Periimplant Tissue Management:

Optimal Timing For An Aesthetic Result

Markus B. Hürzeler, DMD, PhD
Dietmar Weng, DMD

When implants are utilized to restore the dentition in an aesthetically prominent region, there are four different time points when the
periimplant tissue can be influenced — prior to implant placement, simultaneously with implant placement or during the healing
phase of the implant, at second-stage surgery, and during the maintenance phase. There is no single optimal point in time for man-
aging the periimplant tissues; the patients present for treatment at various stages, and each case has to be individually evaluated and
an appropriate treatment plan designed. The earlier periimplant tissue management is initiated, the greater are the opportunities for
a successful result. The learning objective of this article is to review these options by means of case presentations. The different
surgical procedures are explained and their advantages or disadvantages discussed. Four case reports are used to demonstrate the
rationale and the clinical procedures. An improvement in the aesthetic harmony was attained in all four cases.

S
oft tissue management has be-
come a key topic in aesthetically
oriented implant dentistry.1,2
While previous challenges with
dental aesthetics could be ad-
dressed by improving manufacturing pro-
cedures and technical skills, gingival aes-
thetics remains as a critical factor in the
overall success of an implant-supported
restoration. If a restoration is acceptable
only in cases with a low lip line, the treat-
ment should be considered an aesthetic
failure (Figure 1). Factors such as insuffi-
cient bone structure, discrepancies between
natural root-form and implant design, and
improper implant position/angulation
Figure 1. Implant-supported ceramometal crown restoration of the maxillary left central
Dr. Hürzeler is Associate Professor, incisor. Note the unaesthetic periimplant tissue contour.
Department of Prosthodontics, Albert-
Ludwigs-University, Freiburg, Germany,
contribute to the inability of the peri- 1. Prior to implant placement.
and Clinical Assistant Professor,
implant soft tissue to provide adequate 2. At implant placement or during
Department of Stomatology, Division of support.3 As a result, the soft tissue col- the healing phase of the implant.
Periodontics, Dental Branch, University lapses, revealing the implant-supported 3. At second-stage surgery.
of Texas-Houston Health Science substructure. Therefore, the appropriate 4. In the maintenance phase.
Center, Houston, Texas. time and surgical approach must be care-
fully selected for proper periimplant tissue The purpose of this article is to re-
Dr. Weng is an Assistant Professor, view these options by means of case pre-
management in order to maintain and
Department of Prosthodontics, Albert- sentations. The different surgical proce-
improve the gingival architecture.
Ludwigs-University, Freiburg, Germany. dures are explained and their advantages
Furthermore, the position of the implant
and/or disadvantages discussed.
Address correspondence to: should be considered from a prosthetic
Markus B. Hürzeler, DMD, PhD and aesthetic perspective, since the pres- PERIIMPLANT TISSUE
Department of Prosthodontics ence or absence of bone should be of MANAGEMENT PRIOR TO
Albert-Ludwigs-University minor concern in the era of predictable IMPLANT PLACEMENT
Freiburg, Germany guided bone regeneration.3 In general, four When the tooth-to-be-replaced is still in
Tel: 011-49-761-270-4906 potential points in time can be differenti- its socket, the potential of successful
Fax: 011-49-761-270-4925 ated for soft and hard tissue management: periimplant tissue management is at its

THE IMPLANT REPORT 1996 PP&A 857

optimum. Since the root is still support-
ing the alveolar bone in its original posi-
tion, the buccolingual bone dimension
has not as yet decreased. The mucogingi-
val junction is still located at its natural
level. To preserve the anatomic struc-
tures and extend their longevity, the level
of the tooth should be decreased with
burs to bone level, without traumatizing
the gingival tissues.4 The root, however,
remains in its socket. When the tooth re-
quires extraction due to endodontic diffi-
culties, the extraction socket should be
filled with a nonresorbable bone grafting
material and covered with a collagen
membrane, without elevating a flap.
Following a healing period of 3 to 4 weeks,
the granulation and epithelization pro- Figure 2. Case 1. Preoperative close-up of maxillary anterior dentition. Note the gingival
cess has closed the alveolar wound area margin of four existing ceramometal crown restorations.
almost completely,4 and new keratinized
tissue has been gained. At the time of
implant placement, a full-thickness flap

Gingival aesthetics remains a

critical factor for the success of
an implant-supported restoration,
still to be fully addressed.

is raised from the palatal aspect, which

includes the “perforated” area. The root
is removed with minimal traumatization
of the tissues. Following curettage of the Figure 3. Tooth #7 has been extracted and the socket filled with a bone grafting material.
alveolus, the implant can be placed im- At 4 weeks, the site is partly covered with soft tissue.
mediately. Due to the discrepancy between
the diameter of the implant and the ex-
traction socket in the coronal portion,
the use of a barrier membrane is indi-
cated, with or without a bone grafting
material.5-7 Proper fixation of the barrier
must be guaranteed, preferably with a
resorbable pin device.8 Prior to readapt-
ing the flap, a free connective tissue
graft from the palate9 is placed beneath
the mucosal perforation on top of the
barrier membrane. The graft placement
has to be achieved in order to protect
the implant and the membrane site
from bacterial contamination through
the perforation in the flap.10,11 It can be
used simultaneously with recontouring
of the facial or coronal aspect of the im- Figure 4. Implant immediately following the placement of bone grafting material. Note
plant site, if necessary. the exposure of 8 implant threads.

858 Vol. 8, No. 9 THE IMPLANT REPORT 1996

 Case 1
A 52-year-old female patient presented
with a maxillary right lateral incisor that
had undergone three apicoectomy pro-
cedures (Figure 2). Chronic suppuration
and gingival fistulae developed at 3- to 4-
week intervals, and removal of the tooth
was indicated. Since the patient declined
to have the adjacent canine prepared for
a conventional fixed prosthesis, a deci-
sion was made to place a single root-
form implant to replace tooth #7.
• According to the technique de-
scribed, the tooth was extracted,
and the extraction socket was filled
with a nonresorbable bone grafting
Figure 5. Adaptation and fixation of the augmentation material over the dehiscence-type material. The site was allowed to
bony defect and implant.
heal for 1 month (Figure 3).
• A buccal mucoperiosteal flap was
elevated from the palatal aspect. A

The time and the surgical

approach for proper periimplant
tissue management must be
chosen carefully ...

small hole was present in the crestal

tissue.
• The bone grafting material was re-
Figure 6. Prior to suturing in place, subepithelial connective tissue graft is fixed to the moved completely, and the defect
buccal flap with resorbable sutures. was meticulously debrided with
sharp bone curettes.
• A 15 mm endosseous dental implant
(3i, West Palm Beach, FL) was placed
into the extraction socket in the de-
sired position. Eight implant threads
remained exposed (Figure 4). The
osseous defect was packed with a
bovine-derived bone graft material
(Bio-Oss Biomaterials, Osteohealth,
Shirley, NY) to conform to the shape
of the alveolar ridge. An e-PTFE
membrane (Gore-Tex, W.L. Gore,
Elkton, MD) was fitted to cover the
implant and the grafting material
and fixed in place with titanium
minipins (Figure 5).

Figure 7. Implant and bony ridge 6 months following surgery, immediately following • A subepithelial connective tissue was
removal of the barrier. New bone-like tissue is present. obtained from the palatal mucosa.

THE IMPLANT REPORT 1996 PP&A 859

 The graft was sutured with biore-
sorbable sutures beneath the buccal
flap near the perforation (Figure 6).
• The flap was sutured to the palatal
aspect with horizontal mattress su-
tures. No attempt was made to coro-
nally reposition the buccal flap, and
the graft remained exposed.
Clinical Outcome
Postoperatively, the patient was instructed
to rinse with a 0.2% chlorhexidine solu-
tion and avoid mechanical plaque removal
at the operated site for 2 weeks. Sutures
were removed following a 10-day healing
period, and the patient was evaluated
monthly. A temporary prosthesis, de- Figure 8. Postoperative view of the ceramometal crown restorations. Note gingival con-
signed to avoid pressure on the healing tour and interdental papillae preservation.
socket, was delivered. Since a nonre-
sorbable barrier was used for guided

There are four

different points of time when
the periimplant tissue can
be influenced ...

bone regeneration, a buccal mucoper-

iosteal flap was required at the second-
stage procedure. The barrier was re-
moved, revealing newly formed bone-like
tissue that covered the previously ex- Figure 9. Case 2. Maxillary left lateral incisor 3 weeks postextraction; maxillary right
lateral incisor is scheduled for extraction.
posed implant threads (Figure 7). A heal-
ing abutment was placed, and the buccal
mucoperiosteal flap was readapted and
sutured. Following a healing period of
4 weeks, an impression was taken, and
the implant was restored 7 months post-
placement with a screw-retained porce-
lain-fused-to-metal (PFM) crown restora-
tion (Figure 8).
Discussion
As demonstrated, periimplant tissue
management prior to implant place-
ment maintains the original anatomic
structures at a maximum level. The
buccolingual bone dimension has a criti-
cal role in the visualization of the aes-
thetic success; the dimension can be Figure 10. Diagnostic wax-up of the study cast revealed the insufficiency of gingival
maintained, and additional keratinized tissue on the maxillary left lateral incisor.

860 Vol. 8, No. 9 THE IMPLANT REPORT 1996

 tissue can be created. Based on these peri-
implant measures, the final position of
the implant can be readily determined,
since the anatomic structures are still in
their original position. No compromise
is required for the former position of the
tooth and the buccal bone contour or
volume. For the patient, decreasing the
length of the tooth 3 to 4 weeks prior to
implant placement involves a slightly
prolonged wearing of the provisional
restoration. However, in relation to the
healing for osseointegration, it is of
minor importance. The harvest of a free
connective tissue graft from the palate
results in a second surgical site during
Figure 11. Four weeks following reduction of tooth #7 to the alveolar crest, buccal flap implant surgery. However, the single in-
was elevated, residual root was extracted, and an endosseous implant placed. cision line,12 which provides primary
wound healing with an improved aes-
thetic result, justifies the procedure.

When tooth-to-be-replaced is
still in its socket, the potential of
successful periimplant tissue
management is at optimal height.

TISSUE MANAGEMENT AT
IMPLANT PLACEMENT OR
DURING HEALING PHASE
When teeth have been missing for
Figure 12. An additional implant was placed at tooth #10 and subepithelial connective longer periods of time, the existing
tissue was grafted over both implant sites and sutured with horizontal mattress ties.
bone structure either does or does not
allow implant placement. In the latter
case, bone augmentation procedures
have to be performed prior to implant
placement.13 However, whenever possi-
ble, an attempt should be made to place
the implant and augment the surgical
site simultaneously. Such combined
treatment reduces the number of sur-
geries, and the total healing period can
be reduced by 6 to 8 months.14 Due to
the inevitable bone loss on the buccal
aspect, measures have to be taken to re-
contour that site. In case of exposed im-
plant threads, guided bone regeneration
must be used to cover these areas.15 Due
to the defect morphology, a bone graft-
Figure 13. Facial view 3 months following implant placement revealed the missing tissue ing material, whether autogenous or
in the region of tooth #10. not, should be used to secure the space

THE IMPLANT REPORT 1996 PP&A 861

beneath the barrier membrane.13 It is
preferable to place a free connective
tissue graft from the palate.10,11 This pro-
vides an adequate thickness of the peri-
implant tissue and compensates for the
shrinkage during the healing phase. It
may be necessary to place an autogenous
graft from the palatal area during the 6-
month healing period to ensure thick tis-
sue over the implant for a predictable
aesthetic result.
Case 2
A 34-year-old female patient in good
general health presented with a frac-
tured maxillary right lateral incisor. An
apicoectomy had been completed on the
maxillary left lateral incisor; however, Figure 14. Occlusal view of the maxillary dentition; both lateral incisors have been
the tooth continued to abscess and fistu- extracted, and implants have been placed.
late. It was decided to remove the left
lateral incisor and treat the right lateral
incisor according to the protocol de-

When the final restoration

is already completed,
it severely limits the
periodontal opportunities.

scribed in Case 1 (Figures 9 and 10).

Four weeks following extraction of tooth
#10 and reduction of tooth #7 to the
alveolar crest, the implants were placed. Figure 15. The site of tooth #10 is reconstructed with soft connective tissue. Note
adequate soft tissue thickness to achieve an aesthetic result.
• A buccal mucoperiosteal flap was
elevated on both sides.
• The remnant of the root of tooth
#7 was extracted, and implants (3i,
West Palm Beach, FL) were placed
in both sites (Figure 11).
• An e-PTFE membrane was fitted to
cover the dehiscence type of defect
on tooth #10 and the extraction
socket of tooth #7. In addition, the
defects were filled with a bovine-
derived grafting material (Bio-Oss
Biomaterials, Osteohealth, Shirley,
NY) prior to securing the membranes
in place with titanium minitacks.16
A connective tissue graft from the Figure 16. Implant in the site of tooth #10 at uncovering. The e-PTFE barrier requires
palatal aspect was obtained and removal prior to the placement of the healing abutment.

862 Vol. 8, No. 9 THE IMPLANT REPORT 1996

 positioned over the e-PTFE mem-
brane on both sides and sutured to
the buccal flap. The flaps were su-
tured using e-PTFE sutures with
horizontal mattress ties (Figure 12).
• The patient was given appropriate
postoperative instructions, including
the use of 0.2% chlorhexidine rinse
twice a day for 3 weeks. Sutures were
removed 2 weeks following surgery.
Clinical Outcome
Following a 3-month healing period,
an excessive shrinkage over the implant
in the site of tooth #10 became evident
(Figures 13 and 14), and soft tissue aug-
Figure 17. The healing abutments are in place, and the flaps are repositioned and sutured. mentation was required prior to the abut-
ment connection. A subepithelial connec-
tive tissue was harvested from the palatal
aspect following a pouch preparation in
the site of tooth #10. Connective tissue

The second-stage surgery

provides an additional
opportunity for periimplant
tissue management.

was placed over the buccal recession de-

fect of the left central incisor. Following
another 4 months of healing, the abut-
Figure 18. Occlusal view of the final restorations. Central incisor prostheses are supported ment connection was performed. Inspec-
by natural teeth, those of lateral incisors by implants. tion of the area demonstrated a sufficient
amount of thick soft tissue over the im-
plants to ensure a predictable aesthetic
result (Figure 15). Prior to the healing
abutment placement, the e-PTFE mem-
branes were removed (Figures 16 and
17). Following a 4-week healing period,
the central incisors were prepared, the
impression was taken, and 4 single PFM
crown restorations were fabricated and
seated (Figures 18 and 19).
Discussion
The described approach has to compensate
for the previous reduction in buccolingual
bone dimension. Bone regeneration on
the facial aspect of the maxilla becomes
more difficult due to the altered defect
Figure 19. Facial view of the final restorations (Restorative Dentistry: Dr. Max Rohde). morphology: In Case 1, the circular ex-
traction defect had evolved into a buccal

THE IMPLANT REPORT 1996 PP&A 863

dehiscence with reduced bone height.
Consequently, the aesthetic result became
less predictable. The quality of the periim-
plant tissue can be improved by means of a
free connective tissue graft. Therefore, dur-
ing the healing phase of the implant, the
aesthetic result is more predictable at the
second-stage surgery. Despite the unfavor-
able bone morphology, the implant must
be placed in the prosthetically correct posi-
tion to avoid further compromise.3

PERIIMPLANT TISSUE
MANAGEMENT AT
SECOND-STAGE SURGERY
The second-stage surgery provides an ad-
ditional opportunity for periimplant tissue
Figure 20. Case 3. Presurgical appearance of the dentition. Note the color disharmony of
management. As in the previous cases, the maxillary right lateral incisor.
the focus should be on the buccal tissue
contour. The position of the mucogingi-
val junction also has to be evaluated, since

Aesthetic improvement of a
cemented or screwed-in implant
restoration is a difficult task
for the periodontist.

it is a factor in the color match to the ad-

jacent tissues. In the opinion of the au-
thors, two surgical approaches provide
predictable aesthetic results — the modi- Figure 21. Six months post implant placement in site of tooth #7, the barrier was removed
fied roll flap technique17,18 and the free and soft connective tissue graft was performed.
connective tissue graft.19 The selection is
determined primarily by the position of
the mucogingival junction and the width
of the keratinized mucosa. Sufficient
width of keratinized tissue and proper po-
sition of the mucogingival junction favors
the modified roll technique, raised from
an orally placed incision line. If the muco-
gingival junction needs repositioning, the
modified roll technique should not be
used in order to preserve as much kera-
tinized tissue as possible. In that case, a
partial-thickness flap should be raised,
which allows the shifting of the muco-
gingival junction. To recontour the facial
aspect and to improve the emergence pro-
file, a free connective tissue graft has to be Figure 22. Occlusal view of soft tissue 4 months after augmentation of the area with
placed under the split-thickness flap. subepithelial connective tissue.

864 Vol. 8, No. 9 THE IMPLANT REPORT 1996

 Case 3
A 28-year-old male patient presented
with a discolored maxillary right lateral
incisor (Figure 20). Two apicoectomy
treatments had been completed, result-
ing in a reduced length of the root; two
large, but insufficient, composite restora-
tions were present. A treatment plan
was formulated that included the extrac-
tion of tooth #7 and the placement of
an implant.
• Two months following extraction, a
buccal and lingual mucoperiosteal
flap was elevated. An endosseous
oral implant (Brånemark, Nobel
Biocare, Chicago, IL) was placed in
Figure 23. Two vertical incisions were made on the palatal side, and a modified roll flap
conjunction with a bone graft mate-
was prepared.
rial and an e-PTFE membrane.
• The membrane was secured in place
with titanium minipins. The flaps

A color mismatch
is more apparent
to the untrained eye than a
difference in contours.

were repositioned over the mem-

brane and sutured with a combina-
tion of horizontal and vertical mat-
Figure 24. Buccal flap was reflected with an intact connective tissue tail. tress sutures.
• The patient was instructed to rinse
twice daily for 2 weeks with 0.2%
chlorhexidine solution.
Clinical Outcome
Prior to the abutment connection surgery
(Figure 21), a soft connective tissue graft
was placed during the healing phase of
the restorative process (Figure 22), as in
Case 2. To enhance the final aesthetic out-
come, a modified roll flap was performed
on the day of healing abutment place-
ment (Figures 23 through 25) — 10
months following the implant placement.
Subsequently, the implant was restored
and has been in function for 2 years
(Figures 26 through 28).
Discussion
Figure 25. Connective tissue tail was folded along the inner surface of the buccal flap to The periimplant tissue management at
increase the thickness of the ridge. second-stage surgery has to accommodate

THE IMPLANT REPORT 1996 PP&A 865

the implant in the selected position. If
the position is not prosthetically deter-
mined, the only technique to improve
the aesthetics is by manipulation of the
periimplant soft tissues. The objective of
the methods described is to improve the
facial contour and the position of the
mucogingival junction. From an anatomic
perspective, it is preferable to have a bony
base instead of a soft tissue cushion. The
requirement of a zone of keratinized mu-
cosa around the implants has been widely
discussed in the literature.20,21 Although it
has been proven that keratinized mucosa
is not a prerequisite for the long-term
stability of dental implants, two practi-
cally based rationales — aesthetics and
tissue rigidity — speak in its favor. A zone Figure 26. Periimplant soft tissue 2 months following provisional restoration placement,
of keratinized mucosa at the emergence at the removal of provisional crown restoration.
profile contributes to the natural appear-
ance of the implant restoration. A color
mismatch is more apparent to the un-

Sliding the tissues away

from the adjacent teeth
requires challenging secondary
wound-healing capacity.

trained eye than a difference in contours.

The second advantage of keratinized mu-
cosa, the enhanced rigidity, is based on its
tissue components. The richness in colla- Figure 27. Close-up view of the final restoration and the adjacent teeth. Note ideal
gen fibers provides resistance to mechan- emergence profile and healthy periimplant tissues.
ical injury, inflicted by insensitive brush-
ing or food.
PERIIMPLANT TISSUE
MANAGEMENT IN THE
MAINTENANCE PHASE
Aesthetic improvement of a cemented or
screwed-retained implant restoration is a
difficult task for the periodontist. The pa-
tient has generally undergone months or
years of treatments and surgeries; during
the maintenance phase, the aesthetic re-
sult has deteriorated by recession of the
periimplant tissue on the buccal aspect.
Recontouring the facial aspect can be
accomplished only with a free connective
tissue graft from the palate in combina-
tion with a lateral repositioned flap Figure 28. Postoperative clinical anterior view of the final restoration. (Restorative
around the natural teeth as described by Dentistry: Dr. Helma Mormann.)

866 Vol. 8, No. 9 THE IMPLANT REPORT 1996

 Nelson.22 However, the success of the
procedure is difficult to predict, and se-
veral surgeries may be required, each
following a 3-month interval. In such
cases, prediction of the aesthetic success
to the patient should be avoided.
Case 4
A 27-year-old male patient presented
with a gingival recession at the implant-
supported restoration of tooth #8 (Figures
29 and 30). Treatment options included
the removal and replacement of the im-
plant or retention of the implant and re-
construction of the periimplant tissue on
the buccal aspect. New PFM crown restor-
ations were required on the implant and
Figure 29. Case 4. Preoperative clinical view. Gingival recession of 8 mm on the on the left maxillary central incisor.
maxillary right central incisor.
• The existing fixed restorations on
the implant and on the left maxil-
lary central incisor were replaced

With the patient demand for

aesthetic restorations,
periimplant tissue management
has become a major concern.

by two acrylic provisional restora-

tions (Figure 31). For this procedure,
a new preparation line was deter-
Figure 30. Preoperative radiograph demonstrates a well-osseointegrated aluminum-oxide
mined on the cemented abutment
implant. on the implant, and the rest of the
abutment was polished (Figure 31).
• A lateral sliding flap from the buc-
cal aspect of the right maxillary lat-
eral incisor was prepared.
• A subepithelial connective tissue
graft was harvested from the palate
and sutured with resorbable sling
sutures on the abutment (Figure
32) before the lateral sliding flap
was adapted and fixed over the au-
togenous connective tissue graft.
• Following a 3-month period of
healing, an additional periodontal
plastic surgery — the “envelope”
technique, described by Raetzke23
Figure 31. Following removal of existing restorations, acrylic provisional restorations — was performed to cover the re-
were cemented on the right (implant) and left central incisors. maining buccal recession defect.

THE IMPLANT REPORT 1996 PP&A 867

Clinical Outcome
Once the optimal aesthetics and function
were obtained with the provisional restora-
tions, the final impression was taken, and
the implant and the left maxillary central
incisor were restored with PFM crowns. A
postoperative x-ray was taken immedi-
ately following cementation of the crown
restorations, which have been in place for
2 years (Figures 33 and 34).
Discussion
Even though the surgical approaches
demonstrated may result in a marked
improvement of aesthetics, the proce-
dure is still a struggle against the previ-
ous ill-advised treatment plan. If an Figure 32. Soft connective tissue from the palatal aspect is adapted and fixed over reces-
aesthetically motivated surgery has to sion type of defect. Lateral sliding flap is prepared from the maxillary right lateral incisor.
be performed following the final restora-
tion of the implant, the preceding op-
portunities have been missed. Since tis-
sue can no longer be gained from the
lingual aspect of the implant site, uti-
lization of the laterally repositioned flap
is an expedient. However, sliding the
tissues away from the adjacent teeth re-
quires challenging secondary wound-
healing capacity. Therefore, the proce-
dure should be avoided whenever
possible.
CONCLUSION
As the presentation of the four cases in-
dicates, periimplant tissue manage-
ment should be performed as early as Figure 33. Postoperative radiograph of the two PFM crown restorations, taken following
the final cementation.
possible. The sooner it is initiated, the
more surgical options are available to
suit each clinical circumstance. When
the tooth to be replaced is still in its
socket, every opportunity for aesthetic
success is present; when the final restora-
tion is completed, it severely limits the
periodontal opportunities. Success with
implant-supported restorations requires
close interdisciplinary teamwork be-
tween the prosthodontist and the perio-
dontist and a treatment plan with equal
attention to function and aesthetics.
With the increasing patient demand for
aesthetic restorations, proper periim-
plant tissue management has become a
major concern of every clinician in- Figure 34. Postoperative view exhibits significant improvement. Note color and soft tissue con-
volved in implantology. tours when compared with preoperative view (Figure 29). (Restorative Dentistry: Prof. J. R. Strub.)

868 Vol. 8, No. 9 THE IMPLANT REPORT 1996

 REFERENCES
1. Lazzara R. Managing the soft tissue margin:
The key to implant aesthetics. Pract Periodont
& Aesthet Dent 1993;5(5):81-87.
2. Studer S, Pietrobon N, Wohlwend A. Maxillary
anterior single-tooth replacement: Comparison
of three treatment modalities. Pract Periodont
& Aesthet Dent 1994;6(1):51-60.
3. Garber DA. The esthetic dental implant: Letting
restoration be the guide. JADA 1995;126:319-323.
4. Langer B. Spontaneous in situ gingival augmen-
tation. Int J Perio & Rest Dent 1994;14:525-535.
5. Dahlin C, Sennerby L, Lekholm U, et al.
Generation of new bone around titanium
implants using a membrane technique: An
experimental study in rabbits. Int J Oral
Maxillofac Imp 1989;4:19-25.
6. Becker W, Becker B. Guided tissue regeneration
for implants placed into extraction sockets and
for implant dehiscences: Surgical techniques
and case report. Int J Perio & Rest Dent 1990;
10:376-391.
7. Gelb D. Immediate implant surgery: Three-year
retrospective evaluation of 50 consecutive cases.
Int J Oral Maxillofac Imp 1993;8:388-399.
8. Hürzeler MB, Strub JR. Guided bone regenera-
tion around exposed implants: A new biore-
sorbable device and bioresorbable membrane
pins. Pract Periodont & Aesthet Dent
1995;7(9):37-47.
9. Langer B, Calagna L. The subepithelial connective
tissue graft. J Prosthet Dent 1980;44:363-367.
10. Edel A. The use of a connective tissue graft for
closure over an immediate implant covered
with occlusive membrane. Clin Oral Impl Res
1995;6:60-65.
11. Chen ST, Dahlin C. Connective tissue grafting for
primary closure of extraction sockets treated
with an osteopromotive membrane technique:
Surgical technique and clinical results. Int J
Perio & Rest Dent 1996;16:349-355.
12. Hürzeler MB, Kohal R. A new technique for
harvesting subepithelial connective tissue from
the palatal. (In preparation.)
13. Buser D, Dula K, Belser UC, et al. Localized
ridge augmentation using guided bone regen-
eration. II. Surgical procedure in the mandible.
Int J Perio & Rest Dent 1995;15:10-29.
14. Lazzara RJ. Immediate implant placement into
extraction sites: Surgical and restorative advan-
tages. Int J Perio & Rest Dent 1989;9:332-343.
15. Nyman S, Lang NP, Buser D, Brägger U. Bone
regeneration adjacent to titanium dental
implants using guided tissue regeneration: A
report of two cases. Int J Oral Maxillofac Imp
1990;5:9-14.
16. Hürzeler MB, Quiñones CR, Morrison EC,
Caffesse RG. Treatment of periimplantitis using
guided bone regeneration and bone grafts,
alone or in combination, in beagle dogs. Part I:
Clinical findings and histologic observations.
Int J Oral Maxillofac Imp 1995;10:474-484.
17. Scharf DR, Tarnow DP. Modified roll technique
for localized alveolar ridge augmentation. Int J
Perio & Rest Dent 1992;12:415-425.
18. Israelson H, Plemons JM. Dental implants,
regenerative techniques, and periodontal plas-
tic surgery to restore maxillary anterior esthet-
ics. Int J Oral Maxillofac Imp 1993;8:555-561.
19. Seibert JS, Salama H. Alveolar ridge preserva-
tion and reconstruction. Periodontology 2000
1996;11:69-84.
20. Warrer K, Buser D, Lang NP, Karring T. Plaque-
induced periimplantitis in the presence or absence
of keratinized mucosa. An experimental study in
monkeys. Clin Oral Impl Res 1995;6:131-138.
21. Strub JR, Gaberthüel TW, Grunder U. The role
of attached gingiva in the health of peri-
implant tissue in dogs, Part I: Clinical findings.
Int J Perio & Rest Dent 1991;11:316-333.
22. Nelson SW. The subpedicle connective tissue
graft. A bilaminar reconstructive procedure
for the coverage of denuded root surfaces.
J Periodontol 1987;58:95-102.
23. Raetzke PB. Covering localized areas of root
exposure employing the “envelope” technique.
J Periodontol 1985;56:397-402.
PRACTICAL
LEARNING OBJECTIVES:
PERIODONTICS &
AESTHETIC DENTISTRY
The 10 multiple-choice questions for this
exercise are based on the article “Periimplant
soft tissue management: Optimal timing for
an aesthetic result” by Marcus B. Hürzeler,
DMD, PhD, and Dietmar Weng, DMD. This
article is on Pages 857-869. Answers for this
exercise will be published in the January/
February 1997 issue of PP&A.
1. How many points of time for
management of periimplant
soft tissues are discussed by
the author?
a. 2.
b. 4.
c. 3.
d. None of the above.
2. The position of the implant
should be considered from
which aspects?
a. Prosthetic.
b. Aesthetic.
c. Bone regeneration.
d. a and b.
3. The potential points in time for
soft and hard tissue management
include:
a. Prior to implant placement.
b. At implant placement or during
the healing phase of the implant.
c. At second-stage surgery, and in
the maintenance phase.
d. All of the above.
4. When the tooth-to-be-replaced
is still in its socket, the potential
of successful periimplant tissue
management is:
a. At its optimal height.
b. Of no consequence.
c. To be considered at some point
in the future.
d. None of the above.
10. If several surgeries are required for
5. The buccolingual bone dimension:
a. Has no impact on the aesthetic
success.
b. Has a critical role in the visualiza-
tion of the aesthetic success.
c. Can be maintained, and additional
keratinized tissue can be gained.
d. b and c.
THE IMPLANT REPORT 1996
Self-Instruction Exercise No. 157
The purpose of this article is to review each
of the options of periimplant soft tissue
management by means of case presenta-
tions. The different surgical procedures are
explained and their advantages or disadvan-
tages discussed. Upon reading and comple-
tion of this exercise, the reader should have:
• A thorough comprehension of soft
tissue management.
• An improved rationale for treatment
planning.
• An increased ability of clinical imple-
mentation.
6. When teeth have been missing for
longer periods of time and the exist-
ing bone structure does not allow
implant placement:
a. An attempt should be made to
place the implant and augment
the surgical site simultaneously.
b. Bone augmentation should precede
implant placement by two years.
c. Bone augmentation should precede
implant placement by one year.
d. None of the above.
7. Periimplant tissue management at
second-stage surgery should consider:
a. Buccolingual dimensions and
contour.
b. The position of the mucogingival
junction.
c. Color match to the adjacent tissues.
d. All of the above.
8. In the opinion of the authors,
which surgical approach provides
predictable aesthetic results?
a. The modified roll flap technique.
b. The free connective tissue graft.
c. The modified excisive technique.
d. a and b.
9. Recontouring the facial aspect of a ce-
mented or screwed-in implant restora-
tion can be accomplished only with:
a. The modified excisive technique.
b. A free connective tissue graft in
conjunction with a lateral reposi-
tioned flap.
c. The modified roll flap technique.
d. Lateral repositioned flap.
periimplant tissue management in
the maintenance phase, how long
should the interval be between the
procedures?
a. 6 months.
b. 6 weeks.
c. 3 months.
d. 3 weeks.
PP&A 869