Received: 12 August 2022 Revised: 23 December 2022 Accepted: 23 January 2023

DOI: 10.1111/cid.13188

ORIGINAL ARTICLE

Vertical soft tissue augmentation to treat implant esthetic

complications: A prospective clinical and volumetric case series

Lorenzo Tavelli DDS, MS 1,2,3 | Giovanni Zucchelli DDS, PhD 3,4 |

Martina Stefanini DDs, PhD 4 | Giulio Rasperini DDS 1,5,6 |
2
Hom-Lay Wang DDS, MS, PhD | Shayan Barootchi DMD, MS 2,3
1
Department of Oral Medicine, Infection, and Immunity, Division of Periodontology, Harvard School of Dental Medicine, Boston, Massachusetts, USA
2
Center for clinical Research and evidence synthesis In oral TissuE RegeneratION (CRITERION), Boston, Massachusetts, USA
3
Department of Periodontics & Oral Medicine, University of Michigan School of Dentistry, Ann Arbor, Michigan, USA
4
Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
5
Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
6
IRCCS Foundation Polyclinic Ca’ Granda, Milan, Italy

Correspondence
Lorenzo Tavelli, Division of Periodontology, Abstract
Department of Oral Medicine, Infection, and
Introduction: Challenging implant esthetic complications are often characterized by
Immunity, Harvard School of Dental Medicine,
188 Longwood Avenue, Boston 02115, MA, implant malpositioning and interproximal attachment loss of the adjacent teeth. How-
USA.
ever, limited evidence is available on the treatment of these conditions. The aim of
Email: [email protected]
this study was to evaluate the clinical, volumetric, and patient-reported outcome fol-
lowing treatment of peri-implant soft tissue dehiscences (PSTDs) exhibiting interprox-
imal attachment loss on adjacent teeth, performed through vertical soft tissue
augmentation with implant submersion.
Methods: Ten subjects with isolated PSTD in the anterior maxilla characterized by
adjacent dentition exhibiting interproximal attachment loss were consecutively
enrolled and treated with horizontal and vertical soft tissue augmentation, involving
crown and abutment removal, two connective tissue grafts, and submerge healing.
Clinical outcomes of interest included mean PSTD coverage, mean PSTD reduction,
clinical attachment level (CAL) gain at the implant and adjacent sites and soft tissue
phenotype modifications at 1 year. Optical scanning was used for assessing volumet-
ric changes. Professional assessment of esthetic outcomes was performed using the
Implant Dehiscence coverage Esthetic Score (IDES), while patient-reported esthetic
assessment involved a 0–10 visual analogue scale.
Results: The mean PSTD depth reduction and mean PSTD coverage at 1 year were
2.25 mm, and 85.14%, respectively. A mean keratinized tissue width (KTW) gain of
1.15 mm was observed, while the mean gain in mucosal thickness (MT) was 1.58 mm.
A mean CAL gain of 1.45 mm was obtained at the interproximal aspect of the

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© 2023 The Authors. Clinical Implant Dentistry and Related Research published by Wiley Periodicals LLC.

204 wileyonlinelibrary.com/journal/cid Clin Implant Dent Relat Res. 2023;25:204–214.

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TAVELLI ET AL. 205

adjacent dentition at 1 year. Greater linear dimensional (LD) changes were observed
at the midfacial aspect of the implant compared to the interproximal sites. The mean
final IDES was 6.90 points, while patient-reported esthetic evaluation was 8.83
points.
Conclusions: The present study demonstrated that vertical soft tissue augmentation
with a submerged healing is an effective treatment approach for the treatment of
challenging PSTDs with adjacent dentition exhibiting interproximal attachment loss.
This technique can be effective in resolution of esthetic complications in most cases,
providing a substantial gain in interproximal attachment levels at the adjacent
dentition.

KEYWORDS
3D analysis, connective tissue graft, dental implants, esthetic complications, patient-reported
outcomes, peri-implant soft tissue dehiscences

SUMMARY BOX

What Is Known
• Peri-implant soft tissue dehiscences are common conditions. Their treatment can be compli-
cated by implant malpositioning, shallow peri-implant papillae and interproximal attachment
loss in the adjacent teeth.
• Only case reports are available in the literature when assessing the efficacy of surgical
approaches for the treatment of challenging peri-implant soft tissue dehiscences that require
vertical soft tissue augmentation at the implant and the adjacent sites.

What This Study Adds

The present report describes a series of successfully treated esthetic complications, as part of a
controlled study setting, with an in-depth evaluation of clinical, volumetric, and patient-reported
outcomes following vertical soft tissue augmentation with implant submersion for implants with
adjacent sites exhibiting attachment loss.

1 | I N T RO DU CT I O N Anderson et al. found a mean PSTD coverage of 40% and 28% follow-
ing CAF + subepithelial CTG and the acellular dermal matrix, respec-
By now, it is well known that the anatomy of dental implants—relative tively.17 Indeed, this does not appear to be in line with the treatment
to natural dentition—and its adjacent tissues differ from the periodon- outcomes commonly observed when the same techniques are per-
1,2
tia. Nonetheless, soft tissue deformities around implants and teeth formed for GRs.19–21 It has been advocated that the type of graft can
3
also have similar features. Both peri-implant soft tissue dehiscences also play a role on the treatment outcomes of PSTDs, with CTG
(PSTDs)4,5 and gingival recessions (GRs) are highly prevalent clinical obtained from the superficial palate or the maxillary tuberosity that
conditions.6–9 Also, their main indication for treatment is patient's should be preferred due to its higher amount of lamina propria and
10–13
esthetic concerns. GRs and PSTDs also share several common minimal presence of fatty and glandular tissue.3,12,22 Similarly, it has
etiological factors, including lack of keratinized tissue, limited soft tis- been suggested that an envelope CAF can also be beneficial in several
sue thickness, buccal bone dehiscence and malposition, among cases of PSTDs,12,23 while the prosthetic-surgical approach, involving
others.7,14–16 the removal of the crown (but with the abutment left in place) at least
From the first studies describing the outcomes of PSTD 1 month prior to the surgical procedure, can be advocated in other
treatment,17,18 it appeared that traditional root coverage techniques— instances.3,22 With this technique, Zucchelli and coworkers obtained a
as performed in natural dentition—have limited predictability for the mean PSTD coverage of 96.3% and 99.2% at 1 and 5 years,
correction of implant esthetic complications. When the conventional respectively.22,24
coronally advanced flap (CAF) was performed with subepithelial con- More challenging case scenarios involve implant esthetic compli-
nective tissue graft (CTG), Burkhardt et al. reported none of the cations characterized by implant malpositioning which may have also
implants resulted in a complete resolution of the PSTD at 6 months.18 resulted in interproximal attachment loss of the adjacent dentition.7
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206 TAVELLI ET AL.

These types of PSTDs are associated with papilla(ae) loss and the Guideline for improving the quality of case series reports (http://
occurrence of black triangles, which are often the main reason for www.processguideline.com/).33,34
25–27
patients inquiring esthetic treatments. However, limited evidence
is available on papilla reconstruction between dental implants and
teeth with interproximal attachment loss.25,26,28–30 Urban et al. 2.2 | Vertical soft tissue augmentation with
showed that papilla reconstruction in the above condition can be implant submersion
obtained through a multidisciplinary approach involving implant expla-
nation, guided bone regeneration, soft tissue augmentation and utili- Participants were informed that the surgical approach would require
zation of a customized abutment.28 Stefanini and coworkers crown as well as abutment removal, with the delivery of a provisional
described a successful case management for a PSTD with adjacent prosthesis (either a resin-bonded fix dental prosthesis or an essix
teeth showing interproximal attachment loss by application of a modi- retainer) at the day of the surgery. All patients also received a session
fied “connective tissue platform technique”,31 previously introduced of dental prophylaxis, including oral hygiene instructions. The surgical
for soft tissue augmentation of edentulous areas.26 The authors stabi- procedure consisted of a vertical and horizontal soft tissue augmenta-
lized one CTG on the buccal aspect of the implant and two CTGs, one tion with implant submersion, similar to the modification of the con-
on top of the other, over the implant platform and on the de- nective platform technique31 previously described by Stefanini et al.26
epithelialized occlusal ridge, aiming for a submerged healing approach (Figure 1).
for the implant with PSTD.26 A horizontal incision was performed from the soft tissue margin
The aim of the present study was therefore to consequently of the implant to the gingival margin of the adjacent teeth, where
enroll and treat patients with esthetic concerns due to PSTDs exhibit- intrasulcular incisions were made. Next, horizontal and vertical inci-
ing interproximal attachment loss on adjacent teeth, through horizon- sions were made at the level of the adjacent teeth to create anatomi-
tal and vertical soft tissue augmentation with implant submersion, and cal papillae of adequate dimensions and surgical papillae including
assess the clinical, volumetric and subjective patient-reported keratinized tissue, as wide as possible. The flap included at least the
outcomes. two adjacent teeth (mesial and distal to the implant with PSTD). In the
presence of additional sites with gingival recessions, the flap was
extended. Flap elevation occurred split-thickness around the dental
2 | MATERIALS AND METHODS implant and interproximally using a miniblade (Salvin Dental Special-
ties, Charlotte, USA), while the midfacial portion of the teeth included
2.1 | Study population in the flap was elevated full-thickness until exposing the crestal bone
using a microperiosteal elevator. A split-thickness dissection was also
Ten patients presenting with esthetic concerns related to an isolated performed on the palatal aspect, only at the level of the implant
PSTD in the anterior maxilla with adjacent dentition exhibiting inter- region, to expose a portion of the palatal connective tissue with the
proximal attachment loss were consecutively enrolled between goal of facilitating closure, adaptation and stabilization of the buccal
August 2020 and April 2021. All patients were at least 18 years old, flap. After flap release with deep and superficial cuts, the anatomical
with good general health and oral hygiene (full-mouth plaque scores papillae and the soft tissue on the ridge were de-epithelialized with a
≤15%), without systemic/periodontal disease. The isolated implants miniblade and a small round bur. The horizontal augmentation around
must have been without notable peri-implant disease characterized by the implant site (and if needed also around the adjacent sites) involved
class II, III, or IV and subclass c PSTD,4 with presence of at least one the harvesting of a CTG from the lateral palate as a free gingival graft
adjacent tooth with interproximal attachment loss and interproximal that was then extraorally de-epithelialized and stabilized over the
GR at least 1 mm. In addition, the presence of at least one notably implant site with simple interrupted sutures to the periosteum and
visible “black triangle” in an exaggerated smile was required, and de-epithelialized adjacent papilla soft tissue (7/0 PGA, Butterfly,
patients must have been willing to undergo removal of the abutment Cavenago di Brianza, Italy). The vertical augmentation at the level of
and implant-supported crown, and its replacement after the the implant site was performed with a second CTG, that was har-
treatment. vested either from the maxillary tuberosity (if available) or from the
Smoking, pregnancy (or planning to become pregnant), active palate as an epithelialized free gingival graft. After extraoral de-epi-
periodontal disease, history of soft tissue grafting at the experimental thelialization, the graft was stabilized over the occlusal ridge on the
site(s) within the past 6 months and the presence of peri-implant dis- implant platform and sutured against the papilla(e) of the tooth (teeth)
32
eases at the implant site were considered to be exclusion cri- with interproximal attachment loss using simple interrupted sutures
teria. The study protocol was approved by the Institutional Review for anchorage to the periosteum and the de-epithelialized soft tissues
Board of the University of Michigan (HUM00146261), in accor- (7/0 PGA, Butterfly, Cavenago di Brianza, Italy). Autogenous platelet-
dance with the Declaration of Helsinki of 1975, revised in Forta- rich fibrin membranes (PRF) were prepared as previously described35
leza in 2013. Written informed consents were obtained from all and applied over the CTGs prior to flap closure. A closure by primary
individuals who participated in the study prior to the surgical pro- intention - or with a minimal exposure of the graft—was obtained. A
cedures. This manuscript is prepared following the PROCESS 2020 first layer of one or more horizontal mattress suture(s) from the buccal
 17088208, 2023, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/cid.13188, Wiley Online Library on [14/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
TAVELLI ET AL. 207

F I G U R E 1 Vertical soft tissue augmentation with submerged implant healing for the treatment of a peri-implant soft tissue dehiscence with
adjacent teeth exhibiting interproximal attachment loss and gingival recession. (A–C) Baseline. (D) Crown and abutment removal. (E) Flap design,
with a horizontal incision on the buccal mucosa and two divergent vertical incisions. (F) Split-thickness flap elevation, except for the midfacial
portion of the natural teeth that was raised full-thickness until exposing the bone crest. (G) Occlusal view after flap elevation and releasing.
(H) De-epithelialization of the anatomical papillae and occlusal ridge. (I) Connective tissue grafts from the lateral palate and from the tuberosity.
(J) Connective tissue grafts in place. (K–L) Stabilization of the graft from the lateral palate to the periosteum and de-epithelialized occlusal ridge.
(M) Stabilization of the graft from the tuberosity over the occlusal ridge and against the lateral incisor in the attempt to promote interproximal
clinical attachment level gain. (N) Platelet-rich fibrin membrane. (O) Application of the platelet-rich fibrin membrane over the grafts prior to flap
suturing. (P) Flap closure.

flap to the palatal flap was performed, followed by simple interrupted incisions (6/0 and/or 7/0 polypropylene [Ethicon, Johnson & Johnson,
sutures approximating the edges of the buccal and palatal flaps (6/0 Somerville, USA]).
and/or 7/0 polypropylene [Ethicon, Johnson & Johnson, Somerville, Oral and written post-operative instructions were provided to
USA]). Flap adaptation was completed with sling sutures at the level patients, as well as prescriptions for analgesics (Ibuprofen 600 mg
of the elevated papillae, and simple interrupted sutures for the vertical every 4–6 h as needed), antibiotics (Amoxicillin 500 mg every 8 h for
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208 TAVELLI ET AL.

F I G U R E 2 (A–C) Frontal, lateral and occlusal view at baseline. (D–F) Outcomes at 6 months with temporary crowns. (G–I) Outcomes at
12 months. Note that the implant was left submerged.

7 days), and a mouth rinse (chlorhexidine gluconate 0.12% for the first using a punch biopsy technique to identify the cover screw. A tempo-
2 weeks). The sutures were removed at the 2-week post-op visit, where rary crown was then delivered, while the final implant-supported res-
the subjects were instructed to resume oral hygiene procedures using torations were delivered at least after 6 months (Figure 2).
an extra-soft toothbrush for the first month, prior to switching to a
soft-bristle toothbrush. Patients were recalled at 1, 3, 6, and 12 months
for post-operative healing assessment and measurements. 2.4 | Study endpoints

The main outcome of the study was the assessment of the mean
2.3 | Restorative phase PSTD coverage (in %) after 1 year. Secondary endpoints included ver-
tical soft tissue gain—assessed as mean PSTD reduction (in mm)—and
As previously implied, the implant-supported crown and abutment interproximal clinical attachment level (CAL) gain at the implant and
were removed at the day of the surgical procedure and replaced with adjacent sites. Changes in mucosal thickness (MT), keratinized mucosa
a cover screw. Based on the bucco-lingual position of the implant, its width (KMW) were also evaluated at the implant site, while gingival
mesio-distal distance from the adjacent teeth, and the restorative sta- recession (REC) depth and keratinized gingiva width (KGW) were
tus of the adjacent dentition (unrestored, with a previous crown or assessed in the adjacent dentition at the midfacial and interproximal
restoration), a decision was taken together with the patient regarding (toward the implant) aspects.
the restorative plan for the implant with the PSTD. In case of buccally Volumetric changes were assessed using digital impressions
positioned implants, < 1.5 mm apart from the adjacent tooth showing a obtained with intraoral optical scanning at baseline and 1 year. The
significant interproximal attachment loss, and adjacent teeth with pre- Implant Dehiscence coverage Esthetic Score (IDES)13 was utilized for
existing crowns or extensive restorations, it was suggested to leave the the professional assessment of the esthetic outcomes following verti-
implant submerged also after the healing, and finalize the case with a cal soft tissue augmentation after 1 year. Patient-reported outcome
fixed dental prosthesis, a resin-bonded fix dental prosthesis or alterna- measures (PROMs) included the evaluation of post-operative discom-
tive solutions involving anchorage to the adjacent dentition. The final fort during the first 2 weeks and final esthetic assessment at 1 year
decision was always taken in agreement with the patient. using questionnaires with 0–10 visual analogue scales (VASs). Willing-
For implants that could be restored, the sites were opened ness for retreatment, if needed, was also set as an outcome and evalu-
3 months following the vertical soft tissue augmentation procedure, ated at the 1-year follow-up.
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TAVELLI ET AL. 209

FIGURE 3 Digital workflow for the 3D assessment of volumetric changes between baseline and 1 year.

Additional information on the assessment of the above- measurements. A semi-automated alignment, based on the selection
mentioned clinical, esthetic and patient-reported parameters are of reproducible points on the digital models and on a best-fit algo-
described in the Appendix S1. rithm was used to superimpose the STL files.36,37 The STL file at the
1-year follow-up was superimposed to the one obtained at baseline
(prior to treatment), which was used as the reference (Figure 3). The
2.5 | STL file acquisition and volumetric outcomes region of interest (ROI) was defined as previously described.38,39
assessment Briefly, the ROI was a rectangular shape with the soft tissue margin as
its coronal border, extending 7 mm in a corono-apico direction. The
An intraoral optical scanner (Trios, 3Shape, Denmark) was utilized at ROI was delimited by two lines perpendicular to the occlusal plane
baseline and at the last follow-up visit to generate digital models that and to the CEJ of the adjacent teeth, passing through the mid-point of
were saved as STL files and imported in an image analysis software the mesial and distal papillae of the implant.38 The volumetric out-
(GOM Inspect, GOM, Germany). A single pre-calibrated examiner with comes of interest were calculated as linear dimensional (LD) changes,
experience in 3D volumetric analysis (L.T.) performed all the assessed at the interproximal and midfacial aspects of the implant site
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210 TAVELLI ET AL.

at 8 points, 1 mm apart from each other, starting from the tip of the were central incisors, 2 lateral incisors and 2 canines. Eight PSTDs
papilla at baseline (for the interproximal sites) and starting from the were diagnosed as class IV subclass c and the remaining 2 were class
most coronal point of the buccal soft tissue at baseline (for the midfa- III subclass c.4 Six sites showed 1 black triangle, while 4 implants
38,40,41
cial site). LD outcomes at the mesial and distal papilla were exhibited 2 black triangles. The mean PSTD depth at baseline was
then merged. 2.60 mm, while the mean baseline REC and CAL at the adjacent teeth
were 1.55 and 2.85 mm, respectively. An average interproximal CAL
of 3.3 mm was observed at the level of adjacent dentition at baseline
2.6 | Statistical analysis (Table 1).
No intra- or post-operative complications had occurred. The heal-
Descriptive statistics were used to present the clinical, ultrasono- ing was uneventful at all sites with the subjects reporting a mean mor-
graphic, and volumetric data, as well as PROMs, with means ± stan- bidity during the first 2 weeks of 2.63 points on a 0–10 VAS. Five
dard deviations (SD). Adjusted paired t-tests were utilized to implant sites were re-opened, and new implant-supported crowns and
statistically compare the changes in these outcomes between baseline abutments were delivered, while in the other 5 cases, the implants
and 1 year. To explore for statistically meaningful influence of any were left submerged, and the restorations relied on the adjacent
clinical parameters at baseline (to the final outcome), linear regression dentition.
analysis was used which also accounted for subject/patient baseline Table 1 depicts in detail the outcomes at 1 year following vertical
characteristics that could potentially influence the results (e.g., age, soft tissue augmentation. The mean PSTD depth reduction and mean
sex). A p value threshold of 0.05 was set for statistical significance. PSTD coverage at 1 year were 2.25 mm, and 85.14%, respectively. A
The analyses were performed in Rstudio (Rstudio Version 1.1.383, mean KTW gain of 1.15 mm was observed, while the mean gain in
Rstudio, Inc., Boston, USA) by an author with experience in data and MT was 1.58 mm. A mean REC reduction and CAL gain of 1.28 and
statistical analysis (S.B.). 1.45 mm, respectively, was obtained at 1 year at the interproximal
aspect of the adjacent dentition. At the 1-year assessment, 5 sites
showed only 1 black triangle, while the other treated implants did not
3 | RESULTS show any black triangles. The overall percentage of black triangle
reduction (compared to baseline) was 64.3%.
Ten systemically and periodontally healthy patients (3 males and LD changes are depicted in detail in Table 2. Overall greater LD
7 females, mean age of 52.8 ± 13.9 years) were included in the study. changes were observed at the midfacial aspect of the implant site
All cases were bone-level implants, and the mean loading time prior to compared to peri-implant papillae. Mean LD changes at the midfacial
the initial visit was 8.6 ± 2.7 years. Among the treated PSTDs, six aspect of the implant range between 2.11 and 3.15 mm, while at the

TABLE 1 Clinical outcomes at baseline and 1 year.

Outcome Baseline 1 year BL—1 yearb (p-value)

PSTD depth (mean ± SD) (mm) 2.60 ± 0.61 0.35 ± 0.47 2.25 ± 0.82 (<0.001)
Mean PSTD coverage (mean ± SD) (%) 85.14 ± 21.11
PD (mean ± SD) (mm) 2.35 ± 0.47 2.17 ± 0.41 0.17 ± 0.75 (0.611)
CAL (mean ± SD) (mm) 4.95 ± 0.69 2.58 ± 0.49 2.17 ± 0.68 (<0.001)
KMW (mean ± SD) (mm) 2.40 ± 0.77 3.55 ± 0.60 1.15 ± 1.06 (0.007)
AM (mean ± SD) (mm) 0.40 ± 0.52 1.33 ± 0.68 0.75 ± 0.94 (0.107)
MT (mean ± SD) (mm) 0.93 ± 0.12 2.51 ± 0.53 1.58 ± 0.61(<0.001)
Midfacial REC depth adjacent teetha (mean ± SD) (mm) 1.55 ± 0.84 0.30 ± 0.41 1.25 ± 0.94 (<0.001)
Midfacial PD adjacent teetha (mean ± SD) (mm) 1.30 ± 0.47 1.25 ± 0.41 0.05 ± 0.58 (0.705)
Midfacial CAL adjacent teetha (mean ± SD) (mm) 2.85 ± 0.95 1.45 ± 0.54 1.40 ± 1.20 (<0.001)
Midfacial KGW adjacent teeth (mean ± SD) (mm) 2.60 ± 0.82 3.58 ± 0.91 0.98 ± 1.22 (0.002)
Interprox. REC adjacent teeth (mean ± SD) (mm) 1.55 ± 0.63 0.28 ± 0.34 1.28 ± 0.66 (<0.001)
a
Interprox. PD adjacent teeth (mean ± SD) (mm) 1.78 ± 0.41 1.60 ± 0.45 0.18 ± 0.59 (0.201)
Interprox. CAL adjacent teetha (mean ± SD) (mm) 3.33 ± 0.67 1.88 ± 0.53 1.45 ± 0.84 (<0.001)

Abbreviations: AM, attached mucosa; BL, baseline; CAL, clinical attachment level; Interprox, at the interproximal aspect; KGW, keratinized gingiva width;
KMW, keratinized mucosa width; MT, mucosal thickness; PD, probing depth; PSTD, peri-implant soft tissue dehiscence; REC, gingival recession; SD,
standard deviation.
a
Data from the mesial and distal teeth were merged.
b
Note that the difference between the outcome measures at baseline and 1-year are given as absolute values.
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TAVELLI ET AL. 211

T A B L E 2 Linear dimensional changes at the midfacial aspect of dentition, resulting in “black triangles”, which are typically one of
the implant and peri-implant papillae evaluated from superimposition patients' main concerns.25,46,47
of the digital scans at baseline and 1 year after vertical soft tissue
Vertical reconstruction of the lost hard and soft tissue architec-
augmentation.
ture at implant sites is considered one of greatest challenges when
Outcome Midfacial Papillaea treating PSTDs. Urban and coworkers illustrated a case of an implant
LD0 (mean ± SD) (points) 3.02 ± 1.97 0.68 ± 0.42 esthetic complication successfully managed with implant removal, ver-
LD1 (mean ± SD) (points) 3.15 ± 2.04 0.99 ± 0.52 tical bone augmentation, delayed implant placement with simulta-
LD2 (mean ± SD) (points) 2.36 ± 1.62 1.39 ± 0.78 neous CTG (placed vertically, on top of the implant head) and
LD3 (mean ± SD) (points) 2.19 ± 1.21 1.95 ± 0.82 prosthetic soft tissue conditioning.28 The same group recently showed

LD4 (mean ± SD) (points) 2.47 ± 0.97 1.94 ± 0.75 that vertical bone and soft tissue augmentation can further benefit
from the application of recombinant human platelet-derived growth
LD5 (mean ± SD) (points) 2.11 ± 1.05 1.75 ± 0.60
factor-BB (rhPDGF-BB) on the root surface of the adjacent dentition
LD6 (mean ± SD) (points) 1.48 ± 0.96 1.14 ± 0.79
showing interproximal attachment loss.48 Based on the concepts of
LD7 (mean ± SD) (points) 1.57 ± 0.85 1.11 ± 0.76
the connective tissue platform technique, advocating that localized
LD8 (mean ± SD) (points) 1.59 ± 0.90 1.19 ± 0.86
alveolar ridge defects can be corrected with soft tissue augmentation
Abbreviations: LD, linear dimensional changes; SD, standard deviation. alone,31 Stefanini and coworkers described the management of a chal-
a
Data from the mesial and distal papilla were merged.
lenging PSTD with the adjacent teeth exhibiting interproximal attach-
ment loss with multiple soft tissue augmentation procedures.26
T A B L E 3 Esthetic outcomes evaluated with the Implant Enamel matrix derivative (EMD) was also used with the aim of pro-
Dehiscence coverage Esthetic Score (IDES) at 1 year after vertical soft moting periodontal regeneration at the interproximal aspect of the
tissue augmentation. adjacent dentition.26
Outcome 1 year We designed a prospective case series to further evaluate the
STM (mean ± SD) (points) 3.80 ± 1.55 predictability of vertical soft tissue augmentation with a submerged

PPH (mean ± SD) (points) 1.80 ± 1.03 healing approach for the treatment of PSTDs associated with inter-
proximal papilla loss. We observed an overall mean PSTD depth
PMC (mean ± SD) (points) 0.70 ± 0.48
reduction of 2.25 mm, corresponding to a mean PSTD coverage of
PMA (mean ± SD) (points) 0.60 ± 0.52
85.14%. Few studies reporting the outcomes of PSTDs treatment are
Final IDES (mean ± SD) (points) 6.90 ± 2.33
available in the literature. The lack of uniform inclusion criteria and
Abbreviations: PMA, peri-implant mucosa appearance; PMC, peri-implant diagnosis of PSTDs may explain the wide range of mean PSTD cover-
mucosa color; PPH, peri-implant papillae height; SD, standard deviation;
age observed among studies (28%–96.3%).12,17,18,22,49 With the goal
STM, level of the soft tissue margin.
of promoting standard criteria for characterizing different types of
PSTDs and allowing for the comparison of the obtained outcomes
interproximal aspect the mean LD changes were between 0.68 and between different studies, our group recently proposed a new classifi-
1.95 mm. The professional esthetic outcomes, evaluated with the cation for PSTDs.4 This classification system identifies four classes of
IDES, revealed a mean final IDES of 6.90 points (Table 3). Patient- PSTDs that, except for class I, are based on the bucco-lingual position
reported esthetic assessment at the last visit was 8.83 points on a 0– of the implant-supported crown and implant head, and 3 PSTD sub-
10 VAS, with all the treated subjects stating that they would be avail- classes, which are determined by the height of the peri-implant papil-
able for retreatment, if needed. Supplementary Table 1 displays the lae.4 The present study included only PSTD subclasses c, which are
results of the exploratory regression analysis for assessing factors considered the most difficult conditions to address.
related to the final outcome of mean PSTD coverage (in %) after To the best of our knowledge, this is the first case series
1 year. Among the variables, the analysis indicated that gender had a addressing exclusively PSTDs with papilla loss and adjacent teeth
significant association with the results among this dataset, such that with interproximal attachment levels and, therefore, comparison
males obtained a significantly lower coverage of their treated PSTD between our outcomes, relative to the amount of PSTD coverage,
(model estimate 35.9 (95% CI [ 53.50, 18.31]), p < 0.01). and the literature is not feasible. Interestingly, regression analysis
showed that, in our cohort, females obtained higher PSTD cover-
age than male at 1 year. Due to the preliminary nature of the pre-
4 | DISCUSSION sent study and the limited sample size, this finding should be
interpreted with caution and further studies are needed to explore
Dental implants have reached a very high level of popularity among the impact of gender on the outcomes of vertical soft tissue
patients and clinicians. Indeed, this also accompanies an inevitable augmentation,
42–45
increase in the occurrence of implant complications as well. Another interesting finding from this study is the interproximal
PSTDs associated with implant malpositioning are often characterized attachment level gain at the adjacent teeth, which is probably related
by loss of interproximal papilla and attachment levels of the adjacent to the two CTGs employed (one “horizontally” and the other
 17088208, 2023, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/cid.13188, Wiley Online Library on [14/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
212 TAVELLI ET AL.

“vertically”). We found an average interproximal recession reduction Readers should be aware that a possible concern related to an
and CAL gain of 1.28 mm, and 1.45 mm at 1 year, respectively. When excessively augmented vertical soft tissue dimension (supracrestal
assessed with 3D digital technology through intraoral scanners, the tissue height) is a potential increased risk for peri-implant dis-
mean papilla gain ranged from 0.68 to 1.95 mm. In a recent commen- ease.58,59 This concern may be more valid for posterior implants in
tary, Rasperini and coworkers highlighted the anatomical factors patients with a history of periodontal disease rather than in implants
affecting the height of the papilla in natural dentition and the chal- with a previously treated PSTD in the esthetic zone. Further studies
25
lenges related to its augmentation. It can be assumed that papilla are necessary to evaluate the long-term effects of the described
augmentation at implant sites share the same (or even more) chal- approach on peri-implant esthetics and health. Similarly, the lack of
lenges and limited predictability than natural dentition, if the a control group, involving conventional augmentation approaches
implant-supported restoration is not removed. Soft tissue recon- without submerge healing or different graft materials, does not
struction at implant sites can tremendously benefit from removing allow to draw general conclusions on the described vertical soft tis-
the prosthetic component—either the crown alone or with the sue augmentation by a submerged healing for the treatment of chal-
abutment—that results in an increased vascular bed between the lenging PSTDs and, therefore, future research is required to explore
implant and the adjacent dentition, which is crucial for the nutrition these aspects.
3
and survival of the graft and flap. With respect to the obtained LD
gains, it should be noticed that superior outcomes were overall
achieved at the midfacial aspect of the implants with PSTD com- 5 | CONC LU SIONS
pared to the interproximal areas. It can be speculated that this find-
ings may be due to the different recipient bed and vascularization Within its limitations, the present clinical study described a series of
receive by the grafts. At the midfacial aspect, the CTG is positioned consecutively treated cases, and their outcomes, following a vertical
on the periosteum and healthy connective tissue fibers adherent to soft tissue augmentation by a submerged healing for management of
the implant fixture, and it is then completely covered by the flap, challenging peri-implant soft tissue dehiscences with adjacent denti-
while at the interproximal areas, the CTG is placed against the tion exhibiting interproximal attachment loss. This approach can be
denuded root surface of the natural tooth with interproximal clinical effective in resolution of esthetic complications in most cases, provid-
attachment loss and may receive less blood supply from the recipi- ing a significant gain in interproximal attachment levels and root cov-
ent bed and the overlying flap, compared to the graft sutured at the erage at the adjacent dentition.
midfacial aspect.
It has been suggested that applying rhPDGF-BB or EMD on AUTHOR CONTRIBU TIONS
the root surface of the adjacent teeth during vertical soft tissue Lorenzo Tavelli and Shayan Barootchi equally contributed to study
augmentation may further enhance the interproximal CAL design, clinical procedures, data collection and interpretation, drafting
26,48,50
gain. We can speculate that the use of PRF in our study may the article, critical revision of the manuscript and final approval of the
have positively contributed to the interproximal CAL gain and, article. Shayan Barootchi performed the data analysis. Giovanni Zuc-
overall, to the treatment of the PSTDs. PRF may have facilitated chelli, Martina Stefanini, Giulio Rasperini, and Hom-Lay Wang contrib-
the maintenance of soft tissue closure (or facilitate an early closure uted to data interpretation, critical revision of the manuscript and final
when healing by primary intention was not aimed and achieved) approval.
during the first phases of healing since it has similar growth factors
as those noted in the rhPDGF-BB, which can positively affect the FUNDING INF ORMATI ON
survival, dimensional stability, and attachment of the CTG to the The authors do not have any financial interests, either directly nor
root surface. indirectly, in the products or information listed in the paper. The study
It has to be mentioned that the concept of vertical soft tissue was self-supported.
augmentation has been originally introduced for preventing/
minimizing marginal bone loss occurring at implant sites character- CONFLIC T OF INTER E ST STATEMENT
ized by thin vertical soft tissues (nowadays defined as “supracres- The authors declare no conflicts of interest.
tal tissue height”).51–53 A vertical soft tissue gain ranging from
1.33 to 2.21 mm was described within the first 2–6 months when DATA AVAILABILITY STAT EMEN T
using a human or xenogeneic acellular dermal matrix.54–57 The data that support the findings of this study are available from the
Although these results are not comparable with our findings due to corresponding author upon reasonable request.
the different clinical conditions (augmentation at implant place-
ment vs treatment of implant complications with flat papilla/ae OR CID
and adjacent dentition exhibiting interproximal attachment loss) Lorenzo Tavelli https://orcid.org/0000-0003-4864-3964
and graft utilized (dermal matrices vs CTG), we can conclude that Martina Stefanini https://orcid.org/0000-0002-9154-637X
the limit of vertical soft tissue augmentation at implant sites is, on Giulio Rasperini https://orcid.org/0000-0003-3836-147X
average, within 2.5 mm. Shayan Barootchi https://orcid.org/0000-0002-5347-6577
 17088208, 2023, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/cid.13188, Wiley Online Library on [14/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
TAVELLI ET AL. 213

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