfect soft-tissue contour.
M N
O P
Q R
S T
U V
Implant placement in the correct prosthetically oriented
position. (K, L) Buccal contour augmentation with dem-
ineralized bovine bone matrix collagen and a collagen
membrane. (M, N) Submucosal healing of the implant for
3 months. (O, P) Clinical situation prior to abutment con-
nection. Insertion of an implant-supported provisional
crown (Q, R), allowing for soft-tissue conditioning of the
peri-implant mucosa (S, T). (U, V) A screw-retained all-
ceramic crown was inserted, showing an esthetically pleas-
ing result with a harmonious soft-tissue appearance.

Clinical concept for hard- and soft-tissue
preservation (socket seal technique) with
a hard-tissue substitute and an
autogenous soft-tissue graft
A 24-year-old male medical student attended with
pain at his central right incisor, tooth #11. The clinical
assessment demonstrated buccal fistulae; however,
without increased pocket depth. Cone beam com-
puted tomography revealed a large apical and
pararadicular radiolucency involving also the apex of
tooth #12 but with intact vitality. The buccal bone
plate seemed to be partially intact, at least in the
coronal part. As the patient was taking his course
examinations at this time-point he was not ready for
implant placement. Therefore, implant placement
was not possible within the next 0–2 months and an
alveolar ridge preservation procedure was indicated.
The level of the soft-tissue margin af tooth #11 before
tooth extraction was more apical compared with the
A B
E F
I J
M N
Fig. 5. (A) Buccal fistula of tooth #11 with a probing depth
of 10 mm at the buccal aspect. (B) X-ray showing extensive
root-canal treatment. The diagnosis was a vertical root
fracture of tooth #11 after trauma. (C, D) Open flap access
to extract the tooth. (E–G) Augmentation of the buccal bone
contour using a demineralized bovine bone matrix material
mixed with autogenous bone from the surrounding tissue
Alveolar ridge preservation in the esthetic zone
gingival margin of the contralateral tooth (Fig. 4). In
order to compensate for this slight soft-tissue defi-
ciency, it was decided to harvest an autogenous graft
from the palate to seal the extraction socket. After
atraumatic tooth extraction it became obvious that
tooth #11 had a long root fracture. After gentle clean-
ing of the granulation tissue at the apex of #12, the
extraction socket, including the apical bone defect,
was filled with demineralized bovine bone matrix
with collagen up to the level of the palatal bone. After
harvesting the autogenous punch graft from the
palate (21) the graft was meticulously sutured to the
host soft-tissue margin. The postoperative regime
was the same as described in the section ‘Soft-tissue
preservation techniques’. Seven months later the soft
contour was partially maintained and implant place-
ment was indicated. The open flap approach revealed
very well-regenerated bone regeneration of the entire
area, except for some fibrous tissue distocoronally
C D
G H
K L
and covered with a collagen membrane. (H, I) A palatal
pedicle flap was prepared in order to close the orifice of the
extraction socket. Following a healing period of 6 months
(J), the implant could be inserted without any further inter-
vention (K, L) and was left to heal transmucosally (M). (N)
Clinical situation with a screw-retained porcelain-fused-to-
metal crown.
173
Jung et al.
that was removed before implant insertion. Bearing
in mind the large bone defect at the time of tooth
extraction, the socket seal technique was considered
to be very effective for facilitating implant placement
in the correct prosthetically oriented position. Again,
this described technique did not allow for 100%
maintenance of the buccal contour, and therefore
augmentation of the buccal contour with demineral-
ized bovine bone matrix collagen and a collagen
membrane was performed. The implant was left for
3 months to allow submucosal healing and then
abutment connection was performed. After soft-tis-
sue conditioning of the peri-implant mucosa, a
screw-retained all-ceramic crown was inserted. The
final clinical picture presents an esthetically pleasing
result with a harmonious soft-tissue appearance.
Clinical concept for hard-tissue
preservation using a guided bone
regeneration technique
A 37-year-old female patient attended with a fistula
on the buccal aspect of tooth #11 and a probing depth
of 10 mm, also at the buccal aspect of tooth #11. The
diagnosis was a vertical root fracture of tooth #11
after trauma. As a result of the expected large buccal
bone defect, open flap access was chosen (Fig. 5).
After flap elevation it was obvious that implant place-
ment was not possible because of the presence of a
14-mm bone defect and the proximity to the nasal
floor. Therefore, the extraction socket and the buccal
bone contour were augmented using a demineralized
bovine bone matrix material mixed with autogenous
bone from the surrounding tissue and covered with a
collagen membrane. The membrane was additionally
stabilized with resorbable pins made of polylactic
acid. Based on systematic reviews it has been shown
that a significantly better outcome can be achieved
when the flap is closed (40). In this particular case a
palatal pedicle flap was prepared in order to close the
orifice of the extraction socket. Following a healing
period of 6 months the implant could be inserted
without any further intervention and was left to heal
transmucosally. Thereafter, a screw-retained porce-
lain-fused-to-metal crown was inserted.
Conclusion
The clinical decision-making process for alveolar
ridge preservation in the esthetic zone starts before
tooth extraction. Whenever a failing tooth can be
replaced by an implant 0–2 months after tooth
174
extraction, no alveolar ridge preservation is indicated.
The only exceptions are cases with soft-tissue defects
at the time of tooth extraction, in which a soft-tissue
preservation technique can improve the soft tissues.
In all other cases where implant placement is not
possible or not indicated 0–2 months after tooth
extraction, alveolar ridge preservation procedures
should considered.
Acknowledgments
The work on this review was funded by the Clinic of
Fixed and Removable Prosthodontics and Dental
Material Science, University of Zurich, Zurich,
Switzerland.
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Periodontology 2000, Vol. 77, 2018, 176–196
Printed in Singapore. All rights reserved
Implant placement in the
esthetic area: criteria for
positioning single and multiple
implants
T I Z I A N O T E S T O R I , T O M M A S O W E I N S T E I N , F A B I O S C U T E L L A
, H O M -L A Y W A N G
& GIOVANNI ZUCCHELLI
Implant-based rehabilitation is a clinical challenge,
especially in the esthetic area, which is defined as
between the first or second contralateral premolars.
Numerous factors influence the outcome of the reha-
bilitation; however, the two main factors are the bone
and soft-tissue deficiencies at the intended implant
site (66). Planning for these deficiencies is helped by
the use of computerized guided surgery (which allows
insertion of the implant to be planned in detail) and
stereolithographic and three-dimensional printed
surgical guides (to aid implant insertion in the most
appropriate prosthetic position).
These techniques make implant rehabilitation a
more predictable treatment modality and implant sur-
vival rates have improved over recent years, as
reported in several publications and systematic
reviews (55). Nevertheless, expectations from the treat-
ment have changed and esthetics plays an important
role in defining the success of rehabilitation. Various
surgical approaches are described in terms of timing of
implant placement (32) and management of regenera-
tive procedures (73). More than the osseointegration
of the fixture, patients expect optimal esthetic results
(30) from their rehabilitation, with a concomitant
shortening of the treatment time, if possible. These are
the main reasons why implantologists have shifted the
focus of their study to esthetics, measured using new
indices (5, 31, 70) that evaluate the aspects of the pros-
thesis and soft tissues. Another way of assessing
implant ‘success’ is by using patient-reported outcome
measures, introduced at the Eighth European Work-
shop on Periodontology. Patient-reported outcome
measures define the perception of the oral health of
176
© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
PERIODONTOLOGY 2000
the patients and their quality of life, their satisfaction
and nonclinical parameters (25, 45). The esthetic area
is highly involved in these perspectives and is very
challenging for the clinicians. The aim of this article is
to discuss the different implant placement alternatives
in the esthetic area, in particular:
 the timing of implant placement/regenerative pro-
cedures/skeletal growth/altered passive eruption.
 the correct three-dimensional position of the fix-
ture between the cuspids and in the premolar area.
 cases of multiple missing teeth in the esthetic area
with single tooth/pontic or cantilevered options/
prosthetic compensation.
 implant placement into infected sites.
 the influence of the morphology of the abutments
and the crowns on implant position.
Timing of implant placement/
regenerative procedures/skeletal
growth/altered passive eruption
The frequently cited consensus statements (32)
regarding timing of implant placement defines four
categories: immediate implant placement (type 1);
early placement with soft-tissue healing (type 2); early
placement with partial bone healing (type 3); and late
placement (type 4). A recent systematic review (14)
investigated the outcome of immediate and early
placement of implants in the esthetic area: despite
the great heterogeneity of the studies included,
immediate implant placement provides good soft-tis-
sue esthetic outcomes. The main concern following

immediate implant placement is the greater extent of
recession of the mid-facial mucosa, compared with
early implant placement. Immediate loading in postex-
traction sockets also leads to promising results (26).
Regenerative procedures play an important role in
immediate placement, and soft-tissue stability depends
strongly on bone volume support and blood supply.
Tarnow et al. (68) evaluated changes occurring on the
facial and palatal ridges during flapless immediate
implant placement and showed that less bone resorp-
tion occurred when a bone graft was placed together
with a provisional restoration. According to the
authors, the bone graft could be placed in the gap
between the implant and the alveolus wall and also
coronal to the implant–abutment interface in order to
provide support and volume to the soft tissues (17).
The bone graft particles are incorporated within the
soft tissues without any inflammatory response (1).
Others have reported similar results in soft tissues (16),
and the facial soft-tissue thickness is reported to be
greater in grafted sites compared with nongrafted sites
and when a provisional restoration is provided. The
thickness of soft tissues is important for helping to
maintain their stability at the crown margin and to
mask the greyish appearance caused by the titanium
abutment and the implant collar itself. An established
threshold of 2 mm is defined to avoid this complica-
tion (37). These esthetic-outcome findings are con-
firmed by Rieder et al. (57) in randomized clinical
trials. The Pink Esthetic Scores of postextraction,
immediately loaded implants were superior to those of
immediate implant placement and delayed provisional
restorations, early implant placement with immediate
loading or early implant placement with early loading,
and significantly superior when compared with the
group with early implant placement and immediate
loading. The results of immediate placement and
immediate loading seem promising and show how reli-
able this approach can be. Nevertheless, it is necessary
to point out that this approach is technique sensitive
and that the skill and experience of the surgeon play a
fundamental role in the outcome of the therapy. In
immediate implant placement, the biotype used to be
considered as an important factor, with several studies
in the past only including patients with a thick biotype.
However, Khzam et al. (42), in a recent systematic
review, failed to find a clear correlation between
esthetic results and a thick biotype. In immediate
implant placement, soft-tissue augmentation seems to
be less important than bone augmentation: a recent
systematic review failed to find consistency regarding
this topic, although a significant increase in keratinized
gingiva was found (47). This is important as keratinized
Implants in the esthetic area
gingiva is thought to contribute toward maintaining
health of peri-implant tissues (49, 61).
Resorption of buccal bone follows tooth extraction
and early implant insertion (2), necessitating bone aug-
mentation using autologous or heterologous bone cov-
ered by a membrane and primary tension-free wound
closure. Bone augmentation is necessary in early
implant placement cases to re-establish a correct bone
volume to support soft tissues (8) with a physiological
biological width (21, 40). With a follow-up of 5–9 years,
Buser et al. (7) obtained excellent results in terms of
esthetic parameters (Pink Esthetic Score and White
Esthetic Score) and clinical and radiological findings.
The latter were obtained using cone-beam computed
tomography postoperatively, permitting assessment of
dimensional changes caused by bone resorption (7).
In the last few years, quality of life and patient satis-
faction evaluations have been reported in implant lit-
erature. Usually, a questionnaire or visual analog
scale is used, with no standardized approach to
reporting patient-reported outcome measures (25). In
clinical studies that evaluated quality of life, immedi-
ate implant placement emerged as the preferred
alternative because of shortened treatment time,
immediate esthetic improvement, reduction of mor-
bidity and fewer surgical interventions (36). This
short-term, high satisfaction appears to be main-
tained in studies with a longer follow-up (44). Never-
theless, only a handful of studies address this issue
and conclusive outcomes are still missing (42).
The relationship between time and implant place-
ment is not only related to the time of tooth extrac-
tion but also to the age of the patient. In young
patients with teeth missing as a result of agenesis or
trauma, implant rehabilitation should be postponed
until after jaw growth has ceased. Implants do not fol-
low the eruption of natural dentition during growth,
with intimate contact with bone; therefore, implant
placement in a growing jaw could result in a discrep-
ancy in the occlusal and gingival planes and an unes-
thetic result (52). Early implant placement presents a
further risk in young patients as it could alter the
development of a normal jaw. The population can be
divided into normal, long or short facial types, and
the skeletal growth in each of these categories is dif-
ferent. According to Heji et al. (33), implants inserted
during growth in patients with a short facial type will
tend to shift palatally compared with the natural den-
tition. In patients with a long facial type, there is
increased vertical movement of the dentition, result-
ing in disharmony of oral implants. Factors to con-
sider when evaluating growth cessation in younger
patients are summarized as follows (33):
177
Testori et al.
 check the tracing of cephalometric radiographs
taken at least 6 months apart.
 no growth changes for 1 year.
 body growth, in length, annually for 2 years:
annual growth should be <0.5 mm per year.
 control change of dental position (e.g. of the sec-
ond molar).
Schwartz-Arad & Bichacho (62) compared the sub-
mersion rate (formerly ‘percent of crown occlusal-
gingival length per year’) of implants in the maxillary
incisor region and natural dentition in two groups: 30
years of age and older; and younger than 30 years of
age. The younger group showed a submersion rate
three times greater than observed in the older group.
Submersion is therefore more important in patients
between the ages of 20 and 40 than in those over
40 years of age and its mean rate varies with age. Fur-
thermore, in a large clinical study, Fudalej et al. (54)
state that the growth of the skeletal base continues
after puberty but the amount of growth decreases
steadily after the second decade of life. They also
reported a difference in the amount of growth
between the sexes, with the rate of eruption in maxil-
lary central incisors being greater in female patients
than in male patients. Another developmental condi-
tion to consider when planning implants is altered
passive eruption, defined as incomplete passive erup-
tion of teeth in patients with completed facial and
skeletal growth (77). Altered passive eruption can
result in esthetic deficiencies, plaque retention and
gingival inflammation (77). When a patient with
altered passive eruption needs implant rehabilitation
in the esthetic area, it is advisable to plan the peri-
odontal plastic surgery in order to establish correct
tooth/soft-tissue parameters before implant place-
ment, to obtain a good esthetic outcome. In cases of
dental agenesis, bone recontouring is often needed in
order to establish the correct apicocoronal position of
the implant (Fig. 1). The following key concepts in
implant placement/regenerative procedures/skeletal
growth/altered passive eruption should be noted:
 immediate implant placement has a good success
rate in terms of esthetics.
 in immediate implant placement, less bone
resorption occurs when a bone graft is placed
together with a provisional restoration.
 immediate implant placement and immediate
loading are technique-sensitive procedures.
 in early implant placement bone augmentation is
necessary in order to support the soft tissues.
 quality-of-life evaluations reveal that the preferred
alternative for patients is immediate implant
placement.
178
 cessation of skeletal growth should always be
assessed before implant placement.
 periodontal plastic surgery should be planned
before, or simultaneously with, implant placement.
The correct three-dimensional
position of the fixture between the
cuspids
In the esthetic area, more than elsewhere, placing the
implant in the proper position is essential in order to
avoid esthetic complications. The objectives are:
 to minimize the resorption of the bundle bone.
 to maintain the correct distance between adjacent
teeth/implants to preserve adequate blood supply
and maintain healthy, hard and soft tissues.
 To allow a correct prosthetic phase.
As mentioned before, postextraction resorption of
bundle bone and consequent mucosal recession are
the main concerns in the esthetic area. Therefore,
thorough evaluation of the site and buccopalatal
planning of the position of the fixture are vital. To
determine the feasibility of immediate implant place-
ment, evaluation of the sagittal root position is
important. Four classes of sagittal root position have
been described by Kan et al. (39):
 Class I: adjacent to the vestibular bone plate.
 Class II: in the middle of the alveolar crest without
any contact with vestibular or palatal cortical bone.
 Class III: adjacent to the palatal bone plate.
 Class IV: two-thirds engaging the vestibular bone
plate.
Class I represents the most favorable clinical situa-
tion as it has a sufficient amount of palatal bone to
achieve primary stability during immediate implant
placement (Fig. 2 ). Buser et al. (9) and a recent sys-
tematic review (48) identified a so-called ‘comfort
zone’ where the implant should be placed 1.5–
2.0 mm palatal to the incisal margin of the central
maxillary incisors and should be inserted leaving at
least 2 mm of buccal bone (3, 31). In postextractive
cases, it is extremely important to evaluate the dis-
tance between the implant and the outer surface of
the alveolar bone wall. If it is <4 mm, internal (in the
alveolus) and external (outside the buccal bone) graft-
ing is recommended to maintain the volume and
contour of the ridge in order to achieve a good
esthetic outcome (11). The mesiodistal implant posi-
tion determines the sustaining bone and the blood
supply that allows papilla preservation, a fundamen-
tal factor in defining a good esthetic outcome. The
root position of adjacent teeth should be carefully

A B
D E
G H
J K
Fig. 1. Bone recontouring is required to establish the cor-
rect apicocoronal position of the implant in dental agene-
sis. (A) Preoperative phase. The patient presents agenesis of
the lateral incisor and altered passive eruption. (B–D). Dur-
ing implant insertion, the first objective is to correct the
altered passive eruption in order to place the implants in
the correct position. (E, F). Insertion of the implant (right
lateral incisor position): the site is prepared and a scalloped
ostectomy is created at the vestibular plate to allow correct
three-dimensional implant placement in harmony with the
Implants in the esthetic area
C
F
I
L
adjacent teeth. An unavoidable fenestration (G) was neces-
sary to place the implant in the proper position and subse-
quently vestibular bone augmentation was performed with
deproteinized bovine bone (H) and a collagen membrane
(I). (J–P) Second-stage surgery: the incision made on the
right-hand side preserved the papillae, allowing better mat-
uration in the provisional phase compared with the left-
hand side where the papillae were detached. Radiographic
evaluation pre (Q–T) and post (U) implant insertion. (V, W)
Final restoration. (X, Y, Z1–Z3) Eight-year follow-up.
179
Testori et al.

M N O

P Q R

S T U

V W X

Y Z1 Z2 Z3

Fig. 1. Continued.

evaluated as when they are too close to the future
implant site, the residual thin bone could be
resorbed, resulting in reduced support for the soft tis-
sues. Orthodontics could be very useful to re-estab-
lish a proper restorative space. Implants should be
placed at least 1.5 mm away from the adjacent tooth
(31), a measurement that derives from the process of
horizontal remodeling of the proximal bone (67).
When there are two adjacent implants, a distance of
3 mm should be left between them (31) in order to
preserve bone level at the implant shoulder. Platform
switching, defined as reducing the diameter of the

180
 Implants in the esthetic area

abutment with respect to the diameter of the implant
(46), could reduce peri-implant bone loss, thus pre-
serving soft-tissue levels (34). Some authors present
evidence that with platform switching, the interim-
plant distance could be reduced (72). This is interest-
ing, especially when the space available for implant
placement is reduced, such as for maxillary lateral
incisors. In the apicocoronal dimension, a distance of
5 mm from the contact point and alveolar crest
allows good soft-tissue esthetics to be maintained (15,
69). As with teeth, in implant restoration, the level of
the papilla is strongly related to the bone level adja-
cent to the teeth/implant (15). In the apicocoronal
direction, the implant should be inserted 3–4 mm
apical to the gingival margin of the future restoration
(12, 59). The use of a surgical stent (reproducing the
dimensions of the definitive prosthetic crown) during
implant placement is helpful in determining this
measurement (35) (Table 1) (Fig. 3).
The correct three-dimensional
position of the fixture in the
premolar area
When it comes to evaluating an esthetic result, the
patient’s perception may differ from that of the clini-
cian. The commonly used subclassification of esthetic
outcome, based on a high, medium or low lip line,
may not fulfill the patient’s needs, and the authors
suggest considering each anterior case as an estheti-
cally important case regardless of the lip line. In the
premolar area, the implant should be buccally
inclined to provide two clinical advantages: first, to

Fig. 2. Radiograph showing the most frequent class of

sagittal root position classification, Class I (86.5% in the Fig. 3. Correct maxillary anterior implant position,
maxillary central incisors), according to Kan et al. (39). B, mesiodistally and apicocoronally (courtesy of Capelli &
buccal; L, lingual. Testori [12]).

Table 1. Literature corresponding to the correct three-dimensional positioning of an implant

Literature Mesiodistal Literature Apicocoronal Literature Buccopalatal

Grunder 1.5 mm to Buser et al. 1 mm palatal to the point

et al. (2005) adjacent tooth (2004) (9) of emergence of the
(31) adjacent teeth

Vela et al. 1 mm to Saadoun et al. (1999) (59), 3 mm below the

(2012) (72) adjacent tooth Grunder et al. (2005) (31), apical margin
with platform Capelli & Testori (2012) (12) of the crown
switching
Grunder 3 mm to Buser et al. (2004) (9) 1 mm apical to the Scutella et al. Long axis of the implant
et al. (2005) adjacent cementoenamel (2015) (63) should correspond to
(31) implant junction of the the incisal edge of the
adjacent tooth future restoration or to
the adjacent teeth

181
Testori et al.
A B
D E
G H
Fig. 4. Buccal positioning of implant. (A) Destructive caries
renders a first upper premolar as hopeless. (B) Tooth socket
after atraumatic extraction of the hopeless tooth. (C)
Implant direction pin parallel to the root of the adjacent
premolar, which shows that the implant should be angled
toward the buccal side. (D) Intra-external grafting with
small particles of deproteinized bovine bone. (E) Bone graft
covered with a collagen membrane. In our experience this
avoid apical fenestration as a result of the natural
morphology of the maxilla; and, second, to achieve
the correct emergence profile of the future crown if
the implant platform is more buccally positioned. It is
easier to create the correct prosthetic profile when
the implant is buccally inclined (Fig. 4).
Multiple missing teeth in the
esthetic area with single tooth/
pontic or cantilevered options/
prosthetic compensation
In the esthetic area, when multiple teeth are missing
or need to be extracted, careful planning is required
182
C
F
grafting prevents resorption of the buccal bone plate with a
subsequent concavity in the esthetic zone. The membrane
is intentionally left exposed in order to avoid any secondary
mucosal approximation and to increase the amount of ker-
atinized peri-implant mucosa in a single procedure. Defini-
tive prosthesis: vestibular (F) and occlusal (G) views. (H)
Radiograph of the final prosthesis with the platform switch-
ing concept.
to determine the number of implants to be placed
and their positioning. Cone-beam computed tomog-
raphy can be used to measure the available residual
bone in three dimensions. In the mesiodistal aspects,
as mentioned above, the interimplant distance
(3 mm minimum) should be greater than the tooth–
implant distance (1.5 mm minimum) in order to pre-
serve the residual bone and achieve stability of the
soft tissues.
It is important to evaluate the changes in the resid-
ual bone in the edentulous arch in order to plan the
correct number and position of the implants. For
example, when replacing four anterior teeth, the use of
four implants is rarely possible because of space issues.
According to the author’s clinical experience, 5 mm of

A B
D E F
G H
Fig. 5. (A) Rehabilitation of four implants replacing four
maxillary incisors (courtesy of M. Capelli & T. Testori [12]).
(B) Preoperative clinical photograph of the failing fixed par-
tial prosthesis. After removal of this failing fixed partial
prosthesis (C), periapical radiographs revealed that both
lateral incisors were fractured and unsalvageable (D, E). (F)
Implants were placed in the central and lateral incisor posi-
tions. Occlusal view (G) and radiographic images (H, I) of
the laboratory-fabricated screw-retained provisional
restoration placed 1 day after implant placement. (J) Six
months later the implants in the lateral incisor position
were uncovered and the soft tissue was left to heal for an
additional 2 months. (K) Implant pick-up impression cop-
ings were placed onto the implants and periapical radio-
graphs were taken to ensure proper seating of the copings.
(L, M) A silicone impression of the provisional restoration
was used to create the second provisional restoration as
well as the definitive restorations. (N) The silicone
interimplant space is recommended in the esthetic
zone (70). Therefore, in a rehabilitation involving the
four maxillary incisors, it is possible to insert four
implants only if there is a minimum intercanine pros-
thetic space of 33 mm and thus the correct distance
between teeth and implants and between implants can
Implants in the esthetic area
C
I
impression was fitted onto the land area of the cast (over
the ZiRealâ Posts) and identified the amount of reduction
needed. (O) A red marker pen was used to indicate the loca-
tions of the planned reductions on the abutment. (P) The
prepared abutments in place on the master cast. These
were prepared consistent with the contours of the provi-
sional restoration. (Q) Composite image of the prepared
ZiRealâ Posts in place on the implants. Note that the mar-
gins of the abutments were subgingival. (R) Clinical pho-
tograph of the provisional restorations in place. (S, T)
Postrestorative periapical radiographs show minimal bone
remodeling around the implants, more than 1 year after
placement. (U) Clinical photograph of the definitive
restoration at the 9-year follow-up. Note the stability of the
peri-implant soft tissues. (V) Extra-oral view of the final
case. The patient has a very low lip-line. Orthopantomo-
graph (W) and periapical radiographs (X, Y) of the definitive
restoration at the 9-year follow-up.
be respected (70) (Fig. 5). A tooth-borne computerized
surgical stent is recommended in such cases, although
training is necessary to avoid complications (51). Plac-
ing four implants to replace four missing maxillary
incisors will allow for the provision of four single pros-
thetic crowns and a better distribution of the occlusal
183
Testori et al.

J K L

M N O

P Q R

S T U

V W X Y

Fig. 5. Continued.

forces. In any case, implants with oversized or greater In Table 2 (12), the ideal diameter of an implant
diameter are considered a risk factor for the esthetic according to the site of implantation, as well as the
area leading to midfacial recession (10, 18). anatomical features of the tooth being replaced, are

184

Table 2. Ideal diameter of implants in relation to the implantation site and the anatomic features of the tooth being
replaced
Maxillary Mesiodistal dimension Mesiodistal dimension of roots at the
of the crown (mm) cementoenamel junction (mm)
Central incisor 8.6 5.5
Lateral incisor 6.5 4.3
Canine 7.6 4.6  1
First premolar 7.1 4.2  1
Fig. 6. Two implants replacing maxillary lateral incisors
(Courtesy of M. Capelli & T. Testori [12]).
stated for the maxillary anterior region. However, fol-
lowing tooth/teeth extraction, the ridge will resorb
preferentially buccally, reducing the arch available for
placing implants, resulting in palatal displacement of
the available residual bone. When the placement of
four implants is contraindicated, provision of two
implants in the lateral incisor sites, supporting fixed
dental prostheses with two ovate pontics in the cen-
tral positions, is one feasible solution (Fig. 6) (43). In
some clinical scenarios the root morphology of the
adjacent teeth prevents placement of the implant in
the most favorable prosthesis position. In such cases,
the use of cantilever restorations is strongly recom-
mended (Fig. 7). Rehabilitation in the esthetic area
could be impaired by a great deficiency of bone in
horizontal and vertical dimensions. This could lead to
unsatisfactory restoration in terms of soft-tissue vol-
umes, incorrect tooth proportions, misalignment of
the tooth axes and an unsupported lip profile (19).
Sometimes there is no alternative but to reconstruct
both hard and soft tissues and use artificial gingiva to
compensate for the soft-tissue deficiencies (20, 60)
(Fig. 8).
Postextraction implants in infected
sites
Teeth are often extracted because of an irreversible
infective process. In the past, any ongoing infective
process represented a contraindication to implant
Implants in the esthetic area
Implant diameter (mm)
4–5
3–3.25
4/5
4/5
insertion because of the possibility that the infection
could interfere with the healing process, hinder
osseointegration and lead to implant failure. How-
ever, later investigations showed that an accurate
socket debridement before implant placement could
allow successful osseointegration of the fixture. Stud-
ies show that survival rate does not significantly differ
from those of implants placed into noninfected or
healed sockets (4, 13, 22, 23, 28, 29, 38, 50, 64, 71). A
recent retrospective study with 369 patients and 527
implants placed in infected and noninfected sites, fol-
lowed for an average of 54 months, found no statisti-
cal difference between the two approaches in terms
of implant survival rate (78) (Fig. 9).
Influence of abutment morphology
and crown contours on peri-
implant soft tissue
There is little literature regarding the soft-tissue
response to different implant abutment designs, with
a PubMed search revealing only four studies investi-
gating this topic, none of which were randomized
controlled trials (Table 3). The gold standard, con-
cerning abutment shape, is still the one with a diver-
gent profile to establish an emergence profile similar
to a natural tooth. However, divergent transmucosal
profiles can have an adverse effect on tissues, with
negative pressure, ischemia and a tendency for reces-
sion. Rompen et al. (58), in 2007, were the first to
show that a concave, gingivally converging transmu-
cosal profile could improve soft-tissue stability and
thus avoid tissue recession. In this study, experimen-
tal titanium abutments with a concave, inwardly nar-
rowed profile at the transmucosal level were selected
(Curvy; Nobel Biocare AB, Goteborg, Sweden). They
evaluated 54 implants placed in esthetically demand-
ing areas, with a follow-up of 1–2 years; vertical gain
or no recession in soft tissues was observed in 87% of
the tested sites, while no recessions >0.5 mm were
185
Testori et al.

A B C

E F G

H I J

K L M

N O P

found in the remaining sites. These authors related blood clot forms, providing space for soft-tissue
the positive behavior of the soft tissues to the combi- growth and thickening; second, the curved profile
nation of three factors: first, the circumferential allows for increased area of the interface between the
microgroove creates a void chamber in which the soft tissue and the implant; and, third, after soft-

186

Fig. 7. Four failing upper incisors requiring extraction
because of root resorption after trauma. Frontal (A) and
occlusal (B) views, together with an orthopantomograph
(C) and periapical radiographs (D) showing root resorp-
tion. Frontal (E) and occlusal (F) views after extraction of
the teeth; frontal view (G) and orthopantomograph (H)
after provisional restorations are in place. (I) Adapted pro-
visional restoration after implant insertion to permit
A B
D E
G H
J K
M N
Fig. 8. Preoperative phase: patient presents an existing,
fixed prosthetic restoration in the esthetic area (A) and two
cuspids with a hopeless prognosis (B, C). (D) Implants
were inserted in the canine sites and in the right lateral
incisor site. The final fixed restoration with pink ceramic
(E, F) to compensate for the bone deficit, allowing ade-
quate lip support as well as improving facial esthetics.
Implants in the esthetic area
correct healing. (J, K) The soft tissues are conditioned by
the provisional prosthesis. The implants were placed in
positions 1.1 and 2.2 because of the altered morphology of
the cuspid with a mesially curved root. Frontal view (L)
and periapical radiograph (M) of the metal ceramic bridge
immediately after placement. Twelve-year follow-up:
extra-oral (N) and intra-oral (O) frontal views and periapi-
cal radiograph (P).
C
F
I
L
O
Intra-oral frontal (G), lateral (H, I) and occlusal (J) views.
Extra-oral side (K) and frontal (L) views. Orthopantomo-
graph (M) showing the three implants in the esthetic area
without bone reconstruction and prosthetic compensa-
tion. Twelve-year follow-up. Intra-oral frontal view (N)
and periapical radiographs (O).
187
Testori et al.

A B C

D E F

G H I

J K L

M N O

188
 Implants in the esthetic area

Fig. 9. Patient with two hopeless central incisors: extra-oral
photograph (A); medium lip-line smile (B); a sinus tract pre-
sent (C). Periapical radiographs (D) and cone-beam com-
puted tomography images showing the fracture line (E) and
external root resorption (F). After atraumatic extractions,
two implants are positioned intentionally, leaving a gap
buccally (G). Two provisional posts are adjusted intra-orally
and an acrylic-resin splinted, screw-retained provisional
restoration is placed (H). Postoperative radiograph (I). Final
result with a definitive prosthesis 3 years postextraction
and implant placement (J, K). Note the maintenance of the
buccolingual width (L). Periapical radiograph 3 years post-
operatively showing bone preservation both distally and
mesially (M). Cone-beam computed tomography images
3 years postoperatively (N, O). Note that the buccal wall
thickness is maintained.

tissue maturation, a ring-like seal is created, stabiliz-
ing the connective tissue adhesion, thus mimicking
(from a functional point of view) the effect of the
Sharpey’s fibers on natural teeth. However, the study
was designed without a control and therefore the sci-
entific impact of such an experiment is limited. Rede-
magni et al. (56) retrospectively evaluated the
soft-tissue stability around immediate implants and
single-tooth restorations with a concave abutment
(Curvy; Nobel Biocare AB, Goteborg, Sweden). The
study was performed on 28 patients with a mean fol-
low-up time of 20.4 months and showed buccal soft-
tissue stability and very little recession. However, the
prosthetic design was not the only variable investi-
gated. Sometimes the implant–bone gap was filled
Table 3. Studies published on implant design
with biomaterial and, in all cases, connective tissue
was harvested from the palate and grafted without
raising a flap. Patil et al. (53) published a compara-
tive, single-center, prospective clinical study to evalu-
ate the effect of two different abutment designs –
conventional divergent type and curved (Curvy;
Nobel Biocare, AB, Goteborg, Sweden) – on soft-tissue
healing and the stability of the mucosal margin in 29
patients. They concluded that abutments with a cir-
cumferential groove do not lead to a different
response of the mucosal margin compared with a reg-
ular abutment and they are no more resistant to
removal than regular abutments after 6 weeks of
function. Finally, Bishti et al. (6) recently undertook a
systematic review to determine the peri-implant

Study Study type Follow-up Number of implants Surgery procedure Results

period and protocol

Rompen Pilot clinical 24 months 41 patients; 52 implants: 13% with recession

et al. 54 implants. 1-stage approach. <0.5 mm.
(2007) (58) Replace, select 2 implants: 33.3% with recession = 0.
25 postextraction 2-stage approach. 53.7% with vertical gain.
implants
and 29 in
edentulous sites.
Redemagni Prospective, 20.4 28 patients; Connective tissue Buccal recession of 0.0
et al. comparative (range 6–50) 33 implants. harvest and (range: 0.5 1) mm.
(2009) (56) months Xive, immediate Bioss Collagen Significant loss of
placement, when gap present. height, on average
immediate 0.21 (range: 0.5 2)
provisional mm at mesial papilla.
but no loading. No significant loss of
height, on average
0.021 (range: 0.5 1)
mm at the distal papilla.
Patil et al. Retrospective, 6 weeks 29 patients; No guided bone No significant
(2011) (53) clinical 58 implants. regeneration. difference in marginal
with split-mouth Replace select, recession and in
design delayed. deseating force
(concave abutment between abutments
vs conventional from the experimental
abutment) group and the
control group.
Bishti Systematic review Searching randomized controlled trials, specifically on this topic, found
et al. that no long-term clinical studies are available.
(2014) (6)

189
Testori et al.

A B

Fig. 10. A convergent abutment profile (B) is the ideal morphology to allow soft tissue to proliferate compared to a diver-
gent design (A).

A B

Fig. 11. A natural maxillary incisor. (A) The lateral view shows a convexity corresponding to the cervical contour. (B) The
emergence angle is formed by the junction of a line through the long axis of the tooth (red line) and a tangent drawn to the
coronal aspect of the tooth as it emerges from the sulcus (blue line).

tissue response to different implant abutment materi-
als and designs, assessing, at the same time, the
impact of tissue biotype. The focus of their research
included the transmucosal part of abutments, scal-
loped implants, platform switching and abutment
materials. They concluded that the current literature
provides insufficient evidence regarding the effective-
ness of different implant abutment designs and mate-
rials on the stability of peri-implant tissues. However,
it stands to reason that circumferential reduction of
the prosthetic abutment will leave more room in the
area of the subcritical contour (65). This space will
eventually be filled with new tissue that will be thicker
and may be more stable. This is why a gingivally con-
vergent abutment profile, rather than a divergent
one, would be ideal to create such a void into which
tissues are allowed to proliferate (Fig. 10). Another
important restorative aspect is the contour of the
coronal restoration, which contributes strongly to
maintaining healthy and thick soft tissues.
The implant/abutment contour has been divided
into two separate portions (65): (i) critical contour,
defined as the area of the implant abutment and
crown located immediately apical to the gingival mar-
gin, corresponding to the artificial crown contour;
and (ii) subcritical contour, located apical to the criti-
cal contour and corresponding to the intramucosal
portion of the implant abutment not covered by the
artificial crown. These two entities will exist provided
that sufficient ‘running room’, defined as the distance
from the neck of the implant to the free gingival mar-
gin, is present (65). Both critical and subcritical

190
 Implants in the esthetic area

A B C

D E F G

Fig. 12. (A) The center of the implant corresponds to the cingulum of the adjacent teeth. (B) Occlusal view of the final zir-
conium abutment. The distance A-B will be filled by the cervical contour of the final crown (marked by inner and outer
semicircles shown in yellow). (C, D) The definitive lithium disilicate crowns with a cervical contour (marked by red dashed
lines and black arrows) out of the physiologic parameters determined by the implant position associated with a vertical fin-
ish line geometry. (E) Provisional restoration in place. (F) One-year follow-up of the definitive crown showing signs of tis-
sue reaction (marked by black dashed-line oval). (G) Periapical radiograph of the definitive crown.

contours, if properly modulated and shaped, may be
used to modify the esthetic outcome of the coronal
restoration. As mentioned above, in order to prevent
buccal bone resorption, the literature suggests
implant placement at the cingulum of the future
restoration or 1.5–2.0 mm palatal to the incisal mar-
gin of the central maxillary incisor. However, this
approach can lead to problems that may jeopardize
the esthetic outcome as well as the survival of the
implant as the crown contour created by such place-
ment is substantially different from the natural crown
contour. In the natural dentition, the tooth contour
comprises two separate entities: the emergence pro-
file; and the cervical contour. The emergence profile
is straight and corresponds to the part of the tooth
emerging from the gingiva. In contrast, the cervical
contour is convex and is located at the bottom of the
gingival sulcus, corresponding to the area where the
enamel overlaps the cementum at the cemento–
enamel junction (Fig. 11A). This convexity has been
identified by Wheeler (75), who referred to it as the
cervical ridge or cervical contour, and has the func-
tion of holding the gingiva under definite tension.
The amount of this convexity is given by the value of
the ‘emergence angle’ (Fig. 11B), which is defined as
‘the angle formed by the junction of a line through
the long axis of the tooth, and a tangent drawn to the
coronal of the tooth as it emerges from the sulcus’
(24, 41). The emergence angle was recently measured
on extracted, natural maxillary teeth and it was found
to have a mean value of 15° (27). In implant
rehabilitation, the value of the emergence angle and
the convexity of the cervical contour are influenced
by the buccopalatal position of the implant. The more
palatal the implant placement, the greater the emer-
gence angle and therefore the greater the cervical
contour. As one of the tasks of the restorative dentist
is to make artificial crowns appear similar to and to
function like natural teeth, the restorative angles and
contours should also be very similar to those of natu-
ral teeth (75).
Through the years it has become evident that
implant placement following the traditional guideli-
nes, using abutments with a light chamfer or feather
edge geometry, often results in fabrication of crowns
with a critical contour that is greatly different from
those of a natural tooth. An implant placed in accor-
dance with conventional guidelines (i.e. at the cin-
gulum of the future restoration) and restored using
a shoulderless narrow abutment (to allow a thicker
tissue) resulted in a final restoration with an exces-
sively convex contour that in the short term (after
1 year) was already causing the surrounding soft tis-
sue to react adversely (Fig. 12). Traditional guideli-
nes for implant placement have been conceived and
widely adopted for restorative wide abutments made
with a horizontal preparation (shoulder). However,
placing a shoulderless abutment in a cingulum or a
palatal (Fig. 13) position would lead to a crown with
a cervical contour far from the anatomic ones
described by Wheeler & Du (27, 75). On the other
hand, when the implant is slightly more buccally

191
Testori et al.

positioned, the emergence angle and cervical con-
tour look much more natural. There is no scientific
evidence at the moment that an excessive artificial
cervical contour, out of the physiological range (75),
is either beneficial or detrimental to soft-tissue sta-
bility, even though some adverse soft-tissue behav-
ior has been noted. However, increasing the
convexity of the critical contour will create an
undercut that will ultimately make cement removal,
in a cemented crown restoration, more difficult (74).
Leaving residual cement inside the gingival sulcus is
more likely to occur with restorations that have a
ridge lap, thus placing the implant at great risk of
peri-implantitis and eventual loss (76). Whenever a
light chamfer or a feather edge preparation, rather
than a wide shoulder, is chosen in the definitive
implant abutment, the buccolingual position of the
implant should be changed, especially in the
esthetic area. The center of the implant should cor-
respond to the incisal edge of the future restoration
or of the adjacent teeth, assuming that 1.5–2.0 mm
of buccal bone can be maintained. This is the only

Fig. 13. The long axis of the implant aiming (A) at the incisal edge of the future restoration, (B) at the cingulum of the
future restoration and (C) palatal at the cingulum of the future restoration.

A B C

D E F

Fig. 14. (A) The position of the implant is driven by a computerized surgical stent. (B) Occlusal view of the implant in place
at the time of the final impression. The center of the implant (yellow circle) corresponds to the incisal edge of the adjacent
teeth. (C) Occlusal view of the final zirconium abutment in place. Phisiologic profile determines a good tissue response as
marked by the two yellow lines. The screw access hole has been filled with Teflon and composite. (D) The ideal placement
of the implant will generate a correct cervical contour and emergence angle (marked by the red circle). (E) Final lithium
disilicate crown cemented. (F) The final radiograph.

192

position that enables fabrication of a restorative
crown with a cervical contour resembling, as closely
as possible, the natural tooth dimensions. It also
eliminates problems with cement removal, reducing
the incidence of iatrogenic peri-implantitis and
making dental-hygiene procedures much easier (63)
(Fig. 14). In summary:
 the critical contour should resemble the physio-
logic contour of a natural tooth and it is mainly
influenced by the implant position.
 traditional guidelines for implant placement have
been conceived for restorative abutments made
with a wide horizontal preparation.
 the long axis of the implant should correspond to
the incisal edge of the future restoration or to the
adjacent teeth, assuming that 1.5–2.0 mm of buc-
cal bone can be maintained.
 the sub-critical contour should be concave, rather
than convex, allowing growth of soft tissue, which
will become thicker and less susceptible to reces-
sion, thus also creating a strong barrier for bone
protection.
Conclusions
Implant rehabilitation in the esthetic area is a clini-
cal challenge because patients expect not only
implant osseointegration but also an esthetically
ideal result and a reduction in the treatment time.
Of the many factors that contribute to the final out-
come, the two most important ones are the bone
and soft-tissue deficiencies at the implant site. Com-
bining our long-standing clinic experience and the
pertinent literature, the following conclusions can
be drawn:
 immediate implant placement can be a successful
procedure in terms of esthetics but it is technique
sensitive and requires an experienced team.
 immediate placement is less traumatic to the
patient as fewer surgical procedures are involved
and patients tend to prefer this clinical approach
regarding quality of life.
 the diagnostic phase is of utmost importance, with
not only bone and soft-tissue deficiencies being
addressed but also skeletal growth, dental/im-
plant soft-tissue parameters (such as altered pas-
sive eruption) and the morphology of the roots
adjacent to the edentulous area.
 postextraction immediate loading is feasible in
infected sites.
 the correct position of the fixture should follow
widely accepted guidelines but the abutment
Implants in the esthetic area
morphologies play a role in the vestibular/palatal
position of the implant.
 the long axis of the implant, aiming at the incisal
edge of the future restorations, is the most appro-
priate implant position when a shoulderless abut-
ment is used and allows a restorative crown
morphology with a cervical contour resembling a
natural tooth.
 the use of a shoulderless abutment gives
more space for the tissue to grow compared with
the traditional abutment with a shoulder finish
line.
Acknowledgment
Caterina Ceci for helping to edit the manuscript.
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Periodontology 2000, Vol. 77, 2018, 197–212
Printed in Singapore. All rights reserved
Immediate implant placement
and provisionalization of
maxillary anterior single
implants
JOSEPH YUN KWONG KAN, KITCHAI RUNGCHARASSAENG, MATTEO DEFLORIAN,
T O M M A S O W E I N S T E I N , H O M -L A Y W A N G & T I Z I A N O T E S T O R I
Achieving and maintaining optimal gingival esthetics
around anterior single implants is a demanding task
(49, 73). In spite of the high success rates achieved
with osseointegrated implants, gingival recession of
up to 16% has been reported in anterior single
implants (38). On the other hand, spontaneous
rebound of the receded gingiva has also been
observed after a few years of function (20, 45, 50).
These changes in the peri-implant mucosa were pos-
tulated as being an attempt to establish a stable bio-
logic dimension (9). An understanding of the
dentogingival complex and its implant counterpart
(the peri-implant mucosa) allows clinicians to bal-
ance the biologic/physiologic requirements and
esthetic demands of single-implant restorations in
the esthetic zone.
The impending loss of a single tooth in the esthetic
zone in a patient with an otherwise healthy periodon-
tium can be a distressing experience (48–50, 56), and
the inevitable loss of soft and hard tissue following
tooth extraction often results in a compromised site
for implant placement in terms of esthetics. Various
surgical augmentation techniques have been advo-
cated as corrective procedures, but they are challeng-
ing and the results are not predictable (7, 44, 67, 70).
Since 1998, when Wo € hrle (87) first demonstrated suc-
cess with immediate implant placement and provi-
sionalization of single anterior maxillary implants,
numerous studies have substantiated the viability of
such treatments (6, 14, 18, 27, 29, 32, 39, 43, 51, 52, 55,
69, 71, 81, 84). One of the most desirable features of
immediate implant placement and provisionalization
© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
PERIODONTOLOGY 2000
is its efficacy in optimizing esthetic success by pre-
serving the existing osseous and gingival architecture
(37, 48, 52, 87).
The esthetic success of immediate implant place-
ment and provisionalisation procedures is influenced
by a number of factors that can be categorized as
intrinsic and extrinsic (53). Intrinsic factors are
patient-dependent and include the relationship
between hard and soft tissues, gingival biotype and
sagittal root position in the alveolar bone (47, 57).
Extrinsic factors, on the other hand, are clinician-
dependent and include three-dimensional implant
position and angulation, as well as the contour of the
abutment and the provisional restoration (48, 57).
The aim of this paper was:
 To review the literature in order to address topics
related to immediate implant placement and provi-
sionalization of maxillary anterior single implants,
specifically:
○ advantages of the flapless procedure;
○ the opportunity to fill the gap between the
implant and the buccal bone;
○ augmentation of soft tissue at immediate
implants;
○ the true advantage in terms of esthetics;
○ the esthetic evaluation and patient-centered
outcome; and
○ advantages and disadvantages with respect to
other delayed approaches.
 To provide a full clinical protocol for immediate
implant placement and its provisonalization in the
esthetic area.
197
Kan et al.
Advantages of the flapless
procedure
The traditional approach in implant surgery involves
flap reflection to prepare the site for fixture position-
ing. The flapless approach avoids this step, inserting
the implant without raising any flaps, simplifying the
procedure, reducing operative time and patient dis-
comfort, and favoring acceptance of the implant pro-
tocol (3, 61, 80). On the other hand, there is a learning
curve associated with this technique, and complica-
tions such as bony dehiscence and fenestration
occur. A clinical study reports a dehiscence rate of
4.73% with flapless surgery (13).
From a biologic point of view, the main advantage
of a flapless procedure is preservation of the perios-
teum and supraperiostal plexus and consequently the
blood supply to the alveolar bone is maintained (24,
82). Some clinical studies suggest that flapless surgery
prevents marginal bone loss (8, 76). A recent meta-
analysis (61) compared marginal bone loss and
implant survival rate between flapless and flapped
procedures. They found no statistically significant dif-
ference between the two, concluding that the flap
design should be chosen for patient comfort, need for
access and ridge augmentation, and experience level
of the surgeon (61). A case-series study evaluated soft-
tissue alterations in anterior maxilla that were rehabil-
itated with immediate implant placement and with
conventional implant treatment (74). Immediate
implant placement was performed with a flap or a
flapless procedure. Sixteen patients were treated with
immediate implant placement and 23 with conven-
tional treatment. The immediate implant placement
group showed only 7% recession, while in the control
group the recession was approximately 43%. Specifi-
cally, the flapless approach had significantly less
recession than the flap approach at the 26-week fol-
low-up. Flapless surgery is usually combined with
guided implant surgery templates. In the esthetic
area, with proper case selection, flapless surgery could
be very useful in maintaining soft-tissue health and in
obtaining good esthetics with peri-implant papilla
preservation (40). Fu € rhauser et al. (35) evaluated, in
terms of three-dimensional accuracies and pink
esthetic score, 27 patients rehabilitated with flapless
single-tooth implants for delayed replacement of
upper incisors. The results showed that this is a pre-
dictable treatment modality in terms of esthetics (me-
dian pink esthetic score = 13) and accuracy.
Nevertheless, the authors highlight that a deviation of
as little as 0.8 mm at the implant site is enough to
198
compromise implant esthetics. These findings high-
light that computer-guided surgery is a reliable proce-
dure only in the hands of skilled surgeons because it is
not free of complications (75). Before planning a com-
puter-guided surgery we should bear in mind that the
accuracy of cone-beam computed tomography, mea-
sured in dry skulls, is 0.6 mm (60) and the accuracy of
three-dimensional printers, frequently used to pro-
duce surgical templates, is between 0.25 and 0.5 mm
(79). Therefore, after three-dimensional planning a
global inaccuracy of 0.85–1.1 mm, before surgery, is
predicted. Clinicians should be aware of these data in
order to plan and prepare for surgery.
The opportunity to fill the gap
between the implant and the
buccal bone
In the literature, there are many studies investigating
various approaches to deal with the residual space
between the implant surface and the alveolar walls in
cases of immediate implant placement. Many animal
studies have quantified the amount of bone in direct
contact with the implant; they found that sponta-
neous bone formation occurs only after 4 months
with a maximum gap between the implant and the
buccal bone of 1–1.25 mm (11). The scientific evi-
dence is scarce in humans. Paoloantonio et al. (72)
found the degree of bone–implant contact after
immediate placement to be 70% in the mandible and
64.8% in the maxilla, which was similar to that found
for implants placed in healed sites. Connective tissue
without inflammatory cells in the coronal portion of
the implant was found in very few cases. Cornelini
et al. (23) found that the degree of bone–implant con-
tact was 61.4% and 3.2 mm of supracrestal connec-
tive tissue. Wilson et al. (86), in a human model,
found the average degree of bone–implant contact to
be 50% with a 1.5 mm gap. The degree of bone–im-
plant contact was reduced in cases with a 4 mm gap.
Bone resorption following tooth extraction is not
reduced by immediate implant placement per se but
is influenced by the apicocoronal and buccopalatal
position of the implant (47). Human studies show
that demineralized autologous graft, or other allo-
plastic grafts, left residual granules surrounded by
connective tissue or by immature bone after 6–
9 months (4, 17, 33). Deproteinized bovine bone has
been analyzed in animal studies in postextraction
sites and revealed osteoconductive properties in the
new-bone formations (10). Artzi et al. (4) tested

deproteinized bovine bone in 15 postextraction
human alveoli, followed by biopsies after 9 months,
and showed that using this approach the bone is pre-
served. Deproteinized bovine bone has been evalu-
ated using preoperative and postoperative computed
tomography scans (30 and 90 days postoperatively) in
order to assess the resorption of bundle bone.
Authors found that bone resorption was reduced by
20% in areas where biomaterials were used (68).
Soft-tissue augmentation at
immediate implants
Immediate implant placement is an effective proce-
dure from an esthetic point of view. Nevertheless, this
approach is usually associated with soft-tissue reces-
sion (9, 29, 52, 71). The absence of a vestibular bone
plate and the presence of a thin periodontal biotype
are considered to be risk factors for recession of peri-
implant tissues (47). In the esthetic area, the ultimate
goal for clinicians in implant therapy is to re-create a
natural restoration. Therefore, care must be taken, in
any chosen surgical procedure, to reduce any poten-
tial risk factors that might hinder the provision of
such a restoration. Surgical intervention should
include augmentation of bone volume and thickening
of soft tissues in order to achieve stability over time.
For thickening of soft tissues, different techniques,
such as connective graft, or a tunnel or a bilaminar
technique, have been proposed (22, 54, 89), all with
the objective of re-creating thicker soft-tissues. It is
easier to obtain this result in patients with a thick
periodontal biotype (65, 66) and therefore there is no
indication to perform any additional surgery. On the
contrary, in patients with a thin periodontal biotype
and usually thinner bundle bone, greater bone
resorption (34) is usually observed followed by soft-
tissue contraction (41). Regardless of the use of bone
grafts, connective tissue grafts alone thicken soft tis-
sues and, at the same time, compensate for the
unavoidable tissue contraction following tooth
extraction, leading to optimal esthetic results. A
recent systematic review found that a combination of
immediate loading of implant and connective tissue
graft allows for better stability of the gingival margin
and thickens the peri-implant soft tissues (59).
The main advantage in terms of
esthetics
Immediate implant placement postextraction does
not reduce bone resorption (16). Recent publications
Esthetic immediate tooth replacement
demonstrate that postextractive immediate implant
placement is a favorable clinical protocol, in terms of
esthetics, only through the combination of different
factors (19, 83). A careful presurgical diagnostic phase
includes evaluation of the morphology of the alveolar
process (47) and the periodontal biotype (41), fol-
lowed by surgical planning to provide a guide for
implant placement (41), to manage the peri-implant
gap (15, 88), and management of the less-invasive soft
tissue (using the flapless approach) and eventually its
thickening (54). Immediate loading plays an impor-
tant role in conditioning the soft tissues during heal-
ing with the provisional prosthetic restoration (77)
and, on its own, is capable of shortening treatment
time.
Esthetic evaluation and patient-
centered outcomes
Implant therapy has been evaluated in various ways
over the years, starting with ‘fixture survival’, being
the only parameter considered to judge successful
therapy. Together with technical advances, esthetics,
in terms of soft-tissue contour and prosthetic
restoration, became another important parameter by
which to judge rehabilitation. Most recently, the
patient’s perception of their surgery emerged as an
important parameter for comprehensive evaluation
of the therapy. In the literature, there are a large
number of studies but no consensus regarding the
correct method to undertake this type of research
(63). Nevertheless, the available literature reports
some interesting findings. Hof et al. (42) interviewed
150 patients about their perception of implant ther-
apy. Regarding the time of treatment, fewer intervie-
wees anticipated a healing period of at least
2 months after tooth extraction compared with a
healing period of at least 2 months after implant
placement (89% and 96%, respectively) and only 12%
were willing to tolerate increased risk of implant fail-
ure for the sake of shortening treatment duration.
De Bruyn et al. (28) published a systematic review of
oral health-related quality of life in implant dentistry,
with ‘quality of life’ being defined as the patients’
evaluation of their health in their daily lives (63).
Regarding the timing of implant placement, the
authors found no significant differences in shorten-
ing treatment time from a patient’s perspective. A
10-year retrospective study analyzed the vertical
dimension of vestibular bone of the one-stage post-
extraction implant with simultaneous bone regenera-
tion and also evaluated patient-related parameters.
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Kan et al.

Seventeen patients were evaluated after 10 years Table 1. Advantages and disadvantages of immediate
using a questionnaire with a visual analog scale in implant placement and provisonalization
aspects including chewing function, esthetic satisfac- Advantages Disadvantages
tion, peri-implant soft-tissue health, access for oral
hygiene, speaking ability and overall satisfaction (58). Shorter treatment time Risk of mucosal recession

A self-assessed score on a visual scale (of 1–10) for Preserves soft-tissue Skilled operator required
chewing function was 10, for esthetic appearance morphology
was 9, for mucosal health was 8, for cleansability of Better immediate esthetics
the restoration was 9, for overall satisfaction was 9
and for speaking ability was 9.5. Interestingly, these
encouraging results were not associated with loss of
facial bone, the concern most commonly recognized Table 2. Checklist for diagnostic and surgical prerequi-
in esthetic implant therapy. The authors found no sites
correlation between vertical bone loss and the posi- Diagnosis: parameters Gingival level in relationship to
tion of the facial mucosal margin or the papilla index to be evaluated adjacent teeth
system scores. However, this clinical study has lim- Osseous tissue–gingival tissue
itations: the radiographic images provide limited relationship at facial aspect
data of the facial bone volume and the vestibular Bone sounding of adjacent teeth
bony wall; and the thickness of the peri-implant tis- (peri-apical X-rays)
sue at baseline was not assessed.
Gingival biotype
Sagittal root position (cone-beam
The advantages and disadvantages computed tomography if needed)

with respect to other delayed Labiopalatal width

approaches Inter-radicular mesiodistal width

Diagnostic wax-up (tooth shape)
In the esthetic area, the immediate placement of an Surgical procedure Minimally traumatic extraction
implant and its immediate provisionalization are deli- prerequisites
Evaluation of the labial bony plate
cate procedures with favorable results, as demon-
with a periodontal probe
strated by the 5-year, multicenter, prospective
Correct three-dimensional implant
evaluation by Cooper et al. (21). The authors ana-
position
lyzed 55 implants in fresh sockets and 58 in healed
Primary implant stability
ridges. The survival rate was, respectively, 94.6% and
98.3%, with all the failures occurring in the first year: Evaluation of the gap morphology
this difference was not statistically significant. The (implant and vestibular bone
plate)
same result was noted in interproximal crestal bone
levels and soft-tissue levels. The authors remark that
these results could be obtained by using appropriate
guidelines and with careful patient selection. On the
other hand, Cosyn et al. (25), in another 5-year Table 3. Predictive factors for post-extractive immediate
prospective study, found that the mean mid-facial implant placement
recession increased with borderline significance
Variable Low risk High risk
between 1 and 5 years. The authors wondered if it
was feasible to recommend this approach in daily Biotype Thick Thin
practice. A recent literature review evaluated immedi- Gingival form Flat scallop High scallop
ate implant placement and immediate restoration
Tooth position/free Coronal Ideal or apical
with a single crown in the anterior maxilla; it reported
gingival margin
626 implants with a success rate of 97.96% and a sur-
vival rate of 98.25% (medium follow-up: 31.2 months) Tooth shape Square Triangular
(85) in accordance with the systematic review of the Position of the osseous crest: High crest Low crest
literature by Del Fabbro et al. (30), who reported an < 3 mm from adjacent
overall implant survival rate of 97.62% (range: 78.6– teeth and facially
100%) after 1 year of function. Modified from Kois & Kan (57).

200

A B
Fig. 2. The osseous–gingival tissue relationship can be
evaluated by bone sounding and should measure 3 mm on
the facial aspect of the failing tooth.
The Osteology Consensus Group (40) stated, in
2011, that the survival rate of postextraction implants
in the esthetic area is high but there is also a very high
risk of mucosal recession. Accordingly, case selection
should be carried out evaluating the following poten-
tial risk factors:
 smoking.
 < 1 mm vestibular bone.
 thin biotype.
 vestibular position of the implant.
In the same way, a recent International Team for
Implantology consensus statement underlines that,
Fig. 3. Sagittal root position classification. Class I (Cl I): the root is positioned against the labial cortical plate. Class II (Cl
II): the root is centered in the middle of the alveolar housing without engaging either labial or palatal cortical plates at the
apical third of the root. Class III (Cl III): the root is positioned against the palatal cortical plate. Class IV (Cl IV): at least
two-thirds of the root is engaging both labial and palatal cortical plates.
Esthetic immediate tooth replacement
Fig. 1. (A) The gingival level of the
failing tooth (#7) should be (i) at the
same level as (or more coronal than)
that of the contralateral tooth and (ii)
harmonious with the adjacent denti-
tion. (B) Harmonious horizontal facial
gingival tissue contour is observed in
the maxillary anterior region.
with immediate implant placement, the risk of muco-
sal recession increases (64). The research group rec-
ommends a careful case selection, to ensure:
 intact socket walls.
 facial bone wall at least 1 mm in thickness.
 thick soft-tissue.
 no acute infection at the site.
 availability of bone apical and palatal to the socket
to provide primary stability.
The use of surgical templates is suggested as well as
a provisional fixed restoration.
Regarding the timing of loading, the guidelines of
the International Team for Implantology group are as
follows (36):
 a torque of 20–45 N for immediate loading.
 no systemic health contraindication.
 more benefits than risks.
In the anterior region, immediate loading should be
performed with caution and by experienced clinicians
and should not be considered a routine procedure
(Table 1).
The American Academy of Fixed Prosthodontics (5)
remarks that:
“The risk–benefit of immediate loading in scenar-
ios in which support and stability from the
201
Kan et al.
A B
recipient site is diminished must be critically eval-
uated because of the difficulties in achieving
esthetic outcomes after failure.”
Diagnosis and treatment planning
Proper diagnosis of the patient’s condition is vital to
allow clinicians to formulate an optimal and pre-
dictable treatment plan (Tables 2 and 3). By recogniz-
ing unfavorable conditions, adjunctive procedures
can be incorporated to avert compromised situations.
The following parameters must be evaluated for an
immediate implant placement and provisionalization
procedure:
 The gingival level of the failing tooth should be: (i)
at the same level as (or more coronal than) that of
the contralateral tooth; and (ii) harmonious with
adjacent dentition, as some gingival recession can
be expected after the procedure (Fig. 1) (49).
Therefore, when the gingival level of the failing
tooth is more apical than that of the contralateral
tooth, orthodontic forced eruption is recom-
mended before immediate implant placement and
provisionalization (78).
 The osseous tissue–gingival tissue relationship can
be evaluated by bone sounding and should mea-
sure 3 mm on the facial aspect of the failing tooth
and 4.5 mm on the proximal aspect of adjacent
teeth (Fig. 2). There is a propensity for tissue reces-
sion after extraction, with or without immediate
implant placement, in low crest situations where
bone sounding measurements are greater than
those indicative of an optimal relationship (57).
Depending on the level of the gingival tissue,
orthodontic and/or periodontal treatment can be
202
Fig. 4. Cone-beam computed tomog-
raphy image (A) and periapical radio-
graph (B) of the failing tooth.
used to improve the osseous tissue–gingival tissue
relationship.
 Gingival biotype can be assessed during bone
sounding and categorized according to the visibility
of the underlying periodontal probe (SE Probe
SD12 Yellow; American Eagle Instruments Inc.,
Missoula, MT, USA) through the gingival tissues
with higher visibility corresponding to reduced
thickness of tissues (Fig. 2) (46, 56). A thin gingival
biotype, which has been shown to sustain more tis-
sue recession after surgical insults than a thick bio-
type, can be enhanced by using a bilaminar
subepithelial connective tissue graft at the time of
implant placement and provisionalization (53).
 A sagittal root position (47) of the failing tooth in
the alveolar bone can be identified via cone-beam
computed tomography and can be categorized as
one of four different classes (Fig. 3):
○ Class I: the root is positioned against the labial
cortical plate.
○ Class II: the root is centered in the middle of the
alveolar housing without engaging either labial
or palatal cortical plates at the apical third of
the root.
Fig. 5. Minimally traumatic extraction results in intact soft
and hard tissues.
 Esthetic immediate tooth replacement

Fig. 6. Facial bone-defect classification. V-shaped defect: isolated only to the mid-facial portion of the facial bony plate. U-
shaped defect: extends to mesial and/or distal aspects of the failing tooth. UU-shaped defect: extends to the mesial and dis-
tal aspects of the immediately adjacent teeth.

○ Class III: the root is positioned against the pala-

tal cortical plate.
○ Class IV: at least two-thirds of the root is engag-
ing both labial and palatal cortical plates.
It is important for clinicians to recognize cases that
are favorable for immediate implant placement and
provisionalisation (Class I sagittal root position),
cases that are more technique-sensitive and entail
additional attention (Class II and Class III sagittal root
position) and cases that are contraindicated for
Fig. 7. The implant should be placed at the center of the
immediate implant placement and provisionaliza- predetermined mesiodistal width of the final restoration
tion, requiring augmentation of hard and/or soft tis- with a minimal distance of 2 mm from the adjacent tooth.
sue before implant placement (Class IV sagittal root
position) (47).
 Buccolingual width and inter-radicular mesiodis-
tal widths of the failing tooth determine the diam-
eter of the implant to be used and can be
evaluated using cone-beam computed tomogra-
phy and periapical radiographs (Fig. 4).

Clinical procedure
Fig. 8. Papilla-sparing incisions are used for grafting pro-
cedures. Bone graft material is placed into the gaps
Diagnostic wax-up between the implant and the bony socket to maintain a
A diagnostic wax-up of the failing tooth on the study facial osseous contour.
cast should: (i) represent, as closely as possible, the
definitive restoration; (ii) match the contralateral
tooth; and (iii) be harmonious with the adjacent den-
tition. Proper diagnostic waxing provides information
necessary for treatment planning, especially when
adjunctive procedures (orthodontic and/or periodon-
tal intervention) are required. Provisional restoration,
as well as implant and soft-tissue surgical templates,
can be accurately fabricated from a well-crafted diag-
nostic wax-up. In situations where the coronal por-
tion of the failing tooth is intact and esthetically Fig. 9. A screw-retained provisional restoration is placed.

203
Kan et al.

A B

Fig. 10. (A) Bone graft material and

subepithelial connective tissue graft
are placed. (B) Placement of absorb-
able membrane.

A B

Fig. 11. Lateral (A) and facial (B)

views showing primary closure
achieved using chromic gut suture.

A B

Fig. 12. Periapical radiograph (A)

and cone-beam computed tomogra-
phy image (B) after immediate
implant placement and provisional-
ization of tooth #7.

acceptable, it can be modified after extraction to be

used as a natural-looking provisional restoration.

Surgical procedure
Immediate implant placement entails extraction of
the failing tooth followed by implant placement. The
extraction must be minimally traumatic with con-
trolled expansion of the bony socket to avoid soft-
and/or hard-tissue damage (Fig. 5). This can be Fig. 13. Clinical image of provisional restoration after
accomplished by first using Periotome (Nobel Bio- 4 months of healing.
care, Yorba Linda, CA, USA) to make a sulcular inci-
sion with transeptal fiberectomy that extends apically
beyond the marginal bone. This incision separates the labial plate must be verified using a periodontal
the tooth from the periodontal tissue, facilitating probe. Fenestrations located at least 5 mm apical to
extraction with minimal damage to the usually thin the intact facial marginal bone are generally inconse-
labial bony plate. After the extraction, the integrity of quential to the immediate implant placement and

204
 Esthetic immediate tooth replacement

A B

Fig. 14. Frontal (A) and occlusal (B)

images of the definitive restoration
3 years after the surgery. Note the
negligible changes in vertical and
horizontal gingival tissue architec-
ture, resulting in an esthetically
pleasing result.

Fig. 15. Periapical radiograph of the definitive restoration

3 years after the surgery. Fig. 16. (A, B) Intra- and extra-oral vision of the case.
Patient complains about mobility of tooth #52 and
unpleasant esthetics because of the morphology of teeth
#52-11-21-22 and their gingival contour.
Table 4. Checklist for procedures after implant inser-
tion
1. Immediate Relining and connection of
provisionalization provisional crown to a favorably to immediate implant placement and provi-
prefacbficated abutment sionalization with guided bone regeneration (Fig. 6).
2. Regenerative procedure Bone regeneration
It should be noted, however, that significant facial
and soft-tissue gingival recession, after 1 year of function, has been
Subepithelial connective
management reported when this technique was attempted on fail-
tissue graft (thin biotypes)
ing teeth with U-shaped (extending to the mesial
3. Postoperative instruction Antibiotics, analgesics
and/or distal aspects of the failing tooth) or UU-
Soft diet (4 months) shaped (extending to the mesial and distal aspects of
4. Definitive restorations 6 months after surgery the immediately adjacent teeth) defects (Fig. 6) (54).
Therefore, a failing tooth with a U-shaped or a UU-
provisionalization procedure, as these defects can be shaped defect is contraindicated for immediate
addressed predictably with grafting. implant placement and provisionalization.
When a facial osseous dehiscence/defect is Primary implant stability is a prerequisite for
detected, the predictability of immediate implant immediate implant placement and provisionalisa-
placement and provisionalization, in conjunction tion and is usually achieved by engaging the palatal
with guided bone-regeneration procedures, is deter- wall and the bone 4–5 mm beyond the apex of the
mined by the shape/size of the defect (54). A extraction socket. Therefore, a Class I sagittal root
V-shaped defect, which is confined only to the position, with a considerable amount of bone pre-
mid-facial portion of the facial bony plate, responds sent on the palatal aspect for implant engagement

205
Kan et al.

Fig. 17. Periapical radiograph shows

radicular resorption on tooth #52.

to attain primary stability, is optimal for immediate A

implant placement and provisionalization; and a
Class IV sagittal root position, with a limited
amount of bone for implant engagement, is a con-
traindication (47). Class II and Class III sagittal root
positions present compromised and/or challenging
conditions for immediate implant placement and
provisionalisation (47). In Class III sagittal root posi-
tions, implant stability must rely on its engagement
with the available bone on the labial aspect, which
can potentially lead to facial fenestration or perfora-
tion (47). In Class II sagittal root positions, as avail-
able bone on both the palatal and labial aspects is
inadequate, implant stability relies primarily on the B
amount of available bone beyond the apex of the
extraction socket (47).
The final implant diameter should be within the
confines of the tooth socket but, in order to help
prevent perforation, should not engage the usually
thin coronal portion of the labial plate. Further-
more, a minimal distance of 2 mm between the
implant and adjacent teeth is recommended to
minimize marginal bone loss occurring as a result
of encroachment (31). The final implant position
and angulation are in accordance with the following Fig. 18. (A, B) Atraumatic extraction of tooth #52 and
guidelines: detection of the vestibular bone plate at the soft-tissue
 mesiodistally: the implant should be placed at the level.
center of the predetermined mesiodistal width of
the final restoration with a minimal distance of
2 mm from the adjacent tooth (Fig. 7) At the incisal level, the implant should emerge at
 labiopalatally: the implant should be placed along the incisal edge of the final restoration. With this
the palatal wall of the extraction socket for pri- labiopalatal position/placement, a gap of at least
mary stability. At the cervical level, the implant 1.5 mm between the implant and the buccal bone
should emerge slightly lingual to the predeter- is maintained and the integrity of the labial bone
mined buccolingual width of the final restoration. is ensured.

206

A 
B UT, USA) to capture the cervical gingival emergence
C plate would undergo remodeling, characterized by
Fig. 19. (A–C) The implant site is prepared with the use of
a surgical guide, based on a diagnostic wax-up.
A B
Fig. 20. (A–C) Clinical and radiographic control before implant insertion.
Esthetic immediate tooth replacement
apicocoronally: the neck of the implant is placed
approximately 3 mm apical to the predeter-
mined facial free gingival margin of the final
restoration.
Immediate provisionalization
For immediate provisionalization, a prefabricated zir-
conium abutment (Nobel Biocare) or metal tempo-
rary abutment is manually prepared extra-orally and
then hand-tightened onto the implant. The provi-
sional shell is then relined with light polymerized
acrylic resin (Ultradent Products, Inc., South Jordan,
of the extracted tooth and adjusted to clear all centric
and eccentric functional contacts. The provisional
restoration can be screw-retained or cement-
retained. A cement-retained provisional restoration is
usually more esthetic, especially when the implant
access opening is at, or facial to, the incisal edge.
However, it also is at higher risk of gingival inflamma-
tion at the abutment–cement–restoration interface,
as well as cement debonding. It has recently been
demonstrated that following immediate implant
placement in an anterior tooth socket, the facial bony
bone fill from the inside of the socket and resorption
of the labial bony plate from the outside. Without the
bone graft, this usually results in significant horizon-
tal and vertical facial bone loss and subsequently in
facial gingival tissue loss (1, 2, 12, 26).
Papilla-sparing incisions are used for grafting pro-
cedures (Figs 8 and 9). After facial flap reflection, the
provisional restoration is secured either with screw
(Fig. 9) or with provisional cement (Temp-bond; Kerr
USA, Romulus, MI, USA) and excess cement is
removed. To maintain a facial osseous contour, bone
graft material [Bio-Oss (Osteohealth, Shirley, NY,
USA) and Puros (Zimmer Dental, Carlsbad, CA, USA)]
are placed into the gaps between the implant and the
C
207
Kan et al.

A B C

Fig. 21. (A–C) The provisional crown is prepared after implant insertion, post-extraction. Connective tissue graft is inserted
to augment the vestibular soft-tissue volume before its connection.

bony socket (Fig. 8) as well as over the facial aspect of

the socket in conjunction with absorbable membrane A
(Bio-Gide; Osteohealth) (Figs 9 and 10). If the thin
gingival biotype is present, a subepithelial connective
tissue graft can be placed facially at the gingival level
to improve the gingival condition (Fig. 10A) (53, 62).
Primary closure is achieved using 6-0 chromic gut
suture (Johnson & Johnson Ethicon, Livingston, UK)
(Fig. 11). The fit of the prosthesis and implant posi-
tion can be ascertained using periapical radiographs
and cone-beam computed tomography images
(Fig. 12).

Postoperative instructions
Appropriate antibiotics and analgesics are prescribed
B
for postoperative use. The patient is instructed not
to brush the surgical site, but instead to rinse gently
with 0.12% chlorhexidine gluconate (Peridex; Procter
& Gamble, Cincinnati, OH, USA). A liquid diet is
required for 2 weeks after the operation, and a soft
diet is recommended for the remaining duration of
the implant-healing phase, which typically lasts for
4 months (Fig. 13). The patient is also advised
against any activity that could irritate the surgical
site.
C
Definitive restoration
The final implant impression is usually made
6 months after the surgery. A customized zirconium/
gold alloy abutment (Procera; Nobel Biocare) is fabri-
cated, duplicating the gingival emergence profile of
the provisional restoration. The abutment should be
tightened onto the implant using the manufacturer’s
recommended amount of torque, and the fit should
be verified with a periapical radiograph. Subse-
quently, definitive cement (RelyXTM Unicem; 3M
ESPE, St Paul, MN, USA) should be used for the Fig. 22. (A–C) Clinical healing at the 6-month follow-up.

208

A A
B
Fig. 23. (A–C) Definitive prosthetic phase. Zirconia
implant abutment and prepared teeth (#11, #21, #22) for
veneer (Courtesy of Lorenzo Vanini MD, DDS, Visiting Pro-
fessor in Esthetic Dentistry, University of Chieti, Chieti,
Italy; Universite De La Mediterrannee, Marseille, France;
Private practice, Chiasso, Switzerland).
definitive restoration (Figs 14 and 15). Follow-up
appointments with the patient should be made at 1,
3, 6 and 12 months, and annually thereafter, in order
to ascertain the functional and esthetic outcomes
(Table 4).
Conclusion
Immediate implant placement and immediate load-
ing in the esthetic area are great opportunities in
modern dentistry (Figs 16–24). Nevertheless, the final
results are influenced by many surgical and pros-
thetic factors, not only the timing itself.
A review of the literature shows that:
Esthetic immediate tooth replacement
B
Fig. 24. (A–C) Initial and clinical comparison at the 5-year
follow-up. Peri-implant tissue appears stable around tooth
# 12, and teeth # 11, # 21 and # 22 are now in accordance
with dental esthetic guidelines and the final periapical
radiograph.
 immediate loading positively influences the
esthetic result.
 flapless procedures reduce surgical discomfort but
a skilled clinician is required.
 it is important to fill the gap between the implant
and alveolar socket with slow-resorbable biomate-
rial to prevent bone resorption after tooth extrac-
tion.
 in the case of a thin biotype, soft-tissue augmenta-
tion is suggested.
Careful case selection is the key for clinical success.
Immediate implant placement and immediate load-
ing should be performed only in certain types of
patients. The clinician should relate the difficulty of
the case to his experience and dexterity, evaluating
209
Kan et al.
other techniques such as the delayed or traditional
approach.
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Periodontology 2000, Vol. 77, 2018, 213–240
Printed in Singapore. All rights reserved
Horizontal bone-augmentation
procedures in implant dentistry:
prosthetically guided
regeneration
MATTEO CHIAPASCO & PAOLO CASENTINI
Experimental and clinical studies show osseointegra-
tion to be highly predictable, and dental implants cur-
rently represent a reliable means for restoring dental
function in partially and completely edentulous
patients (1, 16, 32). Although surgical and prosthetic
procedures are well consolidated as a result of more
than 30 years of clinical experience, treatment plan-
ning in oral implantology has, in recent years, under-
gone tremendous evolution. Implants were originally
used in restoring fully edentulous patients based on
the concept of ‘surgically and anatomically driven
implant placement’. Implant placement was primarily
determined by the location of available bone, and the
main goal was to allow adequate bone anchorage to
provide a functionally efficient prosthetic rehabilita-
tion. Following this concept, because osseointegra-
tion was the primary outcome of surgery, prosthetic
rehabilitation did not fulfill the esthetic ideal. In
these cases, dental restorations were often implant-
supported overdentures or fixed implant-supported
prostheses with distal cantilevers (Toronto bridge
concept) and it was possible to compensate for inade-
quate implant position using acrylic flanges (9, 59).
As oral implants have also been used for the
rehabilitation of partially dentate patients, esthetic
outcomes have become more important because
implant-supported partial prostheses have to inte-
grate with the adjacent natural dentition, both from a
functional and an esthetic point of view (6). A good
esthetic result can be achieved only if the implant is
placed in a carefully planned position, as determined
by the prosthetic needs. Therefore, the concept of
‘restoration-driven implant placement’ has been
introduced to optimize both function and esthetics
(44). As correct implant position is vital in order
to achieve a good esthetic result (14, 15), optimal
© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
PERIODONTOLOGY 2000
conditions of the alveolar bone, in terms of adequate
volume, as well as optimal conditions of the sur-
rounding soft tissues, are key prerequisites to obtain
a good clinical outcome. When these conditions are
lacking, because of hard- and soft-tissue deficiencies
(for instance, following atrophy, sequelae of peri-
odontal disease, traumas or congenital malforma-
tions), the bone volume and/or the surrounding soft
tissues (keratinized mucosa) must be augmented.
A host of bone-augmentation techniques, such
guided bone regeneration (11, 48, 57, 74), bone-
grafting techniques (10, 23, 29, 41, 51, 53, 60), and
alveolar bone expansion (3, 31, 72), have been pro-
posed and different systematic reviews have been
published to evaluate the outcome of various bone-
and soft-tissue augmentation procedures (2, 7, 27, 34,
56, 64). The aim of this article is to present a rational,
evidence-based and prosthetically driven approach
for the treatment of edentulous ridges affected by
horizontal defects, using augmentation procedures
and dental implants. A diagnostic protocol, a classifi-
cation of bone defects and the main augmentation
techniques will be described in detail. The selection
criteria for different surgical techniques for different
classes of bone defects will also be discussed.
Diagnosis and treatment planning
for partially dentate patients with
compromised alveolar ridges,
following a prosthetically driven
diagnostic protocol
As the rehabilitation (with implant-supported prosthe-
ses) of partially dentate patients affected by horizontal
213
Chiapasco & Casentini
defects of the residual alveolar ridge is often com-
plex from prosthetic and surgical viewpoints, a team
approach involving prosthodontists, periodontists, oral
and maxillofacial surgeons, orthodontists and dental
technicians is very important. The treatment plan
should include different, consecutive steps.
Exclusion of local and general
contraindications
Thorough analysis of the relative and absolute con-
traindications for implant therapy is a fundamental
prerequisite before taking any further steps in treat-
ment planning. It is beyond the scope of this chap-
ter to analyze all the local and general factors that
might contraindicate implant therapy. For more
details, specific publications are available in the
literature (42). Selection criteria used for standard
implant therapy (edentulous sites with no significant
bone defects) are also applied in the case of more
complex situations, bearing in mind that increasing
treatment complexity, from a surgical viewpoint,
may correspond to a higher incidence of compli-
cations in patients with compromised health (i.e.
partial or total loss of a bone graft in heavy smok-
ers or bone graft infection in immunocompromised
patients).
Examination of esthetic and functional
needs of the patient
The next step in implant therapy should always be to
analyze the individual needs and expectations of the
patient. It is important to identify patients with exag-
gerated and unrealistic expectations, as in some cases
these expectations may not be completely met in
spite of treatment to an adequate standard, and the
patient must be aware that a certain degree of com-
promise may be required and should be accepted. In
some cases, it is important to explain to patients that
the possibility of achieving a certain outcome is not
only related to the quality of the surgical intervention
but it may be compromised by initially unfavorable
conditions. For the same reason, in the presence of a
bone defect, patients must be informed that correc-
tion of the defect is vital to achieve a favorable final
result. In order to improve communication with the
patient, and to increase his/her involvement and
compliance toward treatment, traditional and digital
previsualization techniques are recommended. A
wax-up simulation, placed directly in the patient’s
mouth, is a useful technique to achieve an agreement
with the patient in terms of reasonable final results
214
(see ‘Evaluation of prosthetic feasibility’ in this sec-
tion). Patient’s compliance and collaboration during
treatment must always be evaluated because where
bone defects are present, staged, multiple surgical
procedures and a longer treatment time are usually
needed.
Preliminary clinical and radiographic
examination
A preliminary clinical examination will allow the clini-
cian to verify whether the patient is healthy from a
periodontal and dental point of view, and whether
the occlusal pattern is favorable. In the case of
pathology in these fields, it is paramount to treat the
pathology before any implant procedures. During the
preliminary diagnostic phase, the presence of ridge
defects should also be recognized. A panoramic radio-
graphic and periapical radiographs are usually suffi-
cient to achieve a preliminary ‘overview’ of the
conditions of the patient’s dental arches and to iden-
tify the presence of any bony pathology.
Evaluation of prosthetic feasibility
The concept of prosthetically driven implant dentistry
is well recognized and represents the gold standard
for implant-supported prostheses. In particular, a
good match between the position of the implant and
the future implant-supported restoration, in three
dimensions, is considered a prerequisite in the treat-
ment of partially dentate individuals and in the
esthetic area (15, 21, 26, 44). Furthermore, several
publications have underlined possible risks associ-
ated with inadequate implant positioning in the
esthetic area (22, 46), and surgical techniques have
been developed to manage these malpositioned
implants (81). In many cases, it has been reported
that failure, from an esthetic point of view, can be
attributed to placement of implants in residual bone
without considering the prosthetic position of the
restoration (Fig. 1A,B).
As a general rule, the feasibility of an implant-
retained restoration must be checked first from a
prosthetic point of view. Mounted plaster casts can
be used to provide a diagnostic wax-up that should
simulate, with wax of different colors, the ideal ridge
profile and the anatomy of dental units to be
replaced. If the restoration involves only one side of
the mouth, the contralateral side should be consid-
ered as a reference for the alveolar ridge and dental
morphology. The wax-up allows the recognition of
intermaxillary discrepancies or asymmetries between

A A
Fig. 1. Esthetic implant failure as a result of inadequate
three-dimensional implant placement (A): two implants of
excessive diameter have been positioned too far apically,
too close each other and with a pronounced buccal incli-
nation (B), with the aim to improve primary stability in the
available bone.
the two sides of the dental arch (Fig. 2A,B). It also
allows caliper measurement of the wax thickness sim-
ulating the vertical/horizontal augmentation that
may be necessary to achieve the ideal morphology.
Good communication with the dental technician is
paramount to define, from the outset, a precise treat-
ment strategy. Clinical intra-oral and extra-oral pic-
tures should be included in the diagnostic protocol
because they represent a very important tool for com-
munication between the different components of the
team as well as the patient.
The wax-up can also be used as a communication
tool with the patient, in order for them to recognize
anatomical discrepancies and the need for grafting
procedures to achieve a good final outcome. When
the esthetic area is involved in implant treatment,
the final result can be previsualized by means of a
fixed or a removable mock-up that is placed directly
in the patient’s mouth. The mock-up will be useful
in collecting the patient’s point of view regarding
esthetic parameters (dimensions of teeth, smile-line,
etc.) and will guide subsequent treatment steps. Pre-
visualization of a reasonable treatment outcome will
also be useful to guide patient’s expectations and
Prosthetically guided regeneration
Fig. 2. Wax-up of the posterior mandible (A): the ideal
ridge shape is primarily obtained with a layer of red wax.
Teeth are then waxed on top of the corrected ridge (B).
will increase patient’s motivation and involvement in
the entire treatment process (Fig. 3A,B).
Nowadays, the diagnostic process can be started
using digital treatment-planning techniques in which
the clinician can provide the dental technician with
specific digital information regarding the prosthetic
project and subsequently the wax-up that can be cre-
ated (35) (Fig. 4A–E).
Evaluation of surgical feasibility and
planning of ridge-augmentation
procedures
Once the prosthetic plan has been finalized and a ridge
defect has been identified, the next step is to carry out
a precise evaluation of the anatomy of the bony defect
in relation to the prosthetic replacement. In other
words, it is important to understand if the bone volume
that the patient has is compatible with prosthetically
driven implant placement (in order to achieve what
has been planned with the wax-up) or if grafting proce-
dures are needed. The wax-up will be duplicated to
produce a diagnostic template with radiopaque tooth/
teeth, reproducing the ideal tooth/teeth position. The
215
Chiapasco & Casentini
A
B
Fig. 3. Wax-up of different edentulous quadrants of the
maxilla (A). The wax-up can also be used inside the oral
cavity to previsualize the treatment outcome (B). Once
again, teeth and alveolar ridge tissues have been repro-
duced with wax of different colors.
diagnostic template, constructed with sufficient reten-
tion, can be placed in the mouth at the time of compu-
terized tomography. A 2-mm-diameter perforation
A B
D E
Fig. 4. The diagnostic process of this patient started with
extra-oral and intra-oral photographs and impressions to
create study casts (A). A digital design of the desired
restorations is created with the aid of a presentation soft-
ware (Keynoteâ Apple) (B) and transferred to the dental
216
inside the radio-opaque tooth can be used to simulate
the ideal axis for the planned implant. In the case of
replacement of anterior teeth, as it is preferable to
have a screw-retained, rather than a cement-retained
restoration, the axis of implant placement should
reflect this. In the posterior segments, the central per-
foration should be placed to correspond to the central
fossa of the tooth to be replaced and should have a
slight palatal/lingual inclination (Fig. 5A–E).
To maximize information, the computerized
tomography scan should be analyzed using dedicated
implant/dental software that allows virtual placement
of implants. In particular, the following informa-
tion can be obtained: (i) residual bone dimensions;
(ii) localization of important anatomic structures;
(iii) soft-tissue thickness; and (iv) the relationship
between the residual bone and the planned restora-
tion. This is the most important information as it
verifies the possibility of placing implants in a pros-
thetically driven way, with or without the need for
bony augmentation. If the existing bone volume does
not allow implant placement, depending on the exist-
ing defect, it will also be possible to choose the most
appropriate augmentation procedure and the ideal
diameter and length of the planned implants. The
diagnostic template used for computerized tomogra-
phy may be modified into a surgical template (the 2-
mm-diameter perforation is usually widened, and
flanges are eliminated to avoid interference with flap
elevation). The template will help the surgeon to
insert the implant in an ideal position from a pros-
thetic point of view.
C
technician to create a wax-up (C). A silicon index, based on
the wax-up and filled with flowable composite (D), was
then used to create a fixed mock-up in the patient’s mouth
to previsualize treatment outcome (E) (Dr Paolo Casen-
tini).

A B
Fig. 5. (The same patient as shown in Fig. 3.) A radio-opa-
que diagnostic template is created from the wax-up, which
also served as a mock-up (A–C). Cone-beam computerized
tomography is performed with the diagnostic template
in situ, allowing precise quantification of the horizontal
Classification of horizontal defects
according to a prosthetically driven
diagnostic protocol and surgical
options
After an appropriate prosthetically driven diagnostic
protocol, it should be possible to classify a clinical
case into one of four classes (class 1–4), outlined in
the following sections.
Class 1
In class 1, no discrepancy exists between the ideal
position of the implant(s), the implant-supported
prosthetic unit(s) and the alveolar bone anatomy. In
this class, no bone augmentation is required and
implants can be placed directly into the residual
bone, guided by the surgical templates. In this case,
the implant will be completely surrounded by an ade-
quate volume of bone (> 1.5–2 mm on every surface).
Measurements on computerized tomography scans
will allow the selection of ideal implant sites as well as
the correct dimensions of implants (Fig. 6A,B). In
reality, this situation is rarely encountered and, if
found, is associated with immediate postextraction
A B
Fig. 6. In a class 1 clinical situation no augmentation procedures are needed to modify the alveolar ridge profile: the
implant can be inserted in an ideal, prosthetically driven position and it will be completely embedded in the residual alve-
olar bone (A, B).
Prosthetically guided regeneration
C D E
discrepancy between the residual bone volume and the
ideal prosthetically determined implant position (D, E). In
this case, a bone-augmentation procedure before implant
placement will be needed in order to achieve the ideal
implant-supported rehabilitation. B, buccal; L, lingual.
sockets or recently healed sockets treated with ridge-
preservation protocols (40, 47). In some cases,
although the bone anatomy can be ideal to host an
implant in the correct three-dimensional position, a
cosmetic defect can still be present. In this case, a
connective tissue graft is recommended to improve
the final esthetic result (Fig. 7). This clinical situation
is often present in the esthetic area (45) (Fig. 8A–D).
Class 2
In class 2, a moderate horizontal deficit is present. In
this situation, implant(s) can be placed in the correct
prosthetically driven position but a simultaneous
hard-tissue-augmentation procedure is indicated.
During preparation of the implant site, a fenestration
or a dehiscence of the buccal plate is commonly seen,
or the thickness of the residual buccal bony wall
(< 1 mm) is not able to guarantee a favorable long-
term prognosis (Fig. 9A,B).
The main therapeutic options in class 2 cases
involve implant placement associated with guided
bone-regeneration techniques using autogenous par-
ticulate bone and/or alloplastic materials in associa-
tion with a semipermeable barrier (resorbable or
nonresorbable), and sagittal osteotomy techniques
217
Chiapasco & Casentini

Fig. 7. In a class 1 clinical situation a connective tissue

graft (CTG) can be indicated to correct a cosmetic defect. C

and/or the use of osteotomes to expand the available

bone volume. The use of reduced-diameter implants
can be helpful in the management of horizontally
atrophic ridges, provided that the implant is placed in
the correct, prosthetically driven position (28, 70)
(Fig. 10A–E). Hard-tissue-augmentation techniques
can be combined with augmentation of soft tissues
by means of a connective tissue graft taken from the
palate. Once again, in the esthetic area, where a larger D
amount of soft tissue helps to achieve favorable mor-
phology of the peri-implant mucosa, this procedure is
often recommended to improve the final esthetic
result (52) (Figs 11 and 12A–F).

Class 3
In class 3, a significant horizontal deficit is present
and the residual bony anatomy does not allow the
implant to be placed in an ideal prosthetic position
and achieve primary stability (Fig. 13A,B). Following
correction of the horizontal deficit, an adequate heal-
ing period should be allowed (4–9 months, depending
on the technique selected and grafting material)
before implant placement as a second-stage surgical
procedure. The main surgical techniques that can be
used for the correction of advanced horizontal deficits
are: (i) guided bone-regeneration techniques using
autogenous particulate bone and/or alloplastic mate-
rials in association with semipermeable barriers (re-
sorbable or nonresorbable); and (ii) autogenous bone
blocks harvested from intra/extra-oral donor sites,
Fig. 8. In some cases, and commonly in the esthetic area,
although the volume of the alveolar crest is adequate to guar-
antee an ideal implant position, a connective tissue graft is
recommended to achieve a better esthetic result (A, B). The
connective tissue graft is secured to the internal aspect of the
mucoperiosteal flap by means of thin, 5.0 resorbable sutures
(C). The final restoration demonstrates a favorable biomi-
metic integration of the implant-supported crown (D).
(Surgery and prosthetic rehabilitation, Dr Paolo Casentini.)
and nonautogenous bone blocks. Techniques such as
guided bone regeneration and reconstruction with
autogenous bone blocks are supported by a signifi-
cant bulk of literature, as demonstrated by some sys-
tematic reviews (27, 49). On the other hand, the use of
nonautogenous bone blocks, including allografts and

218

A B
Fig. 9. In a class 2 clinical situation, a certain degree of atrophy is present: the implant can be placed, but a simultaneous
bone-augmentation technique is needed (A, B).
A B
D E
Fig. 10. To replace the missing left central incisor (A), a
reduced-diameter implant was utilized. The implant was
placed following the indications of a surgical template
obtained from the wax-up (B). As the edentulous ridge pre-
sented moderate horizontal atrophy, a peri-implant dehis-
cence was produced on the buccal wall and a guided bone-
regeneration technique was used. The defect was corrected
by grafting a 50:50 mixture of autogenous bone particles
harvested with a bone scraper (from the mandibular
ramus) and particulate xenograft (deproteinized bovine
bone – Mineral- Biossâ; Geistlich Biomaterials, Wolhusen,
xenografts, is supported by less, and often contradic-
tory, literature with some publications reporting posi-
tive results and others reporting questionable results
(4, 5, 18, 30, 33, 36, 39, 61, 66, 67, 75, 79).
The choice between different bone-augmentation
techniques is related to local defect morphology (dis-
cussed in the following section) and to the surgeon’s
preferences/skills. The bone-augmentation procedure
should precisely follow the original prosthetic project,
according to the concept of ‘prosthetically guided
regeneration’ (21, 26). For this purpose, the use of a
diagnostic template (rendered from a computerized
tomography scan) during the bone-augmentation
Prosthetically guided regeneration
C
Switzerland). A deliberate, slight overcorrection of the
defect was performed to compensate for potential partial
resorption of the graft during healing. The graft was then
protected and separated from the soft tissues with a
resorbable collagen membrane (Bio-Gideâ; Geistlich Bio-
materials) (C). In order to stabilize the graft, the mem-
brane was fixed with titanium pins (D). The temporary
implant-supported restoration shows favorable integration
of the prosthesis (E). (Surgery, Dr Matteo Chiapasco &
Dr Paolo Casentini; prosthetic rehabilitation, Dr Paolo
Casentini.)
procedure is recommended. The same template can
be used to guide the second stage of implant place-
ment. The continuity of the therapeutic flow, starting
from the diagnostic process to bone augmentation,
implant placement and the restorative phase, usually
guarantees a favorable outcome for the patient. The
use of reduced-diameter implants is recommended to
avoid more aggressive implant site preparation in
the reconstructed area (28) (Fig. 14A–F). Hard-tissue-
augmentation procedures are often combined with
soft-tissue grafts to achieve an optimal shape of the
edentulous ridge before the placement of implant-
supported restorations (Fig. 15A,B).
219
Chiapasco & Casentini
Fig. 11. In Class 2 clinical situations, implant placement
and bone-augmentation procedures can be combined with
a soft-tissue graft (connective tissue graft [CTG]), to
improve the shape of the recipient site.
Class 4
In Class 4, a combined horizontal and vertical defect
is present. Detection of the vertical component of the
bone defect is highlighted by the prosthetically driven
A B
D E
Fig. 12. The treatment plan for this partially edentulous
anterior mandible (A) included one implant supporting
one mesial cantilever and one lithium disilicate veneer on
the right cuspid in order to achieve better management of
the mesiodistal space. The implant was placed following
the indications of a surgical template obtained from the
wax-up (B). Despite the implant being fully surrounded by
native bone, the residual buccal bony wall (less than
1 mm) was considered too thin to guarantee a favorable
220
diagnostic protocol where the wax-up reveals longer
clinical crowns and/or a bulk of pink wax (Fig. 16A,
B). Correction of vertical defects increases the com-
plexity of treatment and necessitates the use of more
demanding surgical techniques, which are associated
with a higher incidence of complications (27, 34). The
complexity and potential risks/drawbacks of treat-
ment, such as early graft exposure, infection, resorp-
tion and increased morbidity, must be considered
and discussed with the patient. In some cases, treat-
ment can be simplified by limiting the reconstruction
to the correction of the horizontal component of the
defect. A quantity of pink ceramic may reproduce the
missing, vertical soft tissues and achieve clinical
crowns of the correct length. In some cases affected
by extremely advanced horizontal and vertical atro-
phy, a certain amount of pink porcelain may be rec-
ommended, in spite of vertical and horizontal bone
augmentation, to achieve a better esthetic and func-
tional rehabilitation.
The main surgical alternatives for the correction of
combined horizontal-vertical techniques are: (i) auto-
genous bone blocks harvested from intra/extra-oral
donor sites (Fig. 17A–G); (ii) guided bone-regeneration
techniques using autogenous particulate bone and/or
alloplastic materials in association with semiperme-
able barriers (resorbable or nonresorbable); and (iii)
Le Fort I osteotomy with advancement and lowering
C
F
long-term prognosis. As the presence of an atrophic ridge
could also affect the final esthetic result, a guided bone-
regeneration technique using a xenograft, covered with
multiple layers of a collagen membrane, was performed
(C, D). Moreover, as the thickness of the surrounding soft
tissues was reduced, a connective tissue graft was used to
optimize the peri-implant tissue quality and final esthetic
outcome (E, F). (Surgery, Dr Paolo Casentini; prosthetic
rehabilitation, Dr Martin Thurthchenthaler.)
 Prosthetically guided regeneration

A B

Fig. 13. In class 3 clinical situations, the greater degree of alveolar atrophy prevents implant placement. Implants are
placed with a delayed approach following bone-augmentation procedures and adequate healing (A, B). B, buccal; L, lingual.

A B C

D E F

Fig. 14. (The same patient as shown in Figs 3 and 5.)
After the diagnostic protocol confirmed a high degree of
horizontal atrophy, which contraindicated implant place-
ment (A), the defect in the anterior maxilla was cor-
rected with two autogenous bone blocks harvested from
the mandibular ramus (B, C). The diagnostic template,
made following a computerized tomography scan, was
used to ‘guide’ the reconstructive phase (D). After a 6-
month healing period, needed for adequate integration
and revascularization of the grafts, the same template
was used as a surgical guide during implant placement
(E, F). (Bone-augmentation surgery, Dr Paolo Casentini
& Dr Matteo Chiapasco; implant surgery, Dr. Paolo
Casentini.)

of the maxilla and interpositional bone grafts (only in this section, aiming to highlight the benefits and
for severe atrophy of the maxilla associated with limitations of each technique.
increased interarch distance and maxillary retrusion).

Guided bone regeneration with

Choice between different surgical
techniques in the treatment of
horizontal defects
Once a defect has been classified following the
diagnostic protocol, it will be easier to select the most
appropriate surgical technique to treat the defect.
The main surgical techniques will be briefly described
resorbable membranes
The principle of guided bone regeneration is based
on the use of a barrier separating the deficient bone
site from the surrounding soft tissues to create a pro-
tected space for bone regeneration. The protection of
the membrane allows the bone defect to be popu-
lated by blood vessels and osteogenic cells coming
from the bone marrow cavities and the bone surface

221
Chiapasco & Casentini

A barrier effect (Fig. 12). A greater degree of stability of

the membrane can be achieved by fixing the mem-
brane using titanium pins.

Indications

Guided bone regeneration with a resorbable mem-

B alveolar atrophy is present. Guided bone regeneration
Fig. 15. (The same patient as shown in Figs 3, 5 and 14.)
During abutment connection, a double connective-tissue
graft, harvested from the maxillary tuberosity, can be used
to improve soft tissues and final esthetic outcome the recip-
ient site (A). The final photograph shows the temporary
implant-supported restorations (B). (Soft-tissue augmenta-
tion and prosthetic rehabilitation, Dr Paolo Casentini.)
(8) and excludes any epithelial/soft-tissue infiltration
of the area. In guided bone-regeneration techniques,
the use of a membrane is combined with autogenous
particulate bone and bone substitutes (discussed in
the following section). Collagen membranes are the
most common resorbable membranes used for
guided bone regeneration (12, 17). However, as their
barrier effect is lost in a few weeks, a multiple-layer
technique is recommended to guarantee a prolonged
brane is the preferred technique for the treatment of
small peri-implant defects such as a dehiscence or
fenestration. Following the classification presented
above, guided bone regeneration is indicated in all
class 2 cases when a moderate degree of horizontal
with a resorbable membrane has also been applied
successfully in class 3 cases when advanced horizon-
tal atrophy is present and implant placement is
delayed (77). Class 3 defects have also been treated
following the principle of guided bone regeneration,
combining collagen membranes with the use of tita-
nium plates (63). When collagen membranes are used
for the correction of class 3 advanced horizontal
defects, a significant volume of particulate autoge-
nous bone is recommended by the authors.
Surgical recommendations
Before applying the membrane, small perforations of
the residual alveolar ridge cortex are recommended,
to increase migration of osteogenic cells underneath
the membrane and accelerate revascularization of the
graft. If part of the implant surface is exposed, it is
recommended to cover it with some autogenous par-
ticulate bone, collected from adjacent areas using
chisels or bone scrapers, to improve and expedite the
regeneration process (Fig. 18). The autogenous bone
in contact with the implant surface should be covered
with an osteoconductive bone substitute, such as

A B

Fig. 16. In class 4 clinical situations, the horizontal alveolar atrophy is combined with vertical atrophy. It is not possible to
insert implants in the correct three-dimensional position. As in class 3 cases, implants will be placed with a delayed
approach following bone augmentation and healing (A, B). B, buccal; L, lingual.

222

A B
D E
Fig. 17. Treatment of the posterior mandible affected by a
combined horizontal-vertical defect and knife-edge ridge
(the same patient as shown in Fig. 2) (A). Computerized
tomography scan confirms the presence of severe bony
atrophy, incompatible with implant placement (B). A wax-
up is used to reproduce the ideal profile of the ridge and
the missing teeth, from which a surgical stent is obtained
(C). The bone-augmentation procedure, performed with
autogenous bone blocks, is guided by the surgical stent.
Fig. 18. After perforation of the buccal cortical layer, auto-
genous bone chips are placed to cover the exposed implant
surface.
deproteinized bovine bone mineral with a degree of
‘over correction’, in order to compensate for partial
resorption of the graft during healing (Fig. 19). The
collagen membrane is trimmed to the correct shape
and adapted to cover the augmented site. Handling
of the ‘dry’ membrane usually facilitates trimming
and adaptation to the defect. Multiple layers are
recommended to increase the barrier effect of the
membrane (Fig. 20). During handling and adaptation
of the membrane, where possible, the treated area
should not be contaminated with saliva. Although it
has been shown that guided bone regeneration can
work without primary wound closure (57), it is recom-
mended to provide a sealed, tension-free closure of
Prosthetically guided regeneration
C
F G
After 6 months, adequate bone volume has been created
and the graft appears well integrated (D). Preparation of
implant sites is carried out with the aid of the same surgi-
cal stent used during the bone-augmentation procedure
(E). Final clinical (F) and radiographic (G) appearances of
the rehabilitated area show good integration of the
implant-supported prosthesis. (Bone augmentation,
implant and soft-tissue surgery, and prosthetic rehabilita-
tion, Dr Paolo Casentini.)
Fig. 19. (The same patient as shown in Fig. 18.) Placement
of deproteinized bovine bone mineral.
the wound. For the same reason, the use of ‘bone
level’ submerged implants is recommended. In every
bone-augmentation procedure, as the local volume
increases, the periosteal layer of the flap must be
released to achieve tension-free primary wound clo-
sure (Figs 21 and 22). During the healing phase, the
treated area should be protected from pressure; for
this purpose, temporary prostheses must be modified
in the majority of cases.
Benefits and limitations
Guided bone regeneration with a resorbable mem-
brane for treatment of small defects is a ‘user friendly’
technique that requires a low degree of surgical skill.
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Chiapasco & Casentini
Fig. 20. (The same patient as shown in Figs 18 and 19.)
Placement of a collagen membrane in multiple layers is
recommended to increase the barrier effect of resorbable
membranes.
Fig. 21. (The same patient as shown in Figs 18–20.) In
every augmentation procedure, tension-free, primary
intention wound closure is recommended.
Fig. 22. (The same patient as shown in Figs 18–21.). Clini-
cal appearance of the treated area after rehabilitation.
(Implant and augmentation surgery, Dr Paolo Casentini;
prosthetic rehabilitation Dr Martin Thurthchenthaler.)
Surgery can usually be performed under local
anesthesia. Complications of this technique (such as
exposure of the membrane) are limited and they are
usually easily dealt with (e.g. by local disinfection
with chlorhexidine gel). Treatment of more advanced
defects (class 3) is more demanding but resorbable
224
membranes can still be used for these defects. How-
ever, resorbable membranes are not indicated for
defects that present a vertical component (class 4).
These aspects need to be discussed with the patient
who must read and sign a detailed informed consent
form, in which the indications, advantages, disadvan-
tages, potentials and limits, as well as alternatives to
each proposed modality of treatment, must be thor-
oughly described for each type of augmentation pro-
cedure, be it routine or complicated.
Guided bone regeneration with
nonresorbable membranes
The benefits of nonresorbable membranes derive
from the greater stiffness that guarantees a longer
barrier effect that lasts until the membrane is
removed. For this reason, these membranes are uti-
lized for correction of more severe alveolar bone
defects, including those with a vertical component.
Expanded-polytetrafluoroethylene membranes rein-
forced with titanium (11, 13, 23, 73, 74) or titanium
meshes (38, 68, 69) have been used as nonresorbable
barriers. Unfortunately, the greater stiffness of this
kind of barrier is associated with a higher rate of com-
plications, such as membrane exposure and partial or
total failure of the augmentation procedure. In the
case of exposure of a nonresorbable membrane,
unlike exposure of a collagen barrier, in the majority
of cases the membrane must be removed (43).
Indications
Guided bone regeneration with nonresorbable mem-
branes is indicated in the correction of class 3 and 4
defects, with a significant horizontal and/or vertical
component in partially edentulous patients. The
application of this technique in fully edentulous
patients is not supported by sufficient literature. In
particular, this technique is indicated when the defect
has an irregular shape and it would be difficult to
adapt an autogenous block graft (Fig. 23A,B). The use
of a mixed graft, composed of autogenous particulate
bone and a bone substitute, is usually recommended
with this type of membrane. Implant placement is
usually delayed for a period of 6–9 months, and the
barrier is removed during second-stage surgery.
Surgical recommendations
As in smaller defects, the cortical plate is perforated
to promote migration of osteogenic cells from the
residual bone. Before cutting the nonresorbable bar-
rier, it is convenient to use a piece of sterile paper as
a stent which can be adapted to the defect, simulating
 Prosthetically guided regeneration

A A

B
B

Fig. 23. (A, B) Guided bone regeneration with a nonre-

sorbable membrane is indicated in irregular, complex
defects, especially with a vertical component, where it Fig. 24. To facilitate adaptation of the membrane, a sterile
would be difficult to adapt a block graft. paper stent is first adapted to the defect (A). The nonre-
sorbable membrane will then be trimmed, based on the
stent (B).
the final area and shape of the barrier required. Once
the final shape of the barrier has been defined, the
nonresorbable membrane can be trimmed until the
proper shape is achieved (Fig. 24A,B). Nonresorbable
barriers need to be immobilized with titanium pins or
microscrews. Titanium screws can also be used to
support the membrane in the central part, thus
achieving a ‘tent effect’ (Fig. 25). The membrane is
usually partially fixed before filling the defect with the
graft. The defect is then filled with autogenous partic-
ulate bone or with a mixture of autogenous bone and
an osteoconductive biomaterial (73). Definitive fixa-
tion of the membrane is then achieved. Particular Fig. 25. A screw is used to provide mechanical support to
care should be taken to assure a minimal distance of the expanded-polytetrafluoroethylene membrane.
1.5 mm between the membrane edges and roots of
the adjacent teeth because the gingival sulcus could the flap because palatal tissues cannot be released. In
represent a source of contamination during healing the mandible, and in particular in the posterior area,
(Fig. 26). The membrane should be in tension and if a passivation of the lingual flap helps to achieve ten-
titanium mesh is used, the sharp edges should be sion-free coverage of the augmented area. A combi-
eliminated to reduce the risk of soft-tissue dehis- nation of single and horizontal mattress sutures is
cences during healing. used to assure closure of the flaps (Fig. 27A,B).
Tension-free, primary closure of the flap is manda- During the healing phase, the treated area should be
tory and periosteal releasing incisions are necessary protected from pressure, and temporary fixed pros-
in order to mobilize the flap. In the maxilla, the theses, such as Maryland bridges, are usually pre-
releasing procedure is limited to the buccal side of ferred. If the membrane does not become exposed,

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Chiapasco & Casentini

Fig. 26. The space underneath the membrane is then filled B

with a mixture of autogenous particulate bone and an
osteoconductive biomaterial, and the membrane is finally
secured with titanium pins.

Fig. 28. Delicate removal of the membrane after a period

of healing of 9 months (A). An adequate volume of bone
for implant placement has been regenerated (B).

A
B

B
Fig. 27. (A, B) A tension-free suture assuring a primary
intention closure of the flap is mandatory when a nonre-
sorbable barrier is utilized.

its removal is usually performed after a 6- to 9-month

healing period, and implants are placed at this time.
Removal of the membrane should be performed care-
fully to avoid damaging the underlying regenerated
bone (Figs 28A,B and 29A,B).

Benefits and limitations

Guided bone regeneration using nonresorbable barri-
ers represents an effective surgical technique and
should be considered as the preferred technique in
irregular defects with a vertical component (class 4).
However, a higher rate of complications (between
10% and 20%) has been reported, even by experi-
enced surgeons. This technique requires advanced
Fig. 29. Clinical (A) and radiographic (B) aspects of the
treated area after delivery of the implant-supported crown.
(Augmentation and implant surgery, Dr Paolo Casentini;
prosthetic rehabilitation Dr Martin Thurthchenthaler.)
surgical skills because it is technically demanding and
therefore should only be performed by adequately
trained and experienced surgeons. As nonresorbable

226

barriers are usually used in conjunction with a
significant amount of autogenous bone, the need to
harvest this bone increases the total complexity of the
procedure and postoperative morbidity. As longer
surgical times can be expected, intravenous sedation
in association with local anesthesia is often recom-
mended. The use of guided bone regeneration is very
well supported by the literature as far as the treat-
ment of partially edentulous patients is concerned.
On the contrary, the use of vertical guided bone
regeneration in fully edentulous patients is supported
by very limited literature.
Crest splitting and expansion techniques
Splitting techniques represent an alternative to
guided bone regeneration in ridges with a moderate
horizontal atrophy (class 2, according to the classifi-
cation presented here) and can be carried out in con-
junction with implant placement. Compared with
guided bone regeneration, the indications for these
are limited because the presence of a layer of cancel-
lous bone between the two cortical plates is vital and,
for this reason, the technique is rarely applied in
the mandible. Buccal inclination of the crest is a
contraindication for these techniques as splitting
usually increases the buccal inclination of implants
simultaneously inserted. The techniques are operator-
sensitive and require a level of training and experience.
For these reasons, the technique has had a limited
uptake compared with guided bone regeneration.
Nonetheless, if the technique is applied correctly, in
carefully selected cases, it is possible to achieve ade-
quate correction of the atrophic ridge (3, 31, 72).
Indications
These procedures are indicated in class 2 cases with
moderate, horizontal maxillary alveolar atrophy, and
A B
Fig. 30. A moderate, horizontal alveolar atrophy is present in the posterior area of the maxilla (A). Computerized tomogra-
phy indicates separation of the two cortical layers by a layer of cancellous bone (B).
Prosthetically guided regeneration
where the cancellous component of bone and its
elasticity allow expansion (Fig. 30A,B). On the con-
trary, sparse scientific data are available on expansion
techniques applied to the mandible.
Surgical recommendations
In expansion techniques, minimal elevation of the
flap is recommended, in order to reduce the risk of
resorption of the split buccal bone. If a sagittal osteot-
omy technique is performed, it is recommended to
undertake a mid-crestal bone cut utilizing the least
invasive technique, such as piezosurgery or a thin
cutting disc. Mesial and distal releasing bone cuts are
carried out with the same instruments. The sagittal
split is then performed using chisels, expansion
screws or special expansion devices (Fig. 31A,B).
Excessive buccal inclination of implants should be
avoided. For this purpose, during implant site prepa-
ration, the bur should be kept in contact with the
palatal wall of the sagittal osteotomy and excessive
contact with the buccal wall should be avoided.
As expansion techniques usually create a conical
cavity in the bone, the use of conical implants
is recommended (Fig. 32A,B).
Benefits and limitations
Theoretically, the benefit of expansion techniques,
compared with guided bone regeneration, is seen in
the low morbidity in the postoperative period, if a
minimal size of flap is elevated, as well as in a
reduced cost, as membranes and bone substitutes are
not usually used. On the other hand, the limitations
of this technique should be mentioned: (i) the indica-
tions are limited as a result of the local anatomy (e.g.
the need for a layer of cancellous bone between the
cortical plates, excessive buccal inclination of
implants in the case of a buccally tilted crest and this
technique is rarely applicable in the mandible); (ii)
227
Chiapasco & Casentini
A B
Fig. 31. A thin, mid-crestal osteotomy is performed with
piezosurgical instruments. Expansion devices are inserted
into the osteotomy site and gradually activated (A). After
expansion, implant sites are prepared and implants are
inserted (B). (Implant and augmentation surgery, Dr Paolo
Casentini.)
the risk of fracture/unpredictable resorption of the
buccal cortical layer; and (iii) it is an operator-
sensitive technique requiring advanced surgical skills.
Autogenous bone block grafts
The best, scientifically documented, technique for
correction of a significant horizontal and/or vertical
alveolar bone defect is the use of autogenous bone
blocks (2, 27, 56, 64). The biologic behavior of trans-
planted autogenous bone blocks is well known and
combines osteoclastic degradation and osteoblastic
substitution, which lead to healing and integration of
the graft. During the integration process, the space
between the graft and the recipient site is primarily
filled with newly formed woven cancellous bone.
Then, new bone tissue grows inside the graft, by the
formation of so-called ‘cutting cones’, which repre-
sent tunnels connecting the native bone and the graft.
The cutting cones, which are filled with concentric
layers of lamellar bone, form the basis for formation
of osteons or Harvesian systems (8). During integra-
tion, the grafted bone is usually completely replaced
with osteons. Although complete bone remodeling of
the graft may take several years, from a clinical point
of view, after 4–6 months of healing, sufficient inte-
gration and revascularization of the graft has occurred
and it is possible to place implants (Fig. 33A–C).
Indications
Bone grafting is a very predictable technique in the
treatment of class 3 (advanced horizontal atrophy)
and class 4 (advanced horizontal atrophy with a
228
A
B
Fig. 32. Clinical (A) and radiographic (B) appearance of
the treated area after rehabilitation. (Prosthetic rehabilita-
tion, Dr Paolo Casentini.)
vertical component) situations. The only situation
when a block graft is not ideal is when a defect has an
irregular shape and size. In this situation, as previ-
ously stated, guided bone regeneration with a partic-
ulate graft and a nonresorbable barrier might be
preferred. Bone grafting is also the best documented
technique for the treatment of advanced atrophy in a
completely edentulous arch.
Surgical recommendations
Every bone-augmentation procedure should be based
on the prosthetically guided regeneration concept
(Fig. 34A,B). After flap elevation, the dimensions of
the recipient site are measured to allow a block of
adequate width, height and length to be harvested
and to facilitate surgical modeling of the graft before
fixation (Fig. 35). Cortical perforations are carried out
in the recipient site to facilitate migration of osteo-
genic cells and accelerate revascularization. The graft
is harvested from the donor site with the mandibular
ramus being the site preferred for grafts of limited
dimensions (one to three missing teeth) because
dense bone blocks of the desired dimensions can be
readily harvested. Osteotomies in the donor site are
carried out using piezosurgical instruments. The bone

A A
B
C volume does not allow implant placement in a correct,
Fig. 33. Autogenous graft integration (A): after a period of
6 months, the graft has the same appearance as the sur-
rounding native bone (B). Fixation screws can be removed
and one implant is placed (C). (Augmentation surgery, Dr
Paolo Casentini.)
block is then detached by rotation of a chisel inserted
in the osteotomy lines (Fig. 36). Before removing the
block, a small amount of particulate bone can also be
harvested from the same area with a chisel or a bone
scraper. Autogenous bone chips will be used to fill
small gaps between the block and the recipient site.
The graft is then trimmed with burs or with piezoelec-
tric instruments with copious irrigation with sterile,
refrigerated saline, and its adaptation to the recipient
site is verified. As a general rule, precise adaptation
and intimate contact with the native site should
Prosthetically guided regeneration
B
Fig. 34. (A, B) The missing left central incisor is associated
with a class 3 horizontal defect where the residual bone
prosthetically driven position.
Fig. 35. After flap elevation the recipient site is measured
in order to establish bone block dimensions.
facilitate migration of osteogenic cells and guarantee
rapid integration of the graft. Once the best position
of the graft has been defined, the perforation for the
fixation screw is performed with specific drills. During
this step, the bone block is immobilized with a hemo-
static clamp or with specific instruments, such as
the Luniatschek graft holder. Perforation should be
widened more in the block and conversely it should
be precise in the recipient site, allowing gentle com-
pression of the graft by the fixation screw. Fixation
screws with a 1.5-mm-diameter of varying length
229
Chiapasco & Casentini
Fig. 36. An autogenous bone block is harvested from the
mandibular ramus. From the same area, small particles of
bone can be harvested with a bone scraper. In this specific
case, the buccal exostosis on the upper left lateral incisor
was also used as a source of particulate bone.
A
Fig. 37. Small gaps between the recipient site and the graft
can be filled with particulate autogenous bone; in this
case, part of the bone chips were placed before block
fixation (A). The block was then secured with two
osteosynthesis screws, and sharp edges were rounded with
a 3-mm-diameter diamond bur (B).
230
(according to surgical needs and graft thickness) are
considered ideal for bone block fixation. The number
of screws may vary significantly according to the clini-
cal situation, with the general rule being to apply the
minimum number of screws required to immobilize
the graft confidently. If a significant gap is present
between the graft and the native bone, this should be
filled with autogenous particulate bone (Fig. 37A).
This is to guarantee good contact between the graft
and the recipient site and to avoid connective tissue
ingrowth in between, which may be detrimental to
the graft integration process. Sharp edges of the graft
should be eliminated in order to avoid flap perfora-
tion and dehiscence during healing (Fig. 37B). The
graft can be covered with a thin layer of bone substi-
tute with a low resorption rate, such as deproteinized
bovine bone mineral (37, 62, 78) (Fig. 38A). The bone
substitute should not be placed between the graft
and the recipient site, as it could interfere with graft
integration. Any gaps between the graft and the recip-
ient site should be filled with autogenous particulate
bone. The grafted area is then covered with a resorb-
able collagen membrane (Fig. 38B). The use of mem-
branes and bone substitutes in association with bone
graft seems to prevent the potential, partial, bone
A
Fig. 38. The graft is covered and surrounded by depro-
teinized bovine bone mineral (A) and then protected with
two layers of a collagen (resorbable) membrane (B).
 Prosthetically guided regeneration

resorption of the graft during healing (38, 63, 79). In

cases of larger defects, in which intra-oral sites are
unable to provide enough bone volume, extra-oral
sites, such as the calvarium and the pericranial peri-
ostium (pericranium) can be used to protect and
prevent resorption of the graft (24). Tension-free,
primary wound closure is essential, as in all augmen-
tation techniques (Fig. 39).
Implants, in areas grafted with bone blocks, are
usually placed after a healing period of 4–6 months
depending on the quality of the grafted bone. If
the donor site is the iliac crest, a shorter period
Fig. 40. Re-entry after 6 months shows good integration of
(4 months) may be sufficient, as the iliac crest, the graft and the absence of resorption.
because of its structure of predominantly cancellous
bone, will undergo faster integration. In case of blocks
harvested from the mandibular ramus, the chin or A
the calvarium, a longer healing time (6 months) is
suggested (Figs 39–42). However, excessively long
healing times might lead to excessive graft resorption
as a result of the absence of mechanical stimuli lead-
ing to disuse atrophy.
Bone density in an area grafted with a bone block
(with the exception of iliac bone) is usually high; for
this reason, implant site preparation should be deli-
cate and drills with a good cutting capacity should be
used. The implant should be placed gently and any
excessive pressure fit or insertion torques should be
B
avoided. The latter might damage the bone graft, as
the remodeling phase is still active, reduce its vascu-
larization or eventually detach the graft from the
recipient site. For the same reason, wide-diameter
implants are usually not recommended after aug-
mentation with bone blocks and, in many cases,
reduced-diameter implants placed in a precise, pros-
thetically driven position are preferred. In complex
three-dimensional defects, when traditional adapta-
tion of the graft to the recipient site cannot be readily
achieved, it is possible to use block grafts such as bio-
logical membranes to build up bony walls and to fill Fig. 41. An implant is placed in the previously augmented
area, following the guidance of a surgical stent (A). A con-
nective tissue graft was sutured to the internal part of the
buccal flap to improve the shape of the edentulous crest to
facilitate soft-tissue conditioning (B).

the residual space with particulate autogenous bone.

With this approach, it has been demonstrated that, in
spite of large parts of bone block not being in contact
with the recipient site, bone regeneration still occurs
(55) (Figs 43–45).

Benefits and limitations

Fig. 39. A tension-free primary intention wound closure is Bone reconstruction using autogenous blocks is a
achieved after interrupting the periosteal layer. very well-documented technique that has a lower

231
Chiapasco & Casentini
A vertical alveolar defects, ranging from single tooth
B
Fig. 42. Clinical appearance of the treated area after reha-
bilitation. Note the ‘pleasant’ symmetry between the trea-
ted site and the contralateral central incisor, in both
buccal (A) and occlusal (B) views. (Augmentation and
implant surgery, Dr Paolo Casentini; prosthetic rehabilita-
tion, Dr Massimiliano Balsamo.)
complication rate compared with guided bone regen-
eration with nonresorbable barriers (23, 27). It is
applicable in a wide range of clinical situations, allow-
ing the simultaneous treatment of horizontal and
A B
C D
Fig. 43. A previous implant failure left an atrophic knife-edge edentulous crest with a trespassing defect (A, B). The missing
buccal and lingual bony walls were re-created with two block grafts harvested from the mandibular ramus and the empty
space was filled with autogenous particulate bone (C–E).
232
spaces to edentulous arches. When extra-oral donor
sites are used, a practically limitless amount of bone
is available to treat advanced atrophies and complex,
three-dimensional defects (Figs 46–50). Like all bone-
augmentation procedures, the use of bone blocks is
an operator-sensitive surgical technique. In particu-
lar, harvesting techniques from extra-oral donor sites
require specific training in maxillofacial surgery and
knowledge of anatomy. On the other hand, harvesting
of significant amounts of bone from extra-oral sites
increases a patient’s morbidity and requires general
anesthesia or deep sedation. These aspects need to
be discussed with the patient who must read and sign
a detailed, informed consent form in which the indi-
cations, advantages, disadvantages, potentials and
limits, as well as alternatives, must be thoroughly
described.
Le Fort I osteotomy with interpositional
bone grafts
The use of Le Fort I osteotomy was originally con-
ceived in orthognathic surgery for the correction of
class III skeletal malocclusion because it allows move-
ment of the entire maxillary arch in the anterior–
posterior, vertical and transverse planes until a class I
occlusion is achieved (sometimes in association with
sagittal osteotomies of the mandible). In the case of
severe atrophy of the edentulous maxilla (class VI
according to the Cawood & Howell classification) (19),
the residual ridge may present not only insufficient
E
 Prosthetically guided regeneration

A A

Fig. 46. Failure of a previous, severely inadequate

Fig. 44. After a period of healing of 6 months the graft was
perfectly integrated (A) and an implant could be placed
(B).
bone volume to host implants but also an unfavorable
vertical, transverse and sagittal interarch relationship
as a result of the tridimensional resorption pattern
of long-standing edentulism. Finally, maxillary sinus
pneumatization may further reduce the bone volume
available for safe and reliable implant placement. In
such a situation, even autogenous onlay bone grafts,
in association with bilateral sinus grafting procedures
(27, 34), may be insufficient/inadequate as a recon-
structive procedure. Onlay grafts may create adequate
volume for implant placement but they may be insuf-
ficient in recreating the correct intermaxillary rela-
tionship, thus jeopardizing the final outcome both
implant-supported rehabilitation followed by chronic peri-
implant infection, loss of integration of the majority of
implants (initially 12 in the maxilla and 10 in the mand-
ible) and an extreme degree of bone loss in both jaws (A).
After the removal of all residual implants and a 3-month
healing phase, a severe bone deficit involving both the
maxilla and the mandible was present, thus rendering
implant placement impossible, as demonstrated by the
computerized tomography scans (B).
from an esthetic and a functional viewpoint. In such
a situation, Le Fort I osteotomy along with autoge-
nous interpositional bone grafts allow forward and
downward repositioning of the maxilla, thereby simul-
taneously correcting intermaxillary vertical, anterior–
posterior and transverse discrepancies. At the same
time, the interpositional bone grafts (inlay nasal and
maxillary sinus grafts) allow enough bone-volume
augmentation to embed implants of adequate dimen-
sions (25, 50, 58, 65, 76, 80).

A B

Fig. 45. Clinical and radiographic appearance of the treated area after the final prosthetic rehabilitation demonstrated
good integration of the crown (A) and the implant (B) in the surrounding tissues. (Bone augmentation and implant surgery,
Dr Matteo Chiapasco; prosthetic rehabilitation, Dr Paolo Casentini.)

233
Chiapasco & Casentini
A A
Fig. 47. A three-dimensional bone reconstruction was per-
formed with bone blocks harvested from both the calvar-
ium and the iliac crest and stabilized with titanium screws
(A, C). At the same time, sinus floor elevation and grafting
was performed on both maxillary sinuses (B).
Indications
Le Fort I osteotomies with interpositional autogenous
bone grafts are indicated in cases of severe atrophy of
the edentulous maxilla (class 4: advanced horizontal
atrophy with a vertical component), such that the
maxilla appears retruded compared with the mand-
ible (Fig. 51A–C). In this situation, even with ‘thick’
onlay grafts, it is impossible to restore adequate sagit-
tal intermaxillary relationships (Class I intermaxillary
relationship). Grafting alone could lead to a situa-
tion where there is sufficient bone volume to place
implants but not in a prosthetically driven position.
234
Fig. 48. After a 6-month healing period, planning software
was used to aid implant placement (A). Eight reduced-dia-
meter implants were placed in the maxilla and five were
placed in the mandible (B), utilizing a computer-guided
surgical procedure by means of a bone-supported guide.
Severe horizontal alveolar atrophy is often associated
with severe vertical resorption with such an increased
intermaxillary distance to render a prosthetic restora-
tion supported by implants difficult to accomplish. Le
Fort I osteotomy with interpositional bone grafts,
taken from the iliac crest, may allow simultaneous
correction of the horizontal and vertical intermaxil-
lary relationships as well as allow the increase in bone
volume to enable implant placement in a prostheti-
cally driven position.
Surgical recommendations
Every bone-augmentation procedure should be based
on accurate, prosthetically driven treatment planning
(Fig. 52). The patient is always treated under general
anesthesia with nasotracheal intubation. The proce-
dure starts with harvesting of a bicortical bone block
from the anterior iliac crest which is used in the
reconstruction of the anterior and posterior maxilla.
Surgical access is then closed in layers after adequate
 Prosthetically guided regeneration

Fig. 49. After 3 months of further healing, a vestibulo-

B
plasty with mucosal grafts taken from the palate was per-
formed to improve the quality of peri-implant soft tissues.
After another 2-month healing period, abutments were
connected and provisional prosthetic rehabilitation was
started.

hemostasis and positioning of a vacuum drain. A

midcrestal incision from the molar area on one side
to the molar area on the opposite side is outlined and
a full-thickness flap is elevated until the whole maxilla
is exposed. The nasal floor and the lower margin of
the nasal walls are identified and a subperiosteal dis-
section of the nasal mucosa is performed. The poste-
rior part of the maxilla on both sides is exposed until
the pterigoid-maxillary sutures are identified. Then a
‘classical’ Le Fort I osteotomy is performed using
oscillating saws or piezoelectric instruments and fine
chisels. Bone cuts include the anterolateral wall of the
maxilla, the medial sinus walls, the nasal septum and
Fig. 50. (A, B) After 6 months the final prosthesis was
delivered. Despite the significant bone reconstruction, the
definitive rehabilitation required the use of a certain
amount of pink porcelain to re-establish correct esthetics
and function. (Bone augmentation, Dr Matteo Chiapasco;
implant surgery, Dr Matteo Chiapasco & Dr Paolo
Casentini; peri-implant soft-tissue management, Dr Mat-
teo Chiapasco & Dr Paolo Casentini; prosthetic rehabilita-
tion, Dr Paolo Casentini.)

the maxillary-pterygoid sutures. Whenever possible,

the sinus mucosa is left intact, although this is not
mandatory and not performed by many surgeons.
The maxilla is then mobilized and brought downward
and forward; the degree of these movements is dic-
tated by the surgical template previously created on
study casts (Fig. 53A,B). The autogenous bone block,
taken from the anterior ilium, is then cut into pieces
and shaped to fit into the anterior and lateral parts of
the down-fractured nasal floor and maxillary sinuses.
Two blocks are used – one on each side – as interposi-
tional grafts for the reconstruction of the posterior
maxilla, and one block is used in the anterior maxilla.

A B C

Fig. 51. (A–C) Extremely atrophic edentulous maxilla (class 4) with maxillary retrusion as a result of severe horizontal
atrophy along with vertical resorption. Even after bony reconstruction, the maxilla would still be too retruded to allow an
adequate, prosthetically driven prosthetic restoration, indicating the need for a Le Fort I osteotomy.

235
Chiapasco & Casentini
Fig. 52. Impressions are taken and plaster casts are
mounted on an articulator. The severe retrusion of the
edentulous maxilla is clearly visible. The ideal position of
the dental arch in the edentulous area is simulated with a
wax-up and, on the basis of this, a surgical template is con-
structed. With this information, advancement and lower-
ing of the maxilla is simulated until the maxilla is in
contact with the template, simulating its final position
after surgery.
A
B bone gain obtained and the correction of the horizontal
Fig. 53. Following a midcrestal incision involving the max-
illary mucosa from the molar area of one side to the oppo-
site side, a full-thickness mucoperiosteal flap is raised and
osteotomies along Le Fort I lines are performed. The max-
illa is down-fractured and advanced according to the pros-
thetic plan using the surgical template (A). The maxilla is
then fixed in the new position and interpositional bone
grafts are placed and tension-free, primary wound closure
is carried out (B).
236
The down-fractured maxilla and bone blocks are sta-
bilized using titanium plates and screws and all
remaining spaces between the down-fractured max-
illa and the bone blocks are filled with particulate iliac
bone. Periosteal releasing incisions of the flap are
performed to obtain tension-free primary wound clo-
sure (Fig. 54A,B). Implants are usually placed after a
6-month healing period, using the surgical template
and following the principle of prosthetically driven
implant placement (Fig. 55). If screws and plates used
to stabilize the mobilized maxilla interfere with the
placement of implants, they should be removed
(Fig. 56A–C).
Benefits and limitations
Le Fort I osteotomies, in association with interposi-
tional autogenous bone grafts, are well-documented
techniques (20, 25, 54, 58, 65, 71, 76, 80), although the
number of cases treated and available literature are
by far less than those related to autogenous bone
grafts followed by implant placement. This technique
allows correction of severe intermaxillary discrepancy
A B
Fig. 54. (A, B) Postoperative radiographs clearly show the
retrusion of the maxilla, recreating a class 1 intermaxillary
relationship.
Fig. 55. Six months after the reconstruction, implants are
placed in the reconstructed maxilla using the surgical
template.

A B
Fig. 56. Clinical (A) and radiographic (B) appearance of the treated area, after the definitive prosthetic rehabilitation,
demonstrates an excellent result from a prosthetic and functional point of view as well as a major improvement in the
facial profile of the patient (C). (Bone augmentation and implant surgery, Dr Matteo Chiapasco.)
associated with extremely atrophic edentulous maxil-
lae with re-creation of adequate bone volume to allow
placement of implants in an ideal position from
esthetic and functional points of view. Maxillary
advancement and lowering allows also significant
improvement of facial and peri-oral soft-tissue
support, with a general ‘rejuvenation’ of the facial
appearance. The main drawbacks of this technique,
compared with the others discussed previously, are:
(i) more severe postoperative morbidity, mainly tem-
porary gait/ambulation problems as a result of har-
vesting bone from the anterior ilium; (ii) longer
surgical times and need for general anesthesia; and
(iii) necessity of expertise in orthognathic surgery.
Therefore, this technique should be limited to extre-
mely atrophic edentulous maxillae in which bone
grafts alone are insufficient in allowing adequate cor-
rection of the bone defect and the unfavorable inter-
maxillary relationships.
Conclusions
In the last 30 years, osseointegrated implants have
transformed the possibilities of prosthetic rehabilita-
tion of partially and completely edentulous patients
with very encouraging long-term results. However,
the initial ‘pioneering’ concept of implant-borne
prostheses, using the residual available alveolar bone
as a ‘pure anchorage’ to support prosthetic restora-
tions, often led to less than ideal results from a func-
tional and, in particular, esthetic point of view. Over
the years, the concept of ‘prosthetically driven’
implant dentistry has gained credibility and is now
considered the gold standard in such treatments. This
concept is particularly important in situations in
which the residual bone, as a result of atrophy, seque-
lae of periodontal disease, trauma, etc. is reduced in
volume in the horizontal and/or vertical dimension.
Regarding horizontal alveolar defects, although
reduced-diameter implants are available and may
Prosthetically guided regeneration
C
allow acceptable prosthetic results, the present trend
is to re-create, where possible, ideal conditions in
terms of bone volume and surrounding soft-tissue
quality (presence of adequate amounts of keratinized
mucosa). The approach of prosthetically guided regen-
eration, presented in this article, allows for the recon-
struction of lost alveolar and soft-tissue contours as
well as implant placement in positions to permit
prosthetic restorations that are optimal from a func-
tional and esthetic viewpoint.
Acknowledgments
The Authors thank the dental technicians who pro-
duced the prostheses for the clinical cases: Mr Alwin
Schoenenberger, Mr Anton Mairunteregger, Mr Carlo
Pedrinazzi and Mr Roberto Colli.
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Periodontology 2000, Vol. 77, 2018, 241–255
Printed in Singapore. All rights reserved
Vertical ridge augmentation in
the esthetic zone
ISABELLA ROCCHIETTA, LUCA FERRANTINO & MASSIMO SIMION
Bone remodeling after tooth extraction often leads to
inadequate ridge dimensions for the ideal three-
dimensional implant position (45). The lack of bone
volume, often associated with a scarcity of soft tis-
sues, constitutes a major challenge for the clinician.
This is especially true when dealing with esthetic sites
and, as such, managing severe defects in the anterior
maxillae is complex and often unpredictable. The
presence of the nasal cavity limits the bone height
available for implant placement, and a large inter-
arch space alters coronal length and form and pro-
duces an unfavorable crown-to-root ratio in the final
prosthetic reconstruction. This can result in either an
esthetically unacceptable final prosthetic restoration
and/or in difficulties performing adequate oral
hygiene, hence potentially jeopardizing the long-term
prognosis (35). Bone augmentation (horizontal and/
or vertical) using different techniques, based on dif-
ferent biological principles, is often performed to
overcome these deficiencies (12).
The first distractor reported in humans dates to
1992, in which an extra-oral distractor was used in
patients with hemifacial microsomias (33). However,
distraction osteogenesis may now be considered an
obsolete therapy to augment bone because it is lim-
ited to achieving bone regeneration in one vector
only, often resulting in a lack of horizontal volume
and needing further regenerative procedures (2, 18).
Autogenous block grafting has been advocated for
the correction of larger bone deficiencies (14, 78).
Nonetheless, the increased morbidity of the recipient
site or long-term volumetric instability has encour-
aged clinicians to utilize alternatives (13, 39). The use
of titanium meshes has been shown to achieve three-
dimensional alveolar ridge reconstruction (46, 47).
However, its major drawback is the osseointegration
of the mesh itself, which makes it difficult to be
© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
PERIODONTOLOGY 2000
removed at the second phase of surgery. For mild and
moderate ridge defects, guided bone regeneration
offers the possibility of restoring the reabsorbed bone
architecture through the application of particulate
bone graft materials, in conjunction with barrier mem-
branes, to stabilize and protect the graft materials
placed (59).
The use of short or angled implants has also been
proposed in order to avoid major bone-augmentation
procedures in the posterior mandible and maxilla
(41, 68). However, this is not normally contemplated
in the anterior maxillary region because of the high
esthetic demands of this area. The advent of biomate-
rials, in the treatment of alveolar defects, has created
a paradigm shift in the therapeutic options available
(60). The ease and reliability of three-dimensional
imaging and diagnostic tools has complemented the
use of tissue-engineering techniques to achieve bone
regeneration in complex three-dimensional alveolar
defects (19, 36). However, these novel techniques
require long-term data to assess predictability and
stability.
The techniques mentioned above are frequently
reported in the literature with regard to very specific
parameters, such as implant-success/survival rates,
marginal bone loss, complication rates, increased
bone volume and other site-specific data (48). Very
little information is given regarding patient-centered
outcomes. Bone-augmentation techniques, such as
guided bone regeneration, are indicated in the ante-
rior maxilla, which is considered an ‘esthetic area’.
Hence, data on esthetic parameters and patient-dri-
ven parameters would aid clinicians in the decision-
making process. The aim of this narrative review is to
assess patient-centered outcomes regarding vertical
bone-augmentation procedures performed in the
anterior maxilla.
241
Rocchietta et al.
Guided bone regeneration
Guided bone regeneration is a procedure derived
from the principles of guided tissue regeneration
around natural teeth (42). The PASS principle (pri-
mary wound closure, angiogenesis, space and stabil-
ity of the clot) remains a cornerstone for successful
guided bone regeneration (80). Schenk et al. (52)
demonstrated how newly regenerated bone pro-
gresses, in a programmed sequence, through a series
of biologic steps that closely mimic the pattern of
normal bone growth and development. The princi-
ples of guided bone regeneration were applied in the
early 1990s to atrophic jaws. Alveolar vertical defects
were treated using a titanium-reinforced, nonre-
sorbable barrier membrane, in conjunction with tita-
nium dental implants (62). The surgical techniques
and materials utilized have been developed since,
aiming toward less invasive techniques with more
predictable outcomes. The expansion of indications
for guided bone regeneration to include a large vari-
ety of bone defect types led to the widespread use of
this technique in clinical practice. However, vertical
defects still represent the biggest challenge to this
technique, especially in the anterior maxillae in which
the aim is to achieve function and excellent esthetic
results (29). The effectiveness of guided bone regener-
ation with nonresorbable membranes, in obtaining
vertical regeneration of the alveolar crest, has been
clinically and histologically documented in many
studies (44, 69). Moreover, the stability of bone verti-
cally regenerated around dental implants and its
favorable response under functional loading have
been demonstrated in human subjects (1, 58). A sys-
tematic review on clinical outcomes when using
guided bone regeneration for vertical bone augmen-
tation, reported long-term stability (up to 7 years) of
the augmented bone, confirming that vertically aug-
mented bone responds to implant placement simi-
larly to native, nonregenerated bone (48). This was
confirmed by Urban et al. (73), who reported crestal
remodeling of 1.01  0.57 mm at 12 months, which
remained stable throughout the 6-year follow-up per-
iod after guided bone regeneration.
Vertical guided bone regeneration appears to be
highly technique-sensitive and requires a long and
controlled learning curve. A review reported failure
rates ranging from 0% to 45% when using vertical
guided bone regeneration (48), This was explained by
the variety of operators who performed the surgery,
who may have adopted their own surgical techniques
and/or protocols. The main reasons for failure of
242
vertical guided bone regeneration are poor bone
augmentation as a result of soft-tissue dehiscence
and graft shrinkage because of poor blood supply.
Granulation tissue formation and lack of adequate
bone callus formation are generally caused by graft
instability, exposure of graft material to the oral envi-
ronment and infection. Insufficient or delayed vascu-
larization of the graft often leads to a mismatch
between blood flow and bone resorption/formation
coupling, which can result in unpredictable bone
augmentation (79). The latter data derived from
studies using nonresorbable expanded polytetrafluo-
roethylene titanium-reinforced barrier membranes.
Recently, new nonresorbable barrier membranes
were introduced with different pore sizes and struc-
tural modifications. These have been speculated to
be more resistant to bacterial penetration, protecting
the regenerating bone and/or underlying implants
whilst achieving the same bone volume results
(32, 49). However, thorough investigation and robust
studies are required to confirm the hypothesis.
Barrier membranes and grafts
The desired clinical outcome, as well as knowledge of
local anatomy and biology of healing, drives the
choice of a specific membrane and graft. Guided
bone regeneration may be performed utilizing resorb-
able or nonresorbable barriers, with or without graft
materials. Recently, guided bone regeneration using
resorbable membranes has been shown to correct/
augment ‘knife edge’ ridges (75). Nonetheless, when
intended to augment vertically, titanium-reinforced
dense-polytetrafluoroethylene membranes may be a
better choice because of their ability to maintain/cre-
ate space that is necessary for bone augmentation.
Generally, when the alveolar defect may be self-con-
tained (within the bony contours), the application of
a resorbable barrier membrane in combination with
a particulate graft material allows for stabilization of
the latter and hence bone regeneration (26). On the
contrary, when the alveolar defect presents extensive
horizontal and/or vertical bone deficiency, a space-
maintaining approach is required to counteract the
overlying pressure of the soft tissues (6). The combi-
nation of titanium-reinforced polytetrafluoroethylene
membranes and particulate grafts have shown clini-
cal, histologic and long-term success in the treatment
of vertical bone defects of the jaws (57).
A variety of techniques, using various combinations
of natural and synthetic graft materials, can be used

Table 1. Classification of bone-grafting materials
Autogenous Allogenic
Bone from Bone from same species but
same individual another individual
Block Free frozen bone
Particulated Freeze-dried bone allograph
– Demineralized freeze-dried bone allograph
– Deproteinized bone allograft
to achieve vertical alveolar bone augmentation. Mate-
rials used for bone augmentation are divided into nat-
ural transplants (autografts, allografts and xenografts)
and synthetic materials (alloplasts) (22) (Table 1).
These graft materials are used clinically based on
the theory that they are osteogenic, osteoinductive,
osteoconductive or possess a combination of these
properties (70).
Treatment protocols for vertical bone augmentation
that are less invasive and less technique sensitive,
procedures with a higher degree of reproducibility
and appropriate biomaterials are constantly being
developed in the light of developments in bone-
regeneration therapeutics. Extensive studies have
reported successful vertical bone regeneration using
bone morphogens or growth factors in combination
with an array of different scaffolds (61, 71). In fact, the
advent of tissue engineering applied to vertical bone
regeneration has exceeded expectations, allowing sig-
nificant vertical bone regeneration, even in the most
challenging defects (61).
Esthetic considerations in guided
bone regeneration
The esthetic area is considered by clinicians and
patients to be the portion visible when smiling,
namely the anatomic site ranging between the maxil-
lary premolars (30). The smile line varies significantly
between individuals and between men and women,
according to age, anatomy and facial expression. For
simplicity, clinicians have divided patients according
to the location of the smile line, into high, medium or
low lip lines (9). Patients usually consider the esthetic
outcome of dental implant therapy in the anterior
maxilla an essential factor – often even surpassing
functional aspects (66). Hence, in the anterior maxil-
lae, esthetically unsuccessful treatment outcomes
may lead to disastrous clinical situations that can
GBR in the esthetic zone
Xenogenic Alloplastic
Bone from Bone from
different species synthetic origin
Animal derived Calcium phosphates
Coral derived Glass ceramics
Calcifying algae Polymers
– Metals
only be rectified by removal of implants and sub-
sequent tissue-augmentation procedures.
Esthetic parameters that have been defined for
conventional dental restorations may also be used for
implant patients during the preoperative planning
(3, 30). These parameters may help in defining poten-
tial risk factors for esthetic shortcomings. The main
esthetic objectives for implant therapy from a surgical
point of view are: achievement of a harmonious gingi-
val margin without abrupt changes in tissue height;
maintaining intact papillae; and obtaining or preserv-
ing a convex contour of the alveolar crest (4). Soft-
tissue handling, precise implant placement in a
restorative-driven three-dimensional approach and
follow-up procedures represent a variety of chal-
lenges for the implant surgeon. These are multiplied
when the anterior segment is severely atrophic and
requires vertical guided bone regeneration surgery.
Anatomic alterations in the esthetic site
The anterior maxilla goes through significant alveolar
remodeling when teeth are absent as a result of previ-
ous loss or extraction. After tooth extraction, a mean
alveolar bone loss of 1.5–2 mm (vertical) and 40–50%
(horizontal) occurs within 6 months (29, 76). Most of
the alveolar dimensional changes occur during the
first 3 months (54). If no treatment to restore the den-
tition is provided, then continued bone loss occurs
and up to 40–60% of the ridge volume is lost in the
first 3 years (63). The loss of vertical bone height leads
to great challenges in dental implant placement
because of surgical difficulties and anatomic limita-
tions. This lack of sufficient bone volume and height,
if unresolved, is eventually detrimental to the final
esthetic treatment outcome as well as to implant
success and survival (70).
It is crucial to ascertain the location of the naso-
palatine foramen and the distance to adjacent teeth
and to the floor of the nose before performing guided
243
Rocchietta et al.

bone regeneration. Implant contact with neural tissue Inter-implant papilla

may result in failure of osseointegration or lead to
sensory dysfunction (23, 40). Recently, Urban et al.
(72) reported a patient-centered outcome assessment
on pain or ‘foreign body’ sensation following vertical
ridge augmentation by lateralization of the naso-
palatine nerve and vessels. The authors concluded
that not only was this technique predictable but also
that patients did not report any clinically measurable
impairments of neurosensory function (72).
A single-tooth gap in the anterior maxilla offers less
of a challenge to the final successful outcome com-
pared with a multiple-tooth gap as a result of the
presence of adjacent teeth. These adjacent teeth often
have marginal bone levels that may be used as a ref-
erence for guided bone regeneration. The healthier
the clinical attachment level of the adjacent teeth, the
better the prognosis of a successful outcome follow-
ing vertical guided bone regeneration and subsequent
implant placement. The greatest limitation when per-
forming vertical guided bone regeneration is the
inability to regenerate bone beyond existing bone
peaks, in the most coronal position, which is aggra-
vated by compromised periodontal attachment of
neighboring teeth. However, recently, authors have
published case reports in which guided bone regener-
ation was coupled to guided tissue regeneration
allowing for the formation of papillae next to compro-
mised roots (56, 74).
Patients with extended edentulous spaces present
additional anatomic challenges, making it more diffi-
cult to finish the case with a predictable, outstanding
esthetic outcome. Understanding the fundamental
planning objectives in the anterior esthetic zone –
such as tooth axis, interdental closure, gingival con-
tours, balance of gingival levels, interdental contacts,
tooth dimensions and form – will help produce a
wax-up that will guide the surgeon toward the goals
necessary for replacement of the missing teeth and
tissue (31). Patients presenting with the loss of a cen-
tral and lateral incisor or a lateral incisor and canine
are clinically more challenging because the edentu-
lous space is smaller than the two central incisor
spaces and the inter-implant soft tissue tends to be
less voluminous (9). Guided bone regeneration, in
these scenarios, aims at reconstructing enough
volume of bone to position carefully sized implants
to adapt to the limited mesiodistal space. Often
the result is the unpleasant loss of the inter-
implant papilla, which alters the harmony of the
smile, as well as the emergence profile of the pros-
thetic reconstruction.
The esthetic appearance of a natural or restored smile
results from balance between the gingival and dental
components (50). In health, the most esthetically
pleasing state, the relationship between these two
components produces gingival extensions or off-
shoots between adjacent teeth. These gingival exten-
sions, the interdental papillae, convey a festooned
appearance to the gingival component. In health, the
tip of the interdental papilla reaches the contact point
between teeth, thereby obliterating the interdental
space (64). Conversely, the absence of interdental
papillae in a smile is often a sign of pathology and
causes the formation of interdental ‘black triangles’
or ‘black holes’ (55). Interdental black triangles dele-
teriously impact on the smile and create discomfort
for the patient as a result of trapping food and plaque,
speech alterations and passage of saliva in the spaces.
The aim, after guided bone regeneration with
subsequent implant placement, is to recreate the
inter-implant papilla, which can be unpredictable.
Numerous attempts to preserve or even reconstruct
the inter-implant papillae have been published; how-
ever, long-term evaluation of papilla reconstruction is
needed (8, 11). It is important to remind ourselves
that the interdental papilla depends on the underly-
ing alveolar bone anatomy; hence, when this is lost,
the papillae are also lost. Prosthetic management of
the lost tissues may be a viable, although not ideal,
option to improve the esthetic appearance of the final
restorations in the case of loss of inter-implant
papillae (43, 77).
Soft-tissue alterations
The aim of vertical ridge augmentation in the ante-
rior region is to provide sufficient bone volume for
implant placement and to provide an esthetically
satisfying result for the patient. Therefore, treatment
planning should consider both the quantity and the
quality of soft tissue in the area to be augmented as
a lack of optimal soft tissues can jeopardize the final
esthetic outcome of the whole implant-supported
prosthetic restoration (15, 82). Furthermore, kera-
tinized tissues around the implant are advocated to
prevent peri-implant diseases (28). For these reasons,
the treatment plan may seek to include the use of a
connective tissue graft (10), normally harvested from
the molar/premolar area of the palate or from the
maxillary tuberosity. A connective tissue graft can be
used during and/or after a vertical guided bone

244

regeneration procedure (56). Using these procedures,
it is possible to avoid a concave contour of the buc-
cal aspect of the implant mucosa and simultaneously
to provide adequate keratinized mucosa around
dental implants. The information provided in this
section should be interpreted with caution as the
available literature is primarily based on case
reports. Furthermore, no information is currently
available regarding the possibility of scars generated
by the incisions during flap design when performing
bone augmentation.
Esthetic indices
Several indices have been proposed to assess the
esthetic appearance of both the reconstruction and
the adjacent mucosa in an objective way (20, 24, 38,
65). The most frequently used indices in implant liter-
ature are:
 Jemt’s Papilla Index (24). The Jemt papilla index is
the oldest and probably the most cited index;
however, it only evaluates the presence of the
interdental papilla adjacent to an implant.
 Implant Crown Aesthetic Index (37). This index
evaluates the esthetic result of an implant-
supported crown considering nine aspects (five
related to the prosthesis and four related to the
soft tissues). The adjacent and the contralateral
teeth are used as references.
 the Pink Esthetic Score (20) was developed for
soft-tissue evaluation around single-tooth implant
crowns. It is based on seven variables.
 the Pink and White Esthetic Score (5) is a modifica-
tion of the pink esthetic score. The soft-tissue
evaluation has been simplified (five parameters
instead of seven) and five variables have been
added for evaluating the esthetic outcome of the
crown.
 the Complex Esthetic Index (27) is a more recent
and articulated index compared with the previous
indexes. The authors of this system found that the
other indexes did not consider the bone crest
beneath the soft tissue, which is a predictive factor
for esthetic outcome of the implant-supported
restoration. The 15 variables considered in this
index are divided into three parts [(i) soft tissue;
(ii) predicting factors; and (iii) implant-supported
restoration], with five parameters each.
In addition, technical equipment, such as photogra-
phy, computer software, spectrophotometry and opti-
cal scanners, has been applied in clinical trials to
measure the esthetic features of the mucosa and the
supra-structure (17, 51, 53, 81). However, it must be
GBR in the esthetic zone
noted that variation of intra- and inter-observer agree-
ment, depending on the investigators’ specialization,
has been reported (21, 37). To the best of our knowl-
edge, the above indices are only used in the implant,
restorative and prosthetic literature and are rarely
found in studies reporting outcomes of guided bone
regeneration or other bone-augmentation techniques.
Assessment of esthetics and patient-
centered outcomes
The literature reporting outcomes of vertical bone
augmentation, irrespective of whether this was per-
formed in the posterior or anterior regions, does not
provide information related to patient-centered out-
comes and often vague, subjective esthetic parameters
are used. For example, papers report ‘. . .acceptable
esthetic results. . .’ or ‘. . .harmonic soft tissue architec-
ture surrounded the implant restoration. . .’ or ‘. . .this
technique offers predictable functional and esthetic
reconstruction. . .’ (16, 56, 61). These descriptions sug-
gest that the standard esthetic assessment parameters
used in conventional dentistry are seldom used when
assessing outcomes following vertical guided bone
regeneration in the esthetic zone. On the contrary,
interesting manuscripts have recently been published
in the implant literature, focusing on esthetic assess-
ments and patients’ perception of implant treatment.
Two systematic reviews, published in 2012, evaluated
the literature regarding the professional assessment
of esthetics and patient-centered outcomes in
implant dentistry (7, 34). The authors concluded with
the need for development and application of vali-
dated and reproducible assessment methods. There
is a strong need for a consensus on objective and
well-defined parameters to assess the esthetics in
implant dentistry.
In recent years, dentistry has focused more on
patient-centered care, especially in implant treat-
ments where clinicians have evaluated the patients’
needs and their satisfaction with treatment outcome.
From a patient perspective, implant survival rates
and marginal bone-level changes are not the only rel-
evant outcome parameters. Recently, Thoma et al.
(67) reported outcomes after implant and bone-
regenerative treatment in terms of cost, treatment
time and patients’ morbidity using standard patient
questionnaires. In order to obtain a clearer under-
standing of the patient’s perspective and needs, it
is important to use studies with a qualitative
design. Using such studies, it might be possible to
improve further dental care and quality of life for
patients (25).
245
Rocchietta et al.
Case presentation
A young patient (a 25-year-old woman, with good
general health status) attended the first consultation
assessment concerned about the poor esthetic of her
smile and the mobility of several teeth (Figs 1–3).
Following clinical and radiographic examinations
(Fig. 4), the patient was diagnosed with severe local-
ized aggressive periodontitis. After initial, nonsurgical
periodontal therapy and wisdom teeth extraction,
Fig. 1. The patient’s initial situation, frontal view.
Fig. 2. The patient’s initial situation, particularly of teeth
2.3 and 2.4.
Fig. 3. The patient’s initial situation, particularly of teeth
1.1 and 2.1.
246
four teeth were considered to have a hopeless prog-
nosis as a result of the presence of marked soft-
tissue recession and bone loss. Therefore, teeth 1.1,
2.1, 2.3 and 2.4 were extracted (Fig. 5) and a
ridge-preservation procedure, with deproteinized
bovine bone (Geistlich Bio-Ossâ; small granules;
€ hne AG, Geistlich Sons Ltd., Manchester,
Geistlich So
Fig. 4. Panoramic radiograph of the patient showing
severe bone loss between teeth 1.1 and 2.1, between teeth
2.3 and 2.4 and in the posterior regions. Only four teeth
were considered hopeless.
Fig. 5. Occlusal view after extraction of the four hopeless
teeth (1.1, 2.1, 2.3 and 2.4).
Fig. 6. Frontal view showing ridge preservation after
extraction of the four hopeless teeth (1.1, 2.1, 2.3 and 2.4).

Fig. 7. Two connective tissue punches were positioned on
the sites of extracted teeth 1.1 and 2.1 to cover the bioma-
terial inserted into the socket.
Fig. 8. The same ridge preservation technique using a con-
nective tissue punch (as shown in Figs 6 and 7) at the sites
of extracted teeth 2.3 and 2.4.
Fig. 9. Panoramic radiograph showing the sockets filled
with the xenograft.
UK) and connective tissue punch, was performed
(Figs 6–11). A resin retained temporary Maryland
Bridge was delivered to ensure good esthetics for the
patient. During the healing phase, periodontal surg-
eries (osseous resective surgeries) were performed on
the remaining teeth to treat periodontitis.
Six months post-extraction, vertical and horizontal
bone ridge augmentation procedures were performed
simultaneously in both edentulous sites following the
guided bone regeneration technique. The latter
GBR in the esthetic zone
Fig. 10. The surgical site after 1 week of healing.
Fig. 11. The surgical site after 1 month of healing.
Fig. 12. A full-thickness buccal flap with two releasing
incisions was elevated from the distal portion of tooth 1.3
to the distal portion of tooth 2.5. The palatal flap (without
releasing incisions) was also elevated.
was performed using two nonresorbable, titanium-
reinforced, expanded-polytetrafluoroethylene mem-
branes (Gore-texâ; regenerative membrane titanium
reinforced TR6Y; W. L. Gore & Associates, Inc., Flag-
staff, AZ, USA) fixed to the residual bony walls by
eight pins (FRIOSâ Membrane Tacks; Dentsply Corp.
York, PA, USA), two tenting screws (Maxilâ; Titanium
Micro-screw 1.5 9 9 mm; OMNIA S.p.A, Fidenza,
Italy) and a 3:1 (vol/vol) mixture of autologous bone
chips (harvested with a bone scraper in the recipient
area) and deproteinized bovine bone (Geistlich Bio-
Ossâ. small granules; Geistlich So
€ hne AG; Figs 12–22).
247
Rocchietta et al.

Fig. 13. The atrophic crest in an occlusal view. The white

arrow indicates the nasopalatine canal: the structures con-
tained in it were removed and the empty space was
included in the regeneration procedure.
Fig. 16. Tooth sites 1.1 and 2.1 were filled with a mixture
of autologous bone chips and xenograft; the nonresorbable
membrane was fixed on the palatal site.

Fig. 14. The tenting screw was positioned between teeth

1.1 and 2.1; the amount of vertical bone regenerated is
approximately 4 mm. Fig. 17. The same phase of surgery described in Fig. 16, in
tooth sites 2.3 and 2.4.

Fig. 15. The second tenting screw was positioned between

teeth 2.3 and 2.4. Similarly to that shown in Fig. 14, verti-
cal bone augmentation of 4 mm was needed.
Both sites healed uneventfully (Fig. 23) and,
4 months later, the patient started orthodontic treat-
ment to correct tooth position and optimize space
for implant placement. Eight months after the aug-
mentation surgery, the two nonresorbable mem-
branes, two tenting screws and eight fixation pins
Fig. 18. The nonresorbable membrane covered the mix of
particulated bone and was carefully adapted onto the graft
and the bone surfaces of tooth sites 1.1 and 2.1.
were removed (Figs 24 and 25) and four implants
were inserted into the regenerated bone (Fig. 26).
Two 13 9 3.75 mm MKIII implants (Nobel Biocare,
Kloten, Switzerland) were inserted in tooth sites 1.1
and 2.1; and two 13 9 4 mm Nobel Speedy implants

248

Fig. 19. Occlusal view of the nonresorbable membrane at
tooth sites 2.3 and 2.4.
Fig. 20. Occlusal view after suturing. It is possible to see
the 5/0 expanded polytetrafluoroethylene (GORE-TEXâ
Suture CV5; W. L. Gore & Associates, Inc., Flagstaff, AZ,
USA) internal mattress suture and the 6/0 polypropylene
(Prolene 6.0 Ethicon; Johnson & Johnson Inc., New Bruns-
wick, NJ, USA) interrupted suture.
Fig. 21. Frontal view 2 weeks after the augmentation
surgery.
(Nobel Biocare) were inserted in tooth sites 2.3 and
2.4. In addition to implant placement, deproteinized
bovine bone xenograft particles (Geistlich Bio-Ossâ;
€ hne AG) and two resorb-
small granules; Geistlich So
able collagen matrixes (Geistlich Bio-Gideâ; Geistlich
€ hne AG) were positioned on the buccal portion to
So
enhance and protect the newly regenerated horizon-
tal bone volume (Figs 27–32).
GBR in the esthetic zone
Fig. 22. Panoramic radiograph showing the two regener-
ated sites in which the tenting screws and the fixation pins
are clearly visible.
Fig. 23. Occlusal view before surgically opening the flaps
to remove the nonresorbable membrane.
Fig. 24. Vestibular view of the two nonresorbable mem-
branes in situ.
Four months post-implant placement, the soft-tis-
sue volume of the two regenerated areas was aug-
mented using two collagen barrier matrices (Geistlich
Mucograftâ; Geistlich So € hne AG; Figs 33–36). One
month after soft-tissue grafting, four healing abut-
ments were connected to the implants using a small-
punch approach in order not to disturb the newly
formed soft and hard tissues (Figs 37 and 38). One
week later, an impression of the implant position was
taken, and screw-retained provisional prostheses
249
Rocchietta et al.

Fig. 29. Panoramic radiograph showing the implant posi-

Fig. 25. The newly formed bone was visible after removing tioned in the upper jaw.
the nonresorbable membranes.

Fig. 30. Frontal view of the healing at the surgical sites

after 2 weeks.

Fig. 26. Occlusal view of the four implants placed in the

regenerated bone.

Fig. 31. Closer view of the buccal contour at sites 1.1 and
Fig. 27. A second horizontal bone-augmentation surgery
2.1 showing good soft-tissue contour.
was performed at time of implant placement; Bio-ossâ
particles are positioned on the 1.1 and 2.1 buccal areas.

Fig. 32. Frontal view of the 1.1 and 2.1 sites after implant
placement. Vertical gain of the alveolar crest is clearly
Fig. 28. Xenograft covered by two resorbable membranes. visible.

250
 GBR in the esthetic zone

Fig. 33. Frontal view of the soft-tissue augmentation sur-

gery; a partial-thickness flap was raised. Fig. 37. Occlusal view of the two regenerated sites before
the connection of the healing abutments.

Fig. 34. The Mucograftâ positioned under the flap.

Fig. 38. The four implants were uncovered with the aid of
a soft-tissue punch and then connected to four healing
abutments.

Fig. 35. Occlusal view 2 weeks after soft-tissue augmenta-

tion surgery. Fig. 39. The first implant screw-retained dental prosthesis.

Fig. 36. Buccal aspect following 2 weeks of healing after Fig. 40. Frontal view of the transfers connected to the
the soft-tissue augmentation procedure. implants for the final impression.

251
Rocchietta et al.
Fig. 41. The polyether impression was taken to fabricate
four zirconia definitive abutments.
Fig. 42. The second provisional prosthesis luted to the zir-
conia abutments.
Fig. 43. The smile of the patient showing the final metal-
free prosthesis.
Fig. 44. Intra-oral view of the final restoration.
were positioned after a further 14 days (Fig. 39). The
four definitive zirconia abutments were screwed after
3 months (Figs 40–41); a second, luted provisional
prosthesis was fabricated (Fig. 42) in order to maxi-
mize the soft-tissue adaptation and tooth form.
252
When the result was satisfactory for both the
patient and the prosthodontist, the case was finalized
with two metal-free fixed dental prostheses luted on
zirconia abutments (Figs 43 and 44).
Conclusion
Advances in biomaterials research and the develop-
ment of new and improved surgical techniques and
armamentarium have resulted in ever-increasing pos-
sibilities to regenerate bone in the most challenging
defects. In addition to functional and health-related
aspects, the visual appearance of the reconstruction
and surrounding soft tissues has become an impor-
tant factor for clinical success in esthetic sites.
Some implant, restorative and prosthetic studies report
esthetic outcomes (using well-defined indices) and
patient-centered outcomes. However, literature report-
ing bone atrophies treated using vertical and/or
horizontal guided bone regeneration often do not eval-
uate the final esthetic result or patient-centered out-
comes. Future studies on guided bone regeneration
should focus on investigating the esthetic results as the
primary outcome variable as well as patient-reported
outcomes.
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Periodontology 2000, Vol. 77, 2018, 256–272
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
256
© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
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
 Buccal soft-tissue dehiscence treatments

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.

257
Mazzotti et al.
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,
258
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

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
Buccal soft-tissue dehiscence treatments
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
259
Mazzotti et al.
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
260
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

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
Buccal soft-tissue dehiscence treatments
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
261
Mazzotti et al.
B advanced flap with connective tissue
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.
262
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
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.
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

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.
Buccal soft-tissue dehiscence treatments
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
263
Mazzotti et al.
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
264
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.
 Buccal soft-tissue dehiscence treatments

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).

265
Mazzotti et al.

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

266

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
Buccal soft-tissue dehiscence treatments
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
267
Mazzotti et al.
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
268
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

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.
Buccal soft-tissue dehiscence treatments
 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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